Revue Française de Civilisation Britannique French Journal of British Studies

XXIV-3 | 2019 The NHS at Seventy: Framing Health Policy in Britain Soixante-dix ans après la création du : Quelles politiques de santé publique au Royaume-Uni?

Louise Dalingwater (dir.)

Édition électronique URL : http://journals.openedition.org/rfcb/4105 DOI : 10.4000/rfcb.4105 ISSN : 2429-4373

Éditeur CRECIB - Centre de recherche et d'études en civilisation britannique

Référence électronique Louise Dalingwater (dir.), Revue Française de Civilisation Britannique, XXIV-3 | 2019, « The NHS at Seventy: Framing Health Policy in Britain » [En ligne], mis en ligne le 30 août 2019, consulté le 18 mars 2020. URL : http://journals.openedition.org/rfcb/4105 ; DOI : https://doi.org/10.4000/rfcb.4105

Ce document a été généré automatiquement le 18 mars 2020.

Revue française de civilisation britannique est mis à disposition selon les termes de la licence Creative Commons Attribution - Pas d'Utilisation Commerciale - Pas de Modifcation 4.0 International. 1

SOMMAIRE

Introduction: Seventy Years On: Framing Health Policy in Britain Louise Dalingwater

Parliamentary Debates on the Anniversaries of the British National Health Service 1958-2008: ‘plus ça change?’ Martin Powell

From Adult Lunatic Asylums to CAMHS Community Care: the Evolution of Specialist Mental Health Care for Children and Adolescents 1948-2018 Susan Barrett

Public Health and the NHS at 70: Fit Enough for the Challenge of New Enemies in a New Landscape? An Example of Public Health Measures to Address Alcohol Consumption Fiona Campbell et Andrew Lee

Approche iconoclaste d’ au ministère de la Santé (1960-1963) : entre liberté économique et puissance étatique ? Stéphane Porion

Dévolution et politiques de santé en Écosse : un modèle de continuité et d'efficacité ? Edwige Camp-Pietrain

Right to Reply: Using Patient Complaints and Testimonials to Improve Performance in the NHS Louise Dalingwater

The Interplay of Health, Pleasure and Wellness in British Seaside Resorts: the Case of Skegness on the Lincolnshire Coast Mohamed Chamekh

Wasteful Spending in Health Care: A US and UK international comparison Max Holdsworth

Interviews

Interview with a Clinical Equipment Training Co-ordinator and Union Representative John Mullen

Interview with an NHS speciality registrar Louise Dalingwater

Book Reviews

Review of In Search of the Perfect Health System by Mark Britnell Hira Rashid

Compte rendu de l’ouvrage La politique de la petite enfance au Royaume-Uni (1997-2010) : « Une nouvelle frontière » de l’Etat-providence britannique? de Susan Finding Aurore Caignet

Review of The Co-operative Movement and Communities in Britain, 1914-1960. Minding Their Own Business by Nicole Robertson François Deblangy

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Compte rendu de Le multiculturalisme britannique au 21ème siècle : Enjeux, Débats, Politiques d’Olivier Estèves et Romain Garbaye Vincent Latour

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Introduction: Seventy Years On: Framing Health Policy in Britain Soixante-dix ans après la création du NHS : Quelles politiques de santé publique?

Louise Dalingwater

1 The National Health Service (NHS) turned 70 in 2018 and, to mark the event, this special issue wishes to pay tribute to an organisation and to its workers (doctors, nurses, and administrators) who provide health care to the British population. The institution still promises to provide services free at the point of use from “the cradle to the grave”. It is one of the largest employers in Europe, with over one million staff. The NHS is considered essential as it not only provides health care services to the British population but also aims to ensure social cohesion and a robust workforce. Public support for the NHS is strong because the British believe resolutely in universal access to health care. Indeed, according to a survey by the think tank, The Kings Fund, 90% of those polled in 2017 stated that the founding principles of the NHS to provide health services free at the point of use should be upheld1. Recent Ipsos polls have reported similar results.

2 But the NHS has experienced a turbulent life since its inception. Public health care is very costly to deliver. British hospitals and public health institutions have been facing a significant cash crisis for years, which has led to debates on how much longer such a funding model can survive. The nature and scope of the work of the NHS has been transformed from ensuring post-war men were fit for work and combating infectious diseases to coping with ageing populations and long-term illnesses. Moreover, the reconfiguration of the NHS by successive governments, the changing nature of demand for health care and the shifting focus has meant that public health services are no longer considered from a purely “public good” perspective. Financial pressures, the redefinition of health and social care and globalisation have transformed the public health sector. 3 The National Health Service alone can no longer manage the health of the population. It is thus important to consider the provision of public health services and policy which goes beyond the scope of the NHS but has a significant impact on public health.

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Moreover, taking a wider perspective on public health, beyond the remit of the NHS, is essential because other areas related to health such as employment, income, and housing can have a significant impact on the health of the population. In recent years, health policy has also been conceptualised to mean much more than curing disease, but also enabling people to attain the highest degree of health and wellness. In light of the changing face of the NHS, this special issue seeks not only to reflect on the 70 years of the institution but also consider new and emerging trends in health care provision. 4 In this special issue, Powell maps the issues that the NHS has faced since its inception by examining the presentation of the NHS in political debates of the of Commons. In keeping with the theme of this special issue, his article focuses on broad debates on each anniversary of the NHS. Apart from the 10th anniversary, these anniversary debates have been largely neglected, perhaps because the 1958 debate was the only Commons debate there has ever been to mark an anniversary. He concludes that the view ‘plus ça change’ ought to be nuanced, but he does agree that old arguments have certainly not gone away or been resolved. Factors such as the longstanding pressures of medical technology, ageing populations and rising expectations, the question of whether the NHS has delivered enough for all the extra spending… have indeed marked every anniversary. Many of the problems seem to be hardy perennials whether it be finance, demography, technology, waiting lists, staff shortages, staff morale or reorganisation. While most anniversaries have been the occasion to discuss most of the themes, their salience has nevertheless tended to vary over time. 5 Barrett also takes a historical approach in her analysis of the NHS looking specifically at Child and Adolescent Mental Health Services (CAMHS) before and since the inception of the NHS. She demonstrates how the creation of a specific child and adolescent mental health service within the NHS was influenced by a number of factors including in adult mental health policies, the evolution of society’s attitudes towards children and parenting, and a greater biological and psychological understanding of how children develop. She describes the care for young people with mental health problems in the early years of the NHS and the split between child guidance clinics and hospitals. She contends that while a single unified service was created in 1987, national guidelines for its organisation were only introduced in 1995 and these guidelines were not necessarily implemented in the same way across the country. She concludes that while there has been considerable progress in the services available for mentally unwell children and teenagers over the past seventy years, nationwide availability of high-quality, effective care for those children and adolescents suffering from severe and complex mental health problems still does not live up to ambitions to provide physical and mental health services on an equal footing. 6 Campbell and Lee show how while the NHS may still ensure free health care to the population, the health of the nation still remains vulnerable to the commercial interests of powerful actors such as corporations and industry. Their contribution underlines how such industries may actually impede or curtail health policy and preventative health measures in the community. In particular alcohol and tobacco industries manage to fight public health policies aimed at curbing alcohol and tobacco consumption by publishing poor science, political lobbying and through legal action at national and international levels. So while the NHS and local authorities may work towards better public health and health care, the authors provide evidence to show

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that better public health cannot be achieved solely through the promotion of healthy behaviour, but also requires active efforts to counter those powerful entities with vested interests in commercial profit. The manner in which the British government’s commitment to introducing a minimum unit price (MUP) for alcohol in and saw an extraordinary U-turn has been described as a cautionary tale of the power of the alcohol industry to influence public health policy. 7 Porion’s paper looks at a controversial figure in history, Enoch Powell, who was appointed health minister in 1960 under Harold Macmillan’s Conservative government. Porion underlines how Powell’s stance on the NHS and health policy was somewhat at odds with his supposed political values. While his aim was to rationalise spending in the NHS, he also wished to modernise and humanise this public health institution in the Disraeli tradition. He led an ambitious project of hospital building among other things. Such investment in the public good stood in sharp contrast with his overall hard right approach to spending and public intervention. The author analyses Powell’s iconoclastic approach by using primary sources from Kew’s national archives and Powell Papers from Cambridge. In order to enhance historiographical debates, his analysis focuses on three main issues: Powell’s handling of the cost of drugs, cigarette advertising and the fluoridation of water. This leads onto an additional dilemma that Powell had to face on how to maintain freedom of choice in a public health service where the State was the main driver. 8 Camp’s contribution reminds us that we should not consider the NHS as one single institution but also consider how each country of the differs in the way it provides public health services. She underlines how the provision of public health has changed quite significantly and especially since the devolution of powers to the separate regions of the UK. She focuses specifically on the Scottish case. She contends that, since 1999, 's Parliament and government have striven to improve the health of the by restoring a public service based on co- operation and not on competition, while devising policies aimed at modifying the behaviour of individuals. She concludes that while some success has been achieved thanks to the devolution of powers, political issues have somewhat clouded effective attempts to solve the health issues of the Scottish population. Moreover, tensions have been fuelled by tighter budgetary constraints and constitutional upheavals. 9 Dalingwater and Chamekh’s contributions turn to some emerging trends in health and wellness. Dalingwater discusses the recent focus on person or patient-centred care in the NHS and the different methods currently in place to actively encourage patients to judge the provision of health by sharing their experiences of care and treatment, completing surveys, etc. Yet information and other data on user experiences are not currently well aggregated or used to drive improvements in health care delivery. So while the right to reply from the patient’s perspective might be a way to improve care, this paper underlines a number of difficulties in collating and effectively using such information. It draws on a case study of Stafford Hospital and its failure to provide adequate care to its patients. This study shows how important it is to monitor quality care not only from external sources but from internal sources, especially patients and family. However, the conclusions are stark: a really effective nationwide system whereby staff and patients can freely air their views without fear of reprisal still has a long way to go.

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10 Chamekh’s article underlines the potential of seaside resorts to improve health and wellness. His study of Skegness as a seaside resort across the ages demonstrates how the use of seawaters to treat diseases contributed to the rise of seaside resorts. He explores the potential of resurrecting them as wellness destinations and fulfilling the wider health policy objectives of improving the nation’s health, wellness and happiness. Chamekh essentially calls on policy makers to take a lesson from the past when the importance of seaside resorts for better health was partly driven by increasingly stressful lifestyles and the recognition that climate can contribute to improved health and wellbeing. He reminds us that this tendency was strengthened by an all-inclusive health strategy adopted by the Ministry of Health in 1919 which sought to combine preventative medicine, lifestyles, and better health care provisions to improve the health of British citizens. While preventative policy is no longer the remit of the NHS, Chamekh underlines that the government’s new health strategy which seeks to prevent the physical and mental problems of an ageing population could avoid hospitalisation and reduce the burden on the NHS. Health policy makers should thus encourage the British population to seek the sea air to ensure good physical and mental health. 11 Finally Holdsworth contrasts the UK and US health care systems. Both countries are working to decrease wasteful spending. The United States wastes money in its unnecessarily high use of testing and procedures and through its volatile prices that affect how health services are managed. Administrative costs in the US are also high, due to its relatively un-regulated complex system. The UK, on the other hand, spends less per-capita on health with verifiably better outcomes. However, both countries need to monitor more carefully forms of wasteful spending. In the US, the government needs to follow the Choosing Wisely recommendations more carefully to reduce certain practices that physicians claim do not produce sufficient benefits. The UK, as it moves past 70 years, needs to support accountable care and integrated budgets to maximize the population health benefit of limited investment. The author concludes by underlining that at a time when prices continue to rise, the population is ageing and chronic diseases are preventing a part of the population from living life to the full, it is essential that health care systems address wasteful spending and strive to produce the equitable care and services that people deserve. 12 This issue has been prepared and stylized for online publication with the LODEL software programme by John Mullen and Arnaud Page.

NOTES

1. https://www.kingsfund.org.uk/publications/what-does-public-think-about-nhs

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AUTHOR

LOUISE DALINGWATER

HDEA, Sorbonne-université, Paris

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Parliamentary Debates on the Anniversaries of the British National Health Service 1958-2008: ‘ plus ça change?’ Débats parlementaires sur les anniversaires du service national de santé britannique 1958-2008: « Plus ça change? »

Martin Powell

Introduction

1 On 5 July 2018, the British National Health Service (NHS) celebrated its 70th birthday. As a largely publicly financed and provided service, the NHS is necessarily the subject of political debate. The most obvious place to explore such debate between the Government and opposition parties is in the adversarial House of Commons, which is charted in the ‘Hansard Parliamentary Debates’. This article charts political perspectives on the NHS over a period of some 60 years through the lens of political debates in the House of Commons, focusing on the closest broad debate on the NHS to each anniversary. Apart from its 10th anniversary, these anniversary Debates have been largely neglected, perhaps because Timmins (2008: 9) states that the 1958 debate was the only Commons debate there has ever been to mark an anniversary. However, as we see below, this is not the case, and so the material presented here explores largely original material.

2 It draws on interpretive content analyses that includes attention to both manifest and latent content, and also draws much more attention to the contexts in which people make, convey, and receive communications (Krippendorf 2013; Drisko and Maschi 2016). Manifest content refers to what is overtly, literally, present in a communication. Latent content refers to that is not overtly evident in a communication, but is implicit or implied, often across several sentences or paragraphs. Coding in most

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interpretive content analyses is largely descriptive, and starts inductively with the preliminary raw data. Such “emergent” coding contrasts with the a priori or deductively generated coding used in many basic content analyses. Interpretive content analysis allows for the use of connotative categories which are based not on explicit words but on the overall or symbolic meaning of phrases or passages. Most data presentation in interpretive content analysis centres on descriptive narratives, or themes, summarising the collected and coded data. It is possible to code material in a large variety of ways. The main rationale was a search for a set of themes that emerged inductively from the material and were present in most or all of the time frames in order to trace issues over the 50-year period from 1958 to 2008. The following themes are explored: creation, principles, stewardship, achievements and problems. It was found that every Debate contained a discussion about the creation of the NHS, with the Labour Party stating that they founded the NHS, while the Conservatives opposed it, This was continued into arguments over the principles of the service, where Labour tended to argue that they supported the principles (free at the point of use; available to all; largely funded from taxation) of the NHS, while the Conservatives opposed them, claims hotly contested by the Conservatives. This was paralleled by a wider discussion of stewardship, where the Conservatives argued that they had presided over much of the period of the NHS, and had increased resources for the service, while Labour had starved it of funding. Achievements and problems represent a mirror image coding of ‘positive’ and ‘negative’ features Sometimes these claims were partisan, in the sense of the speaker arguing that their party was responsible for the achievements of the service, while the opposition (while in government) was responsible for its failures. However, at other times, speakers appeared to look beyond partisan issues, pointing to broader issues such as the cost implications of medical technology and an ageing population. This presentation uses the terminology of the period such as ‘mental hospitals’, and provides party affiliations for the first time for each speaker, with the Hansard column number for reference.

Tenth Anniversary

3 A Debate was held in the House of Commons to mark the tenth anniversary of the creation of the NHS. Klein (2013: 23) noted that it was an ‘exercise in mutual self- congratulation as Labour and Conservative speakers competed with each other in taking credit for the achievements of the NHS’. According to Timmins (2008) it was a ‘ matter of quiet congratulation’, with a strong sense that something big and good had been created in 1948. The 1958 Debate was introduced by former Labour Minister of Health, and founder of the NHS, .

4 The theme of creation reflects a common theme throughout the period, where Labour attempted to claim credit for founding the NHS, while pointing out that the Conservatives opposed it. For their part, the Conservatives argued that the 1944 White Paper outlining the NHS had been produced during the wartime Coalition Government under a Conservative Minister of Health. Moreover, they claimed that in 1946 they voted against particular elements of the NHS put forward by the 1945-51 Labour Government, while supporting the broad concept of the NHS (in effect, their version of the service from some two years earlier).

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5 Bevan (c1386) stated that Conservative Members voted against the NHS on every conceivable occasion and for every conceivable reason. Similarly, John Baird (L, c1500) claimed that the Tory Party attacked the Bill most viciously in the country and in the House at every stage, with wrecking Amendments of all kinds. ‘If they had had their way there would be no NHS as we know it today.’ 6 However, Minister of Health Derek Walker-Smith (C, c1400) considered that Bevan was ‘less than generous in his reference to his predecessors at the Ministry of Health and in his total omission of any reference to the Coalition Government’s White Paper of 1944.’ Sir Hugh Linstead (C, c1461) and (c1426) argued that the Conservatives put forward a reasoned Amendment, but supported the idea of a comprehensive NHS. 7 The precise principles of the NHS have never been fully clear, although most commentators point to issues such as being comprehensive (covering all medical treatments), universal (available to all, rich and poor, on the basis of citizenship, rather than based on any insurance contributions), free at the point of use (no price barrier) and largely funded from national taxation (which was seen as more progressive than regressive insurance payment or out of pocket fees) (Powell 1997). 8 According to Bevan (c1383), two main conceptions underlay the NHS. The ‘comprehensive’ principle was to provide a comprehensive, free, health service for all the people of the country at time of need. The ‘redistributive’ principle was the redistribution of national income by a special method of financing the NHS. 9 Parliamentary Secretary to the Ministry of Health, Richard Thompson (c1487) stated that while the House may differ on means, it was ‘fairly broadly united about the end, which is to provide a comprehensive Health Service for need.’ One of the few (minor) exceptions to that was that Mr Shepherd (c1449) favoured increasing the amount that employers pay as a contribution towards the NHS. 10 Given its short history of ten years, there was there was little discussion of stewardship (what parties did during their time in government), as there was relatively limited evidence of ‘track record’ (Labour presiding over the NHS from 1948 to 51 and the Conservatives from 1951 to 1958). As we shall see, this relative silence did not last, with future anniversaries having longer periods from which to make claims. 11 The only significant remark about stewardship was from Bevan (c1393) who admitted that Labour introduced some small charges in 1951, intending that they should last for four years, but the Conservatives made them permanent and increased them. 12 In contrast to the first two themes which remain largely constant in content over time, claims of achievements vary significantly over time in two ways. First, speakers pointed to both ‘objective’ measures such as mortality statistics and the number of staff and hospital beds. Second, they made more discursive claims (rarely backed up with evidence) such as the NHS being ‘the best in the world’. 13 Bevan (c1385) pointed to the ‘remarkable’ declines in the infant mortality rate and the maternal mortality rate since 1948. Derek Walker-Smith (c1401) pointed to increases in effective beds, the number of in- and out-patients treated, and the ratio of treatments to beds, and to a decrease in waiting lists. 14 Bevan (c1398) claimed that the NHS was ‘regarded all over the world as the most civilised achievement of modern Government’. Future Labour Minister of Health, (L, c1442) stated that ‘the ten years of the Health Service have seen, in effect, a social revolution. We have, without doubt, the finest Health Service in the

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world’ (but see criticisms/ problems below). Moreover, he expressed his confidence that it provides a pattern that would be copied by many other countries in the years to come (c1447). 15 Similarly, the nature of ‘problems’ varied over time. Members pointed to various problems such as some mental hospitals being in a disgraceful condition (Bevan, c1396; Robinson, c1442; Shepherd, C, c1450), the ageing population (Walker-Smith, c1404; Mr Blenkinsop, L, c1457; Thompson, c1499), the need for more on the preventative side (Rev. Llywelyn Williams, L, c1425), the neglect of ‘positive’ health (Thompson, c1497) and the democratic deficit in the NHS (Sir Fred Messer, L. c1432). 16 However, there were different Conservative views of expenditure. While Robert Cooke (c1420) claimed that ‘the cost is threatening to get out of control’, Mr Shepherd stated that ‘We are not really spending much more, if any more, of the percentage of the national income on health than we did in 1938’ (c1450). 17 Finally, different comparisons were made by Conservative Members. Gower (c1427) stated that the decline in deaths in childbirth and the increase in longevity is happening all over the world, and several countries were ahead of us. However, according to Shepherd (c1453), it is only when one investigates services in other countries that one realises how poor theirs are and how good is ours.

Twentieth Anniversary

18 Klein (2013: 46) regarded the time of the NHS twentieth anniversary as a period of innovation. Timmins (2008) pointed to a mix of “technological pull” and “demographic push”, including ‘a pharmaco-technological revolution that it could not afford.’ The 1968 Budget had seen Labour reintroduce prescription charges. The Secretary of State for Social Services (, c 253-4) stated that ‘it is right to scrutinise the Health Service today, because it comes of age on Saturday, 5th July, 1969.’

19 There appeared to be few references to creation beyond Laurie Pavitt (L, c285) who stated that the whole basis of the comprehensive service is part and parcel of the philosophy on which his party came to power in 1945. 20 Turning to principles, for the Conservatives Maurice Macmillan (c250-1) argued that there was no question of finding all the extra money required by the NHS from taxation, so some system of insurance, charges, or increased contributions had to be faced. Labour Secretary of State, Richard Crossman (c256-9) rejected the possibility of a larger private sector, as this might lead to the NHS becoming a second-class service. Charges in the NHS were ‘a very mixed bag’ and ‘many of them are surprisingly uncontroversial’ such as charges for Part III accommodation for a place in an old people’s home, amenity beds, or dental charges. However, any proposed charges for a hospital bed or to visit the doctor were ‘outrageous’ (c261). He appeared willing to consider the possibility of a higher NHS flat-rate contribution (c263). Within the Labour ranks, David Marquand had ‘no dogmatic objection to charges’ (c276). Some charges appeared to have been accepted such as amenity beds, but there was more concern for prescription and dental and ophthalmic charges (e.g. Dr John Dunwoody, L, c298). Laurie Pavitt (L, c285) argued that ‘If one is to maintain a comprehensive service, it can only be paid for comprehensively’. He claimed that the philosophy of the Opposition was the old philosophy of a minimum provision and a safety net, which inevitably leads

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to a first-class service for those who are wealthy and a second-class service for the man in the street (c289). He urged the Government to restore the basic principle of this party on health matters (c291). 21 For the Conservatives, Dudley Smith (c280) favoured ‘selective charges’. Charles Morrison (c269) considered that a prescription charge can be commended, but was continually worried about the exemption categories. He did not consider that expanding the private side of the NHS would lead to a second-class service, or that tax relief would not be a breach of principle. Julian Snow (L, c307-311) claimed that underlying most of the Opposition speeches was a feeling that there should be a place for a system such as B.U.P.A. as an alternative to the NHS for higher income groups, which he found ‘unattractive and unacceptable’. 22 Stewardship was discussed mainly in terms of expenditure. Crossman (c254) pointed out that Labour increased the real cost of the NHS by 23 per cent, while the hospital building programme had doubled in five years. Pavitt (c289) stated that it is to the credit of the Government that the NHS’s proportion of national wealth increased from 4 per cent to just over 5 per cent in the last four years—the biggest rise since the inception of the service. Marquand (L, c274-5) pointed to the past neglect of the NHS during the 13 years when the Conservatives were in power. Snow, appeared to produce some faint praise that ‘the record of this Government is not all that bad’ as expenditure in real terms has increased 30 per cent since taking office in 1964 (L, c307). For the Conservatives, Macmillan (c253) and Morrison (c269) criticised the consistency of Labour of abolishing prescription charges in 1965 to re-introducing them in 1968. 23 Achievements were discussed both in specific (mortality) and general terms. Pavitt (L, c283) claimed that one of the problems of financing the service arises from the success story that because of the NHS, people are living longer and that it has been one of the great successes in the world: more hospitals, doctors and nurses, and fewer people dying from tuberculosis. More modestly, Snow stated that ‘We have nothing to be ashamed of in our National Health Service’ (L, c311), but also considered that with all its shortcomings—and there are many, the NHS is admired throughout the world (c307) and that ‘We in this country are giving a lead to the world’ (c311). 24 Dunwoody (L, c291) argued that the NHS faced very serious problems: excessively long waiting lists for surgical treatment; a shortage of doctors in all parts of the service; overcrowded waiting rooms; and a nursing profession disgruntled as perhaps never before. He considered that the cause of the problem of increasing demand was inevitable for two reasons: an ageing community (Marquand, L, c275) and medical advances (Macmillan, C, c243; Crossman, L, c256). 25 As Paul Dean (C, c303) put it, the problem would become worse rather than better, because these built-in growth factors were multiplying all the time. The sort of conditions that people were prepared to accept in hospital ten years ago were not accepted today, because standards were rising. Perhaps most important of all were the advances in medical science. Crossman (c254) pointed to the ‘basic fallacy’ of the assumption in the of 1942 that a comprehensive Health Service would lead to the improvement in the health of the nation and the flattening out the costs within a few years (cf Macmillan, c243). Marquand (c274) stated that everyone has agreed that health gets nothing like a satisfactory proportion of Gross National Product (GNP). At 5 per cent, Britain was still a long way behind other countries. However, Snow (c307) argued that comparisons with other countries can be very misleading. Macmillan

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(c248) noted that we are proportionately spending less on mental health provision than we were three years ago. Crossman (c255-6) pointed to the problem of inherited inequalities. For example, ‘one of the main inequalities was between the regions in 1948.’

Thirtieth Anniversary

26 Klein (2013: 76) pointed to ‘the politics of disillusionment’, with low increases in expenditure, and a period of medical and trade union militancy. For the first time in the history of the NHS, doctors took industrial action, resulting in ‘the politics of ideological confrontation’ over pay beds (p. 85). Klein also pointed to ‘the politics of organisational statis’ and a sense of crisis that led to the setting up of a Royal Commission of the NHS (p. 90). The Debate in March 1979 on the state of the NHS was primarily about the question of nurses’ pay, but ranged into wider territory.

27 There was only one reference to the creation of the NHS, when Dr Miller (L, c783) claimed that the Conservatives did not approve of the principles of the NHS in the first instance and retain even now some objections to the way it is funded. 28 Discussion of principles related mainly to the funding mechanism of the NHS. Robert Boscawen (C, c780) argued that some new thinking was required with regard to the funding of the NHS, instead of falling back every time to raising the resources from central taxation. He discussed "hypothecated revenue ", and believed that there is a case for looking at a partial funding of the NHS through a national insurance fund system. He hoped that there would be a continuing debate, especially when the Royal Commission on the NHS reported, into more sensible ways of finding funding for a Health Service free at the point of use (cf Dr Vaughan, c 811). 29 Miller (L, c783) disagreed with those who talked about the Socialist concept and principles of the Health Service being responsible for what were considered its ills, and that the whole matter should be left to free enterprise. Most of the carping against the NHS came from those who are lukewarm about accepting the basic principles of the Service. Labour Members claimed that the Conservatives would ‘increase charges all around’ (c811). 30 There was some discussion of the ‘national insurance principle’, although it was unclear what was meant by the term. Roland Moyle, the Minister of State at the DHSS stated that it meant that people receive the service in return for contributions, and asked what happens when they run out of benefit? Did it mean that they have to go without health care, as happens in a number of European countries (c814)? However, Vaughan (c811) had already stated that the Conservatives were as determined as Labour to have an NHS that provides proper, first-class health care to every person who requires it, but the differences lie in the way in which that sort of care is achieved. 31 Similarly, much of the discussion of stewardship also related to funding. Mr Ridsdale (C, c766-7) contrasted the 13 years of good Conservative rule that made wealth for the country with the 12 miserable years of Socialist rule that have brought us to equal shares of misery. He looked forward to a new Conservative Government that would be able to make wealth for the country in order to finance the NHS. 32 Most problems were associated with funding. A number of Labour back benchers and the Conservatives urged the Labour Government to spend more on the NHS. However,

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Moyle (c725, c813) and Mrs Wise (c807, c822) asked the Conservatives where they would find the money, given their broad position of wishing for cuts rather than increases in public expenditure. Vaughan responded that Labour has no right to imply that they wished to cut the resources available to the NHS (c799). 33 Vaughan (C, c803) stated that the Labour Government have had the responsibility for the NHS for over four years yet had decided not to put right the present chaos. He pointed to the ‘absolute disgrace’ of waiting lists of over 800,000. Since 1974, the queues for treatment had got steadily worse (c807). More generally the decline had been steady, progressive and disastrous, not only in the standard of service offered to patients but to the morale of the Service as a whole (c813). Winding up the Debate, Moyle (c813) admitted that the rate of growth had not been as high as Labour would have liked, but it increased the percentage of GNP to the NHS to 5.6 per cent (c821-2). He added that the number of patients admitted to hospital had increased from just over 5 million to 5,340,000, and outpatient attendances had increased from 45 to nearly 47 million, and day case attendances had increased very substantially from about 400,000 to 536,000 (c822) 34 There appeared to be little on achievements, part from Mrs Jeger (L, c775-6) who stated that ‘We should not knock the NHS so much… If ever I have to be ill… I would rather be ill in this country than anywhere else in the world.’ 35 Conversely, there was a significant amount of discussion on problems. Mr Stallard (L, c729) was ‘horrified at the state of the NHS … It cannot be denied that the NHS is seriously ill.’ He continued that a recent editorial in the ‘British Medical Journal’ stated: ‘most of the problems of the NHS are commonly attributed to lack of money.’ However, he added that the shortage of money is not all that is wrong with the NHS. Ridsdale (C, c763) considered that the Service was facing a crisis because of lack of funds. 36 Miller (L, c760) noted that Britain spent less per head than many comparable countries. Ridsdale (C, c763) claimed that the NHS compared poorly to other countries. Vaughan (c809-10) made a similar point. When challenged by Labour to say if he considered that superior systems included the USA, he denied this, pointing to France. 37 Miller (L, c782) pointed to the funding problem of technological advances. Boscawen (C, c779) pointed to the initial assumption that in a few years it would pay for itself by cutting down the cost of ill health and the cost arising from people being away from work, but that had not happened. Other problems include a loss of morale (Stallard, c730; Vaughan c809), poor management and leadership (Stallard, c730; Raison, C, c758) and remote administration (Vaughan, c811), staff shortages (Wise, c796-7; Vaughan, C. c801), increasing waiting lists (Ridsdale, c766; Wise, c796; Vaughan, c806-7). Vaughan (c807-8) stated that the waiting lists had increased due to industrial action: ‘there are over 600 hospitals dealing with emergencies only. Nine hospitals are closed completely, and 5,500 beds are out of action. What a terrible indictment of the Socialist Administration.’ 38 Others problems included the need for smaller units (Vaughan c806), private donations to keep the kidney unit in Hammersmith going (Stallard, c732), and a hospital experience that ‘reads like something which might have been made into a novel by Charles Dickens’ (Miller (L, c727). A number of Members outside pointed to regional inequality (Stallard, c731; Allen McKay, L. c786). Timothy Raison (C, c755) contrasted over-provision in London with under-provision in other areas. Secretary of State, David Ennals (c766) responded that the Government was reallocating resources.

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A number of Members pointed to the problems associated with the recent re- organisation, although Labour Members (e.g. Mrs Jeger, c768; Miller, c786; Moyle, c816) tended to blame Sir (Conservative Secretary of State, 1970- 1974), while Conservative Members (e.g. Vaughan, c803) tended to blame his successor, Richard Crossman (Labour Secretary of State, 1974-). 39 Many Members of the main parties pointed to planned hospital closures, notably the Elizabeth Garrett Anderson and the Royal Homeopathic Hospital, both in London, which had been the subject of previous Early Day Motions. However, as Stallard (c732) put it, ‘there is hardly an area (i.e. constituency) which has not been touched by this disease.’ McKay (L, c786) summed up that the NHS ‘is the jewel in the crown of Socialism, but at present it appears that the lustre of the jewel has gone.’

Fortieth Anniversary

40 Timmins (2008) pointed out that 1987 had seen not just the triumphant re-election of for an unprecedented third term, but the worst financial crisis in the NHS’s history. The result in early 1988 was the NHS Review which led to the 1989 White Paper ‘Working for Patients’ (Secretary of State for Health 1989) and the 1991 internal market. Klein (2013) characterised the period as ‘the politics of value for money’ (Ch 5) which led to ‘the politics of the big bang’ (Ch 6) which marked the ‘end of consensus on the NHS’ as the 1989 White Paper brought about the biggest explosion of political anger and professional fury in the history of the NHS. (p. 105).

41 The NHS 40th anniversary saw three House of Commons Debates. In the first brief Debate, Mr Fatchett asked the Secretary of State for Northern Ireland if he had any plans to celebrate the 40th anniversary of the National Health Service (Northern Ireland: NHS (Anniversary). The second (Petition: National Health Service) involved a Petition presented by Dr. Lewis Moonie on behalf of the Royal College of Nursing, signed by 500,000 people from all parts of the UK which wished to reaffirm that the NHS shall remain funded from taxation and free at the point of delivery; and that the cumulative underfunding of the NHS identified by the House of Commons Social Services Select Committee (1988) should be remedied. 42 We focus on the longest Debate (Hansard House of Commons 1988) introduced by Shadow Health Secretary, Robin Cook, which congratulated present and past staff of the NHS on forty years of service to the public; reaffirmed its support for a comprehensive health service, free at the point of use to all citizens and funded out of general taxation; welcomed the recent conversion of ministers to the fundamental principles of the NHS; and invited them to demonstrate their commitment to it by tackling the serious underfunding confirmed by the latest report of the Social Services Committee (House of Commons Social Services Committee 1988). 43 After being relatively neglected in the two previous anniversaries, the theme of creation returned, with Cook (L, c 908) stated that the Health Secretary had claimed that it was not Bevan who formed the NHS in 1948 but Churchill in 1944. However, there was ‘one inconvenient historical fact in that reconstruction of history, which is that every Conservative Member voted against the creation of the NHS on the Third Reading of the Bill.’

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44 Secretary of State, John Moore (c916) accused Labour of ‘rewriting history’ as the White Paper of 1944 was produced by the wartime Coalition government, which stated that ‘The Government have announced that they intend to establish a comprehensive health service for everybody in this country.’ He continued that the Conservative amendment to Bevan’s Bill of 1946 stated that ‘this House, while wishing to establish a comprehensive health service…’. He claimed that what was debated at the time was not the basic aim of access to health care free of the ability to pay. However, the reasoned amendment disagreed with two features of the proposal: the method of paying salaries to GPs, and the taking over of charity and local authority hospitals. 45 Michael Foot (L, c922-3), the only remaining Member from the 1946 debate, stated that the Tories voted against the Bill on Second and Third Reading, and in turn accused Moore of rewriting history. He quoted his biography of Bevan: ‘Future generations may learn that Aneurin Bevan did not make the NHS; he inherited it from that much underrated social visionary Sir ’. Ronnie Fearn (Liberal, c945) also pointed to ‘the well-known liberal, , who first conceived the idea of an NHS.’ However, Jill Knight (C, c955) pointed out that Bevan stated in the 1946 Second Reading debate that: ‘it has been the firm conclusion of all parties that money ought not to be permitted to stand in the way of obtaining an efficient health service’. 46 Some of the discussion of principles followed the well-worn path about funding. However, there was also a new element relating to whether the ‘internal market’ broke the principles of the NHS. According to Jerry Hayes (C, c910) a public expenditure White Paper of January 1988 stated: ‘The Government remain committed to the principle that the NHS should be financed largely from taxation.’ Cook (c911) noted that ‘the "largely" had started to disappear’, and pointed to increases in prescription charges of 1,200 per cent and the introduction of charges for eye tests by the current Government. 47 Moore (c916) claimed that across the 40 years of the NHS there had been a consistent commitment to the initial underlying aim that access should not be dependent on means, but ends must not be confused with means (c922). Conservatives broadly rejected the insurance-based approach and tax relief for private insurance (Raison c930; Yeo, c939), and there was some support for a specific health tax (e.g. Owen, SDP, c 933-4; Knight, C, c957-8). 48 However, they broadly supported the internal market approach of Professor Enthoven (cf Owen, SDP, c933-4). As Maples (C, c974-5) put it, that a free service does not necessarily have to be provided by the state. I believe passionately that we should have a free Health Service, but it does not have to be provided by the state. Moreover, to some extent, ‘that is happening already. It is not a revolutionary idea. For example, in 1985, 28,000 NHS patients were treated in private hospitals.’ Yeo (C, c939) supported ‘a pluralist provision of health care’, with the private sector expanding (cf Knight, c957-8; Roger Sims, C, c968; Gillian Shepherd, C, c980), and supported ‘some slight extension of charging, which is already accepted for prescriptions, to cover hotel services for better- off people; that would appear ‘entirely inoffensive.’ In general, Conservatives stressed their commitment to the principles of the NHS, and stated that they were concerned with means rather than ends (e.g. Whitney, c942; Knight c956; Newton, c988). 49 On the one hand, Moonie (L, c939) considered that there had been a surprising degree of consensus about the basic philosophy which underlies the NHS, and that there would be little change to it. On the other hand, Fearn (c946) argued that the Tory

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regime did not in its heart of hearts believe in an equitable health service, free at the point of delivery, because it had not committed itself to that principle and had not understood or committed itself to the need to fund the service properly. Challenged to provide ‘one piece of evidence to support his statement that Conservative Members do not believe in an NHS’, he pointed to ‘underfunding’. 50 Harriet Harman (L, c983-4) was concerned about beefing up the private sector and marginalising the NHS. She criticised introducing the market into the NHS as competition drives down the quality of care, pointing to evidence from the USA. However, Conservatives appeared to be looking more to Europe than to America. Shephard (C, c980) argued for the need to accept, as our neighbours in Europe accept, the proper blend of private and public sector work. Knight (C, c956) stated that ‘there must be no doubt in this House or elsewhere that I and my hon. Friends are totally committed to the continuance of the Health Service. Never would we tolerate, for instance, the American system. The truth is that for a lot more money the American health service is not as good as ours.’ Whitney (c944) suggested that ‘we forget the USA.’ It was a convention, when defending the Bevanite structure of the NHS, to say, "If we are not careful, we shall end up like the United States." Let us consider instead our continental neighbours, such as France, Germany, Italy perhaps, and the Netherlands. 51 Funding yet again formed the main element of stewardship. Conservatives pointed to the record of previous Labour administrations. This included the introduction of charges in 1951 (Moore, c915-6; Newton c987). In particular they contrasted the funding of the NHS by the 1974-79 Labour Government with the current government (e.g. Maples c972). As Michael Fallon (C, c908) put it, the last Labour Government cut the hospital building programme, reduced nurses’ wages in real terms, increased waiting lists, and presided over severe industrial action. They claimed that the current government had a better record on expenditure and activity (e.g. Moore c922; Sims, c967; Shephard c980; Newton c988). Moore (c 915-6) and Newton (c 988) pointed out that on the 30th anniversary of the NHS in 1978, BMA could not even sign a congratulatory note. More broadly, Raison (c928) argued that the achievement of the NHS had taken place largely under the Conservatives. 52 Moore (c916-7) stated since 1948 there had been major and phenomenal achievements in the health of our country and in what the NHS offered, with extraordinary changes in the kind of diseases that then dominated debates in the House. TB, diphtheria and polio, all key issues at the time, had now been virtually wiped out. He continued that the NHS had seen a massive increase in the number of patients treated from 2.8 million patients in 1948 to 6.5 million in 1986. 53 Raison (c928) stated that the NHS had a notable record of achievement. Simon Burns (C, c977) claimed that it had improved in every year since 1948. Paisley (c963) regarded it as ‘the envy of the world.’ Owen (c932) considered that it gave ‘better value for money than any other health service in the world.’ Knight (C, c956) considered that 40 years on we had a better Health Service than ever before. 54 However, in addition to the ‘ever-green’ issue of funding, the on-going NHS Review introduced a new element to the theme of problems. Cook (L, c913) argued that the NHS Review was not undertaken because the Government were anxious to set about improving the NHS, but was born out of panic, as the Government reeled from the publicity last winter about the underfunding crisis in our hospitals, and ‘that crisis

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remains.’ The term ‘crisis’ was also used by Fearn (c946) and Kinnock (L, c991). However, Owen considered that the NHS is not about to collapse (c935) 55 A number of Members across the parties agreed that the NHS was underfunded (e.g. Frank Field, L, c952; Sims, C, c966; Rev. Martin Smyth, c973; Sir David Price, C, c950; Owen, SDP, c932). However, there appeared to be less consensus on the ‘how much’ and ‘how to spend’ questions. Many Conservatives pointed to the large increases in funding since 1948 and under the current Government since 1979. For example, Knight (C, c955) stated that Lord Beveridge thought that the cost of the NHS per annum would fall, but ‘how wrong he and others were.’ 56 Neil Kinnock (c991) pointed to the view of the BMA and the Select Committee of the need that year for an additional £1-1.5 billion of expenditure to ensure that there would not be a repetition crisis the following year. Price (C, c950) considered that the 2 per cent growth asked for by bodies such as the BMA was not enough. Owen (c 932) pointed out over the last twenty years ago spending on the NHS increased from 4 per cent of national wealth to about 6 per cent, while spending in the USA increased from a little over 5 per cent to well over 11.5 per cent. He argued that over a period of three years or so, we should aim to increase the spending on the NHS as percentage of national wealth by a full 1 to 1.5 per cent to 7.5 per cent., which will bring us nearer the average figure for Western industrialised democracies. 57 Price (C, c950) pointed to exponentially increasing demand. Moonie (L, c940) pointed to demographic change (cf Price, c950) and the supposedly inexorable increase in medical technology (cf Sims, c966). According to Health Minister, Tony Newton (c 989), it has become a cliché to say that the Health Service is in some sense the victim of its own success. 58 Conservatives such as Moore (c921-2), Sims (c943), Maples (c972-3), Burns (c978) and Shephard (c980) argued that Labour was wrong to simply call for more expenditure: the problems of the NHS would not be solved by simply throwing money at it (Sims, c943). Whitney (c943) argued that for 40 years problems stemmed from flawed financial and organisational structures. Raison (c 929) considered that while there must be an additional injection, the funding problem is only a part of what we must face. 59 Other problems included substantial waiting lists (Owen, c932); monopolistic structure (Raison, c929); being monolithic and centralised (Eric Forth, C, c981); being largely a sickness service (Moonie (c940); lacking autonomous local hospitals (Whitney, c945); and having centralised rather than localised services; large rather than small services; distant rather than and local services. (Price, c950).

Fiftieth Anniversary

60 According to Klein (2013) Labour claimed in the 1997 Election campaign that there were ‘14 days to save the NHS.’ The landslide Labour victory saw ‘the politics of the third way’ (ch 7). The White Paper ‘The NHS. Modern. Dependable’ (Secretary of State for Health 1997) contained a Foreword by Labour Prime Minister that stated that ‘creating the NHS was the greatest act of modernisation ever achieved by a Labour Government.’

61 On this occasion, the reference to creation was used in a ‘defensive’ way by Labour: as Labour created the NHS, you can trust the same Party to modernise it. The Debate on

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the White Paper was introduced by the Labour Secretary of State for Health, , who set out the proposals to renew and modernise NHS, which Labour founded (c796). He continued that in 1998 the NHS celebrated its 50th birthday. The Labour party that founded the NHS is now setting about modernising it to prepare it for the challenges of the next 50 years (c798). 62 As in the previous anniversary, discussion of principles was partly associated with the internal market. Dobson (c796) stated that Labour would abolish the internal market, because it failed. But the proposals went with the grain, building on what has worked and discarding what has failed: ‘what counts is what works.’ There would be a third way —a new model for a new century. He explained that while the separation between planning and providing services would be retained, competition would be ended, and short-term contracts would be replaced with long-term agreements (c796-7). 63 For the Conservatives, Maples (c799) welcomed the Government’s acceptance of many of the principles of the internal market, which ‘builds on principles that were established by our reforms.’ However, Simon Hughes (Liberal Democrats, c803) considered that the internal market was not being abolished: if there are purchasers and providers, and if there are contracts—even if they are called service agreements— the reality is that there is a market. Dobson (c804) replied that there was no internal market: there cannot be a market unless there is competition, and there is not going to be competition. For Labour, Ivan Lewis (c808) claimed that the only basis for the competition in the health service under the previous Government was that they were preparing it for privatisation. Dennis Skinner argued that the NHS was on its way to the hands of insurance companies and other speculators, which would probably create a service costing twice as much and similar to that in America (c809). 64 The theme of stewardship was also raised in a defensive way by Labour. Dobson (c796) stated that the White Paper was a turning point for the health service. This Government were elected to save the heath service, and to change it for the better. The plan was to give our country a modern and dependable health service that would be once again the envy of the world. We will continue to raise spending in real terms every year on the health service (c798). 65 However, the Conservatives attempted to use discussion of stewardship in offensive terms, pointing to increases in funding and activity under their term of office. Maples (c800) asked if Dobson could promise that, under Labour, the number of qualified nurses will increase by at least 3,000 a year on average, as it did under the former Government; that the number of in-patient and day cases treated will increase by an average of more than 4 per cent a year; and that the increase in NHS funding would beat the previous Government’s record of more than 3 per cent a year in real terms? 66 Former Health Secretary, (C, c805) pointed out that the last Conservative government increased funding by an average of 3 per cent in real terms over the past 18 years, but Labour was looking at 1.7 per cent. She continued that the only specific target announced so far was to take 100,000 people off the waiting lists, but that was followed by the biggest increase in the number of people on waiting lists that the NHS has ever known. 67 There appeared to be little discussion of achievements in the debate, with more discussion on problems. Dobson (c796) argued that the Conservative internal market was wasteful and bureaucratic. The White Paper proposals would break down the Berlin wall between health and social care, so that patients get swift access to care and

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treatment rather than being passed from pillar to post. Maples (c799) pointed out the difficulties of achieving policy objectives in the context of an aging population, medical advances, rising expectations and limited money. Dave Hinchliffe (L, c802) pointed to the problem of fragmentation under the internal market, and considered that historically, one of the most damaging decisions for health care in this country was the 1974 Conservative reorganisation that removed from local authorities the public health function and started to create the confusion that has reigned ever since on the issue of social care and health care.

Sixtieth Anniversary

68 The ‘politics of reinvention’ (Klein 2013, Ch 8) took the story to the end of the Blair premiership, while the ‘the politics of transition’ (Ch 9) covered the Brown premiership, which was a period of transition from political stability to political uncertainty, from an era of optimism about the economic future to one of anxiety, and also a period of transition for the NHS: from market creation to market shaping. There was a brief Debate on the NHS 60th Anniversary on 3rd July 2008, but we focus on the longer debate of the Opposition Day. The Shadow Secretary of State for Health, (c 216) moved that this House celebrates 60 years of the NHS.

69 The Shadow Secretary of State for Health, Andrew Lansley aimed to invent a consensual creation for the NHS. He (c216) wished to conduct the Debate ‘entirely in the spirit in which the NHS was created… In a spirit of consensus, I will acknowledge that the NHS was inspired by the work of a Liberal, William Beveridge, designed by a Conservative, Henry Willink, and implemented by a socialist, Aneurin Bevan.’ 70 He was challenged by Jim Devine (L, c217) who cited the 1946 Debate, and asked ‘When did the Conservative party start supporting the NHS?’ Secretary of State, (c226), stressed that in 1946 the Conservatives voted against the NHS at every stage (cf Stephen Hesford, L, c237). However, Simon Burns (C, c246) pointed out that he was not even born in 1946. 71 Lansley stated that NHS principles are unchanging, and ‘I do not believe that we disagree about the principles.’ However, there were differing views on the policy direction of the NHS (col 223). 72 Labour’s Jim Devine (c227) asked if Conservative Members might say whether they are covered by private medical insurance. ‘The difference between Conservative and Labour Members is not only that we created the NHS, but that we actually use it, too.’ Burns (C, c227) countered that the Conservatives have supported the principle and the exclusive use of the health service ever since we were born. However, Johnson (c228) pointed out that every single Conservative Member won their seat on a manifesto that supported the NHS to such an extent that they would have paid people to leave it. Dorrell (c243) claimed that in 2008 the NHS ‘is built on a political consensus that includes every single Member of this House from every party’. He continued that ‘as we look forward to the next 60 years of the health service, I hope that we can move on from silly arguments about who is committed to it. Over 60 years, we have all been committed to it, and we all remain committed to it’ (c246). According to Shadow Health Minister, Stephen O’Brien (c249), Conservative Members were unequivocal advocates for and supporters of the NHS.

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73 Lansley stated that ‘in the 60 years since the establishment of the NHS, it has been under the stewardship of Conservative and Labour Governments—Conservative Governments for 35 years and Labour Governments for 25 years. Lansley (c228) pointed out that since the 1950s, the year in which the largest reduction in NHS spending took place—a reduction of 2.9 per cent in real terms—was 1977-78, under a Labour Government. Burns (c239-230) reminded Labour that it first introduced the charges for prescriptions and dental and eye care, which led to , Freeman and Bevan resigning from the then Labour Government: it may have set up the health service, but they brought in financial cuts that led to three Cabinet Ministers resigning. 74 For Labour, Hesford (c237) pointed out that the Churchill Conservative government in the 1950s were still so “dischuffed” with the NHS that they set up the Guillebaud committee. The Conservatives hoped it would say that the NHS was too expensive, but Guillebaud said that the NHS was very good value for money, and so the Tories were stuck with the NHS. ‘I submit that they have never properly digested that lesson.’ Ann Keen, the Parliamentary Under-Secretary at the DH, pointed out that people died on waiting lists for cancer, hip and heart operations in 1997 (c245). 75 Discussion of achievements saw a reference to a number of different elements such as international comparison, and improvement in terms of health status and the delivery of health care. Lansley argued that ‘internationally, we can see that we have a treasure in the NHS’ (in the sense of its principles). The NHS has exhibited continuous gain, from the point of view of the people of this country (c217). Dorrell (c243) stated that there has been an improvement in the delivery of health care in Britain over the past 11 years, just as there was during the previous 49 years. A year-by-year improvement in the delivery of health care is the consistent story of the NHS since 1948. According to Johnson (c231), ‘the NHS was in rude health: we no longer debate its survival, but its continuing success.’ 76 Conversely, discussion of problems involved both international comparisons, and reference to operational efficiency in terms of the link between financial inputs and outputs and outcomes. Lansley (c222) and Dorrell (c222), pointed to poor international comparisons. Norman Lamb, (Lib, c235-7) praised Labour for its increase in expenditure, but criticised the NHS for being ‘ludicrously over-centralised’, with dreadful waste and inefficiency and an absolute failure to let go a democratic deficit. Conservatives pointed out Labour’s large increases in NHS expenditure had not resulted in proportionate increases in outcomes (e.g. Dorrell, c222, 243). Peter Bone, C, c253) pointed to the Government’s missed opportunity: while doubling the amount of money spent on the NHS, they have increased output by only 29 per cent.

