Nye's neglected baby left in tiers

The National Health Service
April 10, 1998

The National Health Service at 50 presents historians with a daunting challenge. We are so close and involved - and who would want to kick a much-loved national institution when it is down? The dilemma, moreover, must be doubly difficult if, like Charles Webster, you happen also to have been its official historian. The scholarly monuments put out by HMSO always demanded bureaucratic blandness and tight-lipped prose. Released from that straitjacket, would a different Webster emerge, revealing himself in his true colours?

Readers hoping to encounter "Webster Unbound" will not be disappointed. The National Health Service: A Political History is, by any standards, contemporary history at its finest. Webster's mastery of technicalities is apparent from every page, as one would expect from a scholar steeped in the archives who has already researched much of this story in a brace of books ten times longer. Above all, secure in his sources, Webster does not hesitate to speak his historical mind.

So how does he take the pulse of the NHS? It is not for nothing that this volume is called a "political history". This is in part to signal that it is not polio and penicillin that are centre-stage: there are no familiar photos here of gleaming new hospitals or smiling kiddies getting their booster jabs. What Webster chiefly means to convey by his subtitle, however, is that the NHS has perennially been politically embroiled. While the "political football" cliche is mercifully avoided, it might not have been inappropriate.

The NHS, Webster insists, did not just spontaneously emerge out of the state's growing involvement in health care from Victorian times onwards. It was not the product of some mythic national "consensus". Nor was it forced into being by irresistible "necessity" after a devastating world war.

Rather the NHS was the creation of the Labour Party - specifically, Webster insists, the fruits of the incomparable vision, drive and charisma of Aneurin Bevan, arguably the only minister of health who has ever managed to drag all players into line. Some sort of health reform would doubtless have followed had Churchill won the 1945 election, but there is no reason to suppose that it would have included the key principles of the system inaugurated on the Appointed Day - a nationalised hospital network and universal access to primary care, free at point of service.

Thereafter, politics were rarely far from the surface. Matters of principle brought Bevan's resignation in 1951 over prescription charges - an episode obliquely echoed by Barbara Castle's later losing battle over pay-beds. Into the 1950s certain Conservatives, for their part, continued to hanker after a health service run on the insurance principle; and not till Iain Macleod, argues Webster, was there a Tory health spokesman who truly endorsed the NHS - as part of Disraelian one-nation Toryism.

There was, of course, the Butskellite interlude when the two main parties played Tweedledum and Tweedledee in undertakings for NHS expansion. But political infighting never ceased, and industrial action flared during the pay pauses of the 1970s, culminating in Callaghan's disastrous Winter of Discontent. And by then the new right was already hatching its plans to roll back the welfare state.

In 1979, for the first time since the war, there came to power a leader viewing welfarism as halfway to communism with devotees determined to go on the offensive against the "granny state". If, as we were soon being told, there was no such thing as society, what sort of future would there be for socialised medicine?

In addressing the Thatcher and Major era, Webster seems at times to be engaged in a dispute with himself. The "big picture" he paints is that Thatcherism launched a calculated and concerted attack on the NHS, in an "act of determined political will". "Each step preparing the way for further change", the prime minister proceeded "by means of progressively discrediting, destabilising and supplanting existing institutions until the process of radical transformation was complete," states Webster in a chapter significantly headed "Continuous revolution". Doubtless that is precisely what the "ideologues of the right" wanted, denouncing socialist "red tape" and "inefficiency" and urging the promotion, through tax incentives, of private medicine.

Yet Webster's year-by-year narrative does not exactly confirm this vision of the inexorable implementation of a master strategy. By this, I am not merely alluding to the fact that Tory manifestos and policy statements never ceased to voice stout support for the NHS, from Mrs Thatcher's famous pledge at the 1982 Party Conference that the NHS was "safe with us", through to her insistence, just before her fall, that "the National Health Service will continue to be available to all, regardless of income". After all, were not those 18 years times of stupendous deception and duplicity?

