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National Health Service

The cornerstone of Britain's new 'Welfare State', now 60 years old

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On 5th July 1948 Prime Minister Clement Attlee made a BBC radio broadcast to the nation outlining the implications of the new tax-funded National Health Service. For the first time in British history, medical advice and care would be freely available to everybody, whether insured or not. All citizens would be protected from the 'cradle to the grave'.

Prior to this the provision of free medical care in Britain amounted to an ad hoc system mainly derived from the efforts of 19th century philanthropists and social reformers to help the poor. Although some low paid workers were entitled to free healthcare this did not always extend to their families. In addition, hospital fees had to be paid upfront, to be reimbursed later, but many poor people were unable to pay in advance. In essence, before 1948 healthcare in Britain was a privilege for those who could afford it.

The new National Health Service was the culmination of a series of policy proposals dating back to the National Insurance Act of 1911, which introduced a system of sickness and unemployment cover for low-paid workers. Subsequent landmarks in the advancement of nationalised social health care included the 1920 Dawson Report, which recommended the establishment of Primary Health Centres operating under the auspices of a single authority, and the 1926 Royal Commission on the National Health Insurance, which pioneered the concept of a publicly funded health service.

However, it was the groundbreaking 1942 Beveridge Report that provided the blueprint for the modern welfare state as we know it. Commissioned by Churchill's wartime administration to suggest ways in which Britain should be rebuilt after the war, economist Sir William Beveridge produced a report entitled 'Social Insurance and Allied Services'. Published in December 1942, it recommended a programme of national insurance, a national health system, secondary education for all, council housing and full employment, to combat the five 'giant evils' of want, disease, ignorance, squalor and idleness. The hardship of war had generated a strong sense of social solidarity in the British public and the introduction of a free health service in the postwar period seemed a logical and popular transition, in line with the new Labour government's commitment to a programme of public ownership of industries and services.

It was assumed by the government that a better health service would produce a healthier population that would make fewer demands on health services and social security benefits allocated for sickness and disability. In reality, the National Health Service became a victim of its own success. New developments in medical technology meant more people were receiving increasingly complex treatments. More mothers wanted to have their babies delivered in hospitals, cardiac surgery and joint replacements were regularly performed, and more costly drugs were being prescribed. Such advancements led to rising expectations of the service and initial estimates of the cost of the NHS were soon exceeded. In its first year, the running cost of the service amounted to £248 million, roughly £140 million more than forecast. As a means of raising additional revenue, in 1951, just three years after the creation of the NHS, the government introduced fees for dental and ophthalmic treatments. Aneurin Bevan, the Labour Minister of Health and key legislator of the NHS in 1948, so strongly disagreed with the imposition of these charges that he resigned from office on grounds of principle. Later that year the Conservative government succeeded Labour and moved to introduce prescription charges to address the new Service's escalating pharmaceutical bill, a system which has more or less been in place ever since.

While scientific advancements can impose additional pressure on health care resources, the discovery of new procedures and drugs can offset expenditure in the long term by precluding the need for surgery time and hospital treatment. The first decade of the NHS saw a plethora of medical breakthroughs. In 1953 James Watson and Francis Crick revealed their discovery of the DNA structure; the following year Sir Richard Doll established a link between smoking and lung cancer, and in 1958 a programme of polio and diptheria immunisation was launched, revolutionising childhood survival.

Medical advancement proceeded apace over subsequent decades with a succession of highly-publicised NHS triumphs. In 1968 the first NHS heart transplant was performed on 26-year-old labourer Patrick Ryan by Dr Donald Ross at the National Heart Hospital in London; and in 1978 Louise Brown made headlines as the first baby to be born as a result of in-vitro fertilisation. Breakthroughs in diagnostic scanning techniques, keyhole and non-invasive surgery, drugs and vaccines to combat cancer, HIV and more recently meningitis: all have meant improved health and an increased life expectancy for the population.

Since its inception the NHS has subjected to frequent and rigorous review. As early as 1953, concern over increasing expenditure led to the appointment of the Guillebaud Committee of Enquiry to assess the efficiency of the service. As it was, the report, published in 1956, stated that the committee found no evidence of inefficiency or wastefulness. Subsequent reviews have been less uncritical, among them 1980's Black Report, which highlighted a correlation between socio-economic position and life expectancy. The Whitehead Report in 1987 and 1998's The Acheson report reached similarly gloomy conclusions. Providing the best possible service within the limits of available resources has been an unrelenting challenge for governments, but any attempt to dismantle what is regarded as the 'sacred cow' of British politics has always been hotly contested. The NHS Plan of 2000, still being implemented, sets out a full-scale modernisation programme incorporating new principles of healthcare delivery designed around the patient.

Katy McGahan

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