Conclusions

77 Writing on the 60th anniversary of the NHS, Timmins (2008) noted that his brief history of the big anniversaries demonstrates ‘plus ça change’ – that many of the issues that the NHS is grappling with right now, and will continue to grapple with, always have been there. Factors such as the longstanding pressures of medical technology, ageing populations and rising expectation, the question of whether the NHS has delivered enough for all the extra spending, and the mere fact that old arguments have not gone away despite the extra cash may explain the intense interest in the 60th anniversary.

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78 This exploration of political debates associated with NHS anniversaries suggests more nuanced conclusions. Interpretative content analysis of the themes shows that while most debates have discussed most of the themes, their salience has varied over time. 79 First, while Labour has always stressed that it created the NHS and the Conservatives voted against it, there is some evidence of an inverse relationship over time in that the further we get from the creation, the more important those become. There was some discussion of this in 1958, but little in 1968 and 1978, before becoming more important again since. The Conservatives appear to have placed greater stress over time on the 1944 Coalition White Paper, and that their votes in 1946 were reasoned rather than wreaking Amendments, based on differing means while agreeing on the end of a comprehensive NHS. 80 Second, the debate on principles has continued, but they seem to be rather poorly defined and flexible. At the maximalist end, Labour stressed comprehensive, free at the point of use, equitable, and largely financed from progressive taxation. At the minimalist end Conservatives stressed comprehensiveness and largely free at the point of use. 81 Third, in their stewardship of the NHS, Conservatives stressed that they increased expenditure and activity more than Labour; while Labour introduced charges in 1951, and re-introduced prescription charges in 1968. In turn, Labour claimed that Conservatives had not provided sufficient funding; introduced and increased charges; looked to the USA, and aimed to privatise the NHS. 82 Fourth, discussion of achievements appeared in two broad ways. The first related to statistics of increased expenditure and activity and falls in deaths, but it may be difficult to associate much of the latter with the NHS as they are part of long-term declines, and declines in deaths from some infectious diseases related to the introduction of antibiotic drugs. The second was based on variants of the ‘best in the world’ claim, largely without much evidence, and sometimes related to an apparent ignorance of other systems. 83 Finally, many of the problems seemed to be ‘hardy perennials’: finance, demography, technology, waiting lists, staff shortages, staff morale, reorganisation and the ‘Beveridge fallacy’ of assuming that demand for health care would fall. The term ‘crisis’ was used in 1978 and 1988. 84 In general terms, political debates largely squared with Timmins (2008) argument of the ‘best of times and the worst of times’. He wrote that the NHS managed to fulfil Bevan’s great dictum at the time of its launch: “We shall never have all we need … Expectations will always exceed capacity. The service must always be changing, growing and improving – it must always appear inadequate.” However, he also cited the Secretary of the BMA who stated in 1974 that ‘morale has never been lower’, adding ‘almost every day that I’ve reported on the NHS since then, “morale has never been lower” ’. Timmins (2008) is also correct in that ‘old arguments have not gone away.’ Issues such as who created the NHS, funding the NHS, breaking principles appear to be hardy perennials, and are likely to be debated but not resolved, generating more heat than light, on the 80th Anniversary of the NHS. 85 Martin Powell is Professor of Health and Social Policy at the Health Services Management Centre, University of Birmingham. He has research interests in the history and contemporary policy of the British National Health Service for over

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30 years. His latest book on the NHS is Dismantling the NHS? (co-edited with Mark Exworthy and Russell Mannion, Policy Press, Bristol, 2016).

BIBLIOGRAPHY

Drisko, James and Maschi, Tina. Content Analysis (Oxford, , 2016).

Guillebaud Report of the Committee of Enquiry into the Cost of the National Health Service (Chair: Claude Guillebaud), Cmd 9663 (London: HSMO, 1956).

Hansard House of Commons, National Health Service, 30 July 1958, 592, cols 1382-1506. http://hansard.millbanksystems.com/commons/1958/jul/30/national-health-service.

Hansard House of Commons, National Health Service (Financing), 1 July 1969, vol 786, cols 242-313. http://hansard.millbanksystems.com/commons/1969/jul/01/national-health-service- financing#S5CV0786P0_19690701_HOC_280.

Hansard House of Commons “National Health Service”, 15 March 1979, c 707-830. http://hansard.millbanksystems.com/commons/1979/mar/15/national-health- service#S5CV0964P0_19790315_HOC_293.

Hansard House of Commons “National Health Service,” 5 July 1988, c 907-996. http://hansard.millbanksystems.com/commons/1988/jul/05/national-health-service.

Hansard House of Commons “Northern Ireland: NHS (Anniversary)” HC Deb 30 June 1988 vol 136 cc512-4. http://hansard.millbanksystems.com/commons/1988/jun/30/nhs-anniversary.

Hansard House of Commons “Petition: National Health Service”, HC Deb 05 July 1988 vol 136 c1034. http://hansard.millbanksystems.com/commons/1988/jul/05/national-health-service-1.

Hansard House of Commons, “National Health Service”, 9 December 1997 c 796-810. http://hansard.millbanksystems.com/commons/1997/dec/09/national-health- service#S6CV0302P0_19971209_HOC_128.

Hansard House of Commons, “Opposition Day”, NHS (60th Anniversary), 24 June 2008, c 216-259. https://publications.parliament.uk/pa/cm200708/cmhansrd/cm080624/debtext/ 80624-0013.htm#080624123000001.

Hansard House of Commons “NHS 60th Anniversary”, 3 July 2008: Column 1125-1132. https://publications.parliament.uk/pa/cm200708/cmhansrd/cm080703/debtext/ 80703-0020.htm.

House of Commons Social Services Committee, Third Report. Resourcing the National Health Service: Prospects for 1988–89, Session 1987–88, HC 547 (London: HSMO, 1988).

House of Lords Select Committee on the Long-term Sustainability of the NHS, The Long-term Sustainability of the NHS and Adult Social Care, HL Paper 151 (London: TSO, 2017).

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Klein, Rudolf . The New Politics of the NHS, 7th edn (Abingdon: Radcliffe Medical, 2013).

Krippendorf, Klaus. Content Analysis, 3rd edn (London: Sage, 2013).

Powell, Martin. Evaluating the National Health Service (Buckingham: Open University Press, 1997).

Secretary of State for Health, Working for Patients, Cm 555 (London: HSMO, 1989).

Secretary of State for Health, The New NHS. Modern. Dependable, Cm 3807, (London: TSO, 1997).

Timmins, Nicholas. (ed,)Rejuvenate or retire? Views of the NHS at 60 (London: Nuffield Trust, 2008.

ABSTRACTS

This article examines the 70th anniversary of the British National Health Service (NHS) through the lens of Parliamentary Debates in the House of Commons, focusing on the closest broad debate on the NHS to each anniversary. It draws on interpretive content analyses, exploring the following themes: creation, principles, stewardship, achievements, and problems. Although there is some continuity over time, it suggests more nuanced conclusions in that while most debates have discussed most of the themes, their salience has varied over time. Issues such as who created the NHS, funding the NHS, breaking principles appear to be hardy perennials, and are likely to be debated but not resolved, generating more heat than light, on the 80th Anniversary of the NHS.

Cet article analyse le 70e anniversaire du système national de santé (NHS) du Royaume-Uni sous l’angle des débats parlementaires qui ont eu lieu à la Chambre des communes tous les dix ans au moment de l’anniversaire de l’institution. Il s’appuie sur une analyse interprétative du contenu de ces débats en explorant les thèmes suivants: la création de cette institution; les principes; les réalisations et les problèmes. Bien qu’il y ait une certaine continuité dans le temps, des conclusions plus nuancées sont proposées. Certes la plupart des débats parlementaires ont abordé les mêmes thèmes, mais leur importance a varié au fil du temps. Des questions telles que la personne à l’origine du NHS, son financement et les principes importants sont des thèmes qui reviennent régulièrement et qui sont susceptibles d’être débattus mais non résolus à l’occasion du 80e anniversaire du NHS.

INDEX

Mots-clés: service de santé national, anniversaire, débats parlementaires, analyse de contenu Keywords: National Health Service, anniversary, Parliamentary debates, content analysis

AUTHOR

MARTIN POWELL

Health Services Management Centre, University of Birmingham

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From Adult Lunatic Asylums to CAMHS Community Care: the Evolution of Specialist Mental Health Care for Children and Adolescents 1948-2018 Des asiles psychiatriques adultes aux soins pour jeunes dans la communauté : l’évolution des services de santé mentale pour les enfants et les adolescents 1948-2018

Susan Barrett

Introduction

1 As the psychiatrist William Parry-Jones has pointed out, the development of psychiatry, and the care offered to the mentally ill, has always depended not only on “the prevalence and severity of cases but on economic, social, political and cultural factors.”1 This has led the social historian Martin Gorsky to argue that although mental health services have always been part of the National Health Service (NHS), psychiatric care forms one of three “subaltern narratives [… which] stand somewhat apart”2 in general histories of the NHS as the way they have evolved is the consequence of very specific issues. I would like to suggest that child and adolescent mental health care is a separate narrative within this subaltern narrative. Its development has resulted not only from changes in policies for adult mental health care, but also from changes in society’s attitudes towards children and parenting, and from a greater biological and psychological understanding of how children develop. Most of the existing scholarly articles on the evolution of child and adolescent mental health care have been written by psychiatrists and focus on the changes in clinical practice. This article attempts to situate the history

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of care for young people suffering from psychopathologies3 within a wider social and political context.

Incurable lunacy or transitory developmental problem: the treatment of children with mental health needs before 1948

2 Prior to the foundation of the NHS, mental health was the form of health care which received the largest amount of public funding as a result of two acts of parliament dating back to 1845: the County Asylum Act and the Lunacy Act. These two acts together made counties legally obliged to provide asylums for their lunatics in order to remove the insane from workhouses. There was no minimum age for admittance to these asylums and although many of the asylums were reluctant to admit children, the workhouses were keen to get rid of them, and there are records of children as young as six being admitted and kept on wards alongside adults. The young people admitted to adult asylums were most likely to be suffering either from “idiocy” or from “moral insanity,”4 although Maudsley’s influential 1867 textbook stated that children could also suffer from “monomania, choleric delirium, cataleptoid insanity, epileptic insanity, mania and melancholia.”5 There were no specific treatments for child and adolescent patients but this was perhaps less problematic than it might seem since the general consensus at the time was that lunatics were exhibiting child-like behaviour and should be treated as children.6

3 Less seriously disturbed children were treated in child guidance clinics, the first of which was set up in East London in 1927. The aim of these clinics was “the treatment of children who had emotional problems or nervous difficulties.”7 Unlike the asylums, the clinics were not always publically funded and the first ones to be opened relied on private or charitable donations. Things changed in the mid-1930s when the Board of Education allowed attendance at a child guidance clinic to be counted as school attendance, leading many local authorities to set up and fund their own clinics. The staff at these clinics worked in teams with a psychiatric nurse, a social worker and a psychiatrist. They used medical language – the children who came to see them were “ patients” and the psychiatrists looked for the “aetiology” of the children’s problems; as the historian John Stewart points out, for the first time, childhood was being pathologised,8 an attitude which was to re-emerge in NHS policies. Another factor which was to have an impact on later policies was the clinics’ belief that normalcy was a continuum. A child was not born either “maladujusted” or “normal” and any child’s position on this continuum could change due to different circumstances. The implication of this was that since “even the most normal child could experience maladjustment, […] the total child population had to be constantly monitored and surveyed, both by and by professionals;”9 in other words, what went on inside the family was no longer a private affair. 4 The clinics claimed that early intervention was good for society as a whole, stating that they were “equally a social service to a sick society as a personal service to children and their parents.”10 However, although the clinics recognized that children’s psychological problems were affected by social conditions such as poverty, poor housing and unemployment, they paid more attention to the role of family relationships

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(particularly family break-ups) on the child. This resulted in the belief that it was not just the child who should be treated but the whole family (although in practice it was usually only the mother). Although the clinics claimed not to be blaming the parents, they published advice leaflets on how to raise well-adjusted children, which were widely distributed to all parents. It was therefore almost inevitable that those who ended up seeking help from the clinics would feel that they had failed in some way as parents. 5 The belief that parents were largely responsible for their child’s mental health was challenged by the work of Anna Freud and Melanie Klein in the 1930s who believed that even very young children had their own internal life, and that children could be treated directly with therapy without having to treat the parents at the same time. Like many things in Britain, however, the availability of help for mental health was linked to social class. The type of psychoanalytic-psychotherapy that was practised by Freud and Klein was only available privately and even in the child guidance clinics psychotherapy tended to be reserved for the brightest children and teenagers from middle class families with the aim of helping them (re)adapt to normal life. Children from working- class families, who were diagnosed by doctors as “difficult,” were sent away to residential schools in an attempt to prevent them from becoming delinquents.11 6 The end of the Second World War brought with it profound changes in the structure of British society and it was inevitable that these changes would influence the treatment of mentally ill adults and children. 1946 saw the first attempt to unify the provision of mental health services for the population as a whole with the foundation of the National Association of Mental Health (NAMH).12 This was done by merging three existing mental health organisations: the Central Association for Mental Welfare (a voluntary group which helped mentally-handicapped people), the National Council for Mental Hygiene (whose aim was to educate both medical students and the general public about the importance of mental health), and the Child Guidance Council. The NAMH recognised the lasting effect of poor childhood mental health on adult life and stated that its first aim was to “to establish the principle that [good mental health] foundations must be laid in early childhood if healthy mental and emotional development is to be achieved;”13 a principle which can be found in all later policy statements about child and adolescent mental health care. 7 The 1944 Education Act, (which was implemented only after the Second World War had ended) placed what it termed “maladjusted children” (those with emotional and behavioural problems) into the same category as those with a physical disability. This meant not only that children with mental health problems now came under the remit of school medical services, but also that schools were required to provide them with an education. This paved the way for a wider acceptance of the idea that mentally unwell children could continue to lead a normal life while undergoing treatment within the community. 8 The return of thousands of evacuee children, many of whom exhibited serious psychological problems, led to a new academic interest in child development. One of the most significant contributions came from the psychiatrist John Bowlby who proved that attachment stability between a child and its primary care-giver plays a vital role in a child’s mental health. This recognition of the importance of the child-mother relationship underlies many later policies; it led, for example, to the development of

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family therapy as a specific branch of psychotherapy, and became a justification for developing community, rather than institutionalised, care.

The early years: hospital care versus child guidance clinics

9 The existence of state-funded asylums, which provided free care for people from all social classes, meant that the advent of the National Health Service was initially less revolutionary for mental health than it was for physical health. There was, however, no attempt to set up a single, unified mental health service for children and adolescents within the newly established NHS despite the growing interest in problems specific to young people. As a result two separate forms of services for children and adolescents were established, in line with a 1946 report by Blacker, entitled Neurosis and the Mental Health Service, which recommended that children with mild problems should see a psychologist at a child guidance clinic while those with more severe problems should be treated by a psychiatrist in a hospital setting.14 His report made no attempt to clearly define which children should see which service, and offered no guidance as to how children might be transferred between clinics and hospitals if their mental health worsened or improved.

10 Although no specific sum of money from the NHS budget was allocated either to the clinics or to hospital child psychiatric care, the 1950s saw an increase in the number of child guidance clinics, and by 1955 there were 300 clinics spread throughout England.15 The development of hospital psychiatric care was patchier. The first hospital ward specifically for mentally ill children had been opened at the Maudsley hospital in July 1939, but closed two months later when the Second World War was declared, and it was not until 1947 that a dedicated children’s in-patient unit was re-opened there. During the 1950s most of the NHS teaching hospitals opened specific children’s units but outside the larger cities children who needed to be treated by a psychiatrist in a hospital setting continued to be seen alongside adults. By 1964 there were still only seven child and adolescent in-patient units in the whole of England and Wales with a total of just 157 beds.16 11 One of the reasons for the lack of separate child and adolescent in-patient units may have been the lack of recognition that children and adolescents suffer from specific psychiatric problems. The term “child psychiatry” first appeared in a text book title in 193317 but child and adolescent psychiatry was not recognised as a specific psychiatric discipline until 1973 when the first Chair of Child Psychiatry was created.18 Similarly, the widely used American Diagnostic and Statistical Manual of Mental Disorders (DSM) did not initially refer specifically to childhood mental health disorders – the only one listed in the DSM-I, published in 1952, is “mental deficiency.” In 1968, the DSM-II listed what it termed childhood “reactions” such as “withdrawing, being overanxious, running away, being un-socialised or aggressive, group delinquency and hyperkinetic.” It was not until the third edition, published in 1990, that a comprehensive list of child psychiatric disorders was included. 12 Nevertheless, the 1959 Mental Health Act, which for the first time sought not only to distinguish mental illness from learning disability, but also to limit the number of people detained against their will, did recognise children as a separate category. Under

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the terms of this act, adults over the age of twenty-one could only be compulsorily detained in hospital in cases of severe sub-normality or severe mental illness, whereas those under twenty-one could be detained with lesser levels of sub-normality provided they also either showed signs of a “psychopathic disorder,” or were a danger to their self or to others. If it was deemed necessary, parents could be compelled to send their “ mentally disordered” children to a residential training centre to enable them to receive some form of schooling and to prepare them for employment. The rights of children aged sixteen to twenty-one, however, remained unclear as the Mental Health Act used the same definition of “child” as the 1948 Children’s Act. This meant that although minors aged sixteen and above could be detained under the criteria for minors, and their parents ordered to place them in residential care, these minors were deemed capable of making their own decisions about their treatment and could appeal to a tribunal without their parents’ permission. 13 Although this act was supposed to limit the number of mentally unwell people in hospitals, and did indeed result in large numbers of adults being discharged, the 1960s saw an increase in the number of child and adolescent beds. As Christopher Wardle points out, this apparent paradox can be explained by the fact that the act had led to an increasing realisation that children needed to be treated separately from adults.19 The increase in bed numbers was thus not a reflection of an increase in the number of young people receiving in-patient treatment. 14 Throughout the 1950s, psychiatrists and paediatricians discussed how the community child guidance clinics and the hospital psychiatric services could be merged to provide a more unified service. Most of the discussion focussed on who should be in charge, rather than on what treatment should be provided, and it proved almost impossible to reach any sort of compromise.20 The staff working in a hospital setting argued that child guidance clinic resources were often wasted because the clinics made no attempt to diagnose their patients, leading to open-ended therapy which seemed to have no clear goal.21 The staff working in child guidance clinics, on the other hand, claimed that they were underfunded compared to hospital psychiatry and therefore limited in the treatment they could offer. They also accused hospital psychiatrists of damaging the child by removing them from their family and failing to treat the “whole” child.22

Towards a specific child and adolescent mental health service

15 By the late 1960s it was becoming increasingly clear that this dual system was not working – some places had two overlapping services and others had none. It was not until the mid-1980s, however, that any profound changes were made to the provision of child and adolescent mental health care. The reasons which finally led to a specific policy appear to have stemmed partly from changes in adult psychiatric care, partly from a better understanding of the nature of child and adolescent psychopathologies, and partly from new attitudes towards teenage behaviour.

16 In his 1961 “Water Tower Speech,” Enoch Powell, the health minister in the Macmillan Conservative government, drew attention to the need to reform the treatment of the mentally ill by closing down the asylums. He believed that the number of places needed in asylums would gradually decrease not only as a result of the 1959 Mental Health Act

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which had enabled patients to appeal their certification, but also because of recent developments in psychiatric medicines which meant it was now possible to control many previously untreatable conditions. Powell questioned the need to keep the mentally ill in separate institutions from the physically ill and suggested that in the future general hospitals should provide beds for both physically and mentally ill patients. There was no real attempt to turn his ideas into actual policy, however, until ’s 1975 white paper, Better Services for the Mentally Ill, which proved to be a turning point in mental health services for both adults and young people. The white paper argued that mental illness was not just a hospital problem but also a social issue, and that asylums should eventually be replaced “with a local and better range of facilities.” 23 The ultimate aim of this new policy was not to close all asylums – the paper recognised that there would always be some patients who were too unwell to function outside a hospital setting – but to develop community care so that long-stay psychiatric hospitalisation could be avoided for all but the most extreme cases. Reform was undoubtedly necessary, not only were conditions in many asylums appalling due to over-crowding and brutal staff, but all too often people continued to be detained long after they had recovered. Critics argue, however, that reform was motivated as much by financial reasons as by compassionate ones. Gorsky, for example, claims that deinstitutionalisation was “neither liberating nor humane” and that “it was economics, not effective pharmacotherapies which explain [it].”24 Due to the costs involved in implanting the proposed reforms, and the lack of funding as a result of the on-going economic crisis, the report did not give a precise date for the reform to be completed and community care did not become fully part of official government-funded policy until the mid-1980s. 17 During this same period, the Isle of Wight Studies, carried out by Michael Rutter, provided evidence of the need for specific policies for children and adolescents. Not only did Rutter’s studies give precise figures on the rate of mental disorders in children, and proof of the role of family dysfunction in the development of psychopathologies, but they also showed that rates of mental disorders varied according to the areas in which the children lived, suggesting that socio-economic conditions had an effect on children’s mental well-being. The publication of these studies led to similar studies of other populations, such as the 1983 Richman et al. Waltham Forest Study, which reinforced Rutter’s findings and brought to light other elements, including the fact that behavioural problems in pre-schoolers were often a precursor of later disorders. Other studies began to take an interest in psychopathology from a developmental perspective and sought to classify which deviations from the norm should be considered pathological.25 All these studies emphasised the necessity of systematic, standardized methods and measurement, and highlighted the need to treat children as soon as problems started to emerge. 18 Setting up effective community care for children and adolescents proved to be more complicated for children than for adults due to the existence of the 1973 National Health Service Reorganisation Act which created Area Health Authorities (AHA) responsible for the planning and delivery of healthcare services. The majority of the staff in the child guidance clinics fell under the responsibility of the new AHAs, but social workers, who played a vital role in the way the clinics were run, found themselves under the authority of local authority social services departments. Child and adolescent mental health community care thus suffered from the difficulty of co-ordinating two different services, and the problem of securing funding from two different sources. Williams and

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Kerfoot suggest that resources for mental health care were inadvertently reduced still further as a result of the 1980 Education Act, which introduced the process of “statementing” for special needs. This resulted in educational psychologists spending most of their time working with schools to assess pupils’ needs rather than in child guidance clinics providing therapy to children with poor mental health.26 19 Things came to a head in 1986 with a report by the Health Advisory Services entitled Bridge Over Troubled Waters which highlighted the problems within child and adolescent mental health care, in particular the lack of adolescent in-patient beds. In 1987, as a direct result of this report, a unified Child and Adolescent Mental Health Service (CAMHS) was finally created within the NHS. In their history of the first eighteen years of CAMHS, the psychiatrists David Cottrell and Abdullah Kraam, claim that it is not altogether clear what finally pushed the government into creating a specific policy. They suggest that it was probably a combination of a change in three factors in the way society viewed teenagers: firstly an alarmist media focus on “declining family values”, teenage pregnancies and single-parenthood, secondly an increase in reports of sexual abuse of children and the consequent belief that children needed to be protected more effectively, thirdly a growing international recognition of the rights of children which culminated in the publication of the United Nations Convention on the Rights of the Child in 1989.27 20 Although all authorities were required to set up specific child and adolescent mental health services, there was initially no national policy on how the service should be run, no definition of who was eligible for the service and no advice as to what treatments should be offered. Precise guidelines were finally established almost a decade later largely thanks to Virginia Bottomley, the Secretary of State for Health from 1992 to 1995, who had worked as a social worker in a child guidance clinic before becoming an M.P. Bottomley commissioned a national review of CAMHS which was published in 1995 under the title Together We Stand. This detailed report drew attention to the absence of overall strategy, the widely varying expenditure for the same treatment from one area to another, and the fact that access to services depended more on geography than on need. Its main recommendation was that CAMHS should be reorganised into four tiers, each of which would offer a different level of help depending on the severity of the problem. 21 The four-tier system was rapidly implemented nationwide and continues to form the basis of CAMHS care today. Tier 1 is a universal service which covers all children. Its aim is to promote good mental health and it is carried out by people who are not mental health specialists such as G.P.s, health visitors, school nurses, teachers, social workers and youth justice workers. Tier 2 is a targeted, early intervention service for those at risk of developing mental health problems and is delivered by a trained mental health specialist such as a counsellor or a psychologist. Tier 2 services can operate either within a specialised CAMHS clinic or an out-reach basis, for example in a G.P. surgery or in a school. Tier 3 is aimed at those with more severe, complex or persistent disorders, and the services are delivered by a multi-disciplinary team working either in a community clinic or a hospital out-patient unit. Team members include child and adolescent psychologists, psychotherapists, psychiatric nurses, psychiatrists as well as occupational therapists, family therapists and social workers. Tier 4 are highly specialised services for the most complex cases. They are usually hospital-based and include both day units and in-patient units.

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22 Initially the tiers system was greeted with optimism. The child guidance clinics and hospital services had finally been combined, the tiers seemed to offer clear guidelines for organising treatment, and there was money available to implement the changes. In 1999, the Labour government announced that over the next three years they would make an additional £84m available from the NHS Modernisation Fund for core CAMHS services. A further £20m was promised in 2004/5 and another £50m in 2005/6. Local authorities also gave money to help set up and run these new services. However, although new money did undoubtedly enter the service, doubts were expressed about how much money actually arrived at its intended destination28 and there were criticisms that the extra money was used to pay for new managers rather than to recruit more clinicians.29 23 The internal organisation of both Tier 2/3 CAMHS clinics and Tier 4 in-patient units reflected the philosophy of the child guidance clinics with the young person being treated by a team, usually a psychiatrist, a psychologist or psychotherapist, very often a social worker and sometimes a family therapist. However, the same problems that existed in the child guidance clinics also persisted, most notably a lack of provision in many areas for 16-18 year olds who were considered too old for CAMHS but too young for adult services.30 24 Almost from the start, a number of other problems were also apparent. Few studies existed which measured outcomes of different treatments for children and adolescents and even the first NICE guidelines did not contain specific guidelines for young people – in 2005 Cottrell and Kraam could only say that “CAMHS-specific guidelines on depression, attention deficit disorder and obsessive compulsive disorders are in the pipeline.”31 The increase in the number of referrals was not matched by an increase in the number of staff so that in some areas it was becoming difficult to provide long-term psychotherapy. Clinicians were increasingly expected to “be accountable to external bodies rather than the patient”32 which resulted in pressure on Tier 3 services to provide drugs rather than therapy, despite the fact that there were no long-term studies on the side-effects of psychiatric medication on under-eighteens. Thus although the same tiers existed throughout the country, they did not provide the same types of treatment, and there was no unified approach as to how the tiers were administered. A briefing report by the Children’s Commissioner as late as 2017 stated that:

There were no children’s mental health national targets until last year […] for children with emerging problems. There is no clear expectation placed on local areas about which services should be provided, or how ill a child needs to be before they should receive care. […] The evidence that has been collected, by myself and a range of other bodies, reveals a postcode lottery of care.33

25 There was also concern that the tiers were too rigidly defined meaning children with complex problems, who did not fit neatly into one of the tiers, could end up receiving no treatment.

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CAMHS in crisis: child and adolescent mental health care for the 21st century

26 The percentage of young people suffering from mental health problems has risen regularly since CAMHS was set up, although it is hard to find precise national statistics. The number of children seen by mental health services have only been collected regularly and collated since 2016 and although there were three surveys of adult mental health between 2000 and 2014, there was no full survey of child mental health between 2004 and 2018. The 2004 survey concluded that 7.7% of 5-10 year olds and 11.5% of 11-16 year olds suffered from a diagnosable mental health condition. It is the average of these two figures that gives the 10% (or 1 in 10 children) which is still regularly quoted by the media. Statistics from 2016 onwards show a regular increase both in the number of referrals and in the number of young people under the age of 19 in contact with mental health services;34 the latter figure rose from 96,789 in July 2016 to 218,871 in July 2018.35 Various reasons have been put forward to explain this increase, including more pressure at school due to constant testing, the rise in poverty as a result of the politics of austerity, or quite simply more awareness of the symptoms of mental ill-health and a greater willingness to seek treatment. Whatever the reasons, better informed parents, and an increasingly consumer-society, have led to growing demands for child mental health care while at the same time, many Clinical Commissioning Groups have regularly decreased the proportion of their budgets that they allocate to CAMHS.36

27 By the beginning of the 21st century it was becoming increasingly apparent that CAMHS was in crisis. In 2008 an independent CAMHS review concluded that the existing system had a number of serious problems, in particular long waiting times to access the services, significant differences in the availability of services depending on where the child lived and a lack of emergency services.37 The review was particularly critical of the lack of in-patient beds, leading to patients being sent far away from their homes and families in direct contradiction of recommended practice which states the crucial role of “home-leave.” One of the obvious reasons for this was a lack of central planning, which had resulted in more beds in the South East than anywhere else in the country. As clinicians and user groups pointed out, it was not, however, simply a case of transferring some of the units in the South East elsewhere in the country as the total number of beds was insufficient.38 28 Hopes of a reform were dashed by the election of the coalition government in May 2010 which introduced a policy of austerity in public services. According to Callaghan et.al.:

May 2010 represents the beginning of a clear shift in the direction of mental health policy. Rather than ‘evolving’ from previous policy, the decision was to effectively start over, rendering pre-2010 policy generally obsolete. Concepts such as ‘Universal CAMHS’ fell out of use, and the emphasis shifted from policy specific to CAMHS, to a more generic set of policies aimed at ‘all people.’39

29 In their analysis of the language used in government policies before and after 2010, Callaghan et.al. show that there has been a gradual shift towards a biological interpretation of mental health, which excludes socio-economic causes and the effects of the politics of austerity on whole groups of society. Significantly, children and

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adolescents are no longer seen as a group apart with specific needs and the terms “child” and “adolescent” no longer feature in government reports. This is apparent even in the titles of the reports; in 2003 the report was called Every Child Matters, in 2011, No Health Without Mental Health.

30 In response to a parliamentary question in 2015, NHS England reported that £50 million had been cut from CAMHS budgets between 2010 and 2013. The Children’s Commissioner estimated that this meant that only 7% of NHS mental health funding went on children’s services.40 This led to a media outcry and, as a result of the 2015 Future in Mind report, the government promised to invest an extra £1.4 million over five years in order to implement the report’s recommendations. However, CAMHS funding is not ring-marked within overall NHS budgets and a Young Minds’ enquiry into how the money was being spent discovered that “nearly two-thirds (64%) of CCGs [who replied] used some or all of the extra money to backfill cuts or to spend on other priorities.”41 31 The current government places great emphasis on early intervention and on actions which increase resilience. Early intervention is justified financially by the figures given in the 2017 briefing report which noted that the majority of the CAMHS budget went towards helping those with severe needs: 38% went towards in-patient costs, which is accessed by only 0.001% of children aged 5-17, and 46% went on providing CAMHS community services which are accessed by just 2.6% of children. The report underlined the high cost of in-patient treatment (on average £61,000) compared to just £5.08 per pupil for an emotional resilience programme in a primary school. It went on to argue that “a targeted therapeutic intervention delivered in a school costs about £229 but derives an average lifetime benefit of £7,252. This is a cost-benefit ratio of 32-1.”42 This emphasis on value for money is a clear departure from the original CAMHS policies which focussed on every child’s right to a happy childhood. 32 Although the briefing stated clearly that “any child with a more serious condition [should be] able to access high-quality, specialist support within clear waiting-time standards,”43 early intervention is being promoted without any increase in funding, which means it can only be undertaken by diverting existing funds. CAMHS clinicians have warned that this means the most complex cases are likely to receive less treatment. My cynical view is that the government wants to stop treating complex cases for two reasons. First the government wants to use statistics to prove that its policy of early intervention works and to do this it needs to focus on children with simple problems who can be treated quickly. Second those children and adolescents with complex cases are likely to have recurrent mental health problems throughout their lifetime. There is, therefore, no point in spending money on them when they are young to improve their experience of childhood as they will continue to be a burden on society throughout their lives. 33 The government’s frequent use of the term resilience suggests that young people are to a certain extent responsible for their own mental health – those who develop resilience get better, while those who do not become one of those mentally ill adults who “ represent up to 23% of the total burden of ill health in the UK.”44 By ignoring the role of socio- economic conditions on children’s mental health, current government statements about young people’s mental health reproduce “dominant discourses of strivers and skivers that characterise public debate on benefits and welfare and that function to problematize and demonise poverty and dependency.”45

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34 Recent changes in society’s attitudes towards childhood may have helped to make the current government’s policies towards CAMHS more palatable for some voters. Gianna Knowles suggests that society currently recognises two categories of children, and although attitudes towards both categories can cause psychopathologies, only one type of child is seen as deserving of help. According to Knowles, the first category is a variant on the eighteenth-century romanticised view of childhood being a pure state. Adults feel the need to protect children’s innocence and do so by keeping them in an infantilized state. This creates a tension with the child’s natural desire to explore the world and can lead to anxiety disorders. These anxious children are generally seen as deserving of help to develop the resilience necessary to succeed in life. The other category of children stems from the nineteenth-century idea of the delinquent child who needs to be controlled. This vision of what Knowles terms the “demon” child has been promoted by the media since the 1990s, leading parents and schools to demand treatment for what should be regarded as normal childhood behaviour, and causing a rise in diagnoses of ADHD and conduct disorders.46 35 It is not only the media vision of childhood which has changed over recent years. Recent biological research supports the idea that the development of the adolescent brain is only complete when the person is in their mid-twenties.47 Most long-term psychopathologies first become apparent in the second half of the teenage years – according to the government’s 2011 mental health strategy for England, No Health without Mental Health, half of those with life-time mental health problems first experience symptoms by the age of 14.7 years and three quarters before their mid- twenties. There is therefore both a biological and an administrative argument for extending CAMHS up to the age of twenty-five. Some mental health professionals have suggested that CAMHS should be split into two services: one for children and younger teenagers dealing primarily with behavioural and emotional disorders and one for older teenagers and young people in their early twenties dealing with the psychopathologies and personality disorders that are likely to continue into adulthood. A few CAMHS, such as Brighton and Hove, or Tavistock and Portman, have already implemented this idea and have created a “Young Adult Service” for those aged fourteen to twenty-five. 36 There are also attempts by some CAMHS to rethink the tier system. Hertfordshire, for example, is one of ten trusts which plan to replace the existing system by 2020 with a new system called “I Thrive,” a framework developed by the Anna Freud Centre and the Tavistock and Portman NHS Foundation Trust. The new system still divides young people’s needs into different categories, which to some extent overlap with the existing tiers, (“Thriving”, “Coping”, “Getting Help”, “Getting More Help”, “Risk Support”), but the new system has been designed as a continuum, with the idea that children and young people can move easily from one category to another, and the different categories are represented visually as a circle rather than as the levels of a pyramid. Whether these changes will be anything other than cosmetic remains to be seen – the Hertfordshire report notes that the effectiveness of these proposed changes is dependent both on continued funding, and on the ability to recruit and retain enough qualified staff.48

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Conclusion

37 There has undoubtedly been considerable progress in the services available for mentally unwell children and teenagers over the past seventy-years. However, despite the growing media interest in mental health,49 and the 2018 government report Closing the Gap which specifically states that: “mental health must have equal priority with physical health, that discrimination associated with mental health problems must end and […] everyone who needs mental health care should get the right support, at the right time,”50 nationwide availability of high-quality, effective care for those children and adolescents suffering from severe and complex mental health problems looks far from certain. Although child psychiatry is now a fully-established medical speciality, and there are specific training programmes for child and adolescent psychotherapists, there is no ring-fenced budget for CAMHS, and working conditions for CAMHS clinicians are becoming increasingly difficult due to insufficient resources. The driving force behind current government policies is not child welfare but financial savings. Laudable as their aim is to bring mental health services within all schools, there still needs to be properly funded accessible care available nationally to all those who need it.

38 Susan Barrett is a senior lecturer in the English department of Bordeaux- Montaigne University. Her main research interests are in marginality, identity and belonging in South African and Australian studies, and she has published widely in these areas. She is currently working on a new long-term research project on child and adolescent mental health care in the United Kingdom. Blacker, Carlos Paton, Neurosis and the Mental Health Services (Oxford, Oxford Medical Publications 1946). British Medical Association, Lost in Transit: Funding for Mental Health Services in England, 2018. Callaghan, Jane, Lisa Chiara Fellin, Fiona Warner-Gale, “A critical analysis of Child and Adolescent Mental Health Services Policy in England”, Clinical Child Psychology and Psychiatry 22:1 (2017), pp.109-127. Children’s Commissioner, Briefing: Children’s Mental Health Care in England (October 2017), https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/10/Childrens- Commissioner-for-England-Mental-Health-Briefing-1.1.pdf consulted 15 April 2018. Cottrell, David & Abdullah Kraam,“Growing Up? A History of CAMHS (1987–2005)”, Child and Adolescent Mental Health 10: 3 (2005), pp. 111–117. Davidson, Jo. Children and Young People in Mind: The Final Report of the National CAMHS Review, (2008), http://webarchive.nationalarchives.gov.uk/20090615071556/http:// publications.dcsf.gov.uk/eOrderingDownload/CAMHS-Review.pdf consulted 15 April 2018. Department of Health, Better Services for the Mentally Ill, Cmnd 6253 (HMSO, London, 1975). Department of Health, Closing the Gap: Priorities for essential change in Mental Health (2014), https://assets.publishing.service.gov.uk/government/uploads/system/uploads/ attachment_data/file/281250/Closing_the_gap_V2_-_17_Feb_2014.pdf consulted 29 March 2018. Evans Bonnie, Shahina Rahman, Edgar Jones, “Managing the ‘unmanageable’: interwar child psychiatry at the Maudsley Hospital, London”, History of Psychiatry 19:4 (2008), pp. 454–475.

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Framrose, Rustam, “The First Seventy Admissions to an Adolescent Unit in Edinburgh: General Characteristics and Treatment Outcome”, British Journal of Psychiatry 126 (1975), pp. 380-389. Gontard, Alexander von,“The Development of Child Psychiatry in 19th Century Britain”, Journal of Child Psychology and. Psychiatry 29: 5 (1988), pp. 569-588. Gorsky Martin, “The British National Health Service 1948–2008: A Review of the Historiography”, Social History of Medicine 21:3 (2008), pp. 437–460. Gowers, Simon & Andrew Cotgrove, “The Future of In-patient Child and Adolescent Mental Health Services”, British Journal of Psychiatry 183:6 (2003), pp. 479-480. Health Advisory Service, Bridge Over Troubled Water: A Report from the NHS Health Advisory Service on Services for Disturbed Adolescents (1986). Healthy Young Minds in Herts, Child and Adolescent Mental Health Services (CAMHS) Transformation Plan for Hertfordshire 2015-2020, (Herts. County Council, 2017), http:// www.enhertsccg.nhs.uk/sites/default/files/ Healthy%20Young%20Minds%20in%20Herts%20plan%202015-20_Oct%202017%20refresh_final.pdf consulted 29 March 2018. H.M. Government, No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of all Ages (2011), https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_data/file/138253/dh_124058.pdf consulted 29 March 2018. Hersov, Lionel, “Child Psychiatry in Britain: The Last 30 years”, Journal of Child Psychology and Psychiatry 27:6 (1986), pp. 781-801. Knowles, Gianna, Ensuring Every Child Matters: A Critical Approach (London: South Bank University, 2009). Maclay, D.T., “The Working of a Child Guidance Clinic”, Health Education Journal 26:4 (1967), pp. 171-186. Parry-Jones, William, “The History of Child and Adolescent Psychiatry: Its Present Day Relevance”, The Journal of Child Psychology and Psychiatry 30:1 (1989), pp. 3-11. Parry-Jones, William, “The Future of Adolescent Psychiatry”, British Journal of Psychiatry 166 (1995), pp. 299-305. Parry-Jones, William, “Historical Themes”, in Jonathan Green and Brian Jacobs (eds.), In-patient Child Psychiatry: Modern Practice, Research and the Future (London, Routledge, 2002) pp. 22-36. Rey, Joseph et. al., “History of Child Psychiatry” in IACAPAP Textbook of Child and Adolescent Mental Health. (2015), http://iacapap.org/wp-content/uploads/J.10-History- Child-Psychiatry-2015.pdf consulted 25 May 2018. Rutter, Michael, “Child and Adolescent Psychiatry: Past Scientific Achievements and Challenges for the Future”, European Child and Adolescent Psychiatry, 19:9 (2010), pp. 689-703. Stewart, John, “‘The Dangerous Age of Childhood’: Child Guidance in Britain c. 1918-1955”, History and Policy Oct. (2012), http://www.historyandpolicy.org/policy- papers/papers/the-dangerous-age-of-childhood-child-guidance-in-britain-c.1918-1955 consulted 15 June 2018. Turner John, et. al., “The History of Mental Health Services in Modern England: Practitioner Memories and the Direction of Future Research”, Medical History 59:4 (2015), pp. 599–624. Wardle, Christopher J, “Twentieth-Century Influences on the Development in Britain of Services for Child and Adolescent Psychiatry”, British Journal of Psychiatry 159 (1991), pp. 53-68.

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Williams, Richard and Michael Kerfoot (eds), Child and Adolescent Mental Health Services: strategy, planning, delivery and evaluation (Oxford University Press, 2005).Young Minds, “Children’s mental health funding not going where it should be” (December 2017), https://youngminds.org.uk/about-us/media-centre/press-releases/children-s-mental- health-funding-not-going-where-it-should-be/ consulted 29 March 2018.

NOTES

1. William Parry-Jones, “The Future of Adolescent Psychiatry”, British Journal of Psychiatry 1995, 166, p. 299. 2. Martin Gorsky, “The British National Health Service 1948–2008: A Review of the Historiography”, Social History of Medicine, 21:3, 2008, p. 442. The other “subaltern narratives” are “public health” and “care for the elderly”. 3. For reasons of space I have excluded the care of children suffering from developmental delays and learning disabilities. The creation of specific services for these children followed a slightly different path. 4. Alexander von Gontard, “The Development of Child Psychiatry in 19th Century Britain”, Journal of Child Psychology and Psychiatry, 29:5, 1988, p. 579. Initially the term “moral insanity” included traits that are today considered to be symptomatic of Autistic Spectrum Disorder: “social withdrawal, difficulty making and maintaining friendships, intense interest in precise topics such as railways timetables”. The same term was later used to refer to what would currently be called psychopathy, sociopathy and conduct disorders 5. Ibid., p. 580 6. William Parry-Jones, “Historical Themes”, in Jonathan Green and Brian Jacobs (eds.), In-patient Child Psychiatry: Modern Practice, Research and the Future (London, Routledge, 2002), p. 26. 7. D.T. Maclay, “The Working of a Child Guidance Clinic”. Health Education Journal, 26:4, 1967, p. 171. 8. John Stewart, “‘The dangerous age of childhood’: child guidance in Britain c.1918-1955”, History and Policy, Oct. 2012, http://www.historyandpolicy.org/policy-papers/papers/the-dangerous- age-of-childhood-child-guidance-in-britain-c.1918-1955 consulted 1 June 2018. 9. Ibid. 10. Maclay, p. 174. 11. Evans Bonnie et.al. “Managing the ‘unmanageable’: interwar child psychiatry at the Maudsley Hospital, London”, History of Psychiatry, 19:4. 2008, p. 458 and p. 461. 12. The NAMH was renamed “Mind” in 1972 and is today one of the leading mental-health charities. 13. “A History of Mind”, https://www.mind.org.uk/about-us/what-we-do/our-mission/a- history-of-mind/ consulted 30 March 2018. 14. Hersov, Lionel, “Child Psychiatry in Britain: the last 30 years”, Journal of Child Psychology and Psychiatry, 27: 6, 1986, p. 783. 15. In 1944 there were 95 clinics. Christopher J. Wardle, “Twentieth-Century Influences on the Development in Britain of Services for Child and Adolescent Psychiatry”, British Journal of Psychiatry, 159, 1991, p. 56.

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16. Framrose, Rustam, “The First Seventy Admissions to an Adolescent Unit in Edinburgh: General Characteristics and Treatment Outcome”, British Journal of Psychiatry, 126, 1975, p. 380. 17. Parry-Jones, William, “The History of Child and Adolescent Psychiatry: Its Present Day Relevance”, The Journal of Child Psychology and Psychiatry, 30:1, 1989, p. 7. 18. Ibid., p. 8. 19. Wardle, op. cit., p. 60. 20. For further details see Hersov, p. 785. 21. Rey, Joseph et.al., “History of Child Psychiatry” in IACAPAP Textbook of Child and Adolescent Mental Health, 2015, http://iacapap.org/wp-content/uploads/J.10-History-Child- Psychiatry-2015.pdf consulted. 25 May 2018. p. 16. 22. Hersov, p. 784. 23. Better Services for the Mentally Ill, Cmnd 6253, HMSO London, 1975, par. 11.5. 24. Gorsky, p. 442. 25. For full details of all these studies see Michael Rutter, “Child and Adolescent Psychiatry: Past scientific achievements and challenges for the future”, European Child and Adolescent Psychiatry, 19:9, 2010, pp. 689-703. 26. Richard Willams and Michael Kerfoot, Child and Adolescent Mental Health Services: Strategy, Planning, Delivery and Evaluation, Oxford University Press, 2005, p. 17. 27. David Cottrell and Abdullah Kraam, “Growing Up? A History of CAMHS (1987–2005)”, Child and Adolescent Mental Health, 10: 3, 2005, p. 111. 28. William & Kerfoot, p. 25 29. John Turner et. al. “The History of Mental Health Services in Modern England: Practitioner Memories and the Direction of Future Research”, Medical History, 59(4), 2015, pp. 599–624 30. Although the Tiers system was implemented across the country, the upper-age limit has always been decided on a local level. 31. Cottrell & Kraam, p. 114. 32. See John Turner et. al. “The History of Mental Health Services in Modern England: Practitioner Memories and the Direction of Future Research”, Medical History, 59(4), 2015, pp. 599–624. 33. Children’s Commissioner, Briefing: Children’s Mental Health Care in England, October 2017, https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/10/Childrens- Commissioner-for-England-Mental-Health-Briefing-1.1.pdf consulted April 15 2018, p. 2 34. “In contact” literally means that they are “in contact.” They may just be on a waiting list and not actually receiving any treatment. 35. See NHS Digital. https://digital.nhs.uk/ consulted 20 July 2018. 36. See British Medical Association, Lost in Transit: funding for mental health services in England, 2018. 37. Jo Davidson. Children and young people in mind: the final report of the National CAMHS Review, 2008, http://webarchive.nationalarchives.gov.uk/20090615071556/http://publications.dcsf.gov.uk/ eOrderingDownload/CAMHS-Review.pdf consulted 15 April 2018. 38. Simon Gowers & Andrew Cotgrove, “The Future of In-patient Child and Adolescent Mental Health Services”, British Journal of Psychiatry, 183:6, 2003, p. 479. 39. Callaghan, Jane, Lisa Chiara Fellin, Fiona Warner-Gale,” A Critical Analysis of Child and Adolescent Mental Health Services policy in England”, Clinical Child Psychology and Psychiatry, 22:1,2017, p. 111. 40. Children’s Commissioner, Briefing, p. 16 41. Young Minds, “Children’s mental health funding not going where it should be,” December 2017, https://youngminds.org.uk/media/1285/foi-2016-press-release.pdf consulted 29 March 2018. 42. Children’s Commissioner, Briefing, p. 4.

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43. Ibid, p. 6 44. H.M. Government, No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of all Ages 2011, https://assets.publishing.service.gov.uk/government/uploads/ system/uploads/attachment_data/file/138253/dh_124058.pdf consulted 29 March 2018, p. 10 45. Callaghan et.al., p. 119 46. Gianna Knowles, Ensuring Every Child Matters: A Critical Approach, London: South Bank University, 2009. p. 3 and p. 6. 47. See for example William Parry-Jones, 1995, p. 300. 48. Healthy Young Minds in Herts, Child and Adolescent Mental Health Services (CAMHS) Transformation Plan for Hertfordshire 2015-2020, Herts. County Council, 2017, http:// www.enhertsccg.nhs.uk/sites/default/files/ Healthy%20Young%20Minds%20in%20Herts%20plan%202015-20_Oct%202017%20refresh_final.pdf consulted 29 March 2018. 49. See for example: N.A. Murphey et. al., “The changing face of newspaper representations of the mentally ill”, Journal of Mental Health, 2013, 22(3), pp.271-82 which notes that “the rate of increase [in the number of articles on mental health in British newspapers] was far greater than that for the increase in the total number of articles carried in the press over this time period [2003-2013]” (271). 50. Department of Health, Closing the Gap: Priorities for essential change in Mental Health, 2014, p. 4.

ABSTRACTS

The creation of a specific child and adolescent mental health service within the NHS was influenced by a number of factors including changes in adult mental health policies, the evolution of society’s attitudes towards children and parenting, and a greater biological and psychological understanding of how children develop. In the early years of the NHS, care for young people with mental health problems was split between child guidance clinics and hospitals with little communication between the two. A single unified service was not created until 1987, and national guidelines for how the service should be organised were drawn up only in 1995. The effectiveness of Child and Adolescent Mental Health Services (CAMHS) has, however, been hampered both by a failure to implement the guidelines in the same way throughout the country, and by a lack of financial investment.

