A Revision of Expectations

On the evening of 10 March 1969, Richard Crossman, Harold Wilson’s new Secretary of State for Social Services (‘SSSS? Impossible!’ Crossman wrote in his diary), reached into one of his three ministerial red boxes to find a long report by a still rather obscure Conservative barrister. Geoffrey Howe had entered Parliament in 1964, only to lose his seat when Wilson increased Labour’s majority from four to 95 in 1966. Crossman’s predecessor, Kenneth Robinson, had appointed Howe to chair an inquiry into scandalous allegations, made in the News of thr World, of cruelty, torture and theft at Ely Hospital, a psychiatric institution near Cardiff. Howe’s final report had been submitted in September 1968, a month before Crossman took up his new portfolio. The Ministry had by then spent six months arguing that Howe’s explosive eighty thousand words should remain confidential; only a brief summary would be published. ‘Not on your life,’ Howe had said, according to Crossman’s diary. Eventually, with three drafts – complete, slightly curtailed and concise – in his red box, Crossman had two days to approve publication of the concise version.

His instinct was to overrule the more cautious officials and publish the complete report. If he didn’t, ‘Geoffrey Howe would be entitled to go on television and talk about suppression.’ That night he read the appalling details about Ely from cover to cover. The original newspaper story was ‘completely substantiated’. Patients had been ill-treated; ward staff had stolen their food; there was overcrowding and a shortage of properly trained staff; patients and doctors felt isolated and abandoned; and nurses believed they would lose their jobs if they complained. Crossman realised that publication of these findings on their own would be perilous: he had to devise a policy to meet Howe’s criticisms.

Two days later, Crossman had persuaded his officials to take some responsibility for what had gone on at Ely. In 1969, 250,000 people were suffering long-stay hospital care similar to that offered at Ely, ‘cooped up in these old public assistance buildings with no adequate inspectorate’. Crossman’s civil servants opposed outright his plan for an inspectorate: there would be no way of making it work, doctors were likely to reject it and, anyway, there was too little time to make proper arrangements. But if there was still a case for suppressing Howe’s investigation, it collapsed when Crossman discovered that his Ministry had known about the goings-on at Ely for at least three years. Crossman acted swiftly. He won approval for an independent inspectorate that would report directly to him, and received consent to make a statement in the Commons on 27 March. He told full Cabinet on 25 March.

Wilson was furious. Crossman (and, indeed, the Leader of the House) had forgotten that three by-elections were due to take place on the day of the Ely statement. Wilson ‘wondered how it was possible that one should ruin the chances of people voting Labour by having this terrible story blurted out on the six o’clock news’. Crossman began his speech to Parliament with a ‘great frog’ in his throat. He knew immediately he ‘had gripped the House by admitting the truth of the allegations, the excellence of the report and the need for remedial action’. He also spoke about the possibility of appointing a Health Commissioner, or Ombudsman, to investigate complaints about the NHS. But Wilson’s political judgment had been sound: the Conservatives won all three by-elections, with large swings in each case.

Crossman’s achievement was to begin a systematic review of the health services – of the care of the mentally ill, especially – a process unheard of in the NHS since its inception in 1948. In a gratifyingly compressed, although at times grey, account, Charles Webster concludes that the Ely episode brought ‘a fresh spirit of determination’ to the care of long-stay patients. It did more than that: it released additional money, spurred improvements in hospital facilities and raised standards of practice. Ministers at last had a mandate to tackle the organisation and funding of the Service. Crossman’s collaboration with Howe was an agreeable moment of bipartisanship: in the 50-year history of the NHS, there hasn’t been another like it.

