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Parliamentary Debates on the Anniversaries of the British National Health Service 1958-2008: plus ça change?

Débats parlementaires sur les anniversaires du service national de santé britannique 1958-2008: « Plus ça change? »
Martin Powell

Abstracts

This article examines the 70th anniversary of the British National Health Service (NHS) through the lens of Parliamentary Debates in the House of Commons, focusing on the closest broad debate on the NHS to each anniversary. It draws on interpretive content analyses, exploring the following themes: creation, principles, stewardship, achievements, and problems. Although there is some continuity over time, it suggests more nuanced conclusions in that while most debates have discussed most of the themes, their salience has varied over time. Issues such as who created the NHS, funding the NHS, breaking principles appear to be hardy perennials, and are likely to be debated but not resolved, generating more heat than light, on the 80th Anniversary of the NHS.

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Introduction

1On 5 July 2018, the British National Health Service (NHS) celebrated its 70th birthday. As a largely publicly financed and provided service, the NHS is necessarily the subject of political debate. The most obvious place to explore such debate between the Government and opposition parties is in the adversarial House of Commons, which is charted in the ‘Hansard Parliamentary Debates’. This article charts political perspectives on the NHS over a period of some 60 years through the lens of political debates in the House of Commons, focusing on the closest broad debate on the NHS to each anniversary. Apart from its 10th anniversary, these anniversary Debates have been largely neglected, perhaps because Timmins (2008: 9) states that the 1958 debate was the only Commons debate there has ever been to mark an anniversary. However, as we see below, this is not the case, and so the material presented here explores largely original material.

2It draws on interpretive content analyses that includes attention to both manifest and latent content, and also draws much more attention to the contexts in which people make, convey, and receive communications (Krippendorf 2013; Drisko and Maschi 2016). Manifest content refers to what is overtly, literally, present in a communication. Latent content refers to meaning that is not overtly evident in a communication, but is implicit or implied, often across several sentences or paragraphs. Coding in most interpretive content analyses is largely descriptive, and starts inductively with the preliminary raw data. Such “emergent” coding contrasts with the a priori or deductively generated coding used in many basic content analyses. Interpretive content analysis allows for the use of connotative categories which are based not on explicit words but on the overall or symbolic meaning of phrases or passages. Most data presentation in interpretive content analysis centres on descriptive narratives, or themes, summarising the collected and coded data. It is possible to code material in a large variety of ways. The main rationale was a search for a set of themes that emerged inductively from the material and were present in most or all of the time frames in order to trace issues over the 50-year period from 1958 to 2008. The following themes are explored: creation, principles, stewardship, achievements and problems. It was found that every Debate contained a discussion about the creation of the NHS, with the Labour Party stating that they founded the NHS, while the Conservatives opposed it, This was continued into arguments over the principles of the service, where Labour tended to argue that they supported the principles (free at the point of use; available to all; largely funded from taxation) of the NHS, while the Conservatives opposed them, claims hotly contested by the Conservatives. This was paralleled by a wider discussion of stewardship, where the Conservatives argued that they had presided over much of the period of the NHS, and had increased resources for the service, while Labour had starved it of funding. Achievements and problems represent a mirror image coding of ‘positive’ and ‘negative’ features Sometimes these claims were partisan, in the sense of the speaker arguing that their party was responsible for the achievements of the service, while the opposition (while in government) was responsible for its failures. However, at other times, speakers appeared to look beyond partisan issues, pointing to broader issues such as the cost implications of medical technology and an ageing population. This presentation uses the terminology of the period such as ‘mental hospitals’, and provides party affiliations for the first time for each speaker, with the Hansard column number for reference.

Tenth Anniversary

3A Debate was held in the House of Commons to mark the tenth anniversary of the creation of the NHS. Klein (2013: 23) noted that it was an ‘exercise in mutual self-congratulation as Labour and Conservative speakers competed with each other in taking credit for the achievements of the NHS’. According to Timmins (2008) it was a ‘matter of quiet congratulation’, with a strong sense that something big and good had been created in 1948. The 1958 Debate was introduced by former Labour Minister of Health, and founder of the NHS, Aneurin Bevan.

4The theme of creation reflects a common theme throughout the period, where Labour attempted to claim credit for founding the NHS, while pointing out that the Conservatives opposed it. For their part, the Conservatives argued that the 1944 White Paper outlining the NHS had been produced during the wartime Coalition Government under a Conservative Minister of Health. Moreover, they claimed that in 1946 they voted against particular elements of the NHS put forward by the 1945-51 Labour Government, while supporting the broad concept of the NHS (in effect, their version of the service from some two years earlier).

5Bevan (c1386) stated that Conservative Members voted against the NHS on every conceivable occasion and for every conceivable reason. Similarly, John Baird (L, c1500) claimed that the Tory Party attacked the Bill most viciously in the country and in the House at every stage, with wrecking Amendments of all kinds. ‘If they had had their way there would be no NHS as we know it today.’

6However, Minister of Health Derek Walker-Smith (C, c1400) considered that Bevan was ‘less than generous in his reference to his predecessors at the Ministry of Health and in his total omission of any reference to the Coalition Government’s White Paper of 1944.’ Sir Hugh Linstead (C, c1461) and Raymond Gower (c1426) argued that the Conservatives put forward a reasoned Amendment, but supported the idea of a comprehensive NHS.

7The precise principles of the NHS have never been fully clear, although most commentators point to issues such as being comprehensive (covering all medical treatments), universal (available to all, rich and poor, on the basis of citizenship, rather than based on any insurance contributions), free at the point of use (no price barrier) and largely funded from national taxation (which was seen as more progressive than regressive insurance payment or out of pocket fees) (Powell 1997).