La création d’un service de santé mentale spécifique pour enfants et adolescents au sein du NHS a été influencée par plusieurs facteurs, notamment la modification des politiques de santé mentale des adultes, l’évolution des attitudes de la société à l’égard des enfants et de la parentalité, ainsi qu’une meilleure compréhension du développement biologique et psychologique des enfants. Aux premières heures du NHS, l’offre de soins dispensés aux jeunes souffrant de problèmes de santé mentale était assurée soit par des cliniques d’aide à l’enfance soit par des hôpitaux, avec toutefois peu de communication entre les deux institutions. Un service unique et unifié n’a été créé qu’en 1987 et des directives nationales sur son organisation n’ont été élaborées qu’en 1995. L’efficacité de CAMHS a toutefois été entravée par une incapacité à mettre en œuvre les directives de de façon homogène et uniforme à travers le pays et par un manque d’investissements financiers.

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INDEX

Keywords: CAMHS, mental health, young people, NHS, history of medicine Mots-clés: santé mentale, histoire de la médecine, adolescents, Grande-Bretagne

AUTHOR

SUSAN BARRETT

CLIMAS, Université Bordeaux-Montaigne

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Public Health and the NHS at 70: Fit Enough for the Challenge of New Enemies in a New Landscape? An Example of Public Health Measures to Address Alcohol Consumption La Santé publique et le NHS à 70 ans : Capable d’affronter le défi de nouveaux ennemis dans un nouveau paysage? Un exemple de mesures de santé publique visant à réduire la consommation d'alcool

Fiona Campbell and Andrew Lee

Introduction

1 Public health focuses on health at the population level, seeking to reduce disease by improving and protecting health. When the NHS was founded in 1948 the most common cause of premature death and disability were infectious diseases, predominantly tuberculosis and polio. These were successfully addressed with comprehensive vaccination and screening programmes. The landscape has changed and the most common causes of avoidable death today are non-communicable diseases: cancers and cardiovascular diseases (ONS 2017). Health and the social and environmental environment are intrinsically linked, and this is evidenced by the impact of policies directly addressing inequalities, leading to improvements in the health of the population and particularly the health of the poorest. Improving health by creating environments where healthy choices are easy choices brings it directly in conflict with the interests of big business. We will focus on one example, that of minimum unit pricing (MUP) a policy initiative that the UK government had committed to, but at the last minute the government withdrew its support for the policy.

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2 Industry approaches have included challenging evidence from scientific communities by funding ‘counter science’, directly influencing policy makers through lobbying and financial incentives or gifts in kind, seeking partnership arrangements with government bodies and direct legal challenge. Increasingly, those who seek to promote and protect health will need to be equipped with improved scientific literacy in order to be able to critically appraise and challenge information from all stakeholders, including industry. Contemporary public health academics have to be able to communicate across boundaries and package evidence in ways that policy makers can understand and access and there may need to be less naivety about the priorities and methods adopted when dealing with industry. Perhaps public health academics could learn to adopt strategies used by the most effective lobbyists in order to better disseminate and promote their academic outputs.

Founding principles of the NHS

3 The advent of the UK National Health Service (NHS) which came into effect in 1948 saw a monumental shift in British health policy and has influenced attitudes and expectations of health care provision ever since. The NHS made access to health care a fundamental human right, rather than a commodity to be purchased. Health care, free at the point of delivery, was radical in its ideology and its consequent impact on British society and population health, particularly for the poor for whom access to health care had been limited or unobtainable. The passage of the Act of Parliament that would invoke the NHS was contested and there was strong opposition to the idea of ‘state medicine’ (Seaton, 2015). Opposition came not least from the medical profession for whom it threatened a loss of income and autonomy, bringing doctors ‘into the position of the civil service as full-time officers’. As Aneurin Bevan, the then Minister for Health, argued, ‘A free health service is a triumphant example of the superiority of the principles of collective action and public initiative against the commercial principle of profit and greed (Bevan 1952). Opposition to the NHS continues, frequently portrayed in the media as being in a state of crisis and its ideological position challenged for limiting the involvement of the private sector in health care. Despite episodes of negative publicity, and opposition from those who seek a greater role for the private sector in health care public support for the institution has remained resolute over seven decades (Robertson et al 2019).

4 Public health, which seeks the improvement and protection of health over and above the treatment of disease, has been an important part of the NHS’s role. The past 70 years have seen the health of the population in the UK go from an era where polio and TB caused premature death and disability on a large scale to one where free comprehensive vaccination and screening programmes have helped to prevent and detect these diseases. Improvements in health care, and rising standards of living have resulted in huge improvements in population health; life expectancy substantially rose from 66.4 years for men and 71.5 years for women in 1951, to 79.2 years for men and 82.9 years for women in 2017 (ONS 2017). Today, the major causes of premature death and morbidity are no longer the infections that reduced life expectancy in 1948. Instead, in the UK today non-communicable chronic diseases predominate: cancers and cardiovascular diseases and respiratory diseases are the main causes of death and disease (ONS 2017). Of note, many of these conditions are considered avoidable and are

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linked to unhealthy lifestyles and behaviours: 26% of adults are obese (Government Statistics Service 2018), 39% of adults are physically inactive (British Heart Foundation 2018), 15% of adults still use tobacco (ONS 2017), and 31% of men and 16% of women drank alcohol above safe drinking limits (National Statistics 2018). Whilst people may live longer, they live in poorer health for longer, usually with multiple health conditions, and have a greater need for health and social care support (Barnett et al 2012). 5 However, in some respects the NHS has been a victim of its own success. Over the years, the range of health services and treatments afforded to the public have continued to expand. In turn this led to massive inflation of healthcare costs that successive governments have struggled to control. Rising demand for services, an ageing population and changing sociodemographic trends, as well as the rising costs of drugs and new treatment modalities continued to add pressure on limited healthcare budgets. Productivity and efficiency in health services became the key priorities in recent decades, especially following the economic crisis in 2009. Consequently, contemporary healthcare commissioning priorities have focused on managing this demand and costs, leading to an emphasis on issues such as cost effectiveness of therapies, value for money of services, and return on investment arguments (Lee et al 2012). 6 Belatedly, policymakers have attempted to refocus on population health outcomes and their determinants. This represents a shift away from just managing patient demand, waiting list and budgets. The NHS is increasingly seeking to help prevent conditions developing or to detect conditions early. Prevention was one of the three core themes in the NHS policy document, NHS Five Year Forward View (NHS, 2014), and is central to a new long-term plan for the NHS that is being currently implemented. In 2018, the Government set out prevention as one of three priorities for the health and social care system, followed by the release of the Department of Health and Social Care policy document ‘Prevention is better than cure’ (DHSC, 2018) and the Chief Medical Officer’s annual report for England on ‘Better health within reach’ (Davies, 2018). The NHS England ‘Long Term Plan’, published a few weeks later included an entire chapter on prevention. This policy document also recognized the wide disparities in health that need to be addressed such as access to services by traditionally marginalised groups such as those with severe mental ill-health or learning disabilities.

Social determinants of health inequalities

7 Despite the aspirations for the founding of the NHS, which sought to provide comprehensive and equitable accessible health care based on clinical need rather than ability to pay, it is evident in the 70 years that followed that the provision of health care has not led to equity in the experience of health, ill health and access to health care. Differences in mortality and morbidity between social classes are well- documented (Townsend et al 1986, Whitehead and Drever 1997, Pickett and Wilkinson 2015). For example, there are significant differences in maternal, infant and child mortality between social classes (BMA 1999). The infant mortality rate (IMR), defined as the number of deaths under the age of 1 per 1000 live births, can be seen as a proxy for the health of a population (Reidpath et al 2003). The IMR is almost a fifth higher than the national average, in families where parents were in manual occupations (Dorling et

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al 2007). Children in social class V are five times more likely to suffer accidental death compared with those in social class I (Towner 2005)1. Children of unemployed parents are 13 times more likely to die of external causes and injuries that those born in the top social class (Edwards et al 2006)

8 The ONS (Office for National Statistics) in 2019 reported that the life expectancy of women living in the poorest areas of England had fallen by 100 days in recent years. Between 2012-2014 and 2015 -2017, female life expectancy in the richest areas increased by 84 days, widening the gap between rich and poor by half a year. In men, the gap also widened but less dramatically. This marked an end to improvements in life expectancy seen since 1980. While the causes are contested, it is noticeable that these changes have coincided with the most prolonged and extreme austerity measures implemented since the 1930s. It reveals a growth in inequalities, where the gap in life expectancy for women living in the most and least deprived areas in England have widened to 7.5 years. 9 Health inequalities demonstrate the complexity of public health that is determined not only by health care provision, but is also influenced by powerful socioeconomic factors. Indeed, good health care is said to account for as little as 10% of a population’s health and wellbeing (Pye 2018). The health behaviours and lifestyle choices that individuals make are shaped and informed by the social, cultural and environmental factors in which the individuals are embedded. Therefore tackling the causes of today’s diseases necessitates addressing those lifestyle choices and behaviours and the wider factors that influence them. This however brings the commercial interests of corporations and industry and public health into direct conflict. The endeavours to protect and improve public health, particularly the health of the poorest, often clash with the commercial interests of industry and big business. Through the sale and promotion of tobacco, alcohol and ultra-processed food and drink transnational corporations are major drivers of global epidemics of non-communicable diseases (Moodie et al 2013). These corporate disease vectors implement sophisticated campaigns to undermine public health interventions. Industries’ methods to affect public health legislation and avoid regulation with both hard power (building financial and institutional relations) and soft power (influencing culture, ideas and cognition of people, advocates and scientists) have been exposed with the release of industry documents as a result of tobacco and asbestos litigation (Lilienfeld 1991). The food, drink and alcohol industries use similar approaches to those of the tobacco companies in an effort to maximize profits and in so doing undermine public health interventions (Bond et al 2010). We are going to explore this in more depth by an examination of the way the alcohol industry has sought to undermine a specific intervention to address the effects on alcohol harm on the population in the United Kingdom.

Case Study of the Alcohol Industry vs. Public Health

10 The clash between public health and the interests of industry is very starkly exemplified by the alcohol industry’s efforts to contest policies that promote health at the potential expense of industry profits.

11 Harmful use of alcohol is a causal factor in more than 200 disease and injury conditions (World Health Organization, 2005). Long-term alcohol use causes several diseases including alcoholic liver disease and encephalopathy, and increases the risk of many

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chronic disorders such as oesophageal cancers. Acute episodic consumption is associated with acute adverse events such as road traffic accidents, falls and assault (Rehm et al., 2009). 12 The true impact of alcohol on the health of individuals and the wider community is difficult to estimate because of the many effects resulting from alcohol use (Gakidou et al., 2017). The cost of alcohol on public health is so significant that reduction in its consumption is an important global health goal, contributing to around 5% of the global burden of disease, disability and death (WHO, 2018). The resulting disease burden affects the quality of life for drinkers and their families and consumes substantial health care resources. Alcohol-related harm has a direct impact on the NHS, requiring therapeutic services for alcohol poisoning and addiction, and through wider consequences such as domestic and street violence. One study from Newcastle found that alcohol played a role in between 12% and 15% of those cases presenting for attention in A&E (Parkinson et al 2015 published in ch 3 McCartney 2016). In England the total yearly cost of alcohol related harm to the NHS was estimated at £2.7 billion in 2006/07 prices (Bhattacharya 2016). It is also estimated that in the UK, the annual cost to the economy of alcohol-related harm is £21 billion per year. 13 The factors that drive alcohol consumption are complex and interconnected: psychological, behavioural, social, economic, legal and environmental factors. These factors operate at the individual, community and population levels and are shaped by the actions of local and national governments, by consumers, and by alcohol industry practices (Petticrew et al 2017). 14 Interventions to reduce consumption of alcohol used in the UK have typically included education, screening and advice to people with harmful or hazardous drinking patterns, improved labelling of products, and recently the introduction of minimum unit pricing. The alcohol industry has countered this by advocating for the protection of maximum personal freedoms. It has also actively opposed interventions that work at a population level and those that ‘make healthy choices, easier choices’ (WHO). This was also the case for the policy of ‘minimum unit pricing’ and it serves as our example of how industry responds to policies that improve public health but may harm their profits. 15 In order to design and implement effective interventions, it is important to understand the factors that drive consumption. Focusing attention only at the individual level will have limited impact as it ignores the wider factors that also influence consumption. This includes understanding the ways in which the alcohol industry seeks to influence consumption by directly influencing policy, regulation and legislation. Their extensive financial resources, and the addictive nature of their products have enabled them to influence policies at the expense of public health in a number of ways. These include: Direct and indirect lobbying of politicians and policy makers Undermining scientific evidence Legal challenge Seeking partnership status with government agencies (Hawkins et al 2015) 16 We will explore how industry and corporations have responded to a policy initiative, minimum unit pricing (MUP), that has been shown to reduce alcohol harm and inequalities in health. Minimum unit pricing (MUP) of alcohol is a novel public health policy that seeks to reduce the adverse public health consequences of alcohol consumption (Katikireddi et al 2014). The policy links the price of wine, beer, cider and

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spirits to their alcoholic strength where a planned minimum price per unit would mean that low cost, high strength and cheap spirits would rise in price. This policy is expected to not only lead to fewer deaths, hospital admissions and crimes every year, but also reduce inequalities, as it is the very cheapest alcoholic beverages that are disproportionately bought and consumed by the heaviest drinkers (Holmes and Meier 2017).

Direct and indirect lobbying of politicians and policy makers

17 Corporate lobbying of politicians and policy makers on the issue of minimum unit pricing used a wide range of methods, mirroring many of the direct and indirect approaches of the tobacco industry to influence policy at all levels of government (Hawkins et al 2012; McCambridge et al 2013). One integrative review that examined documentary evidence and interview studies described lobbying in the UK between 2007-10 by alcohol industry actors. The dominant approach used was to nurture and sustain long term relationships with policy makers, within which subtle forms of influence were exercised (McCambridge et al 2013). , before becoming UK Prime Minister, said: ‘We all know how it works, the lunches, the hospitality, the quiet word in your ear, the ex-ministers and ex-advisers for hire, helping big business find the right way to get its way’ (cited in McCambridge et al 2013). The lobbyists from the alcohol industry had considerable access to policy makers, across all political parties and at all levels through a range of different channels, including party conferences and Parliamentary All-Party Groups. They were widely consulted and had access to policy makers at all stages of the policy making process.

18 Gornall’s (2014) investigation into the role of the alcohol industry in influencing policy on minimum unit pricing found that the industry enjoyed far greater access to government departments than what was given to representatives from the health community. He also found that it was very easy for industry to build relationships because Members of Parliament (MPs) with constituency interests in alcohol companies as employers were advocates themselves on behalf of the industry. For example, the largest of the 472 All-Party Parliamentary Subject Groups is the Beer Group. Gornall (2014) describes how at the annual dinner for the Beer Group in Westminster, just three days before the announcement that minimum pricing was dead, the Chancellor George Osbourne was named Beer Drinker of the Year for his decision in the Spring Budget to scrap the beer duty escalator and to take a further 1p off beer duty (Gornall, 2014).

Undermining scientific evidence

19 Consumers of research findings, including policy makers, are unlikely to have either the time or the resources to undertake the critical appraisal that may be necessary to evaluate contradictory research evidence. A simple look to establish who funded the research evidence, while useful, may not always be evident. Tobacco and alcohol companies have recruited scientists to provide critiques with the purpose of sowing seeds of doubt regarding the validity and reliability of research that supports healthy public policies, such as traffic light labelling of unhealthy food (Sacks et al 2011). By using seemingly credible sources, such as doctors to undermine research creates a climate of doubt and this is further exploited to influence policy (Moodie, 2013).

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20 One such example was the response of the alcohol industry to an economic model produced by the ’s alcohol research department that had reviewed existing data and modelled the health and social effects of raising alcohol prices. As early as 2008 the researchers in Sheffield had shown that the higher the minimum price, the greater the positive effect on alcohol consumption and health harms with relatively small effects on tax and duty income for the Treasury. It is a policy which has been shown to have a strong association of a beneficial effect on both citizens and the health service. This was through the potential to improve the health of the poorest in society. It is indeed rare to find such an effective policy that can directly reverse the pattern of health inequalities. 21 However, the findings were challenged by the Adam Smith Institute, a right-wing think tank and opponent of ‘big government…regulating businesses [and] and interfering with lifestyle choices’ with a long record of resisting regulation on behalf of the tobacco industry (Gornall 2014). They published a counter-report ‘Minimal Evidence for Minimum Pricing’ (Duffy & Snowdon, 2012) and declared the predictions based on the Sheffield alcohol policy model as ‘entirely speculative and do not deserve the exalted status they have been afforded in the policy debate’. Another right wing think tank the Centre for Economics and Business Research, also attacked minimum pricing as a ‘poor piece of policy that will do little to address the damage caused by alcohol misuse and much to exacerbate the financial challenge facing moderate drinkers on lower incomes’. The report was commissioned by SABMiller, a multinational brewing and beverage company (cited by Gornall 2014). 22 Another strategy adopted by industry are attempts to not only generate doubt regarding the reliability of non-industry sponsored research evidence but also deliberately seek to shape the evidence base itself. There are examples from the food industry where several food companies such as Mars Inc., Nestle, Barry Callebaut and Hersheys, who are amongst the world’s biggest producers of chocolate, have funded research studies exploring the health benefits of cocoa. 98% of all studies funded by Mars have been shown to have a beneficial effect on health, and findings have made newspaper headlines claiming the health benefits of chocolate, that are purported to reduce and even reverse age-related cognitive degeneration, promote weight loss and lower blood pressure (Sokolov et al 2013, Bohannon et al 2015, Grassi et al 2005). Claims that chocolate could reverse cognitive decline were based on the findings of a study published in Nature Neuroscience (Brickman et al 2014). Not only was the study very small (n=37) but it was also only 3 months in duration, an insufficient duration to base claims that it might reverse cognitive degeneration. The study was also vulnerable to risk of bias, because it undertook ‘outcome switching’, a practice where the outcomes that are more favourable to the intervention get described in the published results. The resulting bias (selective reporting bias) is likely to distort the truthfulness of the findings. A Cochrane Review of the health benefits of cocoa in reducing blood pressure (Ried et al, 2012) concluded that the funding source of the trial influenced heavily the direction of the findings, heavily favouring the benefits of cocoa over an alternative.

Legal challenge

23 The effectiveness of industry at influencing policy is demonstrated in the case of attempts at setting a minimum alcohol price which the industry vigorously contested

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to preserve their commercial interests that conflicted with the interests of public health.

24 In 2012 and 2015, the governments of England and Wales set out plans to introduce minimum unit pricing. While the Prime Minister David Cameron acknowledged it might not be popular, he made a commitment to introducing it as “it was nonetheless the right thing to do” (Gornall 2014). In what was described as “an extraordinary U- turn”, on the last day before the summer recess, the commitment was withdrawn. 25 In 2012 Scotland passed the necessary legislation with cross-party support to introduce a minimum unit price for alcohol. However, the initial legislative success was followed by a five-year legal battle with alcohol industry trade bodies. At the heart of the case was the question of whether the policy met the stipulation in EU law that public health policies restricting the free movement of goods must be appropriate to meet their stated aims and that there these aims cannot be achieved through existing measures that are less restrictive of free trade. The case went through the Scottish Outer House Court of Sessions (2012-13), followed by appeals to the Scottish Inner House Court of Sessions (2013-16), a referral to the European Court of Justice (2014-15) and finally an appeal to the UK Supreme Court (2016-17) which dismissed the industry’s case. Scotland was the first nation globally to introduce a minimum unit price in 2018 (Meier et al 2017). It is estimated that for every year that that implementation was delayed at least 1,600 hospital admissions could have been avoided ( Minimum Unit pricing cited by McCartney 2016)

Seeking partnership status with government agencies

26 Another strategy of the alcohol industry in recent years has been to position themselves as key partners with government agencies working to achieve policy goals of reducing alcohol-related harms (Casswell 2009, Hawkins et al 2012). This role includes providing information and expertise to officials, as well as policy delivery by undertaking various regulatory and governance functions (Adams et al 2010). By becoming embedded in the policy process as partners they can oppose and avoid effective health regulation as well as promote voluntary codes and partnerships with government.

27 Whilst these may appear on the surface as mutually beneficial arrangements, with industry sharing the burden of service provision with government, there is no evidence that these partnerships are effective. Indeed, the evidence suggests that these partnerships increase positive perceptions of the sponsors and the behaviours in question (Smith et al 2006). Paradoxically, the attitudes to the behaviours, rather than being challenged, are reinforced instead by these partnerships (Pettigrew et al 2016). Industry attempts to frame issues and influence agendas in order to shape their outcomes, and it is argued that they have been given too great a role in the development and implementation of alcohol policy (Baggott 2006, Baggott 2010). 28 Further evidence of the negative impact on public health of voluntary agreements and codes of practice with industry can also be seen through the UK government’s partnership with the tobacco industry which continued for most of the second half of the century. It resulted in some of the tobacco industry’s most impactful advertising campaigns, led to the delay in the introduction of comprehensive smoke-free

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legislation and the misleading promotion of low tar cigarettes as a healthier option (Gilmore 2018). 29 In 2018, in a development that has caused concern and opposition, Public Health England (an executive branch of the Department for Health and Social Care responsible for public health in England) entered into a partnership with DrinkAware, an organisation funded by the alcohol industry. The partnership shared a campaign of ‘Drink Free Days’ that drew considerable criticism from public health practitioners and academics nationally (Petticrew et al, 2018). In an open letter, public health scientists argued that the partnership would undermine the reputation of and trust in PHE to provide impartial, evidence-based advice. Such a partnership was seen as incompatible with PHE’s remit especially when the alcohol industry had a well-documented history of seeking to undermine public health science and reduce its influence on policy (McCambridge et al, 2014). It is the concerns with regards to the considerable risks of such partnerships, and the lack of evidence of their effectiveness, that has led the World Health Organisation to publicly state that it will not engage with the alcohol industry when developing policy or implementing public health measures (Torjesen 2019).

Ways forward

30 Health systems are inherently complex. Health itself too is complex with multiple determinants, of which socioeconomic factors are powerful. Individual behaviours are highly influenced by other actors and agents in society including industry. While access to good health care is important, it only accounts for as little as 10% of a population’s health and wellbeing. A rising proportion of the UK population live with long-term conditions and the NHS spends considerable resources treating people with conditions that are the consequence of various social determinants. As Michael Marmot stated: ‘Why treat people and send them back to the conditions that made them sick?’ There is a significant mismatch between the multiple drivers of ill health and what the NHS is designed to deliver. If we truly want to improve population health and at the same time manage demand on healthcare services, we will need to address behavioural and lifestyle issues as part of disease prevention. So how does the NHS face the challenges of preventing and reducing the morbidity and mortality of lifestyle-related diseases when the policies that are needed bring the interests of public health directly into conflict with the interests of industry?

31 There is a clear need for health to be a priority across government departments and not just confined as the remit of the Department of Health. The impact of policies on health need to be considered by the Departments concerned with business, education, culture and the environment, i.e. ‘health in all’ policies. Cross-departmental working will allow conflicts of interest to be better understood and policy goals in terms of health outcomes to be prioritised. There is also evidence that policies targeting the reduction of health inequalities have, when measured over the longer term, led to improvements in health and reductions in health inequalities (Robinson et al 2019). There is no evidence that supports partnering with industry to pursue public health benefits. Indeed, such partnerships may be damaging to public health and there needs to be less naivety by policy makers of industry motives and the impact of their activities. Going forward, independence and transparency of reporting and declaration

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of all conflicts of interest in the shaping of policies and campaigns is critical (Hessari et al 2019). 32 There are no easy answers, and policymakers will need considerable skill and expertise to manage the multitude of considerations and to recognize the influence of various stakeholders. Key to better policymaking is the need for it to be informed by robust evidence. Policymakers need better scientific literacy in order to be able to critically appraise the information they receive from various stakeholders including industry, the health professions and academia. Also needed are efforts to address existing evidence gaps and to focus the basis of policy discussions on the evidence. Academics are well placed to help bridge this gap as well as to facilitate and inform policy discussions. They will need to generate ‘demand for evidence’ by policymakers and promote its value to them over and above industry concerns and interests. This will require academics to learn to package the evidence better in a form that policymakers can access, understand and use. Arcane academic pieces are all too easily ignored. 33 If the NHS is to have a future, the demands upon it need to managed, its resources are finite and will always outstrip supply. Prevention is key to managing demand and to avoid ill health taking a toll on British lives as well as on its health services. However, prevention is not the sole domain of the health services but includes wider stakeholders such as local authorities who were statutorily tasked with prevention through the Health and Social Care Act, 2012. Effective disease prevention will require collaborative efforts to implement evidence-based policies that will improve population health that are likely to run counter to the strong vested interests of the food, alcohol and tobacco industries. 34 The NHS today is larger, older and more complex than when it was first set up. It remains vulnerable against the powerful actions of industries and businesses that are driven by profit who pay little heed and experience no consequence arising from the ill-health they generate in society. The NHS risks being a passive victim of circumstance. We need an NHS that is older and wiser that is able to robustly confront the key drivers of avoidable death and disease today. Public health leadership both from within the system but also in collaboration with wider stakeholders are needed, but it is unclear thus far where this will spring from. 35 Andrew Lee is a Reader in Global Public Health at the University of Sheffield whose interests are in health inequalities, public health and health management. He is also a local director of primary care and population health in the National Health Service in the UK and a practicing primary care clinician. 36 Fiona Campbell is a Research Fellow at the University of Sheffield. She has an expertise in evidence synthesis to support decision making in health care and policy making and interests in public health, maternal and child health and nursing.

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NOTES

1. In 1911, the Registrar General introduced a classification system to categorize the British population by social standing on the basis of their occupation. This was later renamed in 1990 as Social Class based on Occupation. This range from Social Class V (Unskilled occuptions) to Social Class I (Professional occupations).

ABSTRACTS

Health for the many, and particularly the health of the poorest, has often been vulnerable to the commercial interests of powerful actors such as corporations and industry. This is exemplified by the efforts of the alcohol and tobacco industries to fight public health policies aimed at curbing alcohol and tobacco consumption: through the publishing of poor science, political lobbying and finally through legal action at national and international levels. There is clear evidence that better public health cannot be achieved solely through the promotion of healthy behaviour but also requires active efforts to counter those powerful entities with vested interests in commercial profit. The manner in which the British government’s commitment to introducing a minimum unit price (MUP) for alcohol in England and Wales saw an extraordinary U-turn has been described as a cautionary tale of the power of the alcohol industry to influence public health policy. In Scotland, where the bill was passed, legislative success was followed by a five-year legal battle with alcohol industry trade bodies. MUP as a policy exposed just how strategically and earnestly industry will fight to preserve its profits and its interests at the expense of public health.

La santé de la population, et en particulier celle des plus pauvres, a souvent été vulnérable aux intérêts commerciaux d’acteurs puissants tels que les entreprises et l’industrie. Cela est illustré par les efforts des industries du tabac et de l'alcool pour lutter contre les politiques de santé publique visant à réduire la consommation d'alcool et de tabac, que ce soit par moyen de la publication d'informations scientifiques médiocres, le lobbying politique ou enfin par des actions en justice aux niveaux national et international. Il est clairement établi que l'amélioration de la santé publique ne peut être obtenue par la seule promotion d'un comportement sain, mais nécessite également des efforts actifs pour lutter contre les intérêts commerciaux lucratifs. La manière dont le gouvernement britannique s’est engagé à introduire un prix minimal unitaire (MUP) pour l’alcool en Angleterre et au Pays de Galles a connu un tournant extraordinaire et a été décrite comme une mise en garde concernant le pouvoir de l’industrie de l’alcool d’influencer la politique de santé publique. En Écosse, où le projet de loi a été adopté, le succès de la législation a été suivi par une bataille juridique de cinq ans avec les organismes du commerce de l’alcool. La politique de prix minimal unitaire a montré à quel point l’industrie allait se battre de

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manière stratégique et sérieuse pour préserver ses profits et ses intérêts, au détriment de la santé publique.

INDEX

Keywords: NHS, Alcohol Policy, Minimum Unit Pricing, inequality, Health policy Mots-clés: NHS, Service national de santé, Politique relative à l'alcool, Prix unitaire minimal, inégalités, politique de santé

AUTHORS

FIONA CAMPBELL

University of Sheffield

ANDREW LEE

University of Sheffield

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Approche iconoclaste d’Enoch Powell au ministère de la Santé (1960-1963) : entre liberté économique et puissance étatique ? Enoch Powell’s Iconoclastic Approach to the NHS (1960-1963): Promoting Economic Freedom and State Power?

Stéphane Porion

Introduction

1 Aneurin Bevan, véritable architecte du National Health Service (NHS), déclarait avec force après sa démission du ministère de la Santé en 1950 : « A free health service is a triumphant example of the superiority of collective action and public initiative applied to a segment of society where commercial principles are seen at their worst »1. À ses yeux, le principe collectiviste avait permis à tous les Britanniques malades d’avoir accès au soin gratuitement dans une société qu’il jugeait ainsi « civilisée », aux antipodes de « l’hédonisme d’une société capitaliste »2. Le NHS avait rapidement remporté l’adhésion et l’affection des Britanniques dans la mesure où il assurait un système de soins universel, global et relativement gratuit depuis sa mise en place en 1948. Cependant, il s’est avéré rapidement que ce système de santé, aussi populaire qu’il fut, ne parvint pas à résoudre trois problèmes fondamentaux d’ordre administratif, politique et économique, qui devinrent des préoccupations grandissantes pour les différents ministres de la Santé. La hausse de la demande de soins accentuait le problème des ressources suffisantes et le financement du NHS. Les méthodes de planification centralisée étaient encore peu développées et la structure même du NHS posait problème ; ce que reconnaissaient volontiers les professionnels du secteur au début des années 1960 : « The tripartite system discouraged rather than encouraged cooperation and only in the 1960s did the Ministry of Health start seriously to develop the skills by

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which relative merits of centralised planning (as opposed to those of the market and local initiative) could be truly tested »3. Même si un consensus perdurait avec l’idée de « universalising the best », le NHS originel conçu par Bevan semblait incapable d’apporter une solution à ces multiples défis.

2 Entre 1951 et 1964, sept ministres conservateurs de la Santé se succédèrent, ne bénéficiant du statut de ministre du Cabinet que pendant une période de deux ans (de 1962 à 1964). Bien que la plupart d’entre eux aient souvent été de moindre envergure, Enoch Powell semble faire exception aux yeux des historiens du NHS4. Par ailleurs, la nomination de l’ancien haut fonctionnaire au ministère de l’Économie et des finances (former Treasury official), Sir Bruce Fraser, au poste de secrétaire permanent du Ministère de la Santé (Permanent Secretary), ainsi que celle de Sir Gorge Godber en tant que directeur général de la Santé (Chief Medical Officer) au début des années soixante, ont conduit à un leadership administratif fort au côté de Powell dans « un ministère revitalisé »5. Selon Nicholas Timmins, « it was a triumvirate of some note who took the NHS into the 1960s »6. 3 Non seulement Powell reconnut lui-même que devenir ministre de la Santé lui permit de se confronter à un nouveau défi intellectuel, mais il conçut également son rôle à ce ministère de manière originale, désireux de réaliser un ou deux projets de grande envergure afin de laisser sa marque dans ce secteur7. Il lança notamment un vaste plan ambitieux de construction et de modernisation des hôpitaux en Grande-Bretagne, et comptait révolutionner la façon dont étaient traités les problèmes de santé mentale, en améliorant les infrastructures et en développant les soins et services d’aide à domicile, hors des instituts spécialisés. Powell se rappelait très bien que lorsque Macmillan devint Premier ministre en 1957, le Parti conservateur s’était engagé à augmenter à la fois les dépenses de santé au vu de l’évolution démographique du pays, ainsi que les dépenses d’investissement, dont une partie serait consacrée à la modernisation des hôpitaux8. Il se trouvait donc dans une situation paradoxale que l’un de ses biographes (Robert Shepherd) a qualifiée de « contorted logic » 9 : il espérait œuvrer pour la modernisation du NHS, tout en rationalisant les dépenses de son ministère – objectif qu’il connaissait bien, ayant été secrétaire financier du ministre de l’Économie et des Finances en 1957-1958 et démissionné à cause d’un manque de volonté de la part du Cabinet de Macmillan d’enrayer la hausse des dépenses publiques, génératrice à ses yeux d’inflation10. 4 Jusqu’en 1960, malgré la pression des ministres de l’Économie et des Finances, ceux de la Santé furent en effet peu enclins à maîtriser leurs dépenses toujours en constante augmentation. Charles Webster estime que cette situation changea en juillet 1960 avec la nomination de Powell au ministère de la Santé : « [His] appointment meant that, for the first time, the Treasury and the Ministry of Health were agreed in their philosophy towards the welfare state in general »11. Powell reconnut d’ailleurs lui-même que sa position ne divergea jamais de celle du chancelier de l’Echiquier pendant ses années passées à la Santé12. Toutefois, il justifiait ce besoin d’humaniser le NHS : Let us not make the mistake of supposing that this unity of the National Health Service can be produced just by clever organisation, by efficient administration, or even by directives, however well composed, from the ministry of Health. The true unity of the National Health Service emerges from its unity in the service of the patient. That is its true, fundamental, psychological unity, and of that we must never lose sight. This has been the impelling force behind all that has been and is being done for what is sometimes called the humanisation of the National Health

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Service. The Service has been intensely conscious of this duty laid upon it in recent years. (...) [T]he service is alive, as it must be alive, to its ultimate dedication to the patient. (...) [T]he Service is given its meaning, is given its justification and is given its unity by one thing only, its duty to the individual suffering man or woman13. 5 Il réaffirma même un objectif crucial en octobre 1963 : si le NHS dépensait un milliard de livres par an, son personnel avait le devoir d’honorer la mission qui lui avait été confiée ; en d’autres termes œuvrer pour le bien-être, la dignité et le respect du patient dans son traitement14. Ainsi, Powell, véritable chantre d’idées libérales, soucieux de défendre les sacrosaints principes de liberté et de choix individuels, se trouvait à la tête d’un ministère à moderniser. Malgré ce positionnement clairement établi depuis son expérience au ministère de l’Économie et des Finances, Powell décida de garder un service de Santé public tout en ne reniant pas son credo libéral ; ce qui en fit un ministre de la Santé iconoclaste.

6 Certaines biographies sur Powell ont analysé ses années passées au ministère de la Santé, tentant qu’expliquer sa stratégie paradoxale d’humanisation et de rationalisation du NHS. Par exemple, Robert Shepherd et Simon Heffer se sont principalement concentrés sur le plan de modernisation des hôpitaux, les problèmes du service hospitalier de santé mentale et du budget difficilement maîtrisable de ce ministère, et la crise avec les infirmières sur la question des salaires15. D’autres études sur le NHS mentionnent à quelques reprises le nom de Powell : pour Ian Holliday, le plan de construction des hôpitaux mis en place par Powell a permis de révéler des « faiblesses structurelles » du NHS16. Brian Watkin estime aussi que Powell avait déjà diagnostiqué les problèmes affectant le personnel médical au sein des hôpitaux et des maternités bien avant la publication de l’ouvrage de Gerda Cohen en 1964 (What’s Wrong with Hospitals?)17. Selon Virginia Berridge qui partage le point de vue d’Harriet Jones, Powell était un bon exemple du dilemme auquel était confronté un ministre de la Santé : « the tension between what was ideologically and economically desirable and what was politically feasible »18. Quant à Charles Webster, il explique pourquoi Powell fut le dernier ministre de la Santé à souscrire à l’opinion que le NHS était un secteur où l’on pouvait réellement diminuer les dépenses publiques19. Enfin mentionnons l’article de Tony Cutler publié en 2011, qui a montré que Powell avait suivi une logique libérale cohérente dans la mise en place de son plan de construction et de modernisation des hôpitaux malgré la dimension de planification du projet; pour cet auteur, ce fut surtout la stratégie de Powell qui posa problème20. 7 Cet article vise ainsi à compléter les débats historiographiques et mettre en lumière d’autres enjeux que ceux mentionnés précédemment, qui ont également marqué les années Powell au ministère de la Santé. Il s’intéressera entre autres aux problématiques de l’achat de médicaments et de son impact financier sur le NHS, mais aussi à la question du tabagisme qui s’inscrit plutôt dans le domaine de santé publique. Ces enjeux seront abordés autour d’un autre dilemme que Powell dut gérer que celui d’humaniser/rationnaliser le NHS : jusqu’à quel point était-il possible de défendre les idées de liberté et de choix dans un système public de santé où la puissance étatique était force motrice ? Dans leur ouvrage intitulé Welfare Policy under the Conservatives (1951-1964), Paul Bridgen et Rodney Lowe répertorient les archives nationales portant sur les politiques sociales des treize années au pouvoir des Conservateurs et indiquent, dans leur section sur Powell au ministère de la Santé, que les sources primaires permettent essentiellement de mettre en lumière l’élaboration et la mise en place de son plan de modernisation des hôpitaux, ainsi que la manière dont il a géré le budget

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d’un ministère dispendieux21. En s’appuyant sur ces mêmes sources primaires, complétées par les archives personnelles de Powell détenues au Churchill Archives Centre à Cambridge, l’étude abordera ainsi les points suivants qui n’ont été encore à ce jour que partiellement analysés: comment Powell concevait la nature et la gestion du NHS, puis comment le ministre géra les questions de coût des médicaments, de la publicité sur le tabac et de la fluoration de l’eau.

Approche powellienne du NHS

8 Au tournant des années 1960, deux questions apparaissaient problématiques pour les Conservateurs et méritaient réflexion: fallait-il qu’ils défendent la philosophie de l’État- Providence mis en place par Clement Attlee impliquant des services sociaux universels assurés par la puissance étatique, ou devaient-ils promouvoir à la fois l’idée de sélectivité des aides sociales publiques à destination des plus fragiles de la société et les canaux privés d’assurances pour ceux qui en avaient les moyens ? De plus, la question de l’augmentation des dépenses publiques visant à assurer un niveau de couverture sociale universelle et globale avait suscité de vifs débats au sein du Cabinet de Macmillan en 1957 et janvier 1958, menant à la démission des trois ministres de l’Économie et des Finances, dont Enoch Powell. Ce fut dans ce climat qu’émergèrent des idées plutôt radicales de la part de certains Conservateurs qui contestaient entre autres une gestion étatique du NHS, lorsque Powell devint ministre. Citons-en quelques- unes qui allaient s’inscrire en porte-à-faux avec la vision powellienne du NHS. Par exemple, dans un article publié dans Crossbow (revue du Bow Group) en 1959 et intitulé « Reshaping Welfare », Brendon Sewill défendit l’idée selon laquelle, à cause de la pression exercée pour contenir les dépenses publiques, il devrait y avoir une réduction d’impôts pour ceux qui souscriraient une assurance de santé privée, « equivalent to the per capita cost of the NHS »22.

9 Par ailleurs, D. S. Lees de Keele publia un article en 1961 par le biais de l’IEA (Institute of Economic Affairs), intitulé Health through Choice, et affirma : « Medical care should increasingly be based on consumer choice and supplied through the market »23. Il estimait en effet, qu’à cause du NHS, les décisions politiques supplantaient les choix des individus, et que par voie de conséquences, les dépenses allouées au NHS étaient alors bien supérieures à ce qu’elles auraient été si le système de santé avait été géré par les forces du marché. Il ajoutait qu’un service étatisé et uniforme, laissé aux seules mains et décisions d’un ministre, empêchait le système de s’adapter aux changements et la liberté d’expérimenter. Ce dernier se trouvait aussi déconnecté du terrain et des professionnels de santé. De manière plus controversée, il avançait l’idée selon laquelle le NHS, de par sa nature étatisée, n’avait pas vraiment permis d’améliorer le niveau de santé des Britanniques ; seules les classes moyennes tiraient réellement profit du système. Ainsi, à ses yeux, les soins médicaux ne devraient pas être considérés comme une forme d’investissement, mais comme un bien de consommation avec un prix à payer. Selon Timothy Raison, « Right up to 1987 official Conservative party policy shied away from Lee’s approach, feeling that the NHS was too popular an institution to replace or even seriously question »24. 10 Plus généralement, au tournant des années 1960, l’IEA contestait la philosophie de l’État-Providence et développait le principe selon lequel il devrait y avoir plus de choix et de liberté. Deux autres Conservateurs relayaient le même message. Keith Joseph

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pensait que c’était une erreur d’attribuer à l’État le rôle permanent de garantir à tous une couverture sociale élémentaire. Quant à Geoffrey Howe, il partageait la vision de Lees et estimait que la Santé devrait être gérée par le secteur privé afin d’éviter ce qui allait être considéré par les partisans du thatchérisme comme « la culture de l’assistanat »25. 11 Au début des années 1950, Ian Macleod, alors ministre conservateur de la Santé, avait accepté, selon Charles Webster, la philosophie travailliste du NHS : « Macleod effectively purged residual rancour towards Bevan’s health service in the Conservative Party »26. Il explique que Macleod voyait le NHS comme l’aboutissement logique d’une tradition respectable ancrée dans la philosophie sociale disraélienne. Macleod avait indéniablement été influencé par son appartenance au « One Nation Group ». Il publia d’ailleurs en 1952 avec Powell, lui-même membre de ce « dining group », une étude intitulée Social Services: Needs and Means qui reflétait cette approche disraélienne de l’État-Providence. Force est de constater que même si Powell s’inscrivait dans cette même approche au début des années 1950, son expérience en tant que secrétaire d’État au ministère de l’Économie et des Finances (Financial Secretary) en 1957-1958 changea entre autres sa vision du financement et du fonctionnement du NHS. Ce même auteur ajoute également : « Powell soon returned from the wilderness to become minister of Health, in which capacity he embarked on an exercise of self-vindication by once again applying his retrenchment philosophy to the health service. The confrontation with the nurses was merely one manifestation of this effort, [as well as] further characteristic interventions concerning health-service charges and the NHS Contribution »27. Malgré une posture consistant à être perçu comme un ministre de l’Économie sous couverture, Powell décida de garder la structure publique du NHS, tout en ne perdant pas de vue les problématiques de liberté et de choix individuels. 12 Dans son ouvrage Medicine and Politics, publié en 1966, Powell expliquait ainsi que les soins médicaux pouvant être, par nature, des besoins aussi vitaux que se nourrir ou se loger, ils relevaient donc d’une gestion étatique28. Plus généralement, il soulevait à nouveau au début des années 1960 la question centrale qui devait guider tout choix politique : At the centre of politics today lies, as never before, the question of what Government should do, or abstain from doing, to control, determine, regulate or alter the behaviour of its subjects in the economic field. There have lately been signs that Conservative leaders either themselves lack clearly defined ideas about the limits and conditions of such Government action. (…) Where matters are not defined by authority, the individual believer is at liberty to use his own judgment29. 13 Selon Powell, il existait deux sortes de critères : « des critères économiques » et des « critères non économiques » de « nature philanthropique »30. Ces critères retenus par Powell font sens au regard des analyses sur le concept de « biens publics » développées par Paul Samuelson31, ainsi que de celles sur les soins médicaux (« medi-care ») menées par Kenneth Arrow32. Parmi les critères non économiques, Powell y plaçait, par exemple, la gestion publique de la santé : « In instituting a universal free medical service, a Government does not act on economic criteria. It acts on the ground that it is a ‘good thing’ for its subjects to be cured of their ailments, if humanly possible »33. Sa position idéologique reflétait, dans une certaine mesure, celle d’Adam Smith développée dans The Wealth of Nations (1776), laquelle avait déterminé des secteurs d’activité compatibles avec une ingérence étatique servant au mieux l’intérêt individuel qui se fondait, dans ce cas précis, sur l’intérêt collectif. Toutefois, la pensée de Powell

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faisait aussi précisément écho à la philosophie d’Hayek et plus particulièrement à « son ordre spontané » : One class of decisions looks to areas where no spontaneous process can operate. The decisions to organize a free health service can only be a decision of government. The free choice of individuals will not automatically build [a hospital]34. 14 Powell concédait toutefois que gérer un service public de santé entraînait des conséquences économiques, et qu’il fallait ainsi laisser un choix viable aux individus s’ils décidaient d’avoir recours à des soins dispensés par le secteur privé. Powell prenait également en compte la dimension humaine du débat en intégrant les « critères non- économiques »35 ; ce qui motiva sûrement sa volonté de développer les hôpitaux et d’améliorer les traitements pour les patients atteints d’une maladie mentale. Il ne faudrait pas, cependant, en déduire que Powell était un fervent défenseur de la planification et un inconditionnel converti aux bienfaits des nationalisations. Considérant le critère humain comme prioritaire, il expliquait dans quel état d’esprit il avait envisagé la planification de la construction et de la modernisation des hôpitaux : I therefore had to form patterns and make genuine plans – in the proper sense of a plan, not a plan about what other people would do but a plan about what you yourself or your successors would do. For good or ill, therefore, the Minister was in a position to mould the pattern of the hospital service, the pattern of the mental health service and the pattern of the community or health and welfare services36. 15 Après son passage au ministère de la Santé, Powell fit en 1966 un bilan de son action et dénonça de nouveau le problème de la gratuité du service, qui entrainait de facto à ses yeux « une demande illimitée », laquelle était toutefois circonscrite par une offre limitée : « Whatever assumptions one makes about generosity, (…) it is that point of conflict, between the potential of the unlimited demand and the supply, which has to be somehow cut down to meet it »37. Toutefois, Powell ne soutenait pas la disparition du NHS au profit d’un système de santé privé car plus le consommateur aurait de choix, plus il dépenserait pour sa santé. Ainsi, les patients pourraient décider de consulter plusieurs médecins, échappant au système public unique, censé garantir la gratuité des soins à tous les individus et l’uniformisation de leur prise en charge38. Si les médecins désiraient une plus grande liberté – que ce système public ne pouvait leur octroyer –, ils devraient chercher eux-mêmes d’autres sources de financements que celles de l’État39. Selon Nicholas Barr, même si Powell avait des inclinations libérales bien marquées, il avait fait le bon choix de conserver un système de santé public : It was acknowledged that a centralized NHS was able to deliver a comparable standard of health care more cost-effectively than the systems of private and social insurance practised in the USA and continental Europe. Policy makers, in short, had grasped the later economic wisdom that governments could do things which private markets for technical reasons either would not do at all, or would do ineffectively40. 16 Malgré la nature centralisée et étatisée du ministère de la Santé, Powell décida dès le départ d’inclure tous les présidents des agences régionales de santé dans les débats et les prises de décision, en les conviant une fois par mois à une réunion à son ministère41. Il déclarait en effet qu’ils se comportaient comme une équipe, arrivant à des conclusions concertées en échangeant et en réfléchissant ensemble42. Selon lui, sa méthode permit d’instaurer un mode consensuel efficace au sein de son ministère : « I never lost by seeking agreement round the table to alterations in financial allocation, to changes of policy, and to planning decisions, even though technically the decisions

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were mine »43. Powell opta sûrement pour un tel mode de fonctionnement afin de contourner le système bureaucratique dont la nature pouvait rapidement s’avérer problématique à ses yeux.44. Selon Neil Small, « Powell combined an appreciation of Realpolitik with a theoretical and ethical appreciation of something he defined as public duty »45. Alors que l’action de Powell au ministère de la Santé déclencha de vives réactions parmi certains professionnels du milieu46, il laissa plutôt une image positive, vu comme « a man of principle, determined, enthusiastic, who has the courage to act according to his convictions »47.

17 Powell dut naturellement gérer la question des finances. Selon lui, « the unnerving discovery every Minister of Health makes at or near the outset of his term of office is that the only subject he is ever destined to discuss with the medical profession is money »48. Il dut en effet veiller constamment à la maîtrise des dépenses de santé, ce qui lui valut des conflits avec certains collègues au sujet de la gratuité des médicaments pour les patients passant par le système privé de santé, ainsi qu’avec certains membres de la profession médicale, tels que les infirmières, par rapport à des revendications salariales en 1962. Powell dut faire face à « la litanie perpétuelle et assourdissante de plaintes qui [émanaient] jour et nuit de toutes parts »49. Il devait assumer la décision du gouvernement de contenir les hausses de dépenses publiques et de celles d’investissement. Robert Shepherd appela cet objectif « Powell’s ‘contract’ with the Treasury »50. Ce dernier avait en effet accepté en 1961 que les dépenses de son ministère n’augmentent que de 2,5% par an jusqu’en 1965/196651, ce qui correspondait à l’objectif du Trésor de contrôler le coût de l’évolution des politiques publiques par la mise en place du Public Expenditure Survey Committee 52. Ainsi, Powell fut perçu comme agissant encore comme secrétaire financier, avec pour mission de maîtriser les dépenses publiques53.

Le coût des médicaments : combat de Powell contre l’industrie pharmaceutique

18 Dès sa nomination au ministère de la Santé, Enoch Powell reçut une lettre de cadrage du Premier Ministre, soulignant les enjeux importants auxquels le NHS était confronté : « There is really the future of the Service, which way it will go. And then there is the terrible expense that ought in some way be reduced, especially in the form of the drug bill »54. Il fut ainsi mandaté pour s’attaquer à la question du coût exorbitant des médicaments qui grevait le budget de son ministère. Les entreprises pharmaceutiques réalisaient en effet d’énormes profits, qu’elles justifiaient par les fonds engagés pour la recherche, la mise au point de ces médicaments et les frais de commercialisation. Enoch Powell analysa ce problème sous l’angle d’une « relation unique entre le fournisseur et le consommateur »55 et indiqua que l’achat d’un médicament par le consommateur faisait intervenir trois acteurs différents au sein du NHS – les médecins commandent les médicaments, les patients les consomment, mais le ministre paie ces dépenses : « I pay the bill, but I don’t order the goods; and I don’t consume them either ».56 De plus, les industries pharmaceutiques n’avaient à traiter qu’avec un seul client sur le marché britannique – le NHS. Alors qu’une étude menée aux États-Unis (le rapport Kefauver) venait de révéler que le problème résidait dans le monopole d’approvisionnement en médicaments détenu par les industries pharmaceutiques britanniques, lesquelles pouvaient ainsi librement fixer un prix de vente élevé au ministère de la Santé,

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puisqu’elles étaient protégées par la loi sur les brevets datant de 194957, Powell décida d’agir en 196158 déclarant : « The pharmaceutical firms cannot view with indifference the danger of being branded as profiteers (…) making large profits out of the sick »59.

