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Read our new booklet, produced in association with UNISON, the public service union, in recognition of the 60th anniversary of the NHS.

This lively, readable guide to the country's best loved institution explores the NHS from its birth in 1948 to the latest reforms of the Blair/Brown governments.

To order:
Price per copy
£2 + £1 postage and packing
Price per 5 copies
£8 + £1.50 postage and packing
Order from NHS Support Federation, Community Base, 113 Queens Road, Brighton, BN1 3XG. Email info@nhscampaign.org.

The NHS is born

The public relies on it. Politicians joust over it. The media makes dramas out of it. The NHS is a mountain in the British consciousness. Since its birth in 1948 the NHS has evoked strong feelings and not a little controversy. We will all rely on its services at some point in our lives and the successful treatment of hundreds of millions of patients since it began is undoubtedly at the heart of its popularity. It was conceived to replace a patchwork of charity, private and municipal hospitals that left many people without care because they could not afford the fees for treatment or medicines. The decision to provide care free at the point of use and to share the cost fairly through taxation was ahead of its time.

Professor Harry Keen, then in the early days of his career as a GP, recalls that the impact of the NHS was immediate. “Before, all working men were covered by the National Health Insurance, but this did not extend to their wives or families, who had to pay. At the end of each consultation with an uninsured person, there was the awkward moment of collecting the fee – usually two shillings or half a crown – which was slipped into one’s trouser pocket. By the end of a busy day, the pocketful of loose change bulged and tinkled.

“Just before the Appointed Day [5 July 1948], I had visited a home on a large, new estate where little Billy had come out in a measles rash and started to cough with the bronchitis that often accompanied it. I examined him, wrote a prescription for some medicine, received my two shillings fee and said I’d call back in a couple of days. When I returned, the mother informed me that Billy was a lot better. But as we spoke, a loud hacking cough came from upstairs, and I commented that he didn’t sound better. ‘Oh, no,’ said the mother, ‘that’s not Billy, it’s Johnny, his brother.’ When I offered to take a look at him she said, ‘I’d rather you didn’t – we really can’t afford it. He’s just the same as Billy, so I’ve given him some of Billy’s leftover medicine.” It was 5 July. I told her that from that day it wouldn’t cost her anything and eventually walked away feeling much lighter in my heart as well as my trouser pocket.

“The transformation that the NHS brought about in British medicine can only be
imagined now. The relief from the burden of financial anxiety was palpable. Finally,
after all the bitter argument and controversy about bringing in the NHS, it was the
unequivocal and enthusiastic support of the public that so conclusively won the
day,” says Professor Keen.

A recipe for success

Eric Best spends some of his time as an NHS patient thinking about what makes the NHS work

As I crossed the hospital in my most recent NHS visit from Xray to ECG, to blood pressure test and finally to the consultant it occurred to me that I was getting a large helping of NHS time and resources. Everyone understands the phrase “it’s on the NHS”. It describes one of the great benefits of our health system - not worrying about paying for health care when we need it. But there must be more to the peace of mind that the NHS provides...

Much of the public support comes from an appreciation for NHS staff and the work that they do. An ethos of public service is still prevalent and means that the NHS is full of committed people who genuinely care about the needs of patients. This is how the NHS has built up and retained public trust throughout its 60 year life. In many ways the NHS is like a recipe, defined by the combination of key elements. Each generation can adapt it, but crucially must retain the key ingredients for it to be recognisable and keep the same important qualities.

