one - The NHS as wealth production

Summary

All health care systems, even including those so unsystematic that they are hardly worthy of that name, claim to produce something. So one way of looking at them is as production systems, with measurable inputs, outputs and social relationships within their processes, so that different ways of organising them can be compared.

From 1948, when the British NHS began, until the early 1980s, when successive governments began to re-introduce most of the features of industrial commodity production and competitive distribution, the NHS was much simpler than any other national public care system. It included every person living in, or even visiting, any part of the country who found themselves in need of medical or nursing care. All contacts between patients and staff, all diagnostic investigations, and all medical or surgical treatments, either at home or in hospital, were entirely free. So were all dental care (including orthodontics), spectacles, hearing aids and a wide range of simple appliances like crutches, sticks and surgical footwear. Direct patient charges (in health economists’ jargon ‘co-payments’) were introduced for the first time in 1952, four years after the service began, starting small but ending very big indeed for some services, most notably for dentistry – but even today, compared with almost all other countries, the NHS is still a universally available service for UK citizens, free at the time of use for more than 80% of users.

Virtually all the wide variety of British hospitals were nationalised in 1948, by a single Act of Parliament, making elected government responsible for the employment and distribution of what soon became, and has since remained as, the largest single workforce in the world after the Red Army. For complex reasons explained in Chapter Four, general practitioners (GPs) were left as independent self-employed contractors, paid by the state to provide a public service, but initially, at least, left free to define for themselves what they actually did. Private practice remained legal and, for about half of all consultant-level specialists, provided significant (sometimes colossal) added income. For most GPs, private practice either vanished, or became a marginal activity.

Originally, all NHS funding was intended to come from taxation, which in those days mainly meant income tax.