1948: The coming of a “free” health service

69 years ago this week, the NHS was born. Monday 5 July 1948 was the ‘appointed day’ on which of whole raft of Labour’s postwar social reforms came into force. This included reforms of social security, pensions and, most famously, the establishment of the National Health Service.

It was a major change for the British people, and especially for the nation’s health workers, most of whom now found themselves working for a single service. But what would it mean to be working for a national(ised) service? Trying to predict the answer to that question meant a lot of raised hopes and optimism (not all met) but also a degree of uncertainty.

In fact, most of the 1940s was a period of uncertainty for health workers, knowing that a change was coming but not being sure what form it would take. Even once the NHS was up and running this continued. The Ministry of Health circulars that rained down on them were an attempt to provide clarity, but their sheer number contributed to everyday anxieties that accompanied the widespread optimism.

A new article by one of our research team, published in the Women’s History Review, takes a closer looks at what this adjustment meant for one professional group in particular. The Lady Almoner – or the medical social worker, as she was increasingly being known by this time – was right at the heart of one of the most important changes. The establishment of a health service providing care ‘free at the point of delivery’ was especially meaningful for the almoner, as until now it had been her role to means-test and collect patient payments in the hospitals.

The almoner had only gained entry to the professional world of the hospital by being prepared to take on assessing patients and taking money off them. It’s something the doctors and hospital secretaries had been keen not to grubby their hands with. By contrast, these educated middle-class women brought with them a training and awareness of the management of domestic finances and the public and charitable support available beyond the hospital that meant they were, they believed, able to judge what would be a ‘fair price’ to ask the patient to pay.

Although London hospitals had started appointing almoners in the 1890s, most hospitals had only begun doing so in the 1920s, some only in the 1930s. So was there a danger that the new NHS would make them redundant, and threaten the very existence of their newly-established profession? On the contrary, the almoners embraced this major change to their job description as a professional liberation.

Making this change work in their favour was a matter of handily aligning their new focus on ‘pure social work’, untainted by money matters, with the planned health service – something they could also use to assert a higher professional status for social work itself.

Among the many changes the arrival of the NHS brought about was a chance for hospital social workers to reinvent their own professional identity. And the more we dig down into the social and cultural history of the NHS, the more of these unexpected stories we uncover. The meaning of the NHS, we’re increasingly finding, was and is far from simple.

 

To find out more… George Campbell Gosling, ‘Gender, Money and Professional Identity: Medical Social Work and the Coming of the British National Health Service’, Women’s History Review (2017) – available open access online here.

Memories of a ‘free’ health service

I’ve spent more than a decade answering a question my Nan asked me. When I was a History student and told her I was studying the social and welfare history of her own childhood, she recounted what was asked of her as a small child between the wars when her father was sick – walking from the east of Bristol to the city’s north to go cap in hand to the vicar to get a ticket, then down into the city centre to the dispensary where the ticket could be cashed in for medicines, which then needed to be taken home. In total over six miles up and down some serious hills – a long journey for little legs. Why, she asked me, was this necessary? Why was there not a National Health Service so he could simply see a doctor?

These questions are at the heart of my new book (which you can read as a free e-book here, thanks for funding from the Wellcome Trust), in which I focus on how people accessed hospital care before the NHS. There were many changes in hospitals during the early twentieth century, a time when developments in medical science and technology meant there were real strides in what being treated in hospital could actually do for you. One of the big changes is that in the 1920s it became the norm for patients to pay something to the hospital where they were treated, either directly at the time or in advance through one of the many local hospital contributory schemes. Before that those who were admitted to hospital were usually those who couldn’t afford to see a doctor privately, while those who could in turn also funded the hospitals through local taxes (for public hospitals) and charitable subscriptions (for the more prestigious voluntary hospitals). A ticket from one of those subscribers worked in the same way as the dispensary ticket my Nan remembered.

We might assume that if the changes in the years following the First World War meant everyone, across class lines, was now being treated in the same institutions and everyone paying something, then the hospital had become a democratic space even before the NHS. In fact, the reality was quite different.

Middle-class people may have started going into hospital for new and more successful operations, but they tried not to stay too long and stayed in separate, private rooms. This was partly their choice, expecting a more comfortable setting than the dormitory-style wards the working-class patients experienced. But they didn’t choose to go private in the sense we know today. A system of income limits barred middle-class patients from the ordinary wards, where treatment was provided either free or at a heavily subsidised rate, but where their admission would be regarded as a scandalous abuse of the charity and welfare provision of hospitals intended for the sick poor still often referred to in the 1930s and 1940s as “the hospital class”.

Paying the hospital was in some rare cases an opportunity for working-class patients to buy their way out of the general wards and into a nice, private room, if they could scrape together enough savings. But middle-class patients, including those just over the threshold, had to find the money for hospital charges maybe ten times higher than those for ordinary wards as well as a private doctor’s fee on top. Who should be treated in which kind of ward was decided by the means test of the hospital social worker, known then as the Lady Almoner.

