What is "Britishness"? Part 12: Health and welfare

It has often been said that the true measure of any society can be found in how it treats its most vulnerable members. After the war in Europe had ended, a wind of change swept across Britain and one of the ways in which this expressed itself was with a radical shake-up of social welfare provision.

The situation at the time was that patients had to pay for treatment. Access to doctors, dentists, opticians and hospitals was limited to those who could afford it or workers who paid National Insurance Contributions. Most women and children were excluded. Free treatment was sometimes available from charitable voluntary hospitals and some local authority hospitals. Prior to the Second World War, there was already a consensus that health care provision in Britain needed to be reformed.

In July 1945, elections were held to choose a new government. The Labour Party, led by Clement Attlee, won a landslide victory and embarked on a major programme of reforms to tackle the ‘Five Giants’ of disease, want, squalor, ignorance and idleness. Between 1945 and 1951, the Labour Government implemented a series of measures which were designed to take care of the British people 'from the cradle to the grave' and would be paid for using money from taxes. Together, these changes created what came to be known as the ‘Welfare State.’

The National Health Service (NHS) was launched on 5 July 1948 by Aneurin Bevan, Minister for Health and was one of the first universal health care systems in the world. It had three core aims: to meet the needs of everyone, to be free at the point of delivery, and to be based on clinical need, not ability to pay. Since NHS was formed, the cost of providing care has continued to rise and some compromises have had to be made to manage the budget. The introduction of prescription charges in 1952 (reversed in Wales in 2007) and subsequent imposition of charges for eye tests and dental treatment mean that treatment is no longer completely free. However, with an aging population and cuts to other services such as social care and welfare, the pressure on the NHS has been increasing and the Conservatives, who originally opposed its creation, have consistently underfunded it. The severe austerity programme pursued by the Tories over the last decade meant that, even before Covid-19, there were waiting lists for many operations. The pandemic has exacerbated this situation.

From its earliest days, the NHS has always enjoyed a special place in the heart of the nation. This is reflected in the abiding popularity of the NHS in film, TV drama and documentaries, and literature. The NHS featured prominently in the opening ceremony for the 2012 London Summer Olympics, when it was described as "the institution which more than any other unites our nation." The country’s appreciation for the dedication and skill of our healthcare professionals could also be seen in the Thursday evening claps for the NHS which took place during the peak of the Covid-19 outbreak.

The UK spends around £170bn a year on health, which, at 20% of total public spending, makes it the single largest item of government expenditure. The scale of the NHS is huge: it deals with over 1 million patients every 36 hours, is the largest employer in Britain (and Europe) with more than 1.3 million staff, and is one of the biggest purchasers of pharmaceuticals in the world. The dilemma facing successive governments has been how to cope with rising demand for its services, whilst managing the budget and keeping the electorate onside. Although increased privatisation has long been viewed as the way to reduce the burden on the Treasury, fear of public retribution has meant that it has tended to be pursued by stealth.

The Conservatives first outsourced cleaning and catering services to private companies in the 1980s. From 1992 onwards, the construction of new hospitals was privatised through Private Finance Initiatives (PFIs). This idea was originally conceived by John Major’s Conservative government but later seized upon by New Labour (1997-2010) as part of their wider reforms aimed at transitioning the NHS from a public sector provider to become both a provider and commissioner of services by embracing the private sector more widely. This paved the way for the Tory-led coalition (2010-15) to legislate for the rapid acceleration of privatisation of healthcare in the Health and Social Care Act (2012), which provided for its break-up into smaller pieces (which might be sold or outsourced more easily), implementation of internal market structures, foundation trusts, GP consortia, further contracting out of administrative services, and introduction of private companies into the commissioning or providing of services, or both. Since 2017, the value of private contracts awarded in the NHS has nearly doubled, from £1.9bn to £3.6bn today. Some £15bn worth of services have been sold off in the last 5 years and therapy services, such as physiotherapy, elderly care, even cancer services, are now all facing privatisation. The Centre for Health and the Public Interest estimates that, excluding General Practitioners, £21bn or around 18% of total annual NHS expenditure was spent with private providers in 2018-19.