William Beveridge’s 300-page report, Social Insurance and Allied Service, was submitted in November 1942. By the end of 1944, it had sold over 200,000 copies. It had been commissioned with postwar reconstruction in mind and was to lead to one of this country’s most underplayed political successes. ‘Assumption B’ set out, in only a few thousand words, a compelling and extraordinary vision. (‘Assumption A’ was a ‘general scheme of children’s allowances’.) What Beveridge proposed was ‘a health service providing full preventive and curative treatment of every kind to every citizen without exceptions, without remuneration limit and without an economic barrier at any point to delay recourse to it’. It was, he concluded, ‘the ideal plan ... to reduce the number of cases for which [social security] benefit is needed’. Judged by this particular measure, Beveridge’s ideal plan has failed. But the NHS is Assumption B’s remarkable monument.

Beveridge was an unlikely hero of the poor. He was born in 1879 in India, the son of a judge who had 26 servants. After he left Oxford, where he read mathematics and classics, he took up research among the poor in London’s East End. He knew Beatrice Webb, who, in 1909, was the first person to put the case for a free state medical service available to all. Some saw him as a kind and humane public servant; others as a vain, mean-spirited bureaucrat. He could be very odd, and once tried to convince Wilson that cycles of unemployment were linked to sun-spot activity.

Although the Second World War brought together a chaotic and haphazard hospital system, the NHS was not the straightforward product of a wartime crisis. Events in the preceding century had made the political argument for some kind of national health system irresistible. Edwin Chadwick, as secretary of the Poor Law Commission, had been the guiding force in drawing up a strategy. His 1842 report led to Britain’s first Public Health Act in 1848. This revolutionary document tried to counter the effects of industrialisation by providing powers to construct decent water supply and sewerage systems, which in turn led to an important decline in infectious diseases such as cholera and typhoid.

That milestone was followed by the Royal Sanitary Commission of 1869-71, and two further Public Health Acts in 1872 and 1875, as a result of which newly appointed Medical Officers of Health were charged with raising standards of community health, preventing infectious disease and combating illnesses arising out of poverty. The Boer War was a further jolt to those anxious about the nation’s health. The dismal physical state of army recruits threatened the war effort and led to recommendations for improving child health, together with the introduction of school meals and medical services. The 1902 Midwives Act professionalised midwifery; the 1907 Notification of Births Act established health visiting as a service provided by local authorities; the 1918 Maternity and Child Welfare Act added further improvements to mother and infant medicine. This abundance of legislation led finally to the creation of a much-needed Ministry of Health in 1919. Free general practitioner services, available to working people earning less than £160 per year, had already been provided under the 1911 National Insurance Act. GPs, fearing state control of their practices and therefore bitterly opposed to Lloyd George’s plans, were bought off by generous payments, based on the number of patients on their lists. The new service flourished. By 1945, two-thirds of GPs and 21 million people (half the population) had signed up to this scheme.

Hospital services, however, remained chaotic. Charitable voluntary hospitals provided reasonable care for patients with acute illnesses, while Poor Law workhouses, transmogrified into public hospitals, soaked up those cases rejected by the swankier doctors. By 1867, the state acknowledged its duty to provide infirmaries for the poor; and with the 1929 Local Government Act, local authorities gained control of public hospitals. Once the state had accepted responsibility for standards of hospital care, it was easy, when war broke out, to link public and voluntary hospitals into an Emergency Medical Service. The 1946 ‘Domesday Book of the Hospital Services’ made even clearer the need for a national service by reporting wide variations in standards of care and a complete absence of co-ordination between services. The war effort had already led to regional blood transfusion and national public health laboratories. A first attempt to create an NHS came in 1944, with the publication of a woolly and confusing White Paper. GPs, for example, were to be employed, probably on a salaried basis, by a Central Medical Board. The British Medical Association concluded that this was ‘the thin end of the wedge of a form of service to which it is overwhelmingly opposed – a state-salaried service under local authorities’. Doctors hated the idea of losing their autonomy to a health minister; and the profession managed to stall all progress, gambling that no politician was likely to defy their collective resistance.