Rather, what the Thatcher and Major administrations actually undertook seems far less decisive. The early 1980s brought little reform beyond the removal of the "area" tier of administration emplaced in 1974 by none other than Sir Keith Joseph - even the Community Health Councils, an obvious target, escaped unscathed. The introduction of "Sainsbury managers" following the Griffiths report (1983) was not an especially doctrinaire response to management shortcomings that were widely acknowledged - and Griffiths himself was to prove no Tory yes-man. Then remarkably little was actually done during Thatcher's second term to transform the NHS. The Treasury, Webster observes, knew that the savings to be made from introducing the "hotel charges" or insurance schemes dear to free-market think-tanks would certainly be marginal, while the prime minister's political instincts taught her that an onslaught on the NHS, like that against the trade unions, would have been electoral suicide.

So what of trusts and fund-holding, broached in 1988, introduced while Thatcher was being toppled, and justly termed by Kenneth Clarke the biggest shake-up the NHS had seen? Webster candidly acknowledges that, far from being a deep-laid scheme, the internal market was a somewhat desperate throw, made faute de mieux in the face of traumatic cash crises. Policy was being made up on the hoof - expedients came first, the ideological rationalisations followed. "There is every indication," Webster is surely correct to write, "that Mrs Thatcher was a late and reluctant convert to the idea of radical interference with the health service. This was one of the few areas of policy where she judged that it was best to leave well alone."

And beyond installing the "unplanned" internal market, the Major years reveal virtually no serious intentions of further radical reform; tellingly, neither the hapless Virginia Bottomley nor Stephen Dorrell even makes it into Webster's index. The most conspicuous development in the 1990s was the mushroom growth of management, as the 1,000 senior managers of 1986 turned into 26,000 by 1995, the total outlay in needless administrative expenditure being reckoned at up to Pounds 1.5 billion a year. Eighteen years of Toryism thus ended not only with the NHS still dominating British health care - private medicine remains "minuscule in scale" - but even with the old administrative pyramids still essentially intact. Webster thus presents two images - Tory butchery and Tory bungling - that do not wholly harmonise.

If the record of events throws into question the former reading, it certainly reinforces Webster's most important insight. The Achilles heel of the service, he insists, has ironically been the fact that, during its entire 50-year span, it has commanded overwhelming public support, thanks to its "capacity to deliver great humanitarian benefits as a surprisingly low cost". The result has been a tragic national complacency - the tendency, in Sir George Godber's words, "to pride ourselves on having the finest health service in the world", which has thereafter excused spending less on health than any comparable nation.

From early days, the presence of the service meant that governments could get away with inattention to health. Ministers of health were not even granted a Cabinet place, thereby making expenditure pegging all the easier. The NHS's cheapness became a fact of life rather than a warning symptom of collective neglect - be it the failure in the 1950s to build new hospitals and health centres or, to this very day, to invest in prevention, education and public health. It is characteristic of this syndrome that, on taking office, Tony Blair (exuding what Webster calls his "fresh-faced version of conservatism") could pledge to cut waiting-lists, but then let them lengthen, safe in the knowledge that an ever-stoical nation would not be up in arms.

This is a powerful book, packed with facts yet fired with passion. Complexities are clarified, even if brevity means much has to be taken as read (will all readers know how Whitley Councils worked?). Nice personal touches abound - Richard Crossman, we are told, was "prone to acts of audacity" - though it seems slightly cruel to refer to "Normal Fowler". Webster's prose is crisp, his tone sardonic and the judgments now and then explosive. Battling against Bevan, the British Medical Association is said to have used "megaphone diplomacy imitative of totalitarian regimes", while, Webster asserts, the conditions of some long-stay patients in the pre-NHS days were "arguably little better than the concentration camp". The politics of health will be the next century's big issue. There is no better introduction to our present impasse than Webster's book.

Roy Porter is professor in the social history of medicine, Wellcome Institute.

The National Health Service: A Political History

Author - Charles Webster
ISBN - 0 19 289296 7
Publisher - Oxford University Press
Price - £9.99
Pages - 241

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