To understand the difference the NHS made to people’s lives, it’s important to understand what it replaced. And we’ve seen this start to trickle through in the memories and reflections submitted by our members here. One anonymous submission from someone who was 17 when the NHS came into being recalled being aware of the difference it made being able to pay the doctor in their childhood:

“I remember as a young teenager visiting our doctor’s surgery and walking straight past a queue of waiting people. We could go straight in as we were able to pay the Doctor. I felt very uncomfortable- and also pleased with myself at the time for being aware of the situation.”

And another submission from Doris Macdonald reflected on the experience of not having to pay in the new NHS:

“I was about 16 or 17 years old and I sat on a chair which had a pair of scissors down the side which went in to my upper thigh. My Mum sent me off to see the GP pronto as it was about 1952 and not many people had tetanus jabs in those days. He prescribed what I now assume was an antibiotic of some kind and he told me very seriously that I should take the whole series as prescribed as they cost 33/- ( that is thirty three shillings in pre metric money and was a lot of money in those days). I can see them now, they were capsule shaped pills in black and red and there were six in the box thaat. When I got back home I told my Mum what the doctor had said and we were in awe that the medicine cost so much but we were able to access it because of the NHS without having to find the money that day.”

Of course, there are times when we pay within the NHS. Dentures and spectacles were provided entirely free for the first few years, until Labour decided to introduce charges, prompting the resignation of the NHS’s founding Health Minister Aneurin Bevan from the government. A year later the Conservatives took this further by bringing in prescription charges. And charges have been a perennial theme in the politics of the NHS. When Harold Wilson, ho had resigned as a junior minister alongside Bevan, became Prime Minister in 1964 his government abolished prescription charges, only to reintroduce them three years later as the economy came to trump all other concerns. New Labour may have sought widespread exemptions rather than abolition of prescription charges, but the devolved administrations they set up have now abolished them in 3 of the UK’s 4 Nations – 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).

Meanwhile there have always been private patients within the NHS. This was a compromise (hoped by some to be temporary) when the NHS was founded. When Labour returned to office in 1974 they set about phasing out the 5,000 pay beds in NHS hospitals, yet there were still 3,000 remaining when Margaret Thatcher was elected five years later and the incoming government immediately dropped the idea. And in the early twenty-first century there was an increase in payments, with the British Medical Journal reporting by 2013 that 89% of NHS acute hospital trusts (119 out of 134) were now offering private or ‘self-funded’ services (where you jump the waiting list by paying at a non-profit rate).

So, as much as we think of the NHS as being ‘free at the point of use’, the reality is often more complicated, changing repeatedly down the years. We’d love to hear from you about how you and the people around you have experienced and navigated these complexities around what you pay for and don’t pay for on the NHS. It’s something we need to understand if we are going to move beyond what politicians and experts have said about the health service, and really get to grips with a people’s history of the NHS.

The image above is a photograph of the children’s ward in a one-sixteenth size model of a modern hospital, commissioned by the King’s Fund and exhibited around the country to raise funds for local hospitals in the 1930s. It is also the cover image for the author’s new book: Payment and Philanthropy in British Healthcare, 1918-48 (Manchester University Press, 2017).

Charity and the NHS Choir

The 2015 Christmas No.1 single was ‘A Bridge Over You’, a medley of Simon and Garfunkel’s ‘A Bridge Over Troubled Water’ and Coldplay’s ‘Fix You’. It was sung by the Lewisham and Greenwich NHS hospital trust choir when they were featured on a BBC TV show with celebrity choirmaster Gareth Malone, but revived by the choir a couple of years later as a seasonal charity single.

The attention it received in the press was largely for its denying the chart top spot to Justin Bieber, who took to twitter to encourage his fans to buy the rival single. The Guardian noted the Canadian popstar had previously spoken out in favour of state healthcare, saying of Americans in a Rolling Stone interview: ‘You guys are evil’ for the financial worries associated with healthcare in the US. There were occasional comments about solidarity with the junior doctors, who had just postponed a national strike and support for the financial security it guarantees in times of illness. However, no comment was made about the discrepancy between the Christmas No.1 campaign’s rallying cry and where the money actually went.

The choir ditched their parochial name and branded themselves the NHS Choir, emphasising the point that buying the single was a way of showing appreciation for all those working over the holidays to keep the health service going. Yet the money raised did not go to the NHS. It was split between a number of health-related charities, including Mind and Carers UK. Even at the end of a year when the financial crisis in the NHS had never been far from the headlines, the NHS itself was not the recipient of the funds raised. The Lewisham and Greenwich choir may well have considered raising funds for their own hospital trust, but it would likely never have crossed their minds that the NHS Choir might raise funds for the NHS itself.

This provoked no comment because it is a fundamental and generally unspoken code underpinning the relationship between the British people and the NHS. Not only is it right to fund health services collectively, but any fundraising appeal must be separated from the routine delivery of healthcare if it is to be thought of as proper. Indeed, this has been the standard from the beginning of the health service nearly seven decades ago.