19 Depuis les années cinquante, les laboratoires Pfizer avaient introduit en Grande- Bretagne la tétracycline. Les entreprises en possession d’une licence pour la commercialiser en demandaient 90 livres pour mille comprimés, sous prétexte qu’il s’agissait d’un antibiotique efficace couvrant un plus large spectre de maladies infectieuses que la pénicilline. Au début des années soixante, son prix de vente avait baissé d’environ 30% pour avoisiner les 60 livres. En 1961, une nouvelle entreprise pharmaceutique, DDSA Pharmaceuticals, pouvait commercialiser la tétracycline au prix de 6 livres 10 shillings pour 1000 tablettes, soit dix fois moins que ce qu’en demandait Pfizer60. Toutefois, A. M. Brunton, directeur médical du groupe Pfizer, justifiait ainsi ce prix élevé : As soon as a valuable new drug is discovered and scientific data published for all the world to see, any chemical manufacturer can, if patents are ignored, enter into production of the discoverer’s new drug without having incurred any of the risks and expenses involved in the research and development of the compound61. 20 Le rapport Kefauver rappelait que l’action de Pfizer était justifiée par une décision antérieure relative au système des brevets déposés : il fallait encourager l’esprit inventif au détriment de la concurrence. Ainsi, les laboratoires disposaient du monopole pour fixer leur prix de vente sans avoir à craindre qu’une autre entreprise ne commercialise leur médicament à un prix inférieur62.

21 Enoch Powell, « l’apôtre du secteur privé »63, allait modifier les choses en profondeur en poussant l’État à injecter de la concurrence dans l’optique de faire baisser les prix. Selon lui, « the government still possesses statutory power to control the prices of drugs. It is a power about as useful, for practical purposes, as a hydrogen bomb in the Vietnam war »64. Lors d’un discours prononcé devant l’Association des Industries Pharmaceutiques Britanniques le 27 avril 1961, il affirma que le système de libre concurrence et de liberté des prix procure de plus grands bénéfices à tous les catégories de la société que tout autre système alternatif65. Powell rappela que, sans concurrence ni liberté des prix, le système actuel pouvait entraîner de sérieux blocages de la part des deux parties (fournisseurs et consommateurs) qui le mèneraient à sa perte : My weakness is that the Health Service must have the drugs you supply: where a patient’s life may depend on having a particular proprietary drug, I cannot refuse on financial grounds to let his doctor order it for him. Your weakness is that virtually your only home market for your ethical drugs is the National Health Service: if I limit the scope or the profitability of that market, you have no alternative outlet. This surely creates for each party not merely a moral duty but a practical necessity, in sheer self-interest, to be fair and reasonable in dealing with the other (…) the one side seeking a good bargain in its vast expenditure, the other looking to earn a profit in fair competition, and both believing that the public good is served by their respective efforts66. 22 Enoch Powell eut ainsi recours à l’article 46 de la loi sur les brevets d’invention de 1949, conçue par Sir Stafford Cripps ‑ alors ministre travailliste et avocat spécialisé en droit des brevets. Celui-ci permettait au gouvernement, en temps de guerre, s’il avait besoin d’un produit breveté, de se le faire fournir par une entreprise sans permis de commercialisation à condition de reverser des royalties à l’inventeur du brevet 67. C’est ainsi que, le 17 mai 1961, Powell accorda le droit à des entreprises sans permis de commercialisation de fournir au gouvernement, même en temps de paix, trois

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antibiotiques : la tétracycline, le chloramphénicol et le chlorothiazide68. Son action se limita aux hôpitaux qui représentaient 14 millions de livres du total annuel du coût des médicaments, lequel s’élevait quant à lui à 110 millions de livres69. Powell conclut ainsi un accord commercial en 1962 avec la DDSA pour qu’elle approvisionne les hôpitaux en tétracycline pour un montant de 240 000 livres70. Quant au groupe Pfizer, il attaqua la décision de Powell en justice mais perdit devant la Chambre des Lords en novembre 196471. Powell remarqua, en 1965, que le gouvernement n’avait plus besoin d’avoir recours à la loi de 1949 et ne renouvela pas ses contrats commerciaux avec les entreprises sans permis de commercialisation, puisque les entreprises brevetées offraient désormais des prix de vente que le ministère jugeait « acceptables »72. Ainsi, Powell avait réussi à contraindre ce marché à s’ouvrir à la concurrence pour faire baisser les prix des médicaments en n’hésitant pas à utiliser les pouvoirs de l’État.

Interdire la publicité des cigarettes ?

23 La Commission des affaires sociales s’était penchée en 1959 sur la corrélation établie entre la consommation de cigarettes et le cancer des poumons. Le ministre de la Santé, Derek Walker-Smith, observait seulement que la consommation de tabac et le nombre de décès provoqués par le cancer des poumons avaient tous deux continué à augmenter depuis que le gouvernement avait décidé d’adopter une politique de transparence : les faits étaient connus par le grand public qui était amené à en tirer ses propres conclusions. Il préconisait de camper sur cette position73. Virginia Berridge estime que le tournant des années soixante fut marqué par un véritable bouleversement dans la politique du gouvernement en matière de campagne d’information de santé préventive (health education) : The late 1950s and early 1960s saw a reorientation of that wartime stance on the part of government: citizens who would act responsibly if given ‘the facts’ were replaced by consumers of harmful substances who needed to be persuaded about risk74. 24 Ce profond changement dans la politique gouvernementale visait à réconcilier deux positions antinomiques : laisser l’individu libre et responsable de ses actes ou lui imposer des choix de vie. Les comptes rendus des réunions du Cabinet soulignent bien ce dilemme dans la stratégie du gouvernement. Alors qu’il était question que ce dernier prenne des mesures afin de réduire, par exemple, la consommation de tabac et la mortalité liée au cancer du poumon, les ministres se demandaient s’il n’était pas préférable une fois les faits connus de laisser la décision finale au jugement des individus75 pour éviter d’être accusé « d’attitude paternaliste sur la question » 76. Dans son arbitrage final, Enoch Powell prit en compte les considérations économiques et sanitaires ainsi que ses idées libérales sur le rôle de l’État et celui de l’individu dans la société77.

25 En avril 1959, le Royal College of Physicians, qui avait d’abord refusé cette initiative en novembre 1956 à cause de son ancien Président Lord Brain, décida de former une commission présidée par Robert Platt, dont la mission serait de préparer un rapport visant à établir le lien entre consommation de cigarettes et cancer des poumons. Cette commission publia ainsi un rapport le 6 mars 196278, lequel confirmait bien que la cigarette provoquait ce cancer-là. Ce rapport soulignait en grande partie le rôle des médias et le consumérisme et préconisait la restriction, voire l’interdiction, de la

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publicité sur la vente de cigarettes après l’active contribution de Jerry Morris au sein de la commission, lequel avait montré que la publicité jouait un rôle indéniable dans l’augmentation des ventes de cigarettes79. Le Cabinet considérait la possibilité d’imposer des restrictions sur les publicités pour le tabac, mais reconnaissait que cela entraînerait de « sérieuses difficultés » dans sa mise en application80. Fallait-il recourir à la loi81, ou encourager les grandes firmes de l’industrie du tabac à limiter leurs spots publicitaires ?82 En dernier ressort, cela pourrait impliquer également que le gouvernement interdise ce genre de publicité dans la presse écrite83. Certaines grandes firmes de l’industrie du tabac décidèrent de limiter leurs spots publicitaires, en ne demandant plus de diffusion après 21h et aux heures de grande audience par les enfants84. L’une d’elle, Imperial, estimait, d’une part, que cette initiative volontaire permettrait de réduire son budget publicité de 50% et que, de l’autre, elle éviterait au gouvernement d’imposer une interdiction totale85. 26 Après de nombreuses réunions et de multiples débats, Enoch Powell décida de rejeter tout projet de loi visant à interdire la publicité de ventes de cigarettes à la télévision86. Sa décision fut entérinée par le Cabinet le 26 novembre 1962,87 même s’il essuya de nombreuses critiques par la suite88. Plusieurs raisons peuvent expliquer son refus, en dépit des dangers que la cigarette représentait pour la santé. Tout d’abord, si une interdiction sur la publicité de ventes de cigarettes à la télévision ou dans la presse écrite avait été imposée, le gouvernement aurait ouvert la boite de Pandore. En effet, Enid Russell Smith, haut fonctionnaire au ministère de la Santé, pensait que, si ce rôle incombait au gouvernement, alors la situation ne s’arrêterait pas au problème de la cigarette. L’État devrait par conséquent légiférer sur tout ce qui pourrait nuire à la santé, comme l’alcool par exemple, et deviendrait ainsi un État gendarme89. Selon Godber qui ne partageait pas le point de vue du ministre de la Santé, Powell avait fait primer l’argument politique et libéral sur celui de la santé publique des individus. Il expliquait ainsi, se plaçant dans un contexte imaginaire où le tabac ne serait pas en vente libre, que si on devait autoriser la vente du tabac, il serait illogique d’en interdire la publicité90. 27 L’argument économique importait beaucoup à Powell qui ne voulait pas entrer en conflit avec le Trésor. La vente de cigarettes générait en effet des recettes non négligeables pour le gouvernement en raison de la TVA sur le tabac. Quelques années plus tard (en 1975), Powell revint sur les raisons qui l’avaient poussé à s’opposer à cette interdiction91. Il pensait que le gouvernement ne voulait pas avoir à réorganiser son système d’impôts indirects. Il serait tout aussi absurde pour un gouvernement de légiférer contre une forme de comportement commun et largement répandu : en soi, être fumeur ne représentait en rien un comportement marginal et dangereux pour autrui92. Powell avait donc appliqué ses croyances libérales à un domaine qui, pour l’époque, pouvait paraître secondaire, si l’on considère que la commission sur la santé et le tabac envisageait bien d’autres solutions pour faire baisser la consommation de ce dernier, telles que son interdiction dans les lieux publics, l’augmentation des impôts indirects ou la prolifération des campagnes de prévention au sein des établissements scolaires93.

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La fluoration de l’eau : un libre choix ?

28 Ce fut avec un certain enthousiasme que le ministère de la Santé avait accueilli dans les années 1950 la proposition visant à fluorer l’eau, puisque cette mesure prophylactique, consistant simplement à ajouter du fluor dans l’eau potable, pouvait prévenir le risque carieux et ainsi permettre de réaliser des économies non négligeables sur le coût des traitements dentaires94. Ainsi, il nomma en 1956 une commission afin qu’elle détermine si la fluoration de l’eau ne présentait aucun danger pour la santé. La possibilité d’une telle initiative suscita une vive opposition de la part de différentes organisations, telles que la British Housewives League, la London Anti-Fluoridation Campaign et surtout la National Pure Water Association95, qui martelaient avec force que la municipalité devait fournir de l’eau « pure et saine »96. Alors que le ministre de la Santé avait été chargé de préparer un projet de loi visant à autoriser les collectivités locales à procéder légalement à la fluoration de leur eau, après des signes favorables de l’Organisation Mondiale de la Santé et des études scientifiques encourageantes97, la Commission des affaires sociales choisit de reporter sa mise en place afin d’éviter une controverse avant les élections législatives. L’objectif financier de la mesure primait sur les avantages de santé publique, car il était clairement question pour les Conservateurs de diminuer le coût des traitements dentaires. Le problème à résoudre serait d’instaurer une loi lorsque des poursuites judiciaires seraient déjà lancées contre une collectivité locale ayant déjà ajouté illégalement du fluor dans ses réserves d’eau municipale98, comme celles d’Andover et de Watford qui avaient défrayé la chronique. De nombreuses questions importantes, laissées ainsi en suspens, allaient restreindre la marge de manœuvre de Powell. Conscient de ces enjeux, il affirma : There is a good deal of popular misconception about ministers and policy decisions. I think a large section of the public imagines the competent minister bustling into his office on a Monday morning with a neatly written list of the new policies which he is going to put into force. In real life nearly all policy decisions emerge out of an existing situation. (…) This is even true in the extreme instance of a new government moving in after a decisive General Election in which they’ve defeated their opponents. They would still find most of the decisions they were taking had arisen out of a pre-existing situation99. 29 Enoch Powell hérita donc d’un dossier très controversé où plusieurs arguments étaient mis en avant pour condamner toute tentative d’imposer une fluoration obligatoire des eaux municipales. La motivation première du Cabinet était économique, dans une perspective de médecine préventive : elle permettrait de lutter contre la carie, alors considérée comme un véritable fléau, et ainsi d’éviter à moindre coût de futurs traitements dentaires. Charles Webster justifie le bien-fondé de cette initiative de l’État en ces mots : « The latter represented one of the simplest, most effective, and most economical measures capable of being applied in the field of preventive medicine »100. Powell soutenait la mesure et affirma lors d’une réunion du Cabinet : « There was no doubt that the addition of fluoride to drinking water would greatly reduce decay in the teeth of children, that it would have no harmful side-effects »101.

30 En 1962, un rapport fut publié s’appuyant sur les conclusions univoques de trois enquêtes pilotes menées sur des eaux fluorées : la fluoration de l’eau avait permis de réduire le risque de caries chez les enfants sans aucun danger observé pour leur santé 102. Ainsi, ces résultats scientifiques vinrent corroborer les dires de Powell, chargé de préparer un projet de loi. Puisque ce dernier était également très sensible à la question

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des libertés individuelles dans une société libérale, il imagina un plan ingénieux pour mettre en place la fluoration de l’eau, qui éviterait au gouvernement d’être accusé d’imposer une décision touchant directement toute la population. Il défendit son projet de loi à la Chambre des Communes en décembre 1962, qui consistait seulement en des mesures limitées visant à encourager la fluoration de l’eau. En s’appuyant sur l’article 28 de la loi sur le NHS de 1946, Powell offrait en effet la possibilité aux collectivités locales de soumettre une proposition à l’État visant à fluorer leur eau sous le régime existant du NHS, lequel les protégerait en cas de poursuites judiciaires éventuelles. Cette mesure s’apparentait en fait à une certaine forme de décentralisation, mais toujours sous l’égide du Cabinet qui en gardait le contrôle. Les résultats de cette politique furent cependant très limités, puisque, à court terme, seulement huit collectivités locales sur 1800 avaient soumis une demande au gouvernement en avril 1963103. À long terme, Charles Webster indique qu’en 1979, seulement 10% des eaux municipales contenaient du fluor ajouté, en raison d’une forte et constante opposition des lobbys104. Les conseillers politiques de Macmillan accusèrent Powell d’avoir très mal géré ce dossier. 31 Les lobbys s’opposèrent à la mesure de Powell en évoquant une raison éthique et morale, comme par exemple la National Pure Water Association105. Cette dernière contestait le bienfondé et la validité médicale de cette mesure et soulevait une question cruciale : quelle était la justification morale pour que chaque conseiller municipal oblige la population à ingurgiter une telle substance, potentiellement nocive qui plus est. Ce fut cet argument qui retint l’attention de Powell, qui laissa deux accolades à côté du point 5 de la circulaire : Fluoridation infringes a fundamental human right which, in a free society, should be inalienable (viz: the right to decide, for ourselves, what substances intended to affect the development of our bodies shall go into our bodies)106. 32 Les individus pouvaient en effet librement décider de recourir à des comprimés de fluor après le brossage des dents ou ajouter du fluor en poudre pendant le brossage, comme le rappela en 1961 Sir Stanton Hicks, professeur émérite en physiologie humaine et pharmacologie de l’Université d’Adélaïde107. Selon A. E. Joll, la fluoration forcée des eaux sans le consentement des individus était assimilable à une pratique qui a toujours été perçue dans notre pays comme typique des régimes totalitaires108. Ce fut également la référence au régime soviétique, que Powell avait en horreur, en raison de la perte affichée des libertés individuelles dans un État communiste, qui retint son attention et qu’il marqua d’une double accolade dans la circulaire. Sa conception d’une société libérale avait été influencée par The Constitution of Liberty, écrit par F. V. Hayek en 1960. La cohérence du Powellisme allait être mise à mal dans plusieurs lettres privées que reçut Powell en 1964, alors qu’il venait d’affirmer que le Parti conservateur était le parti du libre choix, de la libre concurrence et de l’entreprise privée. L’une de ces missives souligne assez clairement la faille de sa vision : When you were Minister of Health you recommended all local Authorities to add sodium fluoride to the drinking water and it was left to them to decide for or against fluoridation and not to the individual citizen. In view of this it certainly seems strange and out of place for you to speak of ‘free choice’109. 33 Robert Shepherd note que Powell fut en définitive frustré de ne pas avoir réussi à régler cette question controversée et de ne pas avoir bien légiféré pour régler le problème110. Il avait opté pour une solution intermédiaire, qui ne produisit pas les effets

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économiques escomptés et qui allait fournir une arme à ses détracteurs, désireux de remettre en cause son projet libéral d’une société libérale tory.

Conclusion

34 Après son passage au ministère de la Santé, Powell laissa une empreinte durable tant il avait mis en œuvre différentes mesures visant à rationaliser, moderniser et humaniser le NHS. Manson estimait que son objectif global fut « de mettre une note de rationalité capitaliste dans le NHS »111. Les actions de Powell révèlent un double impératif dans sa conception du NHS. Il pensait, d’une part, à l’intérêt collectif et il était donc primordial, à ses yeux, d’assurer aux patients l’égalité de l’accès aux soins dans des hôpitaux modernisés et humanisés. Il légitimait ainsi une ingérence étatique positive, puisque seul l’État pouvait décider de la construction d’un hôpital pour le bien collectif, à condition de responsabiliser ensuite les patients qui devaient prendre conscience que les ressources du NHS n’étaient pas illimitées. D’autre part, il défendait une vision publique du NHS tout en remettant le bénévolat au cœur du système et en encourageant dans une certaine mesure les canaux privés112. Son objectif d’humanisation du système public répondait aux exigences de la démarche disraélienne, qui avait fait de la santé publique un de ses grands objectifs en 1872.

35 Son expérience en tant que ministre de la Santé lui permit entre autres de confronter les sacrosaints principes de liberté individuelle et de choix avec le pouvoir puissant de la force étatique parfois nécessaire pour améliorer une situation. T. E. Utley113 avait toutefois rencontré à l’époque des difficultés à rendre compte de l’adéquation entre les actions de Powell à ce ministère et sa philosophie libérale qui se dessinait sous l’étiquette du Powellisme : The task was to administer this service as efficiently as possible. It would continue to exhibit the defects of a monopoly. (...) Powell has never wholly expelled from his mind the proposition that, if life is not to be controlled by the interplay of market forces, it will be better controlled by strong than by weak government114. 36 Cet article a tenté de rendre compte, par le biais de l’étude de l’industrie pharmaceutique, de la publicité sur le tabac et la fluoration de l’eau, des choix de Powell, toujours influencé par l’œuvre libérale de F. V. Hayek – le chantre du libre choix et de la liberté individuelle.

37 Par ailleurs, Powell fut la cible de critiques libérales, qui lui reprochèrent de ne pas avoir assez développé le système privé de santé. Il ne parvint pas en effet à garantir la gratuité des médicaments pour les patients du secteur privé, qui ne furent pas encouragés à aller consulter des médecins hors du cadre du NHS. Ainsi, Rudolf Klein écrit : « Denied the opportunity to exit from a service with a near-monopoly of employment for health care professionals, they engaged in voice in the NHS, i.e. the politics of protest »115. Cependant, le Parti conservateur semble avoir voulu protéger un NHS public et intervenir dans le domaine de la santé publique jusqu’à la fin des années 1980. Quant à l’opinion publique, elle a toujours été encline à soutenir un système de soins gratuits, peu importe les orientations politiques. Ce climat rendait donc compliqué un changement de philosophie avant les années Thatcher. 38 À la suite du passage de Powell au ministère de la Santé, les années 1960 furent aussi marquées par un autre débat sur la nature du NHS116 qui se posait en ces termes: « Was the problem one of constraining the demands made by consumers of health care or of

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restraining the demand generated by the producers of health care? ». Ce questionnement allait de nouveau être l’occasion pour une confrontation entre les théoriciens des forces du marché et les défenseurs du système public de santé. Powell avait déjà clairement mis le doigt sur ce problème de manière pessimiste : il semblait impossible de restreindre la demande des usagers. Richard Crossman, secrétaire d’État travailliste des services sociaux en 1969, formulait le même diagnostic pessimiste, légitimant quelque peu la thèse des théoriciens du secteur privé : « The trouble is that there is no foreseeable limit on the social services which the nation can reasonably require except the limit that the Government imposes »117. 39 Stéphane Porion, agrégé d’anglais, Maitre de Conférences en civilisation britannique à l’Université de Tours, a rédigé son doctorat sur les idées politiques et économiques d’Enoch Powell de 1946 à 1968. Il a beaucoup publié sur cet homme politique et récemment codirigé un ouvrage avec Olivier Esteves, publié chez Routledge en mai 2019 et intitulé The Lives and Afterlives of Enoch Powell: The Undying Political Animal. Ses travaux portent également sur le Parti conservateur britannique depuis 1945, ainsi que sur les droites radicales depuis 1967.

BIBLIOGRAPHIE

Sources primaires

Archives

National Archives (London)

- Prime Minister's Office records

NA, PRO PREM 11/3741, PREM 11/5203, PREM 11/3438

- Treasury records

NA, PRO, T227/1383

- Cabinet and its Committees records

NA, PRO CAB 129/104, C(61), 155, CAB 134/1976, CAB 128/36, CC(62)19, CAB 128/36, CC(62)46, CAB 130/185, GEN.762/1, CAB 130/185, GEN.763/1, CAB 128/36, CC(62)19, CAB 130/185, GEN. 763/13, CAB 21/4878, CAB 130/185, GEN.763/16, CAB 134/1972, CAB 134/1974, CAB 134/1975, CAB 128/36, CC(62)73,

- Public Health

NA, PRO MH 55/2227, PRO MH 55/2204,

Churchill Archives Centre (Cambridge)

POLL 4/1/1, File 5, POLL 4/1/27, File 1, POLL 1/1/13, POLL 4/1/1, File 6, POLL 3/1/30, Powell Papers.

London School of Economics Archives (London)

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BOAPAH, 1980, LSE Library Archives and Special Collections.

Publiées

Aneurin Bevan, In Place of Fear (Londres, Quartet, 1978).

Rex Collings (ed.), Reflections of a Statesman (Londres, Bellew, 1991).

Enoch Powell, A New Look at Medicine and Politics (Londres, Pitman Medical, 1966).

Enoch Powell, ‘The Limits to Laissez-Faire’, Crossbow, vol.3 no.11, printemps 1960, pp. 25-28.

Enoch Powell, ‘My Years as Health Minister’, The Spectator, 20 février 1988, pp. 8-10.

John Wood (ed.), A Nation Not Afraid (Londres, Batsford, 1965).

Sources secondaires

Nicholas Barr, The Economics of the Welfare State (Oxford, OUP, 1993).

Virginia Berridge, Health and Society in Britain since 1939 (Cambridge, CUP, 1999).

V. Berridge, ‘Medecine and the Public: the 1962 Report of the Royal College of Physicians and the New Public Health’, Bulletin of the History of Medecine, 2007 Spring; 81(1), pp. 286–311, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1894742 [Dernière consultation le 17 juillet 2008].

Paul Bridgen & Rodney Lowe, Welfare Policy Under the Conservatives (1951-1964) (Kew, London Public Record Office Publications, 1998).

Tony Cutler, ‘Economic Liberal or Arch Planner? Enoch Powell and the Political Economy of the Hospital Plan’, Contemporary British History, vol. 25, n° 4, 2011, pp. 469-489.

Howard Glennerster, British Social Policy since 1945 (Oxford, Blackwell, 2000).

Simon Heffer, Like the Roman: The Life of Enoch Powell (Londres, Phoenix, 1999).

Ian Holliday, The NHS Transformed (Manchester, Baseline Book Company, 1995).

Norman Hunt (ed.), WhiteHall and Beyond, Jo Grimmond, Enoch Powell, (Three Conversations with Norman Hunt) (Londres, BBC, 1964).

Brian Inglis, Drugs, Doctors and Disease (Londres, André Deutsch, 1965).

Rudolf Klein, The New Politics of the NHS (Harlow, Pearson Education, 2001).

Rodney Lowe, The Welfare State in Britain since 1945 (Basingstoke: Macmillan, 1999).

John Mohan, Planning, Markets and Hospitals (Londres, Routledge, 2002)

John Mohan, “Milburn, Powell and Hayek: For and Against Planning in the NHS”, Journal of Health Services Research and Policy, 9 (1), 2004, pp. 54-56.

Stéphane Porion, « ‘A Local Difficulty’? Enoch Powell’s Secret Motivation to Resign from the Treasury in 1958 and its Aftermath », in Fabienne Portier- Le Cocq, Secret and Lies in the United Kingdom: Analysis of Political Corruption (Washington DC, Westphalia Press, 2017), pp. 47-73.

Timothy Raison, Tories and the Welfare State: A History of Conservative Social Policy since the Second World War (Basingstoke, Macmillan, 1990).

G. Rivett, From Cradle to Grave, Fifty Years of the NHS (Londres, King’s Fund, 1998).

Robert Shepherd, Enoch Powell: A Biography (Londres, Pimlico, 1997).

Neil Small, Politics and Planning in the NHS (Miltonkeynes, Open University Press, 1989).

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N. Timmins, The Five Giants, A Biography of the Welfare State (Londres, William Collins, 2017).

T. E. Utley, Enoch Powell: The Man and his Thinking (Londres, William Kimber, 1968).

Brian Watkin, The National Health Service: The First Phase 1948-1974 and After (Londres, George Allen & Unwin, 1978).

Charles Webster, ‘Conservatives and Consensus: The Politics of the National Health Service, 1951-1964’, in Ann Oakley & A. Susan Williams (eds.), The Politics of the Welfare State (Londres, UCL, 1994), pp. 54-74.

Charles Webster, The National Health Service: A Political History (Oxford, OUP, 2002).

Presse spécialisée

British Medical Journal

J. Seale, ‘The Health Service in an Affluent Society’, British Medical Journal, 1er septembre 1962, pp. 598-602.

‘The Minister of Health’, British Medical Journal, 26 octobre 1963, p. 1012.

‘Is there an Alternative? Medicine and Politics’, British Medical Journal, 4 mars 1967, pp. 555-559.

Webographie http://www.econ.yale.edu/~nordhaus/homepage/homepage/PASandGPG.pdf (site consulté le 2 février 2019). https://aheblog.com/2017/03/07/kenneth-arrow-on-healthcare-economics-a-21st-century- appreciation/ (site consulté le 2 février 2019).

NOTES

1. Aneurin Bevan, In Place of Fear (Londres, Quartet, 1978), p. 109. 2. Ibid., p. 100. 3. Rodney Lowe, The Welfare State in Britain since 1945 (Basingstoke: Macmillan, 1999), p. 195. 4. Charles Webster, ‘Conservatives and Consensus: The Politics of the National Health Service, 1951-1964’, in Ann Oakley & A. Susan Williams (eds.), The Politics of the Welfare State ( Londres, UCL, 1994), p. 56; Rudolf Klein, The New Politics of the NHS (Harlow, Pearson Education, 2001), p. 51. 5. Paul Bridgen & Rodney Lowe, Welfare Policy under the Conservatives (1951-1964) (Kew, London Public Record Office Publications, 1998), p. 62; Rodney Lowe, The Welfare State in Britain since 1945, p. 187; Howard Glennerster, British Social Policy since 1945 (Oxford, Blackwell, 2000), p. 81. 6. Nicholas Timmins, The Five Giants: A Biography of the Welfare State (Londres, Harper Collins, 2017), p. 208. 7. Enoch Powell, A New Look at Medicine and Politics (Londres, Pitman Medical, 1966), pp. 6-7. 8. Ibid., pp. 14-15. Voir également NA, PRO PREM 11/3741, B. Trend minute, 22 décembre 1958. 9. Robert Shepherd, Enoch Powell: A Biography (Londres, Pimlico, 1997), p. 210. 10. Stéphane Porion, « ‘A Local Difficulty’? Enoch Powell’s Secret Motivation to Resign from the Treasury in 1958 and its Aftermath », in Fabienne Portier- Le Cocq, Secret and Lies in the United Kingdom: Analysis of Political Corruption (Washington DC, Westphalia Press, 2017), pp. 47-73. 11. Charles Webster, ‘Conservatives and Consensus’, p. 63. 12. Enoch Powell, A New Look at Medicine and Politics, p. 2.

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13. Enoch Powell, Discours au Congrès annuel du Parti conservateur, 7 octobre 1963, p. 61, POLL 4/1/1, File 5, Powell Papers. 14. Enoch Powell, ‘Humanisation of Hospital Service – Minister of Health Review’, 19 octobre 1962, pp. 1-5, POLL 4/1/1, File 5, Powell Papers. 15. Robert Shepherd, Enoch Powell: A Biography, pp. 204-243; S. Heffer, Like the Roman: The Life of Enoch Powell (Londres, Phoenix, 1999), pp. 266-318. 16. Ian Holliday, The NHS Transformed (Manchester, Baseline Book Company, 1995), p. 9. 17. Brian Watkin, The National Health Service: The First Phase 1948-1974 and After (Londres, George Allen & Unwin, 1978), pp. 118-119. 18. Virginia Berridge, Health and Society in Britain since 1939 (Cambridge, CUP, 1999), p. 26. 19. Charles Webster, The National Health Service: A Political History (Oxford, OUP, 2002), p. 36. 20. Tony Cutler, ‘Economic Liberal or Arch Planner? Enoch Powell and the Political Economy of the Hospital Plan’, Contemporary British History, vol. 25, n° 4, 2011, pp. 469-489. 21. Paul Bridgen & Rodney Lowe, Welfare Policy under the Conservatives (1951-1964), pp. 56-61. 22. Brendon Sewill cité dans Timothy Raison, Tories and the Welfare State: A History of Conservative Social Policy since the Second World War (Basingstoke, Macmillan, 1990), p. 48. 23. Ibid., p. 49. 24. Ibid., p. 50. 25. Ibid., pp. 50 & 51. 26. Charles Webster, The National Health Service: A Political History (Oxford, OUP, 2002), p. 36. 27. Ibid. 28. Enoch Powell, A New Look at Medicine and Politics, p. 68. 29. Enoch Powell, ‘The Limits to Laissez-Faire’, Crossbow, vol.3 no.11, printemps 1960, p. 25. 30. Ibid., p. 26. 31. Voir par exemple: http://www.econ.yale.edu/~nordhaus/homepage/homepage/ PASandGPG.pdf (site consulté le 2 février 2019). 32. Voir par exemple : https://aheblog.com/2017/03/07/kenneth-arrow-on-healthcare- economics-a-21st-century-appreciation/ (site consulté le 2 février 2019). 33. Ibid. 34. Ibid. 35. Ibid. 36. BOAPAH, 1980, p. 15, LSE Library Archives and Special Collections. 37. Transcription du débat entre Powell et le Dr. Henry Miller, « A New Look at Medicine », Third Programme, 1er décembre 1966, p. 2, POLL 4/1/27, File 1, Powell Papers; ‘Is there an Alternative? Medicine and Politics’, British Medical Journal, 4 mars 1967, pp. 555-559. 38. Ibid., p. 14. 39. Ibid., p. 16. 40. Nicholas Barr, The Economics of the Welfare State (Oxford, OUP, 1993), p. 433. 41. Enoch Powell, ‘Social Services’, The Times Health Supplement, 13 novembre 1981, in Rex Collings (ed.), Reflections of a Statesman (Londres, Bellew, 1991), p. 582. 42. Enoch Powell, ‘My Years as Health Minister’, The Spectator, 20 février 1988, p. 9. 43. Ibid. 44. Ibid. 45. Neil Small, Politics and Planning in the NHS (Miltonkeynes, Open University Press, 1989), p. 11. 46. Enoch Powell et Dr. Henry Miller, ‘A New Look at Medecine’, pp. 2, 3 & 16. 47. . ‘The Minister of Health’, British Medical Journal, 26 octobre 1963, p. 1012; N. Timmins, The Five Giants, A Biography of the Welfare State (Londres, William Collins, 2017), p. 208; G. Rivett, From Cradle to Grave, Fifty Years of the NHS (Londres, King’s Fund, 1998), p. 132. 48. Enoch Powell, A New Look at Medicine and Politics, p. 14. 49. Ibid., p. 16.

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50. Robert Shepherd, Enoch Powell: A Biography, p. 218. Voir aussi NA, PRO, T227/1383 et Enoch Powell et Dr. Henry Miller, ‘A New Look at Medecine’, pp. 15-16. 51. Powell changea d’avis quant à l’efficacité de mettre en place le PESC en 1961. Il écrivit d’abord un plaidoyer contre cette idée le 16 septembre 1961, puis changea vraisemblablement d’avis en octobre 1961, après avoir reçu une réponse du Trésor le 27 septembre 1961. POLL 1/1/13, Powell Papers. 52. Powell rédigea par exemple une note pour le Premier Ministre, dans laquelle il montra sa détermination à contenir les revendications de hausse salariale des infirmières selon l’objectif de 2,5% fixé par le Trésor. Lettre de Powell à Macmillan, 10 avril 1962, §8, p. 3, NA, PRO PREM 11/5203. 53. Enoch Powell, A New Look at Medicine and Politics, p. 73. 54. NA, PRO PREM 11/3438, lettre de Macmillan à Powell, 1er août 1960. 55. Robert Shepherd, Enoch Powell: A Biography, p. 235. 56. Enoch Powell, ‘Cost of NHS Drugs – Health Minister on Relations with Industry’, 26 avril 1961, p. 1, POLL 4/1/1, File 6, Powell Papers. 57. Brian Inglis, Drugs, Doctors and Disease (Londres, André Deutsch, 1965), pp. 11-12. 58. Voir NA, PRO CAB 129/104, C(61), 155, ‘National Health Service : The Drug Bill – Memorandum by the Minister of Health’, 6 octobre 1961. 59. Enoch Powell, A New Look at Medicine and Politics, p. 64. 60. Brian Inglis, Drugs, Doctors and Disease, p. 9. 61. Medical News, 8 mai 1964, in ibid., p. 30. 62. Ibid. 63. Ibid., p. 199. 64. Enoch Powell, A New Look at Politics and Medicine, p. 64. 65. Enoch Powell, ‘Cost of NHS Drugs – Health Minister on Relations with Industry’, p. 1. 66. Ibid., p. 57. 67. Enoch Powell, A New Look at Politics and Medicine, pp. 65-66. 68. Enoch Powell confia plus tard qu’il n’avait pas ressenti le besoin de se faire aider par un homme d’affaires et avait mené les négociations seul, car cette décision relevait de la responsabilité et de la transparence publiques vis-à-vis du Parlement et non des compétences du privé. Voir Norman Hunt (ed.), WhiteHall and Beyond, Jo Grimmond, Enoch Powell, Harold Wilson (Three Conversations with Norman Hunt) (Londres, BBC, 1964), p. 55. 69. The Times, 18 mai 1961, in Robert Shepherd, Enoch Powell: A Biography, p. 236. 70. Brian Inglis, Drugs, Doctors and Disease, p. 9. 71. Ibid., pp. 10-11 ; Enoch Powell, A New Look at Politics and Medicine, p. 66. 72. Ibid. 73. NA, PRO CAB 134/1976, ‘5e reunion du Home Affairs Committee’, 20 mars 1959, p. 7. 74. V. Berridge, ‘Medecine and the Public: the 1962 Report of the Royal College of Physicians and the New Public Health’, Bulletin of the History of Medecine, 2007 Spring; 81(1), p. 2. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1894742 [Dernière consultation le 17 juillet 2008]. 75. NA, PRO CAB 128/36, CC(62)19, 6 mars 1962, p. 6. 76. NA, PRO CAB 128/36, CC(62)46, 12 juillet 1962, p. 3. 77. Voir par example, John Mohan, “Milburn, Powell and Hayek: For and Against Planning in the NHS”, Journal of Health Services Research and Policy, 9 (1), 2004, pp. 54-56. 78. NA, PRO CAB 130/185, GEN.762/1, ‘Réunion du comité sur la santé et le tabac’, 28 février 1962, p. 1. 79. V. Berridge, ‘Medecine and the Public’, pp. 7-8. 80. NA, PRO CAB 130/185, GEN.762/1, ‘Réunion du comité sur la santé et le tabac’, p. 1.

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81. NA, PRO CAB 130/185, GEN.763/1, ‘Réunion du comité sur la santé et le tabac’, 23 mars 1962, p. 3; NA, PRO CAB 128/36, CC(62)19, 6 mars 1962, p. 5. 82. NA, PRO CAB 130/185, GEN.763/13, ‘Réunion du comité sur la santé et le tabac’, 15 mai 1962, p. 9. 83. Ibid. 84. Ibid; NA, PRO CAB 21/4878, Lettre du Lord President au Premier Ministre, 25 juillet 1962. 85. V. Berridge, ‘Medecine and the Public’, p. 12. 86. NA, PRO MH 55/2227, ‘Note de service d’Enoch Powell’, 11 novembre 1962. 87. NA, PRO CAB 130/185, GEN.763/16, ‘Note de service du ministre de la Santé’, 26 novembre 1962, p. 1. 88. Robert Shepherd, Enoch Powell: A Biography, p. 233. 89. NA, PRO MH 55/2204, ‘Note de service d’Enid Russell Smith’, 5 février 1962. Ce point de vue est corroboré par toute la commission sur la santé et le tabac. Voir NA, PRO CAB 130/185, GEN. 763/13, ‘Réunion du comité sur la santé et le tabac’, 15 mai 1962, p. 9. 90. Godber cité dans Simon Heffer, Like the Roman, p. 293. Godber ajouta que ce fut le gouvernement travailliste de Wilson qui interdit les publicités de ventes de cigarettes à la télévision en 1965. 91. V Berridge, ‘Medecine and the Public’, p. 13. 92. Il faut considérer qu’à l’époque, l’effet nocif du tabagisme passif n’était pas d’actualité. 93. NA, PRO CAB 130/185, GEN.763/13, ‘Réunion du comité sur la santé et le tabac’, 15 mai 1962, pp. 9-13. 94. Voir NA, PRO CAB 134/1972, CAB 134/1974 et CAB 134/1975. 95. Ibid. 96. NA, PRO CAB 128/36, CC(62)73, 6 décembre 1962, p. 11. 97. Il est précisé dans la 19e réunion du Home Affairs Committee que les résultats scientifiques de cet ajout ne seraient sûrement publiés qu’en 1961. Voir NA, PRO CAB 134/1976, ‘19e réunion du Home Affairs Committee’, 6 novembre 1959, p. 8. 98. Voir Ibid et NA, PRO CAB 134/1976, ‘11e réunion du Home Affairs Committee’, 3 juillet 1959, p. 3. 99. Norman Hunt (ed.), Whitehall and Beyond, p. 45. 100. Charles Webster, The National Health Service, A Political History, p. 129. 101. NA, PRO CAB 128/36, CC (62) 73, p. 11. 102. Ministry of Health, The Conduct of the Fluoridation Studies in the UK and the Results Achieved after Five Years (Londres, HMSO, 1962). 103. Robert Shepherd, Enoch Powell: A Biography, p. 232. 104. Charles Webster, The National Health Service, A Political History, p. 129. 105. The National Pure Water Association, ‘Fluoridation of Public Water Supplies, The Primary Question of Principal’, [n.d.], POLL 3/1/30, Powell Papers. 106. Ibid. 107. Sir Stanton Hicks cité dans A. E. Joll, Lettre à l’éditeur, reproduite dans The Lancet, 8 février 1964, p. 326, POLL 3/1/30, Powell Papers. 108. Ibid. 109. Lettre de E. T. Forrest (Southampton) à Enoch Powell, 6 avril 1964, POLL 3/1/30, Powell Papers. 110. Robert Shepherd, Enoch Powell: A Biography, p. 232. 111. Manson cité dans John Mohan, Planning, Markets and Hospitals (Londres, Routledge, 2002) p. 111. 112. E. Powell, ‘Discours à Crewkerne’, 20 septembre 1963, in John Wood (ed.), A Nation Not Afraid (Londres, Batsford, 1965), p. 44. 113. Ce fut le premier à écrire un ouvrage sur le Powellisme en 1968. 114. T. E. Utley, Enoch Powell:The Man and his Thinking (Londres, William Kimber, 1968) pp. 78-79.

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115. Rudolf Klein, The New Politics of the NHS, p. 53. 116. British Medical Journal, 26 novembre 1966, pp. 1315-1319; J. Seale, ‘The Health Service in an Affluent Society’, British Medical Journal, 1er septembre 1962, pp. 598-602. 117. R Crossman, Paying for the Social Services (Londres, Fabian Society, 1969), in Rudolf Klein, The New Politics of the NHS, p. 55.

RÉSUMÉS

Enoch Powell fut nommé ministre de la Santé en juillet 1960 par Harold Macmillan, puis élevé au rang de ministre du Cabinet en 1962. Calcul politique de la part du Premier ministre, qui ne portait pas Powell dans son cœur, visant à la fois à l’empêcher de critiquer le gouvernement avec son credo libéral pendant les années de la mise en œuvre de la Middle Way et à le mettre en difficulté à la tête d’un ministère assez dispendieux. Powell tenta d’imprimer sa marque et de rompre avec les politiques de ses prédécesseurs : il s’agissait pour lui de rationaliser les dépenses de son ministère, tout en suivant un objectif de modernisation et d’humanisation du NHS par le biais de la mise en place d’un plan ambitieux de construction de nouveaux hôpitaux. Powell était convaincu que le NHS pouvait être modernisé et défendit une vision publique de ce dernier tout en encourageant les canaux privés. Cet article a pour objectif d’analyser l’approche iconoclaste de Powell en s’appuyant sur les archives nationales de Londres et celles de Powell détenues à Cambridge. Afin de compléter les analyses historiographiques, l’étude se penchera sur trois points (gestion powellienne des questions du coût des médicaments, de la publicité sur le tabac et de la fluoration de l’eau) afin de démontrer comment Powell dut gérer un autre dilemme que celui d’humaniser et rationnaliser en même temps le NHS : jusqu’à quel point était-il possible de défendre les idées de liberté et de choix dans un système public de santé où la puissance étatique était force motrice ?

Enoch Powell was appointed Minister of Health by Harold Macmillan in July 1960, before being promoted to the position of Cabinet Minister in 1962. This was seen as a political manoeuvre from a Prime Minister who was hardly well disposed towards Powell. He thus planned to both prevent him from attacking the government with his free market beliefs in the years of the implementation of the Middle Way and put him in a difficult position at the head of a costly department. Powell attempted to leave his mark on it and break with his predecessors’ policies: he intended to streamline NHS spending, while at the same time modernising and humanising the NHS through the introduction of an ambitious Hospital Plan. Powell was convinced that the NHS could be modernised. He believed that the latter should remain in the public domain but at the same time supported private health investment. This paper analyses Powell’s iconoclastic approach by using primary sources from Kew’s national archives and the Powell Papers from Cambridge. In order to enhance historiographical debates, the analysis will focus on three particular points: Powell’s handling of the cost of drugs, cigarette advertising and the fluoridation of water. These issues reveal an additional dilemma that Powell had to face: to what extent could freedom of choice be introduced into a public health service in which the State was the main driver?

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INDEX

Mots-clés : industrie pharmaceutique, publicité sur le tabac, Hayek, Disraeli, hôpitaux, fluoration de l’eau Keywords : pharmaceutical industry, cigarette advertising, Hayek, Disraeli, hospitals, fluoridation of water

AUTEUR

STÉPHANE PORION

Université de Tours

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Dévolution et politiques de santé en Écosse : un modèle de continuité et d'efficacité ? Devolution and Health Policy in Scotland: A Model for Sustainability and Efficiency?

Edwige Camp-Pietrain

Introduction

1 Si le National Health Service (NHS) fut créé en 1948, certains de ses principes étaient déjà appliqués en Écosse1. Sa branche écossaise (Scottish Health Service) fut placée sous l'autorité du Secrétaire d'État à l'Écosse, qui pouvait réclamer des aménagements des politiques britanniques. La dévolution du pouvoir devait permettre sa gestion par un gouvernement et un Parlement écossais. L'espoir d'amélioration, présent dès les projets des années soixante-dix, s'est amplifié en réaction aux politiques néolibérales de Margaret Thatcher et de John Major2. Or, les besoins étaient immenses, l'Écosse étant décrite comme la « malade » de l'Europe occidentale3, en raison de taux de mortalité élevés. Cela résultait du mode de vie (alimentation, consommation d'alcool et de tabac, manque d'exercice physique), aggravé, pour les personnes modestes, par les conditions de vie (emploi, revenu). S'est ensuite ajouté un vieillissement de la population.

2 Depuis l'avènement de la dévolution, en 1999, la santé constitue la préoccupation centrale des dirigeants écossais. Les gouvernements SNP d' (2007-2014) puis de ne se sont guère démarqués de leurs prédécesseurs, les coalitions travailliste/libéral-démocrate (dirigées par Jack McConnell à partir de 2001). Leurs choix politiques ont pu apparaître comme des modèles4. Même les Conservateurs, longtemps hostiles à la dévolution, ont dû s'adapter au consensus fréquent au Parlement de Holyrood.

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3 En 2018, lors des célébrations des 70 ans de NHS Scotland et des vingt ans du Scotland Act de 1998 portant création des institutions dévolues, cet article propose un état des lieux au regard des objectifs fixés par la Convention constitutionnelle qui conçut le projet de dévolution en 1995 : réformer l'organisation et le financement, instaurer des politiques distinctes, améliorer la santé5. Il s'agira de mettre en évidence, à partir de débats parlementaires, les spécificités écossaises dans un contexte assombri par les politiques britanniques d'austérité et par un Brexit rejeté par les Écossais lors du référendum de 2016.

La dévolution, moyen de préservation d'un service public de santé ?

4 Le NHS écossais, priorité budgétaire, est centré sur des structures publiques. La population porte néanmoins un regard critique sur sa gestion.

Une priorité financière

5 Le gouvernement SNP a consacré au NHS 43 % de son budget en 2016-2017, soit 12,9 milliards de livres6. Sur dix ans, la progression a atteint 38 %, ou 8 % en livres constantes. Les dépenses par habitant sont supérieures de près de 10 % à celles de l'Angleterre. L'écart se retrouve sur le terrain, à travers le nombre de médecins généralistes pour mille habitants (0,95 contre 0,75) ou le nombre de lits à l'hôpital7.

6 Cet avantage, dû à des facteurs sociaux (pauvreté relative) et géographiques (dispersion de la population), est aussi lié à une volonté politique. Dans les années soixante-dix, face à la percée du SNP indépendantiste, le gouvernement britannique conçut une formule (Barnett) garantissant la progression du budget écossais, indexée sur l'évolution des dépenses publiques pour l'Angleterre. La somme obtenue a été gérée en Écosse, d'abord par le Secrétaire d'État à l'Écosse, et, depuis 1999, par le gouvernement écossais, qui, libres de procéder à des arbitrages entre leurs domaines de compétences, ont privilégié la santé. Mais l'envolée des dépenses de santé sous Tony Blair a érodé l'avantage de l'Écosse (l'écart dans les dépenses par habitant atteignant auparavant 20 %). Ensuite, les politiques d'austérité de David Cameron ont entraîné une moindre progression. Ainsi, en 2017-2018, la hausse de 1,5 % du budget écossais de santé correspond à une baisse de 0,1 %. Le gouvernement SNP dénonce les attaques de « Londres », tandis que ses adversaires conservateurs fustigent sa gestion, les Travaillistes déplorant les coupes infligées aux collectivités territoriales8. Ces tensions ne devraient pas fléchir car le Scotland Act de 2016 a doté les institutions écossaises de pouvoirs fiscaux substantiels qui imposeront des arbitrages entre impôts et dépenses.

Les health boards au cœur du système

7 Le gouvernement écossais alloue la quasi-totalité de ce budget aux 14 health boards régionaux, selon une formule qui tient compte du profil démographique et socio- économique de leur bassin de population. Il veille à l'équilibre et sanctionne les manquements9. À la fin de 2018, face à la dégradation de leurs bilans, il a annoncé la prise en charge de leurs dettes, tout en assouplissant les exigences comptables10.

