The NHS in the 1960’s

By the late 1950’s the problem with the funding of the NHS was firmly a political issue. Correspondingly during the 1960s’ and 70s’ successive governments pledged extra funding to the NHS in an attempt to win political favour by tackling the problems caused by poverty and ill health (Klein R 1995). Therefore the period 1960 to 1975 represented an era of growth in the NHS (Timmins N 1995). This growth, however, had to be handled very concisely if the delicate balance between the medical and political parties in the NHS was to be maintained. Therefore, increased funding was combined with an increased emphasis on the efficiency and rationality in the use of resources in the NHS. The early 1960’s saw the appointment of economists to the NHS as well as to other governmental departments, and new methods of fiscal policy were developed. Most notably the Public Expenditure Survey Committee (PESC) system was established in 1961 (Curwen P 1997). This was an attempt to inject a greater influence of the state in the running of the NHS by the use of mathematical and accountancy methods (Klein R 1995). The change to centralised planning led to an increased emphasis being placed on cost benefit methods and on

unified planning themes such as Programme Planning and Budgeting (PPB) and Programme Analysis Review (PAR) (Lord Fulton (Chairman) 1962) (Glennerster H 1998). There were, however, countervailing pressures to the achievement of the central control of finances within the NHS.

1. Medical Technology

The increase in financial support seen in the 1960’s was mirrored by an increase in the availability of medical technology (Rivett G 1998). The 1960s were an era of tremendous medical advances. Hip replacement surgery and renal dialysis became available, as did medication for the management of mental illness. These advances were only available at a price and coupled with the increasingly aged population the growth in NHS funds was in danger of being outstripped by demands (Baggot R 1994) (Rivett G 1998).

2. Staffing Pressures

The advances in technology resulted in a change in the professionals who used it. Many new skills and professions developed in the health service and staff came to value their position more. Additionally the national wage settlements in the NHS, which failed to keep pace with inflation, had the effect of a real-terms decline in the wages of NHS workers. These factors combined to increase a sense of militancy among NHS workers and the 1960’s and 70’s were marked by an growing number of industrial disputes in the health service (Lord Walton of Detchant 1998).

3. The Lack of Planning Levers

In order to meet the demand of medical technology and staff wages, planners were forced to consider controlling demands instead of planning the system. However the tools that were available to control demand at a state level were limited. This was because the demand at a local level was under the control of the doctors and patients, and these groups were insensitive to the levers applied from the Ministry of Health (Klein R 1995) (Ministry of Health and Department of Health for Scotland 1956). Therefore any centralisation of demand would require a change in the doctor patient relationship. This however raised a further problem, that of the conflict between the demands of the doctor - to give therapy to an individual - versus the NHS, which functions to provide health care population. This conflict between the absolutist and utilitarian ethics was as great as it was complex. The medical profession was against the utilitarian ethic as they argued that it could lead to the situation where patients may receive sub-optimal therapy, white the NHS argued that it could not support, financially, the absolutist movement(Vaughan P 1950; Platt R 1963).

The only solution to the organisational and technological problems in the NHS was to introduce the rationing of services as a function of planning and demand management (where demands could be controlled) (Webster C 1998). The first attempt at planning a rationed service was the 1962 Hospital Plan for England and Wales, published by Enoch Powell - then Minister for Health (J Enoch Powell 1966). It was an attempt to devise a national plan for distributing hospital beds according to need. It established national norms for hospital beds and called for a £500 million investment in services. The pattern of service was also to change with services being provided on a District

General Hospital basis. District General Hospitals were envisaged as large hospitals

providing about 600 beds serving 100 - 150,000 people. This plan reflected the feeling of the time and served to marry the needs of the medical profession and the rationalistic planners. This was evident when the plan was re-visited in 1969. The Bonham Carter Panel, the panel who reviewed the 1962 plan, had no fewer than 12 doctors on it (Department of Health and Social Security 1969). This panel recommended that the new hospitals should be larger in order to support the consultants working in the hospital. This plan, however, was never accepted as official policy as politicians became concerned at the social impact of building technological palaces to the detriment of local services. In effect members of parliament were left with the political fall out from the closure of local facilities and therefore hospital building began to slide down the political agenda (Klein R 1995). The shrinkage of the building programme coincided with increased salary and other demands from NHS workers and faced with the choice of buildings or industrial unrest, the politicians increased the salaries (Crossman R 1972).

The National Plan for Hospitals was responsible, indirectly, for an increase in organisational problems within the NHS. The plan - as discussed above - can be seen as an attempt to introduce control and prescriptive planning. This move was resisted strongly and two reasons for its inappropriateness were put forward. The first of these was that due to the diversity of local populations, a national plan could not be upheld. The second related to the future needs of the health service. It was argued that it was not possible to set local priorities so that future needs could be met (Allen D E 1979). These conflicts over the 1962 hospital plan only served to emphasise a growing disparity between the central structures in the NHS - the Ministry of Health - and the

peripheral operational structures. This disparity concentrated on the accusations that the centre was not sensitive to the operational needs, while the centre accused the periphery of being too focussed on the local issues and not seeing the bigger picture. These frustrations spilled out into open debate in journals such as the BMJ (Lord Walton of Detchant 1998). This atmosphere of mutual frustration would be one the key themes of the development and change in the NHS in the 1960s and 197O’s(J Enoch Powell 1966; Klein R 1995).