David Ennals’ speech to the Socialist Medical Association

27 MARCH 1977

You have asked me to talk today on a very broad subject – “The Government and the National Health Service”. And in case I fail to range wide enough you have given me a further hint in the all embracing subtitle – “An assessment of the past, the present and a projection for the future.”

I don’t intend to say a great deal about the past, except insofar as it provides us with a measuring rod for the present as well as some lessons for the future. Let me deal first with the measuring rod, because the umbrella title for this seminar is “The State of the NHS” and a lot of strange, sometimes wild, statements have been made on just that subject in recent months. I want to set the record straight right at the beginning.

First, we have to remember the obvious: the National Health Service has existed for less than thirty years. That needs to be said because so many people now take the Service for granted. It is a part of our daily lives, and half the population are too young to remember a time when there wasn’t an NHS to look after them. Even among the older generation – how easily we forget. And how little credit so many of us give for the achievements of the service created by the first post-war Labour Government.

Later today you will be looking in detail at the state of our hospital and primary care services. I dare say one or two speakers will venture a critical word or two. That is all to the good, because we have a 1ong way to go in building the sort of health service that we Socialists want to see in Britain. But I do ask you at the same time to keep in mind not just the road ahead but, also the long and hard mileage behind us. Let me give you just a few facts.

Since 1946, when the National Health Act was passed, the health of the nation has improved enormously. Infant mortality has been reduced to 4 tenths of the 1946 rate. Maternal mortality is down to one tenth. Life expectancy at birth is up by 4 ½ years for men, 6 years for women. Deaths from diseases like diphtheria, measles, whooping ,cough and so on are down dramatically. Compared with the first full year of the Service, far more patients are being treated now by a much larger staff. Manpower is up from about 400,000 whole time equivalents in England in 1949 to over 700,000 in 1975. There are about 20,000 more doctors, 175,000 more nurses, midwives and health visitors and over 25,000 more in the other health professions. Spending on health has gone up enormously, whichever way you look at it. When the NHS began the cost to public funds was about 4 per cent of Gross Domestic Product. It is now about 6 per cent of a far bigger GDP.

The catalogue could go on. I’m sure you know most of the story well enough, but I must also say a word or two about this Government’s stewardship. I am proud to be a Labour Secretary of State with responsibility for the NHS. No-one who holds this office can ever forget that one of his predecessors was Nye Bevan, a man from the valleys who knew how to look up to the top of the mountain. Nye’s picture hangs above my desk where I can keep an eye on the expression of his face. Sometimes I fancy the hint of a smile appears, as if in satisfaction or approval. There was certainly occasion for an appreciative nod from Nye a few months ago when we finally – after a bitter struggle -got the pay beds Bill through Parliament. That was a task long overdue, a job Nye Bevan would have wanted to complete himself. The Labour Party and the Socialist Medical Association have shared for years a determination to end the scandal of queue jumping in our hospitals . This Government was elected on a promise – and I quote the February manifesto – to “phase out private practice from the hospital service”. And that is exactly what we are doing.

We were also elected on a promise to “expand the National Health Service.” Here I must put the record straight on public expenditure, because so many misleading things have been said about cuts. Let’s look at it first in terms of the proportion of Gross Domestic Product we devote to the health service. A few moments ago I gave you the long term figures – roughly speaking, from 4 per cent up to 6 per cent over nearly 30 years. But a very large part of that improvement has taken place under this Government. It took the 23 years up to 1973 to raise the proportion of GDP spent on health by one half of one per) cent. Since then, we have added a further one per cent to take us almost to 6 per cent of GDP.

A large part of this went to staff. I make no apology for that. This Government was determined to give a fairer deal to the many workers in the Service – not least the nurses, the porters and other ancillary staff – whose dedication has been exploited over the years. We welcome dedicated people to the NHS. But their dedication was no reason for paying them less than a fair rate for the job. The role of Government in the NHS – at least the role of a Labour Government – is to make the service a good one and a fair one not only for patients, but for staff too.

