The UK in the 1970s was very a different place to 2018. Well, in part anyway. No mobile phones, no iPads, no internet, the fax machine was king and we were debating whether to join what was to become the European Union.
But many of the challenges facing the NHS looked quite similar to today – so, too, were some of the proposed solutions.
The NHS had not undergone any significant reorganisation since its foundation in 1948, apart from the efforts in the early 1960s by the then Health Secretary, Enoch Powell, to establish additional hospitals and bring mental health in from the cold following the famous “Water Tower” speech. Despite Bevan’s famous quote that when a bedpan fell in Tredegar it reverberated around Whitehall, Ministers often struggled to make an impact; policy-making by exhortation as it was sometimes described. It is not even clear whether the ‘bedpan line’ was proof that Bevan intended for Ministers to be directly responsible for the day-to-day workings of the NHS.
However, whatever Bevan’s intention, in the 1970s, the NHS was still disparate and fragmented, run by so-called ‘feudal barons’, while essential functions like GPs, public health, district nursing and ambulances still operated outside of the nationalised purview. Even Powell’s sweeping reforms had relatively limited impact.
But the economy was struggling, the UK’s place in the world was shifting, domestic politics were increasingly unstable and geopolitically the world seemed to be going mad (sound familiar?). Perhaps in response to this there was growing dissatisfaction within and without the NHS about its financial and operational performance throughout the 1960s and further disruption through industrial action, involving 97,000 NHS staff about low remuneration. In the context of these developments, assumptions about the health service were changing.
In Nigel Lawson’s (not yet spoken) words, the NHS had begun to acquire the mystique of being “the closest the English people have to a religion”. It therefore wasn’t a question of whether the nation could afford a comprehensive health service, as it had been through most of the 50s and 60s, but rather how it should work.
The questions will also be familiar. Were the resources of the NHS being used and deployed effectively? How should the NHS deal with long-term conditions? What management structure should be used? What were the implications of changes in social care? How should the education of healthcare professionals change to meet the needs of patients? How should it use new and innovative technologies, such as new CT scanners, which were becoming more commonplace? What role should the private sector play? How powerful should the unions be?
For the first time since 1948, these questions required a more political solution.
In 1968, the Wilson Government published the first ever Green Paper on NHS reorganisation. This was followed by a White Paper in 1972 and ultimately the NHS Reorganisation Act 1973. To a large extent, we still live with the legacy of that first reorganisation: Baroness Serota, the Minister of State for Health and Social Security in 1970, said, “our basic purposes are to unite the National Health Service and to integrate its separate services locally.” That quote could have been spoken by any Health Minister since – from Dorrell to Hewitt to Hunt.
In his recent report on NHS England, Nick Timmins described the 1974 reorganisation as the first attempt at ‘command and control’. Many of the orphan services were brought into the fold – though some, such as dentists, remained separate – and health authorities were established to replace the regional boards and given a broader remit to plan for populations. Anyone even vaguely familiar with the NHS and its history may feel a sense of resignation from this description. Every reorganisation since has been aimed at broadening and narrowing the remit of differently named but similarly constituted bodies. Indeed, the current cycle of reorganisations has its genesis in the 1974 changes.
Many of the challenges facing the NHS today – finance, access to services, inequality, growing demand, workforce pressures, lack of integration and care quality – have their origins both in how the health service was initially set up and also in how policy-makers have gone about trying to reorganise its constituent parts. Policy-makers put their faith in an organisational fix in the 1970s. And they still do, with increasing frequency, as evidenced by reorganisations in 1982, 1990, 1994, 1999, 2002, 2003, 2006, and ultimately the 2012 Health and Social Care Act – the biggest reorganisation to date.
Each reorganisation reopens old policy debates about the nature of the NHS, what it is and what it should or shouldn’t be doing. The latest was divisive, and to some extent undid and reformed many of the changes brought about by the NHS Reorganisation Act 1973.
The 1974 reorganisation also provided a focus for a growing clamour for the NHS to be depoliticised with a separate board overseeing the day-to-day running of the service. This is another ongoing theme that would ultimately culminate in the 2012 Health and Social Care Act, which in the words of its preceding white paper, Equity and Excellence: Liberating the NHS, attempted to free the NHS of ‘political micromanagement’. For the first time, the bedpan or ‘bucket of slops’ no longer reverberates in Whitehall, but in Leeds. We are still waiting for the full impact of this to be realised, but it is clear that it will continue to have lasting, and perhaps not wholly predictable, repercussions.
The issues the NHS reorganisation in 1974 sought to fix are still familiar (and all the more pressing) concerns in our, post-Brexit, post-fax (though perhaps not in the NHS), internet-enabled world. NHS England – freed from ministerial ‘micromanagement’ – is undertaking activity to change how the NHS operates. But without primary legislation will they stick? These could fundamentally change how the NHS functions – multi-year funding rounds, mergers (with legal fictions to obfuscate statute) and breaking down the barriers between primary and secondary care. These are viewed with suspicion from many quarters, but would they be viewed with any less suspicion if carried out by a Whitehall Minister?
Since 1974, policy-makers have put their faith in organisational reform to solve difficult problems. And the current health secretary, Jeremy Hunt, has hinted that there is – for the first time since 2013 – more political will for change. People are asking ‘will it take yet another reorganisation to overcome the issues we still live with?’
The question policy makers should also be asking is: can the NHS take yet another one?
Peter Wasson, Account Director