People's History of the NHS

Recent weeks have seen campaign buses emblazoned with contested slogans about healthcare touring two countries on opposite sides of the world. In the run-up to Britain’s referendum on its European Union membership, the Electoral Commission declared Vote Leave’s £350million per week slogan to be ‘misleading’. Certainly some voters decided to vote ‘leave’ in the mistaken belief this was a promise extra funding for the NHS. A week later Australians went to the polls. Even before the final result was known, the incumbent Liberal Party had reported the opposition Labor Party to the police for one episode in what is being dubbed, by some, their “medi-scare” campaign.

“Mr Turnbull’s plans to privatise Medicare will take us down the road of no return. Time is running out to Save Medicare”, read a text message sent out on election day by Queensland Labor but appearing to be sent by ‘Medicare’. This was the reported provocation, but it was only part of a larger campaign strategy described by the Deputy Prime Minister, Julie Bishop, as a “monstrous lie”. As in the UK, this came under the spotlight in the wake of a surprising result. While the UK narrowly voted to leave the EU, the widely-predicted comfortable re-election of Australia’s centre-right Liberal/National Coalition turned into a shockingly close contest, leaving PM Malcolm Turnbull waiting more than a week for confirmation he would have enough MPs to remain in office.

So, what is Medicare? This universal health insurance scheme was originally called Medibank when introduced in the 1970s, before being reaffirmed and rebranded with the Medicare name borrowed from the US in the 1980s. It was one of the Whitlam government’s progressive reforms blocked by the conservative Senate in a stand-off only resolved by a rare double dissolution, prompting elections for all seats in both the House of Representatives and Senate. While Coalition governments have repeatedly encouraged private insurance opt-outs, at the heart of the system remains the mechanism of bulk billing. This means the doctor accepts a slightly reduced rebate from Medicare (covering 85% for outpatients and 75% for inpatients) and cannot charge any additional charges to the patient, but equally they avoid the hassle and cost of billing and debt collection. This was the Whitlam government’s way to incentivise extensive coverage without establishing an Australian NHS. The current rebate freeze (introduced by Labor in 2013 but set to continue until at least 2020) makes that incentive less attractive, with Australian GPs warning they might abandon bulk billing altogether as costs rise and move instead to charging patients perhaps a $25 fee for each visit. Labor ran hard on the message that government policies would make it more costly to see the doctor.

Labor managed to set the agenda as they took their Medicare campaign online and associated it with local hospitals in marginal seats. As they promised to end the rebate freeze and broadened out to funding for hospitals and drugs, the Coalition found themselves having to uncomfortably defend a whole host of complex policies from the simple charge of ‘privatisation’. Their position was made harder by the fact their health policies have been changing even faster than Australian Prime Ministers in recent years. In less than three years, the Coalition government’s policy proposals and u-turns have included making patient co-payments ranging from $5 to $15 a condition of bulk billing and cutting medicare rebates by more than half. Meanwhile, policies they have introduced and kept included maintaining the rebate freeze and calling for private sector expressions of interest in taking over the entire Medicare and Pharmaceutical Benefits Scheme. It turns out  that “outsourcing is not privatisation” is a less successful campaign slogan than “Save Medicare”.

It’s not the place of a British historian to take sides in this debate. Liberal spokespersons are not lying when they say they have (now) no policy to make doctors charge patients or to disband the medicare system. However, neither are the Royal College of Australian GPs when they say the government’s policies will have the effect (intended or otherwise) of discouraging bulk-billing and encouraging them to increase charges. Whether or not this can fairly be described in the way the Australian Labor Party has is for a matter for Australia’s voters today and her historians tomorrow.

What I can offer is some comparison of the way healthcare plays in Australian and British election (and referendum) campaigns. Indeed, much looks remarkably similar. In speeches, on placards and even emblazoned on a banner attached to a plane flying around Perth, the ALP has been running hammering home the simple message: Vote Labor, Save Medicare. This has been a common theme in British Labour campaigns. Since the very early years of the NHS, election posters reminded voters that the Conservatives had voted against its creation and suggested the party could not be trusted with it. Even the Labour Prime Minister least associated with social welfarism, Tony Blair, came to power with the rallying cry on the eve of the 1997 election that the British people had “24 hours to save the NHS”.