The point I am making is that spending on the NHS has gone up under Labour – not as fast as we would have liked, but up. Last July and December we had two rounds of unpleasant decisions on the Government’s spending plans. There’s no getting away from that. But nor is there any getting away from the fact that we couldn’t spend money we didn’t have. With a world recession holding down our economic growth we had to trim back the rate of increase in public spending. But there was no across the board percentage cut. We looked at programmes in the light of our priorities, and although we had to make a modest contribution from the health budget, it was a modest one because of the commitment Of this Government to the National Health Service. As a result, current spending will still go up each year in real terms and services to patients will be protected from the full force of the country’s economic difficulties.

Of course we will need that annual increase in order to cope with the rising number of older people who will need health care in the years ahead. So money will be tight. We must all face that fact. But facing it doesn’t mean we have to get into a panic and rush about saying the health service is about to fall apart, collapse, grind to a halt or anything of the sort. That kind of talk is both silly and dangerous. It is silly because it takes no account of the enormous progress the NHS has made over the years including the last three years. It is dangerous because it spreads alarm and despondency among staff and patients.

There is plenty that needs doing in the health service ,We need more modern equipment and hospitals, more staff, better management, a stronger system of primary care, a shift to community care and many other reforms. But none of this should blind us to the fact that the NHS provides a tremendous service to the-British people, a service we should be proud of. In fact, it is about time the moaning minnies who believe – or pretend to believe – that the service is on the verge of collapse asked a few patients what they think. All of us involved in the NHS know that we have a hard task ahead of us over the next two or three years. The pressure will not be eased until we are out of our economic difficulties, because only when the economy gets moving can we create the wealth we need for all the improvements we want to see in the NHS. That is the simple, brutal truth.

In the meantime, we must do the best we can within the resources we have. That is where the Government has a vital role, because when money is tight it becomes that much more important to make the best use of it. A few weeks ago I set out in some detail a programme for getting better value for money in the NHS. Let me mention today just a few of the areas where savings could be made if all of us who work in the service would turn our minds to the task of getting better value for money:

  • There are enormous variations in such matters as the length of time patients stay in hospital for same operation in different parts of the Country;
  • the use of day surgery;
  • the extent to which GPs refer patients to hospitals and use hospital diagnostic facilities.
  • There is the much discussed problem of management costs. We are cutting these by 5 per cent, but with careful administration the health authorities may be able to do even more, and I am planning to reduce DHSS headquarters health staff by 10 per cent.
  • There may well be room for economies on the huge drugs bill; on the £250 million catering bill; on supplies, through bulk purchasing, and so on.

These are all ways in which we might ease the position in the short run. But you have asked me today to look into the future and I assume you mean me to look some way ahead. When I do so I can not avoid the conclusion that we need a heavy shift in the emphasis of the service; if you like, a new phase in its development.

It is commonly said that the National Health Service is largely a curative service. This is true. That is why we have been giving a new thrust to prevention. Our first step was the publication of the Red Book. “Prevention and Health: Everybody’s Business”. This was to analyse the problem and examine the possibilities. Further papers on specific problems are to follow. The next to come will be papers on childbirth and pregnancy and on occupational health.

But we have already taken action on a number of fronts. I have given the Health Education Council an extra million pounds. I have specifically allocated money for fluoridation. And I recently announced new initiatives in the campaign against cigarette smoking. This at least attracted an enormous press which itself must have done some good. Even though comment was as schizophrenic as many smokers are on this issue. (If concern for the health of the people of Britain. makes me a puritan, then I am proud to be called a puritan.)

I am determined that we should move on from the stage of providing a universal health service to which everyone has access to creating a positive and comprehensive government policy to promote health. One step, but not necessarily the most important step, in that direction bas been to give a considerable new emphasis to an allocation of the money available for the NHS according to the need for health services. The report of the Resource Allocation Working Party has enabled us to make a major break – through. We are now moving progressively year by year to an allocation of money which takes account not just of the demographic characteristics or each area and region and the need to provide clinical teaching for medical schools, but of the health status of the population as indicated by its mortality – the best available indicator of relative health which we can use. I cannot justify in a national service a situation in which the best provided region received health services worth £90 a head per year and the worst provided region £63 a head; and where this gap bears no sensible relationship to relative need. Nor can I justify a situation in which the differences in spending between areas are wider still.

One factor which underlies the different health needs of different parts of the country is social class. Those of you who saw the press reports this week of the Royal College of Nursing’s evidence to the Royal Commission will have noted that they saw a link here between the geographical and the social imbalances in health care. I know too that Professor Townsend will be dealing in detail with some of the socia1 factors later this morning. I hope that what I have to say will fit into the same pattern of argument.

