the early days of the nhs the early days of the nhs پیشگاماناقتصاددرمان 1
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پیشگاماناقتصاددرمان
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British National Health Service
[NHS]
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National Health Service
Early Days&
Lessons to learn?
Kavoos Basmenji, PharmD
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◊ What is it?
National Health Service
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◊ Publicly funded healthcare system in
England & Wales◊ The NHS provides
healthcare to anyone normally resident in the
UK
What is it?
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◊ Most services free at the point of use for the
patient ◊ Charges associated
with eye tests, dental care, prescriptions… ,
What is it?
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◊ 1.33 million workers! 5th largest workforce
in the world: The Chinese Army, Indian
Railways, Wal-Mart, United States Defense,
and the NHS!
What is it?
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◊ Annual Budget [2008/09]:
91.7£ billion 1500£ per capita
What is it?
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◊ Public Expenditure on
Health: 86%◊ Health/GDP: 8%◊ NHS/GDP: 6.5%
What is it?
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◊ Basic principles : Access: clinical need,
not ability-to-pay Comprehensiveness Universality Tax-based, free-of-
charge
What is it?
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◊ The largest social reform in the history of
the UK◊ Its existence is beyond
political debate
What is it?
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◊ The story Every story must have a
beginning, a middle and an end – but not
necessarily in this order. Robert Bresson; French
Filmmaker
National Health Service
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Final Cut - 1982
◊ Should we shout?◊ Should we scream?◊ What Happened to the
post-war dream?◊ A place to stay… ◊ Enough to eat…
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Final Cut - 1982
◊ Somewhere old heroes shuffle safely
down the street … ◊ Where you can speak
out loud about your doubts and fears…
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England - 1945
◊ War is over◊ General election◊ Labour wins
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England - 1946
◊ Clement Attlee 1883-1967 Labour Politician Prime Minister; 1946
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England - 1946
◊ Labour Party Manifesto [1945]
The nation needs a trendous overhaul
Cradle to grave welfare
Post-War Consensus
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England - 1946
◊ Immediate actions: 1946 National Insurance
Act National Health Act
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The man
◊ Aneurin Bevan 1887-1960 Labour Politician Minister of Heath to
Attlee’s Cabinet
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The pledge
◊ January 3, 1948 Bevan: in 6 months
time free health will be available to every
British citizen Largest social policy
reform ever conceived
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Opposition begins
◊ Conservatives had fought the bill fiercely
◊ Britain was bankrupt and could not afford the
reform◊ People will exploit a “free
for all service”
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Opposition begins
◊ BMA: The NHS will rob doctors’ of their
independence◊ Senior consultants: Bevan
cannot manage the service with a third of the
GPs
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◊ The situation
For the working class and the poor,
illness was a nightmare
Pre-NHS era
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◊ It is not to every doctor’s taste to work 24
hours a day in the slums to earn what he
can earn in 3 hours in a more congenial locale.
A GP, 1935
Pre-NHS era
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◊ In 1930-40s, doctors’ top priority was money,
not delivering the service to those in need
◊ Main source of funding for healthcare was OOP
Pre-NHS era
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Pre-NHS era
◊ For the majority of people, healthcare
was a matter of charity◊ The hospitals lived on
hand-outs from rich benefactors: never
enough
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◊ There must be another way of
organizing thingsNye Bevan
young MP-1930s
◊ My heart is full of bitterness for when I see the well-nourished bodies of the wealthy, I also see the ill and haggard faces of my own people
The idea
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◊ Tredegar: Local council of workers
established a workers’ health service
Funded by meager premiums paid by the
workers
The Idea
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◊ 6 months to go…
Back to 1948
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◊ If people are frightened to be sick, they will never be free
◊ A lump of socialism must be injected in a capitalist system
The Idea
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◊ Letting the market to decide how people’s ill-health will be tackled is a mirage
The Idea
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◊ We wanta better and fairer
Britain
Clement Attlee
◊ We have beenthe dreamers; we have been the sufferers;
◊ Now, we are the builders
Nye Bevan
The Idea
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But…
◊ How to recruit the nurses, equip the
hospitals and stock the pharmacies?
◊ How to oppose the mighty consultants and the
Tories?
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January 1, 1948
◊ BMA declares war on the NHS
◊ Dr Charles Hill Secretary of the BMA Conservative politician Trusted by the nation
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Charles Hill
◊ Country’s most famous doctor
◊ 14 million audience on BBC:
“ Let’s make sure that your doctor does NOT
become the State’s doctor … your servant or the government’s servant?
