How to save the Health Service

Frank Honigsbaum

  • The Politics of the National Health Service by Rudolf Klein
    Longman, 198 pp, £4.25, March 1983, ISBN 0 582 29602 1

For three decades following its creation in 1948, the National Health Service enjoyed a popularity unrivalled in British politics. It was called the envy of the world and ministers in successive governments vied to see who could do more to improve it. Now its survival can no longer be taken for granted. During the Seventies, the consensus which sustained it began to break down and it may weaken further in the years ahead. If it does fall apart, the public may lose its unfettered right to medical care: financial obstacles could become as common here as they are in America. Private hospitals and other forms of ‘creeping capitalism’ have already spread over the health map of Britain, and the right to free care within the state sector may end up being confined to the chronic sick and others who find it too difficult to bear the cost of private medicine.

Few members of any political party seem anxious to have this happen. Before it does, we need to know more about the consensus that sustained the Health Service for thirty years. How did it arise, what held it together and why is it now in danger of breaking down? Rudolf Klein’s admirable new book goes a long way towards answering this question. He traces the political development of the Service, starting with the consensus that formed it in the Forties and following its fate through three broad periods: one of consolidation which persisted throughout the Fifties; a second of growth and technocratic change, which began in 1960 and lasted until the mid-Seventies; finally, a third of disillusionment (and hardly any growth) which covers the period from 1975 to the present. He concludes with two chapters: one which attempts to assess the performance of the Service, and a second which speculates on its future.

All of this is done within the space of 198 pages. And though the subject is complex, Klein presents it so clearly that even those who know little about the Service will find it easy to follow. Nor will their interest flag. Insights illuminate every page, accompanied by sound judgments that are free from the cant which mars so much writing about the Service. From the standpoint of history, however, the book leaves much to be desired. At the start, Klein disclaims any intent to write a history of the Service, announcing that he will concentrate instead on those issues which offer most insight into political processes, but as a result key developments have been missed.

In particular, Klein has given too much weight to the hospital service, failing to recognise the crucial role which general practice played in the emergence of the Health Service. Would the doctors have even tolerated the thought of universal coverage if a large proportion of them had not experienced state service before 1948? As it was, some eighteen thousand GPs had grown to like the panel system which they had lived with ever since Lloyd George introduced his National Insurance Act in 1911. By 1938, only a few thousand GPs and some two thousand eight hundred consultants (which is all there were at the time) remained outside. Furthermore, roughly half the population was covered by the panel, and since 1930 the British Medical Association had made clear its willingness not only to accept provision for the dependants of insured persons but to add specialist medical services as well. (Throughout its life, the Insurance Act covered only insured persons and offered only GP care as far as medical benefit was concerned.) By the time planning on the Health Service began, the profession had committed itself to everything but hospital inpatient care for 90 per cent of the population.

The full text of this book review is only available to subscribers of the London Review of Books.

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