Medicine and books: The National Health Service: A Political History
Authors: JP Bunker
Journal: BMJ (1998)

Charles Webster 

Oxford University Press, £9.99, pp 233 

ISBN 0 19 289296 7 

Doctors in the United States still express a strong distaste for what they perceive as socialised medicine in Great Britain. But, of course, few of them are familiar with the NHS and how it functions. They are not familiar, for example, with how much greater freedom of practice the British doctor has had, at least up to the recent past. It could be argued, as J R Hampton did in his famous 1983 editorial, that clinical freedom was at an end. But Hampton was arguing that it was the freedom to ignore what we now call evidence based medicine that was at an end. It is another kind of freedom, the freedom of what Eliot Freidson has called “the flexible discretionary judgement that is necessary to adapt to individual [patients’] needs” that is being eroded as the NHS adopts the worst of managerial style, American managed care. 

Charles Webster, in his new and up to date history of the NHS, brilliantly chronicles the events surrounding its inception and political ups and downs, outlines the framework within which medicine has been practised, and provides a wise and fair appraisal of its accomplishment and failure. He writes that “it is universally agreed that the National Health Service represented an enormous improvement on the ramshackle assemblage of health services that it superseded” and “with respect to its all-important purpose, Bevan’s experiment in socialised medicine was a spectacular success from the start.” 

At the same time, he is relentless in his criticism of political failure along the way. Thus, in commenting on the Thatcher reforms and the internal market, he writes that “the new system was not internal nor was it a market in more than a restricted sense. ‘Internal’ was clearly inconsistent with the aspiration to maximise the involvement of outside agencies and the private sector. The ‘market’ analogy was obviously imprecise, since the consumer was unable to exercise choice of services; health authorities or fundholders acted as their surrogates. It was not so much a matter of the patient dictating where the money went, but the patient following whatever channel the professionals dictated.” 

Just how political the provision of care could be when controlled and funded by government is something I never considered when practising in the laissez-faire system that existed in the United States. I worked side by side with colleagues of very different political persuasions from my own, and we had few, if any, differences in the ideology of medical politics with which we had to contend. I had thought that medicine lay outside the province of politics. Here, I have found quite the opposite, as with the introduction of a market philosophy (for which my Stanford colleague, Alain Enthoven, having recommended a trial of an internal market on a limited scale and said nothing about fundholding, is only partly responsible). 


Webster fully appreciates the critical role that inadequate funding has played in NHS difficulties, and he calls attention to the shortfall in cash that existed right from the start, writing that “Bevan consciously adopted goals for his health service that were well beyond reach in the austerity atmosphere of the post-war period.” And, 15 years later, Enoch Powell wrote that “there is virtually no limit to the amount of medical care an individual is capable of absorbing... we would all benefit from having our incipient or suspected ailments detected and treated sooner.” In 1948, and even during Powell’s years as minister of health, there was so much less that we could offer to patients, as Thomas McKeown reminded us. The potential for cure and for symptomatic relief is now vastly greater, the fiscal implications of which have yet to be fully appreciated by politicians. 


March bestsellers BMJ Bookshop 
1   Oxford Handbook of Clinical Medicine R A Hope, J M Longmore, T J Hodgetts OUP, £13.95, ISBN 0 19 262115 7 

2   British National Formulary No 35 (March 1998) BMA/Royal Pharmaceutical Society, £14.95, ISBN 0 85369 411 7 

3   Notes for the MRCGP 3rd ed (updated for the new modular MRCGP exam) K T Palmer Blackwell Science, £19.95, ISBN 0 86542 777 1 

4   Misuse of Drugs BMA/Harwood Academic Publishers, £12.99, ISBN 90 5702 2605 

5   Making Doctors: An Institutional Apprenticeship S Sinclair Berg, £14.99, ISBN 1 85973 955 5 

6   Therapeutic Uses of Cannabis British Medical Association Board of Science Harwood Academic Publishers, £11.99, ISBN 90 5702 3180 

7   Evidence Based Medicine: How to Practice and Teach EBM D L Sackett, W Scott Richardson, W Rosenberg, R B Haynes Churchill Livingstone, £14.99, ISBN 0 443 05686 2 

8   The New Learning Medicine P Richards, S Stockill BMJ Publishing Group, £10.95, ISBN 0 7279 1155 4 

9   Guide to the Internet: An Introduction for Healthcare Professionals 2nd ed M Pallen BMJ Publishing Group, £4.95, ISBN 0 7279 1255 0 

10  From Cradle to Grave: 50 Years of the NHS G Rivett King’s Fund Publishing, £25, ISBN 1 85 717 1489 




Webster stops short of putting his essay in the broader context of other social needs. It was the American economist William Baumol who argued in his 1995 Office of Health Economics Lecture that “productivity growth in the entire economy means that we can afford more of everything”: thus, if the hours of labour invested in manufacturing and agriculture continue to fill at the current rate, more hours of labour become available for health care and education. To take advantage of such an opportunity would require some pretty fundamental social restructuring and seems not likely to happen in the near future. But it is something to think about. 

Webster’s political history of the NHS is a valuable resource for anyone wanting to know how it was conceived and developed. It is also a fascinating account of a major social experiment.