Bringing together prevention and cure, health and social
care, is hardly a new – or strange – idea. So why hasn’t it happened?
The fanfare that surrounded the publication of the NHS Long-Term
Plan made sure to highlight its promise that a shift away from
hospital treatment will not only save
the NHS “over £1 billion a year in new expenditure averted” but also
half-a-million lives. Which rather raises the question: if the locus
of care is to be relocated away from the expensive hospital, then to where? There
is one popular alternative that has had a difficult history, not least with the
Conservative Party, over the past century.
In the aftermath of the First World War, Lloyd George was
turning the attention of his government to post-war reconstruction and social
reform. This included the creation in 1919 of a new government department – the
Ministry of Health – under the direction of Christopher Addison, a GP turned
Liberal MP and one of the Prime Minister’s closest allies. One of his first
acts as Health Minister was to establish a committee under the chairmanship of Lord Dawson, formerly the King’s
physician, to investigate the “schemes requisite for the systematised
provision of such forms of medical and allied services as should… be available
for the inhabitants of a given area”.
interim report the following year outlined detailed
plans for establishing a network of health centres in every area across the
However, a final report was never written, and the health centres were never
built. As Lloyd George’s influence over his own coalition government waned, and
the Tories were demanding ‘retrenchment’ – what today we would call ‘austerity’
– a whole raft of social reforms fell to the wayside.
Two decades later in 1942, when Britain found itself at war
again, Lord Dawson wrote in
the British Medical Journal, saying
that his long-neglected plans “might well form the basis of reconstruction
to-day”. Indeed, by the end of the war, it was widely assumed that the widely
debated new National Health Service would include a host of new health centres.
Four years before the NHS was established in 1948, before Labour had won the
1945 election and Aneurin Bevan appointed Health Minister, medical social workers
were worrying that the inevitable new health centres would be set up too
slowly. Hoping to capitalise on the wartime expansion of social services, social
workers warned in 1944 that: “Unless health centres are
rapidly developed general practitioners will not be able to take full advantage
of the preventive and social services existing for the patient’s welfare”.
Despite expectations, health centres never really became a
feature of the NHS. New health centres were not a priority for a nation in need
of much post-war rebuilding. Meanwhile, the leadership of the medical
profession was suspicious enough of the new state service, without relocating
GPs en masse into NHS health centres.
Over the first 15 years of the NHS, only 17 health centres were opened – hardly
the national network the Tories had scuppered back in the 1920s.
From 70s optimism to Darzi polyclinics – and
The idea of
health centres, as a place to bring together the preventive and curative
services of the NHS, had caught on by the 1970s, when their building peaked at
100 a year. These health centres were often built by local authorities, who
employed health visitors and nurses, renting out space to GPs and dentists.
They proved popular but too expensive for that rate of building to continue
once the financial troubles of the late 1970s set in.
then to radically develop the siting of primary care, to allow for a shift away
from expensive hospital provision, have not been easy. Under Gordon Brown,
Labour’s answer was polyclinics. They offered the possibility of integrating
various health and social care services for those with long-term conditions,
but deeply divided opinion. While Professor Darzi saw them as central to his
2008 ‘Healthcare for London’ plan, questions over funding were combined with
suspicions on the left over the role of the private sector and those on the
right about central government imposing a standardised system on local
communities. Polyclinics didn’t survive the arrival of David Cameron’s
coalition government in 2010 and they aren’t what the new plan is talking
As the Financial
Timesnoted, “the NHS cannot close hospitals until new primary care
facilities are established”, but there’s no proper discussion of such actual centres
in the plan. Instead, there’s talk of digital GP consultations and the promise
of £4.5billion to fund the expansion of multidisciplinary community teams to
work with local GPs. The idea is that over a number of years, in each area, GPs
will enter into a single ‘network contract’ with district nurses,
pharmacists, physiotherapists, dementia workers and others, including from
social care and the voluntary sector (no mention of the private sector).
There’s no plan to physically bring them together, but instead for them to be
supported by undefined ‘community hubs’.
Whether there will be staff needed for these teams, whether
the agreed funding will prove enough or whether these new ethereal health
centres can avoid the setbacks and controversies of their concrete predecessors
over the past century remains to be seen.
Of course, this
isn’t just about which medical services are provided where (or
even by whom). It's also part of the much wider canvas of social provision,
which stretches beyond the obvious health and social care services. After all, the NHS doesn't exist in a vacuum.
Where’s the joined up thinking on prevention?
better than cure” was the motto of the National Health
Society, founded in 1871 by the world’s first woman MD, Elizabeth
Blackwell, the leader of the Victorian public health movement, Edwin Chadwick,
and others. One of their key campaigns was for more urban green spaces, in
which they were soon joined by Lord Meath’s Metropolitan Parks and Gardens
Association and Miranda and Octavia Hill’s Kyrle Society. These city parks and
school playgrounds were intended not only to provide the poor a chance for some
fresh air away from the slums, but also as a space for the masses to engage in outdoor
sports. 140 years ago, their campaigns were based on the understanding that
preventing illness means supporting healthy lives in a whole variety of ways.
It was this same understanding that led Addison to introduce the first council
housing from the new Ministry of Health, and gave Bevan the dual task of
beginning the rebuilding Britain’s blitzed cities at the same time as setting
up the NHS.
In spring of this
year, we’re promised guidelines on Putting
Health into Place, to build on the NHS’s work with the Healthy
New Towns programme to work towards a healthy built environment. But
this features in an appendix on how the plan will allow the NHS to help others.
Something largely missing here is an acknowledgement that the success of the
envisaged shift away from hospital provision rests in no small part on factors
beyond the NHS itself.
The new plan talks
of ‘cutting delays in patients being able to go home’, somewhat downplaying the
fact this doesn’t just mean patients being ready to leave hospital but also
having somewhere to go. It refers repeatedly to integrating health and social
care services, particularly for older people, but the
lack of a parallel plan for residential social care is striking.
If the government
had truly realised that these ambitious plans for the NHS are inextricable from
the wider raft of social and welfare services, wouldn’t Amber Rudd be scrapping
or undertaking a far more fundamental rethink of the much-maligned universal
credit system? Wouldn’t there be a plan to revitalise the local authority
public health and social services that have taken such a battering from a
decade of austerity?
The fact this plan
cuts such a lonely figure suggests the government hasn’t begun to grasp the scale
of the challenge ahead for our NHS.