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The GPs
◊ The moral incentive to oppose
Reluctance to become like the Army, and…
◊ The financial incentive The GPs practice was a
capital investment
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January 17
◊ The BMA plebiscite: Testing all 35,000
members position on the NHS Plan
◊ Leading members opposed in the media
against Bevan Calling the Plan Marxist,
encouraging to vote “NO”!
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Opposition toughens
◊ Churchill likenssocialism to Gestapo, and
◊ The BMA senior members liken Bevan to Adolf Hitler
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February 9
◊ Bevan fights backat the House of Commons
◊ The 4th reading of a bill in the history of the UK!
◊ Bevan determined to prove it’s the parliament,
not the BMA, who rules the nation
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February 9
◊ Bevan:“ They must take pride in
the fact that despite the economic concerns, we
are still able to the most civilized thing in the
world”…
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February 9
“ To put the welfare of the sick in front
of every other consideration”…
“ I hope the House will not hesitate to tell the BMA that we look forward to
this act starting on the 5th of July”.
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War goes on
◊ Local branches of the BMA vote “NO!”
◊ Opponents are in minority and have to fight hard
Socialist Medical Association
Branded as traitors!
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February 18
◊ Plebiscite results: 30,000+ vote against the NHS; >85 % of the BMA
◊ Charles Hill: “Let me ask, how do you propose to work the medical service without doctors?”
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◊ The hardship ,rationing and other
heritages of the War were still in place;
◊ But…
March 1
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◊ Gallop Poll : The morale was high People trusted the
Govn Expected social
change Only 13% were on the
side of doctors
March 1
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March 10
◊ Bevan makes the most audacious move of
his political life◊ Lord Charles Moran
President of the RCP A Doctor with 1
Patient!
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Ice is still there
◊ Bevan on Churchill: A petrified adolescent
◊ Churchill on Bevan: Minister of disease
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March 10
◊ Lord Moran “Corkscrew Charlie”
Very shrewd politician Managed the most
prestigious professional group: The
consultants
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March 10
◊ Consultants never-ending problem:
Large, charity-based hospitals they ran, were
broke Never had enough
budget
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March 10
◊ To have Moran’s backing, Bevan had to
find a way : To put public budget
into these hospitals, and…
Still give the consultants a free hand
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March 10
◊ Aneurin Bevan Consented, and later
uttered the famous words :
“I stuffed their mouth with gold”.
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A little problem…
◊ RCP’s next election was very close
◊ Lord Moran’s rival was Lord Horder, king’s
doctor Bevan & NHS’ die-
hard, sworn enemy
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March 26
◊ Moran routinelydefeated Horder by a
margin of 10:1◊ Horder; 5 times in a
row Final vote: 165 vs.
170 Moran won
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April 5
◊ Lord Moran to Bevan: GPs fear of becoming
full-time, salaried state slaves; civil servants
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April 7
◊ Aneurin Bevan Amended the Law in
the House of Commons Lord Moran
applauded him in the House of Lords
The deal is sealed
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Still…
◊ The BMA refuses to surrender
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Still …
◊ The anti-NHS campaign goes on
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April 26
◊ Aneurin Bevan The NHS will start as
planned: July 5 Massive educational
NHS-pro campaign; without one single
doctor on board!
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The campaign
◊ The publicity bore fruit :
The public pressure on the BMA increased
20 million people signed up in two weeks
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The campaign
◊ The target was still higher :
90% of the population So, the campaign
focused on the final decision-maker of the
nation: housewives!
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The campaign
◊ The campaignalso highlighted the
health of another neglected, vulnerable
group.
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The campaign
◊ A master stroke: In 5 weeks, 75% of
the British population had filled in NHS
registration forms
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May 5
◊ The BMA, in desperation and
unwisely, arranged a second plebiscite:
40% had changed their minds and voted for the
NHS
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A retreat…
◊ Not a surrender The BMA, advised all
doctors to join the NHS◊ Change in tactics:
Delay the Plan Nothing is ready!
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June 2
◊“ That’s a lot of nonsense”.
◊“ We shall never have all we need”.
◊“ If we are short, we should use intelligently
what we have got”.