Following the establishment of the National Health Service in 1948, Aneurin Bevan gathered together representatives of the new regional hospital boards and gave them a stern warning. As NHS hospitals they were no longer to appeal for funds or ask for donations, to do so would be “improper”. There were to be no more fundraising advertisements in local newspapers, appeals on the radio or letters sent out requesting donations. Patients should no longer be encouraged to join contributory schemes. Collecting boxes were to be brought in from railway stations and public houses up and down the country. No more flag days, fetes or bazaars.

This is not to say that charity and voluntarism had no part in the story of the NHS over the following decades. Indeed, the history of the NHS would have been very different if it did not feature an army of volunteers. Gifts have also been import, as has raising money to provide the latest medical equipment and bedside lockers alike. And Christmas has always been a time of charity and community, in the NHS as elsewhere. Yet there are limits to that charity, on which the proper place of both citizen and state rests.

So, while the NHS Choir was new – never before had there been a Christmas No.1 in support of the NHS – it was also deeply traditional. Traditional because it echoed a long lineage of NHS fundraising, but also traditional because it knew its place.

Survey: Gift-giving in the NHS

As we launch our new survey on gift-giving in the NHS, we take a look at the many meanings gifts can carry and why they might be important to look at in the history of the NHS.

bevan-and-jennie-leeMy colleague Natalie pointed me to a story in Jennie Lee’s My Life with NyeAlthough she was a forceful socialist politician in her own right, she is often remembered more as the wife and widow of Aneurin (Nye) Bevan, the health minister who founded the NHS:

“There was a strict rule in Nye’s Ministry that any unsolicited gifts sent to him should be promptly returned. On one occasion, and only one, an exception was made. Nye brought home a letter containing a white silk handkerchief with crochet round the edge. The hanky was for me. The letter was from an elderly Lancashire lady, unmarried, who had worked in the cotton mills from the age of twelve. She was overwhelmed with gratitude for the dentures and reading glasses she had received free of charge. The last sentence in her letter read, “Dear God, reform thy world beginning with me,” but the words that hurt most were, “Now I can go into any company.” The life-long struggle against poverty which these words revealed is what made all the striving worthwhile.”

The giving of gifts has been a common ritual over the seven-decade history of the NHS, whether that’s giving tokens of gratitude to the staff or simply bringing in something for a patient to pass the time while they’re stuck in a hospital bed. Yet it’s an everyday feature of the NHS’s history that’s likely to be forgotten in time. When a large charitable donation is made or a charity provides equipment for a hospital that is likely to be recorded, and of course a gift to a health minister might get a mention in a political memoir. But there’s likely to be no paper trail to find out about the box of chocolates, flowers or thank you card given to the nurses on the ward.

Such displays of gratitude are important. Not just because they are a tangible part of the human interactions at the heart of the NHS on a day-to-day basis, but because they reveal something about what we think of the NHS itself. It’s not standard practice to give a gift anytime medical treatment is received, so we have to ask why it happens when it does. Much of the time, it’s a recognition that a patient or family member thinks of the staff as having gone above and beyond what’s expected. There’s plenty of paperwork to accompany formal complaints, at least in recent years, and thank you gifts are their positive and easy-to-overlook counterpart.

Hil - locker giftsIn a health service that doesn’t (usually) take payment, the fact that people often want to give something back speaks volumes about our relationship with the NHS. This might be a small token of thanks to the nurse or the doctor, but might be about giving back to the institution. We don’t know a huge amount about fundraising for NHS hospitals, for example, but sponsored marathons and the like often seem to be inspired by giving back after a family member has received quality care from the NHS.

Of course, there may be other reasons for giving gifts too. One former nurse told me that when she worked in one maternity hospital it was common practice for the expectant father to give a gift to the nurses when his wife was brought in. Not as a thanks for a job well done, but as a “bribe” to look after her properly.

And we should remember that gifts are not always given to the NHS, its institutions or its staff. Patients in hospital wards might be brought a bag of grapes, bunch of flowers or a pile of magazines to pass the time. And gifts of this kind can also tell us a lot about the NHS. It gives us an idea of what might not be provided – or what people might not expect to be provided – by this ‘comprehensive’ health service. While nobody would imagine the NHS would provide the latest issue of Take a Break, it did surprise me to find bedside cabinets (pictured) being gifted to hospitals by a charity in the 1970s.

In all kinds of ways, then, the NHS is daily the site of gift-giving. And that deserves to be part of how its history is written.

Click here to fill in our anonymous survey and help us include stories of gift-giving in our people’s history of the NHS

Art Trails and Charity Auctions

An auction in Dundee this evening raised £883,000 for charity. Over the summer the Oor Wullie’s Bucket Trail had seen 55 statues of the iconic Sunday Post comic strip character on display all over the city (as pictured above). The statues were auctioned off to raise money for the ARCHIE Foundation’s charity appeal to support a new theatre suite at the Tayside Children’s Hospital.

In just a few years it’s become surprisingly normal to see these public art trails around Britain. The script is always more-or-less the same. A big fuss is made as a huge number of roughly person-sized statues go up all over local landmarks, shopping areas and in well-known public buildings. Each one is from the same mould, but has been painted by a different (usually local) artist. Families pose for photos as they try to find them all. Then, after a few months, they’re auctioned off to raise money for charity.

