This starts to move the debate towards the concept of a hypothecated tax. Despite the drawbacks often cited about hypothecation, the British Social Attitudes survey suggests more support for a dedicated NHS tax — an idea proposed by the Liberal Democrats in their manifesto — than paying more through general taxation.
It goes without saying that there is a significant difference between people saying they would be willing to pay more towards the NHS and the reality of them being obliged to do so. However, the trend of opinion identified in the British Social Attitudes survey over the past three years might be taken as a sign that the British public is beginning to accept that it needs to pay more to retain the services it says it wants. The acceptability of paying more taxes has risen by 8 points between and The recent Ipsos MORI poll for the BBC suggests that most people 51 per cent think charging for services that are currently free is unacceptable 37 per cent say it is acceptable but this question only begins to touch on the hugely complex area of what people think the NHS should provide.
The recently launched consultation into whether some products, such as suncream and gluten-free food, should continue to be available on prescription signals a move towards reducing the remit of the NHS. The public is becoming increasingly aware that this debate has to happen. However, it is likely that any acceptable solution will be complex and will come with some form of cost in financial terms, through narrowing the remit of the NHS or in reducing the services provided.
In essence, the challenge facing the next government boils down to two questions: what are people prepared to pay for and how much are they willing to pay? Whether or not the NHS is a decisive factor in determining how people vote in an election overshadowed by Brexit, pressures on services are unlikely to ease and public concern about the NHS will continue to grow the longer these questions are left unanswered.
Something has to give and the next government ignores this at its peril. Public and patient perceptions of the NHS.
A visit to the emergency room or a lengthy hospital stay won't bankrupt you.
Cuts, funding and staff shortages. What do the public see as the solutions to the funding issues? The debate with the public. Related content. To the extent that it can yet be historicised, the Blair era divides into two phases. The first saw a softening rather than rejection of the internal market, with purchasing replaced by commissioning and GP fundholders by Primary Care Groups, and the acceleration of the Private Finance Initiative PFI building programme.
Hitherto demographic data had persuaded government economists that NHS funding levels were broadly correct, and an annual inflator was calculated based on population change, new technology costs and relative price effects. Armed by the state with National Institute for Health and Clinical Excellence NICE guidelines and the National Service Frameworks standards, health service executives now wielded unprecedented power over clinical practice.
Whether or not this policy mix is a new trajectory is uncertain. Webster's history ends in with cautious praise that at least a substantial rise in expenditure has occurred. Opinion is more divided on individual aspects. PPI's recent history has attracted particular interest, with scholars tracking the changing forms, from the Community Health Councils CHCs set up in and abolished by Milburn in , to the use from of focus groups, citizens' juries and opinion polling, and finally to New Labour prescriptions of Patients' Forums and hospital membership communities.
She argues that the founding principles of the NHS are already lost: universalism, through the abandonment of the RAWP and the reappearance of geographical inequities; comprehensiveness, through the cessation of eye services, capping of NHS dentistry and removal of long-term care to the local authorities; and free access, through cost-shifting to patients for intermediate and long-term care, and the routine offer of private elective surgery.
Before turning to historical evaluations of the NHS, we should briefly note three significant areas of the health service which stand somewhat apart from the grand narrative outlined above. The others are the long-term care of psychiatric and elderly patients, where the issue of deinstitutionalisation looms large.
The declinist analysis of public health was established by Lewis in the s, tracing the marginalisation of Medical Officers of Health MOsH , who were victims of restructuring in and , but also authors of their own downfall, failing to forge a new philosophy of preventive medicine relevant to the post-war environment.
A central theme of psychiatry in the NHS is the shift since the s from institutional to community care. This is not a process which scholars have viewed as liberating or humane, nor is there consensus on the cause.
Some, such as Freeman and Jones, regard the old asylums as essentially benign institutions whose demise was due to the unhappy conjunction of Conservative cost-cutting and wrong-headed anti-psychiatry doctrines. A third subaltern history is that of long-term care for the elderly. Here too there is a trajectory of decarceration and community care, and a theoretical framework which emphasises the productionist features of welfare states, with their tendency to allocate fewer resources to economically inactive groups.
Before examining evaluations of the NHS in its different phases, we should first consider a central theme in Webster's analysis: that the NHS has suffered from cumulative under-funding throughout its existence. One approach to this is to take population health as an indicator. On these terms it was initially argued that the NHS was very good value for money, achieving similar mortality rates at a cheaper cost than other countries, notably the United States. Appleby speculates with his eye on the recent past that managerial reform and new incentive structures were generating improvement even in the absence of more cash.
Throughput is a blunt instrument with which to measure total NHS output, revealing nothing of quality and subject to other influences, such as technological advance. Nor is the causal link between rising throughput and post managerialism straightforward, since major productivity growth also occurred in the parsimonious and statist s.
Thus the jury remains out on the under-funding thesis, though en passant we should note that Appleby buttresses Webster's view of the Left's greater financial commitment: up to , Labour administrations consistently spent more on the NHS, increasing funding in real terms by on average 3. Turning now to evaluations of the early period NHS, it is striking that despite the dismissals of contemporary politicians, historians have been generally kind to the Bevan model.
Klein denies the possibility of impartial evaluation, as in the pluralist polity the NHS serves there are multiple and competing criteria. A surprising aspect of evaluations of the post reforms is just how little evidence there is of beneficial change from all the upheavals. Academic evaluation suggests not.
Where do such findings from recent policy analysis leave the historian, groping towards an assessment of the reform era? The achievement was to shift power to primary care providers, to introduce incentives to enhance responsiveness and to make the activities of the service more transparent and measurable than ever before.
The one is pessimistic, viewing the market-infused NHS as fundamentally inimical to the service's core ethic. How will these readings look at the seventy-fifth anniversary? Or will the trajectory of fragmentation and privatisation continue until it entirely overturns the post-war social democratic project? For now, in summer , with the worm turning again in the political and economic cycle, all this is uncertain.
With this in mind, which research areas might future historians of the NHS prioritise? While their predecessors may have recounted its national political history, much remains to be learned of how policy translated into practice. Here the regional study offers rich possibilities for interrogating some of the themes discussed above, such as the balance of power between clinicians and managers, the resourcing struggles between teaching, general and psychiatric hospitals, the changing fortunes of public health, and so on.
The pre period, now so prone to either idealisation or condemnation, particularly deserves attention. Another promising area, not touched on hitherto, is the cultural history of the NHS. Media representations of medicine and health have until recently been a peripheral theme, though a strong case can be made for their centrality in shaping public perceptions and, by extension, political expectations of health services. Much statistical data gathered at regional level await collection and analysis, particularly for the early period.
The shifting boundary between the public and private sector in the NHS, now so prominent and controversial in the policy literature, also cries out for a full historical survey. The questions of equity and efficiency which such studies might address are, as indicated above, central to the appraisal of the service. This prompts a final observation, and exhortation. With several of the NHS's leading historians now in the latter stages of distinguished careers, it is imperative that others come forward to engage with this subject.
If not, institutional memory will remain weak and the tendency to glib caricature will surely intensify.
Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. The First Phase, — New Labour: — Three Subaltern Narratives. Evaluations and Historical Trajectories. Oxford Academic.
Google Scholar. Cite Citation. Permissions Icon Permissions. Summary This article surveys historical writing on the British National Health Service since its inception in National Health Service , historiography , primary care , hospitals , welfare state , policy , financing.
Origins of the NHS
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