Social State: The Most Important Part of the Welfare State: The NHS
Want, Ignorance, Idleness, Squalor and Disease. Of these five ‘Giant Evils’ identified by Beveridge the most important is the last one: disease. If you are sick or infirm the problems of the other four evils are amplified and become insurmountable. An effective welfare state puts health first, and for that reason the NHS is the most important part of our welfare state.
The NHS is the last safety net of all those that the welfare state provides, when all the other agencies have failed you, the NHS is still there. It is always there.
The fundamental characteristic of the NHS is that treatment is based on clinical need not ability to pay. Everyone receives treatment appropriate to their condition. Equality is so deeply embedded within the NHS, that it is no wonder that those who believe that the world should be based upon status and privilege should want to destroy the NHS: such a bastion of equality threatens conservative thought. But such conservative thought has been codified into the Coalition’s Health and Social Care Act and our NHS, the most important part of the welfare state, is under threat.
Right at the very beginning of our NHS there was a pledge to provide a service that was comprehensive and universal; available to all regardless of income or location. These principles are precious yet vulnerable. Reforms over the last two decades have chipped away at these principles and the final push to abolish them takes the form of the Health and Social Care Act.
Under the guise of “localism” the Act allows a postcode lottery. We now have the situation where patients in one area will get the cataract removed by the NHS from just one eye, whereas patients in another area will have cataracts in both eyes removed. Two people treated differently because of their location: breaking the founding principle of “no limitation on area of residence”. Breaking the NHS founding principles is a core purpose of the Act.
NHS care is delivered according to clinical need and without judgement. The NHS does not have a concept of “deserving” patients and “undeserving” patients; it has no mandate to withhold treatment simply because the patient is considered undeserving. The NHS will treat a fracture whether it is drug-user who’s fallen down a stairwell, or a young man playing Rugby, or an elderly woman who’s slipped on a rug. In pain we are all equal and it is a principle of the NHS and the welfare state, that we are all treated equally. But if the Right get their way then if you fall over when you are drunk it means you are the undeserving patient and you’ll get a bill for your care.
The welfare state depends upon public provision. Private provision does not lower costs. Indeed, it has the opposite effect because funds leave the service as profits, in contrast to publicly-owned Foundation Trusts where surpluses are retained to deliver more services. The government intends there to be an NHS market, but markets depend on expensive excess capacity and on easy entry and exit of providers. NHS providers have a 65 year history of continuity, whereas the market model, reliant upon easy exit, implies short lifetimes of healthcare companies. A recent study by Duedil showed that the average lifespan of healthcare companies is 5.7 years; this is no comfort to a patient with a long term condition who will want their care provider to have a lifespan longer than theirs.
The NHS is tax-funded, spreading the risk of healthcare across the entire nation, but this principle is under threat.
In the first reading of the NHS Act 1946 Aneurin Bevan said “I believe it is repugnant to a civilised community for hospitals to have to rely upon private charity.” The repugnance that Bevan voiced was funding healthcare through charity donations and he made a passionate argument for the public funding of the NHS. But under the Coalition we are seeing the biggest squeeze of public funding of healthcare in modern times. The so-called £20 billion “efficiency savings” is actually a £20 billion underfunding and if there is a Conservative victory in 2015 the underfunding will continue possibly until 2020. This gap caused by this underfunding is so huge that it may lead to co-pay or cash strapped NHS hospitals may return to Bevan’s repugnance: charity funding.
The five ‘Giant Evils’ identified by Beveridge are collectively dealt with by public health. Under the Act public health has been moved to local authorities and some people think this is where it should be since housing and transport are all local authority responsibilities and have significant influence on public health. But issues are appearing with the government’s policy. The funding is nominally ring fenced but there is a danger in moving from an inherently non-political organisation like the NHS to an organisation shaped by politics. Providing sexual health services for drug-using prostitutes is not a vote winner, but it is still a vital public health service, and a universal, comprehensive service treats us all. As funding gets squeezed politicians may use public health money in ways that their electorate will approve, rather than where it is most needed.
There is a problem that the move to local authorities may curtail the ability of Directors of Public Health to act in the public’s best interest. Labour argued during the passage of the Bill that the public health doctors should be protected from dismissal to enable them to be critical of local authority policies if they affected public health. Such protection is not in the Act, and so there is a danger that such policies will not be challenged.
The NHS is in serious danger. The combination of underfunding and a move to private provision will destroy the fundamental principles of the NHS being a universal, comprehensive service. If that happens, the entire welfare state will collapse.
This is why the 2015 election is so important. Most of the new structures will only have existed for two years and the damaging market will have hardly been established. A policy of NHS preferred provider will enable the NHS to plan provision and strengthened democratic oversight from Health and Wellbeing Boards will ensure that commissioning is both efficient and effective.
It can never be possible to remove all private companies from the NHS so policies should be developed to make those companies more publicly accountable. Companies providing patient-focused clinical services should be subject to Freedom of Information requests and should have public board meetings. The new ability of Foundation Trusts to have private patients is controversial. The main force behind this is not the trust’s ability to make money from private patients (there is little evidence that the NHS benefits) but from doctors who wish to earn extra from private work. In no other sector is such “moonlighting” allowed, so an incoming government should correct one of the few mistakes in the 1946 Act and ensure that NHS hospital doctors only work for the NHS.
An incoming government would have to view, with some urgency, NHS rationing, and should make steps to ensure that wherever you are in England you have the same entitlement to care. These actions will ensure that NHS is fair, equitable, comprehensive and universal.