It has long been known that there are enormous differences in health standards by social class. The problem is not new, and it is not confined to Britain. But this does not mean there are no answers to the problem. I am determined to find ways of narrowing the gap. We must move from the concept of making services equally available to everyone to making health equally available to everyone. We may not be able to do as much as quickly as we would wish. But we must go as far in this direction as we can. This is not a short-term objective. It is a long-term objective, because we simply don’t know exactly how and where we can break the cycle of subnormal health or inadequate health in deprived families. I am sure you will agree with me that this is a thoroughly socialist objective.

Some of the socialist medical pioneers may have thought that a universal health service and other improvements in social services would automatically narrow social class differences in health. But let’s look at what’s happened since the “welfare state” was set up after the war. We’ve built seven million new houses. We’ve introduced family allowances and will be making a start with child benefit in a few days time. We have raised the real value of pensions and other social security benefits. We have nearly doubled expenditure in real terms on the national health service since we set it up. But after all this there is no evidence that social class differences in health standards are any narrower than they were forty years ago.

We shouldn’t overstate this failure. Mortality statistics do show that the death rates for professional workers (those in Social Class 1) are lower than for unskilled workers (those in Social Class V). And the difference has not narrowed over time. But we must remember that the number of unskilled workers has fallen considerably in the last 20 years. In 1951, 13 per cent of the working population was in Social Class V but by 1971 the proportion had fallen to 7 per cent. This means that comparisons over time are difficult. We may not be comparing like with like – the number of people in Social Class V has been going down, and the people leaving the class have probably been those with better health. The ones left behind may be those with the poorest health.

But having said this, the crude differences in mortality rates between the various social classes are worrying. To take the extreme example, in 1971 the death rate for adult men in Social Class V (unskilled workers) was nearly twice that for adult men in Social Class I (professional workers) even when account has been taken of the different age structure of the two classes. When you look at death rates for specific diseases the gap is even wider. For example, for tuberculosis the death rate in Social Class V was 10 times that for Social Class I; for bronchitis it was five times as high and for lung cancer and stomach cancer three times as high. Social differences in mortality begin at birth. In 1971 neonatal death rates – deaths within the first month of life – were twice as high for the children of fathers in social class V as they were in Social Class 1. Death rates for the post neo-natal period – from one month up to one year – were nearly five times higher in social Class V than in Social Class 1. Maternal mortality – down a long way from the figures of 40 years ago – shows the same pattern; the death rate was twice as high for wives of men in Social Class V as for those in Social Class I. The differences, as I said, begin at birth. But they go on through life. At age 5 Social Class I children are about an inch taller than Social Class V children. About twice as many people reported long standing illness. which limited their activity in Social Class V as Social Class I. The average number of days off work due to illness or injury was about six times greater in Social Class V than Social Class I. Spells off work due to bronchitis were nearly four times greater for men in Social Class V than for classes 1 and 11; and for arthritis and rheumatism nearly six times greater. A survey showed in 1968 that fifteen per cent of Social Class I adults had no teeth, while 47 per cent of Social Class V adults had no teeth. Finally, the male suicide rate in Social Class V men of working age was approximately twice that of men in Social Class I.

The first step towards remedial action is to put together what is already known about the problem. A good deal of information has been gathered for different purposes in this and other countries. But it needs to be assembled and analysed to bring out as clearly as possible what the cause and effect relationships might be, what the implications for policy are and what other research we need. I have already set this in motion. My Chief Scientist has appointed three scientific advisers with a particular interest in the matter to commission a comprehensive survey as quickly as possible, and I am glad to be able to tell you that Professor Townsend your next speaker in this seminar has agreed to be one of these advisers.

In looking for the causes of these differences in health, certain differences in life-style between the Social Classes are highly suggestive. An obvious one is housing. The poorer people are the worse their housing conditions tend to be.

In 1975 29 per cent of Social Class I men were cigarette smokers compared with 57 per cent of Social Class V. Here the social class gap has widened enormously. Some 15 years earlier 54 per cent of men in Social Class I smoked and 62 per cent in Social Class V. Nearly 40 per cent of those in Social Class I were active in outdoor sports and games compared with under ten per cent in Social class V. Mothers in professional families are much more likely to breast-feed than those in Social Class V. And they do so for much longer.

