James Gubb: The NHS was a glorious idea, but it needs urgent treatment

THE NHS's aims have always been laudable – and they remain so today. A lack of money should never prevent anyone who suffers the misfortune of ill health from getting quality treatment.

It's no accident that its original mouthpiece, Sir William Beveridge's 1942 report Social Insurance and Allied Services, was apparently the Harry Potter of its time, selling some 600,000 copies at a time of war.

In return for everyone accepting a responsibility to contribute in their working lives, Beveridge assumed that "medical treatment covering all requirements (would] be provided for all citizens by a national health service".

By 1948, the Labour minister Aneurin Bevan, battle-scarred from numerous skirmishes with the medical profession, made such a national service a reality.

But from the outset the NHS was not all that was promised. In 1950, a leader in the British Medical Journal cried: "...(the NHS] is facing bankruptcy because of the Utopian finances of the Welfare State".

Both Beveridge and Bevan made the loose assumption that "the development of the service (would cause] a reduction in the number of cases requiring it".

Just 18 months later Bevan realised he had been very wrong. In "shuddering" at the cascade of medicine pouring down British throats he conceded: "We shall never have all we need; expectation will always exceed capacity."

This truism is infinitely more pertinent today. Medicine has seen unparalleled advances in the past 60 years and we – the consumer generation – are no longer content to put up with aches and pains and heaven-long waits.

We assume the NHS will provide instant access to all the latest treatments and drugs where none previously existed. But even if the NHS was more efficient, this is impossible. There is a finite budget.

Rationing – delaying, deterring, dissuading and declining treatment often under the guise of clinical judgement – is just as much a worry with a budget of near 100bn this year as with 437m in 1948.

Just last year 70 per cent of Primary Care Trust (PCT) managers reported restricting access to treatment, the most poignant example being high-cost cancer drugs.

Nor is the NHS delivering on its promise of equity. Unsurprisingly, in the battle for scarce resources, the more articulate middle-classes have garnered the most access to them.

Julian Le Grand, Tony Blair's former policy guru, has shown clearly that beyond seeing a GP, the NHS does significantly more for the employed, rich and better educated than the lowest socio-economic groups. Astonishingly, it carries out 30 per cent more coronary artery bypass grafts on the rich than the poor.

Nye Bevan would be turning in his grave. Yet successive governments

have largely served to make matters worse.

In his 1942 report, Beveridge was at pains to emphasise that "in organising security the state should not stifle incentive, opportunity and responsibility". In their direction and protection of the NHS, those at the top have done exactly the reverse.

For all the Thatcher, Blair and Brown administrations' rhetoric of choice, competition, plurality, 'patient-centred' care and apparently de-centralising initiatives, health care has become ever-more the domain of the state.

Driven by the same desire as the Conservatives to smash

"producer-interest" on behalf of the customer, New Labour has kicked the health service and clinicians like never before.

In 2000, the NHS Plan set some 121 targets on everything and anything. Political pressure demanded results and apparently at any cost; clinical priorities were distorted with the most perverse consequences. Earlier this year the Healthcare Commission released a survey in which, incredibly, only 46 per cent of NHS staff thought patient care was their organisation's top priority.

Of course, the Government now insists the target regime is over, but targets are just being replaced by other means. In a new report the Nuffield Trust, a respected health think-tank, describes at least 24 "quality-reform" methods that New Labour has used.

The latest idea is the most ridiculous yet, rating nurses on the compassion they show – a self-defeating measure if ever there was one. Paul Stanton, a former director of clinical governance in the NHS, is on the button in describing inhumanity as"a deep system property" of the NHS, not an individual one.

Around 58 per cent of the paperwork dumped on NHS organisations by regulation alone serves no internal purpose. We have created a bureaucratic monster.

Aneurin Bevan didn't just want a service that was good enough; he wanted a service that was the best in the world, the envy, even, of private wards.

It is patently clear the NHS doesn't occupy this position. Quality of

care is patchy, hospitals are unsafe, health outcomes on cancer, stroke

and heart disease are below the European average, patients'

experience of care is little better now than in 1997, integration of

care is incredibly poor and inefficiency is rife.

In the 21st century, we need a new paradigm. The NHS's core principle of universal health care free at the point of need should remain, but the means of delivering it must be dramatically altered.

The health service provides what is fundamentally an insurance against ill health; the problem is that it is a monopoly and subject to untold political interference.

Instead, we should look to Europe. Each and every patient should be given the means to choose between competing health insurers or groups of like-minded clinicians for whom to organise their care. The customer would then be you and me, not the government or he who shouts the loudest. With the power of exit, we might just get universal quality as well as coverage.


Your new NHS... will provide you with all medical, dental and nursing care. Everyone – rich or poor, man, woman or child – can use it or any part of it. There are no charges except for a few special items. There are no insurance qualifications.'

– The new National Health Service leaflet 1948

James Gubb is Director of the Health Unit at Civitas, an independent social policy think tank www.civitas.org.uk/nhs