Thirty years of the NHS
Enoch Powell
An American a few days ago asked me how different it would have been if there had never been a National Health Service. He was horribly disappointed, poor fellow, When I told him that it would have been barely different at all. He asked me what I meant. Had not the health service brought medical care within reach of the poor? I told him that the proportion of the national income (assuming one deals in such tomfoolery) devoted to medical care has been running in this country during the last 30 Years at about the same sort of. level as in Other European countries — though not so high as in the United States, where of course everyone, we are told, has to pay (though in fact they don't). Yet in those other countries the systems of distributing and channelling medical care are drastically different from that instituted in the late Forties by the National Health Service. Prima facie, therefore, I said, there is little reason to suppose that had the system in the United Kingdom been different, the rough proportion of effort devoted to medical care would have been so very different.
He still seemed very disappointed. So, wishing to encourage him, I went on to tell him that when the National Health Service Was established thirty years ago, it took over or nationalised no fewer than three distinct Systems. One was municipal, whereby hospital care was available widely at minimal or no cost to the patient; the second was insurance, which covered medical care for a great part of the population; the third comprised various forms of charitable and commercial services, including the fact that general practitioners, as a matter of professional ethic, accommodated their charges to the ability of the patients to pay and considered it the honour of their profession to refuse no one treatment. These three channels would anyway have deepened and broadened during the last thirty years with the increase in affluence and national income.
In short — and this applies, I am sure, beyond the National Health Service — when you compare American circumstances with British circumstances, you must remember that they always have been different, and you must not attribute to any recent form of organisation, social habits and patterns of professional activity of which the roots are far more deep. But then he protested 'people have told me that before the National Health Service they did not get medical treatment because they could not pay for it.' It was then I rounded upon him. 'Who were these people? How old were they?' He seemed puzzled by the question. I asked if they had perhaps been in their forties. He
agreed. 'Well now,' continued the crossexamination, let us take a man of fortyfour. He was 14 years of age, a boy under school leaving age, when the National Health Service came into existence. Are you seriously telling me that these people can remember how at ages 0 to 15 they did not resort to medical care because they could not afford it? There is another aspect which was not brought to your attention. In fact, if your informants were in their fifties, the same argument would apply. For at the beginning of the War in 1939 all the hospitals were taken into public control, so that in effect a National Health Service was in operation as far as hospitals were concerned for the entire population from 1939 onwards — and that is forty years ago, is it not? The attempted comparison is not between the presence and the absence of the NHS. It is the comparison between the present generation and a past generation.'
The factor of continuity is one which, partly perhaps under the influence of journalism, we all too much neglect in judging the behaviour and performance of the state systems. Because these systems are nominally managed by politicians responsible to the electorate, we fall into the error of assuming that the politicians who manage them do in fact have powers of control far greater than they actually possess.
In 1948 Aneurin Bevan took over — I do not think, like Dr Dalton, he would have called it 'a poor bag of assets' — but a pattern of medical services, of staff, equipment, buildings, as they then were — the product of the evolution of past generations. Only minimally, year by year, could these totals be altered or increased. It was therefore only at the extreme margin that any effect could be exercised (even if he knew how to exercise it, or wanted to do so) by the Minister or the Cabinet nominally in charge of the National Health Service. Even these additions, however, were largely beyond such control. The extra things which medicine did in 1960 compared with 1950, or in 1970 compared with 1960, were not things which the politicians had decided upon. I will go further and say they were not even things the profession had decided upon. They were the consequences of forces working in medicine and society which were beyond the foresight, let alone the control, of those at the head of the National Health Service, be they political or professional.
Of course every year we talk about the Chancellor of the Exchequer as if he takes a blank sheet of paper, draws up on it his estimates for public expenditure, and then turns to another blank sheet and draws up his budget. Nothing of the kind. He takes over expenditure as it is. He pushes it in here a little, he pulls it out there a little —no, I exaggerate: a little pops out here, a little subsides there and then it forms his estimates for the coming year. The Health Service is a particularly rigid part of that budgetary total of the state. I may even say that it is largely autonomous, in that the forces which operate within it are perhaps more detached from politics than those at work in any other branch of state expenditure, or any other aspect of the organisation of the state.
I didn't try to explain all that to my American interrogator. He would never have understood that the world, including the National Health Service, is very much what it is bound to be. But if I had been obliged to identify some difference that nationalisation has made, I would have had to say that it has added a psychological dimension. The inevitable and the automatic have been invested with the fallacious appearance of being intentional and avoidable. As I was once candid enough to say, continual complaint is the enduring atmosphere of the National Health Service.
In theory the state can do anything. Now humanity is always frustrated by being able to do less than it would like to do. But outside the sphere of the state we understand very well why, and are more inclined to thank whatever gods there be for what we can do than to rail at the Almighty over the limitations he has placed upon us. Once within the portals of the state, however, we have somebody human to blame. It is the politician. It is because of his fault, his failure, that we do not enjoy all we should enjoy if only he would not begrudge it to us. This dimension, indeed, the National Health Service has added. Perpetual dissatisfaction, but is that an advantage?'
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