We must make sure that our health education efforts are directed at the right targets and in the right way. This raises questions of forms of communication and of the language of communication. But it also raises much wider questions. I can’t help feeling that there are issues here which need to be fed into the major debate we are having on education at school. And. of course there are major aspects of inequality in our society which may well have an important bearing on this problem. How far are poor physical circumstances of life responsible for poor health? How far are the social consequences of poverty responsible for ill health? How far do people with particular personal characteristics come to be poor or to live in a poor environment? We need to sort out causes and effects. Do the lower social classes have higher rates of disease due to poor defences against disease and increased general susceptibility? If so, which psycho-social variables lower defences and increase susceptibility? We need to know much more about Social Class V. How far do people with good health manage to be socially mobile while people with poor health are locked by their health status into Social Class V? How far do people drop down into Social Class V jobs because of poor health including poor mental health? Can we make any generalisations about susceptibility to disease? Do particular ways of life lead to stress? Why do so many more unskilled workers smoke, for example? Is this all a consequence of the insecurities of life and the worries caused by relative deprivation?

But here I am speculating on questions where we need the best expert advice. We need to sort out clearly what we know already, so that we can identify gaps in our knowledge which more research might fill. Of course, much of that research will be long term. But we must get as many right answers as we can, even if it takes years to get them.. It is a major challenge for the next ten or more years to try to narrow the gap in health standards between different social classes.

This is all of a piece with our view – as socialists – health care is not just a commodity to be bought and sold in the market place like any other. Health care is a right for all our people, rich or poor. The National Health Service was set up by a Labour Government to give people equal access to health facilities on the basis of need rather then ability to pay. In further developing the NHS we are developing that principle.

The future role of Government is not only to provide decent curative facilities for all, but also to promote positive good health for all. That is the horizon to which Labour Ministers, and the Socialist Medical Association, must lift their eyes. But in doing so we cannot overlook the difficulties closer to us. The events of the last week or so must have concentrated minds wonderfully.  Suddenly we were all faced with the possibility of a Thatcher Government, a Government that would not only postpone into the indefinite future the sort of progress we have been discussing, but would put at risk much of what has already been achieved.

For Mrs. Thatcher is a considerable political palaeontologist. Most of us had a rational and justified fear of that strange creature – half human, half beast dug up by the Conservatives a few years ago.  Selsdon Man. Mrs. Thatcher seems determined to resurrect a still more primitive and dangerous form of life from an even earlier era. Flint-Age Woman. This creature’s exact characteristics are still not entirely clear. It is clear that the new Tory beast is a throwback to an older one which had. no great passion for the welfare state, but believed instead in the law of the jungle. The Tories never had much good to say for the welfare state. Of course, once a Labour Government had introduced some basic measure like the National Health Service, the Conservatives never had the nerve – or the political stupidity – to attack it openly, to threaten its existence. But there are now signs that if the Tories ever get into power the health service as we know it will be in great danger.

So let us read the signs for a moment. First, we have the leaks in the press about the Conservative Party Working Group on the NHS. It seems that the party which goes around complaining that the burden of taxation is too great nevertheless thinks that the sick should be taxed. They want to put up prescription charges – which have got lower and lower in real terms under Labour, and which we intend to abolish as soon as we can afford to.

They want to make the patient pay for every visit to the GP – in spite of the heavy administrative costs this would involve and the fact that it would deter many who need treatment from going to the doctor. They want to charge patients for being in hospital again in spite of the extra bureaucracy needed to collect the money and administer an exemption system – or are they planning to charge old age pensioners, the low-paid, children and so on?

Of course, it is just plain daft to think that charges like these, set at anything like a tolerable level, could solve the problems of the health service. They might raise, say a hundred million a year out of the five thousand million we spend in England alone. But we must be clear that to raise extra money in this way runs counter to the basic principles of the Nationa1 Health Service. Health care should be provided on the basis of need, not ability to pay: and the service should be free at the point of use. Of course it has to be paid for in the end. But we have always believed that the right way is for everyone to pay through tax and National Insurance. The wrong way is to hit people when they can least afford it – when they are sick.

