by Deborah Harrington

I am sure you will all have seen the NHS described as not fit for purpose because it is ‘a 1948 structure trying to deal with 21st-century problems’. Politicians say it, health ‘think tanks’ like the King’s Fund say it, the IEA and health ministers say it. Even NHS campaign groups say it!!

I would say that we don’t HAVE a 1948-style NHS anymore and haven’t for a long while, so whether or not it is or would be ‘fit for purpose’ is a moot point.

The 1948 NHS had a clear set of principles. It had a basic organisational structure designed to put those principles into action. Hospitals were very haphazardly located pre-1948 according to local charity or local authority available funds and inclination. Rich areas had more hospitals than poor ones, although the distribution of illness meant poor areas should have had more. Many hospitals were completely unfit for purpose.

The public service NHS set about doing something that no other health service did or does. It started a 20+ year programme of redistributing and modernising hospitals to try to provide the same easy access to high-quality care for everyone, regardless of issues of rurality or urban deprivation. The private, voluntary and even local government sectors don’t have the power to do that kind of national planning.

It never reached its optimal distribution because after 24 years of gradual change and development to meet its ambition, it ran into major political opposition in the 1970s (up til then both Labour and Conservative governments carried on the programme, after the mid-70s neither did).

GPs were also badly distributed and although they originally all (well, 96% of them) signed up to the NHS immediately and continued in their own locales, a more equal (although again never quite equitable) distribution was achieved by the 1960s. This was partly as a result of Enoch Powell importing a lot of Indian and Pakistani doctors in the early 60s (all already GMC registered) to put into the under-doctored poorer areas where white middle class doctors couldn’t be persuaded to work.

Universities were linked with major teaching hospitals and the NHS and British Universities were at the forefront of cutting edge medical technology and healthcare innovation.

In the 1970s, for lots of reasons, the political climate changed and the very principle of a planned health service which was fully publicly funded was no longer flavour of the month.

And we have had nearly 5 decades of a slow assault on both the founding principles and the structures designed to provide them as a result.

In addition we have to a large extent dismantled the welfare state which was designed to support and promote good health in the population.

The NHS is now run along entirely different lines. In the ‘paradox of productivity’ although it is run on commercial imperatives with finance in the driving seat this produces worse outcomes for more money. We have closed down entirely, or downgraded, District General Hospitals particularly in poorer and more remote locations on the grounds of ‘financial sustainability’ leading to decreasing life expectancy. We have removed essential social support and exhort the poor to take better care of themselves instead. We pretend that the problem is too many over-qualified staff (our staffing ratio is poor in international comparisons) and use ‘different skills mixes’ which saves money but not lives. We have driven GPs out of the service by making their working lives untenable.

And we no longer have 1 NHS. We have 42 Integrated Care Systems built along US Medicare lines run by boards which are staffed by McKinsey clones and US health insurance ex-executives or private healthcare representatives. The intention of NHS England is to shift our NHS model of a whole population risk pool assumed by the government to a risk-and-reward sharing system where the ICS will be given a fixed, non-negotiable, capitated payment from which they will bear the profit or loss themselves.

Absolutely not the 1948 system. Nothing like it.

( Deborah has asked us to change the title as she does not want people to “make instant assumptions about starched sheets and matrons! (And they will….) So now this post is called Back to the Future,

Deborah is co-director of Public Matters, a policy partnership which has provided the secretariat for an APPG ( all Parliamentary Group)and produces articles, videos and briefings on public policy, particularly the NHS.

Next, listen to Maxine Peake on the damage to our NHS