Guest blog: What is the N in the NHS?

Since 1948, the entire population of the United Kingdom has benefitted from universal and (mostly) comprehensive healthcare, free at the point of delivery. Conventionally, we refer to the provider of these benefits as the ‘National Health Service’. This name, used in Labour Party propaganda and political speeches since the 1930s, was chosen by its founders in part to reflect the changes in medical provision that the new system was intended to ensure.

Prior to this, services were fragmented, variable and often unequal – and they were reliant on a patchwork of charitable, philanthropic and governmental funding. In contrast, the new NHS was to be ‘an all-embracing comprehensive scheme to bring all that modern medicine can bring on the preventive and curative side within the reach of everyone’ (Griffiths 1942). With these words, Welsh MP James Griffiths described his vision of a national health service to Parliament in 1942, as the UK experimented with national medicine in response to the duress of World War Two.

The NHS was to be more than just a service, however: a united system of healthcare – ‘a big comprehensive system’ – was explicitly intended to support Britain as a ‘united nation’ in the face of an existential threat (Beveridge 1942). William Beveridge’s famous 1943 report, too, spoke of a national health service as a feature of his plan to ensure ‘social security’ for all (though he envisioned it rather differently). Either way, this vision of a universal comprehensive service was set out in the government’s white paper and the 1946 National Health Service Bill.

In reality, however, there has never been one single national health service in the United Kingdom. Even the primary legislation that established the health services between 1946 and 1948 distinguished Scotland and Northern Ireland from England and Wales, and in the succeeding seventy years, the medical and health services provided for and in the four home nations have diverged significantly, catalysed further by devolution in 1998.

Yet medical and health professionals, the media and the public still consistently speak of a singular ‘NHS’. This is not because commentators are unaware of the differences between the English NHS, NHS Wales, NHS Scotland, and the HSC in Northern Ireland, but because for most people there is one fundamental feature that all four health services share: they are intended to provide equal and universal access to health and to the care needed to maintain or restore it.

This idea of Britain’s health services as, in language of the day, ‘equalitarian’ – as a force for ensuring equality regardless of economic ability or geographic location – have, since 1948, been at heart of not just of popular visions of the NHS, but of British national identity.

As that identity has waxed and waned in strength, so interpretations of diversity and difference in local and regional provision of NHS services have changed, at least in the eyes of politicians and policy makers. Indeed, the devolved nations – and more recently proponents of regional health devolution – have demanded the freedom to set local priorities, to fund (or, though rarely explicitly, de-fund) specific treatments, and to restructure provision based on knowledge gained closer to the communities served.

However, even prior to devolution to Scotland, Wales and Northern Ireland in 1998, and Greater Manchester in 2015, medical provision in the NHS has been sensitive to local and regional differences, not least because of the enduring role of local authorities in meditating or providing public health and what are now termed ‘social care’ services.

So what is in fact ‘national’ about the NHS?

It is perhaps easiest to identify deeply rooted expectations and understandings of the British health services as national and basically homogenous by looking at public reactions to regional variation, or – as they are most frequently described and reported in the media – to ‘post code lotteries’.

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From its inception in 1948, universal and comprehensive health provision in the UK was an aspiration rather than a reality. The founders of the health services were acutely aware that medical resources were unevenly spread across the country: large regions of the country were desperately ‘under-doctored’; specialist and teaching hospitals were heavily concentrated in urban areas and especially London; and general hospitals, while more evenly dispersed, were certainly unequal in terms of facilities and equipment.

In the first three decades of the NHS, the central health authorities – the Ministry of Health and its successors – and interested parties across the UK struggled mightily to redress these points, both formally through the Resource Allocation Working Party, and informally through a range of direct action health activist groups, regional lobbies, and professional pressure groups.

Thus, by the 30^th anniversary of the NHS, stark inequalities in access to basic services had largely disappeared, though the same could not be said for specialist care, where ‘scandalous’ differences in waiting times for investigation and treatment still existed between the South East and the rest of the country. Here, hostile references to a ‘lottery’ in access to medical care, though rare, first appear in political rhetoric and daily life.

Indeed, it was a point of near-consensus in UK politics that the remaining differences were unacceptable, and required amelioration – usually in the form of centralisation (Kilroy-Silk 1978) – rather than acceptance even in a period of budget-cutting. Variation was ‘discrimination’, and challenged the very idea of a ‘truly national health service’ – instead of ‘a series of regional health services in which there are huge discrepancies and enormous anomalies as between areas in the type and quality of service.’

With the 1980s, however, different forces came into play: the internal market, GP fundholding and devolution all played a role in shifting professional and political attitudes towards diversity in provision within the broad context of a universal health service. What these changes did not shift were public attitudes towards ‘inequality’ in access to health services.

By the 1990s, both parliamentary debates and the national press began to record significant public unease with exactly the local and regional variations that inevitably emerge from the turn towards local decision-making. The ‘post code lottery’ in healthcare became a familiar and well-recognised issue. As a result of this, campaigners started to mobilise on a national level, in defence of the whole NHS, rather than through small and fragmented local groups.

Intriguingly too, local intolerance of difference extended far beyond the sphere of life-threatening variability in access to expensive cancer drugs or cutting edge surgical treatments. Patients were, it seems, equally unwilling to accept differences in access to infertility treatment, specialist allergy advice, experimental flu drugs, non-emergency prostate operations, and mental health care. But these were exactly the areas – non-life threatening, affecting relatively small populations, and providing few directly quantifiable improvements in health outcomes – in which local diversity had been seen by experts as most acceptable.

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As then-political commentator Peter Riddell complained in the Times in 2000, ‘Whenever a national politician talks about local diversity, choice and decentralisation, it is usually humbug. Often the same politician will simultaneously deplore the ‘postcode lottery’ of the services. The contradiction does not occur to them… As important is the belief in national equity and universal access to services.’ Moreover, Riddell argued, protests against what he called ‘postcode rationing’ were entirely understandable given that the NHS was funded through national taxes, and local authorities thus had ‘no real political or democratic legitimacy.’The only ‘equitable’ solution was ‘the man in Whitehall’ (Ridell 2000).

What we have seen since the 2000s, especially as UK residents and citizens look across the borders between England and the devolved nations, is that even when local decision-makers have electoral mandates and direct and indirect fundraising powers, their constituents are no more tolerant of local variations that mean their neighbours can access services unavailable to themselves.

The emotional politics of NHS reform are important: indeed, Ed Smith, chairman of NHS Improvement, has argued that while implementing STPs locally, we must ask people, ‘how do you feel about the NHS?’, and see local populations themselves as STPs, or ‘Sensing Thinking People’ (Smith, 2017).

As we look towards greater health devolution, it is not at all clear that the central tension between the provision of locally responsive health services and of nationally equal ones has been resolved, or is even capable of resolution in a democracy where voters may support the localism of ‘more and closer’ in relation to healthcare, but show no signs at all of accepting that local decisions to provide one set of services, treatments or facilities may mean limitations to another.

What is national about the NHS – the egalitarian meaning with which we have imbued the health service since 1948, and on the basis of which it remains the most loved of UK institutions – may also prove to be the greatest cultural challenge to its successful devolution.