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8 Or, ces health boards sont au cœur du système depuis la loi de 1972 qui intégra les structures existantes11. Leur mise en concurrence sous les gouvernements conservateurs, peu appréciée, fut de courte durée12. Dès 1998, le gouvernement Blair restaura leur rôle en matière de stratégie, affaiblit les trusts, tandis que les médecins généralistes, peu désireux de gérer leurs budgets, furent incités à former des coopératives locales13. En 2004, la coalition de McConnell supprima les trusts et proscrivit les hôpitaux publics autonomes (foundation trusts), créés en Angleterre. Après avoir retrouvé une place centrale, les health boards ont dû se rapprocher des collectivités territoriales chargées de l'aide sociale, sous forme de community health partnerships et d'autorités « intégrées » en 2016. Celles-ci reçoivent 45 % du budget des health boards pour financer les services délégués, notamment les « soins primaires » autour des médecins généralistes. Il s'agit de réduire les séjours à l'hôpital afin de libérer des lits (dans les 14 jours suivant l'autorisation médicale)14. 9 Le secteur privé suscite une défiance persistante. Après 1979, si les souscripteurs à des assurances privées ont augmenté, le nombre de lits dans le secteur privé commercial est resté circonscrit. L'ouverture à la concurrence des services annexes a fait l'objet d'une application tardive et partielle15. 10 S'agissant des soins, le recours par NHS Scotland aux sociétés privées reste l'exception, destinée à faire face à un besoin conjoncturel. Il ne peut être écarté en raison des pressions financières, les dépenses de personnel représentant 50 % du budget des health boards. Certes, la ministre se prévalait en 2018 d'une hausse des effectifs depuis 2007 (12 400 sur un total de 160 000), facilitée par l'absence de frais universitaires pour les études médicales (à la différence de l'Angleterre) et la négociation de conditions de travail en Écosse (assurant un salaire minimum et des progressions supérieurs à l'Angleterre)16. Cependant, son gouvernement ayant dû plafonner les places en formation et les hausses de salaires, ce personnel restait insuffisant au regard des besoins. Les tensions se traduisent par un absentéisme croissant, des postes non pourvus, notamment en milieu rural (tableau 4). Cela oblige les health boards à recruter du personnel intérimaire coûteux. En radiologie, secteur le plus déficitaire, ils font appel à des sociétés privées installées à l'étranger. Le projet de loi publié en 2018, exigeant l'affectation du nombre requis de personnel qualifié, aura une influence sur la répartition, mais pas sur le recrutement ou la fidélisation. 11 Cet attachement aux structures publiques alimente une peur de la privatisation venue d'Angleterre, instrumentalisée lors des référendums de 2014 sur l'indépendance et de 2016 sur le maintien dans l'UE. Le SNP a dénoncé les politiques anglaises (recours à des sociétés privées, frais à la charge des patients) qui entraînent une réduction de la dotation budgétaire à l'Écosse, tout en s'inquiétant du risque d'ouverture à la concurrence de services publics dans le cadre d'accords de libre échange signés à l'issue du Brexit17. 12 Qui plus est, les organismes représentatifs du personnel médical18 craignent une aggravation des pénuries, les médecins et les infirmières originaires de l'UE représentant 5 à 10 % des professionnels de santé en Écosse, 8 % du secteur de l'aide à la personne. Certes, le gouvernement écossais dispose d'atouts, la gratuité des études supérieures étendue aux ressortissants de l'UE, la promesse de prise en charge des frais de dossier de régularisation des salariés du secteur public après le Brexit, et un discours enthousiaste quant à l'apport de ces personnes19. Ces facteurs ont permis au NHS écossais d'échapper à l'effondrement du nombre d'infirmiers arrivant de l'UE dans

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l'année suivant le référendum de 2016. Mais à l'issue du Brexit, l'Écosse sera soumise à la politique britannique d'immigration, appelée à se durcir alors que nombre de professions médicales écossaises, déjà reconnues comme souffrant de pénurie, sont autorisées à recruter dans des pays tiers (avec des quotas). Qui plus, même dans les domaines dévolus, le gouvernement britannique veut imposer un cadre commun, notamment pour la reconnaissance mutuelle des diplômes ou de la couverture sociale.

Le regard critique des usagers

13 Le NHS écossais se veut au service des patients, ce qui est diversement apprécié.

14 Tout d'abord, les patients se voient reconnaître des droits depuis les années quatre- vingt-dix. Dans les années 2000, l'attente pour les opérations planifiées, qui pouvait excéder six mois, a été progressivement réduite, notamment grâce au rachat, en 2002, d'une clinique privée à Clydebank (devenue le Golden Jubilee Hospital) et à divers artifices comptables20. En 2011, Sturgeon a fait figurer ses objectifs dans une loi, approuvée à l'unanimité, garantissant notamment 12 semaines pour une chirurgie21. Depuis 2013, la situation ne cesse de se dégrader. En 2018, les délais d'attente ne sont pas atteints pour 7 des 8 objectifs principaux (tableaux 5 et 6). Si Robison se réjouit de comparaisons avantageuses avec l'Angleterre (prise en charge aux urgences), l'opposition lui rappelle que les pourcentages représentent des cas concrets de patients attendant plus de trois mois, pour consulter un spécialiste (triplement en quatre ans) ou pour une opération (120 000 personnes), ce qui conduit certains à ne pas honorer leur rendez-vous, notamment en zone défavorisée22. En conséquence, son successeur, , a accordé une rallonge budgétaire à des health boards sommés de rendre des comptes détaillés23. Mais elle préfère optimiser les structures publiques au lieu de recourir à des sociétés privées. Elle a reporté l'application des objectifs à 2021. 15 Ensuite, les patients doivent donner leur avis. Dès les débuts de la dévolution, chaque décision de fermeture de services hospitaliers a suscité un tollé, sous forme de manifestations, pétitions, et même de l'élection à Holyrood en 2003 d'un médecin impliqué dans ces mouvements. McConnell a instauré un Scottish health council, consulté par les health boards. Mais c'est en fait le gouvernement écossais qui est tenu pour responsable. Le SNP, élu en 2007 à l'issue d'une campagne ciblant les services d'urgence d' et de Monkland, a subi les conséquences des fermetures ultérieures. Dans ce contexte, le gouvernement Salmond a repris une proposition formulée en 2002 par un député travailliste, l'élection directe de citoyens aux conseils des health boards. Cette réforme, adoptée à l'unanimité en 2009, était censée refléter l'attitude des citoyens écossais, « propriétaires » de leur NHS, par opposition aux consommateurs anglais24. Mais lors des élections de 2010, et en dépit de l'abaissement de la majorité électorale à 16 ans, la participation est restée faible (Fife 14 %, Dumfries & Galloway 22,6 %)25. Par conséquent, en novembre 2013, , ministre de la Santé, est revenu à la nomination de citoyens après avis d'une commission indépendante, incitée à stimuler la diversité des candidatures (sur le modèle de Grampian et Lothian). Le gouvernement Sturgeon, ainsi que plusieurs conseils, ont par ailleurs mis en place des forums de citoyens. 16 Enfin, l'opinion des Écossais est mitigée26. Après 10 ans de pouvoir du SNP, des proportions équivalentes d'Écossais (45%) se déclarent satisfaits et mécontents de sa politique. En dépit des critiques, le SNP a rattrapé son retard sur le Parti travailliste sur

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un enjeu essentiel. Qui plus est, en 2014, il a convaincu nombre d'électeurs d'opter pour l'indépendance afin de protéger le NHS écossais des influences anglaises. 17 Cependant, la majorité des Écossais ne se distingue guère des Anglais, s'agissant des attentes à l'égard du NHS ou de la priorité financière à lui accorder27. Si deux-tiers des Écossais approuvent le principe de dévolution de la santé, seule la moitié en accepte les conséquences, qu'il s'agisse de financement par le Parlement écossais ou de la possibilité de politiques divergentes telle la suppression du ticket modérateur sur les médicaments, présentée comme l'une des innovations permises par la dévolution.

La dévolution, source d'innovations ?

18 Les élus écossais ont tenté de modifier les comportements individuels, toute amélioration de la santé publique devant alléger les dépenses du NHS. Ils ont ciblé les médicaments, l'alimentation et les addictions.

Le coût des soins

19 La gratuité des services publics, en conférant des droits identiques à tous les membres de la société, est censée atténuer les inégalités d'accès. Au sein du NHS, avant 2007, elle avait été restaurée pour les examens dentaires et de vision. En marge de celui-ci, elle avait été accordée aux personnes âgées dépendantes afin de subvenir à leurs frais de soins personnels. Le gouvernement SNP a supprimé les frais de parking à l'hôpital (à l'exception des trois entités construites et entretenues par des sociétés privées dans le cadre de partenariats public-privé) en 2008, avant d'abolir progressivement le ticket modérateur sur les médicaments.

20 90 % des médicaments étaient déjà gratuits, mais cela ne bénéficiait qu'à 50 % des patients (personnes âgées, enfants, certains malades chroniques). Dès 2006, le SNP avait soutenu une proposition de loi du Scottish Socialist Party (SSP), visant la généralisation de la gratuité, mais le gouvernement McConnell craignait une explosion de la demande28. L'année suivante, Sturgeon, ministre de la Santé, a indiqué vouloir abroger cette taxe sur la mauvaise santé, un élargissement des catégories bénéficiaires risquant de créer de nouvelles inégalités et d'entraîner des frais de gestion29. Elle a su convaincre les Travaillistes en évoquant les principes fondateurs du NHS en 1948, surmontant leurs réticences envers l'inclusion des classes moyennes30. 21 Or, le coût de cette abrogation du ticket modérateur ayant fait un bond de 25 % de 2011 à 2018, des professionnels de santé ont réclamé sa restauration, pour les personnes aisées, ou pour les médicaments disponibles sans ordonnance31. Mais le gouvernement écossais a défendu cette mesure emblématique de la dévolution (le ticket atteignant 9 livres en Angleterre), qui évitait un afflux vers des hôpitaux surchargés. Il pouvait compter sur un consensus, avec les Travaillistes (peu désireux de rouvrir le débat qu'ils avaient amorcé en 2012) et les Conservateurs (auxquels Ruth Davidson avait imposé un revirement).

L'alimentation des enfants

22 S'agissant des nourrissons, le Parlement écossais a adopté en 2004 une loi visant à stimuler l'allaitement maternel, notamment dans les milieux défavorisés, où la pression

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sociale à l'encontre de ces pratiques était la plus forte, comme l'avait remarqué Elaine Smith, députée travailliste à l'origine du texte32. Le gouvernement McConnell ne s'y est pas opposé, malgré ses réserves quant à la méthode (empêcher d'interdire l'allaitement maternel dans les lieux publics), en raison de l'objectif de santé publique poursuivi. Seuls les Conservateurs estimaient que ce dernier ne devait pas empiéter sur la liberté individuelle.

23 Quant aux enfants, en 2003, le gouvernement McConnell a axé sa politique sur la qualité des repas servis dans les cantines scolaires, avec des objectifs nutritionnels et éducatifs. Il a introduit certains aliments (fruits, eau, lait), tout en révisant les normes et les portions, ainsi que sur le contenu des distributeurs automatiques (programme Hungry for Success). Confronté à des habitudes alimentaires tenaces, John Swinney, ministre de l'Éducation (SNP), a proposé en 2018 un nouveau plan, pour réduire le sucre, favoriser les fruits et légumes. 24 Le SNP soutenait par ailleurs la gratuité des repas, afin d'encourager les enfants à déjeuner à la cantine, notamment les plus modestes, souvent stigmatisés. La première tentative, portée par le SSP, a échoué en 2002, au regard de son coût33. Arrivé au pouvoir, le SNP a ciblé les trois premières années d'école primaire, d'abord dans cinq collectivités territoriales au niveau de vie inférieur à la moyenne (Glasgow, West Dunbartonshire, , Fife, Borders), puis dans toute l'Écosse34. Dès 2015-2016, parmi les enfants en école primaire, plus de 80 % prenaient leurs repas à la cantine lors des trois premières années, contre 50 % les années ultérieures35. Seuls les Conservateurs sont restés réticents. 25 Cependant, les besoins se sont multipliés en raison de la réforme britannique des prestations sociales qui, en entraînant des retards, des réductions, voire des suspensions dans les versements, pousse nombre de familles à se tourner vers les banques alimentaires. En 2018, North Lanarkshire (gérée par les Travaillistes) a annoncé l'ouverture des cantines pendant les vacances scolaires tandis que Glasgow (dirigée par le SNP) a étendu la gratuité à la quatrième année de scolarité36. En outre, grâce aux compétences transférées par le Scotland Act de 2016, le Parlement écossais a voté en 2018 à l'unanimité une loi portant création d'un service écossais de Sécurité Sociale, afin de revaloriser certaines prestations et de mettre un terme aux sanctions arbitraires, ce qui devrait bénéficier aux enfants vivant dans la pauvreté (15 %, tableau 3)37.

La lutte contre les addictions

26 Les gouvernements écossais successifs ont mené des politiques volontaristes face à des lobbys puissants.

27 S'agissant de lutte contre l'alcoolisme, après avoir obtenu le droit de déterminer la limite acceptable pour les conducteurs (Scotland Act de 2012), les dirigeants écossais ont abaissé cette dernière, de 0,8 à 0,5 g par litre de sang, par une loi votée en 2014 à l'unanimité38. Ils ont bravé l'opposition des gérants de public houses, lesquels continuent à rendre cette loi responsable de leur déclin. 28 Par ailleurs, ils ont cherché à agir sur l'offre. En 2005, la coalition de McConnell a imposé la santé publique parmi les critères à respecter pour les détenteurs de licences de consommation sur place, sans parvenir à convaincre ses opposants39. Le SNP voulait agir sur les prix pratiqués sur les ventes à emporter. En 2010, Sturgeon, ministre de la

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Santé, est simplement parvenue à interdire les promotions liées à la quantité, par une loi votée à l'unanimité40. En 2012, elle a réuni une large majorité autour de l'objectif poursuivi depuis 2009, un prix minimum. Les Conservateurs ont toléré une période d'essai de cinq ans; les Travaillistes ont préféré l'abstention, faute de pouvoir infliger une taxe spéciale aux supermarchés41. Mais l'association des producteurs de whisky (Scottish Whisky association) s'est tournée vers la justice, invoquant le droit communautaire, ainsi que l'équilibre entre santé publique et liberté du commerce. La Cour Suprême a saisi la Cour de Justice de l'UE (laquelle a validé les possibilités de restrictions, proportionnées aux objectifs, pour des raisons de santé publique), avant de conclure, en novembre 2017, que le gouvernement écossais avait un objectif clair, la lutte contre l'alcoolisme, et une méthode, ciblant les alcools les moins chers, prisés par les plus démunis42. Le 1er mai 2018, lors de l'entrée en vigueur de la loi, Sturgeon, Premier ministre, a fixé le prix minimum à 50 pence par degré d'alcool, ce qui concerne 70 % des alcools vendus43. La ministre Robison anticipait des effets sur la santé et les finances publiques44, voire un modèle pour les îles britanniques. 29 Quant à la lutte contre le tabagisme, en 2005, sous le gouvernement McConnell, le Parlement écossais a interdit l'usage de la cigarette dans les lieux publics fermés, se félicitant de montrer la voie au reste de la Grande-Bretagne45. En 2010, sous le gouvernement Salmond, il a prohibé certaines modalités de vente (dans les distributeurs automatiques, ou à des mineurs de moins de 18 ans) et de promotion dans les magasins, tout en créant un registre des distributeurs46. En 2016, nombre de ces mesures ont été étendues au vapotage. Seuls les Conservateurs ont rejeté ces textes, trop contraignants pour les entreprises. En 2018, le gouvernement écossais entend faire des jeunes une génération sans tabac à l'horizon 2034. 30 Les députés écossais, fiers de leur bilan, craignent les effets du Brexit47. La sortie des dispositifs communautaires pourrait remettre en cause la disponibilité des médicaments (et l'accès aux traitements innovants), tandis que le gouvernement britannique pourrait être tenté de conclure des accords de libre échange autorisant des sociétés privées à poursuivre le gouvernement écossais à cause de ses politiques de santé publique. Cela ne pourrait que contrarier l'objectif d'amélioration de la santé des Écossais.

La dévolution, moyen d'amélioration de la santé des Écossais?

31 L'espérance de vie, indicateur synthétique, a progressé de 25 ans en un siècle, pour s'établir à 81,4 ans pour les femmes, 77,4 ans pour les hommes, tout en restant inférieure de deux ans à celle des autres nations britanniques. Elle varie de plus de sept ans pour les hommes selon les collectivités territoriales (tableau 1). À l'intérieur de celles-ci, elle fluctue de 67 ans dans les quartiers défavorisés de Glasgow, à plus de 81 ans dans les quartiers aisés de la collectivité voisine d'East Dunbartonshire. La fourchette est moindre, mais significative, s'agissant des femmes. Si la santé de la population écossaise s'est améliorée, notamment grâce aux choix politiques locaux, les écarts avec les pays occidentaux n'ont pas disparu.

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Une mortalité relativement élevée

32 Entre 1945-1951 et 2001, le taux de mortalité infantile (au cours de la première année de vie) a été divisé par dix (de 53,2 à 5,8 pour mille), tandis que le taux de mortalité des hommes a été divisé par deux dans la tranche 45- 54 ans (de 10,6 pour mille à 5,3 en 2001), en diminuant d'un-tiers au-delà48.

33 Cependant, à la fin des années soixante-dix, l'Écosse se situait au 31e rang sur 33 pays développés pour la mortalité, au 12e rang pour le taux de mortalité infantile (7 e en 1950)49. En 2010, le taux de mortalité restait supérieur à la moyenne européenne, de 21 % chez les hommes et de 30 % chez les femmes50. Mais la chute du taux de mortalité infantile avait été plus rapide qu'en Angleterre. 34 Ce constat valait pour les principaux facteurs de mortalité. Les maladies cardiovasculaires, premières causes de décès, étaient supérieures de 39 % à la moyenne européenne (contre 73 % en 1955 néanmoins). La mortalité liée aux maladies chroniques du foie était la plus élevée d'Europe, et poursuivait sa progression, constituant le deuxième facteur de mortalité des personnes de moins de 65 ans. 35 Qui plus est, l'état de santé fluctue en fonction du milieu social. En 1998, les problèmes cardiovasculaires étaient deux fois plus fréquents chez les ouvriers que chez les cadres supérieurs et professions libérales51. Leurs conséquences étaient plus graves, avec un écart de plus de 4,5 dans le taux de mortalité, en 1992 comme en 200152. La ville de Glasgow, l'une des plus pauvres du Royaume-Uni, cumule les difficultés sociales53 . Les taux de mortalité prématurée (avant 75 ans) due aux maladies du cœur et aux cancers dépassent la moyenne écossaise (de 20%), mais aussi ceux des autres grandes villes (tableau 2).

Des comportements à risque

36 En ce qui concerne l'alimentation, elle est plus déséquilibrée en Écosse54. De plus, on constate des écarts de 1 à 2, selon le revenu, dans la propension à consommer régulièrement des sodas, des frites, des fruits frais, ou à ajouter du sel55. En 2016, seuls 20 % des adultes et 12 % des enfants mangeaient cinq fruits et légumes par jour, ces proportions restant stables depuis 10 ans.

37 La proportion de nourrissons bénéficiant de l'allaitement maternel à 6-8 semaines est passée de 36,5 % en 2004 à 41 % en 2017. Mais si plus de la moitié des enfants sont allaités à un moment, le taux varie fortement selon le niveau de vie de la collectivité territoriale (écarts de 2,5) (tableau 3). 38 L'obésité se développe, affectant 30 % des adultes et 15 % des enfants (cette proportion étant supérieure de moitié dans les milieux défavorisés). L'obésité sévère (IMC supérieur à 40) concerne 4 % de la population écossaise, taux supérieur à celui des nations voisines mais dont la progression relative devrait ralentir. 39 S'agissant des addictions, le tabac est responsable d'un-cinquième des décès et de 128 000 admissions à l'hôpital chaque année. Si l'alcool est la cause d'un décès sur quinze et de 36 000 hospitalisations, il a de multiples effets sociaux : il est cité dans la majorité des délits commis par les jeunes, dans un tiers des divorces et affecte 65 000 enfants élevés par un parent souffrant de cette dépendance56.

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40 Certes, les tendances s'améliorent. Ainsi, la proportion de fumeurs est passée de 50 % des hommes en 1980 à un tiers en 1998, puis un quart en 201357. Entre 2003 et 2013, les syndromes coronariens aigus ont davantage chuté en Écosse qu'en Angleterre58. Quant à la consommation d'alcool par habitant, dans les années 2000, elle était supérieure de 25 % à celle de l'Angleterre, se situant au huitième rang mondial. Elle a baissé entre 2003 et 2013, passant de 16 à 12 unités par adulte et par semaine59. 41 Mais l'écart dans la proportion de fumeurs selon le niveau de vie s'est creusé. Les admissions à l'hôpital dues à l'alcool sont huit fois supérieures dans les quartiers défavorisés par rapport aux zones plus favorisées. C'est à nouveau à Glasgow que la mortalité imputable à l'alcool ou au tabac est la plus élevée (avec un taux 2,5 fois supérieur aux Borders pour l'alcool) (tableau 2). 42 Les politiques de prévention sont diversement appliquées selon le milieu social. La proportion d'écoliers souffrant de caries dentaires variait de 1 à 3 dans les années soixante-dix, de 1 à 2 en 201660. De plus, les personnes résidant dans les territoires démunis sont proportionnellement moins nombreuses à bénéficier des programmes de dépistage (tableau 3). Ainsi, les cancers sont plus souvent détectés à un stade avancé.

Une population vieillissante

43 La hausse de l'espérance de vie, associée à la chute des naissances (le taux de fertilité, 1,7 enfant par femme, étant inférieur au seuil de renouvellement des générations) a entraîné un vieillissement de la population. Ainsi, la proportion de personnes de plus de 65 ans, passée de 5 % à 18 % au XXe siècle, devrait continuer à croître d'ici 2039, en particulier en milieu rural61. Cela va entraîner une augmentation de la demande de soins, l'espérance de vie en bonne santé (sans maladie chronique ou invalidante) étant de 60,3 ans pour les hommes et 62,6 pour les femmes (avec des écarts de 10 ans selon le lieu). La demande sera forte dans les régions rurales périphériques comptant déjà plus de personnes âgées que la moyenne (tableau 3) et dans les régions centrales urbaines, où les problèmes de santé sont plus fréquents. Le financement posera problème, le ratio inactifs (enfants et retraités)/actifs devant passer de 58 % à 67 %.

44 Ce vieillissement est plus marqué en Écosse, où l'âge médian, 41,9 ans en 2016, est supérieur de deux ans à la moyenne britannique. Il s'est accompagné d'un déclin de la population, à partir des années soixante-dix, alors que les trois autres nations poursuivaient leur croissance. Dans les années 2000, la tendance s'est inversée, grâce à l'arrivée de ressortissants des États d'Europe centrale qui ont intégré l'UE en 2004 (le solde naturel restant faible ou négatif). À l'avenir, seule l'immigration peut maintenir cette dynamique, à la différence du reste du Royaume-Uni. Afin d'éviter les conséquences démographiques dramatiques d'une fermeture des frontières consécutive au Brexit, le gouvernement SNP réclame au gouvernement britannique la dévolution de la politique d'immigration, ou, à défaut, une prise en compte des besoins de l'Écosse. Ces immigrés, considérés comme un atout, doivent stimuler la croissance et les recettes fiscales (leur contribution annuelle excédant 10 000 livres62), seuls moyens de maintenir un service public de santé de qualité.

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Conclusion

45 La santé des Écossais s'est améliorée, suivant une tendance générale dans les pays occidentaux, mais aussi grâce à l'attention accordée par les dirigeants politiques aux besoins locaux. Le maintien de structures publiques, un des fondements de la dévolution, n'a jamais été remis en cause, sans pour autant faire la preuve de son efficacité au regard des listes d'attentes ou de la réduction des inégalités, tant pour la prévention que pour les soins. Les politiques publiques ont permis aux élus de distinguer l'Écosse de l'Angleterre, en faisant un modèle en Europe et dans le monde, rompant avec l'image antérieure, tout en alourdissant les coûts.

46 Cependant, en dépit de cette continuité, les politiques de santé n'échappent pas à l'instrumentalisation politique. Le SNP, en cultivant son image sociale, a ravi au Parti travailliste sa position dominante. Il est parvenu à articuler l'austérité pratiquée par le gouvernement britannique aux questions institutionnelles, en faisant un enjeu du référendum d'autodétermination de 2014, puis du Brexit. Il contraint ses adversaires à réagir sur ce terrain, les Conservateurs se démarquant de certaines politiques menées par le gouvernement de Theresa May, tandis que les Travaillistes prônent une hausse des dépenses face à un SNP obnubilé par son objectif indépendantiste. Mais, au-delà des polémiques, le gouvernement Sturgeon est confronté à une situation qui se dégrade, qu'il s'agisse des finances publiques (Audit Scotland, organisme de contrôle des comptes publics, constatant que NHS Scotland n'est pas dans une situation viable) ou de l'espérance de vie (qui régresse pour la première fois en trente-cinq ans). Le secteur de la santé, sur le point de représenter la moitié du budget écossais, va exiger des choix de la part d'un gouvernement minoritaire et privé de nombreux leviers d'action dans le cadre de la dévolution du pouvoir. 47 Edwige Camp-Pietrain est Professeur de civilisation britannique à l'Université Polytechnique des Hauts-de-France (Valenciennes). Membre du laboratoire CALHISTE EA 4343, elle est spécialiste de la vie politique, des institutions et des politiques publiques dans l'Écosse contemporaine.

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SCOTTISH GOVERNMENT (SG), Scotland's Place in Europe. People, Investment, Jobs, Édimbourg, 2018.

SG, Brexit, Protecting What Matters. What's at Stake for Individuals, Édimbourg, 2018.

SCOTPHO, Health and Well-Being Profiles 2015. Scotland Overview Report, Édimbourg, NHS, 2015.

SCOTTISH PARLIAMENT (SP), Official Report (OR), 20 juin 2002.

SP, OR, 18 novembre 2004.

SP, OR, 30 juin 2005.

SP, OR, 16 novembre 2005.

SP, OR, 25 janvier 2006.

SP, OR, 5 décembre 2007.

SP, OR, 12 mars 2009.

SP, OR, 27 janvier 2010.

SP, OR, 18 novembre 2010.

SP, OR, 24 février 2011.

SP, OR, 10 novembre 2011.

SP, OR, 24 mai 2012.

SP, OR, 19 février 2014.

SP, OR, 19 août 2014.

SP, OR, 18 novembre 2014.

SP, OR, 1er novembre 2017.

SP, OR, 21 novembre 2017.

SP, OR, 17 avril 2018.

SP, OR, 25 avril 2018.

SP, OR, 2 mai 2018.

SP, OR, 26 juin 2018.

SP, OR, 4 octobre 2018.

SP, OR, 24 octobre 2018.

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SP, Culture, Tourism, Europe and External Relations Committee, Brexit-What Scotland Thinks, Édimbourg, SP 64, 2017.

SP, Health and Sport Committee (HSC), Stage 1 Report on the Alcohol (Minimum Pricing) (Scotland) Bill, Édimbourg, 2012.

SP, HSC, OR, 6 mars 2018.

SP, HSC, OR, 20 mars 2018.

SUPREME COURT, Scotch Whisky Association and others v. Lord Advocate and Another, Londres, UKSC 76, 15 novembre 2017.

WOODS Kevin, « Scotland's Changing Health System », in WOODS Kevin, CARTER David (dir), Scotland's Health and Health Services, Londres, Stationery Office, 2003, p. 1-29.

ANNEXES

Annexes Tableau 1: Espérance de vie à la naissance dans les collectivités territoriales en 2011-2015

Hommes Femmes

Collectivité Zones les Zones les Zones les Zones les Écosse Écosse territoriale plus riches plus pauvres plus riches plus pauvres

Aberdeen 76,6 77,7 71,4 80,9 81,6 77,9

Aberdeenshire 79,2 79,8 75,6 82,2 82,6 79,9

Angus 78,6 79,3 74 81,9 82,2 78,9

Argyll&Bute 78,2 78,8 72,8 82,2 82,4 78,3

Édimbourg 78 79,1 70,5 82,2 83,2 76

Clackmannanshire 76,9 77,6 73,1 80,1 81 75,5

Dumfries&Galloway 78,1 78,7 74,2 81,3 82 78,4

Dundee City 75,1 76 68,8 80,1 80,3 76,3

East Ayrshire 76,1 76,7 71,9 79,4 80,3 76,1

East Dunbartonshire 80,5 81,2 75 83,5 84,5 79,2

East Lothian 78,4 78,7 75,8 82,5 82,4 79,9

East Renfrewshire 79,3 80,9 72,7 83,4 84 78,6

Falkirk 77,4 78,1 71,7 80,9 81,1 78,8

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Fife 77,7 78,3 72,9 81,5 81,8 78,4

Glasgow 73,4 74,2 67,8 78,8 79,4 74,8

Highland 77,9 78,6 72,1 82,6 83,1 77,9

Inverclyde 75,4 76,3 68,5 80,4 80,9 77

Midlothian 77,3 77,8 74,2 81,5 82 78,7

Moray 78,7 78,7 75 81,7 82 79,4

Hébrides extérieures 76,7 76,6 77,2 82,9 81,1 84,4

North Ayrshire 76,1 77,2 69,7 80,8 81,4 77,6

North Lanarkshire 75,3 76,2 70,2 79,6 80,1 75,7

Orcades 78,8 79,8 75,2 82,8 83 80,2

Perth & Kinross 79,8 80,4 73,7 82,6 83,1 79,5

Renfrewshire 76,3 77,1 69,9 80,6 81,2 75,9

Scottish Borders 78,8 79,5 75,5 82,5 82,8 79,6

Shetlands 77,6 78,3 71,8 81,9 82,4 79,9

South Ayrshire 77,7 78,6 72,9 81 81,3 78,5

South Lanarkshire 77 77,7 71,1 80,8 81,2 77,6

Stirling 78,5 79,7 72,2 82 82,8 77,5

West 74,8 75,1 69,2 78,7 79,2 77,1 Dunbartonshire

West Lothian 78,2 78,3 74,6 80,8 80,8 78,5

Écosse 77,1 78,1 70,8 81,1 81,8 76,8

Source : NATIONAL RECORDS OF SCOTLAND, Life Expectancy for Areas within Scotland 2013-2015, Édimbourg, 2016, tableau 1. Tableau 2 : Espérance de vie (en années) et mortalité anticipée (sur 100 000 personnes) dans les health boards en 2010-2013

Mortalité Mortalité Espérance vie Mortalité Mortalité anticipée pour anticipée pour masculine liée au tabac liée à alcool maladies cœur cancer

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Ayrshire & 76,5 67,3 171,7 333 22,9 Arran

Borders 78,7 43 134,2 279,6 13,4

Dumfries & 77,5 52,2 156,2 306,2 15,2 Galloway

Fife 77 54,5 167,3 333 21,7

Forth Valley 77,4 58,1 170,1 316,2 19,9

Grampian 78 48,4 155,4 281,8 16,3

Greater Glasgow & 74,5 72,1 202,8 389,7 33 Clyde

Highland 77,2 48,9 160,5 265 23,5

Lanarkshire 75,6 72,4 184,4 363,2 28,8

Lothian 77,5 54,7 170,9 303,1 19,4

Orcades 79,7 39,3 121,5 248,6 25,1

Shetland 77,4 51 173,1 275,2 15,1

Tayside 77,3 56,2 155,4 288,2 22,7

Hébrides 76,4 58,1 152,9 312,9 26,4 extérieures

Écosse 76,6 60,7 173,4 325,9 23,8

Source : SCOTPHO, Health and Well-Being Profiles 2015. Scotland Overview Report, Édimbourg, NHS, 2015, pp. 30-43. Tableau 3 : Quelques caractéristiques de la population des health boards en 2010-2013 (%)

Personnes Enfants de 2 mois Prévention Personnes recevant Enfants bénéficiant cancer intestin de plus de 75 allocations liées à pauvres allaitement (personnes de 50 ans l'absence maternel exclusif à 74 ans) d'emploi

Ayrshire & 9,3 16 19 18,1 55,2 Arran

Borders 10,2 10 10,9 32,5 60,4

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Dumfries & 10,8 12 13,9 23,1 58,3 Galloway

Fife 8,5 13,4 16,4 24,9 56,1

Forth Valley 7,9 12,6 14,6 23 54,6

Grampian 7,6 7,3 8,5 33 60,5

Greater Glasgow & 7,6 16,9 20,4 23,3 51,5 Clyde

Highland 9,5 9,9 11,1 31,2 60,4

Lanarkshire 7,5 15,3 16,7 17,8 49

Lothian 7,2 10,8 13,7 34,8 53,5

Orcades 9,7 6,6 6,1 41,2 62,4

Shetland 7,9 6,5 6 41,9 63,8

Tayside 9,5 12,3 14,1 26 60

Hébrides 11 10,3 8,2 30,9 56,6 extérieures

Écosse 8,1 13 15,3 26,5 55,1

Source : SCOTPHO, Health and Well-Being Profiles 2015. Scotland Overview Report, Édimbourg, NHS, 2015, pp. 30-43. Tableau 4 : Le personnel des health boards en 2016

Taux de Part des frais de Taux Taux de vacances vacances personnel contractuel d'absentéisme infirmières/sages- médecins sur total frais pour maladie femmes spécialistes personnel

Ayrshire & 5,01 13,9 0,4 2,7 Arran

Borders 4,36 7,2 3,7 3,3

Dumfries & 5,08 14,5 4,4 6,2 Galloway

Fife 5,12 12,6 2,4 2,9

Forth Valley 5,1 3,6 3,4 2,4

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Grampian 4,62 6,2 7,3 3,4

Greater Glasgow & 5,39 3,9 4,3 2 Clyde

Highland 5,09 6,1 5,4 4,3

Lanarkshire 5,2 10,1 3,3 3,3

Lothian 5,02 3,5 1,6 3

Orcades 5,1 37 8,8 5,2

Shetland 5,2 0 8,1 6,8

Tayside 5,04 6,9 2,9 1,9

Hébrides 5,93 0 0,8 6,2 extérieures

Écosse 5,16 6,5 3,6 2,8

Source : AUDITOR GENERAL, NHS in Scotland 2016, Édimbourg, 2016, pp. 30-31.

Tableau 5 : Résultats des objectifs de prise en charge dans les health boards en 2017 : parcours de soins

Du renvoi au Traitement hospitalier Renvoi au Urgences, prise Conseil et spécialiste vers le débutant en 12 spécialiste en 12 en charge en objectif traitement en 18 semaines suivant semaines (95%) 4h (95%) semaines (90%) décision (100%)

Ayrshire & 73,6 82,6 86,6 93,7 Arran

Borders 90 90,8 95,7 93,2

Dumfries & 89,5 92 86,3 93,7 Galloway

Fife 89,1 95,5 91,2 95,2

Forth valley 79,4 91,6 63,5 97,2

Grampian 74,5 72,6 74,4 96,1

Greater Glasgow & 89,7 86 87,2 90,7 Clyde

Highland 78,2 63,4 75,8 96,8

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Lanarkshire 78,7 83,4 66,7 90

Lothian 79,1 72,7 81,4 95,7

Orcades 94,3 67,8 90,3 97,5

Shetland 84,2 68,1 98,1 97,1

Tayside 86,7 86 81,2 98,6

Hébrides 95,6 95,6 100 99,3 extérieures

Écosse 83,2 80,7 82,2 93,8

Source : AUDITOR GENERAL, NHS in Scotland 2017, Édimbourg, 2017, annexe 3.

Tableau 6: Résultats des objectifs de prise en charge dans les health boards en 2017 : pathologies spécifiques

Problèmes mentaux Problèmes drogue Cancer : 62 jours Cancer : traitement Conseil et de mineurs, ou alcool, rendez- entre renvoi au débutant dans les objectifs rendez-vous en 18 vous en 3 spécialiste et 31 jours suivant la semaines (90%) semaines (90%) traitement (95%) décision (95%)

Ayrshire & 93,8 96,8 92,8 99,7 Arran

Borders 98,4 94,4 95,1 98,3

Dumfries & 100 97,1 96,3 96,5 Galloway

Fife 84,5 96,6 80,5 97,8

Forth valley 99,7 98,7 89,3 96,6

Grampian 45,2 93,3 86,2 92,2

Greater Glasgow & 98 96,8 83,3 93,9 Clyde

Highland 96 84 87,2 97,8

Lanarkshire 87,2 99,8 95,9 96,9

Lothian 47,8 83,3 90,6 93,6

Orcades 100 100 84,6 100

Shetland 100 88,9 94,1 100

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Tayside 95,2 96,7 89,6 93,1

Hébrides 100 94,2 85 100 extérieures

Écosse 83,6 94,9 88,1 94,9

Source : AUDITOR GENERAL, NHS in Scotland 2017, Édimbourg, 2017, annexe 3.

NOTES

1. Des structures publiques, et peu coûteuses pour les patients, avaient été instaurées dans des régions pauvres, les Highlands en 1913, les environs de Glasgow en 1941 (les hôpitaux militaires étant ouverts aux civils). SP, OR, 26 juin 2018, col. 71. 2. HAMILTON David, « Health », in MACDONALD Margo (dir), The Radical Approach, Édimbourg, Palingenesis Press, 1976, p. 74. 3. LUDBROOK Anne, THEODOSSIOU Ioannis, GEROVA Vania, « Health and Deprivation » in ERMISCH John, WRIGHT Robert (dir), Changing Scotland, Bristol, Policy Press, 2005, p. 99. Le qualificatif avait d'abord été attribué à l'économie britannique. 4. DAYAN Mark, EDWARDS Nigel, Learning from Scotland's NHS, Londres, Nuffield Trust, juillet 2017. 5. SCOTTISH CONSTITUTIONAL CONVENTION, Scotland's Parliament, Scotland's Right, Édimbourg, 1995. 6. AG, NHS in Scotland, Édimbourg, Audit Scotland, 2017, 10. 7. BEVAN Gwyn, KARANIKOLOS Marina, EXLEY Jo, NOLTE Eileen, CONNOLLY Sheelah, MAYS Nicholas, The Four Health Systems of the United Kingdom, Londres, Nuffield Trust, 2014, p. 49. 8. SP, OR, 2 mai 2018, col. 40 (Shona Robison, ministre de la Santé). 9. Il a supprimé le conseil d'Argyll & Clyde, lourdement déficitaire en 2005 et évincé la direction de Tayside qui avait puisé dans un fonds protégé alimenté par des dons (2018). Il existe aussi 7 health boards nationaux, axés sur la santé publique, la qualité des soins, la formation du personnel, les ambulances, les urgences psychiatriques, les appels téléphoniques, les listes d'attentes. 10. SP, OR, 4 octobre 2018, col. 49 (Jeane Freeman, ministre de la Santé). 11. HUNTER D., « The Reorganised Health Service », Scottish Government Yearbook, 1977, p. 30-32. 12. MCTAVISH Duncan, « Scottish and English Health Policy from 1948 to the 1973 Reforms », Scottish Affairs, n° 51, 2005, p. 60. BRUCE Allan, FORBES Tom, « From Competition to Collaboration in the Delivery of Health Care », Scottish Affairs, n° 34, 2001, p. 109. WOODS Kevin, « Scotland's Changing Health System », in WOODS Kevin, CARTER David (dir), Scotland's Health and Health Services, Londres, Stationery Office, 2003, chapitre 1. 13. GREER Scott, Territorial Politics and Health Policy, Manchester, Manchester University Press, 2004, p. 79. 14. HEENAN Deirdre, BIRRELL Derek, The Integration of Health and Social Care in the UK, Londres, Palgrave Macmillan, 2018, p. 68. 15. MILNE Robin, « Competitive Tendering of NHS Hotel Services in Scotland », Scottish Affairs, n°3, 1993, p. 145. Les directives publiées en 1983 ont privilégié la restauration, déconseillant la blanchisserie en raison de la faiblesse du marché écossais. 16. SP, OR, 1er novembre 2017, col. 53 (Maree Todd). 17. Le gouvernement britannique n'avait pas exigé d'exceptions dans les traités négociés par l'UE (accord sur le commerce des services dans le cadre de l'OMC en 2005, projet de traité

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transatlantique). DODDS Anneliese, « The Politicisation of Trade in Health and Education Services », Scottish Affairs, n°46, 2014, p. 56-75 ; SP, OR, 19 août 2014, col. 33578, Alex Neil, ministre de la Santé; SP, HSC, OR, 6 mars 2018, p. 11 ; HC, Hansard, 23 mai 2018, Chris Stephens (SNP). 18. SP, Culture, Tourism, Europe and External Relations Committee, Brexit-What Scotland Thinks, Édimbourg, SP 64, 2017, p. 80. 19. SG, Brexit, Protecting What Matters, Édimbourg, 2018, p. 14, 18. 20. Les personnes indisponibles étaient soustraites des listes (jusqu'en 2008), tandis que le nombre de patients sans garantie était en progression. AG, Tackling Waiting Times in the NHS in Scotland, Édimbourg, Audit Scotland, 2006. 21. SP, OR, 24 février 2011, col. 33553. 22. AG, 2016, op. cit., p. 20. 23. SP, OR, 24 octobre 2018, col. 2. 24. SP, OR, 12 mars 2009, col. 15 811 (Ian McKee, SNP), 15 816 (Richard Simpson, travailliste). 25. GREER Scott, WILSON Iain, STEWART Ellen, DONNELLY Peter, Health Board Elections and Alternative Pilots, Édimbourg, SG, 2012, 3.9. 26. Sondages YouGov (octobre 2015-avril 2017), IPSOS-MORI (mai 2017), www.whatscotlandthinks.org, consulté le 1er juin 2018. 27. ORMSTON Rachel, CURTICE John, « Attitudes Towards a 'British Institution' », Scottish Affairs, n°61, 2007, p. 69. KEATING Michael, LINEIRA Robert, « Getting to a Wealthier and Fairer Scotland », in KEATING Michael (dir), A Wealthier, Fairer Scotland, Édimbourg, Edinburgh University Press, 2017, p. 134-135. 28. SP, OR, 25 janvier 2006 (Andy Kerr, ministre de la Santé). 29. SP, OR, 18 novembre 2010, col. 30581. 30. SP, OR, 5 décembre 2007, col. 4065 (Des McNulty). 31. MCARDLE Helen, « Free Prescription 'Save NHS Money' Despite Soaring Bill for Ageing and Obesity », The Herald, 5 octobre 2017, p. 6. 32. SP, OR, 18 novembre 2004, col. 12116. 33. SP, OR, 20 juin 2002, col. 13976 (Tommy Sheridan). 34. SP, OR, 19 février 2014, col. 27917 (, ministre des Enfants). 35. MCADAMS Rachel, Evaluating Universal Infant Free School Meals, Scotland, Édimbourg, NHS Health Scotland, 2016, p. 7. 36. BROOKS Libby, « Council Plans Free School Meals All Year to Tackle 'Holiday Hunger' », The Guardian, 16 février 2018. 37. SP, OR, 25 avril 2018, col. 117. 38. SP, OR, 18 novembre 2014, Kenneth MacAskill, ministre de la Justice, aurait souhaité la dévolution des pouvoirs de sanctions. 39. SP, OR, 16 novembre 2005, George Lyon, ministre délégué aux Finances. 40. SP, OR, 10 novembre 2011, col. 30243. 41. SP, OR, 24 mai 2012, col. 9426 (Jackie Baillie), 9427 (Jackson Carlaw). 42. SUPREME COURT, Scotch Whisky Association and others v. Lord Advocate and Another, Londres, 2017, paragraphe 63. 43. The Herald, 1 er mai 2018, p. 1. Le prix minimum d'une bouteille est porté à 14 livres pour le whisky, 4,88 livres pour le vin. 44. SP, OR, 21 novembre 2017, col. 19. 45. SP, OR, 30 juin 2005, col. 18709 (Kerr). 46. SP, OR, 27 janvier 2010, col. 23160 (Sturgeon). 47. SP, HSC, OR, 20 mars 2018, col. 30. 48. PATERSON Lindsay, BECHHOFER Frank, MCCRONE David, Living in Scotland, Édimbourg, Edinburgh University Press, 2004, p. 157.

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49. BROOKS Richard, « Scotland's Health » in INGRAM Keith, LOVE James (dir), Understanding the Scottish Economy, Oxford, Martin Robertson, 1983, p. 107. 50. MCCRONE David, The New Sociology of Scotland, Londres, Sage, 2017, p. 115. 51. PATERSON et al., op.cit., p. 200. 52. MCCRONE, op.cit., p. 122-123. 53. HAMILTON David, « Health and Health Care in West Central Scotland », Scottish Government Yearbook 1978, p. 79. 54. CHURCH Jenny (dir), Regional Trends, Londres, HMSO, 1994, p. 102. MCLEAN Joanne, CHRISTIE Joanne, GRAY Lindsay, Scottish Health Survey, Édimbourg, SG, 2016, p. 105. 55. PATERSON et al., op.cit., p. 136. MCKENDRICK John, « What is Life Like for People Experiencing Poverty ? », in MCKENDRICK John, MOONEY Gerry, SCOTT Gill, DICKIE John, MCHARDY Fiona (dir), Poverty in Scotland 2016, Londres, CPAG, 2016, p. 120-121. 56. SP, HSC, Stage 1 Report on the Alcohol (Minimum Pricing) (Scotland) Bill, Édimbourg, 2012, paragraphe 10. 57. PATERSON et al, op.cit., p. 133-134. 58. ROBERTSON Tony, MARSDEN Sara, KAPILASHRAMI Anuj, « A Public Health Politics that is People's Health », in HASSAN Gerry, BARROW Simon (dir), A Nation Changed ?, Édimbourg, Luath Press, 2017, p. 127. 59. AG, NHS in Scotland, Édimbourg, 2016, p. 24. 60. HAMILTON, 1978, op. cit., p. 82. AG, Health Inequalities in Scotland, 2012, p. 11. 61. HC, Scottish Affairs Committee, Demography of Scotland and the Implications for Devolution, Londres, 2016, p. 22. 62. SG, Scotland's Place in Europe, Édimbourg, 2018, 130.

RÉSUMÉS

Depuis 1999, le Parlement et le gouvernement écossais se sont efforcés d'améliorer la santé de la population écossaise, en restaurant un service public fondé sur la coopération et non sur la concurrence, tout en concevant des politiques publiques visant à modifier les comportements individuels. En dépit des succès obtenus, ils n'ont pu éviter la politisation de cet enjeu, dans un contexte de restrictions budgétaires croissantes et d'incertitudes institutionnelles.

Since 1999, Scotland's Parliament and government have striven to improve the health of the Scottish people by restoring a public service based on co-operation and not on competition, while devising policies aimed at modifying the behaviour of individuals. Even though they have achieved some success, they have proved unable to avoid politicizing the issue. Tensions have been fuelled by tighter budgetary constraints and constitutional upheavals.

INDEX

Mots-clés : dévolution, santé, SNP, enfants, inégalités Keywords : devolution, health, SNP, children, inequality

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AUTEUR

EDWIGE CAMP-PIETRAIN

Université Polytechnique des Hauts-de-France (Valenciennes)

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Right to Reply: Using Patient Complaints and Testimonials to Improve Performance in the NHS Droit de réponse: Les plaintes et les témoignages de patients comme instruments d’amélioration de la performance du NHS

Louise Dalingwater

Introduction

A health service that does not listen to complaints is unlikely to reflect its patients’ needs. One that does will be more likely to detect the early warning signs that something requires correction, to address such issues and to protect others from harmful treatment. (Robert Francis Q C, Staffordshire enquiry)1 Carl Rogers is believed to have developed the first person-centred approach to health care in the area of psychotherapy2. Then, in the late 1970s, the American psychiatrist George Engel promoted a biopsychosocial model of health; that is, a person-centred model of health care. Neither of these approaches have specifically been adopted by the National Health Service today but they have helped to put focus on the need for empathy and for the professional to be prepared to suspend judgment and appreciate the service user’s or patient’s perspective3. Person-centred care has become a particularly prominent part of national health policy and local practice in recent years. In 2013, the Department of Health declared a shared commitment to making ‘person- centred coordinated care’ a key part of health and social care delivery4. A number of different methods are currently in place within the NHS which actively encourage patients to judge the provision of health by sharing their experiences of care and treatment, completing surveys, etc. Testimonials are also a way of evaluating the

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provision of health care and are posted regularly on NHS websites (Patient Opinion, NHS Choices, etc.), and also on special care and charity websites. Stories told by individuals from their own perspective and in a health care setting can provide health care providers with an opportunity to understand experiences of care and to gain an insight into what could be done to improve the patient’s experience. Providing an outlet for patients to complain can be a useful way of not only ensuring that individual rights to quality health care are respected but also of increasing awareness of safety- related problems within health organisations, or various problems relating to health care delivery. Traditional evaluation and monitoring of health care systems are not necessarily sensitive to specific failures in care and so patients and families can provide valuable insights into health care delivery5. All NHS health care organisations in England and Scotland must carry out postal surveys to give patients a chance to air their views on their recent experience of health care. These national surveys aim to compare results locally and should enable policy makers and regulators to examine overall performance of health services. However, such information and other data on user experiences are not currently well aggregated or used to drive improvements in health care delivery. So, while the right to reply and using patients’ experiences and/or complaints might be a way to improve care, this paper underlines a number of difficulties in collating and effectively using such information. It starts by underlining the drivers behind initiatives to give patients or service users a voice in health care provision. It then gives an extensive but not exhaustive review of NHS and nationwide initiatives to take account of the user/ patient’s perspective on health care provision. It also underlines the essential weaknesses in using patients’ complaints and care testimonials to judge the quality of care and drive improvements. Finally, it uses a case study of the Mid-Staffordshire Hospital Trust negligent care scandal of the period 2005 to 2008 to illustrate why a patient-led approach to monitoring care provision is essential but difficult to implement in practice.

Drivers for collating patients’ views and correctly processing complaints

Since there has been an increase in the reporting of adverse effects, that is people dying or being seriously injured, it would seem important to take criticisms of health services seriously. Indeed 400 people have been reported as dying or being seriously injured after the use of medical devices in the NHS, 10,000 people had adverse reactions to drugs prescribed by NHS consultants and 1150 people committed suicide despite being in contact with NHS mental health services. The NHS receives roughly 28000 written complaints a year on clinical treatment in hospital and pays £400 million on clinical negligence claims6. Adverse effects have been reported to be higher in Great Britain (around 10%) than France, for example (3.7%)7. Apart from fatal cases, a number of other reasons for complaints have been put forward including lack of information, lack of compassion, lack of dignity and care, staff attitudes and lack of resources8. The Complaints Task Force and NHS management documents support the thesis that complaints can enable managers to manage risks and threats better (risk management programmes for example). Complaints can be used in order for providers to understand how users view their services and identify

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issues which need to be dealt with. They can also be used to rectify past mistakes and enable services to be put right in the future. Well-handled complaints can increase trust in patients and identify adverse effects which might not have been detected otherwise. Patient complaints and testimonials can capture failures in quality or other questions (such as dignity) which cannot be measured through traditional metrics. As an aggregate measure and provided they are correctly processed, they can reveal problems in health care provision. A series of investigations and reports which examine patient complaints and testimonials on care emphasise the importance of using such material to drive improvements in health care: the Wilson Report ‘Being Heard’ of May 1994, the Public Law Project’s report ‘Cause for Complaint?’ of September 1999 and the York Health Economics Consortium’s report (the York Report) published in March 2001 are just some examples of work in this area. These reports have been instrumental in improving the complaints procedure and the development of a person-centred or patient-centred approach within the NHS.