8According to Bevan (c1383), two main conceptions underlay the NHS. The ‘comprehensive’ principle was to provide a comprehensive, free, health service for all the people of the country at time of need. The ‘redistributive’ principle was the redistribution of national income by a special method of financing the NHS.

9Parliamentary Secretary to the Ministry of Health, Richard Thompson (c1487) stated that while the House may differ on means, it was ‘fairly broadly united about the end, which is to provide a comprehensive Health Service for all in need.’ One of the few (minor) exceptions to that was that Mr Shepherd (c1449) favoured increasing the amount that employers pay as a contribution towards the NHS.

10Given its short history of ten years, there was there was little discussion of stewardship (what parties did during their time in government), as there was relatively limited evidence of ‘track record’ (Labour presiding over the NHS from 1948 to 51 and the Conservatives from 1951 to 1958). As we shall see, this relative silence did not last, with future anniversaries having longer periods from which to make claims.

11The only significant remark about stewardship was from Bevan (c1393) who admitted that Labour introduced some small charges in 1951, intending that they should last for four years, but the Conservatives made them permanent and increased them.

12In contrast to the first two themes which remain largely constant in content over time, claims of achievements vary significantly over time in two ways. First, speakers pointed to both ‘objective’ measures such as mortality statistics and the number of staff and hospital beds. Second, they made more discursive claims (rarely backed up with evidence) such as the NHS being ‘the best in the world’.

13Bevan (c1385) pointed to the ‘remarkable’ declines in the infant mortality rate and the maternal mortality rate since 1948. Derek Walker-Smith (c1401) pointed to increases in effective beds, the number of in- and out-patients treated, and the ratio of treatments to beds, and to a decrease in waiting lists.

14Bevan (c1398) claimed that the NHS was ‘regarded all over the world as the most civilised achievement of modern Government’. Future Labour Minister of Health, Kenneth Robinson (L, c1442) stated that ‘the ten years of the Health Service have seen, in effect, a social revolution. We have, without doubt, the finest Health Service in the world’ (but see criticisms/ problems below). Moreover, he expressed his confidence that it provides a pattern that would be copied by many other countries in the years to come (c1447).

15Similarly, the nature of ‘problems’ varied over time. Members pointed to various problems such as some mental hospitals being in a disgraceful condition (Bevan, c1396; Robinson, c1442; Shepherd, C, c1450), the ageing population (Walker-Smith, c1404; Mr Blenkinsop, L, c1457; Thompson, c1499), the need for more on the preventative side (Rev. Llywelyn Williams, L, c1425), the neglect of ‘positive’ health (Thompson, c1497) and the democratic deficit in the NHS (Sir Fred Messer, L. c1432).

16However, there were different Conservative views of expenditure. While Robert Cooke (c1420) claimed that ‘the cost is threatening to get out of control’, Mr Shepherd stated that ‘We are not really spending much more, if any more, of the percentage of the national income on health than we did in 1938’ (c1450).

17Finally, different comparisons were made by Conservative Members. Gower (c1427) stated that the decline in deaths in childbirth and the increase in longevity is happening all over the world, and several countries were ahead of us. However, according to Shepherd (c1453), it is only when one investigates services in other countries that one realises how poor theirs are and how good is ours.

Twentieth Anniversary

18Klein (2013: 46) regarded the time of the NHS twentieth anniversary as a period of innovation. Timmins (2008) pointed to a mix of “technological pull” and “demographic push”, including a pharmaco-technological revolution that it could not afford.’ The 1968 Budget had seen Labour reintroduce prescription charges. The Secretary of State for Social Services (Richard Crossman, c 253-4) stated that ‘it is right to scrutinise the Health Service today, because it comes of age on Saturday, 5th July, 1969.’

19There appeared to be few references to creation beyond Laurie Pavitt (L, c285) who stated that the whole basis of the comprehensive service is part and parcel of the philosophy on which his party came to power in 1945.

20Turning to principles, for the Conservatives Maurice Macmillan (c250-1) argued that there was no question of finding all the extra money required by the NHS from taxation, so some system of insurance, charges, or increased contributions had to be faced. Labour Secretary of State, Richard Crossman (c256-9) rejected the possibility of a larger private sector, as this might lead to the NHS becoming a second-class service. Charges in the NHS were ‘a very mixed bag’ and ‘many of them are surprisingly uncontroversial’ such as charges for Part III accommodation for a place in an old people’s home, amenity beds, or dental charges. However, any proposed charges for a hospital bed or to visit the doctor were ‘outrageous’ (c261). He appeared willing to consider the possibility of a higher NHS flat-rate contribution (c263). Within the Labour ranks, David Marquand had ‘no dogmatic objection to charges’ (c276). Some charges appeared to have been accepted such as amenity beds, but there was more concern for prescription and dental and ophthalmic charges (e.g. Dr John Dunwoody, L, c298). Laurie Pavitt (L, c285) argued that ‘If one is to maintain a comprehensive service, it can only be paid for comprehensively’. He claimed that the philosophy of the Opposition was the old philosophy of a minimum provision and a safety net, which inevitably leads to a first-class service for those who are wealthy and a second-class service for the man in the street (c289). He urged the Government to restore the basic principle of this party on health matters (c291).