Recipe for a traditional NHS

Serves: a nation of 60 million on a daily basis
Ingredients:
1. No charge on the door
Most care in hospital or from your GP is still free. But, these days, even as an NHS patient, handing over money to your dentist is almost inevitable. And we seem to be getting used to it. It’s happened with long-term care too. But there was a time when both were free under the NHS. Cost pressures and market reforms – which mix public and private under the same roof – mean there’ll be a further drift towards charging. Then how easy will it be to raise tax-based funding, if we’re already paying out of our own pockets?
2. Share the cost fairly
The whole idea of the NHS was to make healthcare available as a right, not a privilege. It was inspired by a group of Welsh miners who started a kitty to help pay for the care of those who suffered serious health problems. None of us knows when we will need healthcare, so we pool our resources, via tax, to pay for the treatment of whoever requires it.
3. Put patients first
This is possible because the NHS doesn’t work for profit – well, it didn’t used to. Hospitals are becoming businesses that must compete with private companies. The same is also true of the work of GPs. Commercial values are changing the way the NHS works. There’s now a lot of money to be made out of providing care. This is all part of the Government’s plan to create a competitive market for treating patients. But who will treat the patients that don’t make a profit?
4. The NHS is a network
As a group, if you have the same aim, you can work co-operatively. This is how, for many years, the NHS has shared ideas, staff, expertise and new technology. For instance, patients can be moved around the country to get the care they need. But here, too, commercialisation is undermining this advantage. Now that different providers are competing for NHS contracts, there is little incentive to help anyone else. You can’t run the NHS on goodwill, but it won’t work without co-operation either.
5. A right to healthcare for all
The NHS is not a charity for providing healthcare to the poor. By sharing the cost we can afford the highest quality care for all in our society. This is not how it works in the United States, where everyone makes his or her own provision. Forty five million people there have no cover and can only get second-rate healthcare. Even those who are insured can have funding refused for their treatment – insurers regularly employ medical experts to find ways to reject claims.
6. Less waste
It’s true. The NHS spends less on administration than most other countries’ healthcare systems. This will change as transaction costs for areas such as billing and marketing increase. The new NHS market is a huge cash cow for lawyers and accountants and hospitals have even started to advertise for patients.
7. Staff committed to high standards
The NHS is committed to training its staff well, enabling them to apply high professional standards to the care of their patients.
8. Healthcare to fit need
Ideally, all local organisations and staff would work together to develop services to meet local needs – successive governments have even agreed with this. But recently the commercialisation of the service has meant that there is no incentive for that to happen.

How national is the NHS?

The signs are that devolution is creating four very different ways to organise health services. In each of the home countries there are ideas that are distinct and even somethat are contradictory. England champions competition between all healthcare providers, public and private alike. But in Scotland they are returning to traditional themes of cooperative planning. In the past the dominant ideas from the political centre in Westminster have ensured a one track approach but no more. There is now room for some free expression and perhaps a real chance to see which healthcare ideas really work.

Where did their love go?

Not everyone is in love with the NHS , some disagree with it on principle or think that it can never work. What do these opponents of the NHS say and are they right? Here we respond to some of the arguments put forward by the NHS doubters.

“The NHS is doomed because it can’t keep up with the costs of new drugs and treatments”

This pressure exists in every healthcare system around the world. New treatments and drugs are being developed all the time and push up costs by around 2-3% a year. This is why it is essential that the government maintain their commitment to adequately fund the NHS. In other countries the cost of medical advances is passed on to the individual in the form of higher insurance premiums or medical fees. Whilst the NHS is funded through taxation it has the fairest system for handling this pressure.

Also medical advances can help save money. Treating more hospital patients as day cases, with less invasive techniques such as key hole surgery, has reduced costs and speeded up patient recovery. Investment in detecting illness earlier also saves money. Better treatments mean that conditions like diabetes and heart disease can be managed effectively without visiting hospital.

There have been many changes in treatment since the NHS began. To its credit the NHS has incorporated many of these into its service, making them available to the whole population. This will become more difficult as the NHS moves away from being a cooperative network, toward a more fragmented set of competing businesses.

“The NHS is a big hole into which public funds endlessly pour”

Overall our NHS costs over a £100bn a year, a bafflingly large number. In fact it’s almost a fifth of overall government spending and roughly equal to the value of the entire economy of Finland. But then the NHS does employ 1.5 million staff (ONS) and treats 1 million patients every 36 hours. It is undoubtedly a massive and costly exercise, but despite this it might surprise a few critics of the NHS that a recent international comparison by the Commonwealth Fund put the UK top of the table for providing value for money.

For decades the NHS has struggled to do its job on far less investment than most other countries. But in the last five years consistent increases in spending have pushed the UK to just under the international average. But we are coming from a long way back, so even though the amounts of public money going in are large, it would be wrong to think of ourselves as big spenders on health, or of our health service as expensive.

Costs will rise every year but it is vital that money goes on patient care. Worryingly in the last few years the government’s drive to introduce competition and the private sector has meant more waste than previously. We should bear in mind the last experiment with
competition in the NHS in the early 1990’s, which doubled administration costs.

“The private sector is more efficient than the NHS and can help it keep down costs”

There is no evidence that the private sector involvement in the NHS has made it more efficient. In two specific areas its impact has been the reverse.