Aneurin Bevan became the youngest member of Attlee’s Cabinet in July 1945. The new government had a decisive majority and Bevan moved briskly to break the veto power that doctors had wielded against health reforms. By March 1946 he had produced his own White Paper, covering general practice, hospitals and public health. What he was proposing, said one critic, was ‘the greatest seizure of property since Henry VIII confiscated the monasteries’. In retrospect, he seems to have achieved the impossible. He had to gather public support, pacify doctors, and – most troublesome of all – win the backing of a sceptical Cabinet. The NHS Bill received Royal Assent on 6 November 1946.

The doctors, outraged at Bevan’s proposals, channelled their opposition through a profoundly reactionary BMA. Webster’s account of all this is sketchy, perhaps because he has covered the ground in previous books. Here he takes a chronological approach and argues that it is therefore ‘not practicable to engage in interpretative debate’. By aiming for a neutral historical review, he sacrifices much of the drama that has marked the NHS’s short life. His is a history of NHS planning, not of its politics.

The political struggle that characterised the last months of the NHS’s gestation can be relived by reading the angry pages of the British Medical Journal. Hugh Clegg, the journal’s editor, was the mouthpiece for the campaign against Bevan. ‘The medical profession in Britain is now faced with the most important issue in the whole of its long history,’ he wrote early in 1948. Doctors portrayed the NHS as an attack on their clinical freedom: any attempt to force them into the service of the state would, they said, undermine the trust between patient and doctor which lay at the heart of the Hippocratic tradition. Another way of putting it would be that they feared a salaried state medical service that would deny them the financial opportunities of self-employment. State intervention, Clegg argued, was ‘something essentially harmful to medicine’, the only way to counter the widespread support for the NHS was to launch a virulent witchhunt against Bevan.

A plebiscite of doctors was planned for 31 January and the BMJ urged the profession to say No to this ‘evil’ proposition. In Bevan, the BMA found itself negotiating with a man at once brilliant and a bully. Dr Guy Dain, chairman of the BMA’s council, who had already called Bevan ‘a complete dictator’, now claimed that he was ‘rude, blustering and threatening’. Clegg published a report noting that ‘Hitler at the very inception of the Nazi regime imposed almost the same conditions on the profession in Germany.’ The plebiscite form asked for approval or disapproval of the 1946 NHS Act. The Lancet, which had close associations with the Labour Government, urged doctors to recognise that their ‘true interest, like that of the people, is in peace’. Clegg and the BMA asked for war. Bevan became utterly fed up and spoke of ‘a small body of politically poisoned people’ opposed to his plans. Not so small: 40,814 doctors voted against the NHS, a nine-to-one majority. The Observer demanded Bevan’s resignation.

The size of the majority persuaded Clegg to harden his position. He published dozens of letters urging doctors to resist Bevan’s proposals. The Minister’s ‘vicious remarks’, he said, had been ‘ill-timed, inept and untrue’. He wallowed in his victory and continued to publish comparisons with Nazi Germany: ‘When Hitler was building up for his aggressive war upon the liberties of the world, a part of his technique was to declare himself an essentially reasonable man whose generous intentions were consistendy misrepresented by gangs of ruffians, Jews ... Mr Bevan has borrowed extensively from this technique.’

It fell to the Royal College of Physicians to offer an olive branch. Lord Moran, its president, asked the Minister to make it clear that he would amend the Act to ensure that a system of salaries would not be implemented, suggesting that, in return, doctors would support the NHS. Bevan agreed, and an amending Act was drawn up. Michael Foot, in his recently republished biography of Bevan, concludes that ‘the Minister and the president of the Royal College of Physicians established an accord.’ It was an accord that split the profession (the BMA accused the College of ‘defeatism’), revealed the BMA’s leaders to be obstinate and obsessive fools and finally saved the NHS from annihilation. Bevan hoped that this concession – putting into writing what he had said many times before – ‘will finally free doctors from any fears that they were to be turned in some way into “salaried civil servants” ’. The Lancet offered its support, hoping for an ‘armistice’ and a ‘common endeavour’ to make the NHS work.