21For the Conservatives, Dudley Smith (c280) favoured ‘selective charges’. Charles Morrison (c269) considered that a prescription charge can be commended, but was continually worried about the exemption categories. He did not consider that expanding the private side of the NHS would lead to a second-class service, or that tax relief would not be a breach of principle. Julian Snow (L, c307-311) claimed that underlying most of the Opposition speeches was a feeling that there should be a place for a system such as B.U.P.A. as an alternative to the NHS for higher income groups, which he found ‘unattractive and unacceptable’.

22Stewardship was discussed mainly in terms of expenditure. Crossman (c254) pointed out that Labour increased the real cost of the NHS by 23 per cent, while the hospital building programme had doubled in five years. Pavitt (c289) stated that it is to the credit of the Government that the NHS’s proportion of national wealth increased from 4 per cent to just over 5 per cent in the last four years—the biggest rise since the inception of the service. Marquand (L, c274-5) pointed to the past neglect of the NHS during the 13 years when the Conservatives were in power. Snow, appeared to produce some faint praise that ‘the record of this Government is not all that bad’ as expenditure in real terms has increased 30 per cent since taking office in 1964 (L, c307). For the Conservatives, Macmillan (c253) and Morrison (c269) criticised the consistency of Labour of abolishing prescription charges in 1965 to re-introducing them in 1968.

23Achievements were discussed both in specific (mortality) and general terms. Pavitt (L, c283) claimed that one of the problems of financing the service arises from the success story that because of the NHS, people are living longer and that it has been one of the great successes in the world: more hospitals, doctors and nurses, and fewer people dying from tuberculosis. More modestly, Snow stated that ‘We have nothing to be ashamed of in our National Health Service’ (L, c311), but also considered that with all its shortcomings—and there are many, the NHS is admired throughout the world (c307) and that ‘We in this country are giving a lead to the world’ (c311).

24Dunwoody (L, c291) argued that the NHS faced very serious problems: excessively long waiting lists for surgical treatment; a shortage of doctors in all parts of the service; overcrowded waiting rooms; and a nursing profession disgruntled as perhaps never before. He considered that the cause of the problem of increasing demand was inevitable for two reasons: an ageing community (Marquand, L, c275) and medical advances (Macmillan, C, c243; Crossman, L, c256).

25As Paul Dean (C, c303) put it, the problem would become worse rather than better, because these built-in growth factors were multiplying all the time. The sort of conditions that people were prepared to accept in hospital ten years ago were not accepted today, because standards were rising. Perhaps most important of all were the advances in medical science. Crossman (c254) pointed to the ‘basic fallacy’ of the assumption in the Beveridge Report of 1942 that a comprehensive Health Service would lead to the improvement in the health of the nation and the flattening out the costs within a few years (cf Macmillan, c243). Marquand (c274) stated that everyone has agreed that health gets nothing like a satisfactory proportion of Gross National Product (GNP). At 5 per cent, Britain was still a long way behind other countries. However, Snow (c307) argued that comparisons with other countries can be very misleading. Macmillan (c248) noted that we are proportionately spending less on mental health provision than we were three years ago. Crossman (c255-6) pointed to the problem of inherited inequalities. For example, ‘one of the main inequalities was between the regions in 1948.’

Thirtieth Anniversary

26Klein (2013: 76) pointed to ‘the politics of disillusionment’, with low increases in expenditure, and a period of medical and trade union militancy. For the first time in the history of the NHS, doctors took industrial action, resulting in ‘the politics of ideological confrontation’ over pay beds (p. 85). Klein also pointed to ‘the politics of organisational statis’ and a sense of crisis that led to the setting up of a Royal Commission of the NHS (p. 90). The Debate in March 1979 on the state of the NHS was primarily about the question of nurses’ pay, but ranged into wider territory.

27There was only one reference to the creation of the NHS, when Dr Miller (L, c783) claimed that the Conservatives did not approve of the principles of the NHS in the first instance and retain even now some objections to the way it is funded.

28Discussion of principles related mainly to the funding mechanism of the NHS. Robert Boscawen (C, c780) argued that some new thinking was required with regard to the funding of the NHS, instead of falling back every time to raising the resources from central taxation. He discussed "hypothecated revenue ", and believed that there is a case for looking at a partial funding of the NHS through a national insurance fund system. He hoped that there would be a continuing debate, especially when the Royal Commission on the NHS reported, into more sensible ways of finding funding for a Health Service free at the point of use (cf Dr Vaughan, c 811).

29Miller (L, c783) disagreed with those who talked about the Socialist concept and principles of the Health Service being responsible for what were considered its ills, and that the whole matter should be left to free enterprise. Most of the carping against the NHS came from those who are lukewarm about accepting the basic principles of the Service. Labour Members claimed that the Conservatives would ‘increase charges all around’ (c811).

30There was some discussion of the ‘national insurance principle’, although it was unclear what was meant by the term. Roland Moyle, the Minister of State at the DHSS stated that it meant that people receive the service in return for contributions, and asked what happens when they run out of benefit? Did it mean that they have to go without health care, as happens in a number of European countries (c814)? However, Vaughan (c811) had already stated that the Conservatives were as determined as Labour to have an NHS that provides proper, first-class health care to every person who requires it, but the differences lie in the way in which that sort of care is achieved.

31Similarly, much of the discussion of stewardship also related to funding. Mr Ridsdale (C, c766-7) contrasted the 13 years of good Conservative rule that made wealth for the country with the 12 miserable years of Socialist rule that have brought us to equal shares of misery. He looked forward to a new Conservative Government that would be able to make wealth for the country in order to finance the NHS.

32Most problems were associated with funding. A number of Labour back benchers and the Conservatives urged the Labour Government to spend more on the NHS. However, Moyle (c725, c813) and Mrs Wise (c807, c822) asked the Conservatives where they would find the money, given their broad position of wishing for cuts rather than increases in public expenditure. Vaughan responded that Labour has no right to imply that they wished to cut the resources available to the NHS (c799).