We may have gotten quickly used to seeing all these statues, but where did they come from?

Surprisingly enough, the answer is Switzerland (via Chicago).

In 1986 Zurich became home to painted statues of lions, the city’s symbol. Twelve years later this was the inspiration behind artistic director Walter Knapp’s ‘Land in Sicht’ public art exhibition of life-sized painted fibreglass cows, which were auctioned off for charity. The next year the idea was mimicked by a Chicago businessman for the ‘cows on parade’ exhibition, which has since been taken to 79 cities around the world, from Sydney to Istanbul and Rio de Janeiro to Shanghai, with local artists painting the statues and the auctions raising money for local charities. These public art trails have mostly been very popular, despite the occasional controversy. Such as when David Lynch’s gruesome Eat My Fear cow design was rejected for the New York exhibition, or when the Militant Graffiti Artists of Stockholm kidnapped one of the fibre-glass cows in protest at their corporate sponsorship. “Advertisements can never be art”, they declared as they threatened to decapitate the cow unless there was a public statement that they were “non-art”. No such statement was forthcoming. The fibre-glass cow was decapitated.

Although the cows soon arrived in London, Manchester and on the Isle of Wight, it took a decade for a British spin on the idea to come about. Liverpool’s popular Superlambanana – Taro Chiezo’s 17 foot high yellow statue of a lamb with a banana for a tail, which had appeared in the city’s Albert Docks in 1998 – became the model for 124 two metre high mini-Superlambananas around the city. This Go Superlambanas! exhibition was part of the City of Culture programme in 2008, while the statues were auctioned to raise money for the Lord Mayor’s Charity.

'Big Hoot' (2105) photograph taken by George Gosling

shaun-in-the-cityThis became the model for a new wave of public art trails in towns and cities around the UK, often run by the same Wild in Art company behind Go Superlambanas! The first of these tended to raise money for arts and environmental charities, as with Wow! Gorillas in Bristol in 2011, but since there have been a huge range of different themes and causes. There were barons in Salisbury for the Trussell Trust, lions in Bath for a young carers charity, dragons in Newport for a vulnerable young people’s charity, and toads in Hull for environmental projects.

Children’s charities and particularly children’s hospitals, however, have become a common choice. This is due in part to two art trails in Bristol for the Wallace and Gromit Appeal for the Bristol Children’s Hospital – with statues of both 80 Gromit and 120 of Shaun the Sheep (pictured right). The Gromit Unleashed auction in 2013 raised £2.3million and 2015’s Shaun in the City auction a further £1.1million, with the sale of merchandise and spin-off events as far afield as Hong Kong bringing in more than £4.5million and counting. Beyond Bristol, children’s hospitals had received the funds raised from the auction of Dolphins in Aberdeen two years ago, of Birmingham’s Big Hoot owls (pictured above) a year ago, and of the Oor Wullies in Dundee this year; and it’s set to continue with bears in Birmingham next year.

For all the visibility of its incredibly successful branding, there are times when the NHS is hidden. And, despite its popularity, the NHS remains firmly in the small print of these charity art trails and auctions. To some extent, the charity in general is kept distinctly backstage. While entertaining community events have raised money for local hospitals and supporting charities throughout the history of the NHS, it wouldn’t be entirely unfair to say these are part of a new generation of public activities putting the fun back into fundraising. But the NHS is one step again behind the children’s hospital as the focal point of the charity auction.

And this speaks to a thorny issue running through the NHS’s history. Namely, that it can be a cash-strapped beloved national institution, a rallying cry for popular sentiment, and yet still seen as an improper recipient of charitable support. Giving money is  a way of showing support, but at the same time an abandonment of perhaps the most important founding principle of the NHS: that paying for the health services we collectively require is the responsibility of the government. It may be deeply popular and going through some tough times, but in terms of where we might want to send our cash, the NHS will always be a far more complex good cause than sick children.

 

Oor Wullies (2016) photos kindly donated by Dave Morris, Shaun in the City (2015) by Jennie Maggs, Big Hoot (2015) by George Gosling.

Jeremy Corbyn, Owen Smith and NHS Privatisation

Seven decades after the Labour government of Clement Attlee and his Health Minister Aneurin Bevan founded the National Health Service, the party is having a leadership election. While the popularity of the NHS is enduring amongst the British public, in the Labour fold commitment to it is an article of faith. So at this moment, when the party is polarised and ideological purity is prized above all else by many of the membership, it has unsurprisingly become an important issue in the campaign.

Accusations that Jeremy Corbyn’s challenger, Owen Smith, pushed for privatisation of the NHS have been doing the rounds. They go back to his time as Head of Policy and Government Relations for the major pharmaceutical company Pfizer and then corporate affairs at the biotech company Amgen, before he became an MP in 2010. Inevitably there is scepticism amongst many on the left of connections to big pharma at a time when Amgen was dealing with a US investigation into cancer patient deaths and Pfizer was locked in international disputes with governments of the Philippines and South Africa, who were fighting to gain access to cheaper drugs for treating hypertension and AIDS respectively. The Guardian has pointed to the fact Smith took the industry line on use of non-patent drugs in his early days as an MP.

