Chris Bowlby looks at the history behind the current debate to reform the NHS
Reform of healthcare in England is one of the most hotly debated of the current government’s plans. And it is a debate with an unusually high reliance on assertions about the past. Critics of the plans claim they will lead towards privatisation, and warn of a return to a pre-National Health Service era, when quality of care was determined solely by ability to pay, with poorer people receiving little adequate care.
Supporters of change suggest the health service is returning, at least in part, to more mixed care provision with admirable historical roots. They suggest that revived ideas of more independent provision and greater patient influence would counter what is seen as the excessive centralised control of the NHS era.
One historian well placed to scrutinise such claims is George Campbell Gosling of Oxford Brookes University. He has researched healthcare in the decades before the creation of the NHS in the 1940s. And he focuses on a major period of change around the end of the 19th century, as care was modernised while social demand for care was transformed. Care had been a matter of the wealthier paying for doctors to visit them, while poorer sections of society depended upon hospitals, provided charitably or by the Poor Law.
But then changes such as improved technology meant hospital treatment became essential for all – doctors could not carry X-ray machines around in their bags. So, says Dr Gosling, “the better off started reluctantly accepting the necessity of hospital treatment. By the time of the NHS, doctors had started treating both their private patients and the so-called sick poor in hospital. Previously separate things were now happening in the same place.”
In one sense, therefore, different social classes now received more similar treatment. But did patients’ status change? Today’s reformers are keen to find precursors of the modern ‘consumer patient’. As the old Poor Law provision fell away local authorities began to run a public hospital system alongside continuing charitable provision. And many patients were now making greater contributions to their maintenance through direct payment or insurance schemes. But Gosling says he has found “little evidence that payment actually increased patient influence”.
Meanwhile hospital accommodation kept a “two-tier system in place”. Special rooms with one or two beds were created for middle class patients as their expectations – and the fees they paid – were substantially higher. Something of that system was carried over into the NHS with its controversial ‘pay beds’.
But what is also striking, Dr Gosling notes, is that income from private patients remained marginal to hospitals. “The desire of the medical profession to keep private practice and hospital work separate was crucial.” This was partly to protect lucrative opportunities for private practice. In hospital treatment, however, sensitivities about profit were always evident. Studying interwar Bristol hospitals, Gosling discovered that they “did not move into healthcare for profit, but rather maintained philanthropic commitment to treating the sick poor”.
Also evident for many decades has been the debate about how far healthcare and hospital provision should be centralised and standardised. From the early 20th century, argues Dr Gosling, there was much agreement that the inherited system was too variable and fragmented. Yet the march towards more collectivised provision as the NHS was created was not always decisive. Compromises were made between central and local government, or between government and the medical profession.
And since the 1980s politicians have been proposing more independence and mixed provision for care providers as they try to increase market competition and restrain the costs of a service free at the point of care.
So future provision, if reform continues, may make healthcare look in some ways like its precursors in a more localised, mixed provision era. But what will remain constant is the debate about how uniform care can be provided across society, whether providers should make a profit, and how doctors reconcile their public and private roles.
Chris Bowlby is a presenter on BBC radio, specialising in history
This series is produced with History & Policy. You can find out more about them and read their papers at www.historyandpolicy.org