The NHS Consultants' Association

Editorial September 2005

SALUS POPULI SUPREMA EST LEX

Cicero lived in different times to those we inhabit. Nevertheless, his view that the health or good of the people is the first obligation of government still holds true. The only problem is how to achieve this, a problem addressed in turn by Adam Smith, Thomas Malthus, Karl Marx and Maynard Keynes. As the world changed, each shed new light on how the economy worked and introduced ideas that in their turn changed the world. All of their philosophies have contributed to the concept of democratic socialism, the only political regime under which the large majority of the indigenous population of this country has ever lived. And let us remember for a moment how fortunate we are.

In 1946, the first essay I remember being required to write at primary school was on nationalisation. I recall my English teacher saying to me, as I had precociously announced my intention to become a doctor, "You know, they are planning to nationalise doctors too." It occurred to me that this would not be too bad an idea, and the next year they did. What an extraordinary act of political faith! The country was on its knees. Our war hero, Winston Churchill, had faced the people in a post-war general election and had been beaten by his deputy, Clement Attlee. The voters at that 1945 election, the first I remember, had faced and overcome two tyrannies, the great economic depression of the 1930s and its German solution, fascism. Their solution was a Labour government, and it did not let them down in promptly making a reality of William Beveridge's concept of a Welfare State. My generation has been the beneficiary - free education through university, free health care, pensions, unemployment benefits, sickness benefits, affordable housing. It is hard to think of any generation in any country anywhere that has been so comprehensively protected and nurtured by the State. We have come to think of such benefits as our rights and have perhaps forgotten our responsibilities. How wonderful but ungrateful a society we must seem to the people of the poor world.

The Welfare State was indeed an act of political faith - faith that the country could afford it, that the NHS for example would somehow pay for itself by reducing the costs incurred in caring for the sick who would in future be cured. Many doctors opposed the idea, fearing a deluge of demanding patients and loss of income, but most adapted to it fairly quickly. When I entered medical school it was only 9 years old. As a houseman in 1962, our patients with heart attack were offered bed rest and crossed fingers. Our orthopaedic waiting list extended over three years. Our annual salary was £650, with a substantial deduction for compulsory residence. We had, I think, six weeks holiday but study leave was unheard of. We covered casualty at nights as well as the wards. One of my consultants only ever came in to do a ward round on Sunday afternoons - much of the rest of his time was spent in private practice. And of course the tax rates went up and up, and even on our poor salaries we were in the net. As a background to this scenario, most men worked in heavy industry, few women went out to work, and motor cars for most of us were a distant dream. It may seem strange to young people now, but we actually enjoyed working in hospitals in those far off days. There was a sense of camaraderie about the mess, a pride in working long hours in a job that attracted a great deal of public respect, and an extraordinarily effective working relationship between all employees of the hospital. But of course the work was never so intensive, so compacted into short hours, as it is today.

The survival of the NHS in those early years seemed to depend on two factors; what would now be regarded as unacceptable exploitation of the workforce's altruism (not just the doctors') and high levels of personal taxation. And it has to be admitted that it did not provide a very good service to the patients. General practice, in which as registrars we all worked in the evenings and at weekends to make a few extra pounds, was appalling. I remember the queues along the street outside one for which I did evening surgeries, over 100 patients, getting about one minute each. Hospital waiting lists were huge, and physicians, for all our airs, provided little useful by way of treatment. Outpatient clinics were little different from general practice. Two things did make a difference, however. First, the rest of the Welfare State protected the population from the consequences of de-industrialisation and provided the opportunities through education for individuals to rise from a traditional background of poverty. Second, the advance of medical and surgical science and their application in preventive and curative medicine contributed to the improving life expectancy of the population. But these are the very factors that are responsible for the present dilemmas facing politicians and us with regard to the future of the NHS.