33Vaughan (C, c803) stated that the Labour Government have had the responsibility for the NHS for over four years yet had decided not to put right the present chaos. He pointed to the ‘absolute disgrace’ of waiting lists of over 800,000. Since 1974, the queues for treatment had got steadily worse (c807). More generally the decline had been steady, progressive and disastrous, not only in the standard of service offered to patients but to the morale of the Service as a whole (c813). Winding up the Debate, Moyle (c813) admitted that the rate of growth had not been as high as Labour would have liked, but it increased the percentage of GNP to the NHS to 5.6 per cent (c821-2). He added that the number of patients admitted to hospital had increased from just over 5 million to 5,340,000, and outpatient attendances had increased from 45 to nearly 47 million, and day case attendances had increased very substantially from about 400,000 to 536,000 (c822)

34There appeared to be little on achievements, part from Mrs Jeger (L, c775-6) who stated that ‘We should not knock the NHS so much… If ever I have to be ill… I would rather be ill in this country than anywhere else in the world.’

35Conversely, there was a significant amount of discussion on problems. Mr Stallard (L, c729) was ‘horrified at the state of the NHS … It cannot be denied that the NHS is seriously ill.’ He continued that a recent editorial in the ‘British Medical Journal’ stated: ‘most of the problems of the NHS are commonly attributed to lack of money.’ However, he added that the shortage of money is not all that is wrong with the NHS. Ridsdale (C, c763) considered that the Service was facing a crisis because of lack of funds.

36Miller (L, c760) noted that Britain spent less per head than many comparable countries. Ridsdale (C, c763) claimed that the NHS compared poorly to other countries. Vaughan (c809-10) made a similar point. When challenged by Labour to say if he considered that superior systems included the USA, he denied this, pointing to France.

37Miller (L, c782) pointed to the funding problem of technological advances. Boscawen (C, c779) pointed to the initial assumption that in a few years it would pay for itself by cutting down the cost of ill health and the cost arising from people being away from work, but that had not happened. Other problems include a loss of morale (Stallard, c730; Vaughan c809), poor management and leadership (Stallard, c730; Raison, C, c758) and remote administration (Vaughan, c811), staff shortages (Wise, c796-7; Vaughan, C. c801), increasing waiting lists (Ridsdale, c766; Wise, c796; Vaughan, c806-7). Vaughan (c807-8) stated that the waiting lists had increased due to industrial action: ‘there are over 600 hospitals dealing with emergencies only. Nine hospitals are closed completely, and 5,500 beds are out of action. What a terrible indictment of the Socialist Administration.’

38Others problems included the need for smaller units (Vaughan c806), private donations to keep the kidney unit in Hammersmith going (Stallard, c732), and a hospital experience that ‘reads like something which might have been made into a novel by Charles Dickens’ (Miller (L, c727). A number of Members outside London pointed to regional inequality (Stallard, c731; Allen McKay, L. c786). Timothy Raison (C, c755) contrasted over-provision in London with under-provision in other areas. Secretary of State, David Ennals (c766) responded that the Government was reallocating resources. A number of Members pointed to the problems associated with the recent re-organisation, although Labour Members (e.g. Mrs Jeger, c768; Miller, c786; Moyle, c816) tended to blame Sir Keith Joseph (Conservative Secretary of State, 1970- 1974), while Conservative Members (e.g. Vaughan, c803) tended to blame his successor, Richard Crossman (Labour Secretary of State, 1974-).

39Many Members of the main parties pointed to planned hospital closures, notably the Elizabeth Garrett Anderson and the Royal Homeopathic Hospital, both in London, which had been the subject of previous Early Day Motions. However, as Stallard (c732) put it, ‘there is hardly an area (i.e. constituency) which has not been touched by this disease.’ McKay (L, c786) summed up that the NHS ‘is the jewel in the crown of Socialism, but at present it appears that the lustre of the jewel has gone.’

Fortieth Anniversary

40Timmins (2008) pointed out that 1987 had seen not just the triumphant re-election of Margaret Thatcher for an unprecedented third term, but the worst financial crisis in the NHS’s history. The result in early 1988 was the NHS Review which led to the 1989 White Paper ‘Working for Patients’ (Secretary of State for Health 1989) and the 1991 internal market. Klein (2013) characterised the period as ‘the politics of value for money’ (Ch 5) which led to ‘the politics of the big bang’ (Ch 6) which marked the ‘end of consensus on the NHS’ as the 1989 White Paper brought about the biggest explosion of political anger and professional fury in the history of the NHS. (p. 105).

41The NHS 40th anniversary saw three House of Commons Debates. In the first brief Debate, Mr Fatchett asked the Secretary of State for Northern Ireland if he had any plans to celebrate the 40th anniversary of the National Health Service (Northern Ireland: NHS (Anniversary). The second (Petition: National Health Service) involved a Petition presented by Dr. Lewis Moonie on behalf of the Royal College of Nursing, signed by 500,000 people from all parts of the UK which wished to reaffirm that the NHS shall remain funded from taxation and free at the point of delivery; and that the cumulative underfunding of the NHS identified by the House of Commons Social Services Select Committee (1988) should be remedied.

42We focus on the longest Debate (Hansard House of Commons 1988) introduced by Shadow Health Secretary, Robin Cook, which congratulated present and past staff of the NHS on forty years of service to the public; reaffirmed its support for a comprehensive health service, free at the point of use to all citizens and funded out of general taxation; welcomed the recent conversion of ministers to the fundamental principles of the NHS; and invited them to demonstrate their commitment to it by tackling the serious underfunding confirmed by the latest report of the Social Services Committee (House of Commons Social Services Committee 1988).

