Feature

Blair and Bevan: more than 50 years apart

Labour’s white paper on the NHS emphasises collaboration over competition, but it is still closer to Thatcher than Bevan, says Charles Webster

Last year’s election victory for Labour after a long period of Conservative domination has given special significance to the 50th anniversary of the NHS. The anniversary is an occasion both for celebrating the past and a major turning point for the future. Labour has always traded on its image as the political party responsible for establishing the NHS. The health service accordingly figured prominently in its general election campaign, when it was promised that a Labour government would ‘rescue’ and ‘rebuild’ the NHS.

Within a few months of taking office, the Blair administration went a long way to spelling out its intentions with the important White Paper, The New NHS and its equivalents for Scotland and Wales. These return to the theme of rebirth. Although New Labour is usually chary about its links with the past, on the health service it displays no such inhibitions.

The recent White Papers self-evidently hark back to the spirit of 1948. In stating the aim of the health service to treat ‘according to need and need alone’, in stressing that in the new regime of integrated care ‘co-operation will replace competition’, and in aspiring to make the health service the ‘envy of the world’, the English White Paper is consciously echoing the sentiments of Aneurin Bevan, architect of the NHS. The New NHS even takes its title from the heading of the house-to-house leaflet distributed 50 years ago to explain the benefits offered by the new health service. A photograph of the cover of the house-to-house leaflet is granted place of honour as the first illustration in the White Paper, taking precedence over a photograph of the Prime Minister in the foreword.

The New NHS has generally been well received as a conscientious effort to improve upon the internal market. Everyone now hopes that integrated care and additional resources will inject new stability and harmony into the NHS. But despite rhetoric to the contrary, the proposed system is nearer to Thatcher than to Bevan in many of its characteristics and it contains many fundamental features that were anathema to the post-war Labour government. Particularly repugnant to Bevan would have been the decision to preserve the Thatcher government’s purchaser/provider split, entailing the ‘separation between the planning of hospital care and its provision’ (The New NHS, para 2.6). John Pater, one of Bevan’s main assistants, identified failure to observe ‘the cardinal principle of combining planning and execution in the same local hands’ as the main weakness of the Conservative plan that Bevan rejected.

In defending his audacious proposal for nationalisation of the entire hospital system and its organisation on a regional basis, Bevan insisted that it was essential that the ‘bodies carrying out the hospital services of the country are, at the same time, the planners of the hospital service. One of the defects of the other scheme is that the planning authority and executive authority are different. The result is that you get paper planning or bad execution’ (House of Commons, 30 April 1946).

New Labour’s design not only abandons the principle of unity of planning and execution, but also follows Conservative precedent in many other respects. For instance, Bevan would have regarded the system of unintegrated NHS trusts as a reincarnation of the vices of the pre-war voluntary hospital system. He would have been shocked by the undemocratic character of the NHS in the 1990s, and perhaps especially by the elimination of regional health authorities and their replacement by regional offices of an over-powerful NHS Executive.

Both the Blair and Bevan plans give priority to primary and community care. But whereas Bevan looked forward to these services being provided in health centres controlled by local government, Blair opts for Primary Care Groups and Trusts, which will be entrepreneurial operations controlled by independent contractors. In the light of such disparities, it is perhaps not altogether surprising to find that Labour’s spin doctors have avoided mentioning Aneurin Bevan by name in the White Paper.