The NHS Bill – an historical perspective.

At the very least, the NHS Bill is provoking lively and vigorous debate. Just the other week, the proposed legislation was referred to by Ed Milliband as “David Cameron’s Poll Tax”! Objections against the changes put forward are too many and too wide-ranging to explore in detail here. But, succinctly, the main bone of contention lies in the expansion of outsourcing of NHS services to private companies – in effect the privatisation (‘modernisation’ some prefer) of the NHS – and its possible effects upon the quality and cost of patient care in England. But just what is it about privatisation in the bill that worries people?

Privatisation is certainly a loaded term; for some it carries the implicit assumption that something will be lost in the process– that things could get worse for consumers rather than better. Are we even somehow resentful of the loss or degradation of our once-proud institutions like the post office and the NHS? Given that the latter only dates from 1948, this seems less likely although there is certainly a residual fondness for what has been, for the most part, a success story of public health.

It is worth considering the provision of healthcare in Britain in the past, and especially in terms of the question of private enterprise. Four hundred years ago, the concept of public healthcare simply did not exist – this was the original ‘medical marketplace’. How, then, did this manifest itself in the sickness experiences of our forebears? How did these proto-consumers of healthcare cope with this situation, and what types of medicine and practitioner were available to them? What, ultimately, can we learn from them?

The early modern period was characterised by a diversity of medical service providers. These included university-trained and licensed physicians who often catered for wealthy clients, and who were largely based in large towns and cities. Surgery was a separate branch of medicine, while apothecaries, although nominally banned from doing so, also provided medical advice as well as remedies and ingredients as they were more accessible and more affordable for many people. At a local level were an undifferentiated mass of medical practitioners, ranging from specialists, such as occulists, bonesetters and wart-charmers, to travelling ‘doctors’ who would claim to cure anything from toothache to the ‘itch’ for a few pennies. Even the local blacksmith could be called upon to knock out a rotten tooth.

This was a true consumer market with a massive variety of choices for the early modern patient.  Most people self-medicated. Some grew their own herbs, but many remedies and ingredients were available locally, even in rural villages. Surprising as it might sound, given our perceptions of contemporary living conditions, maintaining a healthy lifestyle was also important. People invested in healthy ‘regimens’ – daily steps to staying fit from fresh air and exercise to early modern equivalents of the tonic or health drink.

So if medicine in the early modern period was fully private, was it better? Clearly, conditions in the seventeenth-century differ markedly from that which the proposed NHS bill would create. In effect, this aims to drive down costs by putting more services out to tender giving the customer – the patient – access to care through different providers but still essentially free at the point of delivery. The early modern marketplace though, was patchy and uneven, with the availability of care and cure varyying widely geographically, demographically and economically. In terms of public health, for example, authorities might intervene to contain epidemic outbreaks, but this did not generally extend to treatment or tangible support for the afflicted.

The closest thing to ‘official’ medical support could be found in local parish poor relief funds. Here the parish might pay for the treatment of a sick parishioner, sometimes even paying for them to travel if the most appropriate specialist was not nearby. Friends or neighbours might also be employed by the parish to care for a sick person. This phenomenon actually resonates with current questions surrounding the boundaries of public care provision. In very recent times, for example, the language of deserving/undeserving has returned to political discussions about welfare provision – a terminology very familiar to our forebears. Could a similar scaling back as that mooted for things like housing or child benefit eventually affect the willingness of the state to fund certain lifestyle-related conditions, say through smoking, binge-drinking or overeating?

Turning the question around, are things actually better now? Free healthcare, massively more effective drugs and treatments and a similar diversity of practitioners suggest so, but stories about people extracting their own teeth as they could neither find an NHS dentist to take them on, nor afford private care, are reminders of the failures that can still exist. According to a recent survey in a popular newspaper, four in ten adults consider dental care a luxury, while the cost of prescriptions in England is set to rise in April 2012.

Nonetheless, it is worth noting that we already engage widely with a private medical market. Like our early modern counterparts, we are vigorous self-medicators. The first recourse for many of us is the chemist (the local apothecary) where we purchase over-the-counter palliatives, despite the option of a cheaper prescription. Many visit private practitioners such as medical herbalists, whether professionals or one of the increasing number of high-street outlets.  Also, the option to purchase bespoke treatment remains a way to bypass waiting lists and, dare I say it, get a ‘better’ service, perhaps in more comfortable surroundings. ‘Lifestyle’ in the form of health food and drinks, spa treatments and even private gym memberships attest to our continuing desire to stay healthy and try and fend off illness before it arrives – a sentiment very familiar to those in the seventeenth-century. This is a market worth billions.

So to raise the question again, what are we afraid of? There is already, as these examples suggest, a broad acceptance of the idea of private enterprise in medicine. Whether alternative therapies, such as high-street herbalists, should be banned hasn’t really been debated. Whether they should be available on the NHS has. The potential problem with the intervention of the private sector, and here the experience of the early modern period does bear relevance, is the potential risk of uneven quality of care. People across the country in the seventeenth century faced widely varying quality in medical provision, based not only on their ability to pay, but on the lack of centralised training or regulation. The NHS provides a safety net that people in the past simply didn’t have. The danger in throwing the doors open to different companies, say in parallel to the privatisation of rail services, is that quality will again vary regionally and demographically; rather than having consistent levels of services across the whole country, and for people at all levels of society, patients’ care will suffer. This is something that the government will have to think carefully about. Things were not always better in the past.

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