Another plebiscite was called. The BMA again set itself against Bevan. As Foot argues, his critics ‘dared not oppose the end but they strove to sabotage the means’. ‘What we have secured falls short of what we sought,’ the BMA’s leaders summed up, ‘the freedoms of the profession are not sufficiently safeguarded.’ Clegg repeated the BMA’s advice in an editorial preceding the vote, but it’s possible that he concealed his personal feelings to preserve his delicate relationship – as well as his job – with the BMA. In a private letter to Moran, Clegg thanked him for doing ‘a very great service to the medical profession ... when the shouting has died down medical men will recognise this.’ Once again, doctors rejected Bevan’s offer of compromise: 14,620 (36 per cent) approved of the NHS while 25,842 (64 per cent) disapproved. The majority had been cut substantially.

Since seven thousand GPs had changed their minds following Bevan’s concessions, the BMA’s mandate to oppose the NHS quickly dissolved. It decided to accept Bevan’s invitation to restart negotiations. Some doctors now accused the BMA and BMJ of appeasement, but the BMA realised that, if it was to retain the public’s trust, it had to back both the NHS and Bevan. Clegg tried hard to claim victory: ‘The BMA has come through the ordeal of six years’ debate with enhanced prestige and strength.’ On the contrary, the BMA had proved itself deeply protectionist, concerned only with the narrow interests of doctors, especially their freedom to earn money outside the NHS. Hospital specialists had been bought off with an agreement to double their salaries at the discretion of a panel of their senior colleagues – the misleadingly named ‘distinction awards’ are still in place and are only now receiving sceptical political scrutiny. ‘I stuffed their mouths with gold,’ Bevan later admitted.

On 3 July, Clegg ended his witchhunt and invited Bevan to write a message to doctors about the new NHS. ‘It has not had an altogether trouble-free gestation!’ Bevan noted. He dwelt on the eradication of commerce from medicine. The doctor-patient relationship would be ‘freed from what most of us feel should be irrelevant to it, the money factor’. Clegg could not refrain from a final dig, and spoke of ‘the dangers of dogma, timidity, lack of incentive, administrative hypertrophy, stereotyped procedure, lack of intellectual freedom’. His conservative line had strong political support. ‘I can think of no better step to signalise the inauguration of the NHS than that a person who so obviously needs psychiatric attention should be among die first of its patients,’ Churchill remarked, with Bevan in mind. The BMA, Clegg and the Tories had misjudged the public mood. By the end of 1948, 97 per cent of the population – almost 40 million people – had registered with the NHS. And after one year, a Parliamentary Select Committee concluded that the service was ‘settling down with surprisingly little friction’.

There were early signs of political jitters. The first two years put the NHS deeply into the red. No one predicted the vast use that would be made of GP services. Projected costs for 1948-49 and 1949-50 were £268 million and £352 million, respectively; the actual costs were £373 million and £449 million. The shock this produced was used by Bevan’s enemies, both Labour and Conservative, to undermine his position and, Webster reminds us, eventually led to his resignation from the Government in April 1951. When the Korean War broke out and the Cabinet was faced with a costly (£4.7 billion) rearmament programme, it panicked and imposed health charges for dental treatment and spectacles. The free NHS had been lost, and Bevan with it. That was the moment at which the impression was formed of the NHS as a barely controllable drain on the public purse. The NHS, it was feared, would bankrupt the nation. Since then, its handling by politicians has been disastrous. There have been 22 Ministers of Health since 1948, most of whom were inferior or ineffectual managers presiding over a service chronically starved of resources and denuded of coherent policies. The health portfolio was considered so marginal to government that Hilary Marquand, Bevan’s successor as the Minister of Health, no longer sat in Cabinet.

