Welch, L., 2003. Letters to the Editors: New, Modern, Dependable?!. Reformulation, Summer, pp.9-10.
Like the patient whose current self-perpetuating chaotic destructive personal tensions are located deep in the past of an interpersonal history of abuse and neglect, the NHS today represents the problems of an historic compromise in which a small and fragile space was carved out from the control of the rich and powerful to meet the health needs of the majority. Like the patient who finds it hard to remember, who wants to forget the pains of the past, pretending it never happened, who wants a solution now without the recognition of what led to the current difficulty, so the history of the NHS is forgotten, usually glossed over in a weight of bureaucratic detail and whose memory is limited to the failures of the last government.
The failure of the government to address the needs of the working and unemployed population after World War One and the bitter experiences of the thirties strengthened the resolve of the population for the need for comprehensive medical care. By the end of the Second World War this meant that the victorious Churchill led his party to defeat and the landslide vote for Labour shifted the balance of forces for a brief moment in British politics. Bevan, “notorious as a backbench irritant and leftist political maverick” (Sked & Cook 1993), after fierce battles with the medical profession and the existing civil administration, managed to introduce the idea of a nationalised health service in three short years. This at a time when Britain had lost some £7 billion of earnings, had had to negotiate a demanding new loan with the US, experienced the most severe fuel crisis since 1880-81 and faced an acute shortage of goods and services. A fundamental human principle was established and embodied in social practice, that the health of all was the social responsibility of all, not a purely individual responsibility, in contrast to the principle that the better nature of the rich should be called on to respond to the deserving poor.
Despite the massive support for the NHS in the late forties – even winning over the GPs after 5th July 1948 – the dominant conservative political thinking within which this revolutionary idea was introduced quickly rallied, ensuring that this achievement was limited from birth. From the outset the NHS has been starved of resources, with funding set at artificially low limits. In 1950 an artificial ceiling was established of £400 million and this remained in place for a decade, all improvements expected to be gained by efficiency savings, increases in National Insurance contributions etc.
Modernisation today is of course wonderfully old fashioned. Resources nowhere near match need. The Regional Hospital Board in the North West estimated that £30 million was required to build ten new hospitals. They “inherited mental hospitals, some of which are in the neighbourhood of a hundred years old and most of them have been victims of damage and destruction by bombing during the last war.” It attracted £500,000 for all its capital expenditure (Webster, 2002).
Behind the virtue of prudence over resources, the debate about finance is narrowed and constricted to a remarkably Kleinian like lamentation about the demanding and needy child created by this national structure. The real social conflict between those relatively few rich who, under a myriad of self interested claims generalised as representing the good of all, vacuum the bulk of available wealth in the country, and the majority working population, who are the real wealth producers, is successfully thrown out of focus. Radical, reforming ‘socialist’ Labour, with enough of a connection to the demands of the working population in post 1945 Britain, still paid £164 billion to the owners when they nationalized the mines.
The current injection of finance into the NHS is welcome but the accounting of it is highly opaque and there is no clear statement about meeting historic shortfalls. Of course today’s old modernisers, steeped in the ancient hierarchies, are right when they say that the issue is not just about resources but also about how the NHS is organised. While Bevan did an extraordinary amount between 1945-48, proclaiming in a leaflet distributed to all households that “everyone, rich or poor, man, woman or child can use [the NHS] or any part of it” it was from the outset dominated by the medical profession and the civil service. Everyone could use it; only the powerful could shape it. The struggles to introduce political democracy in Britain ended with the extension of the vote to women in 1928. There was and is no question of allowing the workforce or patients a real say in the running of the NHS. One person, one vote means just that. And it is rationed to once every five years. Modernization means the imposition of abstract plans written with a view to harvesting votes every five years, not a realistic appraisal of the needs of NHS.
While the traditionalist modernisers trumpet their desire to extend democracy in the NHS, it is no coincidence that when they talk of democracy it is always secondary to the term modernisation. If democracy were at the heart of their plan for Foundation Hospitals then they would have to extend the principle to all at once. The extension of democracy requires a leap of faith, the espousal of the value that the mass of people can collectively determine their fate. Importantly, it requires listening to and engaging with the other ‘fool’. Open, critical debate, where it exists in the NHS, is a hard won prize, constantly under attack from the powers that be. Dissent is seen as an irrelevance slowing down the urgent striving of the ‘pragmatists’ who often genuinely believe that the way of the bureaucrats is the only way forward. Reality, as it exists in the present, forgets the historical development of the NHS beyond the immediate past and crushes talk of a future outside of its narrow ultimately market driven picture of health care.
In its overwhelming outpouring of plans, New Labour hides the absence of real analysis of the problems. It seems this is no coincidence. Webster (2002) argues that the 1956 Guillebaud Report into the costs of the NHS, which found no evidence of waste, was such a shock to the prevailing views that the NHS needed reining in, that no government has set up an independent inquiry into this area subsequently. Other inquiries providing evidence unfavourable to the dominant model of the NHS are quickly suppressed, such as the Black report into inequalities in health in 1980. More recently, the Commission on the NHS in 2000, sponsored by the CHCs, highlighted the ‘democratic deficit’ in the NHS and argued for a Constitution for the NHS, and the setting up of local and regional elected bodies. The government response? The abolition of CHCs in favour of the Patient Advocacy and Liaison Service (PALS!) giving rise to “the suspicion that [they] represent a vastly complicated and inferior substitute to the CHCs.” (Webster, 2002).
The NHS was founded in response to an overwhelming demand for universal healthcare at the end of a war reaping unparalleled destruction on Britain. That brief moment of constrained revolutionary impulse, although sustained through all the ensuing grey years of prudence and cost cutting consciousness by a popular support successive governments have acknowledged but never believed, can repeat itself. Recent history is full of occasions where seemingly impregnable blocs have fallen: the Soviet State, the Berlin Wall, Apartheid. Although it was hardly surprising that the Stop the War protest did not achieve its aim, the scale of the protest opened up debates unheard of for many years. For the NHS to truly reflect its founding values an indispensable element is that these values are debated in at all levels in the NHS. Debate and openness is the vital blood of a democracy based on election not selection. Democracy is the only sustainable structure for the NHS to fully embody its core values.
Hutton, W. New Life for Health: The Commission on the NHS.
2000. London, Vintage.
Sked A, Cook C: Post-War Britain. A Political History 1945-1992
London, Penguin, 1993
Smith, D. Physician, Heal Thyself: The NHS needs a voice of its own.
2002. Nottingham, Spokesman Books for Socialist Renewal.
Webster C: The National Health Service: A Political History
Oxford University Press, 2002
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