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The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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Bevan’s view of the NHS was more nuanced and more clever than that of some of his current ‘followers’.

Filed Under (Health Policy, Nye Bevan, Reform of the NHS) by Paul on 23-04-2012

Last week I began a process of asking questions about the different things that different people want to ‘save’ about the NHS.

I’m continuing the theme with this post – but from the other end of the telescope. This post considers an interesting phrase that Nye Bevan used to describe the NHS that he was creating.

I am not sure what Bevan would have made of the last year of NHS debate but I think he might, 60 years on, have found it a bit depressing.

The fact that it has been an inept disaster for the Conservative Party is not something that would worry him at all. (Famously – in a time when debate was rather more ‘robust’ – he got into trouble by referring to the Conservatives as ‘vermin’. So he wouldn’t have cried any tears over their problems with NHS reform).

Had he come to the debate a few months in, he would have been very worried by some of the left’s claims that the Bill will lead to the end of the NHS. He would after all feel protective about the NHS and would not want to see it destroyed. Given that the Bill was passed and is now an Act he would have been worried that, in their own terms, its defenders had failed to save the NHS by defeating the Bill.

In terms of both argument and ideology both sides have ‘lost’.

The right secured the Act, but now many people now believe that, as a result, their NHS will be privatised.

The left lost the battle to stop the Act and now have to face up, in their terms, to the end of the NHS.

It won’t surprise regular readers of this blog that I have had little admiration for either side of this debate.

The whole debate has not just missed the point but has missed several different points about the NHS.

Last week I suggested that many of those wanting to ‘save the NHS’ in fact wanted to save a particular form of state organisation that they thought of as ‘the NHS’. They believe that really being on the left means that you have to believe in central state control.

Not only is that historically and politically untrue, it is not true of the founder of the NHS.  Nye Bevan was clear about what made the NHS, even if this has been misunderstood by many on the left engaged in the present debate.

One of the axiomatic beliefs of many people who see themselves as defenders of the NHS seems to link the core being of the NHS with central state control of the whole organisation.  In fact Nye Bevan recognised that the NHS could not be controlled by the centre.  In 1950 he observed that,

“…the NHS is a novel experiment.  It is an attempt on the part of British society to reconcile two normally conflicting interests, centralised financial responsibility and de-centralised administration at the periphery.”
Speech to the Institute of Hospital Administrators on May 5 1950

This is an enormously interesting quote (for which I thank Cyril Chantler who used it in a lecture he gave). Let me explain why.

First, the founder of the NHS saw it as an organisational experiment. As an intellectual and a politician Bevan would have liked to have been in a position to have looked at what was happening and tweaked it in a number of directions. Organisationally, as an experiment, he would have expected there to be changes and developments. He would have been a bit surprised if 60 years later his name was called upon to assist an argument which said lessons should not be learnt and changes should not be made.

Second, and not in this quote but in the reality of post-war politics, he felt that the principle of central funding was in fact a principle (not an experiment). Famously he – and Harold Wilson – resigned from the government when it introduced prescription charges. This is an example of what action you take over what is fundamental and what is an experiment. So Bevan was not saying ‘let’s play around experimenting with everything’, he was saying that the principle that people should not pay at the point of need is crucial.

Third, the fact that there was a tension between normally conflicting interests was at the heart of his system. Bevan had the creativity to develop a major national institution that was BASED on normally conflicting interests. Most people, in creating an organisation, will do it in such a way that they operate WITHIN a set of principles. Only someone really clever and imaginative creates an organisation which has to ‘reconcile two normally conflicting interests’.

Fourth, having created a health service with normally conflicting interests in it, you are not surprised that they conflict. You don’t spring back in horror at the tension between the fact that the NHS has both centralised financial responsibility and de-centralised administration at the periphery. What you say when these two things grind against each other and create a problem is “Great! The system is working. Now what do we do about it?”  Too many people at the moment feel that because there is a tension here that there is something inherently wrong. Not true. Because there is a tension here the NHS – as envisaged by Bevan – is working.

(A contemporary example. Look at NICE. NICE as a national organisation recognises that the NHS works within a limited central budget. NICE develops its work within centralised financial responsibility. GPs, hospital doctors and nurses prescribe drugs within a de-centralised administration at the periphery. The centre cannot get into every consultation and stop professionals doing their work at that periphery. So the two absolutely essential things are in tension. And that tension is what makes the NHS work.)

Fifth, and most obvious for our discussion today, the twin parts of that tension centralised financial responsibility and de-centralised administration at the periphery. are both central pillars of making the NHS work in 1950 and in 2012. Let me repeat this is NOT centralised administration and de-centralised financial responsibility. In the NHS is money is centralised and the administration is at the periphery.

This is complex and a difficult thing to make work. But it’s the right thing to do.

Bevan was one man. This was 62 years ago. I am not saying that what Bevan said should dominate what we do in 2012. It’s just that some people claim they are ‘saving the NHS’ that he created.

But I would suggest if we are saving the NHS, we are saving centralised financial responsibility and de-centralised administration at the periphery.

Tomorrow I want to try and explain how Bevan’s politics and biography brought him to this position on organisation in his work in creating the NHS.


2 Responses to “Bevan’s view of the NHS was more nuanced and more clever than that of some of his current ‘followers’.”

  1. Bevan described the Tories as, ‘lower than vermin’, in fact. The passage of time hasn’t invalidated his judgement.

  2. I suspect that Bevan would see the context of widening health inequalities, the public sector being deliberately “hollowed-out” by the Tories and right-wing Liberals, and the inefficiencies of the free market US system (health spend at 17% of GDP anyone?) – and conclude that these reforms could not be trusted.

    Monitor’s David Bennett once compared regulated public healthcare to regulated utlities markets – but recently the FT reported water, for example, has risen at twice the rate of general inflation.

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