But the threat to tax the sick is only part of the danger. The second strand in Tory thinking would undermine the NHS in another way,and their Policy document, “The Right Approach” spells it out clearly enough. For those of you not on the Central Office mailing list, let me read the relevant passages

“‘We should encourage rather than deter private provision”. “It will be our aim… to reverse the rundown in NHS pay beds” .

“We see no reason for quantitative controls over the development of the private sector outside the NHS. We are examining ways of providing greater financial incentives to employer-employee medical insurance schemes, for example by restoring income tax relief”.

The implication of all that is pretty clear. The Conservatives want to see two health services. And of course they won’t be equal services. What would be the point of having two? One will be for the rich, and one for the poor. If you can afford it, get yourself insured privately. Get your treatment in private hospitals, staffed no doubt by doctors and nurses trained at public expense! And meanwhile the NHS would be allowed to run down till it was just a second best, a safety net for the poor, the old and the chronically sick. That is the sort of prospect you face with today’s Conservative party. And if anyone thinks I am scaremongering, they’re right. It’s about time people got scared about this. It’s about time they woke up to the danger.

That is one vision of the future. A nasty one. But there are other possibilities. And of course we have a Royal Commission sitting at this moment considering the whole range of issues on the structure, financing and control of the National Health Service. A great deal of evidence has been sent in by all sorts. of bodies. The Commission is considering it all and the Government will have to look at the Commission’s Report in due course, so you will not expect me today to give you a clear blueprint for the NHS in the 80s and 90s. But before I sit down there are a few general points I do want to make about my own vision of the future.

First, we must get more money into the NHS. First we must get economy right. Then we will be able to afford the public expenditure to replace the many old hospitals we still have. We will be able to shift resources more rapidly both geographically and between services – into the priority fields such as mental. illness and handicap. We will be able to shift the emphasis from institutional to community care. We will have the cash to build up primary care teams based on health centres; to intensify the attack we have begun on waiting lists; and so on.

Second, our Labour view of the health service has to go beyond the simple, though crucial, idea of nationalising the hospitals. Although great progress has been made in the last 30 years, we have not done enough to bring together the three branches of the service – the hospitals, primary care and community care. There is also a need to strengthen the links between the health service and the Personal Social Services. We have made some progress here through joint planning and I recently announced a trebling of the funds for joint financing of projects.

This leads, of course, to the third point – the need for some sort of reorganisation of the service. The Tory reorganisation, which we never favoured, has been costly. I have put that with great delicacy; and with the Royal Commission at work I must not go too deeply into this area. Suffice it to say, there is a general feeling that there are too many tiers of management and there are difficult problems to consider in the area of democratic control of the service. Within the present structure, Community Health Councils are playing an important part in representing the interest of the consumer. But there are other aspects of democracy too: a role for the staff and I mean all the staff, not just the professions. And of course there is the issue of the relationship between the NHS and our Parliamentary democracy.

That takes me to my final point about the future. It is a point which goes to the heart of the topic you asked me to speak on today – the Government and the NHS. It is being said by many people that the service should somehow be separated, insulated from Government; that we should have some sort of Central Health Services Board which would take the NHS out of politics. I suppose for some people this bas a superficial attraction – the sort or people who talk sadly about things being treated as ‘political footballs’. But let me remind those who think that way that if we are not allowed to kick the football we will never score any goals!

The fact of the matter is that the health service is political. You cannot ‘de-politicise’ questions like

  • How much money will we devote to health?
  • How will we divide it between the regions?
  • And between different parts of the service?
  • What are our priorities?
  • How will we raise the money to pay for the NHS?
  • What place is there for private practice?
  • How is the service to be run?
  • What say will the staff have?
  • And the public?

These are all political questions. Asking them brings out the importance of maintaining a National Health Service; a service responsive to the needs of both those it serves and those who work in it; and a service responsible – through Ministers to Parliament.

I am convinced that only within such a framework can we make – and carry through – decisions about the aims of the service, its funding and its priorities. The Government must take responsibility for the health of the nation. It cannot abdicate its responsibility to the medical profession, to management experts, technocrats, boards or anyone else. Least of all- can it allow such matters to be. settled in the market place. Since the National Health Service was set up the Government has played a central role. It must continue to do so which makes it all the more important to ensure that the Government continues to be a Labour Government.