GPs have been an anomaly since the creation of the NHS, working as independent contractors under contract to the NHS. This did not matter whilst GP surgeries were run as small businesses focused on their patients and not on making profits and paying shareholders. However, the introduction of Alternative Provider of Medical Services (APMS) contracts in 2003/4 changed this by allowing companies to run chains of surgeries in which GPs became salaried employees rather than partners. These companies have a profit motive and, therefore, are not focused primarily on patient care. Of even more concern is the way that some of these companies are quietly being allowed to pass into the hands of US health insurers, such as the takeover in February 2021 of AT Medics, one of Britain’s biggest GP practice operators, by Operose Health, a UK subsidiary of US health insurance group Centene Corporation. The merger is expected to create the largest private supplier of GP services in the UK, with 58 practices covering half a million patients. Concerns have been raised by doctors, campaigners and academics who have called for an investigation into how GP services have come to be controlled by foreign-owned companies and what this might mean for the future care of patients and quality of service.

Since the 1980s, the Tory mantra has been to portray the public sector as wasteful and inefficient and the private sector as lean and competitive. In reality, the impact of the introduction of the profit motive into the NHS on the delivery of healthcare can be described as mixed at best, with services under pressure, increasing waiting lists and waiting times, rising costs, and core values being undermined. The crux of the issue for the NHS is that with demand for its services rising by an average of 4% a year, funding has not been keeping pace. As a result, spending per person on healthcare is falling.

The progressive fragmentation of the NHS has had a disastrous effect on its ability to cope with the pandemic. An effective and efficient response to the outbreak of a highly infectious virus demands a coordinated and integrated healthcare system. From the outset, the Government’s infection control strategy was slow and muddled, revealing a lack of joined-up thinking and leadership at the highest levels. From the fiascos surrounding the lack of PPE for front-line staff and ventilators for seriously ill patients, to the scandalous death toll in care homes caused by elderly residents being discharged by hospitals without testing, the travesty that is the test and trace system, and the failure to share government data with regional health officials, the fundamental weaknesses of the market approach have been glaring. But faced with an unprecedented crisis, rather than turning to those with experience and expertise within the service, this government has doubled-down on its commitment to the private sector by squandering vast sums of money on untendered contracts with private companies and hiring expensive consultants. These lucrative deals are too often awarded to cronies, despite the fact that they have no track record for delivering what is being paid for, or no relevant qualifications to do the job in hand. It is, therefore, of little surprise to anyone (except their paymasters) when they fail to come up with the goods. The issues we have seen during this pandemic are the direct result of political decisions that have been made and implemented surreptitiously over time, compounded by an abject lack of foresight and planning, and awful crisis management. Collectively, these failings amount to those in power betraying the trust of the British people. By their actions, they have tainted the good name of the NHS and made mockery of their repeated protestations that the NHS is “safe in our hands” and “not for sale.” This criticism is in no way intended to detract from the selfless dedication and devotion to duty shown by our health professionals in caring for patients generally or victims of this virus in particular. They deliver a remarkable service, though sadly this is too often despite rather than because of the organisation they work for. Their skill and ingenuity have, to some extent, compensated for the failings of those responsible for ensuring the NHS is fit for purpose.

A rainbow drawn on the ground in chalk to thank the NHS and key workers during the COVID-19 pandemic. Photo by Sue Martin on 123RF.

More than ever through this emergency, front-line staff have shown that the NHS is its people - they are its beating heart. Those in Government who believe that they can improve the service simply by tinkering with management structures do not understand what makes the NHS tick. If they focus purely on technical fixes, they risk its greatest asset - the immense amount of goodwill, human compassion and pride that staff have invested in looking after patients and doing a good job. Rather than ignoring the human side of the service, the Government and NHS senior management should be looking for ways to develop and channel it. Any management guru will tell you that culture always eats strategy for breakfast. It’s time to think again to make sure that our beloved NHS, and those who work in it, are properly primed, funded and supported for the changing and increasing demands they will face for its services in future.

