Continuing the retrospective season on the NHS's half- century, and hard on the heels of Geoffrey Rivett's From Cradle to Grave , comes this slimmer, but no less informative and insightful, political history of the service. The book breaks little new ground, covering material already available elsewhere, much of it contributed by the author. Its chief virtue lies in its accessible and succinct synthesis of a vast volume of material.
Webster's account 'concentrates on points involving political controversy and central issues of policy-making', and draws attention to the topicality of many of the issues which have so vexed policymakers for 50 years. The target is New Labour and its stewardship of the NHS. For Webster, 'history both highlights errors that have been made repetitively and reveals potential solutions that have sometimes remained long neglected'.
There are two recurring themes that have plagued the NHS from its inception. First, the under funding of the service was a fundamental flaw from the outset, and second, the inequalities and variations which the NHS was established to address remain largely untouched. The position of the vulnerable and disadvantaged is not so different from before the existence of the NHS.
For all its considerable strengths, Webster's account leaves the reader slightly confused. On the one hand, the NHS remains a much respected, if not revered, national institution which 'represented an enormous improvement on the ramshackle assemblage of health services that it superseded'. On the other hand, it has been a spectacular failure marked by 'a policy track record that has shaken a great public service to the point of breakdown'. As a result, it now 'risks the fate of Eastern Europe, a worst-of-both-worlds situation, comprising a defective socialised system, with no viable private-enterprise alternative within reach of the greater part of the population'.
It is hard to reconcile these differing perceptions unless the NHS's popularity and value arise from little more than a deep-seated psychological need. Its mere existence takes the anxiety and worry out of healthcare problems for many patients. Yet surely there is more to the NHS than this?
Webster offers a gloomy and depressing scenario. Perhaps he is deliberately indulging in shock tactics in the hope that this will jolt New Labour into action. The New NHS white paper appeared too late for comment, so whether the government's prescription for change will suffice is not known. Probably not, since the solution, in Webster's view, lies in additional funding and inspired political leadership of a kind not seen since Bevan. In their continued absence, Webster predicts 'disastrous consequences for social solidarity and cohesiveness'.
Yet there are countervailing arguments, only briefly mentioned in this account, to be considered. For instance, comparisons with other countries are of limited use when like is not being compared with like. Moreover, when total spending on healthcare is analysed, levels of public spending are not so dissimilar across European countries, including the UK.
What is strikingly different, and accounts for the overall difference between UK spending and that of most other countries, is the level of private spending on healthcare. It remains low in the UK.
An unstated assumption in the book is that countries enjoying higher spending on healthcare are somehow free of the pressures bearing down on the NHS. But this is not so, as the outbreak of healthcare reform across countries, largely driven by a cost containment agenda, amply demonstrates.
There is remarkable convergence across countries concerning the policy puzzles with which they are wrestling, notably resource constraints, hospital closures, rationing and so on. Nor has any country been any more successful at putting health before healthcare. These problems may be more acute in the NHS as a result of the resource pressures, but it may also be that the NHS offers a potentially more effective instrument for tackling them than the arrangements prevailing in other countries.
These issues go deeper than the mere availability of funds. As Webster acknowledges, since the beginning of the NHS, 'substantial resources are being wasted on expensive hospital facilities on account of the failure to provide much cheaper support within the community'. Many commentators would agree and argue that it therefore makes little sense to inject further funds into the NHS without tackling the issue of the uses to which those resources are to be put.
The NHS may be conceptually and structurally flawed by constant political meddling. Under enlightened political leadership this could be seen as a strength, but in its absence it is a recipe for weak strategic direction and bad management. Perhaps the time has come to be radical and to reconsider, in the context of devolution and regionalism, the local government option rejected by Bevan in 1946. Crucially, and often overlooked, Bevan did not rule out this option indefinitely. Strong and revitalised regional and local government, truly accountable to local communities and committed to a public health approach, could offer hope that those deep-seated inequalities which have long defeated the NHS might be successfully tackled.
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