Conservative governments and their 15 Ministers of Health have ruled over the NHS for 35 of the past 50 years. Webster makes the point that it was Iain Macleod, Minister from 1952 to 1955, who ‘effectively purged residual rancour towards Bevan’s health service in the Conservative Party’. Enoch Powell is a more complex figure in NHS history. He became minister in July 1960 and, like Macleod, lasted three years. Webster too readily supports the view that Powell was the butcher of the Welfare State. It is true that he adopted a hardline approach to funding. In 1961, he cut subsidies on milk, increased dental and eye charges and doubled the prescription charge – alterations that penalised the poor. As a former Treasury Minister he was obsessed with limiting public spending and could never reconcile his hawkish approach to economics with his charge of a high-spending ministry. In 1962, he disastrously misjudged the strength of feeling among nurses by resisting their justified pay claim. Most chillingly, he used his ministerial position to squeeze himself onto Lord Kilmuir’s Committee on Commonwealth Migrants, his excuse being that immigrants made a disproportionate claim on health services.

Yet a simple list of his prejudices leaves a distorted picture of Powell’s legacy. He embarked on an ambitious hospital building plan, involving £500 million over ten years to build 90 new hospitals and to renovate almost five hundred more. In July 1963, the first district general hospital since 1948 was opened, to serve Welwyn and Hatfield. Powell also began to tackle the huge Victorian mental asylums that still littered the country. It was widely known that conditions in these human museums were appalling: a hundred patients were often crammed into each ward – some had not been seen by a doctor for years. Every Health Minister since Bevan had faced this scandal; none had felt the need to act. In 1961 Powell announced that the asylums would be gradually closed, and their patients, now safely medicated, discharged back to their communities. The asylums, ‘which our forefathers built with such immense solidity’, were ‘the defences we have to storm’. His plan eventually fell foul of the economic failures of his own and future governments. The Ely Hospital incident was waiting to happen, and the first asylum did not close until 1986. Powell sought improvements in maternity services through a ‘Mother’s Charter’; he encouraged greater visiting rights for parents on children’s wards; he launched the first anti-smoking campaign; and he challenged drug companies over the extortionate prices they charged the NHS. His achievements as Minister of Health are not easy to sum up. Despite his arrogance, his manifest failings and his blind devotion to market economics, he showed a continuing concern with the difficult long-term issues.

The only other Conservative politician to leave a lasting mark was Margaret Thatcher, who had no qualms about mixing markets with medicine. Nor was there any attempt to disguise feelings of mutual loathing between doctors and government during the Thatcher years. It began straight away, when Patrick Jenkin, her first Health Minister, rejected the report of Douglas Black, Chief Scientist at the DHSS, on inequalities in health. Black provided a radical analysis of what the NHS had to do to restore the notion of a universal and comprehensive service distributed according to need. Matters got progressively worse. In a 1989 speech at the Royal College of General Practitioners, Kenneth Clarke enraged doctors by saying that he ‘wished the more suspicious of our GPs would stop feeling nervously for their wallets any time I mention the word “reform” ’. The BMA hated Clarke’s bruising heartiness. They spent £3 million on an advertising campaign to defeat the Thatcher/Clarke reforms. In a massive poster war, they showed a picture of a steamroller next to the headline ‘Mrs Thatcher’s plans for the NHS’.

Webster is at his most interesting in writing about Thatcher. He shows how she, like Bevan, exchanged the status quo for a revolutionary reappraisal of how to govern the Health Service. She and her ministers – Jenkin, Norman Fowler, John Moore and Clarke – replaced consensus with confrontation (Clarke to the BMA: ‘you buggers will sabotage it’). They imported asphyxiating management practices from Sainsbury’s, and, by undermining professional commitment, introduced a nine-to-five culture into the NHS. Efficiency replaced effectiveness as Thatcher’s goal. The most destructive change – it is the origin of much current discontent – was in the ethos of the NHS. Its values were now those of a business, not a service. We learned new words: ‘trusts’, ‘fund-holders’, ‘purchasers’, ‘providers’, ‘internal markets’, ‘managed competition’. Webster likens the perpetual revolution she introduced to that of Chairman Mao.

