What Bevan would think of Blair

by Clare Beckett New Statesman

Monday 23rd August 2004

The founder of the NHS would regard Labour’s reforms as unspeakably evil, argues Clare Beckett

Within a month of the vesting day of the National Health Service, in 1948, 97 per cent of the general public were “signed up” for treatment. This was a triumph for the then minister of health, Aneurin Bevan, who built a system of care and disease prevention on a single belief – that he saw “the sale and purchase of medical practice as an evil in itself”. We are now seeing the damage that can be caused by a Labour prime minister who believes the opposite.

Because of Bevan’s achievement, my generation – the baby boomers – will hardly ever see the damage of neglected and untreated conditions of the sort that haunted our grandparents: women with prolapsed internal organs which had been in that state for years; men with hernias and lung disease which had never been examined. Children who were born after 1948 went to the doctor with cuts and bruises, coughs and colds, and were treated. I and my two brothers are among the first generation of children anywhere in the world and at any time in history who had their feet stitched and their fevers cured, their teeth filled and their tonsils out, simply because they needed it – and it was because we lived in Britain.

At another time, in another place, one of us might have died at birth; another might not have survived polio. Instead, here we are, hale and hearty if a little grey, watching a Labour government destroy the most practical response to human need ever developed in a capitalist democracy.

To Bevan, “free at the point of delivery” was part of the conviction of health services. If people were ill, the government should provide ways to make them better. Full stop. Systems that delivered healthcare only to some were not only an attack on basic human rights, they also made ordinary people resentful and apathetic. Only freedom from fear and insecurity would make society healthy and productive. Only absolute equality guaranteed choice.

True, Blair has retained the principle that treatment must be free at the point of delivery. But principles are about more than words. Blair has also committed himself to differential funding according to hospital performance. It will no longer be true that the government is responsible for funding treatment at every hospital, and that every hospital has the same provision and the same standard. Blair’s defence of “free at the point of delivery” is yoked to his belief in private funding – which is never concerned only with treating illness.

Take foundation hospitals. Hospital managers will no longer be under the direction of the Department of Health. Money can be raised from banks to finance capital programmes; money from the sale of land and assets can be kept by the trust. They will be able to get funds from central development budgets without having to submit formal bids. Trusts will be allowed to establish private companies, and reward staff above nationally agreed terms and conditions. Though the idea of old-style co-ops (where local people, staff and patients are able to become “members”) sounds good, the members will only get to elect a board of governors. Operational control will remain in the hands of a board of directors. Would-be foundation trusts have been invited to set out their own proposed governance arrangements. So there is likely to be substantial variation. And at this point the service becomes a different concept, no longer underpinned by Bevan’s belief that everybody should be able to rely on a comprehensive, state-funded system with transparent aims and policies.

When I was a child, hospitals came in all shapes and sizes. There was the new redbrick Watford General where I was born, the huge and scary North London Hospital where I had my foot stitched, and the little Staines Cottage Hospital where I stayed for six weeks. The respect given to hospitals then seems hopelessly old-fashioned now. The NHS is beleaguered, criticised, overstretched – but what it meant in my lifetime was that we could be sure of being treated wherever we were. The familiar, local hospital, which friends and relatives could easily visit, was also the hospital that would provide the best treatment. We may not have known about performance indicators, but we were free to use the service most accessible to us.

The most attractive parts of Blair’s plans are built around “choice“, yet how much choice will we really have?

Will the next generation of parents have to ensure that their children cut their feet in one county and not another because of the variation in hospital standards? Will children who need bone marrow transplants fail to get them because their parents cannot afford to live near hospitals with the right facilities? If patients are competing for places at the “best” hospitals, won’t the providers want those who are most likely to recover quickly?

Bevan had no idea how the cost of medical treatment would rise. He did not foresee the potential for hip replacements or advanced heart surgery, let alone IVF or cloning technology. He expected that, by now, our society would be well housed, educated, and probably fully employed. He would have said that nothing was too good for the working class; that if your illness was curable, it should be cured; and that to cure a rich person and let a poor one die from the same illness was unspeakably evil. He held the realistic hope that, in the immediate postwar world, ordinary people would benefit from a health service that gave first priority to good treatment for all. But that hope always depended on governments accepting responsibility to pay for and run the service. The evidence, so far, is that the present one will avoid that responsibility.

SHA Response

Clare Beckett does not seem to have learned much about Bevan if she thinks that he would condemn what Blair is doing to the NHS.

Bevan was a pragmatist who knew that only by negotiation, trial and error and compromise could his principles be delivered. He was well aware that absolute equality was a myth and that variations in services and hospitals would persist. “Some of the hospitals are thoroughly bad, just as some of them are good; but the great majority are mediocre and too small” – memo to cabinet 1946.

He was also quite relaxed about private medicine. For example he wrote to the Secretary of the Socialist Medical Association on 11 March 1946 to explain that under the NHS Bill then in preparation “any patient shall be able to obtain any part of the treatment he requires under the Service, or privately, as he may desire… …at some hospitals at least there will be private accommodation where private treatment will be given by specialists on the staff of the hospital”. On 6th April 1946 in a speech to hospital administrators he announced that “Management Committees should not be tyrannically controlled by the Regional Board….improvisation, experimentation, individuality should be allowed”.

She is also under an illusion if she imagines that before the present NHS reforms “we could have been sure of being treated wherever we were”. The sad fact is that until recently many patients in need of treatment died on the waiting list. Services were often well used by the middle classes but no efforts were made to ensure that poorer people who needed them more got the treatment they needed. Until the establishment of the National Institute for Clinical Excellence by Labour the question of whether expensive treatments such as bone marrow transplants should be provided was decided by local health authorities. There is now and always will be variations in the quality of health care between different institutions, but at least this government is trying to ensure that an acceptable standard is available everywhere. Many well loved institutions have been closed because they were unable to provide a decent standard of health care, something which Clare Beckett seems to neither know nor care about.

The future of the NHS deserves debate, but based on facts, not sentimental claptrap such as is presented by Ms Beckett.

Martin Rathfelder