Attitudes to the rest of the Welfare State are more mixed. Whilst some see the benefits system as a necessary “safety net” to prevent people becoming destitute, others are worried that it encourages a “benefit culture” that disincentivises people from taking responsibility for their own destinies. Unfortunately, being dependent on state benefits can carry a social stigma as shown by the hostile and insulting language that certain sections of the press direct towards claimants, such as ‘benefit scroungers,’ ‘benefit scum,’ and ‘skivers.’ In fact, the Welfare State touches more people’s lives that we might expect. As at February 2020, the Department for Work and Pensions (DWP) reported that 20 million people were claiming DWP benefits in Britain, with two thirds of them (13 million) of State Pension Age. Another myth is that being on benefits allows people to live the life of Riley, when nothing could be further from the truth. Benefits were never generous but 8 years after Iain Duncan Smith first took an axe to the social security budget in 2012, claimants under the resulting ‘bare minimum’ safety net regime are now faced with severe financial hardship. And this assumes that they can overcome the eligibility hurdles to qualify for benefits in the first place.

The introduction of Universal Credit was a Tory flagship policy that was supposed to simplify the benefits system but has actually made it harder to access support. Universal Credit is means-tested. Claimants are only allowed savings of £6,000 before benefits start reducing. People with £16,000 or more in savings are not entitled to Universal Credit. The number of children for whom benefit can be claimed is limited to two. There is a five-week delay in payment of benefits that was a key design feature of Universal Credit. This means that claimants’ wait for an initial benefit payment is longer now than ever in the history of the Welfare State and there is evidence that this can push people who are already struggling into crisis, by forcing them into debt, food bank use and rent arrears. Claimants are currently offered a repayable interest-free loan to tide them over but this leaves them between a rock and a hard place, either to go without income for at least five weeks, or have repayments subtracted from their Universal Credit payments which are barely enough to survive on anyway.

One of the effects of Covid-19 has been to double the number of people on Universal Credit to 6 million. Many of the new claimants come from middle income families who would never normally have needed benefits but, through no fault of their own, have found themselves with no or reduced income and been forced to turn to the system for help. Some have been shocked to find that the emergency safety net was not there for them when they needed it. A study, funded by the Health Foundation and part of the Economic and Social Research Council project Welfare at a Social Distance, estimates that during the first wave of the pandemic (March to July) at least 290,000 people were turned down for benefits – about one in 10 of all claims made for Universal Credit. Most were rejected as a result of the household wealth test. For those hoping that their need of benefits will be short-lived, it can feel grossly unfair that money prudently set aside for mortgage deposits or retirement deprives them of support in a crisis. Two-thirds of those rejected said that they suffered mental health problems as a result, whilst almost half reported increased financial strains and one in six struggled to afford food.

The NHS, although only a relatively recent development in our country’s history, has nonetheless become a highly cherished institution that is tightly woven into the fabric of society. How much it matters to people is clearly demonstrated by the way in which the (baseless) promise of £350 million a week additional funding for the NHS helped to carry the Brexit vote in 2016. The British public is very protective of its NHS and suspicious of anyone in Government who is not fully committed to making sure that it is properly resourced to enable it to do the job that is expected of it. The benefits system, however, has always been a political battleground between left and right, between altruism and austerity. Whilst there have always been inequalities in Britain, they are being exacerbated by the pandemic. A report by the Resolution Foundation Caught in a Covid trap (November 2020) reveals that it is the poorest who are being hardest hit, with the bottom 20 per cent of the working population seeing their incomes falling sharply and savings exhausted. For them, there’s little or no spare cash to for even the most frugal of Christmases, while those at the other end of the scale are saving more money than ever. Charities that would normally recycle funds to those in need are also struggling for cash. The divisions that have long-bedevilled this country are becoming deeper and clearer and it is not pleasant. It has never been more apparent than in the unholy row over extending meal vouchers to cover school holidays to help the poorest children in our society. There are still plenty of people who care, like those restauranteurs and food retailers who, despite their own struggles, provided free meals to desperate families over the half-term break in October. The Government has subsequently backed down and promised more money to help those who are struggling next year but the spat was unnecessary and unseemly, creating uncertainty and inflicting more suffering on the most vulnerable.

My hope is that the pandemic will change minds about the kind of benefits system that is required, as many more people who would not normally need it have suddenly found themselves in need of support. Rather than seeing the benefits system as a drain on resources, it should be seen as a sign of strength that we care for the deprived in our society. Which of us would not like to know that if the unexpected happened and we found ourselves with no job and no money to live on, we could rely on the State to provide a genuine and decent welfare safety net to help us get back on our feet? Also, who, as a claimant, would not want to be treated with dignity and respect? For these are the marks of a civilised and compassionate society.