Private Finance Initiative (PFI)

Under this scheme NHS trusts have signed contracts with private consortiums to fund the building and maintenance of new hospitals. There is now overwhelming evidence that this is a hugely expensive way of building hospitals. According to a Parliamentary answer £8bn worth of PFI building projects will cost a staggering £53bn across the course of the contracts.

This has a direct effect on patient services as hospital trusts pay rent and maintenance provided by the PFI consortia first, which puts pressure on the budgets for other services.

Independent Sector Treatment Centres (ISTCs)

are private clinics usually specialising in straightforward treatments, such as cataract operations or hip replacements. The NHS signs contracts with private companies to carry out the work at a fixed overall price, which is paid whether the operations are actually performed or not. This means that ISTCs get special treatment, with contracts that guarantee full funding regardless of how many patients opt to use their services.

The government originally made lofty claims that ISTCs would provide the extra capacity to cut waiting times, stimulate innovation and choice. A Parliamentary report by MPs found that this was not the case. And the Government’s own figures confirm that ISTCs cost on average 11.2% more than the NHS alternative.

Many commentators believe reductions in waiting times cannot be attributed to the private sector either. Former Labour health secretary Frank Dobson said “In 1998 we did 170,000 cataract operations. In 2004 we did 300,000. The private sector did just 20,000 operations. It wasn’t the private sector that brought down waiting lists.”

“The NHS is too inflexible, will never meet expectations and so we must change to a more European style system”

In the UK we fund health care largely from public taxes. The most popular alternative in other countries is to pay into some form of insurance scheme. This can be set up either by the government, or by encouraging people or employers to buy private medical insurance.

No solution in funding the NHS like France and Germany.

There is no point in changing to a way of funding that is less fair and costs more to administer. Social insurance as used in France and Germany would increase costs to patients and to employers, who may well move businesses elsewhere if they had to contribute to employees’ health care fees. Less care would be provided free at the point of use and more costs would be picked up by the individual. There is no evidence to show that core problems with waiting times and quality of care would be improved simply by changing the way we collect payment for our health service. It is interesting that no other country that funds their health care through taxation has moved to social insurance and yet there are countries, including France that are moving the other way.

The NHS Confederation, which represents health service managers, said it was an “inescapable fact” that health costs across the world were rising faster than people’s
willingness to pay. Its policy director Nigel Edwards said, “If healthcare is not sustainable by tax, there’s no reason it would be sustainable by social insurance. The basis for social insurance is directly from people’s incomes and is usually compulsory - that sounds to me
like a tax.”

Charging fees will end the NHS - some suggest that patients should pay more. In France and the Netherlands about 20% of total health expenditure is from private sources. Charging patients does place the burden of care more heavily on the poor or unemployed. No evidence exists that charges deter only unnecessary use, and evidence from Sweden shows that they reduce access. Only a very significant expansion of the use of charges or co-payments would have anything other than a very,limited impact on the issue of resource constraints.

It would be an end of the idea that the health service should make healthcare available to all its citizens. Using the same funding system as France or Germany won’t help shorten waiting lists - countries with social insurance still have long waiting lists, for example the Netherlands. The level of underfunding of services has in the past left them overwhelmed by demand. Even if enough staff and beds are available if funding runs out
patients are made to wait until the next funding year.

Health systems across the globe are suffering under the same pressures. Health costs and patient expectations are rising and at the same time medicine continues to find ways to do more. However no other system of funding offers us a better way to respond to
these pressures.

A day in the life

Dr Nick Edwards gives his account of a day in his working life. These extracts are taken from his book “In stitches – the highs and lows of life as an A&E doctor”.

One day a lady in her 80s was brought in by ambulance after becoming increasingly short of breath. She came in with her husband of 58 years. She had been very unwell the last five years since suffering a stroke and then having a series of mini strokes causing a form of dementia (called infarct dementia).

The husband has refused all previous plans to put her in a nursing home, as he had made a promise five years ago that he would look after her himself. She was immobile, incontinent and had severe dementia, but he had still kept to his word. Day after day he
lovingly cleaned her, held her hand and talked to her. He was an angel in every sense of the word. Before the ambulance arrived, we had got a call explaining that they thought she might have suffered a respiratory arrest (ie stopping breathing). As soon as she arrived I could see how unwell she was. My SHO (junior doctor) gave oxygen and fluids and organised a chest X-ray, while I talked to the husband.

