3The paradox of the NHSWhy did Britain, with a strong tradition of insurance funded health care, and of health services funded in local government, adopt a tax funded system for the NHS based on the hospital sector and centrally directed?
4Plan of the lecture 1.The paradox of the NHS 2.The origins of the NHS: more distant and immediate3.The successes and deficiencies of the NHS4. Issues for the present.
5Some key dates 1911 National Health Insurance 1919 Ministry of Health 1920 Dawson Report plans universal system1929 End of the Poor Law1937 Political and Economic Planning Report1939 Emergency Medical Service1942 Beveridge Report1944 Coalition White Paper1945 Labour Government elected1946 NHS Act5 July 1948 ‘The appointed day’.
6Early precedents Precedent – friendly societies Liberal welfare reformsSchool medical inspectionOld age pensionsUnemployment insurance1911 Health insuranceCompulsory for wage earnersCosts: employees, employers, stateBenefits: wage replacement, practitioner attendance, not hospital care
7Inter war developments 1: health insurance Insurance income limit gradually raised: excludes dependents not in work, housewives, children under 16 and elderly.Unequal treatment for private and ‘panel’ patients.Restrictions on clinical freedom by ‘approved’ societies.Widespread self medication and ‘ counter prescribing’.
8Inter war developments 2: hospitals Voluntary hospitals- charity in decline- growing demand- uneven provisionPoor Law institutions- the end of the Poor Law?- what happened to PL hospitals- poor quality and stigma
9Inter war 3: public health as a state system? The Medical Officer of Health and his ‘ empire’Did public health fail or was it a success? Could public health and the local authorities have formed the basis of the NHS?
10Problems of the pre war system Overall problems pre war: integration; finance, comprehensiveness.The rising demand for planning e.g PEP The British Health Services
11Wartime planning Emergency Medical Service Beveridge report 1942 The 1944 White Paper A National Health Service1945 Labour victory and the negotiationsHenry Willink
12The National Health Service Free comprehensive health service at the point of need ‘universalising the best’Direct taxation, not insurance or local taxationNationalisation of hospitals and regional structuresGPs paid according to capitation, not salariedPrescriptions, dental care and spectacles free (until 1951)Health centresLocal authority limited role
13The coming of the NHSI well remember our Brian being born. He was delivered by a doctor up at Oldham, a Scotsman, he got called up and killed in the war, so we never paid for Brian. The doctors were very good. You’d go to the doctor. He had your name and address. And after, you’d got a bill, and if you couldn’t pay it, which very few people could, each doctor had his own collector. The collectors used to come round each week and you’d pay sixpence. My wife’s father and mother used to say they’d never be straight in their lifetime. When the National Health came in all those doctors’ bills were written off. The collectors used to be the same type who were park collectors in them days-they’d be no use today, kids’d throw them in the pond - but they were always little wizened fellers.
14Historical debates Consensus or conflict? The role of public opinion? Bevan - hero or villain?
15Successes and problems Access for all especially women. Popular support. Fear of poor health and inability to pay removed.Advances in medicine: hence a sickness hospital based serviceFinancial profligacy?Top down and centralised?Failure of integrationPublic and patient involvement: the democratic deficit.Pre 1948 issuesInterface health and social careDoctors and the state
16Current issues with a history The political nature of health because of tax.Integration of services and boundaries with social careSpecialist/general: the Darzi proposals.The ‘new localism’ and democracyRising expectations and allocation of resources.Prevention and cureOther echoes from history?