43After being relatively neglected in the two previous anniversaries, the theme of creation returned, with Cook (L, c 908) stated that the Health Secretary had claimed that it was not Bevan who formed the NHS in 1948 but Churchill in 1944. However, there was ‘one inconvenient historical fact in that reconstruction of history, which is that every Conservative Member voted against the creation of the NHS on the Third Reading of the Bill.’

44Secretary of State, John Moore (c916) accused Labour of ‘rewriting history’ as the White Paper of 1944 was produced by the wartime Coalition government, which stated that ‘The Government have announced that they intend to establish a comprehensive health service for everybody in this country.’ He continued that the Conservative amendment to Bevan’s Bill of 1946 stated that ‘this House, while wishing to establish a comprehensive health service…’. He claimed that what was debated at the time was not the basic aim of access to health care free of the ability to pay. However, the reasoned amendment disagreed with two features of the proposal: the method of paying salaries to GPs, and the taking over of charity and local authority hospitals.

45Michael Foot (L, c922-3), the only remaining Member from the 1946 debate, stated that the Tories voted against the Bill on Second and Third Reading, and in turn accused Moore of rewriting history. He quoted his biography of Bevan: ‘Future generations may learn that Aneurin Bevan did not make the NHS; he inherited it from that much underrated social visionary Sir Henry Willink’. Ronnie Fearn (Liberal, c945) also pointed to ‘the well-known liberal, William Beveridge, who first conceived the idea of an NHS.’ However, Jill Knight (C, c955) pointed out that Bevan stated in the 1946 Second Reading debate that: ‘it has been the firm conclusion of all parties that money ought not to be permitted to stand in the way of obtaining an efficient health service’.

46Some of the discussion of principles followed the well-worn path about funding. However, there was also a new element relating to whether the ‘internal market’ broke the principles of the NHS. According to Jerry Hayes (C, c910) a public expenditure White Paper of January 1988 stated: ‘The Government remain committed to the principle that the NHS should be financed largely from taxation.’ Cook (c911) noted that ‘the "largely" had started to disappear’, and pointed to increases in prescription charges of 1,200 per cent and the introduction of charges for eye tests by the current Government.

47Moore (c916) claimed that across the 40 years of the NHS there had been a consistent commitment to the initial underlying aim that access should not be dependent on means, but ends must not be confused with means (c922). Conservatives broadly rejected the insurance-based approach and tax relief for private insurance (Raison c930; Yeo, c939), and there was some support for a specific health tax (e.g. Owen, SDP, c 933-4; Knight, C, c957-8).

48However, they broadly supported the internal market approach of Professor Enthoven (cf Owen, SDP, c933-4). As Maples (C, c974-5) put it, that a free service does not necessarily have to be provided by the state. I believe passionately that we should have a free Health Service, but it does not have to be provided by the state. Moreover, to some extent, ‘that is happening already. It is not a revolutionary idea. For example, in 1985, 28,000 NHS patients were treated in private hospitals.’ Yeo (C, c939) supported ‘a pluralist provision of health care’, with the private sector expanding (cf Knight, c957-8; Roger Sims, C, c968; Gillian Shepherd, C, c980), and supported ‘some slight extension of charging, which is already accepted for prescriptions, to cover hotel services for better-off people; that would appear ‘entirely inoffensive.’ In general, Conservatives stressed their commitment to the principles of the NHS, and stated that they were concerned with means rather than ends (e.g. Whitney, c942; Knight c956; Newton, c988).

49On the one hand, Moonie (L, c939) considered that there had been a surprising degree of consensus about the basic philosophy which underlies the NHS, and acceptance that there would be little change to it. On the other hand, Fearn (c946) argued that the Tory regime did not in its heart of hearts believe in an equitable health service, free at the point of delivery, because it had not committed itself to that principle and had not understood or committed itself to the need to fund the service properly. Challenged to provide ‘one piece of evidence to support his statement that Conservative Members do not believe in an NHS’, he pointed to ‘underfunding’.

50Harriet Harman (L, c983-4) was concerned about beefing up the private sector and marginalising the NHS. She criticised introducing the market into the NHS as competition drives down the quality of care, pointing to evidence from the USA. However, Conservatives appeared to be looking more to Europe than to America. Shephard (C, c980) argued for the need to accept, as our neighbours in Europe accept, the proper blend of private and public sector work. Knight (C, c956) stated that ‘there must be no doubt in this House or elsewhere that I and my hon. Friends are totally committed to the continuance of the Health Service. Never would we tolerate, for instance, the American system. The truth is that for a lot more money the American health service is not as good as ours.’ Whitney (c944) suggested that ‘we forget the USA.’ It was a convention, when defending the Bevanite structure of the NHS, to say, "If we are not careful, we shall end up like the United States." Let us consider instead our continental neighbours, such as France, Germany, Italy perhaps, and the Netherlands.

51Funding yet again formed the main element of stewardship. Conservatives pointed to the record of previous Labour administrations. This included the introduction of charges in 1951 (Moore, c915-6; Newton c987). In particular they contrasted the funding of the NHS by the 1974-79 Labour Government with the current government (e.g. Maples c972). As Michael Fallon (C, c908) put it, the last Labour Government cut the hospital building programme, reduced nurses’ wages in real terms, increased waiting lists, and presided over severe industrial action. They claimed that the current government had a better record on expenditure and activity (e.g. Moore c922; Sims, c967; Shephard c980; Newton c988). Moore (c 915-6) and Newton (c 988) pointed out that on the 30th anniversary of the NHS in 1978, BMA could not even sign a congratulatory note. More broadly, Raison (c928) argued that the achievement of the NHS had taken place largely under the Conservatives.