It soon became clear what the situation was. Taking over her breathing and sending her to ICU was not an appropriate thing to do. It would be more humane to let her die peacefully. I explained this to the husband. He broke down in tears and just said “I can’t cope any more and nor can she.”

I smiled and invited him to be with her. She spent the last few hours of her life held tightly by her husband, listening to him tell her how much he loved her and recounting all the good times they had in the past.

It was a sad but beautiful sight that I felt privileged to witness. Emergency medicine is not just about the high drama of saving someone’s life.

Sometimes the most important skill in medicine is knowing when to let nature take its course and not interfere. It was sad to see but also the right thing to allow to happen.

“The effects of bloody accounting rules…”

It’s not just me who gets annoyed with how accounting rules forget about patients. I went to a conference last week and heard a story about a patient from a fellow A&E doctor. A 45 year old man had come to A&E. He had tingling in his thumb, index and middle finger – it’s called carpel tunnel syndrome. The irritation was so bad that he was
having trouble sleeping. He had seen his GP and had been referred to the local surgeon, who with a couple of minor cuts to the structures in the wrist, could resolve his problem.
However he hadn’t had the operation. The surgeon had available time, there were some brand spanking new theatres and the day ward had a lot of free space because the local private treatment centre had nicked most of their patients. The problem was that new budget rules mean the PCT pays for each individual operation and his local trust was overspent. His referral was put back until after April, and the government could say that it had fulfilled its targets.

The people who weren’t happy were the surgeon and theatre staff, who were bored with twiddling their thumbs and the A&E doctor who had to give out strong pain killers at 2.00am for a problem that could have been sorted weeks ago. And let’s not forget, most importantly the patients.

Dr Nick’s lie detector

How patients lie....

Patient says: I am an ex smoker
Means: I gave up an hour ago

Patient says: I don’t drink much
Means: I drink less than my doctor

Patient says: Will you break confidentiality with the police?
Means: I have been very naughty

How doctors lie....

Doctor says: This won’t hurt
Means: It will hurt

Doctor says: don’t worry I have done this procedure loads of times
Means: Don’t worry I have read about this procedure earlier today

Doctor says: Ermmmm..... I’ll just be a minute
Means: I haven’t got a clue I’ll just look on the internet for some inspiration

Doctor says: so what accident and emergency do you have
Means: Why are you wasting my time

Doctor says: I’ll get a second opinion
Means: I still haven’t a clue

A source of pride

Dave Prentis
UNISON General Secretary

The NHS reaching 60 is something that everyone in the country should take immense pride in. As commentators and politicians continually remind us, the NHS is a defining feature of life in the UK.

And the NHS is a particular source of pride for UNISON. Above all, it is a human service: people caring for other people, and different parts of the service working together in partnership. The members of UNISON, and those of our predecessor unions, have been instrumental in the huge leaps forward in care and the population’s health that the NHS has brought about.

Our members have been in it from the start, and to this day UNISON remains the largest and most active health service union.

The NHS provides security and peace of mind; a certainty that you will be treated regardless of the cash in your pocket or the credit card in your wallet. This is what distinguishes our system from those, such as the US, where only those that can afford to be treated get the care they need.

Of course, so much has changed since 1948 and the NHS has proved remarkably good at adapting. But the essential values and aspirations that held sway in 1948 are still relevant today: care that is free at the point of need, accessible to all, and comprehensive. These, and not greed or personal wealth, are what continue to motivate the UNISON members that form the backbone of the NHS.

After all, health workers are all potentially patients as well. Everyone will use the NHS at some point in their lives, so staff want to see improvements as much as everyone else. And there have been massive improvements, particularly in recent years with proper
investment and an engaged workforce transforming the care that, for example, cancer, heart and stroke patients receive. Changes that make staff proud and for which they deserve their share of the credit.

And finally, it is this pride in the NHS and the desire to retain peace of mind for future generations that motivates UNISON’s campaigning: against those that wish to move away from free, comprehensive services, and against attempts to break down the collaborative ethos of the NHS with market reforms. Markets that are not bound by compassion, but by the desire to make money.

Instead, as it moves into its next 60 years, the pursuit of fairness and equity must remain the key goals for the NHS and all those that work in it.