What good came out of 18 years of Conservative government? First, its reforms shifted power away from hospital specialists, who had largely been concerned with furthering their own interests, towards GPs, who must inevitably take a wider view of the health needs of their community. As Nicholas Timmins puts it in The Five Giants (1996), we now saw hospital ‘consultants sending GPs Christmas cards, not the other way around’. Second, Thatcher’s Health of the Nation plans, with targets set for cutting diseases such as breast cancer and heart attacks, restored public health to a central position in health strategy. Third, during her regime the Department of Health introduced research and development into the NHS, challenging doctors’ cherished ‘clinical freedom’ to do what they like to their patients and asserting that medical practice should be based on the best available scientific evidence.

Webster believes that Thatcher’s internal market ‘helped temporarily to alleviate the funding crisis’, while stressing that all judgments should remain ‘guarded and provisional’. However, doctors and nurses know that the changes in NHS culture have destroyed morale, leading to shortages in staff across the whole Service and a fatal loss of goodwill. It is hard to forgive Thatcher for this.

Over the past year, Frank Dobson has sought to re-inject some of Bevan’s original spirit back into the NHS, and to reintroduce some of Crossman’s emphasis on planning. He has published a ten-year programme – The New NHS – that aims to scrap the internal market, strengthen primary care, establish regional health strategies along lines suggested by GPs, guarantee that patients with cancer will receive a specialist appointment within two weeks, and create a 24-hour patient helpline staffed by nurses. He has published a Green Paper on public health, which accepts Black’s view that poverty is an important cause of illness. He has set up inquiries into inequalities, mental illness and long-term care of the elderly. And, unlike Clarke, he has shown a willingness to publish his proposals. In March he announced the first 11 health action zones, aimed at modernising health services. They include South Yorkshire coalfield communities, London’s East End, Bradford and Tyne and Wear, and cover six million people. The investment is longterm – seven years. So far, he has wobbled badly only once, over tobacco sponsorship of Formula One.

Dobson’s big problem is cash. The NHS costs £37 billion each year – about £100 million a day. These terrifying numbers reveal Labour’s manifesto pledge to save £100 million by cutting NHS bureaucracy to be pretty trivial. The recent£500 million budget boost was welcome and should allow him to bring waiting lists down to the level he inherited from the Conservatives. The results of a comprehensive spending review may allow Gordon Brown to give the NHS an extra £1.5-2 billion to mark the 50th-anniversary celebrations. If that happens, it will be a huge victory for Dobson.

There are other difficulties facing him, however, which he might prefer to ignore. His most serious challenge is what Cross-man once called the ‘revolution of expectations’. We all expect more from medicine. We do not want to wait for our operation. We expect the best care from the best doctor at the best hospital. We want more of a say in how we are treated. We do not always want to endure the paternalism of doctors, even when it is well-meant. Recent verdicts of serious professional misconduct recorded by the General Medical Council indicate that, in some cases if not all, the public’s voice is at last being taken account of.

The challenge posed by this rise in medical consumerism was identified by Powell in his 1966 book, Medicine and Politics. ‘Every advance in medical science,’ he wrote, ‘creates new needs that did not exist until the means of meeting them came into existence ... there is virtually no limit to the amount of medical care an individual is capable of absorbing ... Improvement in expectation of survival results in lives that demand further medical care.’ As we expect more, so the NHS will be asked to provide more. That inevitable call for further resources will mean escalating costs and unfulfilled expectations. The problem is rationing. This issue is usually, and wrongly, reduced to a fruitless argument about waiting lists. Dobson has threatened hospital managers with penalties if they don’t get their lists down. But the real question is who we should give priority to among those who are waiting. How does one decide, for example, between those who need dialysis treatment, an expensive drug for multiple sclerosis, or stroke rehabilitation? This is a moral dilemma that cannot be solved by the Health Minister alone. And yet it remains his responsibility.

