A still from the film Life in Her Hands (1951)
FIRST PRINCIPLES OF THE OLD NHS
My previous article, based on the book The Plot against the NHS by Colin Leys and Stewart Player, was an attempt to understand how, under New Labour, market principles were insinuated into the National Health Service. But before going any further along this line something should perhaps be said about what the NHS was prior to this process beginning. In what follows I am drawing on three chapters (2-4) of Stephen Harrison's book National Health Service Management in the 1980s as reproduced on the website of the Socialist Health Association.
Chapter 2 provides an 'Overview, 1948-82'.
The basic principle of the NHS was of course the provision of a free service which would be paid for out of general taxation. To quote Julian Tudor Hart (A New Path Entirely - how NHS Wales could lead the world, paper presented to a Bevan Commission seminar, 2012), 'Nye Bevan seldom let principles get in the way of a better life, either for his fellow citizens or for himself ... [His strategy was] to end trade in healthcare as a profitable commodity, and develop an organised gift economy, paid for by everyone according to their wealth and given to everyone according to their need. Sickness was a matter of chance so in a just society, costs of care should be borne by everyone, sick or well.'
The 1948 NHS had a 'tripartite' structure - primary care, community services and hospital centres.
'In the case of primary care, General Medical Practitioners (GPs), General Dental Practitioners, Pharmacists, and Opticians were self-employed practitioners whose contracts were administered by Executive Councils upon which the four professions were themselves heavily represented. This arrangement differed little from that made following Lloyd George’s National Insurance Act of 1911. The staff of the Executive Council, whose role was to maintain GPs’ lists of patients and to receive practitioners’ claims for payment, was headed by an Administrator with managerial control only over the staff, not the practitioners.'
Community services were provided by County Councils and County Borough Councils which 'lost their former duties and rights to provide hospital services, remaining responsible for preventive services, maternal and child welfare, health visiting, home nursing, ambulances, and the school medical service. Such local authorities appointed a health committee of councillors, to whom the Medical Officer of Health (MOH) was responsible for the above services.' Julian Tudor Hart (who was introduced in the previous article), regretted that these services had been left with local government: 'This separated preventive from treatment services, which progress in medical science had been bringing together.'
As for hospitals:
'Hospital authorities constituted the third part of the structure. Great Britain was divided into nineteen (later twenty) Regions, each containing a medical school and each controlled by a Regional Hospital Board (RHB) responsible to the Minister of Health. Groups of hospitals (occasionally single large hospitals) within each Region were presided over by Hospital Management Committees (HMCs) or Boards of Governors in Scotland. Groups of English hospitals with medical undergraduate teaching functions were run by Boards of Governors, who, unlike HMCs, were responsible not to the RHB but directly to the Minister of Health. The membership ol Boards and Committees was part-time, honorary, and appointed rather than elected: doctors were heavily represented. Boards and Committees employed a chief administrative officer (often known as the Group Secretary), and individual hospitals were normally managed on a day to day basis by a triumvirate consisting of Hospital Secretary, Matron, and Medical Superintendent or medical administrator.'
The perceived problem with this was the power and independence of the doctors, one of the conditions for getting the support, or acquiescence, of the BMA, but also a deeply held belief that 'it was neither appropriate not praticable to seek managerial control over doctors ... the 1944 Coalition government White Paper on a National Health Service stated that "whatever the organisation, the doctors taking part must remain free to direct their clinical knowledge and personal skill for the benefit of their patients in the way in which they feel to be best."' And this view was not challenged by Bevan.
As a result there was very little co-ordination between the different responsible bodies and very little scope for overall planning. Harrison calls the administrators in the system 'diplomats', primarily concerned with smoothing relations between the professionals, and comments (quoting a report he himself had written in 1979): 'In the context of diplomacy there is rarely a meaningful overall objective; more often there is a set of partially, or sometimes completely, contradictory objectives held by groups or individuals.'
In 1974 there was a reorganisation begun by the Conservative government but continued by Labour when the existing Regional Boards were reorganised, or renamed 'Regional Health Authorities' which then supervised 90 Area Health Authorities, which in turn supervised 2015 District Health Authorities (reduced by 1979 to 199). At the same time the 'Executive Committees' responsible for primary care (GPs, dentists, opticians, pharmacists) were replaced by 'Family Practitioner Committees', appointed, not elected, by various concerned bodies including the Area Health Authority and the Local Authority. Harrison comments that:
'In hospital medicine too, doctors were not challenged by the formal organisation, which ... remained collegial in character throughout the period under examination. The clearest manifestation of this was the creation in 1974 of consensus teams: a means of providing the formal right of veto to a group which possessed it in practice anyway. Although the post-1974 Health Authorities had a smaller medical membership than their predecessors, this was more than compensated by the formal involvement of doctors elsewhere in the management structure. It is significant that consultant contracts of employment remained at RHA [Regional Health Authority] level, (except in the case of Authorities responsible for undergraduate medical education), and that no attempt to introduce American models of hospital management by clinical ‘chiefs of service’ was made. Indeed, hospital beds were allocated to individual hospital consultants in a form of quasi-ownership, giving the individual virtually unilateral control over their use and utilisation. Moreover, the right to engage in private practice, a major source of uncertainty for managers, was retained, and indeed was enhanced in 1980 (when it was extended to include consultants who were full time employees of the NHS - PB).