From Cradle to Grave

Fifty years of the NHS

King’s Fund Publishing 528 pages pounds25

The NHS is a remarkable, resilient and flexible institution. Despite unremitting criticism that it is bureaucratic, monolithic and slow to change, the NHS has, in fact, displayed impressive adaptive qualities that would be the envy of any organisation, public or private. That it has survived more or less intact for 50 years in a form that its architect, Aneurin Bevan, would still recognise is evidence of the robustness of its design.

A remarkable institution which has confounded most of its fiercest critics demands a remarkable chronicle of its achievements and failures. Geoffrey Rivett’s thorough and - within the confines of a single volume - comprehensive review probably comes as close as it is possible to get to documenting the evolution of the NHS from its beginnings to the present.

During its half-century, the NHS has survived numerous seismic social and economic changes. These are nicely juxtaposed against key developments in the history of the NHS at the start of each of the five chapters chronicling the five decades of its existence.

It is surely a mark of the inner strength of the NHS as an institution and a concept that it has survived with its founding principles not only intact, but still espoused by politicians of all hues. Even during its most right-wing phase, the 1979-97 Conservative government could not rid itself of the largest and most enduring public monopoly of all.

The secret ingredient of the NHS’s durability is its continuing appeal to the majority of the British public. If its public support were ever significantly to deteriorate, then its survival would be seriously in doubt.

Rivett does not ignore or understate the deep changes which have occurred since 1948. As he notes, ‘the NHS was the political creation of a particular epoch’ - in particular, a post-war collectivism which seems particularly anachronistic in an age of rampant individualism and instant gratification. This is what JK Galbraith has perceptively termed ‘the culture of contentment’. The very survival of the NHS in such a context represents a supreme paradox which is hard to comprehend, let alone explain.

As Rivett, in his even-handed account, makes clear, the NHS - or ‘great venture’, as he puts it - did not turn out quite as predicted. It has not solved the problems of inequity. Healthcare, rather than the pursuit of improved health, has dominated the agenda. The priority accorded to the so-called ‘Cinderella’ sectors by successive governments has been long on vision and promise but short on delivery and solid achievement. Yet it is easy to be critical of the NHS. Indeed, in one of the most perceptive observations on the NHS and its operation, former health minister Enoch Powell claimed that the service suffered from a fatal structural flaw - the incentive always to denigrate it in the hope that new resources would be forthcoming. To praise the NHS was seen to be a grave tactical error in negotiations with the Treasury.

For all its failings and shortcomings, the NHS has many positive achievements of which it can be proud. Bevan’s main aims have been achieved. These centred on removing the fear that care during illness would be unavailable and/or unaffordable. Reviewing the balance sheet, Rivett concludes: ‘The overall verdict on the NHS must be positive.’ It is important to remember this as the NHS enters its second half-century.

But if the high politics surrounding the NHS have been largely, though by no means wholly, successful, the same cannot be said of the low politics. At a micro-management level, the NHS has been less successful. Paradoxically, the US ‘non-system’ of healthcare which represents all that the NHS has sought to eradicate has been more successful at this micro-level. Had it sought to focus on this dimension, the NHS could have been even more successful. Structurally, it is tailor-made for effective management at a micro-level. But in its approach to the medical profession and the effectiveness of interventions, the NHS has proved somewhat feeble and wimpish.

Moreover, despite its strong public health tradition, the NHS has singularly failed to capitalise on it, thereby contributing to a loss of direction on the part of public health and a seeming inability to undertake proper health needs assessment. Indeed, it is this continuing failure which has led the government to refocus the NHS on a public health agenda through its commitment to intersectoral partnerships operating through health action zones and health improvement programmes.

Of course, not all the problems with which the NHS has to contend are as old as it is. Many are a product of its successes. The challenge posed by an ageing population is an obvious one, although, without in any way being complacent, we should see this development as a success.

The NHS is an example of an organisation which has survived through a mix of pragmatism, incremental change and a certain amount of muddling through. The mix may be far from perfect, but it has served the organisation rather well. We should exercise great care before disturbing the complex organisational, managerial and professional features which underpin the NHS’s ability to survive through hostile and difficult times as well as good ones.

There is much wisdom and sound common sense in Rivett’s analysis of the NHS’s evolution. As he states: ‘There is no ideal and trouble-free pattern of provision that can simultaneously provide comprehensive care to all, free of charge to the individual, at a cost society can afford, satisfy queues, meet professional aspirations and provide a basis for teaching and research.’

Of course it is precisely for these reasons that the NHS’s critics say the institution is no longer sustainable. While we may have coped hitherto, the juggling act cannot continue indefinitely. The pressures, especially the clash between collectivism and consumerism, are becoming intolerable.

All healthcare systems involve a series of trade-offs and compromises. Some juggling is therefore inevitable in the search for solutions to problems for which there is no final solution. The policy dilemma is whether a better way exists or whether we must be vigilant about the capacity of the NHS to adapt to find the best possible trade-off between what will always be competing objectives.

The government, in its NHS white paper and related public health initiatives, thinks that it has found a way forward that will take at least 10 years to enact.

Making an apparently unworkable system work has been the unique achievement of the NHS. In the current climate of explicitness, transparency and openness, we should not forget the importance of less fashionable attributes, including an acceptance of ambiguity and paradox, making a virtue of muddling through and occasionally fudging the hard choices. Through such means, complex organisations can function in complex settings rather than seize up.

Although Rivett concludes his epic review on a rather pessimistic, if all too predictable note, and warns that it may not be possible to maintain a comprehensive NHS for a further 50 years, we should also acknowledge the consequences of its demise. Society will be the poorer, and in its absence the NHS may have to be reinvented. That, after all, is how the NHS came into being in the first place.

DAVID HUNTER

Professor of health policy and management, Nuffield Institute for Health, Leeds University.