Book review: The National Health Service: A Political History by Charles Webster (Oxford University Press, pounds 9.99)

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"THE NATIONAL Health Service is safe in our hands", Mrs Thatcher famously promised in 1982. And yes, it still exists, which is more than can be said for many other postwar institutions, dismantled during 18 years of Tory rule. This summer marks its half-century - under a Labour government, too, more convincingly pledged to its preservation than the Tories ever were. For 50 years it has survived, much loved but much abused, and now so patched, gutted and restructured that Nye Bevan would scarcely recognise it.

"If it ain't broke, don't fix it". The essential point of Charles Webster's short history is that there was not much wrong with Bevan's original concept. Every restructuring intended to make it more efficient made it less so. A simple tax-base still provides the cheapest health care delivery system in the world. Bevan's NHS was not perfect, but it got saddled early on with a reputation for bottomless extravagance which it has never lived down. In fact, after a huge unanticipated backlog of demand in the first two years, its cost fell steadily through the 1950s.

Webster suggests that the very lack of crisis in this period of consensus fostered a complacency which led to serious under-investment and a failure to correct inherent flaws. During the 1960s health spending did expand - from 4.1 to 5.31 per cent of GDP by 1974 - but this optimistic period culminated in the first disastrous reorganisation by Keith Joseph. When the first oil-price shock brought growth to a halt, the NHS was suddenly overstretched, overmanaged and at the mercy of unscrupulous unions. By 1979 it was in crisis.

Webster asserts that Mrs Thatcher was ideologically bent on destroying the NHS from the moment she took office. In fact she was remarkably cautious. Certainly she would have preferred an American-type insurance system; but (until the poll tax) her success was founded on knowing which battles she could not win. Twice, in 1982 and again in 1987, she backed away from following her instinct when the political outcry was too great.

Patrick Jenkin and Norman Fowler tried every expedient to squeeze costs: raising prescription charges, enforcing the contracting-out of services. Yet spending continued to rise, while the public perceived only cuts. Meanwhile the Griffiths Report unleashed another plague of managers. When finally she was compelled to act, she shrewdly gave the job to Ken Clarke, telling him that if he failed the blame would all be his. The resulting fragmentation - internal market, GP fundholders, hospital trusts - was developed largely on the hoof and has yielded remarkably few benefits.

The official historian of the NHS, Charles Webster is passionately steeped in his subject, yet perhaps not the ideal guide for the general reader. There is too much management structure, too many acronyms. His conclusion is gloomy; but what his book makes clear is that the only thing wrong with the NHS is a lack of the level of resources that most other developed countries spend on health care. Will Blair, Brown and Dobson get the message?

John Campbell

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