52Moore (c916-7) stated since 1948 there had been major and phenomenal achievements in the health of our country and in what the NHS offered, with extraordinary changes in the kind of diseases that then dominated debates in the House. TB, diphtheria and polio, all key issues at the time, had now been virtually wiped out. He continued that the NHS had seen a massive increase in the number of patients treated from 2.8 million patients in 1948 to 6.5 million in 1986.

53Raison (c928) stated that the NHS had a notable record of achievement. Simon Burns (C, c977) claimed that it had improved in every year since 1948. Paisley (c963) regarded it as ‘the envy of the world.’ Owen (c932) considered that it gave ‘better value for money than any other health service in the world.’ Knight (C, c956) considered that 40 years on we had a better Health Service than ever before.

54However, in addition to the ‘ever-green’ issue of funding, the on-going NHS Review introduced a new element to the theme of problems. Cook (L, c913) argued that the NHS Review was not undertaken because the Government were anxious to set about improving the NHS, but was born out of panic, as the Government reeled from the publicity last winter about the underfunding crisis in our hospitals, and ‘that crisis remains.’ The term ‘crisis’ was also used by Fearn (c946) and Kinnock (L, c991). However, Owen considered that the NHS is not about to collapse (c935)

55A number of Members across the parties agreed that the NHS was underfunded (e.g. Frank Field, L, c952; Sims, C, c966; Rev. Martin Smyth, c973; Sir David Price, C, c950; Owen, SDP, c932). However, there appeared to be less consensus on the ‘how much’ and ‘how to spend’ questions. Many Conservatives pointed to the large increases in funding since 1948 and under the current Government since 1979. For example, Knight (C, c955) stated that Lord Beveridge thought that the cost of the NHS per annum would fall, but ‘how wrong he and others were.’

56Neil Kinnock (c991) pointed to the view of the BMA and the Select Committee of the need that year for an additional £1-1.5 billion of expenditure to ensure that there would not be a repetition crisis the following year. Price (C, c950) considered that the 2 per cent growth asked for by bodies such as the BMA was not enough. Owen (c 932) pointed out over the last twenty years ago spending on the NHS increased from 4 per cent of national wealth to about 6 per cent, while spending in the USA increased from a little over 5 per cent to well over 11.5 per cent. He argued that over a period of three years or so, we should aim to increase the spending on the NHS as percentage of national wealth by a full 1 to 1.5 per cent to 7.5 per cent., which will bring us nearer the average figure for Western industrialised democracies.

57Price (C, c950) pointed to exponentially increasing demand. Moonie (L, c940) pointed to demographic change (cf Price, c950) and the supposedly inexorable increase in medical technology (cf Sims, c966). According to Health Minister, Tony Newton (c 989), it has become a cliché to say that the Health Service is in some sense the victim of its own success.

58Conservatives such as Moore (c921-2), Sims (c943), Maples (c972-3), Burns (c978) and Shephard (c980) argued that Labour was wrong to simply call for more expenditure: the problems of the NHS would not be solved by simply throwing money at it (Sims, c943). Whitney (c943) argued that for 40 years problems stemmed from flawed financial and organisational structures. Raison (c 929) considered that while there must be an additional injection, the funding problem is only a part of what we must face.

59Other problems included substantial waiting lists (Owen, c932); monopolistic structure (Raison, c929); being monolithic and centralised (Eric Forth, C, c981); being largely a sickness service (Moonie (c940); lacking autonomous local hospitals (Whitney, c945); and having centralised rather than localised services; large rather than small services; distant rather than and local services. (Price, c950).

Fiftieth Anniversary

60According to Klein (2013) Labour claimed in the 1997 Election campaign that there were ‘14 days to save the NHS.’ The landslide Labour victory saw ‘the politics of the third way’ (ch 7). The White Paper ‘The NHS. Modern. Dependable’ (Secretary of State for Health 1997) contained a Foreword by Labour Prime Minister Tony Blair that stated that creating the NHS was the greatest act of modernisation ever achieved by a Labour Government.’

61On this occasion, the reference to creation was used in a ‘defensive’ way by Labour: as Labour created the NHS, you can trust the same Party to modernise it. The Debate on the White Paper was introduced by the Labour Secretary of State for Health, Frank Dobson, who set out the proposals to renew and modernise NHS, which Labour founded (c796). He continued that in 1998 the NHS celebrated its 50th birthday. The Labour party that founded the NHS is now setting about modernising it to prepare it for the challenges of the next 50 years (c798).

62As in the previous anniversary, discussion of principles was partly associated with the internal market. Dobson (c796) stated that Labour would abolish the internal market, because it failed. But the proposals went with the grain, building on what has worked and discarding what has failed: ‘what counts is what works.’ There would be a third way—a new model for a new century. He explained that while the separation between planning and providing services would be retained, competition would be ended, and short-term contracts would be replaced with long-term agreements (c796-7).

63For the Conservatives, Maples (c799) welcomed the Government’s acceptance of many of the principles of the internal market, which ‘builds on principles that were established by our reforms.’ However, Simon Hughes (Liberal Democrats, c803) considered that the internal market was not being abolished: if there are purchasers and providers, and if there are contracts—even if they are called service agreements—the reality is that there is a market. Dobson (c804) replied that there was no internal market: there cannot be a market unless there is competition, and there is not going to be competition. For Labour, Ivan Lewis (c808) claimed that the only basis for the competition in the health service under the previous Government was that they were preparing it for privatisation. Dennis Skinner argued that the NHS was on its way to the hands of insurance companies and other speculators, which would probably create a service costing twice as much and similar to that in America (c809).

