Welfare State

In the Welfare State We’re In, James Bartholomew argues that there wasn’t a need for the NHS to begin with. His basic premise is that the pre-NHS health system work perfectly well and we shouldn’t have changed it.

Healthcare in Britain was very substantial and impressive prior to 1948. Even the Labour Party pamphlet, which recommended a “National Service for Health” in 1943, could find little to criticise. There is mention of only one waiting list, for “rheumatic diseases”. That implies that there were no waiting lists for all the other specialties and no waiting lists to see consultants. There was no mention of any shortage of doctors (which is so chronic now) or, indeed, of nurses. There was no complaint either, about the quality of care.

At the risk of stating the obvious, that was then and this is now. The public expectations of what the NHS can do has driven up demand exponentially. And the fact that there were no waiting lists was because, for the majority of the population, consulting a doctor was the last resort.

He also overlooks the fact that the population has increased. In 1931 the UK population was 46 million, it is now 60 million, a rise of 30 per cent. The life expectancy then for men was about 60, now it is nearer 80 with all the health implications that come with age.

It’s a bit like saying that the railways were reliable and ran on time in the 1930s, so we should never have got rid of steam trains. Or since Hitler and Mussolini made the trains run on time, perhaps we shouldn’t have joined in WWII.

Nobody’s prefect. If you find any spelling mistakes or other errors in this post, please let me know by highlighting the text and pressing Ctrl+Enter.

2 comments… Add yours
  • Laurence 2nd December 2004

    It is often said that demands made on the NHS are far higher than those which used to be made on the medical service because of higher life expectancy and new technology. But I would welcome a proper, rigorous assessment of this. There is certainly some reason to think in some ways the demands on the medical service were greater in the pre-war years. T

    here was TB for a start, for which treatment was not very effective. So there was a requirement for many more hospital beds in which those who were sick long term could be placed. It was also considered necessary, by the medical opinion of the time, to keep people in hospital far longer than they are kept now. Women who had perfectly normal births could be kept in for a couple of weeks or more. My wife was not kept in hospital even for 24 hours when she gave birth to our two children.

    The result is that in the pre-war years, there were many more beds in hospitals. Time spent in a hospital bed is one of the most expensive aspects of a medical system. So there should have been an enormous saving from that, at least.

    Just in a recent ten year period, the number of hospital beds has fallen from 250,000 to only 200,000. And that is just the latest fall – the continuation of a long trend. Literally hundreds of hospitals were closed in the 1970s by the NHS. It would be good to know the exact figures on a properly comparable basis, but it seems likely that we have half as many beds as before the war.

    As for the idea that people had lower expectations, I am not sure this idea is supported by any evidence. In any case, the document I was referring to was a Labour party pamphlet. In such a document, the authors had every political reason for drawing attention to all and any failings of the pre-NHS system. It is very noticeable how little they found to criticise.

    It is also well known that in some ways, patients pre-war could expect far more from their hospitals. They could expect them to be clean, for instance.

    James Bartholomew, author, The Welfare State We're In,

  • Shooting Parrots 3rd December 2004

    Thanks for posting your thoughts James.

    I agree that some rigorous assessment of the scale of increased expectation of health care would be welcome, but it can't be denied that far more can be done today than in the past.

    And if you believe the Daily Mail, cancer cures are found every other week. That in itself must make (some) people believe that all is possible. Sadly, such articles always end with the words 'in ten years time.'

    The same rigour should also apply to your assertions of what health care was like pre-NHS. I cannot accept that it was better simply because you think so. Yes, there were more beds, mostly occupied by sick people not getting any better. The cures just did not exist.

    The fact that there are now fewer beds is hardly a yardstick of the effacacy of health care — it is simply a measure of how many are needed to accommodate sick people. You could argue that having zero NHS beds should be our aim as an indication a fully healthy nation. It won't happen of course because the sick will always be with us, or at least for the foreseeable.

    But back to expectations, I can't accept that they were greater in the golden age before the NHS. What I think the 1943 Labour party pamphlet was offering was not MRI scanners, or cancer busting drugs, or gender realignment, or IVF, or any of the other things we have come to take for granted. The deal was that you could see a doctor when you were ill and no-one expected cold cash.

    And while propaganda was known, this was the age before 'spin.'

    The 'hospitals were clean' argument is spurious. The modern 'fear' is MRSA. The clue is in the question. MRSA didn't exist pre-NHS. You could argue that it has arisen because of the NHS. It is with us because of antibiotics, their availability free of charge, the failure of patients to finish the course (because they were 'free') and hence the rise of resistant strains.

    The contrary argument is that should have ignored antibiotics. We would still have TB wards and many sick people. But at least there would be no MRSA.

    I haven't read your book, but have no problems with your provocative thoughts. They are just that though. Health, particularly public health is a complex beast that defies simple challenges.

    I have a DVD made by the BBC in 1955 of life and health in Salford. It was hard to see the conditions in whoch people lived within my lifetime. And yet they still do.

    Housing has improved (somewhat), the smog has gone (as has the work) and the poor remain.

    The test is can the children of the poor move forward? Is it wanted? Must their always be an underclass that is self-replicating?

    The welfare state has done its best and its failed. What is the anti-welfare state alternative? I don't believe that there is one. It is a continuum and the saddest, saddest political statement is that there is nothing to break.

    That is the failure of politics and politicians. They say they care. The realty is they couldn't give a toss.


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