1948 healthcare: still appropriate today?

A privatised system?

‘Surely’, critics argue, ‘we should adopt a more privatised system’. It would increase the profitability of healthcare, reduce the strain on waiting lists and provide options for patients, thereby increasing overall satisfaction. The United States of America’s (USA’s) National Bureau for Economic Research published detailed analyses on the effects of hospital privatisation from 2000 to 2018. ² There was indeed significant increase in revenue per patient, accompanying a decline in hospital employment, and a reduction in the number of patients admitted and seen. Hospitals thus make an overall modest surplus per patient – a more ‘sustainable’ economic model. But the report also highlighted a worrying trend of widening health inequalities reflected in a preference towards more ‘lucrative’ patients and a decrease in access and utilisation of Medicaid (USA’s governmental health insurance for those with low-income and disabilities).

Here in the UK, alarming findings were highlighted in a British Medical Association (BMA) report from 2022. ³ Almost £14 billion were spent on Independent Sector Providers in 2020–2021, which equates to 5% of all elective NHS activity. These arrangements have been put into place to tackle the waiting lists, causing governmental NHS funds to be channelled to private organisations. Rather than the ‘modest surplus’ experienced by the hospitals in the USA, the NHS continues to lose money from elective work to Independent Sector Providers, while further reducing its ability to recover costs from emergency healthcare provision and provide good quality care to future patients.

Health inequalities

When the NHS was officially launched on 5 July 1948, at Park Hospital (also known as Trafford General Hospital today), health secretary Aneurin Bevan announced that healthcare would be available to all free at point of delivery and that it would be financed through general taxation. It was no mistake that the NHS was launched in the North of England. Mortality rates from this area were the highest in the country in the 1950s, ranging from 9% higher than the average population in Huddersfield, 18% higher in Manchester and Liverpool, and up to 20% in Oldham and Salford. ⁴ But these inequalities decreased in the decades after the introduction of the NHS. The 1960s and 1970s saw a narrowing of standardised mortality rates between the areas with highest and lowest mortality. The NHS was a hopeful intermezzo to the drama of 1948. From the melancholic death of Gandhi and on the backdrop of the tragedies of war, Bevan’s tune was perhaps UK’s ‘minor fall, major lift’. ⁵

One could argue that 1948 was a far simpler time than the world we are living in today, but this is simply not true. In 1948, the world had just emerged from two world wars. The UK, even though less badly damaged than some other European countries, nevertheless sustained significant destruction of buildings and cities because of numerous air raids. Between the 10 towns in the UK that experienced the most air raids, over 30,000 houses were destroyed across in excess of 2000 acres of land. ⁶ The resources poured into war forced the UK into staggering international debt, amounting to over 40% of its national income in 1945 and rising to an eye-watering 200% of its gross domestic product in the 1950s. ⁷ While the UK pressed on with rebuilding vital infrastructure and improving living conditions, Bevan recognised the power of healthcare to ameliorate existing socioeconomic inequalities. The NHS was not born out of a simpler time. It was part of a host of interventions to repair the fabric of a highly complex, cash-strapped, war-torn society.

Our forerunners were acutely aware of this. In 1956, less than 10 years after the launch of the NHS, a report by the Committee of Enquiry into the Cost of the NHS raised several issues. ⁸ These included changing trends in health and illness, the need for general practitioners and hospitals to work together, concerns around elderly care and economic constraints. That these problems, raised almost 70 years ago, are uncannily like those which brought about the push towards integrated care detailed in the Health and Care Act 2022, suggests an environment today perhaps not too dissimilar to post-war UK. ⁹

The year 1948 was not a simpler time, but the model of universal and/or free access to healthcare continues to be vital for reducing existing inequalities in society. Universal access has been successfully implemented across the world. The international buy-in is well demonstrated by several iterative campaigns by both the World Health Organization and the United Nations. From the Declaration of Alma Ata, through the Millennium and Sustainable Development Goal, to the more recent Triple Billion Targets, universal healthcare sits firmly as the only viable model that reduces health inequalities. These have emerged as sequels to what can only be described as a deeply hopeful cadence to 1948.

In December 1948, the United Nations’ Declaration of Human Rights was published. The entire statement is reproduced below for a full appreciation,

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

A modern model of health

These issues are somewhat outside of the traditional scope of healthcare. So, what else can healthcare workers do to alleviate the immense pressure on the system? Today, up to 40%–60% of personal lifetime health expenditure is spent in the last year of life, usually with little improvement to quality of life. ¹² Most people desire to die at home, but up to 60% end up dying in hospitals. ¹⁴ We can begin to address these issues within our systems.

NHS Scotland’s Realistic Medicine report reframes the way we approach healthcare. Its ‘value-based health and care’ prioritises shared decision making, which benefits individual patients and reduces costs. ¹² The use of words ‘health’ and ‘care’ shifts the focus away from disease management and widens the lens to include social care and social determinants of health. The report also highlights the need to consider the effects of modern healthcare on planetary health, something the Lancet Commission on Climate Change frames as an independent determinant of health that disproportionately affects poorer populations. ¹⁵ Part of the solution involves a shift of power away from professionals and institutions to people and communities, and an equivalent shift of balance towards community health. The related Lancet Commission into the Value of Death highlighted the need for society to regain its understanding of death. ¹⁶ It describes several ‘death systems’ around the world and helps clinicians and academics reframe the unrelenting pursuit of longevity. Similarly, books such as Kathryn Mannix’s With the End in Mind help general readers better understand the normal dying process and thereby fear it less. ¹⁷ By coming to grips with death and dying, we can learn to care for the whole patient and reduce the overall suffering caused by excessive investigations and interventions. These are but some examples of the change in culture required to reduce futile interventions, improve quality of life, address wider determinants of health, and of course, maintain the sustainability of healthcare.

The curtain has not closed on the NHS. It is not a show for paying audiences only, and its finale has not yet been written. It has and should continue to operate a model that reduces health inequalities. The system should strengthen collaboration with non-healthcare organisations to increase its resilience and better serve our increasingly complex population. ¹⁸ We should continue to build on existing patient and public involvement in research, which prioritises user-centred designs. Finally, by focusing on realistic medicine and humanising the many services we offer, both healthcare workers and patients can take part in the participatory theatre that is the NHS. In the first instance though, let us stop confusing health and healthcare. Considering that, allow your imagination to paraphrase this final quote:

I like your Christ, I do not like your Christians. Your Christians are so unlike your Christ. – Mahatma Gandhi