In response, Smith has denied he was a “lobbyist” and suggested it’s in fact a “massive advantage” to know how the private sector works. Meanwhile, supporters point to his role in Labour’s opposition for Pfizer’s take over of British-owned AstraZeneca. In 2014 this was highlighted by the Telegraph, which called him Ed Miliband’s “Pfizer insider” and concluding ” it is not hard to imagine Pfizer’s disappointment that its significant cash investment in Mr Smith might have yielded a better return than this”. Interviews now typically include a statement endorsing the NHS as publicly-owned and free at the point of use.

Disbelief of these reassurances among those who want to #KeepCorbyn are not just a sign of post-truth politics or of an inability to understand the way the world really works. Explanations often fall on deaf ears, but this is about more than an unwillingness to listen. This is not an argument over the correct answer, but a fundamental disagreement about the question itself.

At the heart of the matter is a 2005 report from the think-tank IPPR commissioned by Pfizer, which focused on the Blair government’s choice agenda. It was actually not an endorsement, warning that patient choice as implemented risked worsening inequities in health. Instead of calling for the policy to be abandoned, however, they proposed changes to make sure choice became a tool for empowering disadvantaged patients to get the most out of the NHS, on the assumption that even without formal mechanisms educated middle-class patients would have this in practice simply by knowing how to work the system. The report ultimately set out a vision and plan for working with patient and community organisations to bring about what was termed “progressive choice” and then rolling it out far more widely across the NHS.

Smith said at the time: “We believe that choice is a good thing and that patients and healthcare professionals should be at the heart of developing the agenda.” He may, of course, have simply been paying lip service to the core message of the report being launched. But had he been deeply convinced and converted to the cause, would that amount to supporting privatisation? The annoying but honest answer is: that depends.

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You see, there is no one agreed definition of “privatisation”. As the work of Birmingham University’s Martin Powell and Robin Miller has made clear, academic as well as political debate over many decades has been hampered by the fact that opposing sides often have quite different definitions in mind. So what might be labelled as “privatisation”? Here are some of the most relevant.

Transfer of assets: Selling off family silver, as Harold Macmillan called it in 1985. This is the part everyone agrees about. The transfers of British Telecom and British Rail to private sector ownership and control, for example, were acts of privatisation. The narrowest possible definition covers only this and it is often implicitly the one called upon by politicians when defending themselves against charges of privatisation, although they’re usually being accused of something else – as seen recently with the furore when the Australian Labor Party accused the Coalition government of secretly planning to privatise Medicare.

Contracting out: The choice agenda can be hard to separate from the increased involvement of private sector providers, something the ‘choose and book’ system aimed to make easier and the accompanying ‘payment by results’ to incentivise. However, the IPPR report was actually ambivalent on the question of private provision within the NHS, which was described as:

“an optional route for enabling choice, rather than a necessity. Private provision, additional to or substituting for public provision, could be encouraged without patient choice; likewise patient choice could be implemented without providing independent sector options. The focus of this report is not on the implications of increasing private provision in healthcare, but on the implications and options for patient choice and equity.”

In fact, the report also suggested that private providers contracted to deliver services to NHS patients should be forced to make comparable information available, on the grounds that public accountability should trump commercial confidentiality. So we now have an added complication. Just as different things might be meant by privatisation, we now have differing government and IPPR notions of choice with very different implications for the role of the private sector in the NHS. For many Corbyn supporters, Smith might well be tainted here less by association to the IPPR report than to New Labour.

Replicating the market: Most experts would call this ‘marketisation’ or ‘commercialisation’ instead. But, while I don’t believe “people in this country have had enough of experts”, I do think we do ourselves few favours by insisting upon academic definitions in arguments going on far away from any ivory towers. The word privatisation will often be commonly used to describe a process whereby those within the public sector are made to compete against each other. While the IPPR report was ambivalent about private providers getting in on the action, it never wavered from the assumption the NHS would be improved if NHS hospitals and other treatment centres had to compete against each other for patients.  In fact the report wanted this – with ‘progressive’ safeguards – extended to primary care.

Consumer culture: Also easily dismissed but often in mind when talking casually about privatisation is the culture shift from being seen as a patient or citizen to a consumer or customer. The excellent work of Alex Mold has examined the rise of the patient consumer over a number of decades. In an age where patients are less deferential to doctors and other figures of authority than they used to be, it is perhaps inevitable that they will become less passive and more demanding. This might even be harnessed to empower patients. The big question, especially for those on the left, is whether this runs the risk of pitting individuals against each other within the NHS, which itself symbolises to many an ideal of pulling together and looking after each other.

Providing private services: Going beyond simply imitating a customer relationship with the patient, it is not unknown for patients to be charged or private work to be done within the NHS. This is not new. Barbara Castle was the Labour minister struggling to finally phase out private wards from NHS hospitals when Margaret Thatcher’s election victory brought the plan to an abrupt end. But ‘self-funded’ work for patients not meeting NHS criteria has significantly expanded since the introduction of Foundation Trusts in 2003, broadening out from fertility services at the same time as more straight-forwardly private services have been increasingly provided as a means of securing a new revenue stream. The balancing act New Labour was attempting here was to make this the new normal while not jeopardising access to NHS services free at the point of use when needed.