64The theme of stewardship was also raised in a defensive way by Labour. Dobson (c796) stated that the White Paper was a turning point for the health service. This Government were elected to save the heath service, and to change it for the better. The plan was to give our country a modern and dependable health service that would be once again the envy of the world. We will continue to raise spending in real terms every year on the health service (c798).

65However, the Conservatives attempted to use discussion of stewardship in offensive terms, pointing to increases in funding and activity under their term of office. Maples (c800) asked if Dobson could promise that, under Labour, the number of qualified nurses will increase by at least 3,000 a year on average, as it did under the former Government; that the number of in-patient and day cases treated will increase by an average of more than 4 per cent a year; and that the increase in NHS funding would beat the previous Government’s record of more than 3 per cent a year in real terms?

66Former Health Secretary, Virginia Bottomley (C, c805) pointed out that the last Conservative government increased funding by an average of 3 per cent in real terms over the past 18 years, but Labour was looking at 1.7 per cent. She continued that the only specific target announced so far was to take 100,000 people off the waiting lists, but that was followed by the biggest increase in the number of people on waiting lists that the NHS has ever known.

67There appeared to be little discussion of achievements in the debate, with more discussion on problems. Dobson (c796) argued that the Conservative internal market was wasteful and bureaucratic. The White Paper proposals would break down the Berlin wall between health and social care, so that patients get swift access to care and treatment rather than being passed from pillar to post. Maples (c799) pointed out the difficulties of achieving policy objectives in the context of an aging population, medical advances, rising expectations and limited money. Dave Hinchliffe (L, c802) pointed to the problem of fragmentation under the internal market, and considered that historically, one of the most damaging decisions for health care in this country was the 1974 Conservative reorganisation that removed from local authorities the public health function and started to create the confusion that has reigned ever since on the issue of social care and health care.

Sixtieth Anniversary

68The ‘politics of reinvention’ (Klein 2013, Ch 8) took the story to the end of the Blair premiership, while the ‘the politics of transition’ (Ch 9) covered the Brown premiership, which was a period of transition from political stability to political uncertainty, from an era of optimism about the economic future to one of anxiety, and also a period of transition for the NHS: from market creation to market shaping. There was a brief Debate on the NHS 60th Anniversary on 3rd July 2008, but we focus on the longer debate of the Opposition Day. The Shadow Secretary of State for Health, Andrew Lansley (c 216) moved that this House celebrates 60 years of the NHS.

69The Shadow Secretary of State for Health, Andrew Lansley aimed to invent a consensual creation for the NHS. He (c216) wished to conduct the Debate ‘entirely in the spirit in which the NHS was created… In a spirit of consensus, I will acknowledge that the NHS was inspired by the work of a Liberal, William Beveridge, designed by a Conservative, Henry Willink, and implemented by a socialist, Aneurin Bevan.’

70He was challenged by Jim Devine (L, c217) who cited the 1946 Debate, and asked ‘When did the Conservative party start supporting the NHS?’ Secretary of State, Alan Johnson (c226), stressed that in 1946 the Conservatives voted against the NHS at every stage (cf Stephen Hesford, L, c237). However, Simon Burns (C, c246) pointed out that he was not even born in 1946.

71Lansley stated that NHS principles are unchanging, and ‘I do not believe that we disagree about the principles.’ However, there were differing views on the policy direction of the NHS (col 223).

72Labour’s Jim Devine (c227) asked if Conservative Members might say whether they are covered by private medical insurance. ‘The difference between Conservative and Labour Members is not only that we created the NHS, but that we actually use it, too.’ Burns (C, c227) countered that the Conservatives have supported the principle and the exclusive use of the health service ever since we were born. However, Johnson (c228) pointed out that every single Conservative Member won their seat on a manifesto that supported the NHS to such an extent that they would have paid people to leave it. Dorrell (c243) claimed that in 2008 the NHS ‘is built on a political consensus that includes every single Member of this House from every party’. He continued that ‘as we look forward to the next 60 years of the health service, I hope that we can move on from silly arguments about who is committed to it. Over 60 years, we have all been committed to it, and we all remain committed to it’ (c246). According to Shadow Health Minister, Stephen O’Brien (c249), Conservative Members were unequivocal advocates for and supporters of the NHS.

73Lansley stated that ‘in the 60 years since the establishment of the NHS, it has been under the stewardship of Conservative and Labour Governments—Conservative Governments for 35 years and Labour Governments for 25 years. Lansley (c228) pointed out that since the 1950s, the year in which the largest reduction in NHS spending took place—a reduction of 2.9 per cent in real terms—was 1977-78, under a Labour Government. Burns (c239-230) reminded Labour that it first introduced the charges for prescriptions and dental and eye care, which led to Wilson, Freeman and Bevan resigning from the then Labour Government: it may have set up the health service, but they brought in financial cuts that led to three Cabinet Ministers resigning.

74For Labour, Hesford (c237) pointed out that the Churchill Conservative government in the 1950s were still so “dischuffed” with the NHS that they set up the Guillebaud committee. The Conservatives hoped it would say that the NHS was too expensive, but Guillebaud said that the NHS was very good value for money, and so the Tories were stuck with the NHS. ‘I submit that they have never properly digested that lesson.Ann Keen, the Parliamentary Under-Secretary at the DH, pointed out that people died on waiting lists for cancer, hip and heart operations in 1997 (c245).