NHS and nationwide initiatives to take into account the user’s perspective

Indeed, the complaints system has been gradually improved, especially from 1996 onwards. Since 1985, the Hospital Complaints Procedure Act set forth a host of national procedures for hospitals to deal with complaints. Complaints regarding GPs are made to the Family Health Services Authority (FHSA). However, from the 1990s, complaints procedures were improved because of criticism of the lack of effective treatment of grievances. The Wilson committee was set up to investigate and suggest improvements to the complaints system and, in 1994, a more simplified two-stage structure system for grievances was introduced. In 1996, in line with the patient-centred approach, a unified complaints system was introduced for hospitals, community health services and family services in the NHS. Dissatisfaction with acute, primary or secondary health care should first be addressed to the trust, CCG or other care provider with a view to resolving the issue as quickly as possible (by a Local Resolutions Unit). However, if the complaint is unresolved, it is then addressed to an Independent Review Panel. The panel must investigate the complaint, write a report and make comments and recommendations to redress the grievance and/or make recommendations for service improvements. If this review is not satisfactory, then the complainant can refer the matter to the Health Service Commissioner at NHS England9. The latter then publishes an annual overview and six-monthly reports on investigations into complaints with possible recommendations for action. Beyond providing a system for complaints, the NHS also actively encourages patients to give their views on the health system. The NHS Patient Experience Framework underlines that patient experience is one of the central outcomes to be considered along with effectiveness and safety10. The NHS Future Forum called for the establishment of new metrics to bring together already existing data on patient experience. The NHS has taken several initiatives to enable the patient to share his or her experience of health care provision and in so doing evaluate the quality of care provided. The NHS Constitution and the Health Act of January 2010 impose a legal obligation on service providers to take into account the decisions and actions of patient experience. The NHS Outcomes Framework also makes clear that the

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provision of a good experience of care for patients is a fundamental part of the NHS. The NHS Patient Experience Framework sets forth a definition and measurement of patients’ experiences. Patient-reported experience measures (PREMs) and patient- reported outcomes (PROMS) are also currently used by NHS providers. The Department of Health has also been active in promoting a patient or person- centred approach. The 2010 White Paper, Equity and Excellence: Liberating the NHS 11 underlines that there should be more emphasis on improving people’s experience of health care. More recently, in 2013, a Department of Health Review Team also set up a dedicated postal and email address for people to send accounts and experiences of health care. They received 2500 letters and emails and the team reviewed the data. Seven public engagement events were also held. The review team visited nine NHS hospitals and one hospice to meet up with complaints managers, frontline staff and board members12. The Picker Institute underlined nine quality dimensions which it discovered through its work were most important to patients and families: fast access to reliable health advice, effective treatment delivered by trusted professionals, participation in decisions and respect for preferences, clear, comprehensible information and support for self-care, attention to physical and environmental needs, emotional support, empathy and respect, involvement of, and support for, family and carers and finally continuity of care and smooth transitions13. There have been a number of attempts to monitor the quality of care through the use of Picker surveys. For example, Southampton University Hospitals Trust asked patients to complete surveys on these 9 key quality dimensions. Every month such results are shared across the hospital to “put patient experience at the centre of quality”. It has already helped the trust to recognise and deal with problems such as improving information given to patients14. Some hospital trusts and GP practices routinely seek out more general feedback: how long a patient has been waiting, quality of care, etc. Many trusts also have a specialised complaints department. Moreover, national bodies support quality improvement through patient input such as HealthWatch England, Citizens Advice, Patients Association, Actions for Victims of Medical Accidents, the Consumers Association, National Voices, etc. In England, an annual General Practice Patient Survey is carried out to collate information on people’s experience of primary care. It surveys five million people each year. For hospitals, a National Adult Inpatient Survey has been in place since 2002 which surveys 600,000 patients every year15. The results of this survey have been used to lead policies to improve patient care. The UK also has a number of websites where patients and family members can post their stories about NHS care experiences. For example, Patient Opinion invites patients and families to post short anonymous stories and 45,000 testimonials are available on the website. Once the stories are published, the website administrators contact the relevant health organisation giving them an opportunity to post a reply. The Francis Report (2013) claimed that this site had the potential to improve the quality of care. NHS Choices is another website which provides patients with the opportunity to give accounts of service provision, particularly in a hospital setting. Comments often relate to human errors, incorrect medical recording and medical errors, etc.16. However, there are a number of problems related to using such data and accounts of care to drive improvements in care provision17.

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Obstacles to using patient complaints and testimonials to improve NHS healthcare provision

There are essentially three types of obstacles to using patient complaints and testimonials to improve health care provision. The first is the reliability of the data itself, the second is the ability to aggregate such information to improve health care provision nationwide and the third is related to flaws in the complaints system.

Reliability of data

National surveys are not necessarily adapted sufficiently enough to the local situation or local needs. Researchers Wright et al. carried out a study to assess whether such performance evaluations through questionnaires were reliable18. The conclusions of their study showed that while such evaluations may give formative feedback on a doctor’s professional practice, because of the subjective nature of the feedback, such surveys should not be used in isolation. Moreover, it depends how the questions are formulated. It has been found that responses to closed-ended questions usually give positive answers about care whereas open-ended questions tend to give negative results. This is known as the ‘leniency effect’19. The problem with open access websites is that it is difficult to verify and check the validity of the stories and responses. Some closed access systems also exist and in these systems the patients are sent an invitation to share their care experience, but they must register to share their stories so such systems might be more reliable. The problem with using complaints and/or testimonials to improve the system overall is that patient complaints are not necessarily a systematic sign of failure. The other issue is that they are often emotive and specific to individual health care professionals. Patients might complain without taking into account wider pressures (staff workloads for example) meaning that they are unable to analyse other factors influencing the provision of health care. When things go wrong, the response is often to identify an individual or individuals to blame. But while individual health care workers should be called to account for their actions, in a large number of cases, the failures stretch beyond the individuals to the system at large. In separate studies, Allsop20 and Lloyd- Bostock and Mulcahy21 underline the essential difficulties of using narratives to drive change in health care provision. They note that such accounts contain quite a lot of personal information which might not be relevant to, or comparable with, other cases. They underline that the strength of the emotions may actually not communicate relevant grievances. When a loved one has suffered from a serious illness, carers and family tend to look for someone to blame.

Lack of an aggregated data system

Moreover, there is no systematic nationwide policy in place or standard measure to collect people’s experience of health care in the NHS. The methodologies used to aggregate patients’ complaints are often inconsistent or do not aggregate data sufficiently to give optimal depth to complaints. Data thus remains at a raw and experimental level, unstandardized and difficult to compare. Collection of data for

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primary care is considered to be even more inconsistent. So, while there would seem to be a move towards giving patients opportunities to complain and seek redress, there are limits to the processing and effective use of such material.

Flaws in the complaints system

In terms of criticisms of the complaints procedure, an investigation led by Dame Janet Smith in the Fifth Report of the Shipman Inquiry, and published in 2004, found that complaints were not always investigated properly, adequate explanations were not given, there was a failure to take account of the inherent imbalance of power between health care professionals and patients and there was sometimes patients’ fear of retribution if they spoke up22. There was also a certain lack of impartiality in organisations investigating their own conduct, and a lack of accountability. The charity Mencap found for example that when a death or serious incident occurs, complaints are investigated by members of NHS staff working within the same trust or CCG where the incident occurred. Investigators might even be from the same unit or specialty23. This represents a serious conflict of interest and impartiality in the investigation. The Wilson committee also underlined some inherent difficulties for complainants using the NHS complaints procedures. First, complainants find it difficult to make their views known, but they often fail to receive a correct response. The charity Mencap emphasised that the complaints process is slow, bureaucratic and defensive. Not only do families have to wait years to obtain justice for death caused by mistreatment or negligence, but the NHS does not seem to learn from failures and take steps to avoid deaths or serious incidents in the future24. The charity MIND discovered that patients find it hard to identify to whom they should complain and other inherent difficulties in navigating the complaints systems25. This results in a high number of families not filing for redress26. HealthWatch England describes the complaints system as “off-putting, complex and slow”27. Mulcahy and Tritter’s 1993 study of 1640 households found that 60% of those who were dissatisfied with health services did not lodge a serious complaint because of the lack of knowledge of the complaints system, low expectations, feelings of gratitude, fear of retribution, deference to health professionals and life events28. When complaints are made it is often hard for them to be followed through: patients and families complain about a lack of responses or follow up to phone calls, impersonal letters of reply, not being kept informed of progress, inadequate replies, the length of time29…. Mulcahy and Tritter also reported that people often complain about the complaints procedure because of incomplete explanations, dismissive letters, “pseudo-apologies”, technical language and defensive responses30. Alsop and Mulcaly, in their analysis of patients’ complaints, found that little attempt was made to translate technical or defensive material into simpler language31. So, while data is collected, there is no systematic or reliable way of identifying lapses in standards of care, analysing them and learning from mistakes in order to introduce change. Indeed, a Department of Health report found that while individuals may learn from change, there is no apparent collective learning process in the NHS32. The inability to learn from incidents can be explained by a number of institutional causes: rigidity of belief, values, lack of corporate responsibility, ineffective communication, a tendency for scapegoating, difficulties in understanding complex events33.

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To sum up, the key problems identified in using patient views and complaints to improve the quality of services provision include the lack of consensus on what to report, an absence of proper linkages between reporting systems, inability to make the best use of available information, lack of analysis across different systems and inability to apply recommendations across the board. Both testimonials on care and complaints lodged by patients have the potential to drive change but the system is currently difficult to put in place. The following case study is an illustration of the importance of developing a patient reporting system, but also the current failures to do so inherent in many NHS institutions.

The Mid-Staffordshire scandal34

The Mid-Staffordshire hospital trust crisis is an example of why it is important to use patients’ surveys, testimonials and complaints to detect failures in care and remedy them, but also the difficulties in processing complaints effectively. The specific example of Stafford Hospital is very telling because it is an appalling tale of negligence in the provision of NHS hospital care and an illustration of why current care evaluation systems are not necessarily the most effective way of assessing quality of care in NHS institutions. It also underlines the essential role that patients’ complaints and stories can and should play in driving up the quality of care in the NHS. Substandard levels of care were uncovered at Stafford hospital: mainly because of the persistent complaints made by a very determined group of patients and those close to them. This group wanted to know why they and their loved ones had been failed so badly. (Francis, 2013, Executive summary, p7)35 From 2009 to 2013, a total of 5 investigations and official reports were published, the most conclusive and complete being a final report written in 2013, as a result of a full public inquiry by Sir Robert Francis QC. The scandal came to light when the Healthcare Commission, which compiles mortality rates, became aware of an unusually high number of deaths at Stafford hospital. While the Healthcare Commission already had concerns about the hospital at this point, the investigation was triggered when Cure the NHS, an association of relatives and patients who had experienced substandard levels of care at Stafford Hospital (leading to deaths in some cases), contacted the Healthcare Commission with their concerns and were asked to write a report36. The Commission then carried out an investigation between March 2008 and October 2008 interviewing almost 300 people, including 100 patients. The Commission announced that they were leading an investigation and 103 patients and families contacted this organisation spontaneously. Within this group, 99 were critical or had an experience of poor care at Stafford hospital. The Healthcare Commission’s annual survey of inpatients also showed that the trust was in the bottom 20% for performance for 39 out of 62 criteria37. The reasons given for these failures were numerous. The Healthcare Commission reported that the foundation trust had not set up an effective system to admit and manage patients or monitor outcomes. The hospital trust’s board and senior leaders did not acknowledge the high rates of mortality and concluded that it was due to data problems or errors. Failures to diagnose and treat patients in A&E, inadequate staffing levels and inexperienced staff were also reported38. The Healthcare Commission report was then followed by an independent inquiry led by Robert Francis QC, a barrister who had led many clinical negligence claims in the past.

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The results of the first public inquiry were published in 2010 and compiled evidence from over 900 families39. This report focused on failings in the trust itself. It reported very basic elements of neglect in the provision of hospital care: patients not washed for up to a month, food and drink placed out of patients’ reach, family members having to make sure that they arrived at meal times to feed them, neglected hygiene, etc. Families removed used bandages and dressings from public areas and cleaned the toilets themselves because they were in such a dreadful state. Patients were left for hours in soiled sheeting or forgotten on commodes. Misdiagnosis was also common during the period 2005 to 2008 and patients went for hours without food, drink or medication, inexperienced doctors were left on their own on night shifts and receptionists with no medical experience manned the Accident and Emergency desk40. The first public inquiry of July 2010 also investigated why traditional measures of health provision had failed to detect such poor care provision. Indeed, none of the national and local institutions: the local Strategic Health Authority, the local Primary Care Trust, Monitor ( Regulator of NHS Foundation trusts) and the Care Quality Commission had detected failures in the quality of care. Many of these bodies had been set up under the New Labour government to better detect failures of care. Members of the local campaign group Cure the NHS then called for a public inquiry to understand failings in the broader context of the NHS and to avoid a repeat of such incidents in other NHS trusts. They complained that the independent inquiry published in 2010 was neither wide enough in scope nor transparent41. A full public inquiry was launched in 2010 and published in 2013. The final 2013 report revealed that there was a chronic shortage of staff, especially nursing staff and morale was so low that some showed a lack of compassion towards patients. Staff who wished to report the conditions were deterred from doing so because of bullying. The Francis report found that the reason behind the understaffing and lack of essential equipment on the wards was that there had been staff cuts in the 2006-7 period to try to make savings of £10m in order for the hospital to gain Foundation Trust status42. Indeed, at that time the granting of Foundation Trust status gave a hospital more autonomy to run as an independent corporation, accountable to local communities rather than the central government. It also meant more budget flexibility: This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status at the cost of delivering acceptable standards of care. (Francis report, 2013, Executive summary, p3)43 Sir Robert however underlined that much of the blame should be placed on the trust’s ruling board. The action taken to investigate and try to resolve concerns was inadequate and lacked a sense of urgency. This is where the importance of patients’ complaints and patient and family testimonials on care play a major role. The various quality control reports from outside bodies including the Mid Staffordshire Health Care Commission had given the hospital “good” ratings. However, the trust’s ruling board failed to take into account the patients’/families’ complaints and a number of testimonials compiled by the hospital according to national requirements. In addition, according to a recent report, 64 people wrote letters of complaint to the Department of Health about substandard care at the hospital trust between August 2005 and March 2009, but department officials failed to investigate complaints44. Sir Robert also underlined that staff who tried to raise concerns were not listened to and/or bullied

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into leaving their jobs. For example, a staff nurse at Stafford Hospital who reported a complaint about waiting times was bullied. The trust refused to take the complaint seriously and the Royal College of Nursing advised her to “keep her head down”45. Other external reports should also have been taken into account. In 2004, the trust was re-rated by the Commission for Health Improvement as a zero-star trust and a 2007 Royal College of Surgeons report described the surgical department as “dysfunctional”. Both of Sir Robert’s reports were particularly critical of the failure of senior figures at the hospital and external health quality monitoring bodies (mentioned above) to collate, analyse and take patients’ complaints into consideration. Sir Francis thus recommended, among other things, that the evaluation system needed to be improved: Develop and share ever improving means of measuring and understanding the performance of individual professionals, teams, units and provider organisations for the patients, the public, and all other stakeholders in the system46. (Francis, 2013, Executive summary, p5) The final 2013 report focused on investigating why the system of national inspection had failed. He underlined how important it was to take patients’ and families’ grievances into account within the evaluation process: This was a failure of the trust first and foremost, but it was also a national failure of the regulatory and supervisory system, which should have secured the quality and safety of patient care. Why did it have to take a determined group of families to expose those failings and campaign tirelessly for answers? (Francis, 2013, Executive summary, p.9)47 It points to why ultimately more needs to be done to use patients’ complaints and stories effectively in a more coherent way.

Conclusion

The Stafford Hospital example of failure of care shows how important it is to monitor quality care not only from external sources but from internal sources, especially patients and family. The introduction of Clinical Governance and a whole number of bodies of external evaluators to detect failures in care have not been sufficient to detect shortcomings. There have been recent attempts to implement a more effective complaints system in the NHS and processes to enable patients, family and staff to evaluate and report failings in care. It would seem however that a really effective nationwide system whereby staff and patients can freely air their views without fear of reprisal still has a long way to go. Louise Dalingwater is Professor of British Politics at Sorbonne-Université in Paris. Her current research focuses on health services and wellbeing in the United Kingdom. Recent publications include a book on the NHS in print and several book chapters. She has also authored articles in academic journals including in Interventions économiques, The International Journal of Health, Wellness and Society, and Auto/biography review.

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BIBLIOGRAPHY

Allsop, Judith, “Two Sides to Every Story: Complainants’ and Doctors’ Perspectives in Disputes about Medical care in a general practice setting”, Law and Policy 16, 1994, pp.149-84.

Allsop, Judith and Linda Mulcahy, “Dealing with Clinical Complaints”, Quality in Health Care 4, 1994, pp. 135-143.

Calkin, Sarah, “Ten Frequently Asked Questions: What is the Francis Report”, Nursing Times, 31 January 2013, .

Cure the NHS, “About Cure the NHS”, 2018, .

Department of Health, Department of Health, A Review of the NHS Hospital’s Complaints System: Putting Patients Back in the Picture (London, HMSO, 2013).

Department of Health, Equity and Excellence: Liberating the NHS (London, HMSO, 2010).

Department of Health, An Organisation with a Memory (London, HMSO, 2000).

Department of Health, A First Class Service: Quality in the New NHS, 1 July 1988, HSC 1998/113, (London, Crown, 1998).

Dominiczak, Peter and Mason, Rowena, “More than 60 Mid Staffordshire hospital complaints to Government ignored”. The Telegraph, 24 March 2013, .

Francis, Robert, Robert Francis Inquiry report into Mid-Staffordshire NHS Foundation Trust, HSC 1998/822 (London, Crown, 2010).

Francis, Robert, Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry, HC 947 House of Commons (London, Stationery Office, 2013).

Guiliani, Camila, Nathalie Gault,Valia Fares, Jérémie Jegu, Sergio Eleni dit Trolli, Julie Biga and Gwenaelle Vidal-Trecan, “Evolution of Patients’ Complaints in a French University Hospital : Is There a Contribution of a Law Regarding Patients’ Rights?” BMC Health Services Research 9: 141, 2009, .

Healthcare Commission, Investigation into Mid Staffordshire NHS Trust Foundation Trust (Summary Report) (London, Healthcare Commission, 2009).

Health Foundation, Measuring Patient Experience (London, Health Foundation, 2013).

Healthwatch England, Healthwatch England Annual Report 2015/6: Every Voice Matters, 2016.

Lloyd-Bostock Sally Mulcahy Linda, “The Social Psychology of Making and Responding to Hospital Complaints: An Account Model of Complaint Processes”, Law and Policy 16: 123-47.

Mencap, Death by Indifference (London, Mencap, 2007).

Mulcahy, Judith and Jonathan Q. Tritter, Dissatisfaction, Grievances and Complaints in the NHS, A Report to the Department of Health (London, HMSO, 1993)

Picker’s Institute, Core Domains for Measuring Inpatient Experience of Care (Picker Institute Europe, Oxford, 2009).

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Reader, Tom, Gillespie, Alex and Roberts, Jane, “Patient Complaints in Healthcare Systems: A Systematic Review and Coding Taxonomy”, BMJ Journals 23: 8, 2013 .

Rogers, Carl R. Client-centred therapy: Its current practice, implications and theory (Boston, Houghton Mifflin, 1951).

Wright, Christine, Suzanne H. Richards , Jacqueline J. Hill, Martin J. Roberts, Geoffrey R. Norman, Michael Greco, “Multisource Feedback in Evaluating the Performance of Doctors: The Example of the UK General Medical Council Patient and Colleague Questionnaires” Acad Med 87: 12, 2012, pp. 1668-1678.

NOTES

1. Robert Francis, Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry, HC 947 House of Commons (London, Stationery Office, 2013). 2. Carl R. Rogers, Client-Centred Therapy: Its Current Practice, Implications and Theory (Boston, Houghton Mifflin, 1951). 3. Health Foundation, Measuring Patient Experience (London, Health Foundation, 2013). 4. Department of Health, A Review of the NHS Hospital’s Complaints System: Putting Patients Back in the Picture (London, HMSO, 2013). 5. Tom Reader, Alex Gillespie and Jane Roberts, “Patient Complaints in Healthcare Systems: A Systematic Review and Coding Taxonomy”, BMJ Journals 23: 8, 2013 . 6. Ibid 7. Camila Guiliani, Nathalie Gault, Valia Fares, Jérémie Jegu, Sergio Eleni dit Trolli, Julie Biga and Gwenaelle Vidal-Trecan, “Evolution of Patients’ Complaints in a French University Hospital : Is There a Contribution of a Law Regarding Patients’ Rights?” BMC Health Services Research 9: 141, 2009, , consulted 16 December 2018. 8. Department of Health, A Review of the NHS Hospital’s Complaints System: Putting Patients Back in the Picture, op.cit. 9. Department of Health, An Organisation with a Memory (London, HMSO, 2000). 10. Health Foundation, Measuring Patient Experience, op.cit. 11. Department of Health, Equity and Excellence: Liberating the NHS (London, HMSO, 2010). 12. Department of Health, A Review of the NHS Hospital’s Complaints System: Putting Patients Back in the Picture, op.cit. 13. Picker’s Institute, Core Domains for Measuring Inpatient Experience of Care (Picker Institute Europe, Oxford, 2009). 14. Picker’s Institute, Core Domains for Measuring Inpatient Experience of Care, op.cit. 15. Health Foundation, Measuring Patient Experience, op.cit. 16. Ibid 17. Department of Health, An Organisation with a Memory, op.cit. 18. Christine Wright, Suzanne H. Richards , Jacqueline J. Hill, Martin J. Roberts, Geoffrey R. Norman, Michael Greco, “Multisource Feedback in Evaluating the Performance of Doctors: The Example of the UK General Medical Council Patient and Colleague Questionnaires”, Acad Med 87: 12, 2012, pp. 1668-1678. 19. Health Foundation, Measuring Patient Experience. op.cit. 20. Judith Allsop, “Two Sides to Every Story: Complainants’ and Doctors’ Perspectives in Disputes about Medical Care in a General Practice Setting”, Law and Policy 16, 1994, pp.149-84.

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21. Sally Lloyd-Bostock and Linda Mulcahy, “The Social Psychology of Making and Responding to Hospital Complaints: An Account Model of Complaint Processes”, Law and Policy 16, 1994, pp. 123-47. 22. Department of Health, A Review of the NHS Hospital’s Complaints System: Putting Patients Back in the Picture, op. cit. 23. Mencap, Death by indifference (London, Mencap, 2007). 24. 25. Department of Health, A Review of the NHS Hospital’s Complaints System: Putting Patients Back in the Picture, op.cit. 26. Department of Health, A Review of the NHS Hospital’s Complaints System: Putting Patients Back in the Picture, op. cit. 27. Healthwatch England, Healthwatch England Annual Report 2015/6: Every Voice Matters (London: Healthwatch, 2015). 28. Linda Mulcahy, and Jonathan Tritter, Dissatisfaction, Grievances and Complaints in the NHS, A Report to the Department of Health (London, HMSO, 1993). 29. Judith Allsop, and Linda Mulcah, “Dealing with Clinical Complaints”, Quality in Health Care 4, 1994, pp. 135-143. 30. Linda Mulcahy and Jonathan Q. Tritter, Dissatisfaction, Grievances and Complaints in the NHS, A Report to the Department of Health, op.cit. 31. Judith Allsop and Linda Mulcahy, “Dealing with Clinical Complaints”, op.cit. 32. Department of Health, An Organisation with a Memory. op.cit. 33. Ibid. 34. It is commonly reported as the Mid Staffs scandal because it involved a hospital run by Mid Staffordshire hospital trust. Once a hospital gained foundation hospital status before the 2012 Health and Social Care Act, it meant that it gained semi-independence from the Department of Health. The trust was thus able to make its own decisions about how the hospital should be run and what actions should be taken to keep costs down. 35. Robert Francis, Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry HC 947 House of Commons (London, Stationery Office, 2013). 36. Cure the NHS, “About Cure the NHS”, 2018, consulted 15 December 2018. 37. Healthcare Commission, Investigation into Mid Staffordshire NHS Trust Foundation Trust (Summary Report) (London, Healthcare Commission, 2009). 38. Healthcare Commission, Investigation into Mid Staffordshire NHS Trust Foundation Trust (Summary Report), op. cit. 39. Robert Francis, Robert Francis Inquiry report into Mid-Staffordshire NHS Foundation Trust, HSC 1998/822 (London, Crown, 2010). 40. Ibid. 41. Sarah Calkin, “Ten Frequently Asked Questions: What is the Francis Report”, Nursing Times, 31 January 2013, consulted 10 January 2019. 42. See note 1. 43. Robert Francis, Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry, op.cit. 44. Peter Dominiczak and Rowena Mason, “More than 60 Mid Staffordshire hospital complaints to Government ignored”, The Telegraph, 24 March 2013, consulted 18 January. 45. Robert Francis, Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry, op.cit. 46. Robert Francis, Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry, op.cit.

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47. Ibid.

ABSTRACTS

Within the British National Health Service (NHS), a number of different methods are currently in place which actively encourage patients to judge the provision of health by sharing their experiences of care and treatment, completing surveys, etc. Testimonials are also a way of evaluating the provision of health care and are posted regularly on NHS websites (Patient Opinion, NHS Choices, etc.), but also on special care and charity websites. Providing an outlet for patients to complain can be a useful way of not only ensuring that individual rights to quality health care are respected but also of increasing awareness of safety-related problems within health organisations, or various problems relating to health care delivery. However, such information and other data on user experiences are not currently well aggregated or used to drive improvements in health care delivery. So, while the right to reply and using patients’ experiences and/or complaints might be a way to improve care, this paper underlines a number of difficulties in collating and effectively using such information. It uses a case study of the Mid- Staffordshire Hospital Trust negligent care scandal of the period 2005 to 2008 to illustrate why a patient-led approach to monitoring care provision is essential but difficult to implement in practice.

Un certain nombre de dispositifs sont actuellement en place au sein du système de santé britannique NHS, qui encouragent activement les patients à évaluer l’offre de soins de santé en partageant leurs expériences en matière de soins et de traitement, en remplissant des enquêtes, etc. Les témoignages sont également un moyen d’évaluer la prestation de soins de santé. Ils sont postés régulièrement sur les sites Web du NHS (Patient Opinion, NHS Choices, etc.), mais également sur d’autres sites consacrés à la santé. Donner aux patients un moyen d’exprimer librement leur contentement et leurs griefs peut être un moyen utile non seulement pour garantir le respect des droits individuels à des soins de santé de qualité, mais également pour sensibiliser davantage les organismes de santé aux problèmes de sécurité ou à divers problèmes liés à la prestation de soins de santé. Cependant, ces informations et d’autres données sur les expériences des utilisateurs ne sont actuellement pas bien agrégées ou utilisées pour améliorer la prestation des soins de santé. Ainsi, alors que le droit de répondre et de faire appel aux expériences et / ou aux plaintes des patients pourrait être un instrument utile dans le processus d’amélioration des soins, le présent article souligne un certain nombre de difficultés faisant obstacle à la collecte et à l’utilisation efficaces de ces informations. Il présente une étude de cas du scandale de négligence révélée à Mid-Staffordshire Hospital Trust, de 2005 à 2008, qui illustre la raison pour laquelle une approche centrée sur le patient pour surveiller la prestation des soins est essentielle, mais difficile à mettre en œuvre en pratique.

INDEX

Keywords: NHS, patients’ complaints, Mid-Staffordshire Hospital Trust, health policy Mots-clés: NHS, patients, plaintes, Mid-Staffordshire Hospital Trust, enquêtes patients

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AUTHOR

LOUISE DALINGWATER

HDEA, Sorbonne-université, Paris

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The Interplay of Health, Pleasure and Wellness in British Seaside Resorts: the Case of Skegness on the Lincolnshire Coast L'interaction de la dimension santé, plaisir et bien-être dans les stations balnéaires Britanniques: le cas de Skegness sur la côte du Lincolnshire

Mohamed Chamekh

Introduction

Water has been used as a source of therapy for centuries especially at times when old medicine was not effective as a cure for all ailments. Greek doctors started as early as 460 B.C. to 370 B. C. to recommend baths in waters high in Sulphur to treat diseases. The Romans used balneotherapy1 for the treatment of diseases,2 and it was under the latter that baths were widely used for therapeutic purposes. In Britain, the inland spas were the first health resorts. They were a destination for invalids to drink the waters of the springs. Bath was the most prominent inland health resort which appeared in Roman Britain. From the late sixteenth century, Bath started to attract health seekers and became the leading spa resort in Britain.3 Within the same tradition, other inland resorts like Cheltenham, Buxton, Harrogate, Tunbridge Wells and Woodhall joined Bath as health destinations. In France, water was used for treatment even in colonies. Colonies like Tunisia, Madagascar and Guadeloupe were sites of mineral spas which were appropriated by colonists for their use as sites to treat colonial diseases while Vichy, a spa town in France, was used for cleansing from colonial diseases and the re-integration into French civilisation.4 However, the way waters were used and the type of waters saw constant changes. These changes were concomitant with changes in medical terminology that

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characterised the use of waters for therapeutic purposes. In this regard, terms like aqua therapy, balneology, hydropathy, etc. appeared in response to changes in the use of waters for treatment. A major change was the use of seawaters for the treatment of diseases as many from the medical profession started to encourage their patients to visit seaside resorts for the treatment of diseases. Whole towns developed in response to an expanding number of visitors who took the waters in the quest of good health. In this regard, it needs to be mentioned that the growth of the seaside health resort was part of an overall context which considered nature as “curative”.5 Another aspect of the use of the seaside for health treatment was hydropathy which developed in the nineteenth century as an aspect of health establishments in seaside resorts. There were hydropathic institutes in many British seaside resorts where visitors stayed in metal rooms with compressed air. This air was meant to boost the oxygen levels in the body and at the same time clear “the air passages”.6 The importance of seaside resorts for a better health was partly driven by a growing stress on lifestyles and climates as factors contributing to health. This tendency was strengthened by an all-inclusive health strategy adopted by the Ministry of Health, established in 1919, which sought to combine preventive medicine, lifestyles, and better health care provision to improve the health of British citizens.7 British seaside health resorts have been the focus of seaside resort history8 and partly tourism history9, but their mention as sites for treatment was in the context of seaside history rather than a detailed analysis of the evolution of these resorts as sites for the health improvement or maintenance apart from few studies like Gilbert (1939), who focused on the economic and the demographic development of coastal and inland health resorts10 or Hassan (2003) whose focus was not on the seaside resort as a site of health per se, rather Hassan dealt with the seaside environment in general including recreation, pollution, the socio-economic factors influencing the development of seaside resorts, and the seaside resorts as a liminal space.11 However, the development or the prospective development of British seaside resorts as sites of wellness or as sites for the improvement of the “quality of life”12 remains understudied. 13 This is highly relevant especially with the growing concerns over the health needs of an ageing population and the challenges that should pose to the resources of the NHS and the constant decline of British seaside resorts as holiday destinations. This article seeks to address the following questions: how did Skegness, a British seaside resort, develop into a health seaside resort? Why did it change into a working- class playground? And especially: is it possible for Skegness to develop into a wellness, which in turn would reduce the strain on the NHS if the British population were healthier?

The growth of Skegness into a health resort

The development of Skegness into a health resort was mainly premised on the importance of seaside waters form treatment. Skegness waters were recommended to relieve different disease conditions. Lord Dawson of Penn, a royal physician, considered Skegness to be “the healthiest place in England” when recommending it to a patient from Nottingham.14 The accompanying text to an advertising poster in the Skegness local

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library, dating back to 1880, lauded this resort as healthy and salubrious with perfect sanitary arrangements and unequalled water quality. The health dimension of seaside waters was not specific to Skegness, but was common for all seaside locations. From the middle of the eighteenth century doctors started advising their patients to visit the seaside for health purposes.15 Being beside the seaside, plunging into the sea, walking by its side or drinking its waters were considered of health recuperative values.16 Seaside resorts took over the role of the inland spas like Bath, Harrogate, Tunbridge, Epsom, Scarborough, and Buxton. Hence, the bathing practices in the early seaside bathing places followed similar practices as those in the inland spas. Bathers were, for example, dipped in sea waters for health recuperative purposes, a practice which was common in inland watering places.17 Resorts were considered by Rob Shields (1988) in this era as “clinics”, and he labelled Brighton between 1730 and 1820 as “clinic Brighton”.18 The use of seaside waters for therapeutic purposes was strengthened with Dr Richard Russell’s recommendation of the use of seawater for the same purposes as the inland spa. In 1747, he published De Tabe Glandulari, which was translated as A Dissertation concerning the use of Sea-Water in diseases of the glands, in which he recommended the use of seawater for the treatment of consumption, cirrhosis, leprosy, gonorrhoea, scurvy, languor, epilepsy and so on. Dr. Russell, for example, recommended to one of his patients drinking “half a pint of sea water every morning at five of the clock”. At the same time, he considered cold sea bathing a prerequisite for a “great quiet of body and mind” and advised patients to drink a glass of sea water immediately after coming out of the sea.19 Dr. Russell’s Dissertation played a significant role in the spread of the cult of sea bathing for therapy purposes and henceforth the growth of seaside resorts to the extent that he was considered “the father of all seaside watering places”.20 Many places in Brighton bear the name of Dr. Russell (Russell Street, Russell Square, Russell Place) in recognition of the role he played in the growth of this seaside resort. Russell used for example to recommend Brighton for his patients when he was a practicing physician at Lewes.21 It was in this era that the sea water of Brighton was bottled and sold as medicine in London.22 Sea bathing soon became a health vogue which gained momentum with the visits of members of the royal families to the seaside for medical treatment. Acting on the advice of his physicians, the Prince of Wales, for example, visited Brighton in 1783 for the treatment of his glands.23 Similarly, the recovery of George III from a supposed attack of insanity was accompanied in 1789 with a long stay in Weymouth.24 Skegness followed the same developmental lines of the seaside resorts in England. It was referred to in early Directories as a bathing place frequently visited by people for health purposes.25 Stress was laid in most of these Directories on the importance of Skegness as a bathing place and its health qualities. Skegness was visited by the local gentry and respectable families who used to stay in Skegness for “sometime”26 mainly for health purposes. For this purpose, bathing machines were stationed in Skegness. These machines were meant to hide the body of the bather from observation and give the bather the chance to enjoy the pleasure of a plunge in sea waters, but in a way which ‘protect[ed] modesty’ and did not violate the norms of public decency.27 These machines were mentioned in Skegness in William White’s 1842 History Gazetteer and Directory of Lincolnshire,28 but they existed earlier.29 Similarly, Avery’s Penny popular guide

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to Skegness (1884) pointed to forty bathing machines which were stationed on the beach of Skegness.30 The presence of these machines in Skegness showed to a certain extent that the visitors to Skegness used to follow the norms of order, decency and respectability and a plunge in sea waters, sea air and a gaze at the sea were the major attractions of Skegness. As a health resort, Skegness saw the expansion convalescent homes specifically for its recuperative health qualities. The Hampshire advertiser referred in 1885 to Lady Scarborough’s orders for the building of a convalescent home on her son’s estate for children in Skegness.31 The 1900 Kelly’s Directory pointed to the Nottingham and Notts Convalescent Home for Men at Seathorne and a similar one for women at Castle Donington,32 and Dutton’s Directory of Skegness (1934) referred to the Derbyshire Miners and Friendly Societies Home, which was established by the Miners’ Welfare Fund in 1926, Nottingham Poor Girls Camp Society, Lady Scarborough Convalescent Home, National Deposit Friendly Society, and the Lewison Convalescent Home, and Boots Convalescent Home.33 The frequent reference to convalescent homes in Skegness showed the image Skegness accrued as a health resort and a major destination for health seekers. The growth of Skegness as a health resort was clear in holiday guidebooks of the nineteenth century and the first half of the twentieth century. Avery’s 1889, 1894, and 1898 Guidebooks of Skegness stressed the importance of Skegness for health. His 1889 and 1894 Guidebooks pointed to the fact that Skegness was “a health- restoring place”.34 In addition to the sea waters, the drinkable water of Skegness was considered of organic purity and of “first class quality”.35 The quality of water and the installation of an efficient sewage system made all conditions in Skegness “favourable for healthfulness”. 36 While highlighting both the quality of water and the drainage system in Skegness, The Sheffield & Rotherham Independent (1880) wrote: Skegness is provided with two very important elements, viewed from a sanitary point of view, so essential to the wellbeing of any town, and particularly one of this description to which thousands annually resort for the purpose of recruiting health.37 These aspects (sanitary arrangements and the quality of water) were stressed in other newspapers of the 1880s,38 something which could be explained by the importance of the quality of water and the sanitary arrangements in all ages for health. The focus on health continued in the first half of the twentieth century. The publisher of Picturesque Skegness (C 1900) considered Skegness a “well established seaside health resort”.39 Similarly, the opening pages of the Guide to Skegness and Wainfleet (1925) referred to “invalids and persons seeking health” as among the frequent visitors to Skegness.40 The importance of Skegness as a health resort was brought to the limelight through a conference on “Healthy Holidays for the Worker”, which was held in Skegness in 1937. Speakers at this conference underlined the health restorative values of seaside health resorts. Dr. R. Cove, for example stressed the effectiveness of sea bathing for the promotion of a “healthy vascular coordination”. Similarly, Dame Louise McIlroy addressed the conference on the treatment of gynaecological affections at seaside health resorts.41 The organisation of this conference in Skegness showed the continuing importance of Skegness as a health seaside resort at least till the late 1930s.

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Healthy air of Skegness (1840-1970s)

In addition to the waters of Skegness, the air of Skegness was considered of health recuperative values. A visitor to Skegness described the healing qualities of the Skegness air as follows: Farewell, wide expanded ocean, Boundless source of calm delight All thy breezes health inspiring Lent new vigour to this frame.42 This poem illustrates the way visitors considered their journey to Skegness in the early nineteenth century. A journey which was both therapeutic and at the same time a source of re-invigoration. Similarly, While referring to the health qualities of Skegness air, the holiday correspondent of the Standard (1885) stated that it “must be pronounced bracing enough to satisfy the most robust invalid”.43 In addition, while describing the elements that made Skegness a health seaside resort, the 1889 Avery Guidebook considered Skegness air to be one vital aspect of these.44 The same element was described in the 1894 Guidebook as ‘so pure’ and contained a large amount of ozone, which was seen as a “mysterious health giving element”.45 The same feature was stressed in Seaside Watering Places (2/6) (1888). “Skegness has”, according to this guidebook of seaside health resorts in England and Wales, “what is infinitely more essential to invalids and seekers after quiet and health in its bracing air and salubrious ozone laden atmosphere”.46 The dictionary of Watering places (1881) gave a similar depiction of the Skegness air.47 The air of Skegness was further stressed with the decline of confidence in the importance of sea waters for treatment. According to the 1926 Skegness Holiday Guide, if you wanted relief from asthma, bronchial complaints, or neurosis, visiting Skegness would be the solution.48 “After a few days” of visiting the resort, the Skegness Official Guide Book (1926) stated, “ the bracing air and atmosphere relieves [sic] those sudden paroxysms of difficult breathing, and the tightness of the chest diminishes”.49The writer of this Guide Book (1926) pointed to his own experience with Skegness, presenting a testimony to the fact that he visited Skegness when he suffered from glands and he was relieved after a short stay there. He stated that ‘the supreme thing about the place remains the quality of its air. The best advertisement for this Lincolnshire resort would be to put a taste of atmosphere in small liqueur bottle… The most anaemic city clerk, after a sniff at that bottle would feel capable of getting up and hitting Dempsey.50 In a similar vein, the cover page of the Skegness Holiday Guide of 1931-32 was full of references to the healthfulness of Skegness. It pointed to Skegness as the “Home of Health” and described the place as “bonny” and “bracing”. A brief search for the meaning of both words in the Oxford English Dictionary shows an association between these two and health. Skegness continued to be classified as a health resort in the 1930s. In this context, The Times section on weather continued to refer to Skegness as health resort in the 1930s,51 and the 1936-1937 Holiday Guide Book called on “busy longshoremen” and shipmates to benefit from the weather of Skegness for invigoration, freshness and fitness.52 The stress on the bracing air of Skegness, but to a lesser extent its healing qualities, continued in the second half of the twentieth century.53 This could be explained by the fact that this ‘commodity’ was abstract and hence did not require on-the-ground expenditure. The focus on sea air, as an aspect of the health bringing qualities of

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seaside resorts, was, according to John Beckerson and John K. Walton (2005), “accessible, free and pleasant”.54 It could also be explained by a continuation on the stress on health and healing as major attractions of this holiday destination.55 However, with the inflow of working class excursionists and especially during the golden years of mass tourism, Skegness changed from a health seaside into a working class playground.

A working-class playground

Skegness, despite the continuing emphasis on its healthy climes, changed into a working-class playground. The railway led to gradual change in the social constituency of the visitors to Skegness by bringing the industrial workers from the East Midlands, Yorkshire, and London.56 This type of visitors started to gradually replace the existing ‘well to do’ visitors.57 The extension of the railway to Skegness on July 28, 1873 served as a catalyst for this change, especially as this date was convenient for workers to visit Skegness because it was followed by the August Bank Holiday (the first Monday of August), from Lubbock’s Act of 1871, entitling workers to a day’s holiday. Railway Excursions to Skegness coincided with the second and third phases of railway excursions to resorts, which were respectively in the 1870s, 1880s, and 1890s.58 In comparison with the first phase (in the 1840’s), in which the working class holidays were still in their formative stages and the number of trippers was small, the last two had a serious impact on resorts because the demand for working class holidays was higher.59 Benefitting from the railway nominal fares (3 shilling),60 and the rise in real wages in the closing decades of the nineteenth century, workers arrived in special trains from Lincoln, Nottingham, Derby, London (King’s Cross) and East Midlands industrial towns in general. In Lincoln, workers made use of their foundry trips holiday, a four day holiday at the end of July granted by employers to foundry workers to improve their performance, and organised railway trips to Skegness and other resorts on the East Coast.61 To benefit from this holiday, workers in Lincoln, and in other parts of England, got involved in saving schemes through Friendly Societies, Mechanics’ Institutes, Sick and Dividing Clubs, saving schemes at work, political groups and even in streets.62 A comparison between the early railway excursions, which were organised to exhibitions by working class organisations like the Mechanics’ Institutes and Friendly Societies, and those organised by railway companies to the seaside revealed a major difference in the purpose of each. While the organisers of the former were motivated by the improvement of the health, the culture and the personal improvement of the worker through rational recreation,63 the latter were mainly driven by profit.64 The sheer number of excursionists to Skegness and their socio-economic profile led to the change of the social outlook and the tone of this seaside resort. Describing the excursionists from Lincoln, mainly the foundry workers who used to frequent the Lincolnshire resorts (Skegness, Cleethorpes and Mablethorpe), Lorna Nicholls (1978) stated that they were “weary people from the smoke-laden air of the streets of the city and the mean little houses which clustered around the foundries”.65 The change in the socio-economic profile of the visitors to Skegness was clear in the behaviour of the ‘new’ visitors. This led to the ‘departure’ of the long staying middle class families, especially those who looked for health and especially relaxation and quietude, in search of select seaside resorts, especially as the social mores brought by the working

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class visitors conflicted with norms of respectability and gentility that made many of these families choose Skegness for a holiday before the arrival of the railways. This was the case with all seaside resorts which were accessible in terms of money and fares to the workers of industrial towns.66 In Brighton, for example, Queen Victoria did not return after 1843 when she found that its inhabitants had become “very indiscreet and noisy”.67 The middle class left later to quieter resorts in search of “health-giving pleasure”.68 The change of the socio-economic profile of the visitors to Skegness led to a class conflict between those seeking health giving recreations and a wide section of the working class who sought to fully exploit their free time regardless of health or rational recreation. Being temporarily freed from the factory discipline, workers used to sing, dance, and specially drink until late. In this context, it seems relevant to point to a study by Dingle (1972) on “Drink and working-class living standards in Britain, 1870-1914” which coincided with the era of the excursion trains to Skegness. Dingle found that workers in this era spent most of their money on beer and spirits consumption. Dingle considered workers not morally prepared for the pay hikes and leisure time69 as the brief liberation of the workers from factories led to their indulgence in drinking and ‘noise and bustle’ in general.70 This issue continued in the first half of the twentieth century, something which made police superintendents in some resorts enlist the help of the licensees so as to reduce drunkenness and maintain order.71 Murray’s Handbook for Lincolnshire (1890) described Skegness after the invasion of trippers from Lincoln, Nottingham, and Derby as “the noisiest and most crowded of the Lincolnshire seaside places, except Cleethorpes” and concluded with the fact that it was not recommended for “quieter visitors”.72 Similarly, a local newspaper likened Skegness after the visits of masses of excursionists to Skegness in the August Bank Holidays of 1882 to Egypt after an invasion of locusts.73These years saw the gradual departure of the middle class families in search of resorts which were not in the reach of the excursionists and the working class holiday makers especially during workers’ holidays. In light of the role the railway companies played in bringing workers to Skegness, it seems safe to say that the railways changed Skegness from a health resort into a working-class pleasure playground. This was despite its remoteness, as there were remote resorts, such as in East Anglia, West Wales, and the West Country, that managed to preserve their exclusivity and which remained exclusive because of their remoteness.74 On the contrary, Skegness was appropriated by the working class. It became their holiday sphere and their zone of escape from the factory system and routine, something which was clear through the spread of working-class amusements in this resort. One main aspect of the transformation of Skegness into a working-class seaside resort related to working class amusements and patterns of consumption which adapted to the needs of the new visitors and showed the attempts to profit from mass tourism. In this regard, this era saw the spread of fish and chips restaurants in Skegness. Though it was a major component of the working class diet, the new fast food of the early years of the twentieth century became a main feature of working class popular culture.75 Referring to the spread of the fish and chips trade in Skegness, Winston Kime ironically pointed to the possibility of naming Skegness High Street Dyson’s Street after the Oldham trader who started the fish and chips ‘industry’ in England.76 This was concomitant with the spread of huts on the beach selling tea, beer, coconut, and

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shellfish as part of an overall attempt to adapt to the changing socio-economic profile of holidaymakers. Amusements could be used to decipher the transformation of the resort from a health resort into a working-class playground. The resort amusements were among the parameters Harold Perkin mentioned for the classification of seaside resorts. For Perkin, there should be a distinction between amusements like indoor baths, classical concerts, art galleries, and museums, and amusements like brass bands, donkey and pony rides, beach entertainers, and catch penny amusements.77 A comparison of publicity of the early stages of resort development with those of the second half of the twentieth century revealed a shift towards amusements as the main attractions of Skegness. Guidebooks changed their shift from the resort natural landscape in tune with the visitors’ quest for health to the resort open air amusements like donkey rides, shooting galleries, gambling, festivals, galas, gambling, and bingos. Similarly, there was a major change towards the artificial and the show type. Skegness was converted in the guidebooks of the second half of the twentieth century into a giant theme park. This could be noticed through the changes in guidebook captions, which considered Skegness to be “Britain’s Famous Holiday Playground” (1963), the “ passport to pleasure” (1978), or the “giant theme park with non-stop fun” (1981). These captions replaced the focus on the health dimension of Skegness in most references to Skegness both in directories and early guidebooks of Skegness. The importance of Skegness as a health seaside resort declined sharply with the transformation of Skegness into a working-class pleasure resort with the inflow of working-class excursionists to the resorts. This change was the result of the inflow of excursionists, and at the same time the growing popularity of biomedicine and the success of technology and laboratories from the mid-nineteenth century78 which affected the image of seaside resorts as health destinations. Nevertheless, “the healing power of nature”79 has recently come to the limelight with the renewed emphasis on seaside resorts as sites for wellness and health maintenance.