A bigger question still, for any government in the next century, will be how to engineer the huge shifts in NHS care needed to deal with substantial changes in the population’s age structure. Between 1996 and 2021 the UK population is expected to rise from 59 million to 62 million. Our average age will increase from 38 to 42. These overall estimates mask much more dramatic movements. The number of children under 16 will fall in the next 25 years by 9 per cent. This decline will parallel a 29 per cent increase in those aged over 65;37 per cent for those aged over 85. This trend is part of a global phenomenon. The United Nations Population Division calculates that the average age of the world’s population will rise from 25 in 1995 to 37 in 2050, and then to 43 in 2150. The number of those over 80 will increase most of all: from 61 million (1995) to 1055 million (2150).

This isn’t unremittingly bad news; far from it. Older people will live longer, healthier and more productive lives than ever before. Nevertheless, our health services must adapt to their eventual needs – disability, rehabilitation, long-term community care and family support. Dementia, cancer, stroke, and trauma from falls (especially in women with osteoporosis) will become new priorities. And not only will the NHS have to evolve to suit an older population, it will have to expand, since older people consume two or three times the resources of their younger counterparts. When I qualified in medicine in 1986, I can recall strict age limits for admission to hospital coronary care units. If you had a heart attack but were unfortunate enough to be over 70, you had to take your chance on an ordinary ward with no special cardiac facilities. I saw several people die unnecessarily. These arbitrary and repellent restrictions on care are now disintegrating.

The UK has been incredibly slow to respond to the messages from its population scientists. By contrast, Germany and the Netherlands laid down legislation to plan for the future needs of their older people years ago. One very real concern, for example, is that hospital trusts have eliminated free (and costly) long-stay beds for elderly patients, leaving that role to be randomly absorbed by expensive private nursing homes. The NHS may become effectively closed to chronic geriatric care.

Some issues are predictable and could be addressed now. Extension of hospice services will be required. Questions surrounding quality of life and, inevitably, physicianassisted suicide will press themselves ever more forcefully onto the public agenda. While child sexual and physical abuse is frequently reported, abuse of old people – financial, psychological and verbal – remains neglected. In one survey, 2 per cent of old people reported physical abuse, suggesting at least half a million people suffering harm across the country. Ten per cent of carers admit abusing the person they care for.

How will we pay for the care of old people? Are families willing to take on the care of elderly relatives? How should community care be organised? What is the role of the hospital? How can the terrible loneliness that many older people endure be attenuated beyond the all too common solution of aiming them at a television set in a residential home? A dramatic improvement in the standards of hospital and high-technology medicine to match those found, for example, in the US could be achieved easily only by discarding the principles of universal, comprehensive and free health care. Americans enjoy advanced medicine only by allowing forty million people to live without health-care insurance. President Clinton’s ambitious attempt to introduce comprehensive reform collapsed into embarrassment partly because of the appalling way he went about it but it was the wounds inflicted on his Administration by the enormously powerful health-care industry that proved fatal.

Clinton has since changed tack, confining state coverage to vulnerable groups, such as children – a measure commanding bipartisan support. Still, the brutish nature of US medicine occasionally reveals itself. The best recent example concerned government funding of needle-exchange programmes. All the scientific evidence shows that providing clean needles can cut rates of HIV infection. Given that two-fifths of all new HIV infections in the US are caused by contaminated needles, a clean-needle programme could have dramatic effects. In April, Clinton blocked it: he preferred to appease conservatives rather than argue for a scientifically-proven policy that would save thousands of lives.

Americans with health-care insurance are also expecting to pay more as businesses cut back on their employee subsidies. So far, Dobson has ruled out health charges in the NHS for the lifetime of this Parliament. The British and American experiences show that you can choose equity or excellence but not always both. For the UK, Webster proposes a Royal Commission ‘which would conduct a rolling review of the policy issues faced by the health service’. Yet the difficulties confronting the NHS are already too well known. The Health Ministers of distinction – Bevan, Powell and Crossman – all knew that the great advantage of a state medical service was that it provided the mechanism for successful long-term planning. Few politicians have understood this.