Th

e E

arl

y D

ays o

f th

e N

HS

1

پیشگاماناقتصاددرمان

Th

e E

arl

y D

ays o

f th

e N

HS

2

British National Health Service

[NHS]

Th

e E

arl

y D

ays o

f th

e N

HS

3

National Health Service

Early Days&

Lessons to learn?

Kavoos Basmenji, PharmD

Th

e E

arl

y D

ays o

f th

e N

HS

4

◊ What is it?

National Health Service

Th

e E

arl

y D

ays o

f th

e N

HS

5

◊ Publicly funded healthcare system in

England & Wales◊ The NHS provides

healthcare to anyone normally resident in the

UK

What is it?

Th

e E

arl

y D

ays o

f th

e N

HS

6

◊ Most services free at the point of use for the

patient ◊ Charges associated

with eye tests, dental care, prescriptions… ,

What is it?

Th

e E

arl

y D

ays o

f th

e N

HS

7

◊ 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?

Th

e E

arl

y D

ays o

f th

e N

HS

8

◊ Annual Budget [2008/09]:

91.7£ billion 1500£ per capita

What is it?

Th

e E

arl

y D

ays o

f th

e N

HS

9

◊ Public Expenditure on

Health: 86%◊ Health/GDP: 8%◊ NHS/GDP: 6.5%

What is it?

Th

e E

arl

y D

ays o

f th

e N

HS

10

◊ Basic principles : Access: clinical need,

not ability-to-pay Comprehensiveness Universality Tax-based, free-of-

charge

What is it?

Th

e E

arl

y D

ays o

f th

e N

HS

11

◊ The largest social reform in the history of

the UK◊ Its existence is beyond

political debate

What is it?

Th

e E

arl

y D

ays o

f th

e N

HS

12

◊ 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

Th

e E

arl

y D

ays o

f th

e N

HS

13

Final Cut - 1982

◊ Should we shout?◊ Should we scream?◊ What Happened to the

post-war dream?◊ A place to stay… ◊ Enough to eat…

Th

e E

arl

y D

ays o

f th

e N

HS

14

Final Cut - 1982

◊ Somewhere old heroes shuffle safely

down the street … ◊ Where you can speak

out loud about your doubts and fears…

Th

e E

arl

y D

ays o

f th

e N

HS

15

England - 1945

◊ War is over◊ General election◊ Labour wins

Th

e E

arl

y D

ays o

f th

e N

HS

16

England - 1946

◊ Clement Attlee 1883-1967 Labour Politician Prime Minister; 1946

Th

e E

arl

y D

ays o

f th

e N

HS

17

England - 1946

◊ Labour Party Manifesto [1945]

The nation needs a trendous overhaul

Cradle to grave welfare

Post-War Consensus

Th

e E

arl

y D

ays o

f th

e N

HS

18

England - 1946

◊ Immediate actions: 1946 National Insurance

Act National Health Act

Th

e E

arl

y D

ays o

f th

e N

HS

19

The man

◊ Aneurin Bevan 1887-1960 Labour Politician Minister of Heath to

Attlee’s Cabinet

Th

e E

arl

y D

ays o

f th

e N

HS

20

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

Th

e E

arl

y D

ays o

f th

e N

HS

21

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”

Th

e E

arl

y D

ays o

f th

e N

HS

22

Opposition begins

◊ BMA: The NHS will rob doctors’ of their

independence◊ Senior consultants: Bevan

cannot manage the service with a third of the

GPs

Th

e E

arl

y D

ays o

f th

e N

HS

23

◊ The situation

For the working class and the poor,

illness was a nightmare

Pre-NHS era

Th

e E

arl

y D

ays o

f th

e N

HS

24

◊ 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

Th

e E

arl

y D

ays o

f th

e N

HS

25

◊ 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

Th

e E

arl

y D

ays o

f th

e N

HS

26

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

Th

e E

arl

y D

ays o

f th

e N

HS

27

◊ 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

Th

e E

arl

y D

ays o

f th

e N

HS

28

◊ Tredegar: Local council of workers

established a workers’ health service

Funded by meager premiums paid by the

workers

The Idea

Th

e E

arl

y D

ays o

f th

e N

HS

29

◊ 6 months to go…

Back to 1948

Th

e E

arl

y D

ays o

f th

e N

HS

30

◊ 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

Th

e E

arl

y D

ays o

f th

e N

HS

31

◊ Letting the market to decide how people’s ill-health will be tackled is a mirage

The Idea

Th

e E

arl

y D

ays o

f th

e N

HS

32

◊ 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

Th

e E

arl

y D

ays o

f th

e N

HS

33

But…

◊ How to recruit the nurses, equip the

hospitals and stock the pharmacies?

◊ How to oppose the mighty consultants and the

Tories?