And this is not just opportunism at election time. Healthcare reform has an important part in the folk history of both parties. For British Labour, the NHS has become an emblem of the postwar welfare state established under Clement Attlee in just six years – more familiar and tangible than reforms to social security or the like. Its continuing popularity (greater than that of the Monarchy or the BBC) gives Labour a place in a comforting national story, while the Conservatives will perhaps always be seen by many as the ‘natural party of government’. For Australian Labor, wheeling out 1980s Labor Prime minister Bob Hawke reinforces this sense of history. Indeed, the foundation of Medibank/Medicare is bound up with the even-shorter-lived progressive government of Gough Whitlam, one of a number of long-lasting reforms passed in less than three years before the government was dismissed by the Governor General in the most dramatic and controversial episode in Australian political history.

While there are differences between the Australian federal insurance system and the nationalised health service in Britain, this issue of who pays the doctor has some similarities. In particular, GPs are not salaried employees of the state, which means arrangements for paying them to see Medicare/NHS patients is a perennial headache for policymakers. But does that regularly spill over to become an election issue? It is tempting sometimes to consign NHS prescription charges as a political issue to history – being put to rest when Harold Wilson’s 1960s Labour government reversed its own abolition of them – but that overlooks the vast exemptions introduced after 1997 and their abolition by devolved administrations in Wales (under Labour in 2007), in Northern Ireland (under the power-sharing Executive in 2010) and in Scotland (under the Scottish National Party in 2011).

While prescription charges may be a live issue, and the six years of David Cameron’s Coalition and Conservative governments have been dogged by controversial structural reforms of the NHS and the ongoing contract dispute with the junior doctors, any notion of paying to visit the doctor has been kept firmly off the agenda. In this sense, although the NHS may have been reformed beyond recognition from that founded by Health Minister Aneurin Bevan in 1948, it is still committed to the “collective principle” he outlined in his 1952 book In Place of Fear:

“The collective principle asserts that the resources of medical skill and the apparatus of healing shall be placed at the disposal of the patient, without charge, when he or she needs them; that medical treatment and care should be a communal responsibility that they should be available to rich and poor alike in accordance with medical need and by no other criteria. It claims that financial anxiety in time of sickness is a serious hindrance to recovery, apart from its unnecessary cruelty. It insists that no society can legitimately call itself civilized if a sick person is denied medical aid because of lack of means.”

The fact that Australian Labor’s “medi-scare” struck such a chord suggests both that the electorate was ready to believe the worst. The Conservatives may equally find the British people are ready to believe the worst about them, with Theresa May’s warning from fifteen years ago, that many see them as “the nasty party”, still echoing as they set about the task of establishing a post-Brexit vision of Britain. In fact, the Deputy Chairman of the party recently warned that “working people” see them as “the party of BHS and not the NHS – by BHS I mean the corporate, awful revolting people like that Phillip Green and the dodgy guy he sold it to”.

As she enters Downing Street, however, one of Theresa May’s many challenges is to unite the moderates in her party with the typically more right-wing Brexiteers. They may have brandished half-promises of extra funding on the side of their campaign bus, using the NHS as a national rallying cry, but they tend to be from the traditionalist wing of the party where antipathy towards the NHS is not hard to find. Former Conservative Prime Minister John Major memorably highlighted this during the referendum campaign:

“I mean the concept that the people running the Brexit campaign would care for the National Health Service is a rather odd one. I seem to remember Michael Gove wanted to privatise it. Boris wanted to charge people for using it. And Iain Duncan Smith wanted a social insurance system. The NHS is about as safe with them as a pet hamster would be with a hungry python.”

Yet the conventional wisdom is that high-profile jobs need to be found for prominent Brexiteers as Theresa May puts together her first government. Should anyone with such sympathies be considered for a stint at the Department of Health, she would do well to learn from the Abbott/Turnbull government’s hard-learned lesson that even dabbling with the idea of charging patients opens you up to accusations against which it can prove difficult and costly to defend yourself.

My thanks to Evan Smith and Chloe Ward for their Australian history and politics readings tips.

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