Intended for healthcare professionals


The jewel in welfare's crown

BMJ 1998; 317 doi: (Published 04 July 1998) Cite this as: BMJ 1998;317:2

The NHS will glisten still if it retains middle class support

  1. Nicholas Timmins, Public policy editor.
  1. Financial Times, London SE1 9HL

    “On Monday morning you will wake up in a new Britain, in a state which ‘takes over’ its citizens six months before they are born, providing care and free services for their birth, for their early years, their schooling, sickness, workless days, widowhood and retirement. All this with free doctoring, dentistry and medicine—free bath-chairs, too, if needed—for 4/11d out of your weekly pay packet. You begin paying next Friday.”

    Thus the Daily Mail in its leader column greeted the imminent arrival of the National Health Service on 5 July 1948. It is often forgotten that the birth of the NHS was not just an isolated event. It was part of the biggest single tranche of welfare state reconstruction that the United Kingdom has seen. Its arrival coincided with dramatic improvements to social security—the creation of family allowances, retirement pensions for all, new industrial injuries schemes, the raising of the school leaving age to 15, and the start of a great explosion in council house building.

    It was just one part of the huge effort in postwar reconstruction presaged in the Beveridge report of 1942 and made possible by the immense sense of social solidarity generated by the second world war. And arguably the measures to improve housing and the incomes of the least well off, plus the achievement for close to 30 years after the war of something like full employment, did as much to improve health as the creation of the NHS itself.

    Yet 50 years on the NHS, battered and bruised though in many ways it is, stands isolated and majestic as the remaining jewel in the crown of those reforms. After a strong period of postwar growth state pension provision is steadily withering away. Council house building has come close to being extinct, with home ownership now easily the dominant form of tenure. Benefits have become increasingly linked to prices, not earnings, producing a widening gap between those in work and those not. And while unemployment is currently low by the standards of the past decade or so, it is higher than in the years up to the mid-1970s and likely to remain so. School age education, it is true, remains a popular if controversial cause, second only to health in the British Social Attitudes Survey of areas where the public would like to see higher spending. But in higher education those who receive it are having to pay for more of it themselves.

    Many forces have led to these changes, but among them are a growing resistance to higher taxes and widening income inequality, which has led to rising expectations about standards and service among the majority who make up the better off. Acceptance of standardised fare, or a basic minimum, is much less clearly the order of the day.

    The NHS, remarkably, has survived these changes and managed to do so while Britain spends a smaller share of gross domestic product on health than most other industrialised countries. The belief that health care should be available to all regardless of ability to pay remains deeply embedded in the British psyche.

    To some degree, the NHS has the private sector to thank for that. The numbers covered by private health insurance rose sharply in the 1970s and 1980s, notably at times when the NHS was under acute financial stress. But private health has proved less good at controlling costs than the NHS. Premiums have run well ahead of both inflation and the rise in NHS spending. Cover remains expensive. As a result, since 1990 and despite the end of recession, the numbers insured have remained flat while the types of cover have tended to become more restrictive. Patients have traded down to less comprehensive policies, or to ones offering a smaller choice of hospitals, a change which provides a reflection, albeit watery-weak, of the impact of managed care in the United States.

    Over the past three or four years NHS spending has again been under strong pressure, running at appreciably less than the 3% a year rise in real terms which most of the service's advocates believe it needs to stand broadly still—to sustain, for example, the costs of an ageing population and reasonable medical advance.

    The signs of strain are apparent. The government is trying to address a sharp rise in waiting lists and waiting times just as it introduces yet another reorganisation—arguably as sweeping as any that went before. Involving not just a change in purchasing or commissioning arrangements, the latest reforms represent an ambitious attempt to benchmark the quality of care and push doctors ever more firmly towards medicine which is not just evidence based but cost effective. As with general practice fundholding and the formation of NHS trusts, these ideas have attracted considerable interest worldwide as other countries struggle to contain even higher healthcare costs and to move to more evidence based and managed care.

    The critical questions are whether the NHS can both improve quality and contain costs and whether the government will find sufficient funds to improve not just the quality of clinical care but the standard of amenity in the NHS and the waiting times for access to it. Both issues are likely to be critical to the question of continued middle class support for the NHS. In a sense, that has always been the underlying question about the service. On the NHS's 50th anniversary this question feels at least as acute as ever. The most noticeable difference between the United Kingdom's spending on health and that of other developed countries lies not in much smaller public spending but in much smaller private spending. The critical issue is whether the latest round of reforms can deliver a service which will satisfy nearly everyone for around 5.8% or a little more of gross domestic product. If it cannot, new charges or a renewed flight to the private sector will result.

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