Letter from Glasgow

THE NATIONAL HEALTH SERVICE: 70-YEAR-OLD

On 5 July 1948, 11 months after India’s tryst with destiny, the UK had its own tryst with destiny in the form of the National Health Service (NHS). On that date, the NHS came into existence. Knowing why and how it was born provides lessons for us today.

It was the Beveridge Report, published in 1942, that laid the foundations for the welfare state, including the NHS, in the post- Second World War period.^[1] The Report’s author, William Henry Beveridge, was born in India in 1879 where his father was a judge.^[2] After he trained as a lawyer, he joined the UK Board of Trade, becoming an expert on employment and social security. He went to London School of Economics and then University College Oxford, before joining the wartime government in 1940. In 1942, the report which bore his name was published. In later life, he became a Liberal Party Member of Parliament in the House of Commons and, subsequently, a Liberal Peer in the House of Lords. He died in 1963.^[2]

The Beveridge Report reflected the experience of the UK of the economic depression of the 1930s, the solidarity fostered in the war against Nazi Germany, and the hope of better things to come after the war.^[3] In addition, during the war the Emergency Medical Service (EMS) was established in the UK. The EMS was planned nationally to treat the large numbers of casualties, but it also helped people recognize the need for an effective health service for the whole population.

The Report was hugely influential and, in summary, it intended to remedy the five scourges facing the UK of ‘want’, ‘squalor’, ‘idleness’, ‘ignorance’ and ‘disease’. These were to be tackled by, respectively, providing a social security safety net, improving housing and the environment, ensuring employment, improving education and providing a comprehensive health service. The principles of the Report were as follows:

• First, that the past should not constrain the future, including the vested interests of groups, for example, with regard to healthcare, this includes general practitioners and consultants who could have agitated against change.
• Second, tackling ‘want’ was only one element of a comprehensive policy of social progress. The other elements of ‘squalor’, ‘idleness’, ‘ignorance’ and ‘disease’ also needed to be tackled as an integral part of comprehensive social welfare.
• Third, that social security could only happen if there was cooperation between the State and the individual, as exemplified in the field of healthcare by the creation of the EMS.^[1]

To enact, the Beveridge Report required political will and skill, and in 1945, the election of a Labour Government in the UK ensured that this happened. With regard to healthcare, despite opposition by the British Medical Association, the Minister for Health, Aneurin Bevan showed the drive and political nous to legislate for, and create, the NHS.

Seventy years on, the NHS is, rightly, regarded as an important part of life in UK. The NHS regularly features as a key trusted— and loved—institution, and it was highlighted prominently in the 2014 Olympic Games’ opening ceremony in London. Even then, it still had the ability to stir political discord among politicians.^[4] For the resources the UK spends on healthcare (approximately 9% of its gross domestic product [GDP]), it consistently comes up well in terms of accessibility, effectiveness and efficiency internationally when compared to similar high-income countries although there is ‘room for improvement’ as the Health Foundation states.^[5]

More recently, on the 70th anniversary, the BBC commissioned a report from the King’s Fund, the Health Foundation, the Institute for Fiscal Studies and the Nuffield Trust. These four bodies were asked to review and compare the NHS with health systems in other high-income countries, and answer five questions including ‘how good is the NHS’.^[6] The answer is ‘a mixed bag’ with the NHS: having very good access to and equity of care; lagging in preventing common causes of death such as cancer and good at treating long-term illnesses such as diabetes and kidney diseases. As expected, it has fewer health professionals, hospital beds, CT and MRI scanners than other high-income countries reflecting the lower GDP proportion spent on healthcare in the UK.

On the 70th anniversary, there have been other polls including whether the UK public would pay more tax to fund increased expenditure for the NHS (yes, they would they say), and stories from staff and the public of their experiences of the NHS over the past 7 decades. Not to be left behind, the British Medical Journal ran a poll in which readers could vote on a shortlist of 12 nominations of the greatest achievements of NHS .^[7] These included general practice as the foundation for patient care, working for the common good, championing evidence-based medicine, leading the world in cost-effective healthcare, free contraception for all women, encouraging and supporting research and innovation, comprehensive childhood vaccination, raising the status of anaesthesia, promoting patient-centred care, access to in vitro fertilization and limiting commercial influence on patient care. The one I have left out—and voted for—was care based on need and free at the point of delivery.

For all the faults of the NHS—and in a complex organization, there are always problems—we should remember that it provides primary, secondary and tertiary healthcare 24 hours a day and 7 days a week for the UK population of 66 million people. The paramount principle is that if you need care, you will get it irrespective of what you have contributed financially, based on the care you need and not what you can afford. It is about solidarity between people and of sharing risk at a national level. The NHS still has key issues to tackle as noted above and also others such as variations in outcomes and quality of care, social and health inequalities, prioritizing prevention and public health, and deficiencies in the links between healthcare and social care.

The UK is different now from 1948—it is richer, is a multiracial society and has lost a large part of its heavy industry to mention just 3 aspects. We all sometimes think that what we know and have is best. I am not saying the NHS is the best or only way, merely that it is a humane example of using resources wisely and providing effective healthcare over the past 70 years. How the NHS responds to its challenges requires not only increased funding to provide effective healthcare but also renewed political vision, will and skill so that the NHS continues to evolve based on the principle of need and being free at the point of delivery. Perhaps, we need a ‘Beveridge Report for the 21st century’ for social welfare, including healthcare, to show the way.

Conflicts of interest. None declared