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Deep down
◊ It was obviousthat the NHS was short
◊ The capital need: doubled to £180m
◊ Not enough staff 30,000 nurses needed
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Warnings
◊ Now, the conservative press
predicted a disaster: A free-for-all service
will rob and exhaust the national resources
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Sunday, July 4
◊ The pressure takes its toll in the
Labour rally in Manchester:
◊ Bevan’s “vermin” speech
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Sunday, July 4
…“that is why no amount of cajole or no
attempt at ethical or social seduction can eradicate from
my heart a deep burning hatred for the Tories that
inflicted those bitter experiences on the poor”…
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Sunday, July 4
…“so far as I’m concerned, they are lower
than the vermin. They condemned millions of first
class people to semi-starvation”…
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Sunday, July 4
◊ Churchill replies:“ Even though Mr.
Bevan calls us vermin, we must regard them
as brothers with whom we have very much in
common”.
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Monday, July 5
◊ In the meantime, thousands of medical staff, many of whom resisted Bevan for 6
months, were working to the last second.
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Monday, July 5
◊ Trafford Hospital [now, Park General
Hospital ,]Manchester◊ The NHS is born…
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Monday, July 5
◊ Silvia Diggory ,13 ,is NHS’ first patient.◊ Against all odds, Bevan
had delivered the NHS◊ With all its principles
and promises.
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Monday, July 5
◊ Comprehensive healthcare was freely
available to every British citizen, from the simplest ailment to the
most sophisticated surgery.
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Monday, July 5
◊ Nye Bevan: “We now have the
moral leadership of the world”.
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The NHS
◊ Your new National Health Service begins on 5th July. What is it? How do you get it?
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It will provide you with all medical, dental and
nursing care. Everyone – rich or poor, man, woman
or child – can use it or any part of it. There are no
charges, except for a few special items.
The NHS
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There are no insurance qualifications. But it is not
a “charity”. You are all paying for it, mainly as
taxpayers, and it will relieve your money
worries in time of illness.
The NHS
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Did it pay off?
◊ Pressure on the budget never plummeted
◊ In less than 10 years, infant mortality halved,
life expectancy increased by 10 years, infectious diseases decreased by
80%
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◊ Trivia
National Health Service
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National Health Service
◊ How did these all happen?
◊ Was it a matter of a singular stubborn,
devoted personality?◊ Was it the final outcome
a process?
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The roots
◊ William Beveridge 1879 – 1963 British economist and
social reformer Best known for his
1942 report “Social Insurance and Allied
Services”
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The roots
◊“ A revolutionary moment in the world’s
history is a time for revolutions, not for
patching”.
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The roots
◊“ Organisation of social insurance should be treated as one part
only of a comprehensive policy of
social progress”.
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The roots
◊“ Social insurance fully developed may
provide income security. It is an attack
upon Want”.
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The roots
◊“ But Want is one only of five giants on the road of reconstruction, easiest to
attack“ .◊“ The others are Disease,
Ignorance, Squalor and Idleness”.
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◊ William Temple◊ Archbishop of
Canterbury “Citizen and Churchmen”,
1941 Phrase “Welfare State”
coined
The roots
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The roots
◊ AJ Cronin 1896 – 1981 Scottish writer; one of the most renowned storytellers of the twentieth century
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The roots
◊ The Citadel Takes place in Tradegar! Dramatizes the atrocities of the medical system in 1930’s Britain Huge influence on all social classes in England
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◊ Three main questions: To promote health across
sectors, how should we approach the policy change
process? What skills are needed to
engage in the policy change process?
How do we build collaborations across the policy arenas?
The politics
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◊ Answer to all three questions is:
PoliticsPolicy change
processEngagement skillsCollaboration skills
The politics
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◊ Political Will Leader, strong state,
good institutional capacity, and adequate
political capital. If the reform does not
occur, then there is a lack of political will.
The politics
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◊ Political Will:“ catch-all culprit that
has little analytic content; its very
vagueness expresses the lack of knowledge of
specific detail ”Grindle and Thomas, 1991
The politics
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However, political leaders do need to exercise their
will-power to enact public policy.
Senator Robert Kennedy (‘67):
There are a lot of issues out there, but it’s our job
to decide which one matters most.
The politics
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◊ Political Skills Without political skills,
political will is irrelevant. Data alone are NOT
enoughPolitical AnalysisPolitical Strategies
The politics
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◊ Political Analysis Cost
Concentrated Benefits
Dispersed
The politics
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◊ Political Strategies Players Power Position Perception
The politics
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◊ To be effective, public health advocates need
to become better at politics, learning how to
create political incentives for leaders and how to deal with
political risk.
The politics
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Thank you all for your patience
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