Th

e E

arl

y D

ays o

f th

e N

HS

34

January 1, 1948

◊ BMA declares war on the NHS

◊ Dr Charles Hill Secretary of the BMA Conservative politician Trusted by the nation

Th

e E

arl

y D

ays o

f th

e N

HS

35

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?

Th

e E

arl

y D

ays o

f th

e N

HS

36

The GPs

◊ The moral incentive to oppose

Reluctance to become like the Army, and…

◊ The financial incentive The GPs practice was a

capital investment

Th

e E

arl

y D

ays o

f th

e N

HS

37

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”!

Th

e E

arl

y D

ays o

f th

e N

HS

38

Opposition toughens

◊ Churchill likenssocialism to Gestapo, and

◊ The BMA senior members liken Bevan to Adolf Hitler

Th

e E

arl

y D

ays o

f th

e N

HS

39

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

Th

e E

arl

y D

ays o

f th

e N

HS

40

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”…

Th

e E

arl

y D

ays o

f th

e N

HS

41

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”.

Th

e E

arl

y D

ays o

f th

e N

HS

42

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!

Th

e E

arl

y D

ays o

f th

e N

HS

43

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?”

Th

e E

arl

y D

ays o

f th

e N

HS

44

◊ The hardship ,rationing and other

heritages of the War were still in place;

◊ But…

March 1

Th

e E

arl

y D

ays o

f th

e N

HS

45

◊ Gallop Poll : The morale was high People trusted the

Govn Expected social

change Only 13% were on the

side of doctors

March 1

Th

e E

arl

y D

ays o

f th

e N

HS

46

March 10

◊ Bevan makes the most audacious move of

his political life◊ Lord Charles Moran

President of the RCP A Doctor with 1

Patient!

Th

e E

arl

y D

ays o

f th

e N

HS

47

Ice is still there

◊ Bevan on Churchill: A petrified adolescent

◊ Churchill on Bevan: Minister of disease

Th

e E

arl

y D

ays o

f th

e N

HS

48

March 10

◊ Lord Moran “Corkscrew Charlie”

Very shrewd politician Managed the most

prestigious professional group: The

consultants

Th

e E

arl

y D

ays o

f th

e N

HS

49

March 10

◊ Consultants never-ending problem:

Large, charity-based hospitals they ran, were

broke Never had enough

budget

Th

e E

arl

y D

ays o

f th

e N

HS

50

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

Th

e E

arl

y D

ays o

f th

e N

HS

51

March 10

◊ Aneurin Bevan Consented, and later

uttered the famous words :

“I stuffed their mouth with gold”.

Th

e E

arl

y D

ays o

f th

e N

HS

52

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

Th

e E

arl

y D

ays o

f th

e N

HS

53

March 26

◊ Moran routinelydefeated Horder by a

margin of 10:1◊ Horder; 5 times in a

row Final vote: 165 vs.

170 Moran won

Th

e E

arl

y D

ays o

f th

e N

HS

54

April 5

◊ Lord Moran to Bevan: GPs fear of becoming

full-time, salaried state slaves; civil servants

Th

e E

arl

y D

ays o

f th

e N

HS

55

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

Th

e E

arl

y D

ays o

f th

e N

HS

56

Still…

◊ The BMA refuses to surrender

Th

e E

arl

y D

ays o

f th

e N

HS

57

Still …

◊ The anti-NHS campaign goes on

Th

e E

arl

y D

ays o

f th

e N

HS

58

April 26

◊ Aneurin Bevan The NHS will start as

planned: July 5 Massive educational

NHS-pro campaign; without one single

doctor on board!

Th

e E

arl

y D

ays o

f th

e N

HS

59

The campaign

◊ The publicity bore fruit :

The public pressure on the BMA increased

20 million people signed up in two weeks

Th

e E

arl

y D

ays o

f th

e N

HS

60

The campaign

◊ The target was still higher :

90% of the population So, the campaign

focused on the final decision-maker of the

nation: housewives!

Th

e E

arl

y D

ays o

f th

e N

HS

61

The campaign

◊ The campaignalso highlighted the

health of another neglected, vulnerable

group.

Th

e E

arl

y D

ays o

f th

e N

HS

62

The campaign

◊ A master stroke: In 5 weeks, 75% of

the British population had filled in NHS

registration forms

Th

e E

arl

y D

ays o

f th

e N

HS

63

May 5

◊ The BMA, in desperation and

unwisely, arranged a second plebiscite:

40% had changed their minds and voted for the

NHS

Th

e E

arl

y D

ays o

f th

e N

HS

64

A retreat…

◊ Not a surrender The BMA, advised all

doctors to join the NHS◊ Change in tactics:

Delay the Plan Nothing is ready!

Th

e E

arl

y D

ays o

f th

e N

HS

65

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”.

