“The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged”
Reading: A Free Heath Service, chapter 5 of In Place of Fear, Aneurin Bevan’s 1952 book.
I went back to learn about the reasoning behind some of the decisions made in the formation of the NHS. So much remains relevant.
Various funding alternatives (means testing, insurance, etc) are considered and dismissed. One conclusion from looking at alternatives is:
These schemes all have for their aim the consumption of the apparatus of health. But they leave the creation of that apparatus without plan and central direction.
In other words, you need a national effort to bring together the infrastructure for a nation.
In that section it was reassuring to see thought given to how someone feels when needing treatment, and that worrying about the funding is not helpful in making a recovery.
On the question of funding confusions and visitors:
Many people still think they pay for the National Health Service by way of their contribution to the National Insurance Scheme. The confusion arose because the new service sounded so much like the old National Health Insurance, and it was launched on the same date as the National Insurance Scheme.
And:
One of the consequences of the universality of the British Health Service is the free treatment of foreign visitors. This has given rise to a great deal of criticism, most of it ill-informed and some of it deliberately mischievous. Why should people come to Britain and enjoy the benefits of the free Health Service when they do not subscribe to the national revenues? So the argument goes. No doubt a little of this objection is still based on the confusion about contributions to which I have referred. The fact is, of course, that visitors to Britain subscribe to the national revenues as soon as they start consuming certain commodities, drink and tobacco for example, and entertainment. They make no direct contribution to the cost of the Health Service any more than does a British citizen.
That’s feels like spin, but there’s clearly something in that principle: money spent is taxed, and taxation is used to fund the service. The funding calculations are somewhat involved.
The Conservatives were not happy with the NHS from the start:
They knew the Service was already popular with the people. If the Service could be killed they wouldn’t mind, but they would wish it done more stealthily and in such a fashion that they would not appear to have the responsibility.
This was in part due to early over-spend:
Ordinary men and women were aware of what was happening. They knew from their own experience that a considerable proportion of the initial expenditure, especially on dentistry and spectacles, was the result of past neglect. When the first rush was over the demand would even out. And so it proved.
On private sector involvement:
Danger of abuse in the Health Service is always at the point where private commercialism impinges on the Service; where, for example, the optician is paid for the spectacles he himself prescribes, or the dentist gives an unnecessary filling for which he is paid. Abuse occurs where an attempt is made to marry the incompatible principles of private acquisitiveness with a public service. Does it therefore follow that the solution is to abandon the field to commercialism? Of course not. The solution is to decrease the dependence on private enterprise.
Also in relation to private health care inside the NHS:
Another defect of the Service, which was seen from the beginning, is the existence of pay beds in hospitals. The reason why this was tolerated at all was because it was put to me by the representatives of the royal colleges that in the absence of pay-bed sections in the hospitals the specialists would resort in greater measure to nursing homes. As the full range of medical facilities are available only in the hospitals as a general rule, the specialists should be there, on the spot, as much as possible.
Innovation and export opportunities where active at the beginning, here in helping with hearing:
The way that seemed to offer the best chance of success was to bring the hearing specialist and the aural technicians into conference with each other, to see if a satisfactory aid could be devised, which could then be put into mass production and distributed through the hospitals. The effort met with outstanding success. By September 1951, one hundred and fifty-two thousand aids had been distributed and the users are enthusiastic about them. They cost approximately one tenth of those on sale commercially. There is no reason why, after the home demand has been met, they should not prove the basis of a thriving export trade.
Regarding pay for GPs:
I was anxious to ensure that the general practitioner should be able to earn a reasonable living without having to aim at a register which would be too large to admit of good doctoring. To accomplish this I suggested a graduated system of capitation payments which would be highest in the medium ranges and lower in the higher. This would have discouraged big lists by lessening the financial inducement. The B.M.A. refused this, although now I am told they are ready to reopen the question.
There’s much more I could have quoted, but hopefully you get a sense of how interesting the chapter is. You can borrow the whole book over at the internet archive.