The NHS at 73

On 5th July 1948 after much planning and political wrangling the UK government implemented one of the most radical reforms in healthcare provision in the world at the time.

The NHS was announced to the general public through a leaflet sent to every household.

Your new National Health Service begins on 5th July. What is it? How do you get it?

It will provide you with all medical, dental and nursing care. Everyone – rich or poor, man, woman or child-can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as tax payers, and it will relieve your money worries in time of illness.

In the following charts we see the impact on the average age of death and death rates for the different sex and age groups. The charts start in 1841 (the earliest data I could find) in order to compare the trends before and after the inception of the NHS.

Why focus on deaths when discussing the National Health Service? Good healthcare can delay death but eventually we will all die. Healthcare can sensibly be viewed as delaying death and making life as healthy and comfortable as possible. Death is very rarely misdiagnosed; assessing the success and efficiency of healthcare by measuring the frequency of diagnosis of a condition (such as ‘heart disease’) is futile. For example, it usually does not matter if we save someone from dying of heart disease but they die of liver disease instead. What mostly matters is how long we live and how well we feel until we die.

It’s important to recognise that there was no radical change in the healthcare available at the inception of the NHS. The only real change was that Central Government paid the costs and the people paid tax to cover those costs. This was a change in the economics of healthcare provision - not a change in healthcare. The big change in people’s lives was that if they needed to call for healthcare they did not have to hesitate and worry about paying a bill later. There was no change in the healthcare that they could actually receive.

Health in the UK, as measured by general longevity and rate of death in each sex and age group, had been improving since the late 19th century. Efficiency in food production and distribution, effective regulations concerning food and water purity, the general spread in understanding of germ theory, an increasing emphasis on public hygiene and the introduction of the welfare state (state provided unemployment benefit and pension and local ‘panels’ of GPs) all led to reduced poverty and improved health of the people. By the middle of the 20th century most of these ‘easy wins’ had been realised in the UK and the rate of improvement had begun to level off.

The inception of the NHS resulted in an immediate and significant improvement in death rate among the under 1 year age group (where, from the charts, there is an obvious step down in the rate) and in geriatric (say, over 75s) care. However, from a purely mathematical point of view the rate of improvement in death rate among the under 1s could not continue without reaching zero. From the charts the improvement among older groups is less dramatic than in the under 1s. Consider that an 85 year old person in 1949 had spent 84 years without the care of the NHS and only 1 year with it; just how much improvement would you expect?

As noted above, ‘free’ healthcare interventions such as the GP service and vaccination programs did not start with the NHS. For example, mandatory smallpox (CFR 30-60%) vaccination began in 1853 and contributed to the disappearance of the disease in the UK by 1903. Diphtheria (CFR 10%) vaccination was introduced in the 1940s and rapidly reduced the spread of this deadly disease. Not too surprisingly the timeline of vaccination in the UK shows an initial emphasis on high mortality diseases such as smallpox, diphtheria, polio and tuberculosis with a later shift towards less deadly diseases such as rubella, influenza and rotavirus.

The NHS is undoubtedly a good thing, but it’s a political/economic thing rather than a healthcare thing.

For further reading I recommend visiting The People’s History of the NHS.