Nationalised Healthcare – now there’s a conversation starter. Your opinion on those two words will likely depend on where you are from. And we can probably simplify things further by saying whether you were born in the United States or not. The furore that surrounded the Affordable Healthcare Act, otherwise known as Obamacare, which came into being in 2010, highlighted just how divided Americans are on such an issue. But for the rest of the world, this is simply business as usual.
While National Healthcare is one step short of full-blown communism to many Americans, in many areas of the world it remains a cherished, important part of society. And there is no clearer example of this than with the United Kingdom and its National Health Service (NHS).
If we could move back in time to the days before Covid-19 and ask the UK’s general public about their opinions on the NHS you would likely receive two responses in one. The first would be a general grumble regarding budget cuts and waiting lists, but this would invariably be followed by a staunch defence of an ideal, that even though it has faced difficult times, has been a foundation for the nation since its inception in 1948. If you grew up in the UK, you’ve almost certainly come into contact with the NHS, and its legion workers, who, believe me, are not in medicine for the money.
The Covid-19 crisis has added yet another layer to this complex story as those workers suddenly found themselves in the trenches of the early struggles as the pandemic swept across the country. The idea of healthcare and how we pay for it, has never been in sharper focus.
Universal Healthcare vs Private Healthcare
Before we dive in with regards to the NHS let’s start by taking a look at nationalised healthcare in general and why it has become such a contentious issue around the world – and by around the world, I really mean in the United States.
Like gun control, abortion, and Donald Trump’s hero status, nationalised healthcare has become a deeply political issue in the U.S. The anger that erupted in 2010 when Obama forced through the AHA and so providing health coverage to roughly 20 million people, was met by many a disbelieving shake of the head from people around the world. This is not a video where we will pit the various benefits of the opposing sides against each other, but to get a clearer idea of the NHS, it’s important to highlight the alternative.
So why does America loathe the idea of universal health care so much? Well, actually it’s not quite that clear these days with more and more people gradually getting on board with the idea. But America has always held a slight aversion to big government and universal healthcare is seen as just that. Then take your pick from huge multi-billion corporations lobbying hard for their interests, insurance companies sniffing for blood, the daunting tasks of switching to nationalise healthcare, tax-hikes, and of course good old fashioned stubbornness.
At the moment, the U.S spends more on healthcare per capita than any other country in the world, and considerably so. However in terms of life expectancy it currently ranks 44th in the world – just below Cuba, which no doubt will ruffle some feathers. The UK sits slightly higher at 29th position, with Hong Kong and Japan leading the way.
So it’s clear that the way healthcare systems operate doesn’t necessarily translate into higher life expectancy, but some of the finest patient care in the world can be found in the U.S – as long as you can afford it.
OK, enough of this never-ending, heading-banging into the wall debate. Let’s take a look at the UK’s National Health Service.
Amid the Wreckages
While Britain emerged victorious from World War II, it did so a shattered nation. Cities lay in ruin, thousands were homeless and the rationing of food was to go on until 1954. Winston Churchill and his Conservative Party were booted out of power in the 1945 general election as the Labour Party swept into 10 Downing Street.
The controversial novel, The Citadel, written by A.J Cronin and released in 1937 was an early touchstone to highlight the glaring drawbacks of Britain’s healthcare system before the war. Many of the ideas in the novel would eventually be incorporated by the Labour Party into the creation of the NHS, but this was just one of many reports, papers and books that had appeared since the start of the century which called into question Britain’s way of handling its healthcare.
But the UK had already caught a glimpse of what national healthcare might look like during the dark days of the Second World War. The Emergency Hospital Service had been established in 1939 to provide healthcare for the victims of the war with 2,378 hospitals included and 68,000 beds provided in London alone. This was by no means the kind of comprehensive coverage we see today, as it was very much a loose collaboration of hospitals and health professionals sharing resources.
Fortunately, the numbers of those injured during bombing raids were considerably less than had been expected, but the EHS still provided a level of healthcare that simply did not exist before the war. As the fighting ended things reverted to normal. Britain’s 2,700 hospitals at that time were run either by charities or local councils and only those who with certain jobs were provided with free healthcare.
The NHS was officially formed on 5th July 1948 at Park Hospital in Manchester but came after years of hard work. I should also add that while there was a change in government in 1945, the previous Conservative government had laid much of the foundations for the NHS. On this summer day in 1948, hospitals across the land, doctors, nurses, dentists, opticians and pharmacists began working together for the first time.
When it launched, the NHS came with three core principles:
- That it meets the needs of everyone
- That it be free at the point of delivery
- That it be based on clinical need, not ability to pay
In reality, things had started even before then, and by Day 1, an estimated 94% of the British population were already signed up for the service. It’s easy to recall the national pride that the service eventually became, but the truth was it faced severe criticism in the lead up to the 5th July. The main doctor’s union, the British Medical Association, were vehemently against the idea right up until its launch, along with sizable portions of both the Labour and Conservative parties.
Most of the misgivings came down to the belief that local councils were more adept at running local healthcare services than the giant overlord that was the country’s central government. One memorable quote came from the extremely rich and privileged Lord Horder (I kid you not, that was his real name) who famously proclaimed to the Society of Individualists in 1948,
“If medicine were taken over by the state, it would be as disastrous as was the domination by the Church in the Middle Ages; a greater disaster, because the Church was cultured.”
But while some remained against it, they could not prevent the momentous events in 1948. On 5th July, a young girl by the name of Sylvia Beckingham was admitted to hospital in Manchester to receive treatment for liver problems. No doubt the young 13-year-old had absolutely no idea of the importance attached to her visit to the hospital that day, but Slyvia Beckingham became the first person ever to be treated by the new NHS.