Skegness: A potential wellness resort

Skegness, in light of the changes in the tourism industry, seems well situated to benefit from wellness tourism. The stress on the development of wellness tourism in Skegness derives from the development of a new type of tourism worldwide which seeks to attract tourists seeking wellness. This type of tourism promotes physical exercise, intellectual development and relaxation which should lead to a balanced body, a relaxed mind and a better spirit.80 It is difficult to define wellness tourism. Oxford English Dictionary defines wellness as the the state or condition of being well or in good health, in contrast to being ill; the absence of sickness; the state of (full or temporary) recovery from illness or injury [and] the state or condition of being in good physical, mental, and spiritual health, esp. as an actively pursued goal; well-being.81 As it might appear from this definition, wellness is all-inclusive. It encompasses the mental, the physical and the spiritual. This definition is in tune with Kelly’s definition who considered wellness as the result of “a balance between wellbeing in the body, the mind and the spirit”.82 Similarly, for Edward H. Huijbens (2011), the difference between health and wellness lies mainly in the fact that the former is a state of being while the latter is

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defined by its purpose which is the improvement of the state of the body, the soul and the mind.83 Wellness tourism, however, is considered as a “subset of health tourism”.84 Sometimes, it has to do with other activities not necessarily related to treatment, but with a purpose of maintaining health. As a result, activities like physical exercise, massage, consumption of healthy food, were considered wellness activities.85This type of tourism is considered a niche market at the global level,86 which is gaining momentum. Wellness tourism could regenerate Skegness and seaside resorts facing major economic problems which is the case of most seaside resorts in Britain.87 Stephen J. Page et al., (2017) stressed the way wellness tourism could boost the fortunes of declining seaside resorts. They highlighted in particular the way the old mass tourism seaside resorts could develop into wellness destinations by combining both health and pleasure. They focused in particular on the way well-being tourism should be used to regenerate old seaside resorts especially through the development of small businesses, mainly those meant for health maintenance or promotion, which should combine both well-being and health which would in turn boost the economy of the UK coastal resorts.88

The UK government’s wellness strategy and the potential transformation of Skegness into a wellness resort

Time seems opportune for the transformation of Skegness into a wellness resort especially with the central government and the NHS’s emphasis on wellness as a way to prevent diseases. This was stressed in the 2018 government health vision which highlighted prevention as the government health approach. , Health and Social Care Secretary, outlined this vision in his foreword to the government document on health and social care, in which he considered prevention as the best way to save lives.89 The new recurrent message is “ one of being, or becoming more ‘well’ and, by implication, fitter, happier, and more productive”.90 Despite the constant decline of preventive health spending to local governments from 2009,91 the discourse related to wellness continued to rank high on the government health policy agenda. The transformation of Skegness into a wellness resort could be facilitated by the need of employers (business, industry, government) to control the cost of health care services by opting for strategies that would help them prevent diseases or reduce stress levels among employees.92 This is a major change in comparison with the era of the Industrial Revolution when holidays were considered a preparation for a new cycle of work, a relief from work and a short term recovery , while the new challenge is to “keep the workers fit and productive”93 to prepare them for long term endurance. This change was clear even within the NHS especially with the growth of NHS Trusts among the employees of many healthy establishments under the NHS that stressed wellness among employees. For example, York Teaching Hospital NHS Foundation Trust started a project that was meant to reduce absences from work, prevent diseases and ensure immediate intervention, which was part of an overarching program meant to ‘manage staff health and wellbeing’ and an all-inclusive approach to health which took into consideration aspects like lifestyles and environments as factors impacting on employees.94 This was the case with other NHS Trusts like South London and Maudsley

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NHS Foundation Trust, whose main objective was “to reduce the stress its staff were feeling within the workplace and to increase staff happiness and wellbeing so that they could continue to provide the best care for patients”. 95 Skegness could benefit from the Wellbeing Saturdays organised by the NHS Trusts for its employees by offering tourist services meant to boost the wellbeing of visitors seeking relaxation and physical activity.96 This could then be extended beyond this institution to other companies and institutions on a national basis. Skegness local Council could invest in wellness holidays in the fashion of the weekend and off-season holidays which developed in England in the 1980s and 1990s. This could be done in direct partnership with local governments who are now responsible for preventive healthcare or with local NHS Trusts, especially as some Trusts started initiatives with councils like Nottingham City Council to develop cycling initiatives and at the same times arrange events, like the National Bike Week, which were generally meant to encourage physical activity and boost the wellness of the employees.97 Wellness holidays could give a boost to Skegness especially out of the traditional summer holidays. This, however, does not preclude the fact that Skegness and other resorts in Britain need to cope with major challenges like competitive destinations abroad where holidays are cheaper, facilities better, and especially a more salubrious weather. Skegness local Council and the East Lindsey District Council could play a pivotal role in changing Skegness, in cooperation with local authorities, into a wellness destination especially with the increasing emphasis on the role of the latter in the development of appropriate health strategies. This was clear in the 2010 address by the Secretary of State for Health who focused on localism that was considered at the core of the new health care system. In this regard, he stated that “by giving local government control of public health resources, we will shift power and accountability to local communities and create healthy places with new partnerships in important areas”,98 which will help in addressing major problems such as depression and other health problems. This could be facilitated by the establishment of the wellbeing boards which should bring in the expertise of the NHS and public health leaders in each area to better address the health needs in each area.99 Skegness could be a prospective site for wellness tourism especially with the steady flow of the elderly to the resort. This is very relevant to Skegness which has seen a constant flow of elderly people to the resort from the late twentieth century and continued into the twenty first century. The percentage of people aged over sixty-five, among the residents of Skegness, was found in a study by Jane Atterton above the national level. This age category made 22.2 per cent of the population of Skegness in comparison with 16 per cent at the national level. The situation was similar in the early twenty first century in other coastal resorts. For example, the median age in coastal communities was higher than the median age in Great Britain in 2001 and comprehensibly the percentage of the elderly in coastal towns was higher than their percentage in Great Britain and made almost one quarter of the total population of coastal towns. 100 Skegness local authorities even called on old people to visit the resort. This was clear in a guide book of the late twentieth century (1995) where the language used seemed to avoid the use of the word old or elderly possibly in a bid to appeal to this age category. According to a 1995 guidebook:

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Skegness has a reputation as a resort for all the family and the young and not so young are all catered for here. The popularity of the resort to the less able is obvious. The flatness makes it an ideal resort to everyone, there are gardens to explore, a quiet game for of bowls, the model village to delight the eye, and of course the numerous cafes to relax in and watch the world go by. Come and enjoy a well-earned rest.101 As it might appear from this passage, it is true that there was a call to old people to visit the resort, but the problem is that the facilities and the recreations offered do not make of Skegness a place for people seeking health maintenance or wellbeing. In this regard, it seems sound to say that Skegness local authorities need to develop wellness facilities that could further boost the movement of old tourists to the resort. Skegness Council should support the development of facilities like all-weather entertainment and wellness centres, clinics and even local clubs with wellness objectives, which could help in attracting tourists seeking wellness, in particular among the elderly generation, especially as the government’s new health strategy seeks to prevent and manage physical and mental problems of an ageing population, which is expected to double by 2031 and should consequently pose serious challenges to local authority and NHS resources.102 In this regard, the Ministry of Health and the NHS have started promoting active ageing as a new strategy to prevent health problems, which according to the State Secretary of Health should be “the norm rather than the exception”. 103 This is, according to the Ministry of Health, part of an overarching strategy in which public health will be integrated with other areas like leisure so as to keep people “active and reduce isolation”.104 Skegness, local authorities and the NHS should benefit from a partnership that should promote wellbeing of an elderly generation and at the same time regenerate Skegness. This is a need because the NHS is under continuing pressure to cater for the needs of an ageing population. The local government and the NHS are faced with challenges related to the health needs of an ageing population whose health needs are increasing. In this regard, the local government and the NHS need to be more proactive as admitting people in hospitals would definitely cost more in comparison with the preventive measures that could lessen the financial burdens of medical treatment as the number of people aged 75 or above is expected to double by 2031.105 The location and the environs of Skegness make of this resort an ideal wellness destination for different age categories. The neighbouring Fens, the bracing air of Skegness, and the seaside could be re-packaged to attract tourists seeking fresh air, a space for physical exercise and relaxation. According to Page et al. (2017), The natural attributes of the coast and its association with healthy living can now be repackaged and rediscovered within the wellness paradigm by tourism entrepreneurs. Coastal resorts have many natural advantages that can be harnessed with well-being linked to tourism so as to attract the increasingly ageing populations of the new millennia, many of whom may rediscover the coast in a new age.106 The health attributes of the coast have been given further momentum with studies which associated between the coast and better health. For example, a 2012 study by the European Centre for Environment and Human Health found that people who live close to the sea were more likely to be in good health even in the most deprived areas. Research by the same Centre recommended the coast for stress relief.107Furthermore,

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analysis of the 2011 census found that some seaside resort, like Sussex for example, had more centenarians than anywhere in Britain and the sea air was considered as the secret for longevity.108 Therefore, Skegness and other coastal resorts need to develop new strategies of regeneration that stress health maintenance and wellness in seaside resorts. This is relevant despite the ongoing calls to make towns and the urban environment in general people-friendly, a quest which remains unaccomplished at least in the near future. 109 Nevertheless, the transformation of the old seaside resorts into wellness destinations is not without challenges. For example, the changing of old tourist installations, mainly hotels, into wellness facilities is a daunting task especially as the accommodation sector, has so far failed to respond to the needs of a new clientele who found in resorts in the Caribbean and the Mediterranean state of the art facilities and hence they had higher expectations of local tourist resorts. This is mainly because of the heavy costs of restructuring and partly because of the lack of initiative or what Andrew Clegg considered as “inertia”110Yet, Skegness could change from a mass tourism destination centred on the notion of escape involving hedonism and all the attendant pursuits into a wellness destination focused mainly on stress relief, physical activity and personal development.

Conclusion

Skegness started as a destination for health, but the inflow of the excursionists and the developments in medicine changed the place into a destination for excursionists seeking escape from work through pleasure. However, with the changes in tourism and local and national government health strategies, the resort could benefit from a better infrastructure which should cater for a new type of tourists seeking escape, recreation, spiritual and physical wellbeing. Mohamed Chamekh has a PhD in English Language and literature from the University of Rouen Normandy and is currently a lecturer at Ibra College of Technology, Sultanate of Oman.

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NOTES

1. Balneotheray is the treatment of diseases by using mineral springs. 2. Vivien Breitrück and Elena Nunn, “Health and medical tourism,” in The Long Tail of Tourism, ed. Alexis Papathanassis (Germany, Gabler, 2011), p. 57. 3. Peter Borsay, “Georgian Bath: A transnational culture” in Peter Borsay and Jan Hein Furnée (eds.), Leisure cultures in urban Europe, c. 1700–1870 (Manchester, Manchester University Press, 2016), p. 94. 4. John K. Walton, “Health, sociability, politics and culture. Spas in history, spas and history: An overview”, Journal of Tourism History 4:1 2012, p. 5. 5. Simon Carter, “Leagues of sunshine: sunlight, health and the environment” in Virginia Berridge and Martin Gorsky (eds.), Environment, Health and History (London, Palgrave Macmillan, 2012), p. 95. 6. Jennifer Wallis, “A machine in the garden: The compressed air Bath and the nineteenth century health resorts”, in Jon Agar and Jacob Ward (eds.), Histories of Technology. The Environment and Modern Britain (London, UCL Press, 2018), p. 76. 7. Jane M. Adams, “Healthy places and healthy regimens: British spas 1918–50”, in Virginia Berridge and Martin Gorsky (eds.), Environment, Health and History (London, Palgrave Macmillan, 2012), p. 114.

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8. The most prominent historian of British seaside resorts is John K. Walton. His works on seaside resorts go beyond the scope of the paper and include: John K. Walton, The English seaside resort. A social history 1750-1914 (Leicester , Leicester University Press, 1983). John Walton, Blackpool (Edinburgh, Edinburgh University Press, 1998). John Walton, The British Seaside: Holidays and Resorts in the Twentieth Century (Manchester , Manchester University Press, 2000). Other seaside historians include: John Hassan, The Seaside, Health and the Environment in England and Wales since 1800 (London, Routledge, 2016). John F Travis, The Rise of the Devon Seaside Resorts, 1750-1900 (Exeter, University of Exeter Press, 1993). 9. See for example Susan Barton, Working-class Organisations and Popular Tourism, 1840-1970 (Manchester, Manchester University Press, 2005). See also John K. Walton, “Seaside Tourism in Europe: Business, Urban and Comparative History”, Business History 53: 6, 2011, pp.900-916. 10. Edward W. Gilbert, “The Growth of Inland and Seaside Health Resorts in England”, Scottish Geographical Magazine 55: 1, 1939, pp.16-35. 11. John Hassan, op. cit. For liminality, this concept was first used by Van Gennep in Rites de Passage (1961). It was borrowed by Shields to refer to beaches as places on the margin (liminal zones) where order is suspended. See Rob Shields, “Images of Spaces and Places: A Comparative Study” (PhD diss., University of Sussex, 1988), 192. 12. Muzaffer Uysal et al., “Quality of life (QOL) and Well-being Research in Tourism,” Tourism Management 53, 2016, p. 244. 13. Studies of the development of British seaside resorts as sites of wellness are very few. The most relevant study is Stephen J. Page et al., “Case Study: Wellness, Tourism and Small Business Development in a UK Coastal Resort: Public Engagement in Practice,” Tourism Management 60, 2017, pp. 466-477. 14. Winston Kime, Skeggy! The Story of an East Coast Town (Skegness, Sashell Books, 1969), p.160. 15. E. W. Gilbert, op. cit., 21. 16. James Walvin, Beside the Seaside: A Social History of the Popular Seaside Holiday (London, Penguin Books Ltd, 1978), p. 11. See also John Alfred Ralph Pimlott, The Englishman's Holiday: A Social History (Brighton, Harvester Press, 1976), p. 52. 17. John Travis, “Continuity and Change in English Sea Bathing 1730-1900: A Case of Swimming with the Tide,” in Recreation and the sea, ed. Stephen Fisher, pp. 8-35 (Exeter, University of Exeter Press, 1997), p. 7. 18. Rob Shields, “Images of Spaces and Places: A Comparative Study” (PhD diss., University of Sussex, 1988), p. 186. 19. E. W. Gilbert, op. cit., p. 23. 20. John Whyman, “Aspects of Holidaymaking and Resort Development within the Isles of Thanet, with Particular Reference to Margate, circa 1736 to circa 1840” (PhD diss., University of Kent at Canterbury, 1980), p. 110. 21. Ibid., p. 116. 22. E. W. Gilbert, op. cit., p. 23. 23. James Walvin, op. cit., p. 20. 24. John Whyman, op. cit., p. 118. 25. William White, History, Gazetteer and Directory of Lincolnshire (Sheffield: R. Leader Independent Office, 1842), 302. See also, E. R. Kelly, Kelly’s Directory of Lincolnshire and Hull (London, Kelly Directories, 1889). E. R. Kelly, Kelly’s Directory of Lincolnshire and Hull (London, Kelly Directories, 1900). E. R. Kelly, Kelly’s Directory of Lincolnshire and Hull (London, Kelly Directories, 1905). 26. Richard Gurnham, The Creation of Skegness as a Resort Town by the Ninth Earl of Scarborough, n.d. Local and Family History, Lincoln reference and local Library, L. SKEG. 9, p. 2.

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27. John Alfred Pimlott, op. cit., p. 58. 28. William White, op. cit., p. 302. 29. Richard Gurnham, op. cit., p. 2. 30. John Avery, Avery’s Penny Guide to Skegness and Neighbourhood, with Map (London: Avery, 1894), p. 2. 31. “Lady Scarborough has given instructions for the preparation of premises,” The Hampshire Advertiser, July 11, 1885, p. 7. 32. E. R. Kelly, Kelly’s Directory of Lincolnshire and Hull (London, Kelly Directories, 1900), p. 490. 33. George Dutton, Dutton's Directory of Skegness (Skegness, Dutton Printing Co, 1934), p. 6. 34. John Avery, Avery’s Penny Guide to Skegness and Neighbourhood, with map (London, Avery, 1889), p. 2. John Avery, Avery’s Penny Guide to Skegness and Neighbourhood, with map (London, Avery, 1894), p. 2. 35. “Skegness,” The Leeds Mercury, June 5, 1880, p. 7. 36. Geo Ball, G, Sylvan Skegness (Skegness, Geo. F. Ball, 1932). 37. “Skegness, Lincolnshire,” The Sheffield & Rotherham Independent, March 20, 1880, p. 7. 38. “Skegness,” The Leeds Mercury, June 5, 1880. 39. Anonymous, Picturesque Skegness. (C. 1900). (Skegness, Ensor & Ball, c.1900), p. 1. 40. Abel Heywood, Guide to Skegness and Wainfleet (1925) (Manchester, Abel Heywood & Son, 1925), p. 7. 41. “Healthy Holidays for the Worker: Conference at Skegness,” The British Medical Journal: 1, 1937, pp. 876-878. 42. Eliza, “On Leaving Skegness,” in Methodist Magazine, January 1, 1811, 880, database of British Periodicals 43. “Skegness,” The Standard, September 10, 1885, p. 2. 44. John Avery, op. cit. 45. Ibid., p. 4. 46. Upcott Gill, Seaside Watering Places: A Description of Holiday Resorts on the Coast of England and Wales (London, L. Upcott, 1888), p. 43. 47. Upcott Gill, The Dictionary of Watering Places: Seaside and Inland at Home and Abroad. (London, Upcott Gill, 1881), p. 44. 48. Anonymous, Skegness Official Guide, 1926 L. SKEG.91. Skegness Library, p. 112. 49. Anonymous, Skegness Official Guide, op. cit., p. 21. 50. Ibid., p. 21. 51. “The weather,” The Times, October 10, 1933, 16. See also “The weather,” The Times, January 19, 1938, p. 14. 52. Skegness Urban District Council, Skegness Official Guide 1936-1937 (Skegness: Urban District Council, 1935), p. 5. 53. Skegness Urban District Council. (1963), Skegness. Lincolnshire. (Skegness: Urban District Council, 1963). See also Skegness Urban District Council Publicity Committee, Skegness Official Guide. (Skegness, Urban District Council, 1971). 54. John Beckerson and John Walton, “Selling air: Marketing the Intangible at British Resorts,” in Histories of Tourism: Representation, Identity and Conflict, ed. John Walton, 88-70 (Clevedon, Channel View Publications, 2005), p. 55. 55. Alastair Durie, “A Fading Movement: Hydropathy at the Scottish Hydros 1840–1939,” Journal of Tourism History 4: 1, 2012, p. 57. 56. “Skegness,” The Penny Illustrated Paper and Illustrated Times, August 25, 1906, p. 122. 57. James Mackley and Jennifer Mackley, Skegness through the Years: Skegness from an Agricultural Village to a Seaside Town (Skegness, U3A, 2005), p. 29.

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58. John Walton, The English Seaside Resort: A Social History (Leicester, Leicester University Press, 1983), p. 196. 59. Ibid., p. 198. 60. “One of the Brightest Original Posters,” Illustrated London News, April 11, 1908, p. 546. 61. Lorna Mary Nicholls, ‘Beside the Sea’ Concerning the Growth of the East Coast Resort around 1870 to the Beginning of the Second World War and the People Who Helped Them to Grow” (Diss. For the certificate of Local History, Bishop Grosseteste College, Lincoln, 1978) L. 91, Skegness Library, p. 8. 62. Susan Barton, “Why We're All Going on a Summer Holiday: The Role of the Working-class Organisations in the Development of Popular Tourism, 1850-1950” (PhD diss., De Montfort University, 1999), p. 93. 63. Susan Barton, “The Mechanics Institutes: Pioneers of leisure and excursion travel,” Transactions (Leicestershire Archaeological and Historical Association) 67, 1993, p. 47. 64. “Excursion Trains and Excursionists,” The Observer, August 19, 1861, p. 5. 65. Lorna Mary Nicholls, op. cit., p. 9. 66. Harold Perkin, “The Social tone of Victorian Seaside Resorts in the North-West”, Northern History 11: 1, 1976, p. 182. 67. Rob Shields, op. cit., p. 199. 68. Ibid., p. 206. 69. Anthony Dingle, “Drink and Working-class Living Standards in Britain, 1870-1914”, The Economic History Review 25: 4, 1972, p. 612. 70. John K. Walton, “The Social Development of Blackpool 1788- 1914” (PhD diss., University of Lancaster, 1974), p. 389. 71. “Drinking by Sunday Excursionists,” The Manchester Guardian, February 8, 1937, p. 10. 72. John Murray, Handbook for Lincolnshire, (London: John Murray, 1890), p. 168. 73. David Robinson, The Book of the Lincolnshire Seaside: The Story of the Coastline from the Humber to the Wash (Buckingham: Barracuda Books Limited, 1981), p. 64. 74. Nigel Morgan and Annette Pritchard, Power and Politics at the Seaside: The Development of Devon's Resorts in the Twentieth Century (Exeter, University of Exeter Press, 1999). 75. John K. Walton, “Fish and Chips and the British Working Class, 1870-1930”, Journal of Social History 23: 2, 1989, p. 243. 76. Winston Kime, Skeggy! The Story of an East Coast Town (Skegness, Sashell Books, 1969), p. 166. 77. Harold Perkin, opt. cit., p. 181. 78. Jane M. Adams, op.cit., p. 114. 79. Ibid., p. 120. 80. Áurea Rodrigues, Elisabeth Kastenholz, and Apolónia Rodrigues, “Hiking as a Relevant Wellness Activity-results of an Exploratory Study of Hiking Tourists in Portugal Applied to a Rural Tourism Project”, Journal of Vacation Marketing 16: 4, 2010, pp. 331-343. 81. Definition of “wellness” from Oxford English Dictionary Online, [16 October 2018]. 82. Catherine Kelly, “Analysing Wellness Tourism Provision: A Retreat Operators' Study”, Journal of Hospitality and Tourism Management 17: 1, 2010, p. 109. 83. Edward H. Huijbens, “Developing Wellness in Iceland. Theming Wellness Destinations the Nordic Way”, Scandinavian Journal of Hospitality and Tourism 11:1, 2011, p. 27. 84. Liyuan Huang & Honggang Xu, “A Cultural Perspective of Health and Wellness Tourism in China”, Journal of China Tourism Research 10: 4, 2014, p. 495. See also see also Anthony Gonzales, Logan Brenzel, and Jennifer Sancho, “Health Tourism and Related Services: Caribbean Development and International Trade,” Final report (2001), pp. 57-58. 85. Liyuan Huang and Honggang Xu. op. cit., p. 495. 86. Stephen J. Page et al., op. cit., p. 467.

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87. Works on the decline of British seaside resorts are many. See for example: Tim Gale, “Modernism, Post-modernism and the Decline of British Seaside Resorts as Long Holiday Destinations: A Case Study of Rhyl, North Wales”, Tourism Geographies 7: 1, 2005, pp. 86-112. Gareth Shaw and Allan Williams, The Rise and Fall of British Coastal Resorts: Cultural and Economic Perspectives (London, Mansell Publishing, 1997). Sheela Agarwal and Paul Brunt, “Social Exclusion and English Seaside Resorts”, Tourism Management 27: 4, 2006, pp. 654-670. 88. Stephen Page et al., op. cit., p. 466. 89. Department of Health and Social Care, Prevention is better than cure: Our vision to help you live well for longer, 05 November 2018, [28 February 2019]. 90. David MCGillivray, “Fitter, Happier, More Productive: Governing Working Bodies through Wellness”, Culture and Organization 11: 2, 2005, p. 125. 91. Ibid., p. 89. 92. Joseph Opatz, Economic Impact of Worksite Health Promotion (Illinois, Human Kinetics Publishers, 1994). 93. David MCGillivray, op. cit., p. 126. 94. York Teaching Hospital NHS Foundation Trust, “Improving staff health and, wellbeing”, June 2015, [24 October 2018]. 95. South London and Maudsley NHS Foundation Trust, “Improving Staff Health and Wellbeing”, 24 October 2018, [24 October 2018]. 96. For wellbeing Saturdays see for example: Nottingham University Hospitals NHS Trust, “Excellence in Employee Wellbeing”, June 2015, [24 October 2018]. 97. Nottingham University Hospitals NHS Trust, “Excellence in Employee Wellbeing”, June 2015, [24 October 2018]. 98. Department of Health, Healthy lives, Healthy People: Our Strategy for Public Health in England, Vol. 7985. (London, The Stationery Office, 2010), p. 32. 99. Ibid., p. 54. 100. Jane Atterton, “Ageing and Coastal Communities,” Report for the Coastal Action Zone Partnership Newcastle-upon-Tyne, Centre for Rural Economy. Newcastle University (2006). 101. East Lindsey District Council, Skegness, Ingoldmells and Chapet St. Leonards (East Lindsey District Council, 1995) 102. Department of Health, High Quality Care for All. NHS Next Stage Review Final Report. 26-27, June 2008, [24 October 2018]. 103. Ibid., p. 32. 104. Ibid., p. 48. 105. Ibid., pp. 26-27. 106. Stephen J. Page et al., op. cit., p. 467. 107. Eddie Wrenn, “Life's a Beach: Living Near the Coast is Healthier than Living Inland”, 17 July 2012, [18 December 2018].

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108. John Bingham, “Sea Air the Secret of Long Life as Census Shows Bexhill-on-Sea is Britain's Centenarian capital”, 25 September 2012, [18 December 2018]. 109. For further details on the attempts to make towns people-friendly see Francis Tibbalds, Making people-friendly Towns: Improving the Public Environment in Towns and Cities (London, Taylor & Francis, 2012) and Frey Hildebrand, Designing the City: Towards a More Sustainable Urban Form (London, Taylor & Francis, 2003). James Walvin op. cit., p. 11. 110. Andrew Clegg and Stephen Essex. “Restructuring in Tourism: The Accommodation Sector in a Major British Coastal Resort”, International Journal of Tourism Research 2: 2, 2000, p. 77.

ABSTRACTS

This article seeks to demonstrate the vitality of the health dimension in the growth of Skegness as a seaside resort. It shows the way changes in the medical profession, especially the use of seawaters for the treatment of diseases, contributed to the growth of seaside resorts in Britain. It highlights the way the health culture interacted with the principle of pleasure to contribute to the growth of seaside resorts. This paper also seeks to explore the potential role the National Health Service (NHS) could play in the transformation of Skegness into a wellness destination especially with the NHS emphasis on wellness as a new strategy to prevent and manage health problems, the constant inflow of an elderly generation into the resort, and an ageing population whose health needs are changing.

Cet article cherche à démontrer la vitalité de la dimension santé en tant que facteur déterminant dans le développement de Skegness en une station balnéaire. Il montre la façon dont les changements dans la profession médicale ont contribué à la croissance des stations balnéaires en Grande-Bretagne, particulièrement l'utilisation des eaux marines dans le traitement des maladies. Il met en relief la manière dont la culture sanitaire a interagit avec le principe du plaisir pour concourir à la croissance des stations balnéaires en Grande Bretagne. Cet article cherche également à examiner le rôle potentiel que le système de soins (NHS) pourrait jouer dans la transformation de Skegness en une destination de bien-être, tenant compte surtout de l’accent mis par le NHS sur le bien-être en tant que nouvelle stratégie de prévention et de gestion des problèmes de santé, sur l’afflux constant de personnes âgées dans les stations balnéaires et une population vieillissante dont les besoins en matière de santé évoluent sans cesse.

INDEX

Mots-clés: stations balnéaires, plaisir, NHS, vieillissement, tourisme de bien-être. Keywords: health resorts, pleasure, NHS, ageing, wellness tourism

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AUTHOR

MOHAMED CHAMEKH

Ibra College of Technology

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Wasteful Spending in Health Care: A US and UK international comparison Une étude comparative des dépenses inutiles dans la santé publique aux Etats- Unis et au Royaume-Uni

Max Holdsworth

Introduction

1 The United States and the United Kingdom approach health care very differently. The United States has a largely private health insurance system while the United Kingdom has a public single-payer system. Different histories and contrasting public values have set up the fundamental systems that each country has today. With the UK’s National Health Service recent anniversary of 70 years, it is important to look at its costs and benefits and compare them to systems in other countries. This paper looks into the role of wasteful spending in health care and asks how pervasive it is within the systems of the United States and the United Kingdom. Wasteful spending is a problem because it carries a high opportunity cost, unnecessarily excluding some services in substitute for others. Throughout this analysis I consider that the United States has a private health system because, although public single-payers exist such as Medicare and Medicaid, the dominant insurance scheme is through the employer and non-group coverage. The United Kingdom has a public supported single-payer system which asserts bargaining power and heavier regulation than in the United States. With the resources and definitions I use to explain wasteful spending, I show that both countries’ health systems have waste but the United States has more evident waste with respect to the UK.

2 In 2017 the OECD published a 300-page report to illustrate the prevalence of wasteful spending across OECD countries.1 This report considers wasteful expenditures those that bear high costs relative to their benefits. Although the word “wasteful” is used by

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the OECD, I also use the word “excessive” to express that certain procedures are used more often than medical evidence would recommend; such procedures are used in excess, and therefore constitute dollars wasted. “Low-value” care is also a term I use throughout the analysis to portray how value might be produced, even though the costs to benefits ratio may be exceedingly high. The OECD estimates that about one fifth of health spending across the OECD is wasted.2 Their report categorizes wasteful spending into three different types: wasteful clinical care, operational waste and governance-related waste.3 A related study, from 2012, by Berwick and Hackbarth, quantified wasteful spending in the US.4 Their classifications match up to that of the OECD and therefore I include their definitions to aid understanding.

The Three Forms of Waste in Health Care

3 The first form of wasteful spending is wasteful clinical care. Wasteful clinical care includes any spending on treatments that does not significantly improve outcomes. Such care was either unnecessary, low-value or the final outcome might have been worse than what another treatment plan would have offered.5 Partially, this problem could be the consequence of the patient or provider having an imperfect amount of information. Patients might have limited knowledge about their health condition and related interventions. In this case they may put too much trust in medicine and their provider’s ability to cure them, without assuming personal responsibility. Without critically thinking patients who can evaluate their own care, the provider can, even unknowingly, take advantage. The provider might be incentivized towards defensive practices and a roundabout of tests, which will lead to excess. When it leads to low effective treatments that could have been substituted with more effective ones, this information asymmetry is wasteful.

4 A collaboration of health specialists identified interventions that are commonly used in excess. Such interventions include imaging for lower back pain, antibiotics for upper respiratory infection, induction of labor and others.6 The OECD report suggests that such excessive interventions can be partly attributed to defensive medicine. Financial incentives that reward fee-for-service may be a contributing factor for over diagnosis and treatment.7 Although this category has directly to do with the care a patient receives, not all waste does; some forms of inefficiency, as explained below, create conditions that raise prices and exclude people from seeking the care they need. A Gallup poll conducted over the phone to a random sample of American adults found that in 2014, 33 percent of Americans put off medical care in the past 12 months for reasons of high cost.8 This percentage indicates a system that struggles to contribute to what is best for the health of the financially-burdened individuals. 5 The second form of wasteful spending, operational waste as the OECD defines, are “situations where health care could be produced using fewer or cheaper resources”.9 This category of spending deals with the functioning of the markets that provide and consume health care and services. Although this is considered a form of wasteful spending, it is unlike wasteful clinical spending because it assumes the patient receives the right amount of services.10 Competitive markets are expected to sell and purchase goods at a certain cost that is both reasonable and fair. Similar to the OECD, Berwick and Hackbarth address what they call “Pricing Failures” as one of their six forms of waste. They discuss such failures as the difference between prices in the true market

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and a “well-functioning” market.11 Even if this category produces the outcomes we desire, its prices might be higher than they should be. On a system-wide level, this prevents money being used for other purposes, and on the individual level, anyone without the means or assistance to pay these prices is inevitably harmed. 6 The OECD’s third and final form of wasteful spending is called governance-related waste. Administration is needed to run any health care system, but this category includes spending that is not essential to the delivery of health care.12 Countries’ health care systems differ vastly in their complexity, which contributes to understandable differences in administrative expenditure. For example, a single-payer system like the National Health Service has less administrative spending than the private insurance system in the United States.13 The OECD reported that administrative spending in the US was 8.2 percent of its total health expenditure in 2014, while in the UK administration as a percentage of total health expenditure was only 2.4 percent.14 In addition to wasteful administrative spending, this category includes intentional waste generated through corruption, fraud and abuse. In any large public or private enterprise in which there is profit we see attempts to take advantage of loopholes and weaknesses in the system. As the OECD suggests, increased transparency and common standards of reporting could help to detect and decrease this form of waste.15 7 The framework of wasteful spending presented by the OECD sets the stage for a critical analysis of any system of health care. Even though Berwick and Hackbarth concentrate on the United States, it is feasible to apply their framework to other countries. In the next section, I will use both resources heavily, along with others, to look comparatively at the United States and the United Kingdom.

Clinical, Operational and Governance-related Waste in the United States and the United Kingdom

8 The United States devotes almost double the percentage of their GDP to health care than the average of the OECD countries; in 2015 the US spent 16.8 percent of their GDP on health versus the 9 percent average for OECD countries.16 Even with this expenditure, however, health outcomes in the US fall behind many individual countries and the average OECD rates, such as life expectancy at birth and the infant mortality rate.17 International comparison by The Commonwealth Fund offers comparison between the US and the UK, which again reveals higher American spending with worse outcomes.18 This relationship points to a dissociation between higher spending and lower benefits in the United States’ health care system. Although I concentrate on the effects of health care, it is not the only factor impacting our health outcomes. A model from the University of Wisconsin Population Health Institute shows that the influence of clinical care on our health outcomes bears only 20 percent of the total influence of all health factors; much more impactful factors include economic and social factors such as employment and education.19 Even if a health system is well functioning, the health outcomes such as life expectancy can be determined in many other life style factors. Therefore, I should point out that while I give my attention to inefficient and high spending in health care, the objective to obtain a healthier population must be followed from a more dynamic policy structure that considers health through all of its contributory factors.

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9 In terms of clinical care, the United States’ private system lends itself to a large amount of waste. Patients get admitted for conditions that are preventable, for example, and care can be fragmented when doctors and hospitals do not discuss consistent plans for their patients. Additionally, the threat of malpractice litigation creates defensive medicine and pay-for-service schemes reward the amount of services over the outcomes they produce. Berwick and Hackbarth estimate that across the entire US health care system in 2011 at least $285 billion were wasted between failures of health care delivery, failures of care coordination and overtreatment.20 10 The OECD published data about the use of diagnostic tests across its member countries. In 2014, the rates of computed tomography (CT) exams ranged from 31.9 exams per 1,000 people in Finland to 254.7 exams per 1,000 people in the United States. The figures are normalized over 1,000 people to allow for comparison among countries with different population sizes. The OECD average for CT exams is 131.6 per 1,000 people, and the United Kingdom falls well below that average at 75.7 per 1,000 people.21 Although the data do not show a direct indication of wasteful testing across all exams, such great cross-country variation is one indication of excessive testing in the US particularly. 11 The next form of waste is known as operational waste and is considered to be a failure to procure the least costly goods and services to produce the same intended outcome. Berwick and Hackbarth estimate that pricing failures cost the US health care system at least $84 billion in 2011.22 Inflation measures the increase of the prices of goods and services, and for all products this is targeted by the US and the UK at 2.0 percent per year.23 Here I exemplify pricing failures through high inflation. Health cost inflation can indicate the stability of health care markets in the US and the UK. The Consumer Price Index (CPI) is a measure of the price of certain goods within a designated product or service basket. Chart 1 below displays the change in the CPI for both countries since 1990, including spending categories of all items and medical care/health prices alone.24

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Image 1002721400007492000057E67688A91336E4935F.emf

12 This graph shows that prices for goods and services rise over time. Data on the CPI of all items in the US and the UK show that increases have been consistent. In 2017, the CPI for all items in the US was 188 percent of (or 1.88 times) its value in 1990, and in the UK was 185 percent. On average, this was an increase of about 3.2 percent per year, the same for both countries. However, the CPI for health goods and services (defined as “Medical Care” in the US and “Health” in the UK) both show that health related prices are increasing at a relatively faster rate. In the US, the “Medical Care” CPI was 292 percent higher than it was in 1990, and in the UK the “Health” CPI was 224 percent higher than in 1990. The US had, on average, a 7.1 percent increase per year in the health CPI, and the UK had a 4.6 percent increase per year. Consistently, both countries have a higher inflation rate in health-related prices than for all products, but the difference between the two CPI’s is greater in the US. 13 These relationships show instability in the health market. While prices are the product of many factors, the steeper rise of the health CPI points to a more volatile market in the US. For the majority of the United States’ health care system prices are unregulated by the government. This lack of control subjects the prices of medical care and pharmaceuticals to market forces of supply and demand.25 On the other hand, as a single-payer of health services the NHS is guided by a budget (from 2009/10 to 2016/17 the NHS budget increased on average by 1.3 percent per year26) that offers constraints and necessitates bargaining to hold down prices. 14 The role of prices specific to the American health care system was written about by Anderson et al. in their article titled “It’s the Prices, Stupid: Why the United States is so Different from Other Countries”.27 In the paper they consider the relatively higher input prices of health care in the United States. They attribute this to higher physician salaries, more resource-intensive inpatient care and greater inefficiency.28 Their review of studies on health care payments and their benefits results in a similar conclusion

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seen in Chart 1. They claim that prices are the essential drivers for the overall expenditures of countries.29 The United States, as Chart 1 shows, has a high inflation in health prices, which directly but not independently, contributes to high spending. High prices come with high opportunity costs; if great sums of money are used for some treatments, other treatments must be sacrificed. If high value is not derived from those expensive treatments, money is unnecessarily diverted from other uses, representing a market failure. 15 On a larger scale, there are expenditures involved in operating and renovating health care facilities that may not be made at the lowest cost. Throughout the UK the public finance initiative (PFI) is a scheme to initiate public projects through private sector finance and ownership. For the NHS in England, according to Appleby from Nuffield Trust, there were 127 schemes of PFI contracts between the NHS, social care and the private sector in 2016; the value of those deals was nearly £13 billion.30 The wasteful aspect of PFI’s is that they cost more because of their involvement with the private sector. An article from 1999 showed that the contracts for hospitals in England under the public finance initiative cost 18 to 60 percent more than their construction costs.31 Although the private firms have a responsibility to the public authority that contracts them, they also have accountability to their shareholders. Therefore, the private lender expects a profit, and as the article shows, those lenders could gain real returns of 15 to 25 percent per year.32 Today the costs associated with the procurement of private finance are still apparent. According to a report in 2018 from the National Audit Office, PFI deals entered since 2013 were forecasted to give a return to investors of 2 to 4 percent above government borrowing.33 16 The PFI schemes help complete projects with a lack of public capital available to the NHS. Borrowing to construct hospitals and health service centers, which would have been traditionally a government responsibility in a nationalized NHS, now relies largely on contracts with private companies.34 In addition, the failure of these public finance initiatives is a possibility. For example, the recent liquidation of Carillion plc, which provided services to fourteen NHS trusts, including the building of two new hospitals,35 shows that financial risk is not avoided through PFI’s. Higher private borrowing rates, costs and risks incurred by PFI’s show that the NHS is not investing its resources at the lowest cost and rates available: designating it as a form of operational waste. 17 In terms of the third grouping of wasteful spending, governance-related waste, the United States and the United Kingdom differ. The independent review of wasteful spending conducted by Berwick and Hackbarth on the United States found that combined administrative complexity and fraud and abuse cost at least $189 billion in 2011.36 Although there are no such estimates of governance-related waste in the UK, common measures can help to describe the differences. The OECD report includes data on administrative spending across the member countries. The United States again comes out with the highest value: administrative spending in the US was 8.2 percent of its total health expenditure in 2014. However, the UK spent less on administration as a percent of total health expenditure than the OECD average (2.4 percent in the UK, and 3.2 percent average for all OECD countries37). The entire administrative spending of the US, although high, may not necessarily be wasteful. The US has a very complex health care system and therefore requires more administration. The comparative administrative spending may indicate that the US wastes money on administration, but it might simply show the natural costs of its fragmented care system. Estimates by

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Berwick and Harkbarth show us that non-negligible amounts of money are wasted through administrative complexity in the US: at least $107 billion in waste in 2011.38 18 Figures on combined management and administrative spending in the NHS help compare these costs. In a report by the Health Committee of the House of Commons in 2010, a figure shows the cost of management in the NHS between 1996 and 2009. During that period, the management costs of the NHS as a percent of the NHS budget actually fell from 5.1 percent in 1996-1997 to 3.0 percent in 2008-2009.39 Similar updated figures are more difficult to find. An undated estimate from The King’s Fund that combines spending on administrative and management says that about £8 billion of the £100 billion NHS budget is spent on management and administration.40 Another report from The King’s Fund shows that the number of NHS managers fell by 18.8 percent from 2010 to 2017, while staff numbers in other functional groups, such as nurses and ambulance staff, increased.41 On the other hand, according to NHS Digital, the mean annual earnings of senior managers in NHS Trusts and Clinical Commissioning Groups (CCG’s) in England was £77,435 in the 12-month period ending in September 2018, 2.2 percent higher the amount one year before.42 As with the United States, it is hard to designate such high salaries and spending in the NHS as wasteful. Health care systems serve a large amount of people constantly, and it would be simplistic to think that less administrative and management spending, without other structural changes, could lead to a more efficient system. In both countries, a more in depth cost-benefit analysis of spending on administration and management should be conducted to target its wastefulness.

Alternatives

19 The US and the UK’s health care systems both have varying amounts of wasteful spending. Those who have identified the problem of inefficiency and waste in the US’s health care systems have advocated for fixes in the legislative agenda. The Patient Protection and Affordable Care Act (ACA), which was passed in 2010, made a large legislative effort to expand insurance coverage, improve care delivery and control costs within the United States’ health care system.

20 To alleviate the magnitude of wasteful and fragmented care, the ACA made big changes to government-supported schemes of health care. Both Medicare and Medicaid were amended to incentivize accountable care organizations (ACO’s). Particularly, in Medicare, providers that organize in ACO’s and meet certain quality markers would be allowed to share in the cost savings they create.43 The integration of ACO’s into Medicare pushes forward cost savings as it establishes a shared financial incentive to provide coordinated and evidence-based care at the lowest cost. 21 To create better functioning markets for health insurance, the ACA also established the Medical Loss Ratio to limit the administrative costs and profits of insurance companies. The provision set a limit on non-medical spending to 15 percent of health insurance premiums. This means that a private insurance plan is required to use 85 percent of the premiums consumers pay on “clinical services and quality improvement”.44 Before the ACA, non-health uses of premiums were regulated only by competition to offer the lowest cost premiums. Although medical prices have continued to rise since the passing of the ACA, the Medical Loss Ratio ensures that premiums for health insurance are largely earmarked for health purposes rather than for administration.

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22 Compared to the US, the United Kingdom has an important institution in place to resist wasteful spending and high inflation in health care. Within the provision of clinical care, the National Institute for Health and Care Excellence (NICE), provides independent evidence-based guidance to policy makers and health care providers in England. NICE works to rigorously review new medicines, technologies and diagnostics. Their reviews assess new treatments on both their clinical- and cost-effectiveness.45 Amanda Andler, a consultant physician in England, summarizes that NICE “helps the NHS allocate resources to maximise health for the greatest number of people”.46 The NICE charter describes the methodological framework of their reviews, which include calculating Quality Adjusted Life Years (QALYs) that can be gained by new treatments in relation to the current treatment.47 Since NICE advises NHS England, their academic review process helps maintain the low-cost and effectiveness of covered treatment. The method of NICE’s approval also ensures that producers and providers choose high- value health care services. 23 High costs can also be addressed more formally in the UK. In March 2014, the Procurement, Investment & Commercial Division of the NHS published a report titled “Combating Inflation – Guidance”. The report advised NHS providers, specifically those in the procurement of services, to “resist blanket inflationary price increases from suppliers”.48 The report explained that NHS budgets at that time were not increasing, and therefore higher input prices would not be supported. This guidance exemplifies that resisting inflation can have great cost savings for the NHS; for example, Central Manchester University Hospitals NHS Foundation Trust (CMFT) avoided over £2 million in inflationary increases through such negotiations with suppliers.49 24 Advice like this, outside of the public providers of health care, such as Medicare and Medicaid, is unlikely to be public in the United States and might only occur on a small scale. The NHS document demonstrates the value of bargaining power throughout an entire country. A single-payer system like the NHS is able to conduct price negotiations that a private system like the United States’ cannot. The effects of such price negotiations can be seen in the CPI, where the UK’s health inflation is much lower than that of the US. The strength of the UK’s market to manage prices demonstrates too its ability to keep wasteful operational spending down. Their price negotiations do not appear to be related to lower quality compared to the US either, as shown by The Commonwealth Fund: their report from 2014 ranked the UK the first in quality care among eleven countries, including the US, which came in fifth. Similarly, another ranking, by the World Health Organization, ranked the United Kingdom’s health care system as higher than the United States in terms of overall health system performance (18th for the UK and 37th for the US).50

Conclusion

25 The United Kingdom avoids a lot of sources of wasteful spending that the United States faces. The United States tends to use excessive testing and clinical care, has high health costs and has significantly larger rates of administrative spending. Under Affordable Care Act provisions, including the integration of accountable care organizations, and current policy attempts to stabilize pharmaceutical prices,51 the United States is attempting to reduce its inefficiency. Under the Medicare single-payer program, which regulates its health providers, research has shown that a reduction in payments has

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kept down health care inflation.52 The UK increasingly recognizes that previous legislation has brought less-coordination caused by fragmented care. For this reason, NHS England is embracing integrated care systems similar to ACO’s.53 In terms of administrative spending, the UK’s Department of Health committed in 2010 to a reduction of administrative spending in the NHS and reinvestment of those funds to service delivery.54 Worldwide, too, there is an awareness that low-value spending affects our health care systems. The physician-led campaign to address wasteful clinical spending “Choosing Wisely” was started in the United States and now has expanded to both England and Wales.55

26 Although the United States and the UK are working to decrease wasteful spending, more work needs to be done. The United States needs to address its high prices in relation to the rest of the world, particularly because it harms people that are increasingly unable to afford the insurance or the care they need. The UK’s NHS, as it moves into the future from its 70th year anniversary, needs to support accountable care and integrated budgets to maximize the population health benefit given a limited NHS budget. It is important that both countries put greater monitoring on forms of wasteful spending, and important too is the acceptance of Choosing Wisely recommendations to reduce certain practices that physicians claim do not produce sufficient benefits. In a time when prices continue to rise, the population continues to age and chronic diseases threaten to keep us sicker for longer, it is essential that health care systems address wasteful spending and strive to produce the equitable and efficient care that people deserve. 27 Max Holdsworth is a recent graduate from the Master of Arts program in Urban Affairs and Public Policy at the University of Delaware, in Newark, Delaware, USA. His research interests are in data-driven public health interventions. During Max’s undergraduate and graduate degrees, he followed closely the trends in the health sector of both his home and paternal countries of the United States and the United Kingdom.

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World Health Organization, The World Health Report 2000, (Geneva, World Health Organization, 2000).

NOTES

1. OECD, Tackling Wasteful Spending on Health, (Paris, OECD Publishing, 2017). 2. Kalipso Chalkidou and John Appleby, “Eliminating Waste in Healthcare Spending”, British Medical Journal [Bmj] 356 (2017), p. j570 and OECD, Tackling Wasteful Spending on Health, (Paris, OECD Publishing, 2017).

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3. OECD, Tackling Wasteful Spending on Health, (Paris, OECD Publishing, 2017), p. 61. 4. Donald M. Berwick and Andrew D. Hackbarth, “Eliminating Waste in US Health Care”, Jama 307, no. 14 (2012), pp. 1513-1516. 5. OECD, Tackling Wasteful Spending on Health, (Paris, OECD Publishing, 2017), pp. 61-64. 6. Richard Hurley, “Can Doctors Reduce Harmful Medical Overuse Worldwide?”, BMJ : British Medical Journal 349 (2014), p. g4289. 7. OECD, Tackling Wasteful Spending on Health, (Paris, OECD Publishing, 2017), p. 73. 8. Rebecca Riffkin, Cost Still a Barrier Between Americans and Medical Care, 28 November 2014, https://news.gallup.com/poll/179774/cost-barrier-americans-medical-care.aspx, consulted 29 January 2019. 9. OECD, Tackling Wasteful Spending on Health, (Paris, OECD Publishing, 2017), p. 159. 10. Ibid., p. 159. 11. Donald M. Berwick and Andrew D. Hackbarth, “Eliminating Waste in US Health Care”, Jama 307, no. 14 (2012), pp. 1513-1516. 12. OECD, Tackling Wasteful Spending on Health, (Paris, OECD Publishing, 2017), p. 229. 13. OECD, Tackling Wasteful Spending on Health: Highlights, (Paris, OECD Publishing, 2017), http:// www.oecd.org/els/health-systems/Tackling-Wasteful-Spending-on-Health-Highlights- revised.pdf, consulted 29 January 2019. 14. OECD, Tackling Wasteful Spending on Health, (Paris, OECD Publishing, 2017), p. 232. 15. Ibid., p. 232. 16. World Health Organization, Global Health Expenditure Database, 25 January 2019, http:// apps.who.int/nha/database/, consulted 29 January 2019. 17. Reference made to data available from The World Factbook, Country Comparison :: Infant Mortality Rate, https://www.cia.gov/LIBRARY/publications/the-world-factbook/fields/ 354rank.html, consulted 29 January 2019 and The World Factbook, Country Comparison ::Life Expectancy at Birth physician-led campaign “Choosingacesation to nity cost, whereas on the individual level nd the UK, which assert the high spend, https://www.cia.gov/library/publications/resources/the- world-factbook/fields/355rank.html, consulted 29 January 2019. 18. Reference made to Karen Davis, Kristof Stremikis, David Squires and Cathy Schoen, Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally, 16 June 2014, https://www.commonwealthfund.org/…, consulted 29 January 2019. 19. University of Wisconsin Population Health Institute, What and Why We Rank: County Health Rankings Model, 2018, http://www.countyhealthrankings.org/explore-health-rankings/what-and- why-we-rank, consulted 29 January 2019. 20. Donald M. Berwick and Andrew D. Hackbarth, “Eliminating Waste in US Health Care”, Jama 307, no. 14 (2012), pp. 1513-1516. 21. OECD, Tackling Wasteful Spending on Health, (Paris, OECD Publishing, 2017), p. 74. 22. Donald M. Berwick and Andrew D. Hackbarth, “Eliminating Waste in US Health Care”, Jama 307, no. 14 (2012), pp. 1513-1516. 23. Board of Governors of the Federal Reserve System, Why does the Federal Reserve Aim for 2 Percent Inflation Over Time, 26 January 2015, https://www.federalreserve.gov/faqs/ economy_14400.htm, consulted 29 January 2019 and Bank of England, Inflation and the 2% target, 22 January 2019, https://www.bankofengland.co.uk/monetary-policy/inflation, consulted 29 January 2019. 24. Data sources for the US: Bureau of Labor Statistics, CUUR0000SA0 (all Items); CPI-all Urban Consumers (Current Series) and CUUR0000SAM (Medical Care); CPI-all Urban Consumers (Current Series), https://data.bls.gov/cgi-bin/surveymost?cu, consulted 29 January 2019; data sources for the UK: Office for National Statistics, Cpi Index 00: All Items 2015=100 and Cpi Index 06: Health 2015=100, https://www.ons.gov.uk/, consulted 29 January 2019.