75Discussion of achievements saw a reference to a number of different elements such as international comparison, and improvement in terms of health status and the delivery of health care. Lansley argued that ‘internationally, we can see that we have a treasure in the NHS’ (in the sense of its principles). The NHS has exhibited continuous gain, from the point of view of the people of this country (c217). Dorrell (c243) stated that there has been an improvement in the delivery of health care in Britain over the past 11 years, just as there was during the previous 49 years. A year-by-year improvement in the delivery of health care is the consistent story of the NHS since 1948. According to Johnson (c231), ‘the NHS was in rude health: we no longer debate its survival, but its continuing success.’

76Conversely, discussion of problems involved both international comparisons, and reference to operational efficiency in terms of the link between financial inputs and outputs and outcomes. Lansley (c222) and Dorrell (c222), pointed to poor international comparisons. Norman Lamb, (Lib, c235-7) praised Labour for its increase in expenditure, but criticised the NHS for being ‘ludicrously over-centralised’, with dreadful waste and inefficiency and an absolute failure to let go a democratic deficit. Conservatives pointed out Labour’s large increases in NHS expenditure had not resulted in proportionate increases in outcomes (e.g. Dorrell, c222, 243). Peter Bone, C, c253) pointed to the Government’s missed opportunity: while doubling the amount of money spent on the NHS, they have increased output by only 29 per cent.

Conclusions

77Writing on the 60th anniversary of the NHS, Timmins (2008) noted that his brief history of the big anniversaries demonstrates ‘plus ça change’ – that many of the issues that the NHS is grappling with right now, and will continue to grapple with, always have been there. Factors such as the longstanding pressures of medical technology, ageing populations and rising expectation, the question of whether the NHS has delivered enough for all the extra spending, and the mere fact that old arguments have not gone away despite the extra cash may explain the intense interest in the 60th anniversary.

78This exploration of political debates associated with NHS anniversaries suggests more nuanced conclusions. Interpretative content analysis of the themes shows that while most debates have discussed most of the themes, their salience has varied over time.

79First, while Labour has always stressed that it created the NHS and the Conservatives voted against it, there is some evidence of an inverse relationship over time in that the further we get from the creation, the more important those become. There was some discussion of this in 1958, but little in 1968 and 1978, before becoming more important again since. The Conservatives appear to have placed greater stress over time on the 1944 Coalition White Paper, and that their votes in 1946 were reasoned rather than wreaking Amendments, based on differing means while agreeing on the end of a comprehensive NHS.

80Second, the debate on principles has continued, but they seem to be rather poorly defined and flexible. At the maximalist end, Labour stressed comprehensive, free at the point of use, equitable, and largely financed from progressive taxation. At the minimalist end Conservatives stressed comprehensiveness and largely free at the point of use.

81Third, in their stewardship of the NHS, Conservatives stressed that they increased expenditure and activity more than Labour; while Labour introduced charges in 1951, and re-introduced prescription charges in 1968. In turn, Labour claimed that Conservatives had not provided sufficient funding; introduced and increased charges; looked to the USA, and aimed to privatise the NHS.

82Fourth, discussion of achievements appeared in two broad ways. The first related to statistics of increased expenditure and activity and falls in deaths, but it may be difficult to associate much of the latter with the NHS as they are part of long-term declines, and declines in deaths from some infectious diseases related to the introduction of antibiotic drugs. The second was based on variants of the ‘best in the world’ claim, largely without much evidence, and sometimes related to an apparent ignorance of other systems.

83Finally, many of the problems seemed to be ‘hardy perennials’: finance, demography, technology, waiting lists, staff shortages, staff morale, reorganisation and the ‘Beveridge fallacy’ of assuming that demand for health care would fall. The term ‘crisis’ was used in 1978 and 1988.

84In general terms, political debates largely squared with Timmins (2008) argument of the ‘best of times and the worst of times’. He wrote that the NHS managed to fulfil Bevan’s great dictum at the time of its launch: “We shall never have all we need … Expectations will always exceed capacity. The service must always be changing, growing and improving – it must always appear inadequate.” However, he also cited the Secretary of the BMA who stated in 1974 that ‘morale has never been lower’, adding ‘almost every day that I’ve reported on the NHS since then, “morale has never been lower” ’. Timmins (2008) is also correct in that ‘old arguments have not gone away.’ Issues such as who created the NHS, funding the NHS, breaking principles appear to be hardy perennials, and are likely to be debated but not resolved, generating more heat than light, on the 80th Anniversary of the NHS.

85Martin Powell is Professor of Health and Social Policy at the Health Services Management Centre, University of Birmingham. He has research interests in the history and contemporary policy of the British National Health Service for over 30 years. His latest book on the NHS is Dismantling the NHS? (co-edited with Mark Exworthy and Russell Mannion, Policy Press, Bristol, 2016).

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References

Electronic reference

Martin Powell, « Parliamentary Debates on the Anniversaries of the British National Health Service 1958-2008: plus ça change? », Revue Française de Civilisation Britannique [Online], XXIV-3 | 2019, Online since 30 August 2019, connection on 20 September 2019. URL : http://journals.openedition.org/rfcb/4133 ; DOI : 10.4000/rfcb.4133

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About the author

Martin Powell

Health Services Management Centre, University of Birmingham

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Revue française de civilisation britannique est mis à disposition selon les termes de la licence Creative Commons Attribution - Pas d'Utilisation Commerciale - Pas de Modification 4.0 International.

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