Dependence on the private sector: This is not usually understood as part of privatisation but seems to have crept in during this debate, not least in relation to the development and supply of pharmaceuticals. Jeremy Corbyn adopted an extremely broad definition of privatisation which contrasts starkly with the policies of the last Labour government when he said:

“I hope Owen will fully agree with me that our NHS should be free at the point of use, should be run by publicly employed workers working for the NHS not for private contractors and that medical research shouldn’t be farmed out to big pharmaceuticals like Pfizer and others but should be funded through the Medical Research Council as a way of developing those drugs”.

John McDonnell’s attempt to clarify the final point, suggesting this would in practice mean some change to “manage it more effectively” was clear only as a signal not to take it seriously. The Medical Research Council spends around one-tenth what the private profit-making sector does on research and development in the UK, less than charities or the Department of Health itself. So it would be a radical new direction, to say the least, to use the MRC to bring all medical research in-house.

While this is not coherent policy, it does tap into concerns over the dependence of the NHS on the private sector: everything from privately contracted cleaning staff to the ongoing £3,729-per-minute bill for privately financed hospitals under PFI deals. And this carries over to the price the NHS pays for drugs. Throughout the NHS, as the Health Service Journal noted a few years ago, there is “an unspoken crisis in trust” which they summed up as: “We don’t trust ‘Big Pharma’ and they don’t trust the NHS. They don’t trust our competence and we don’t trust their character.” It would be wrong to dismiss this mentality as the paranoia of the far left, but it would equally be bizarre not to expect it to shape the Labour left’s approach to the NHS. Indeed, Nye Bevan himself wrote that: “The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health.”

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The complexities of the politics and policy debates around NHS privatisation are neither the beginning nor the end of the divisions and animosity in the Labour party. And it’s far beyond the remit of this blog to even attempt to make sense of the relationships between echo chamber thinking and a failure to see things from the other side, or ideological purism and caricature in an increasingly polarised polity (all criticisms that could be levelled to supporters of both sides). By the same token, clear thinking and acknowledging different rationales will not in themselves heal the wounds inflicted.

But on Saturday 24 September, either Jeremy Corbyn or Owen Smith will be announced as having won the leadership election. There is no scenario in which bringing the party together and putting in place a credible policy platform will be anything less than a monumental task facing one of them. If the Labour party is to end the year with a policy on the NHS that is both serious and broadly supported by the membership, it will need to address these issues. This will involve fierce disagreement, not only on the details of policy but on the very premise on which policy should be made.

The NHS will be a rallying cry for the Labour party for as long as it exists. But without digging down beneath the rousing platitudes, different meanings for the same words used make it inevitable that suspicion and caricature will be the defining features of the debate. The factious argument over whether those in the centre or on the right of the party support NHS privatisation or not will continue until those at the top of the party spell out what exactly they are in favour of and why, recognising that the answer is neither simple nor self-evident.

This might sound like technocratic wonkishness, but it’s actually a fundamentally moral question that runs right to the heart of the purpose of the party that founded the NHS.

Australian Labor’s “Medi-scare”

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.

buses

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.

ALP medicare cardLabor 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.

labourshealthservice-1What 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.

Giving Blood in the NHS

Tuesday 14 June 2016 is the twelfth World Blood Donor Day, promoted by the World Health Organization with the tagline: Blood connects us all. So this is a good time to think about the history of blood donations and their place in the history of the NHS.

Blood transfusions have a history dating back to the seventeenth century, though it was the conflicts of the early twentieth century that prompted many of the most dramatic advances. In Britain, blood donations have been part of an organised collective system of healthcare since the Second World War. In the first months of the war, the Medical Research Council decided to set up blood depots. This was not new, but proved its usefulness for both air raid casualties and civilian patients during the war. As attention turned to postwar reforms, plans began to fall into place for a National Blood Transfusion Service, managed by the NHS’s Regional Hospital Boards.

Our research at Warwick University is all about the meaning of the NHS and blood donation in particular has often been read as an activity deeply laden with meaning. In 1970 Richard Titmuss published his influential book The Gift Relationship. Surveying blood donation in the UK, USA, South Africa and the Soviet Union, he made the case for voluntary, unpaid blood donation with anonymous recipients as an example of “altruism in modern society”. In particular he drew attention to the NHS:

“What is unique as an instrument of social policy among the countries we have surveyed is the National Health Service and the values that it embodies. Attitudes to, and relationships with, the National Blood Transfusion Service among the general public since 1948 can only be understood within the context of the Health Service. The most unsordid act of British social policy in the twentieth century has allowed and encouraged sentiments of altruism, reciprocity and social duty to express themselves; to be made explicit and identifiable in measurable patterns of behaviour by all social groups and classes. In part, this is attributable to the fact that, structurally and functionally, the Health Service is not socially divisive; its universal and free access basis has contributed much, we believe, to the social liberties of the subject in allowing people the choice to give, or not to give, blood for unseen strangers.”

