1946 And All That

The Health and Social Care Bill has been, to put it mildly, rather contentious. This morning, the influential editor of the ConservativeHome blog published a piece urging the government to drop the Bill to avoid the risk of it fatally wounding the Conservative’s chances of winning the next General Election. Everyone seems to be united in opposition to it.

From the furious debate it would be easy to think that the Bill involved dismantling the NHS so that it no longer offered universal healthcare to all people in England, free at the point of need. It does not do this. It certainly does not usher in the derided American model of private healthcare or even the French model of socialised medicine which seems to work very well for French people.

One thing on which there is a broad consensus is that the Health Secretary, Andrew Lansley, has not done a great job of explaining what it does do and why it is a good thing (yes, this is an understatement). Looking at the Bill on its merits (bear with me!) its aim appears to be to open up the range of possible providers of NHS healthcare and to have them chosen, or commissioned, by GPs as being closer to the needs of the patients they serve than the old Primary Care Trusts. By broadening the range of providers there’s an assumption that competition will lead to improved quality of service, although this is highly dependent on the quality of regulation. Perhaps it won’t work, perhaps GPs aren’t capable of doing commissioning, perhaps it will just transfer one set of bureaucrats to a different place in the supply chain. Much of what is in the Bill is actually an evolution of the changes that had been put in place over the last decade or so – such as the ability of NHS hospitals to do private work to raise money to support their NHS work. Or, it merely makes express what was more opaque and implicit, such as the applicability of EU competition and procurement rules as I commented on a while back.

However, the substance of the Bill and what it does or does not do has been firmly relegated to the footnotes. The debate is now purely political – what impact on votes will it have, what sort of people are for or against it, who do you trust? Unsurprisingly, that means that the debate has also moved into being partisan and a little silly.

I was disappointed to see Ben Goldacre wading in in this vein. It wasn’t entirely his fault as he was responding to a foolish statement from a government MP about how the BMA was against the foundation of the NHS in 1946 but nevertheless the exchange was silly. Just as it is silly to think it matters much now that doctors were initially against the foundation of the NHS but came round in the subsequent couple of years, it is equally silly to raise, as Goldacre does, the fact that the Conservatives voted against the NHS Bill throughout its passage through Parliament. The point is that what either the Tories or doctors said or did nearly 70 years ago doesn’t really make much difference to what they are saying or doing now. Doctors were “allowed” to change their minds to favour the NHS (partly by having their mouths “stuffed with gold” in the famous phrase), the Conservatives also did, as can be seen by the fact that the MPs of 1946 didn’t move to reverse the nationalisation when they formed the government five years later.

The argument is spurious also because it shows how opinions can be changed by background. Goldacre mentions that the doctors of 1946 had all been trained into a profession where they expected to be private practitioners whereas today’s doctors have been brought up expecting to work their lives in the NHS. Yet, just as the 1946 vintage were capable of overcoming their backgrounds, why could today’s professionals also not change their minds about how the NHS should look? Particularly when the change is a less radical one than the one their forebears were involved with.

He went on to tweet that it would be inconceivable that for example lawyers would do anything other than object to a proposal (a la NHS in 1946) to nationalise legal services. However, I suspect that the contrary may be true. If lawyers who provide services to individuals were to be told that there would be a national legal service funded as generously as the NHS so that all who sought advice and representation could pursue claims to the fullest extent many would bite Ken Clarke’s hands off. The chagrin in the legal professions is that the opposite is happening in that legal aid has been steadily cut back over the years so that it is available to fewer and fewer ordinary people.

For what it is worth, I think the Bill is more modest than the outrage it has caused but that it would be a crippling capitulation for the government to drop it if it believes that the reforms it contains are necessary to improve the NHS. But even if that is (as it appears) a minority view, it should be attacked on the basis of what it actually says and does rather than who it is proposed by and what their forebears a lifetime ago might have believed.


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