Four factors: an end to exploitation of the workforce, reductions in personal taxation, an educated, longer-living, non-subservient population, and a dramatic increase in the preventive, curative and palliative powers of modern medicine. These are the four horsemen of the apocalypse facing the NHS. It is futile to rage against Governments for failure adequately to support the NHS without seeing how such factors influence their relationships with the electorate. I do not recall any Government since 1945 that has stated a wish other than to improve the NHS, nor can I think of any that has not claimed to be pumping more money than ever into it. I cannot recall any time at which the political leaders of the medical profession have done anything other than complain about lack of funding, predict its imminent demise or threaten mass emigration. However, recently, the profession has been wrong-footed by Government by the slogan "Putting patients first". While this was deeply offensive to most doctors in its implication that this is not what they had always done, one has to admit that the medico-political theme has always been that the benefits to patients would flow only when conditions and pay of doctors and other professionals became acceptable - in other words, putting patients a close second! I would contend that NHS pay and conditions are now very good for most doctors and other professionals (though not for those in more menial roles), and have been for a decade or more. So the first horseman has been given a boost - the workforce is no longer exploited, at a considerable cost to the taxpayer.

The second horseman, low personal taxation, has also been encouraged. A majority in this country apparently do not to appreciate the link between taxation and the funding of the Welfare State - this seems to be a political fact. We still hear calls for lower taxation and greater provision of services and political parties promise that this is possible through efficiency savings. There does seem to be evidence that low taxes are beneficial to the economy (and may even increase the total yield), and economic success is the sine qua non of welfare provision in a society (as the Soviet Union discovered). But "efficiency savings" - as someone who was responsible for running a Coal Board research institute through the Thatcher years, I know where these end up; loss of jobs, cost cutting to the disadvantage of patients, increasing stress and sickness absence among managers, inefficiency. There must now be little scope for major cost-cutting in the NHS; Mrs Thatcher's reforms produced a spiralling of unnecessary managerial costs with no obvious benefits in terms of patient care.

The third horseman, a changed population, poses the greatest challenge. The benefits of the Welfare State have now reached their likely maximum, and I doubt our children will be as fortunate as we were. There are justified anxieties about pension provision, and continuation of the societal benefits to which we have become accustomed is predicated upon continuing UK economic prosperity at a time when the global economy is shifting remorselessly eastwards. Never has it been more urgent for Government to support enterprise and innovative industry. At the same time the NHS has to provide for an increasingly elderly and unproductive population, with all the chronic and debilitating conditions that we accumulate as we get older. And we expect that provision - we are no longer prepared to wait patiently for years for a new hip or a coronary artery stent. That is the fourth horseman's fault. Medical science has prevented or cured most of the killing diseases of youth leaving us to grumble into old age, and now we can barely open a newspaper without reading promises of some new miracle cure for the ills of old age. We expect miracle cures, and I have benefited personally from some. All this increases costs.

Is there a solution? Can the NHS survive? The debate must be wider, no matter how much we support the concepts of the NHS and its founding principles. The question is, how best do we provide equitably for the healthcare of our population in the light of the need to sustain a healthy and globally competitive economy? Unfortunately, political science is not scientific and no answers can be given, only hypotheses that are politically untestable. Thus we get successive Governmental initiatives based on what seem good ideas to their originators. It is inescapable that better provision requires more cash and, if that cannot be found from taxation, other sources are required. The world has moved on from the 1940s and I would like to see more devolution of responsibility for health care to regions (answerable to local government and thus to local people, as in Scotland and Wales), much more diversity of provision, and more study of the effects of such diversity on outcomes - less central control. Nevertheless, the improvements in the NHS over the last ten years have been little short of amazing to someone of my generation, and many have come about because of Government pressure to bring the standards and facilities of the poorest up to those of the best. Some have been bought from the private sector, many at a price to be paid by future generations. While these moves may result in a better short-term service for patients, it is well to remember that costs transferred to the private sector entail both provision for profit and the future payment of interest; it is not unreasonable to suggest that such a policy will act to the long-term disadvantage of the NHS and could be a step back towards a pre-NHS two tier system of health care.

I have been a long-term supporter of the NHSCA for three reasons: our aims are clearly disinterestedly in support of service to patients, our members embody the altruism that is so necessary to maintain an equitable service, and the arguments our representatives put forward to politicians are carefully reasoned and assume that Cicero's dictum remains a guiding light for politicians. The NHS must continue to adapt to changing times, but its ideals are worth fighting for.