The health services since the war, vol. 2, Government and health care: the National Health Service 1958–1979

In several important ways Charles Webster's three books about the National Health Service resemble Wagner's music drama Der Ring des Nibelungen. Both achievements are almost uncritizable monuments to an individual; both deal with great and ever-present themes; both show the rise or (usually) fall of major figures; and, to be flippant, both have inevitable longeurs (one counterpart to the endless confrontations between Wotan and Fricka must surely be the account of NHS reorganization in Wales). There such a fanciful comparison should almost end-particularly since Webster has written "only" two volumes of his epic (though he brings the story bang up to date with his paperback political history). Nevertheless, a series of Leitmotiven also runs through this outstanding work, and their development explains why the NHS has taken its present-day form. To start with, Webster shows, the NHS has always been popular: thus at its tenth anniversary the difficulties were thought not to be insurmountable, though even then the state of the hospitals caused anxiety. The latter has continued, given that the service inherited a mass of decrepit buildings, some of them former workhouses over 100 years old, deserving to be bulldozed rather than patched, as happens even today. Moreover, progress in building new hospitals was slow, the first totally new one (in Welwyn) not being opened until 1963, while the plans occasioned by the optimism of the 1960s were dashed by the oil crisis in 1973. In Webster's view one factor behind all this was little-Englandism. Even before the NHS started, health care in other countries had often been superior to that in Britain, and, once it had come into being, observers took refuge in phrases such as the "envy of the world" rather than looking across the channel to see how much better standards were. Then right from the beginning the official documents show just how deep Treasury parsimony ran, with a lower proportion of GDP spent on health care in Britain than elsewhere. During the lean years between the Korean war and the Suez fiasco the NHS was the main target for economies in social expenditure. In the years of growth the NHS lagged behind ambitious programmes, such as defence, nuclear power, roads, housing, and education. To be sure, the Treasury had a minimal basis for its continual accusations of inefficiency. Suddenly announced plans for expanding the hospital building programme found both the health departments and the NHS authorities unprepared. In a few individual cases (such as the development of Liverpool and St Thomas's Hospitals) there was undisputed extravagance and incompetence. Nevertheless, Webster emphasizes, virtually all of the many inquiries found that money had been well spent, and that any deficiencies arose from lack of it. Behind all this lacklustredness was the realization that the health portfolio was a graveyard. Holders were rarely in the post for long. Ministers would often not be included in the Cabinet, where decisions about their department's spending would be taken. And the appointment usually signalled the end of a career, David Owen and Kenneth Clarke being the obvious exceptions to prove the rule. And, whereas ministers were expected to fight on their department's behalf, not all did soparticularly in the early days of the NHS. Enoch Powell, significantly a former Treasury Minister, was the last Minister of Health to think that economies were possible in his field, and was acknowledged by the Treasury to be the most austere of his colleagues.