(This piece also appears in the current issue of Progress magazine)
Given the increasingly fractious nature of politics and debate in English society, it is all the more remarkable that there is such strong agreement on the principles behind the NHS. Political parties that seriously argue for the voters’ attention quickly come across a resilient popular love for both the practical nature of the institution and also the principles behind it.
This is all the more remarkable since the NHS was so clearly an institution created by Labour politics and in the teeth of strong opposition from the Conservative Party and the medical profession. This political consensus that protects the NHS today was not there at its birth. It took one of the most partisan of Labour Cabinet Members, Nye Bevan to force this through from idea to reality. Time and again in 1947 and 1948 he manoeuvred the Conservative Party and the BMA from what they saw as strong positions into defeat.
And he did this because he saw what they wouldn’t see. Their core supporters – the middle class- agree with him and not the Conservative Party on their personal need for an NHS.
I would warn hon members opposite that it is not only the British working class, the lower income groups, which stands to benefit by a free health service. Consider that social class which is called the ‘middle class’. Their entrance into the scheme, and their having a free doctor and a free hospital service is emancipation for many of them. There is nothing that destroys the family budget of the professional worker more than hospital and doctors’ bills.
House of Commons Feb 9 1948
The NHS succeeded then, as its succeeds now, because it has such strong middle class support. People know how ruinous ill health without the NHS can be to middle class family life. That is why in 1997 when New Labour came to power, and middle class support for the NHS was dangerously on the wane, New Labour spent so much time refashioning the services that the NHS could offer to the country. Why reducing waiting time for everyone was such an important achievement by the NHS. When New Labour left power we had resecured that strong belief that everyone had in the NHS.
What Bevan recognised is that if you want to create a genuinely NATIONAL service then you needed the robust support of all classes in society. The NHS succeeds in delivering the principle Equal access for all to health care which is free at the point of need because all classes get that access.
How do we secure that for the next 70 years?
Bevan was clear that it would always have to develop. In his last speech before its inauguration Bevan said “The Service must always be changing, growing and improving; it must always appear to be inadequate”
The contemporary pressure on the NHS comes from its success in helping to create much longer life expectancy. Two thirds of NHS activity now takes place with older people who have two or three long term conditions. Very few of them ever ‘get better’ from the conditions they suffer. The whole country, including the NHS, needs to help these older people to manage their conditions as a part of their everyday life. The winter crisis, comes from too many older people losing control of their conditions and going into a hospital bed as an emergency. If you are over 75 and you spend 10 days in bed in hospital you lose nearly 50% of your muscles, weakening you for a long time. Hospital beds are not a good place to be.
The modern NHS is going to have to help more and more people live with a high levels of illness in their own home. To make that happen some of the fragmentation brought in by Bevan and his government is going to have to be overcome. Famously Bevan nationalised the hospitals and created a small business sector for GPs. (It was the only way to guarantee a GP service at all). This has left the NHS highly fragmented between primary and secondary care. Bevan’s government created for older people a social care system based upon mean tests and run by local government. (Life expectancy for men in 1948 was 65 so it didn’t matter much).
This is why there is so much talk about integration of services.. An 85 year old with three long term conditions with have three specialists, several social care staff alongside district nurses, their primary care team and social care staff. More than 10 people working very separately on their health and care- which is both ineffective and wasteful.
From this year you will increasingly hear about ‘social prescribing’ where an overworked GP prescribed not a set of pills but a long discussion with a health trainer who will link the patient to a walking group to help them get more exercise.
The WHO believes that the world is short of 4.3 million nurses and doctors. In 10 years’ time- as China and India double their health expenditure, this shortage will get greater. The international trade in professional staff will almost certainly swing against England. We will have to create safe health services for an older sicker population with fewer high level professionals per person. We will need all of them to spend their entire working life at the full extent of their skill and will have to have many more nurse associates and health care assistants caring for us.
In ten years time we will still all have equal access to NHS services based on need, but it is certain they will be different services.