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25. Reference made to The Economist, Why Trump’s Plan Will Not Cut Drug Prices, 19 May 2018, https://www.economist.com/leaders/2018/05/19/why-trumps-plan-will-not-cut-drug-prices, consulted 29 January 2019. 26. Reference made to data available from The King's Fund, The NHS Budget and how it has Changed, 02 May 2017, https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget, consulted 29 January 2019. 27. Gerard F. Anderson, Uwe E. Reinhardt, Peter S. Hussey and Varduhi Petrosyan, “It’s the Prices, Stupid: Why the United States is so Different from Other Countries”, Health Affairs 22 (2003). 28. Ibid. 29. Gerard F. Anderson, Uwe E. Reinhardt, Peter S. Hussey and Varduhi Petrosyan, “It’s the Prices, Stupid: Why the United States is so Different from Other Countries”, Health Affairs 22 (2003). 30. John Appleby, Making sense of PFI, 6 October 2017, https://www.nuffieldtrust.org.uk/resource/ making-sense-of-pfi, consulted 29 January 2019. 31. Declan Gaffney, Allyson M. Pollock, David Price and Jean Shaoul, “PFI in the NHS—is there an economic case?”, BMJ 319 (1999), pp. 116-119. 32. Ibid. 33. National Audit Office, PFI and PF2, (London: National Audit Office, 2018), p. 14. 34. Declan Gaffney, Allyson M. Pollock, David Price and Jean Shaoul, “NHS capital expenditure and the private finance initiative—expansion or contraction?”, BMJ 319, no. 7201 (1999), pp. 48-51. 35. NHS Improvement , Update on Carillion liquidation, 15 January 2018, https:// improvement.nhs.uk/news-alerts/update-carillion-liquidation/, consulted 29 January 2019. 36. Donald M. Berwick and Andrew D. Hackbarth, “Eliminating Waste in US Health Care”, Jama 307, no. 14 (2012), pp. 1513-1516. 37. OECD, Tackling Wasteful Spending on Health, (Paris, OECD Publishing, 2017), p. 232. 38. Donald M. Berwick and Andrew D. Hackbarth, “Eliminating Waste in US Health Care”, Jama 307, no. 14 (2012), pp. 1513-1516. 39. The House of Commons: Health Committee, Public Expenditure on Health and Personal Social Services 2009, (London: The Stationery Office Limited, 2010), p. Ev 179. 40. The King’s Fund, Myth four: the NHS has too many managers, https://www.kingsfund.org.uk/ projects/health-and-social-care-bill/mythbusters/nhs-managers, consulted 29 January 2019. 41. The King’s Fund, NHS staffing numbers, 20 May 2017, https://www.kingsfund.org.uk/projects/ nhs-in-a-nutshell/nhs-staffing-numbers, consulted 29 January 2019. 42. Reference made to data available from NHS Digital, NHS Staff Earnings Estimates - September 2018, Provisional Statistics, 20 December 2018, https://digital.nhs.uk/data-and-information/ publications/statistical/nhs-staff-earnings-estimates/september-2018-provisional-statistics, consulted 29 January 2019. 43. Kaiser Family Foundation, Summary of the Affordable Care Act, 23 April 2013, http:// files.kff.org/attachment/fact-sheet-summary-of-the-affordable-care-act, consulted 29 January 2019. 44. Kaiser Family Foundation, Summary of the Affordable Care Act, 23 April 2013, http:// files.kff.org/attachment/fact-sheet-summary-of-the-affordable-care-act, consulted 29 January 2019. 45. National Institute for Health and Care Excellence (NICE), NICE Charter 2018, https:// www.nice.org.uk/Media/Default/About/Who-we-are/NICE_Charter.pdf, consulted 29 January 2019. 46. Amanda Andler, “What Works? what's Good Value for Money? the Role of NICE for the NHS”, The Endocrinologist 127 (2018).

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47. National Institute for Health and Care Excellence (NICE), NICE Charter 2018, https:// www.nice.org.uk/Media/Default/About/Who-we-are/NICE_Charter.pdf, consulted 29 January 2019. 48. Finance & NHS Directorate, Procurement, Investment & Commercial Division (PICD), Combating Inflation – Guidance, March 2014, https://www.gov.uk/government/publications/nhs- resisting-cost-inflation-pressures, consulted 29 January 2019, p. 5. 49. Ibid., pp. 6-7. 50. World Health Organization, The World Health Report 2000, (Geneva, World Health Organization, 2000), p. 155. 51. Reference made to The Economist, Why Trump’s Plan Will Not Cut Drug Prices, 19 May 2018, https://www.economist.com/leaders/2018/05/19/why-trumps-plan-will-not-cut-drug-prices, consulted 29 January 2019. 52. Jeffrey Clemens, Joshua D. Gottlieb and Adam Hale Shapiro, Medicare Payment Cuts Continue to Restrain Inflation, 9 May 2016, https://www.frbsf.org/economic-research/publications/economic- letter/2016/may/medicare-payment-cuts-affect-core-inflation/, consulted 29 January 2019. 53. Chris Ham, Making Sense of Integrated Care Systems, Integrated Care Partnerships and Accountable Care Organisations in the NHS in England, 10 February 2018, https://www.kingsfund.org.uk/ publications/making-sense-integrated-care-systems, consulted 29 January 2019. 54. Reference made to Department of Health, Department of Health - Spending Review 2010, 20 October 2010, https://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/ MediaCentre/Pressreleases/DH_120676, consulted 29 January 2019. 55. Wendy Levinson, “Choosing Wisely Around the World: Professionalism as a Force to Reduce Unnecessary Care”, BMJ Opinion 2017.

ABSTRACTS

In health care, greater attention in the United States and the United Kingdom is being given to maximize the benefit of dollars and pounds spent. With the persistent increase in health care prices and demographic changes, evidence-based high-value care has become essential. This paper examines the nature of wasteful uses of health dollars. The United States wastes money in its unnecessarily high use of testing and procedures and through its volatile prices that affect how health services are managed. Administrative costs in the US are also high, due to its relatively unregulated system. This comparative analysis shows that the UK, on the other hand, spends less per-capita on health with verifiably better outcomes; nonetheless, the UK too has sources of low-value spending. More analysis of this problem could help to produce sound public policy, which would reduce waste and release resources for the improvement of services.

Dans le secteur de la santé, les États-Unis et le Royaume-Uni accordent une plus grande attention à l'optimisation des dépenses. Avec la hausse des prix et les changements démographiques, les soins de qualité fondés sur des recherches scientifiques sont devenus essentiels. Cet article examine la nature de l’utilisation inutile des dépenses consacrées à la santé. Les États-Unis gaspillent de l'argent en utilisant inutilement des tests et des procédures et en raison de la volatilité de leurs prix, qui influent sur la gestion des services de santé. Les coûts administratifs aux États-Unis sont également élevés en raison de son système relativement non réglementé. Cette analyse comparative montre que le Royaume-Uni, en revanche, dépense moins par habitant

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avec de bien meilleurs résultats. Malgré cela, le Royaume-Uni possède également des sources de dépenses à faible valeur ajoutée. Une analyse plus poussée de ce problème pourrait aider à élaborer une politique publique judicieuse, qui réduirait le gaspillage et dégagerait des ressources pour l'amélioration des services.

INDEX

Mots-clés: politique de santé, dépenses de santé, politique comparative, Etats-Unis Keywords: health care, low-value care, health spending, Choosing Wisely, comparative health policy

AUTHOR

MAX HOLDSWORTH

University of Delaware

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Interviews Entretiens

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Interview with a Clinical Equipment Training Co-ordinator and Union Representative

John Mullen

JM : When did you start working for the NHS and what are the different jobs you have done inside it ?

1 Gwyneth Powell-Davies : I started in January 1986 as a technician checking and repairing electronic equipment such as infusion pumps, patient monitors and so on. This has been a growing area as more technology has come into the health sector. The department name and the structure and even location of our larger employer has changed over the years but I still work for the same section which I would now describe as the 'medical equipment management organisation' within an ‘acute’ NHS Trust. We not only mend equipment but ensure the Trust has an accurate inventory, an equipment library, user training and can confirm action is taken on any nationally distributed 'Medical Device Alerts'.

2 In 2002, I moved sideways from my job as a 'senior' repair technician to become the 'Clinical Equipment Training Co-ordinator' organising and delivering a documented and recorded training scheme for clinically trained equipment users. Later I then moved ‘upwards’ in the structure of my department after my union supported me in achieving recognition of the greater responsibility of this role so that I am now employed on a higher grade.

JM : When did you first become a union rep, and what particular union roles have you played ?

3 G P-D : I joined the same union as other departmental colleagues soon after starting my work. This was the union (then ASTMS) that organised the Pathology Labs in many

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hospitals including our own and I found that there was only ONE rep in the whole hospital who worked in the labs. When he sent round a note about needing more reps, I volunteered. This was within a year of my starting. With the existing rep's support I visited all the departments with ASTMS members getting to know speech therapists, psychologists, pharmacy workers, the Medical Artist, Medical photographers, EEG and ECG technicians and, although I had no one contesting my rep position, we made sure there was agreement to my taking the role and I was voted in.

4 The NHS is a multi-union environment and there will be a Joint Union Committee in any large NHS organisation. Over the next few years I played a part in encouraging new workplace reps to come forward for our own union and I went along to represent our union at the JUC, briefly holding the role of JUC chair at one point. 5 After my second child was born in 1995 I managed to find a new person to take on the rep role for my own technical department but I always aimed to attend my union branch which covered NHS members in our union throughout a large geographical area around Bristol (up to Gloucester, down to Weston-Super-Mare and across to Salisbury). I held the relatively lowly branch officer role of 'vice-chair' in late 2008 but found myself stepping in to support the branch secretary as he became ill and then was readily elected for this more time-consuming role when he stood down. Since then I have always been a branch officer through some turbulent and interesting times for our large branch, due to NHS and union re-organisations and wider political debates. We have never, however, been a workplace branch that gets directly involved with negotiating with management. In large NHS organisations it is normally the JUC (not any individual union) that negotiates with management. 6 Since 2010, I have been an elected rep at work again and I could attend the JUC but I have left UNITE representation there to other UNITE reps, especially our senior rep who gets some dedicated days ‘facility time’ each week. 7 I am currently 'Co-Chair' of UNITE Bristol Area Health Sector branch (after deciding not to stand in the, this time contested, election for branch secretary). (I am ‘co-chair’ because the same meeting split evenly in voting for chair however many times they re- took the vote!) 8 Over the last eight years I have attended some national conferences (UNITE health sector, UNITE Rules and UNITE Policy conferences). I have attended various committees in the intricate UNITE structures including Area Activist and Regional committee and I have been an occasional UNITE delegate at the Bristol Trades Council (local all-industry union meeting of lay union activists from TUC affiliated unions). I currently attend the quarterly UNITE 'RISC' for my sector - South West Regional Industrial Sector Committee for Health.

JM : Could you briefly describe your present workplace, and your previous one if you have changed ?

9 G P-D : As briefly explained above I have not myself changed employer but the local sub-section of the NHS that is my employer has changed over my head. In 1986 I was taken on by Frenchay Health Authority. Based then in a Porta-kabin shared with the nascent IT department and situated between asbestos-roofed wards (originally thrown

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up in WW2) that characterised Frenchay Hospital, our department serviced equipment equally in the state of the art Neurosurgery department across the corridor and in all the other NHS organisations in a geographical area to the north and east of Bristol such as the TVs in long-stay wards for people with learning difficulties.

10 I sometimes joke that I shall probably finish my NHS career in a Porta-kabin as has been the fate of other non-clinical departments in what I characterise as the ‘health factories’ of today, built too small on the assumption that we can forever speed up the throughput of our human material. However for the moment I have the fortune to work on Level 6 of the PFI-built Brunel Building at Southmead Hospital and I can survey the slightly larger area where the ‘acute’ physical health needs of the population are served by North Bristol NHS Trust. For departments like mine so little has changed in a way. Our main work is for the operating theatres and wards in our stream-lined employer but ‘service-level agreements’ are signed for maintenance work for community organisations (though we tend to concentrate on medical devices these days).

JM : What is union density like ? How has it fluctuated in the years you have worked there, if it has ?

11 G P-D : Without checking statistics this will be an impression. I imagine my own department is a microcosm of the overall situation. For all unions in the NHS I should think union density has been sustained over the years with occasional boosts but a constant drain away as people retire. When I joined the NHS I found there were older members of staff who took it for granted that they should be in a union but it took effort by active union reps to pull in newer people or those who had resisted so far. This would also characterise the situation now.

JM : When you first began, what were the main issues in working conditions in particular, that unionists were concerned about ? What happened on these issues in the following years ?

12 G P-D : The NHS is a rock battered by the seas of neo-liberalism: cuts, privatisation, attrition of nationally determined terms and conditions.

13 In 1990, I petitioned with Junior doctors who kick-started an active local campaign against Mrs Thatcher’s government’s plans for the NHS. A slogan on a poster was ‘The Government is finalising its plans to dismantle the NHS’. It is just that the NHS (and its public support) has proved to be formed of harder strata than anyone realised.

JM : Was there a before and after 1997 ?

14 G P-D : The main thing most NHS staff would have noticed after the election of the Labour government would have been the move from the use of individual Trust logos for our headed notepaper back to the standard NHS banner.

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15 Looking back at the trajectory (to more cuts, more privatisation, more locally determined pay and conditions) there is no doubt that election of Labour was one of the brakes. Other brakes would be public and union campaigns to defend our NHS and the very real limits to the profits that can be made that occasionally become apparent. 16 However after their election defeat in 1997 Tory spending limits on the NHS were adhered to for the first two years. After that increased spending came with a ‘concordat’ with the private sector to remove limits on involvement in the provision of public health (see for example ‘NHS plc’ by Alyson Pollock.) One could characterise the situation as cuts OR privatisation under Labour but cuts AND privatisation under the Tories. 17 I finish writing this the week of the confident 2018 Labour Party conference which will leave many health campaigners and trade unionists enthused with hope that next time round a Labour government will be finally committed to reversing the trend of the last 30 years.

JM : What have been the main effects on you and your fellow workers of the various reorganisations of the NHS ?

18 G P-D : Each NHS re-organisation is announced as an improvement for patients but usually mainly entails an attempt to cut costs in some way. The gradual trajectory has been as I describe. For anyone who has managed to stay an NHS employee over the years I can discern less certainty about the future job and pension security than in previous years. For any union branch colleagues who find themselves outside the NHS there can be a very abrupt change to pay, pensions and job security.

JM : Recent decades have seen important changes in the way women, gay people and transgender people are seen in society. Has there been a development on the way management or union deal with issues pertaining to these groups ?

19 G P-D : In these areas there is absolutely no doubt that there have been improvements. Thirty years ago when AIDS was a new threat and of great concern to health workers, I heard the chair of a union committee (in the context that the disease was associated mainly with gay sex) talk about people bringing it on themselves. Such talk would be unacceptable now.

20 The whole ethos pushed by management and unions now is one of respect for all and celebration of diversity. Within unions there are equality roles and committees. Within my workplace, the chief executive (a woman) has an annual breakfast on International Woman’s day publicised and celebrated and to which any female employee can apply to go. I have just used a few clicks from the staff Intranet site to find there are guidelines ‘to support staff who wish to transition’.

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JM : What are the present challenges on working conditions and pay ?

21 G P-D : There has just been agreement on an NHS pay deal that was in the opinion of some ‘oversold’ to us by our own unions. GMB was the ONLY major NHS union to recommend rejection of the deal when union members were balloted. The deal was negotiated after a campaign by all 14 unions (including the non-TUC RCN, UNISON, UNITE, GMB and the smaller unions for dedicated groups of staff such as dieticians or radiographers). It did breach the government’s ‘pay cap’ of 1% but it ties us to a three year transition to a completely new pay structure that will involve an element of individual performance pay.

22 There is a possibility that anger will spill out over the paucity of the initial pay rise once it is coupled with the effect of the dates of annual increments and the already existing increases in pension contributions. However unless we have a national rebellion that changes the battlefield, the real challenge to trade unionists will be to get our colleagues to join the unions and strengthen the hand of the JUCs in local negotiations on the local interpretations of movement through the pay grades. 23 What is interesting is that the spark for some more confident local struggles has been sometimes the threats or effects of privatisation for smaller groups of our colleagues. The new scam is the ‘wholly-owned subsidiary’ where services are not even contracted out of the NHS but where an NHS organisation creates its own private company. At my Trust a strong campaign including a joint union petition knocked back one such plan. In other parts of the country plans have gone through but outrage has out when even the ‘oversold’ national pay deal is not applied to these newly privatised staff.

AUTHOR

JOHN MULLEN

Professeur, Université de Rouen Normandie

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Interview with an NHS speciality registrar

Louise Dalingwater

LD: How many years have you been working for the NHS and why did you choose this profession?

1 A: Nine years. I chose this profession because I enjoyed studying and learning about biological science, as well as the human interaction and contact that being a doctor gives you.

LD: How do you find the working conditions/generally working life?

2 A: Much better now that I am a registrar.1 There was a lot of administrative and amanuensis work2 when I was an SHO (Senior House Officer, that is, the grade below registrar). My working hours are generally as they are set out in the rota, apart from an hour or two here or there. I certainly don't have much to complain about compared to some colleagues in other specialties or locations, or indeed professions.

LD: Do you engage in private services/or are you encouraged to engage in private health care service alongside the public provision and what are your views on this?

3 A: I am unable to work in the private sector as I am not a consultant. I think that private work helps relieve some of the waiting list pressures. For example, the waiting time for seeing a consultant for one of my patients was 18 months.

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LD: You mention that waiting lists are a major issue and that privatisation might solve that. Could you perhaps elaborate on the waiting list issue and other issues that you think are actually preventing you from doing your job: that is providing quality health care, free at the point of use on an equitable basis?

4 A: Waiting lists are a major issue. I know that it affects various specialties, especially surgery where the solution has been to stop doing certain operations, though to be fair this may be the ones that are not very evidence-based or at least do not have strong evidence bases. As I mentioned below there was 18 months waiting lists in one of the DGHs (district general hospital) I was working in. There is a specialist clinic in London that has a two-year waiting list. People who, say, have their own business, cannot wait that long for operations, effective treatment of their conditions etc. so for them going private keeps their business afloat. However, this is not within the ethos of the NHS so purely NHS doctors would not acknowledge this as a good reason. Some specialties don't really have a private option, like emergency medicine, for example.

5 I think there is this massive fear that the NHS will get privatised and end up like the US system in its most extreme form prior to the affordable care act changes (not enough money, and no treatment for non-acute conditions). However, it is already partially privatised anyway but not in that sense and it would be realistic to admit that to survive in an increasingly ageing population, with more and more people surviving with ever increasing chronic conditions the NHS simply cannot cope without massive cash injections. So it may have to adapt more along the continental system with people contributing if they can afford it and obviously someone who is unemployed with no money would not have to pay anything. It would be career suicide to state this (hence the anonymity!) but I don't see how the NHS can cope without lots more investment. But of course, if there is a shift in budgeting, then fine let’s keep the NHS going as it is. But without a massive swing in budget, it will not be able to deliver effective care, and there will be lawsuits galore, people switching professions, loss of confidence and general decline. I know that historically this has never come close to happening.

LD: Apart from these pressures, how do you view the changing environment within the NHS? Have you noticed changes since you started working for the NHS?

6 A: I have noticed that we as doctors spend more and more time doing administrative work, which was not the case several years ago. I think doctors have become more fearful of patients complaining or suing them and think very much in medico-legal terms of what they are doing, but in a defensive manner.

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LD: How do you see yourself evolving within this organisation?

7 A: I see myself becoming a consultant, most probably away from the main teaching hospitals, primarily doing general clinical work.

LD: Do you have anything else that you feel might be relevant to our special issue on the 70 years of the NHS?

8 A: I think it is the main thing that holds the country together, and if it was to go (which is highly unlikely, but then so was Brexit a couple of years ago), there would be a palpable social fragmentation.

NOTES

1. In the UK, medical graduates begin their career as “junior doctors” and carry out a two-year work training programme. A speciality registrar (StR) has completed his or her two-year training but must still complete some training in his or her specialty to become a consultant. 2. Documenting the medical notes for another doctor.

AUTHOR

LOUISE DALINGWATER

Professeur, Sorbonne Université

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Book Reviews Comptes-rendus

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Review of In Search of the Perfect Health System by Mark Britnell

Hira Rashid

REFERENCES

Mark Britnell, In Search of the Perfect Health System, Palgrave and Macmillan, 2005, 233 p. ISBN 978– 1– 137– 49661– 4

1 In Search of the Perfect Health System captures the workings of incredibly diverse health systems in 25 chapters that provide brief but relevant country contexts, ranging from the formation and evolution of sickness funds in Germany in the 1883 and health management organizations in Israel in 1995, to the recent push for Kaigo Hoken1 in Japan at the turn of the 21st century. This book aptly captures the similarities across health systems such as limited public financing and coverage gaps between countries with sharp cultural and political contrasts –the United States and China, for example. It documents the economic and political forces spurring the wave of privatization in the welfare-oriented economies of the Nordic countries and tracks the intersection of healthcare innovation and public health policies in the rapidly growing countries of Mexico, Brazil and India.

2 However, it would be overly simplistic to view this work as a series of descriptive essays that summarize the workings of the health systems of countries around the world. Instead it is more accurately described as a commentary on the political, ideological, economic and cultural forces that shape the national and regional health systems of the world, and the strategies used by policy actors to tackle the challenges that arise. 3 This review first discusses five prominent themes that Britnell highlights through the course of the book, with notable examples from his analyses of national health systems. It then moves on to a critical analysis of the structure and content knowledge, and finally concludes with a brief section on lessons learnt and implications of this work.

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4 The first and perhaps most significant contribution of Britnall’s work is the identification of numerous strategies and practices worth replication within selected health systems he discusses in the book. In addition to a description of the financial distribution of healthcare costs, notable health indicators, healthcare delivery mechanisms, consumer access and patient satisfaction measures, each chapter provides critical insights into key policy measures undertaken by local or national policy actors to improve outcomes, reduce costs, or both. 5 The most valuable aspect of this analytical exercise, obviously attributable to Britnell’s extensive experience in the global healthcare industry, is the linkage of policy development to its eventual impact, and the lessons to be learnt from this process. For example, despite Portugal’s progress, Britnell traces the beginnings of a declining health infrastructure, higher out-of-pocket costs, reduced compensation for the healthcare workforce and a general disinvestment from the healthcare sector. He attributes this to the economic collapse, austerity measures and declining living standards in the country. Qatar, on the other hand, driven by the ambition to make its mark on the world, and unencumbered by resource constraints, launched an expensive National Health Strategy in 2011 and has even taken steps towards the launch of a universal health insurance system. However, as Britnell points out, the prioritization of channeling resources towards the construction of new hospitals may not necessarily lead to proportional improvements in population health. 6 Second, the book does a commendable job of delineating the drivers of fragmentation in the healthcare system as well as how it manifests through underutilization of available capacity, coverage gaps, depreciating quality of care, waste in the healthcare industry, overly burdensome administrative tasks for doctors and, subsequent declines in patient satisfaction rates and health outcomes. A consistent critique he levies on health systems – developed and developing - is the lack of standardized regulatory and quality control measures integrated and enforced by a central governance system at the country level. 7 This fragmentation, Britnell points out, is creating an increasing demand for private health insurance among consumers who are able to afford it, thereby reinforcing existing health inequities. The intersection of health policy and access barriers to essential health services grounded in socioeconomic, geographic and demographic inequities is woven into Britnell’s analysis. In the concluding chapters of the book, he aptly notes “two forces – globalisation and wealth inequality – will create fertile ground for the development of universal healthcare but its successful introduction cannot be taken for granted” (p. 155). 8 Third, true to his claim in the introductory comments, Britnell engages practitioners, policy makers and politicians by connecting the dots between hot button political issues and often understated, but vital aspects of the healthcare industry. He captures the impact of workforce shortages in countries like Japan, Hong Kong, Mexico, India and Brazil, where healthcare access is a growing priority for the electorate. He discusses the long-lasting impact of workforce immigration policies as ambitious, well- resourced countries like Qatar draw skilled professionals from the Global North and highlights potential issues with sustainability in the absence of local workforce education and training programs. He draws attention to the increasingly globalized nature of healthcare consumption by presenting examples of the increasing rates of medical tourism in South Korea, Malaysia, Singapore and Mexico.

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9 Fourth, a consistent unifying theme in Britnell’s analysis of these systems and policy measures is the importance of dynamism – policy action and institutional reorganization to address the evolving patterns of communicable diseases, chronic illnesses and ageing. He draws on the example of Brazil, where near-universal access to primary care and workforce distribution strategies to promote family-centered care models has contributed to considerable improvements in health outcomes. Singapore and Japan have introduced new insurance schemes with varying degrees of consumer choice to address the needs of its growing elderly population. South Africa is striving to contain the burden of communicable diseases by expanding access to screening and preventive interventions to remote rural areas using Tutu Tester mobile clinics, while Germany amidst growing pressures to contain growing healthcare costs, has taken steps to improve integration of care and taken legal measures to protect patient rights. 10 Finally, Britnell strongly advocates for patient empowerment in healthcare, urging healthcare delivery systems in developed countries to learn from the initiative of African nations such as Uganda and South Africa. He argues that despite the capital- intensive technological advancement and efficiency enhancing measures in banking and retail industries in countries like Germany, France and Switzerland, healthcare has lagged behind in terms of emotional and social support for patients, particularly those suffering from chronic conditions. He attributes this to two factors: “empowering patients has been viewed as the ‘right thing to do’ rather than crucial to the economic sustainability of healthcare systems, so it has not been pursued with any urgency; and clinicians are wary of the idea because it changes the power relationship between them and their patients” (p. 187). 11 Brevity is perhaps the most attractive feature of this book, yet its most significant limitation. Without further research into each country, one runs the risk of being ill- informed on the workings of these health systems, and the populations they serve. However, in his defense, Britnell opens with the claim that “each chapter can be read in the time it takes to drink a cup of coffee. This is not an academic treatise…” (preface). The book is unquestionably informative, but readers must understand its purpose to be that of an introductory discourse, since it embodies Britnell’s own perspective thus presenting only selective information about the complexity of how they function. 12 An important underexplored theme in this book is the intersection of investments in public health with the performance of the health systems. Recognizing the importance of this aspect of any health system, Britnell notes “we wouldn’t start from where we are, knowing what we now know” (p.211). Despite this, the country level analysis does not do justice to the significance of this statement. While he highlights the high immunization rates and tobacco control policies in Brazil, screening and lifestyle programs in Mexico and the concentration of socioeconomic risk factors among the aboriginal population of Australia, there is little that speaks to the integration of public health policy into the way health systems around the world are structured. 13 The improvement of health outcomes through the creation of accessible health services has increasingly been recognized as an instrumental aspect of the political and economic trajectory of a country. On the one hand, country governments face internal pressures induced by comparative insights into the drivers of affluence and longevity of the populations of the developed world. While on the other, rapidly shifting demographics, stagnating economies and growing gaps in quality of care have given rise to political unrest and unpopular financial restructuring to bring costs down.

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Consequently, health systems around the world are struggling to adapt to the changing needs of the populations they are designed to serve, which also straddling the line between cost efficiency and expected quality standards. Despite its title, the book does not in fact identify a ‘perfect’ health system, it does give the reader a realistic perspective of the issues facing those that are considered to be some of the best and is a timely contribution to the debate many economies around the world are facing.

NOTES

1. Kaigo Hoken refers to the long-term care scheme in Japan, which is expected to improve quality of life for the elderly population.

AUTHOR

HIRA RASHID

Research Assistant, Center for Community Research and Service, School of Public Policy and Administration, University of Delaware

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Compte rendu de l’ouvrage La politique de la petite enfance au Royaume-Uni (1997-2010) : « Une nouvelle frontière » de l’Etat- providence britannique? de Susan Finding

Aurore Caignet

RÉFÉRENCE

Susan Finding, La politique de la petite enfance au Royaume-Uni (1997-2010) : « Une nouvelle frontière » de l’Etat-providence britannique?, Paris : Michel Houdiard Editeur, 2018, 224 p.

1 Publié en 2018, l’ouvrage de Susan Finding résulte d’une recherche menée sur une vingtaine d’années et interroge ce qui a pu faire la nouveauté de la politique du gouvernement New Labour dans le domaine de la petite enfance et de l’accueil des enfants en âge préscolaire. Comme le titre l’indique, l’auteur se demande si cette politique des néo-travaillistes est innovante et constitue « une nouvelle frontière de l’Etat-providence », cette expression ayant été utilisée par Tony Blair dans un discours prononcé en 2005 au congrès du Parti travailliste. L’ouvrage permet de suivre les étapes de la définition d’une politique sociale nationale visant à l’accueil de la petite enfance en lien avec la politisation de l’enfance et de la famille. Placée au cœur du processus de rénovation de l’Etat-providence, la famille est devenue un instrument d’intervention sociale et économique via la création de mesures destinées non seulement à répondre à des besoins et à réduire des inégalités sociales, mais aussi à stimuler le marché de l’emploi dans un secteur des services en pleine expansion. A l’aide d’une approche

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politique, l’auteur offre une analyse détaillée de la politique familiale au Royaume-Uni qui s’est matérialisée dans un contexte de mutations économiques et sociales, ainsi que d’évolutions d’ordre politique et idéologique. Il en ressort que les évolutions politiques ont eu une influence sur les transformations opérées dans le champ d’intervention de la politique de la famille et de la petite enfance.

2 Les concepts de famille et de politique familiale sont définis d’entrée de jeu, tandis que la terminologie anglaise comme « care », « childcare » ou encore « early years education and childhood », est explicitée. Ainsi, des précisions quant aux termes équivalents utilisés en français sont apportées. Un récapitulatif sur la terminologie adoptée par l’auteur est proposé avant l’introduction afin d’éclairer le lecteur sur les différences de dénominations entre le système français et britannique en matière de petite enfance. Cet ouvrage composé de quatre parties découpées en deux chapitres chacune comprend également des annexes : une chronologie des mesures principales en matière d’accueil de la petite enfance allant de 1997 à 2017, une autre plus générale qui remonte jusqu’à la deuxième moitié du XIXe siècle, et un index. Quant à la bibliographie, celle-ci rend compte d’une documentation riche : en effet, l’auteur appuie son argumentation sur une grande variété de publications officielles (statistiques, rapports, documents gouvernementaux) et sur une connaissance fine de la littérature relative aux thèmes mobilisés dans cette étude, en particulier des travaux en analyse politique et sociologique. Nous regrettons cependant l’absence de numéros de pages dans la table des illustrations, d’autant plus que les tableaux qui agrémentent l’ouvrage sont d’une grande utilité en ce qu’ils permettent de synthétiser et de clarifier la démonstration à l’œuvre, notamment lorsqu’il s’agit de comparer les régimes sociaux de plusieurs pays dans la quatrième partie. 3 La première partie est l’occasion pour l’auteur d’examiner la politique de la petite enfance au Royaume-Uni et la façon dont elle a été inscrite à l’agenda politique et dans l’action publique. Le chapitre liminaire retrace l’évolution du problème social que représente la petite enfance au XXe siècle, jusqu’au moment où il devient une priorité politique absolue, en revenant d’abord sur la protection sociale de la famille depuis le début du siècle dernier – marqué par le libéralisme social – et sur des initiatives durant, et après, les deux guerres mondiales. Grâce à ce préambule, on comprend que ce n’est qu’à partir des années 1960 et 1970 que l’on prête attention à la question de l’accueil des enfants. En effet, cette période coïncide avec la libération des femmes et la revendication de la liberté de travailler. Mais à la fin de cette période, le Royaume-Uni connaît des difficultés économiques et une perte d’influence sur la scène mondiale et d’autres enjeux deviennent donc prioritaires. Si la décennie suivante est caractérisée par le dynamisme des associations et du secteur privé – à défaut d’un appui significatif de l’Etat – le début des années 1990 signale un intérêt plus marqué pour la famille, perçue comme un outil de lutte contre la désintégration sociale, ainsi que pour le développement du secteur préscolaire, devenu un enjeu électoral en 1997. L’auteur procède à un état des lieux de l’émergence de la politique de la petite enfance à partir du premier mandat des néo-travaillistes et sa consolidation jusqu’en 2010, ce qui permet de dresser un bilan des mesures mises en place. Finding revient sur les rivalités entre les secteurs public et privé, et entre les multiples formes d’accueil existantes, et met en évidence les différences d’offre en fonction des régions, des municipalités et des colorations politiques.

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4 La deuxième partie de l’ouvrage est consacrée à la place accordée à la famille dans les discours et les actes du New Labour et du Parti conservateur durant la période à l’étude, dans le but de cerner leur positionnement vis-à-vis de la famille. Si l’intervention de l’Etat dans la sphère privée reste limitée, le Parti néo-travailliste tente de donner aux parents les moyens de parvenir à un équilibre entre travail et vie de famille, cette dernière étant réactualisée en reconnaissant à la fois les valeurs traditionnelles et les évolutions de la société. A cet égard, le regard de l’auteur se porte sur les obstacles rencontrés par les familles politiques en matière de politique de la famille. C’est le cas lorsque le Parti travailliste au pouvoir fait la promotion de la famille traditionnelle pourtant associée au Parti conservateur, et que celui-ci tient compte de l’évolution du schéma familial afin de reconquérir l’électorat. Il est légitime de se demander s’il y a continuité ou rupture entre les politiques sociales menées par Major et Blair. Est mise en exergue l’influence mutuelle entre les deux Partis qui ont fait des incursions sur le terrain adverse : une fois au pouvoir, le Parti de Tony Blair s’est inspiré de thèmes qui avaient été développés par le Parti conservateur, lequel a ensuite tenté de se les réapproprier. Est ainsi soulignée une continuité dans les mesures des gouvernements successifs, qui caractérise, en outre, le retour au pouvoir des Conservateurs en 2010. 5 La partie suivante s’intéresse à l’approche pluraliste et synthétique développée par le New Labour dans le domaine des politiques sociales. Sont analysées la réforme des services publics et la tentative de traitement groupé de plusieurs problématiques, à savoir celles de l’éducation, de l’accueil des enfants, de la pauvreté infantile et du chômage. Le New Deal, une politique formulée pour favoriser le retour à l’emploi grâce, notamment, au développement du secteur consacré aux enfants en bas âge et aux familles, a permis à de jeunes chômeurs et à des parents isolés de retrouver un emploi. Bien qu’ayant contribué à une baisse du chômage et de la pauvreté infantile, Finding souligne que le secteur professionnel de la petite enfance a aussi donné lieu à une féminisation des métiers liés à la garde d’enfants en âge préscolaire et à la création d’emplois mal rémunérés et peu flexibles. L’auteur explique également que la réorganisation des services publics, qui tente de réunifier une pluralité de services et de structures tout en acceptant les variations qu’implique le principe de dévolution, repose sur une plus grande liberté (en termes de choix, d’innovation,…) et sur une concurrence amplifiée ; elle démontre que ce n’est pas l’Etat qui fournit les services mais que son rôle se limite à la régulation des services publics et à la stimulation des initiatives qui s’y rattachent. 6 Dans la dernière partie, l’auteur analyse l’évolution du modèle social britannique en proposant, en premier lieu, une réflexion sur les mutations de la société et de la famille au Royaume-Uni dans les années 1980 et 1990 et sur la responsabilisation des parents sous le gouvernement conservateur. Reposant sur l’association entre le travail et la famille, soit entre l’économie et le lien social, le capitalisme moral et social défendu par le New Labour est décrypté, et révèle une ingérence de l’Etat – somme toute limitée – dans le domaine privé qui s’apparenterait à une nouvelle forme de paternalisme. Enfin, le dernier volet de cette partie présente des typologies des régimes sociaux et des modèles de politique de la famille, l’objectif étant de situer le modèle social britannique par rapport aux modèles européen, scandinave et américain. Les études et statistiques sur lesquelles s’appuie l’auteur témoignent, d’une part, d’un rapprochement progressif avec les modèles sociaux européens ; elles montrent, d’autre part, une volonté de proposer un accueil de la petite enfance qui se rapproche du système scandinave. Or,

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comme le fait remarquer l’auteur, il y a un décalage entre les apparences et la réalité puisque l’argent public indispensable à une telle entreprise n’est pas injecté par l’Etat. 7 La conclusion présentée par Susan Finding, qui revient sur les succès enregistrés et les difficultés rencontrées par les néo-travaillistes dans la mise en place d’une politique de la petite enfance et la réforme de l’Etat-providence, met l’accent sur les ruptures caractérisant la philosophie du New Labour vis-à-vis de celle du Parti conservateur, mais aussi sur les continuités qui suggèrent une convergence des idéologies politiques. Finding rappelle que les réformes introduites à partir de 1997 n’ont pas été démantelées après 2010, d’où une mise en conformité du Royaume-Uni avec les normes européennes en matière de petite enfance, alors même qu’une sortie de l’Union Européenne est programmée. Afin de satisfaire la curiosité du lecteur, une postface offre une réflexion brève, mais éclairante, sur la politique sociale menée entre 2010 et 2017 par un Parti conservateur qui, en dépit de l’austérité, a fait perdurer le système d’accueil de la petite enfance de ses prédécesseurs ; c’est la preuve de l’importance accordée à cette politique, qui mérite qu’un ouvrage tel que celui-ci lui soit consacré.

AUTEURS

AURORE CAIGNET

Université Rennes 2, ACE

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Review of The Co-operative Movement and Communities in Britain, 1914-1960. Minding Their Own Business by Nicole Robertson

François Deblangy

REFERENCES

Nicole Robertson, The Co-operative Movement and Communities in Britain, 1914-1960. Minding Their Own Business. (Studies in Labour History), Abingdon-on-Thames, Routledge, 2016 [First published by Ashgate Publishing, 2010], 268 p., £41.99

1 In recent years there has been a quite remarkable upsurge of interest in co-operative principles, fueled by the last economic crisis and the simultaneous rise of the social and solidarity1 economy especially in the richest countries. Growing interest in these alternative stances on wealth production, social accountability and power-sharing has been brought about mainly by grass-roots initiatives but also acknowledged by public figures across the political spectrum2. Little attention had been paid to co-operatives from the second half of the twentieth to the beginning of the twenty-first century, despite their long-lasting influence – with the noteworthy exception of worker co- operatives in the late 1970s.

2 This is particularly true in Great Britain, where historians have extensively researched into and written about the labour movement, neglecting the somewhat less militant and tumultuous history of the co-ops. Nicole Robertson is senior lecturer in History at Sheffield Hallam University. In this book, she aims at reassessing the manifold impacts of the co-operative movement on various British local communities from 1914 to 1960. By covering half a century and the two major world conflicts, Robertson offers her readership a complete account of what co-operatives accomplished for the commercial, industrial, social, educational as well as cultural development of the country.

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3 In doing this, she follows in Arnold Bonner's footsteps and adds a local dimension to his major national study in this field3. The author uses many first-hand historical resources such as newspaper archives, meeting minutes, official statements of policy, advertising banners and business reports. She focuses on eight case studies of different origins, sizes and purposes, scattered over England, Scotland and Wales4. All of them are consumer coops: historically, the British co-operative movement has always been dominated by retail or consumer societies and this is why they are given such a leading role in the book. During the 1990s and the 2000s, influential works were produced by Gurney to show how this broad movement shaped consumption habits and challenged the hegemony of capitalist values5. 4 The book is divided into eight chapters, each examining one aspect of the movement in its contemporary organisational structure. The first chapter consists in a general overview of the development of the British co-operative movement at the time. Many figures – concerning membership, sales and much more – are given through the description of the eight consumer co-operative societies selected for the study. Some of these consumer co-operatives reached considerable sizes – hundreds of thousands of members in Birmingham or London – because "[c]o-operators offered a very different vision, one that shifted the focus beyond male workers, wages and unionism, and broadened out to incorporate the "woman with the basket", prices and consumerism." (p. 4). 5 Robertson then goes on to the main topic of her work and explains how dependent a community could be on a local co-operative society and how tightly-linked they could be. In some co-operative strongholds, societies were able to cater for the whole population and all needs – food, clothing, and mortgages for shelter – were supplied "from cradle to grave." Attempts were even made to build international communities based on lectures in foreign languages and exchange programmes between co-ops of different countries. 6 Communities were built and bound together by means of a shared ideology and sense of belonging. These are the objects of chapters three and four. A common raison d'être was found in opposition to unregulated capitalism, especially during the industrial downturns of the inter-war years. In the newspaper Co-operative News, the movement was personified as St George spearing a dragon identified as « the capitalist menace. » (p. 46-47)

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“The New St George”, Co-operative News, 14 December 1918

7 As the fear of a new global conflict grew, emphasis was placed on the international(ist) and pacifistic principles of co-ops. Despite all events organised locally – from sport contests to shopping weeks – aiming to develop social identification with the cooperative milieu, surveys carried out in the late 30s and early 40s proved that cooperative principles were widely ignored and attendance of quarterly meetings by rank-and-file members was extremely low – Robertson points out that the average attendance rate for London ranged from 0.03 to 0.22% between 1941 and 1947 (p. 59). The leaderships often concluded that this situation might be remedied by more concentration on educating society members.

8 The fifth chapter analyses, then, educational measures taken by the nationwide movement to promote co-operative ideals. The creation of education committees was encouraged through prescriptions to invest a minimal proportion of sales surpluses in educational programmes. This was one of the major failures in the local, practical application of policies designed centrally: when times were tight many societies simply spent the education budget on other priorities such as customers' dividends, in particular in Wales (p. 108). During the 1930s and along with the rise of the Welfare State, co-operative societies finally joined the campaign for the extension of the State- funded education system: "[…] the Co-operative Union advocated for free education in all forms of primary and secondary schools, and a maintenance allowance to be paid to enable children to stay at school from the age of 14 to 16 or 18." (p. 125) 9 Political action and representation of the co-operative leaders in the House of Parliament are tackled in chapters six and seven. The first political struggle led by co- ops was in favour of consumer rights. For example, they called for laws and rules to improve the quality of agricultural products, especially milk. The Co-operative Party was founded in 1917 to defend the interests of the movement in the House of Commons

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– first to protest against wartime quotas and taxation. After the 1918 general election Alfred Waterson became the first co-operative MP for the Kettering seat – one the oldest co-operative strongholds6. Not all societies were engaged in political action and the domination of the Labour Party in co-operative strongholds often led to an overlapping political representation. At grass-roots level, the Co-operative and the Labour Parties often worked successfully together though. After the Second World War, the Cooperative Party repeatedly fought for better housing conditions for working classes. 10 The final chapter of the book draws a portrait of the British co-operative societies as employers of labour and their relationships with the broader Labour movement. The vast majority of the workers in the co-operative movement were employed in retail societies and a tiny proportion of them in productive activities – by the mid-50s less than 5,000 workers were "self-employed" in true worker co-operatives registered in the Co-operative Productive Federation out of 360,000 co-operative employees (p. 183). As an employer of waged labour, the co-operative movement was often ahead of other industrialists: holidays with pay and the 48-hour week were both granted in the early twentieth century. During the 1930s, advertising campaigns stated that, as a cooperator, "You are sure that all L.C.S. [Leicester Co-operative Society] tailoring is done by workpeople earning good wages and working under decent conditions of employment." (p. 188-189) When such advances became widespread in the 1950s, new claims and complaints aroused, primarily concerning conflicting interests of employees and consumers of the co-operative societies – in many societies, the former were initially forbidden from having full voting powers for the management committee. As for relationships between the co-operative movement and trade unions, they were generally friendly and constructive: many societies helped strikers during the 1926 general strike and trade union membership was compulsory in most of them. 11 The thorough archival research work completed for this detailed study makes it a most valuable tool to explore and understand the dense connections between old cooperative societies and the communities in which they were born. This was especially true at a time when the range of needs catered for by the State was for more restricted than today. The two main inputs of this work are the exposure of the links between the activity of local co-operatives and the social and cultural interests of the working and lower middle classes and the delicate day-to-day application – when possible – of co- operative policies in the field on various scales. Given the small number of up-to-date studies of the cooperative history, this volume is a much needed reappraisal. Important milestones of history are discussed in a new light and the exceptional development of the British movement as well as its domination in the International Co-operative Alliance7 are documented. 12 One of the few existing worker co-operatives in that period might also have been chosen among the case studies to help us grasp not only the reasons for their tiny development but also their own role in the setting up of local communities, in the "cooperative heartland" of the Midlands, for instance, but this is a minor criticism of a fine piece of work. 13 François Deblangy est doctorant à l’Université de Rouen-Normandie et travaille sous la direction de John Mullen.

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NOTES

1. According to the International Labour Organization, « The SSE refers to enterprises and organizations (cooperatives, mutual benefit societies, associations, foundations and social enterprises) which produce goods, services and knowledge that meet the needs of the community they serve, through the pursuit of specific social and environmental objectives and the fostering of solidarity. », ilo.org, "Social and Solidarity Economy" 2. For the United Kingdom, see « Cameron launches 'co-op movement' », BBC News, 8 November 2007 and « Jeremy Corbin – 'We support co-operative principles – they are Labour principles' », The Co-operative Party, 14 October 2017 3. Arnold Bonner, British Co-Operation. The History, Principles, and Organisation of the British Co- Operative Movement, Manchester, Co-operative Union Ltd., 1961 4. Other studies of local co-operative societies mainly concerned the industrial North: see Julie Des Forges, « Cooperation and the working class in and the Rhondda », North West Labour History, Vol. 19, 1994/5; Jayne Southern, « Co-operation in the North West of England, 1919-1939: Stronghold or Stagnation? », North West Labour History, Vol. 19, 1994/5 5. Peter Gurney, Co-operative Culture and the Politics of Consumption in England, Manchester, Co- operative Union Ltd., 1996; Peter Gurney, « The Battle of the Consumer in Postwar Britain », The Journal of Modern History, Vol. 77, December 2005, pp. 956-987 6. The presentation of joint candidates with the Labour Party often limited the number of co-operative MPs elected but a first co-operative high tide was reached in 1945 with the election of 23 members. 7. The International Co-operative Alliance was created in 1895 during the first International Co- operative Congress to represent and serve the interest of co-operatives worldwide. According the first article of its constitution, « The International Co-operative Alliance, in continuance of the work of the Rochdale Pioneers and in accordance with their principles, seeks, in complete independence and by its own methods, to substitute for the profit-making regime a co-operative system organised in the interests of the whole community and based upon mutual selfhelp. »

AUTHOR

FRANÇOIS DEBLANGY

Doctorant en civilisation britannique, Université de Rouen

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Compte rendu de Le multiculturalisme britannique au 21ème siècle : Enjeux, Débats, Politiques d’Olivier Estèves et Romain Garbaye

Vincent Latour

RÉFÉRENCE

Olivier Esteves et Romain Garbaye, Le multiculturalisme britannique au 21ème siècle : Enjeux, Débats, Politiques, Paris : PSN - Les Fondamentaux de la Sorbonne Nouvelle, 2017. 96 pages, ISBN 978-2-87854-700-9

1 L’ouvrage comprend une introduction générale, qui invite le lecteur à dépasser la dichotomie parfois stérile en universalisme républicain et « communautarisme » britannique. Elle propose notamment trois niveaux d’analyse du multiculturalisme britannique, entendu dans ses acceptions descriptive, prescriptive et « gestionnaire » (discours, stratégies, politiques publiques dans divers domaines, relations entre Églises et État etc.).

2 Suivent six chapitres équilibrés : un premier, historique, qui revient sur les origines de l’immigration coloniale au Royaume-Uni, les conditions de l’émergence d’une société plurielle et de dispositifs volontaristes à visée antiraciste et antidiscriminatoire. Les cinq suivants sont thématiques : les nouveaux flux migratoires du début des années 2000, en phase avec les besoins de l’économie ; les « premières fissures », apparues au tournant des années 2000, sur fond d’interrogations sur l’identité britannique ; le racisme et à la xénophobie, sous leurs nouvelles formes (racisme « institutionnel » des forces de police ; question du « white backlash ») ; le tournant sécuritaire et anti- terroriste, notamment après les attentats kamikazes de Londres (2005) et son impact sur le multiculturalisme britannique ; un ultime chapitre qui revient, dans une

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perspective diachronique fort bienvenue, sur la « confessionnalisation du multiculturalisme britannique », des années 1980 à nos jours. 3 Enfin, les auteurs nous livrent une conclusion, concise, efficace et accessible, qui remplit pleinement l’objectif de l’ouvrage, rappelé par les auteurs : « contextualiser, synthétiser et clarifier des enjeux trop souvent résumés par une vision sommaire ». Elle revêt une dimension récapitulative et prospective, après le référendum de 2016 sur le Brexit, dont elle rappelle à bon escient la campagne indigne, et conclut sur les formidables ressources du multiculturalisme britannique, faisant pourtant souvent figure d’épouvantail ou de repoussoir. 4 Au final, on ne saurait que recommander très vivement la lecture de cet excellent ouvrage, pédagogique, synthétique et clair, qui s’appuie sur des sources variées et riches et sur les propres analyses, fort éclairantes, développées par ses deux auteurs, dont les travaux font autorité en la matière, en France et à l’international. L’ouvrage intéressera certes les étudiants en études anglophones (du niveau L à la préparation aux concours), mais aussi les étudiants en CPGE, sciences politiques ou grandes écoles, ainsi que leurs enseignants.

AUTEURS

VINCENT LATOUR

Professeur de civilisation britannique, Université Toulouse – Jean Jaurès

Revue Française de Civilisation Britannique, XXIV-3 | 2019