The Early Decades
And so began the NHS’ bumpy ride to its current position. Its first-year budget was recorded at £437 million (roughly £15bn today) and while it must have been a huge relief to millions, the complexities that came with balancing the books meant that it soon ran into financial difficulties. In the first few years, spending quickly overshot what had been predicted, with Prime Minister Attlee even going on the radio to plead with the nation not to over-use their fledgeling service unless really needed.
There is still some debate about the cause of the problems in these early years. If you want to take the hardline and somewhat classist opinion, you would say that the poor began stripping pharmacy shelves and filling their mouths with fillings they didn’t need. Alternatively – and perhaps slightly more logical – was that of course costs skyrocketed because a huge percentage of the population had never got anywhere near having such options. With so many people living without the correct glasses, a mouthful of mangled teeth or health conditions that weren’t life-threatening, you begin to see why the initial years saw such a surge.
In the early 1950s prescription charges were brought in, although they remained low at 1 shilling per prescription (that’s about £1.5 today). Like most countries tend to do, the UK seesawed back and forth between a Conservative and Labour government over the coming decades. As the Conservative Party gained control in the 1950’s it faced a difficult decision. Ideologically they were opposed to the NHS, but the service remained hugely popular across the country. A committee was commissioned to see whether this was the best form of healthcare. The resounding answer, yes it was, and the NHS remained largely untouched.
1960’s to the Modern Day
Over the years the NHS has seen its fair share of ups and downs. The 1960s was seen as a relatively prosperous period but with healthcare costs soaring it once again ran into difficulties during the 1980’s – not least in the shape of the formidable Margret Thatcher.
But again, even though the Iron Lady and her government may have been ideologically opposed to such a system, they refrained from making any sizable changes, to begin with. She even made the famous statement in 1982, that the NHS was “safe in our hands”.
But slowly things began to change. Firstly with management processes but by the end of the decade, with costs reaching uncomfortable levels, the Thatcher government introduced the internal market, which split the purchaser from the provider to encourage competition and increasing efficiency. In a nutshell, this meant moving it slightly further towards the American model in which hospitals could compete with one another and receive greater rewards for their work – known as Payments by Results.
Tony Blair swept to power in the late 1990s on the back of promises to scrap the internal market – something he never did – while the first two decades of the 21st Century have seen massive increases in healthcare costs, coupled with one crippling recession – and another playing out as I speak. And that’s before we even get to Covid-19. The life of free universal health care is never an easy one.
Since devolution in 1999 (the process which transferred much of the power from the main government to smaller regional governments), the NHS has become subdivided into the four home nations, so you have NHS England, NHS Scotland, NHS Wales and NHS Northern Ireland with each operating in a slightly different way.
All offer the same basic services, but the biggest differences come with prescriptions. Scotland and Wales currently offer free prescriptions, while in England and Northern Ireland have a means-tested charge. Scotland also offers free social care service to the over 65’s while the rest of the UK does not.
From the top of each of these organisations, they are subdivided below based on geographical areas. If we take NHS England as an example, these are known as Clinical Commissioning Groups (CCG). From there, various organisations below it provide a wide variety of care but all fall under the same umbrella. These include Acute Trusts (which provide secondary care within the NHS), treatment centres, the Ambulance Service Trust, NHS Care Trust (which provides both health and social care) and the Mental Health Trust. Slightly outside of this lies the NHS pharmacies, dentists and opticians. While the names might change slightly, the same rough structure is used across the UK.
The NHS is currently the 5th largest employer on the planet with a staff of roughly 1.4 million. If you’re interested – and I know you are, the U.S Department of Defence, the Chinese Army, Walmart and Mcdonalds place higher. It draws this number from far and wide, and in 2019 13.4% of NHS workers were from outside of Britain, while the number of doctors was 28.4%.
For the fiscal year 2018- 2019, the NHS budget was a hefty £129 billion – and that is a number that is only going one way. It’s difficult to give any accurate figures right now because of the Coronavirus pandemic, but even if that hadn’t have happened, the budget would have likely grown by a minimum of £5 billion.
The vast majority of funding for the NHS comes from general taxation, with a small additional amount made from National Insurance contributions, which every adult in the UK pays. One benefit of the system is that there is next to no billing which saves enormously on administration costs.
To the British people, the NHS is both a source of frustration and immense pride. It is a service that has gone through some truly difficult times over the years but has always managed to battle through.
The Covid-19 pandemic has shown a light on the NHS probably more than ever in recent years. While it has remained relatively stable, it has highlighted huge deficiencies that have come from years of underfunding. Maybe we’ve all taken this grand old lady who reached 70 in 2018 for granted.
It’s difficult to say where we go from this point. Logically you would say that the NHS will receive a massive spending boost that it deserves and we can all happily continue as normal. But that will most likely depend on how deep a recession the UK lands in post-pandemic. You would think that healthcare would be prioritized after the biggest healthcare crisis of the modern era, but who knows when business and money become involved sometimes the less visible, more expensive options get missed – which is exactly what has happened to the NHS over the years.
As if this wasn’t difficult enough, the NHS will need to grapple with the booming cost of medicine and, as in many parts of the world, and an ageing population. Currently, 18% of the UK’s population is over 65, with that number expected to rise to just over a quarter in the coming decades. We are living longer than ever – which is great news – but does come with quite the economic conundrum.
Whatever you might think about universal healthcare and an organisation like the NHS, it’s difficult to detract from the 1.4 million people who currently work for it. From the doctors and nurses to homecare workers and rehabilitation specialists these people have not entered medicine for the riches, but instead choose to work for an organisation that, though it may be deeply flawed at times, stands for an ideal that the British remain proud of – that medicine should, and must, be free to all.