The NHS was created in July 1948, one of the commitments made by the Labour government before its surprise landslide election victory at the end of WWII in Europe.
The NHS – key in an optimistic vision of a comprehensive welfare state – was founded on three principles: first, it would meet everyone’s needs; second, it would be free at the point of use; and last, it would be based on clinical need and not the ability to pay. The creation of an NHS available to all, regardless of wealth, was both intensely romantic and intensely practical in its ideals and aims.
The NHS is the largest and oldest wholly publicly funded healthcare system in the world, and remains one of the most efficient, egalitarian and comprehensive. While 11% of the UK population uses private healthcare (The King’s Fund, 2014), this is mostly to supplement rather than replace NHS services. The creation of an enduring national health service is indeed an achievement to be celebrated, for which millions of people have worked over its lifetime. The Labour Party and the people of Britain can rightly be proud, but it is important not to look at the NHS’s history only through rose-tinted spectacles. The creation of the NHS was bitterly opposed by some health professions, notably doctors, and the rows over what ‘comprehensive’ access to free services really meant started early, with charges for dental services, eye glasses and prescriptions being reintroduced as early as 1952 amid concern over soaring costs.
From then to now
So what has changed since the creation of the NHS?
- The UK population has grown by a third, from 49 million in 1948 to almost 65 million in 2016 (ONS, 2016).
- Life expectancy has risen by a decade, from 66 for men and 71 for women when the NHS came into being (ONS, 2015).
- The NHS budget in 1948 would equate to around £15 billion in the present. The actual NHS budget for 2015/16 was more than £116 billion (NHS Choices, 2016).
- The NHS now ranks amongst the five largest employers in the world, employing 1.5 million people (NHS Choices, 2016).
- Medical and technological advances have made treatments possible that could barely have been dreamed of in 1948, but these have also made healthcare more expensive and increased demand, creating new debates about what should be funded. Arguments about charging and rationing rage today just as they did 70 years ago.
Health spending across Europe and OECD countries
There has been much debate about what a modern healthcare system costs and whether it is sustainable to spend more on publicly funded healthcare. However the UK is, in fact, a comparatively low spender.
At the turn of the 21st century, Britain was spending 6.3% of its GDP on healthcare, less than most of its European counterparts (OECD, 2015). Amid complaints of falling performance and lengthening waiting lists, a Labour government pledged to raise spending to the European Union (EU) average of 8.5% (Appleby, 2016).
Nine years later, health spending had risen to 8.8% of GDP - but by then, EU averages had risen to 10.1% and the OECD average to 9%. By 2013, the gap between Britain and the rest of Europe was widening again, putting British health spending in 13th place out of the 15 original EU countries (OECD, 2015). Current spending projections will reduce UK health spending back to 6.6% of GDP by 2021, wiping out two decades of relative improvements in funding (Appleby, 2016).
Spending more on health would, of course, require either increased taxation or spending less elsewhere. The question remains, however, whether it is truly a matter of affordability or one of political choice. There are more frail elderly people needing both health and care support in Britain. More is possible medically and technologically. Instead of asking if we can afford to spend more, we should be asking whether we can afford to spend less for the health of the nation, given the NHS’s central aim of improving the quality of care, services and clinical outcomes.
Trade unions and the NHS
At a time when fewer than 27.9% of UK workers are covered by collective bargaining (BIS, 2016), it is remarkable that all 1.5 million NHS staff are covered by collective agreements. Among the greatest successes of the NHS in the early part of the 21st century is that every worker (except doctors and dentists) is covered by a single, harmonised system of pay, grading, and terms and conditions of employment. Therapists, cleaners, nurses, engineers and accountants are all covered by a job evaluation scheme that delivers equal pay for work of equal value.
The NHS determines most core employment issues at national level (except, again, for doctors and dentists), including pay, pensions, holidays, hours of work, sickness, and maternity rights, through single-table bargaining, which works unexpectedly well even though there are about 20 separate recognised unions in the NHS, ranging from the largest and most general in the UK to some of the smallest and most highly specialised. Alongside this are strong social-partnership arrangements for dealing with issues outside collective bargaining. While social partnership does not always get good press, it has delivered real successes in the NHS such as the NHS Constitution, which widened access to the NHS pension scheme, as well as measures to reduce bullying and to improve workplace culture.
But there is no avoiding the fact that things are tough for NHS patients and for staff in 2016, as government tightens controls on public spending to meet debt reduction targets, as demand for health services from an ageing population rises while the social care system struggles under years of successive cuts, while hospitals are required to make savings. It remains unclear whether the NHS will lose 144 000 highly valued EU staff, whose right to remain and work in the UK after Brexit remain uncertain.
It is six years since NHS staff had a real increase in pay. They are paying more than ever for pensions while retirement age rises. They are working harder as colleagues leave and are not replaced. They love and value the jobs they do, but they worry that they can’t always do their best for their patients owing to the pressures they are under, and they experience higher levels of stress than ever before.
UK health unions should respond by doing what trade unions do best. We can offer members a helping hand when they are at their most vulnerable. We can organise so that they are more able to help themselves in future. We can make the case for decent jobs with good pay and conditions. We can advocate on behalf of those weaker than ourselves. We can continue to fight discrimination and unfair treatment at all turns. We can make the case for the value of the international workforce. We can uphold and celebrate the many achievements of the NHS, and we can continue to make sure that its future is safe in all of our hands.
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Claire Sullivan is the Director of Employment Relations and Union Services at the Chartered Society of Physiotherapy (CSP) and heads up the trade union arm of the organisation. Claire worked in the NHS as a physiotherapist in London through the 1980s and 1990s before joining CSP.
Appleby, J. (2016) ‘How does NHS spending compare with health spending internationally?’, The King’s Fund.
BIS (Department for Business Innovation and Skills) (2016) ‘Trade Union Membership 2015,’ Statistical Bulletin, May 2016.
NHS Choices (2016) ‘About the National Health Service (NHS)’, NHS Choices.
ONS (2015) ‘National Life Tables, United Kingdom: 2012–2014,’ London, Office for National Statistics.
ONS (2016) ‘Overview of the UK population: February 2016,’ London, Office for National Statistics.
OECD (2015) ‘OECD.Stat health status’.
The King’s Fund (2014) ‘The UK Private Health Market’ (appendix to the Commission on the Future of Health and Social Care in England).