Allan Massie: The NHS is unchanged

Despite both public perceptions and very real issues, the health service is in as good or bad a shape as it has ever been, writes Allan Massie

NHS creator Aneurin Bevan had expected the demands on it would fall. Picture: Getty

The NHS is in difficulties. It always is. It is said by some to be in crisis. Nothing new there either. It needs reform. It always has.

Faith in the NHS may be, as we are often told, the nearest thing to a religious belief in Britain today, but just as one might think that the Creator might have made a better job of his Creation, so one may hold the opinion that the NHS might be better ordered.

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Criticise it in print, and while many will write to extol the wonderful treatment they or members of their family have received, others will reply that your criticism wasn’t half harsh enough.

All this is natural, and, as I say, there’s nothing new about it. We may value the NHS, but only the most starry-eyed can pretend that it mightn’t be improved.

“There’s nothing sae gude on this side o‘ Time, but it might hae been better,” as Bailie Nichol Jarvie remarked. He was speaking of the Union, but his words may be applied to the NHS, even if you approve of it as he approved of the Union.

I’ve remarked in this column before that the NHS has disappointed the expectations of its political creator, Aneurin Bevan.

He assumed that demand on the service would fall as the nation‘s health improved, and as medical conditions associated with poverty were treated and in time eradicated. This was quite a reasonable assumption in 1947.

In fact, however, the NHS’s success in improving people’s health has led to demands such as Bevan (who himself died in his early sixties) could never have envisaged.

The rate of infant mortality has been sharply – and happily – reduced. Cures have been found and applied for diseases or conditions which used to cause death in youth or middle life, and the consequence is that far more of us live into old age and make even greater demands on the NHS.

Meanwhile, costs rise and rise, and new drugs and treatments which are very expensive may have to be rationed.

Reform is desired by many – and deemed by many to be necessary. Reform is unpopular, and deemed by many to be damaging.


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In any case the effects of any reform are unpredictable, and what at first seems good may have bad consequences, and, of course, vice versa.

No wonder we are confused. We always have been.

In 1988, which is more than a quarter of a century ago, and 40 years or so after the birth of the NHS, the David Hume Institute and the Royal College of Physicians in Edinburgh staged a conference “to discuss the basic issues of financing health services”.

They did so “as the crescendo of parliamentary debate on funding the NHS became more deafening” and they did so because “in Scotland there is a tradition of excellence in medicine and political economy.”

Though neither a medic nor a practitioner of political economy, I was asked by the late Sir Alan Peacock to act as a rapporteur for the conference and to produce a critique of the day’s proceedings. This was published by the Institute as Hume Paper No 9. I have just read it for the first time in many years, and it is a somewhat depressing document. It is depressing because the arguments made in 1988 are still being made today.

Discussion of NHS reform is like a hamster on its wheel; it goes round and round and round.

Distinguished health professionals and economists argued that day about the development of an internal market, about charging, about the role of the private sector within the NHS and about the difficulty of assessing costs and values. And they came to no firm conclusions.

Every reform advocated had its merits, and there were worthy objections to every reform suggested too.

In the last part of my report, which consisted of my reflections on the day’s proceedings, I wrote: “The principal causes of public dissatisfaction with the NHS are the length of waiting-lists, the uncertainty bred by them, and the conviction that hospitals are organised for the convenience of those who work in them rather than those whom they exist to serve.”

I added that: “General practitioners, who in effect act as patients’ agents,” also “find it hard to discover what hospitals plan for their patients”.

I would be surprised if, reporting from a comparable conference today, I didn’t come to similar conclusions.

Yet, on reflection, re-reading my report was more encouraging than depressing, for it made it clear that the NHS is no more bust today than it was then.

Its essential principle has been maintained: that the service should be free at the point of use. It is still financed out of general taxation.

There is still talk of “consumer choice” and this is as misleading as it always was. “A patient,” I wrote then, “rarely chooses, or could be in a position to choose, between two different forms of treatment as he or she might choose between different brands of washing machines”.

It is still the case that, as Robert J Maxwell of the King’s Fund Institute put it, “the easiest way for any NHS hospital to balance its books is to do less clinical work or to reduce standards” and this truth is as unsatisfactory now as it was then.

Prophets of doom always exaggerate. The NHS is imperfect because men and women and all human institutions are imperfect.

Its working could be improved, because pretty well everything is capable of improvement. Yet it continues to function. It’s not going to grind to a halt.

Finally, though private companies may undertake some of its work, the service itself is in no danger of being privatised as long as Aneurin Bevan’s fundamental principle that it should serve all free at the point of use is maintained, and there is no reason to think this more likely to change now than there was in 1988.


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