Th

e E

arl

y D

ays o

f th

e N

HS

66

Deep down

◊ It was obviousthat the NHS was short

◊ The capital need: doubled to £180m

◊ Not enough staff 30,000 nurses needed

Th

e E

arl

y D

ays o

f th

e N

HS

67

Warnings

◊ Now, the conservative press

predicted a disaster: A free-for-all service

will rob and exhaust the national resources

Th

e E

arl

y D

ays o

f th

e N

HS

68

Sunday, July 4

◊ The pressure takes its toll in the

Labour rally in Manchester:

◊ Bevan’s “vermin” speech

Th

e E

arl

y D

ays o

f th

e N

HS

69

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”…

Th

e E

arl

y D

ays o

f th

e N

HS

70

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”…

Th

e E

arl

y D

ays o

f th

e N

HS

71

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”.

Th

e E

arl

y D

ays o

f th

e N

HS

72

Monday, July 5

◊ In the meantime, thousands of medical staff, many of whom resisted Bevan for 6

months, were working to the last second.

Th

e E

arl

y D

ays o

f th

e N

HS

73

Monday, July 5

◊ Trafford Hospital [now, Park General

Hospital ,]Manchester◊ The NHS is born…

Th

e E

arl

y D

ays o

f th

e N

HS

74

Monday, July 5

◊ Silvia Diggory ,13 ,is NHS’ first patient.◊ Against all odds, Bevan

had delivered the NHS◊ With all its principles

and promises.

Th

e E

arl

y D

ays o

f th

e N

HS

75

Monday, July 5

◊ Comprehensive healthcare was freely

available to every British citizen, from the simplest ailment to the

most sophisticated surgery.

Th

e E

arl

y D

ays o

f th

e N

HS

76

Monday, July 5

◊ Nye Bevan: “We now have the

moral leadership of the world”.

Th

e E

arl

y D

ays o

f th

e N

HS

77

The NHS

◊ Your new National Health Service begins on 5th July. What is it? How do you get it?

Th

e E

arl

y D

ays o

f th

e N

HS

78

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

Th

e E

arl

y D

ays o

f th

e N

HS

79

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

Th

e E

arl

y D

ays o

f th

e N

HS

80

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%

Th

e E

arl

y D

ays o

f th

e N

HS

81

◊ Trivia

National Health Service

Th

e E

arl

y D

ays o

f th

e N

HS

82

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?

Th

e E

arl

y D

ays o

f th

e N

HS

83

The roots

◊ William Beveridge 1879 – 1963 British economist and

social reformer Best known for his

1942 report “Social Insurance and Allied

Services”

Th

e E

arl

y D

ays o

f th

e N

HS

84

The roots

◊“ A revolutionary moment in the world’s

history is a time for revolutions, not for

patching”.

Th

e E

arl

y D

ays o

f th

e N

HS

85

The roots

◊“ Organisation of social insurance should be treated as one part

only of a comprehensive policy of

social progress”.

Th

e E

arl

y D

ays o

f th

e N

HS

86

The roots

◊“ Social insurance fully developed may

provide income security. It is an attack

upon Want”.

Th

e E

arl

y D

ays o

f th

e N

HS

87

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”.

Th

e E

arl

y D

ays o

f th

e N

HS

88

◊ William Temple◊ Archbishop of

Canterbury “Citizen and Churchmen”,

1941 Phrase “Welfare State”

coined

The roots

Th

e E

arl

y D

ays o

f th

e N

HS

89

The roots

◊ AJ Cronin 1896 – 1981 Scottish writer; one of the most renowned storytellers of the twentieth century

Th

e E

arl

y D

ays o

f th

e N

HS

90

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

Th

e E

arl

y D

ays o

f th

e N

HS

91

◊ 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

Th

e E

arl

y D

ays o

f th

e N

HS

92

◊ Answer to all three questions is:

PoliticsPolicy change

processEngagement skillsCollaboration skills

The politics

Th

e E

arl

y D

ays o

f th

e N

HS

93

◊ 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

Th

e E

arl

y D

ays o

f th

e N

HS

94

◊ 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

Th

e E

arl

y D

ays o

f th

e N

HS

95

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

Th

e E

arl

y D

ays o

f th

e N

HS

96

◊ Political Skills Without political skills,

political will is irrelevant. Data alone are NOT

enoughPolitical AnalysisPolitical Strategies

The politics

Th

e E

arl

y D

ays o

f th

e N

HS

97

◊ Political Analysis Cost

Concentrated Benefits

Dispersed

The politics

Th

e E

arl

y D

ays o

f th

e N

HS

98

◊ Political Strategies Players Power Position Perception

The politics

Th

e E

arl

y D

ays o

f th

e N

HS

99

◊ 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

Th

e E

arl

y D

ays o

f th

e N

HS

100

Thank you all for your patience