For me personally, it was a different type of solidarity and community that was fostered from my first time giving blood. After hearing all about blood donation from a local nurse, I was part of a group of maybe a dozen sixth formers from Filton High School who travelled down to Southmead Hospital in Bristol, now old enough to start young. We had varied experiences. There were the girls who were told they didn’t weigh enough to safely give blood. Those, like me, where they had trouble finding a vein. A few who felt a bit light-headed afterwards. But we all went to give blood together, we looked after each other when feeling dizzy or sore or just disappointed at being rejected. Importantly, we all had tea and biscuits (I made sure I got the bourbons) together before leaving – even those who hadn’t been allowed to give blood. A variety of experiences, but all experienced together.

Of course, a community is defined as much by who is excluded as who is included. And I felt a huge sense of injustice when I knew my blood was not wanted because of my sexuality. The question on the form read: Are you a man who has ever had protected or unprotected sex with another man? There was no question of rejecting the blood of any straight person for whom Saturday night meant a club followed by a one-night stand. No question of accepting blood from anyone in a long-term monogamous gay couple, or even a straight woman who had ever had sex with a man who had ever sex with another man. I wanted to tell them I’d been tested for everything that might be a concern and which all donated blood would be screened for anyway, but I was on the outside. My blood was not wanted by the NHS.

The lifetime ban was changed to a one-year ban in 2011, delayed until September 2016 in Northern Ireland, and is kept under review by SaBTO (the Advisory Committee on the Safety of Blood, Tissues and Organs). The slow move towards a less exclusionary system is a sign of the shadow cast over blood donation and transfusion by the ethical crises of HIV/AIDS and serum hepatitis. These were not the first fears of infection to provide grounds for the exclusion of whole groups from giving blood. For example, not only those who had overcome tuberculosis or malaria, but those who had lived in the tropics – which in effect meant the exclusion of all ‘coloured’ migrants.

“The central role of blood in transmitting HIV/AIDS”, as medical historian Virginia Berridge has noted, provided “a new twist on the story of the gift relationship.” The risk of contamination entirely separate from any question of personal behaviour – a distinction highlighted with painful satirical honesty in 1990s mock news show Brass Eye as “good AIDS” – served to undermine confidence in the altruistic system of blood donation. Over the 1970s and 1980s, thousands of NHS patients were infected with Hepatitis C or HIV, with many unaware they had been infected until many years later. The only public inquiry held was the Scottish one which reported last year, as victims and families angrily shouted “whitewash”. Prime Minister David Cameron said in the House of Commons that he could hardly imagine the “feeling of unfairness that people must feel at being infected with something like Hepatitis C or HIV as a result of totally unrelated treatment within the NHS… To each and every one of these people I would like to say sorry on behalf of the government for something that should not have happened.”

The insult of rejection hardly compares to the injustice of infection, and the gift relationship must always depend on the gift being a safe one, yet exclusion from donating blood – on the basis of sexual behaviour, drug use, work in the sex industry, getting tattooed or even international travel – does offer a rather different perspective on the boundaries of universality in our universal health service.

What memories do you have of giving blood or not being able to? Have you worked with or perhaps benefited from blood donations?

See our virtual museum gallery of posters encouraging blood donations

NHS History at #SHS40

The UK’s largest annual gathering of social and cultural historians took place this week. So you won’t be surprised to hear we were in Lancaster for the Social History Society’s 40th anniversary conference. On the first day of the conference there were other sessions going on at the same time, but it was great to see so many people coming to see what we had to say that some of them had to sit on the floor!

Mathew, Roberta, Jack and Jane, four-sevenths of the NHS Mafia (as we’re now known to twitterstorians everywhere — thanks, @KingTekkers), were the speakers. Their subjects ranged from explorations of how the NHS featured in political culture to feelings and commitments in the NHS itself, and from NHS  workers to the child audiences of public health messages.

I chaired the session, after speaking in another. With Sarah Flew, Richard Huzzey and Karen Hunt, I kicked off the conference with a roundtable (Question Time style) discussion on new ways of thinking about money in social history. I was arguing we should use the language and the insights of economic sociology to help make sense of the things we do and don’t pay for, not only as economic concerns but social ones too. The NHS is a perfect example. The very fact it is (for the most part) a free health service is hugely important for the social meaning attached to it.

When it came to the ‘Cultural History of the NHS’ session, Mathew Thomson started us off. He talked through what political party election manifestos have said about the NHS since the 1950s. The nine themes he identified across Labour and Conservative manifestos included the NHS as a proud achievement, a reflection of national values and a health service under attack. In some ways the manifestos are an obvious place to look to get an idea of what people are thinking and saying about the health service, he said, but they’re also fantastically revealing.

Roberta Bivins turned our attention to the politics of citizenship and belonging. She used some wonderful political and satirical images to explore what has been a rather complex relationship between the NHS and belonging. It might be a universal health service, but who gets included in its universalism? Can inclusion be earned? With the NHS seen as a magnet for foreign labour since its foundation, can it offer a space for learning to be British? The racial questions that lie behind entitlement in a national health service are not always comfortable ones.

