Andrew Lansley is the latest in a long line of health secretaries who have tinkered with the health service
1948-70: Nye Bevan’s heroic battle to create the NHS left structural tensions which have persisted ever since between hospitals, GPs and local authority social services; the Andrew Lansley reforms try (yet again) to correct them.
Health economists told Bevan that the £400m invested in healthcare would pay dividends, making the NHS cheaper as citizens became healthier. By 1955, the Guillebaud Report claimed NHS spending had fallen from 3.75 to 3.25% of GDP. In reality, suppressed demand tripled the 1948 cost by 1965 (£1.5bn) prompting politicians of all parties to urge remedies including hospital “hotel” charges, ringfenced national insurance health payments (Nics) and charges to visit GPs. In 1951, Labour introduced charges for “teeth and specs” and prescriptions (prompting Bevan’s resignation) while the Tories fell back on higher Nics (not ringfenced). All ducked radical reform.
1970-74: Harold Wilson’s 1964 government had abolished prescription charges, but had been forced to reintroduce them. It abandoned Richard Crossman’s plans to restructure the NHS into a regional system. By 1974, Sir Keith Joseph, the Tory social services secretary, created area health authorities (AHAs) accountable to regions (RHAs) and answerable to Whitehall. It was the first structural reform since 1948 and Labour, back in office with no working majority in 1974, decided not to unpick Joseph’s work. Instead, it wasted energy on a futile, union-inspired drive against private patients in NHS hospitals, part of Bevan’s compromise with the doctors.
The dispute helped boost Britain’s minuscule private sector and contributed to the 1979 election of Margaret Thatcher, who wanted to create an insurance-based system, but was thwarted by her health secretary, Norman Fowler, and by the NHS’s popularity among Tory voters.
Instead, she gave tax breaks for private insurance against the advice of her chancellor, Nigel Lawson. By 1986, NHS nominal costs had almost doubled under her – to £15bn – but was falling in real terms.
1987-91: Thatcher was pushed to radical reforms known as the “internal market” with a purchaser/provider split.
Against her instincts, she put the Heathite Kenneth Clarke in charge. His Working for Patients white paper (1989) kept two core NHS principles: it must be funded through taxes but free at the point of use. But it allowed hospitals to become self-governing NHS trusts with their own budgets while GPs were encouraged to become fundholders, managing their own finances and shopping around for the best provider.
Despite opposition from the NHS unions, including the British Medical Association, Clarke imposed reform in 1990. GP fundholding grew only slowly as another NHS financial crisis loomed.
1999-2007: Tony Blair was elected promising to “save the NHS”, but his first health secretary, Frank Dobson, believed a lack of money was the NHS’s key problem, not inefficiency or a failure to meet patients’ expectations.
Labour abolished GP fundholding and turned the market clock back while also launching a costly programme of hospital building funded by the private finance initiative.
In 2000 Blair and Gordon Brown agreed to a huge increase in NHS funding (partly paid for by a 1% ringfenced Nics increase), doubling it to £100bn-plus by 2010. Brown disrupted many of the moves by reformist health secretary Alan Milburn to restore a version of Kenneth Clarke’s internal market, but they survived. By now, all parties agreed on a role for the private sector in providing competition, patient choice and transparency of performance.
Under David Cameron, the Tories embraced the NHS’s core principles and Lansley was expected to be a safe pair of NHS hands, providing continuity and gradual reform of an increasingly popular service. His NHS white paper in July 2010 overturned the coalition agreement, which had promised no major reorganisations, and caught all sides by surprise.
• This article was amended on 18 January 2011. The original gave the year of Andrew Lansley’s NHS white paper as 2009. This has been corrected.