British Healthcare in a ‘Broken World’

As we approach the seventieth anniversary of its foundation, the NHS faces an uncertain future. The House of Lords Committee on the Long-Term Sustainability of the NHS is currently considering what the British healthcare system might look like in 2030. Given the demographic and financial pressures on the NHS, can it be made ‘fit for purpose’? With new experiments in the devolution of healthcare like those in Greater Manchester, can the NHS even survive in its current form? Should it survive in its current form?

In recent years debates about NHS funding, NHS reform, hospital waiting times, the provision of social care, clinical guidance and a range of public health issues, whether sugar, alcohol or vaccination programmes, have raged almost continuously. Health and healthcare are hardly ever out of the headlines. However, meaningful solutions which inspire public confidence to many of these problems appear to be in short supply.

What role should historians seek to have, what role can they hope to have, in this fast developing and potentially ‘broken’ healthcare world? How can we help to shape, or help the British public to shape, the healthcare of the future? What lessons can we learn from the reforms of the past, the political campaigns of the past, and the initiatives and innovations of the past, and how can they be applied today?

Chair: Alex Mold, LSHTM

Jennifer Crane, University of Warwick

‘History, Historians, and the ‘Save Our NHS’ Movement’

Celebrating the fortieth Anniversary of the National Health Service on 5th July 1988, the campaign group London Health Emergency (LHE) claimed that the foundation of this institution had marked ‘a remarkable and important stride forward for health care in Britain’.  At the same time, LHE also warned that the NHS was ‘clearly in need of intensive care and cash transfusions’, and urged campaigners to fight against cuts and privatisation to prevent a return to ‘the bad old days’ before 1948.  In this paper, I examine the history of this sense that the NHS was highly important, but also under threat, with accompanying fears for imagined histories and futures.

I argue that campaigning in defence of the NHS specifically emerges surprisingly late in the history of this institution – first in the 1960s and 1970s, in disorganised style, to defend local hospitals from closure.  From the mid-1980s, a new form of campaigning developed, which sought to defend the NHS nationally, as a whole, hand-in-hand with a sense of fear that the NHS would be destroyed in a world which was perceived to be changing rapidly, in political, economic and cultural terms.  Fears about this ‘broken world’, and its ramifications for the NHS, in part emerged out of local sites of left-wing renewal, with old and new campaigners attempting to defend the post-war consensus from Thatcher’s reforms.

Reflecting on the politics of this movement, this paper will question the roles and responsibilities of historians of activism in modern Britain.  By charting the history of the NHS, do we chronicle or even accept this sense of decline?  Can and indeed should historians mobilise this history to inform change, and if so how do we work effectively to do this with campaigners, policy-makers, or local communities?

Philip Begley, University of Liverpool

‘End of the ‘Tripartite Monster’: Reassessing the 1974 NHS Reorganisation’

During its sixty-nine year history the National Health Service has been reformed many times. The basic principles which underpin it may remain the same, but its structures and processes have changed significantly. This paper examines the first major reorganisation of the service in 1974. There have been more than twenty since, on average one every two years. The 2012 Health and Social Care Act was the latest but almost certainly will not be the last. However, the first significant changes only took place twenty-six years after the NHS had been established.

The 1974 reorganisation has been covered many times in histories of the NHS, but much of this coverage has been limited and there has not yet been a thorough examination of the relevant archival record. These sources have now been complemented by a witness seminar held in November 2016, which brought together medical professionals, civil servants, ministers and former management consultants, who were directly involved in the reorganisation or experienced it first-hand.

The reorganisation has been popularly remembered as a failure. While it could never be described as a success, by better understanding the context in which the reforms were brought about, the motives of those involved, and the process they went through, we can begin to develop a more nuanced assessment and learn some valuable policy lessons. While the policymaking process was often defined by a more abstract desire for modernisation, there was also a practical need for reform and uncertainty, delay and compromise were also significant factors.

Many of the ‘mistakes’ of the 1974 reorganisation have also been repeated in the course of subsequent reforms, demonstrating the poor institutional memory of the Department of Health. As the NHS continues to face an uncertain future, what lessons can we learn by looking again at this important moment in its early history?

Peder Clark, LSHTM

‘‘Problems of Today and Tomorrow’: Prevention and the NHS in the Late 1970s’

From the vantage point of 2017, there is much about the circumstances surrounding the publication of the 1976 public health green paper Prevention and Health: Everybody’s Business that might appear familiar. There had been a major health service re-organisation a couple of years prior, Health Secretary Barbara Castle had recently headed off a junior doctors’ strike, money was tight, and the service was struggling to cope with the challenges presented by heart disease, cancer and stroke. The list of ‘problems of today and tomorrow’ in the document included ‘Hospital admissions’, ‘Demographic changes’, and ‘Health problems for the aged’.

The solution suggested to these problems was not, as Castle and the UK’s other health ministers admitted in their introduction, new then or new now. Arguing that prevention was indeed better than cure, the consultative document proposed that in these cash-strapped times, the public would have to play their part: ‘To a large extent … it is clear that the weight of responsibility for his own state of health lies on the individual himself”. Prevention and Health went on to discuss what this responsibility meant: not smoking, drinking responsibly, exercising sufficiently, and eating healthily.

Prevention and Health served as a reminder to putative patients that an NHS free at the point of delivery was not without cost. The unhealthy behaviour of the public, it was heavily implied, was culpable for the increasing and unsustainable demands on the NHS. This paper argues that although Prevention and Health’s focus was situated in the particular moment of crisis for the health service, it was also redolent of a wider public health response to non-communicable disease. How does this history help us reflect on the apparently similar problems facing the health service today?

Gareth Millward, LSHTM

‘‘Leo [Blair] has Complicated a Very Sensitive Dilemma’ – Trust in Expertise and Government in the Pertussis and MMR Vaccine Crises’

Trevor Kavanagh wrote these words as political editor of The Sun in February 2002, at the height of the measles-mumps-rubella vaccine (MMR) crisis. The Blairs’ refusal to release their son’s vaccination status added to pre-existing doubts about whether government experts could be trusted when they said that MMR was safe, effective and necessary. The bovine spongiform encephalopathy (BSE), contaminated blood, Alder Hey and Bristol heart scandals were all fresh in the mind.

Similarly, in the 1970s media and voluntary groups demanded that the government provide a compensation scheme for those damaged by vaccination. Reports that the pertussis vaccine may cause brain damage had sent immunisation rates against the disease plummeting. Despite expert protestations about the safety of the whole-cell pertussis vaccine, the memory of the thalidomide scandal loomed large. Both the pertussis and MMR crises were not just about public faith in vaccinations, but in the institutions that provided them. Uptake of both vaccines was eventually restored through a series of government actions and external events; but in both cases, public health re-examined its relationship with the public in the hope of avoiding such crises in the future.

Given that faith in the institutions which claim expertise appear to be under strain again following recent political events, this paper examines what these medical crises can tell us about the public’s relationship with expertise. Medical expertise was contested, but not purely on scientific or – as detractors might frame them – pseudoscientific refutations of vaccine science. Rather, wider political anxieties over state power, welfare provision, medical institutions and the media allowed relatively minor disagreements from a minority of medical professionals to become major news stories with consequences for public health.