Jane Hand kept our focus on visual images, looking in depth at a few examples of public health campaign images. She explained how dental health education in the 1950s and 1960s taught people to be good citizens by looking after their teeth. This was an important part of learning how to use, and not abuse, the health service. It also showed the NHS as being preventive as well as curative, a modern project to train up the next generation of healthy citizens.

Jack Saunders talked about the fact that the NHS didn’t just treat citizens, it also employed them. By the 1970s, it had become the first British institution with over a million staff. So, over a few generations, what has it meant to work for the NHS? It reflected wider trends in British society, including a shift away from manufacturing jobs to work in service industries. And the social mix of the country was largely mirrored within the NHS, with some jobs being typically filled by people of a certain class, gender or race. All of these people were real people, but there were imagined characters too, such as the ‘dedicated nurse’. This was an unattainable ideal regularly called upon in contrast to campaigning or striking nurses, such as those (pictured) eating chips in protest over hospital food.

What was interesting was that everyone found a different aspect of the complex relationship between the NHS and ideas of citizenship. Entitlement is a marker of citizenship and inclusion of all citizens is in turn an emblem of national values. But they need to be acted out, by citizens taught how to behave in healthy ways that live up to the promise of the health service. And the accusation of failing the NHS is a serious one, for politicians eager to prove they too believe as well as for nurses or doctors going on strike.

Social Work and NHS History

World Social Work Day (Tuesday 15 March in 2016) is a good time to look back to the history of social work – and, for us, its historic relationship with the NHS. It suffers from not being a profession with a history as long as medicine or having the totemic figures of nursing. Like occupational health, it can be a largely invisible profession to everyone but those for whom it shapes their experience with the NHS. This means social work is not necessarily an obvious aspect of the NHS’s history for us to think about, but it is an important one. So what is that history?

Of course, there are many kinds of social work, each with its own history. And since illness, disability and, more positively, health, impact so greatly on all our lives, the NHS may be a greater or lesser feature in most social work. But here I’d like to say a little about, and hopefully prompt a few memories of, hospital social work.

Social workers first arrived hospitals to weed out those abusing the hospital by seeking free admission when they could afford to see a doctor, by definition not requiring hospital treatment in an age when medicine was far less dependent on the technology of the hospital, and ask for an appropriate financial contribution from the rest. We might say they operated the hospital means test. But there was no need for this after 1948, as I’ve written about for an entry in our encyclopaedia on Social Work and the Coming of the NHS. What’s more, when charges for prescriptions and other items were introduced just a few years into the NHS, social workers refused to have any role in collecting them. Money continued to be important, but in a different way. As I was told by one person, who had been a social worker’s assistant in the 1960s, a huge amount of the work was geared towards assessing a patient’s financial circumstances. But the purpose of this was not to determine the amount to ask them for, but to ascertain what benefits they should be claiming.

When she came to write her Consumer’s Guide to the British Social Services in 1967, one-time hospital social worker Phyllis Willmott explained that it was that the job was:

to help patients with their worries and difficulties – either practical problems over work, money, housing, or more personal emotional or domestic difficulties, or a mixture of both. She has (if she is experienced) a wide knowledge of all kinds of social services available; she is also trained to understand and help with the very real and acute personal or emotional difficulties which can lie behind some illness, or be caused by them.

This period of social work’s history could easily be lost amidst myriad organisational changes – not least reorganisations of the NHS and local government, just as medical social workers were being moved from one to the other – and being part of wider structures was important. Indeed, there were no new hospital built until the 1960s, but there was a real increase in the number of social workers trained and appointed to work in them before that. The Warwick University Modern Records Centre website hosts recordings of Social Workers Speak Out – interviews with 26 pioneers of social work, 5 of them hospital social workers, who reflect on what was for many a golden age of hospital social work.

Those interviews took the story up until the end of the 1950s, and the next period was one in which the character of social work was changing to become more sociologically and psychologically aware. This took place against of backdrop of the politics of anti-discrimination, a new era to adapt to but also one that some recall fitting well with a long-standing ideal of seeing and respecting the whole person. But how to think of that person: a patient? a case? a client? a consumer? a service-user? etc. etc. And broader political changes meant social workers, as in the early days of the profession, had to once again become experts in helping them navigate a complex mixed economy of welfare. Indeed, the latest chapters of hospital work’s history see social workers themselves increasingly employed by neither the NHS nor local government.

In truth, we know very little about social work in the history of the NHS. That’s why a project like this is so important. So please do share your memories with us. Do you remember a social worker from your time in hospital or did they help you access the support you needed from the NHS? Perhaps you were a social worker or assistant who worked in an NHS hospital. If so, how were you seen and treated by the patients and the other hospital staff? Did the NHS make a difference (good or bad) to the way you worked with your cases when they were dealing with health problems? You can use the comment section below to tell us, or you can sign up as a member to join the general discussion in our MyNHS members area.