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Friday, July 3, 1998 Published at 17:28 GMT 18:28 UK


True to its principles?

Niall Dickson looks at the NHS' core values 50 years on

The founding principles of the NHS have been invoked by politicians down the last 50 years, but has the reality of the NHS lived up to them? The BBC's Niall Dickson reports.
The BMA's Dr Sandy Macara on the NHS
Contrary to popular mythology, Nye Bevan did not dream up the idea of a National Health Service - Winston Churchill's war-time coalition was responsible for producing a play which would have provided free care for all. Bevan's contribution was to make that a reality and take it further by bringing hospitals into public ownership. Just as important, he imbued the new service with his values. This was service founded on fundamental principles - that health care should be free, available to all and of uniform quality no matter where people lived or what their background.

Throughout its 50 years, the NHS has struggled to live up to those principles and though it has never fufilled the most optimistic predictions of officials in the 1940s, it has for the most part remained true to the ideals of its founder.

Free care

Free care has a very short history - Bevan himself was soon under pressure from the Treasury to cut back. The NHS was in financial difficulties almost from the day it was launched with demand running ahead of what the service could supply. It is a story that has continued uninterrupted to this day. Bevan's first concession was to agree a ceiling on NHS spending and he agreed to take powers to introduce prescription charges, hoping that he would be able to prevent them ever being levied.


Dr Sandy Macara on rising demand in the NHS
And before it left office in 1951, Labour had imposed dental and spectacle charges. In later years, the Conservatives introduced charges for eye and dental check-ups and in effect privatised large chunks of long-term care as NHS geriatric wards were closed down and patients sent to private nursing homes.

In spite of all this, it is true to say that the NHS remains largely free - politicians have flirted with charges for GP visits and hospital stays, but have always ended up concluding that it would be unfair, unpopular or impractical.

Avoidable to all

Perhaps the most significant part of Nye Bevan's legacy was his decision to bring all Britain's ragbag of hospitals under one national service. There were those in the Cabinet at the time who wanted to see local government lead the new system. Bevan, though, was conscious of the huge variation in the standards of different hospitals and the parlous state clinically and financially of some of the less prestigious institutions. His aim was to create a uniform service, not for its own sake, but because that would ensure equity. The patient in rural Dorset should have access to the same quality of care as the resident of Knightsbridge. By nationalising the system and agreeing to national pay for NHS staff, including senior hospital doctors, he hoped to end the disparities.

Enoch Powell, as the Conservative minister of health in the early 60s, continued this process by initiating a massive hospital building programme so that every area of the country would have its own district general hospital. The result today is reasonably uniform services, but with significant differences, both in terms of quality and what is available.

NHS patients, though, do not always get the same access to treatment. Traditionally, if there were too much demand in an area for a particular treatment, it was rationed using a waiting list. Until the late 1980s, these lists could stretch for years, so that in reality the treatment was never carried out at all. The shape of services locally was often determined by the interests of the consultants working in that district so that, in some parts of the country, patients might have ready access to a particular specialist while, in others, there would be long waits or possibly no service at all.

Much of this is now more in the open and the rationing more explicit, although the principle is no different. The waiting lists are much longer than they used to be, although perhaps, more importantly, patients spend much less time on them. But the waiting list is not the only rationing device.

Health authorities decide what they will and will not pay for in their areas. So, in some areas renal dialysis may be more plentiful than in others, which means that, in some areas, kidney patients are more likely to die. This is not trivial stuff.

Likewise, some authorities are willing and able to pay for new drugs, such as Taxol for women with ovarian cancer, while others have so far resisted providing it, questioning whether it is cost effective. Taxol has been shown to provide on average about an extra year of life to patients with this terrible disease. And there are plenty of other examples. Beta Interferon is available to some people with multiple sclerosis and not to others, depending on where they live. Fertility treatment, including vasectomies and sterilisations as well as IVF, is not universally available nor is varicose vein surgery and a host of other procedures.

Uniform quality

The recent case of the Bristol surgeons, whose incompentent practice produced an unacceptably high death rate among the children they operated upon, provides a telling reminder of the variations in standards. Theirs was a terrible failing, but many more services are either sub-standard or just mediocre. Until recently, the British NHS, like every other health system in the world, has found it difficult to measure its own clinical performance. That is changing, but it will take time.


NHS financial director Susan Soracen on rising NHS costs
And, lest the NHS celebrations go over the top, it may be salutory to remember that cancer survival rates here compare unfavourably with the United States. What is more, fifty years after socialised medicine first appeared in this country, health inequality is still striking. Children born to manual workers have a life expectancy seven years shorter than those with professional parents.

The government has acknowledged the failure of the health service to address these quality issues. Its solutions, which include a new National Institute for Clinical Excellence, reflect a growing awareness that the health service in general and the medical profession in particular need to be held to account for clinical standards and it is on that that Labour's stewardship of the NHS may well be judged. The danger is that more rigorous monitoring and a policy of name and blame will further undermine morale. The trick for the next five years, if not the next fifty, will be maintaining that balance.



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