This essay is part of our ‘The NHS if’ series that explores hypothetical scenarios and their impact on the future of health and care.
If Beveridge were reporting today, he would be almost totally bemused. It is nearly 75 years since his mighty report on Social insurance and allied services, which is widely seen to have founded the modern welfare state and to have played a key part in creating the National Health Service. The world has changed more than a little since then. So what Beveridge would say today can only be a parlour game.
It has, however, to be incredibly short odds that he would look at the current NHS and at England’s social care system and conclude that the two were just not working well together.
He would note that there are many more older patients with multiple conditions and that modern medicine has long been able to rescue many with lasting conditions who would have died in earlier decades. Helping people with multiple or lasting conditions to live well can depend as much on social care as health.
He’d look back to Stephen Dorrell’s tentative plans for social care reform, to the million pamphlets written since then, to the Royal Commission on Long Term Care (accepted in Scotland, rejected in England) to the (now parked, and quite possibly canned) Dilnot report, to The King’s Fund’s Barker Commission and much else. And he’d decide it was time for action.
He’d conclude that no one is well served by having two separate systems run on two decidedly different sets of principles, and he’d recommend that the two become one.
'He’d conclude that no one is well served by having two separate systems run on two decidedly different sets of principles, and he’d recommend that the two become one.'
Before guessing at what he might recommend, it is worth recalling just how much the world has changed since 1942 – and thus why Beveridge would be bemused. Back in 1942, the worry was not a growing and ageing population. It was rather the reverse. The birth rate had been falling in the 1930s and ‘with its present rate of reproduction, the British race cannot continue… housewives as mothers have vital work to do in ensuring the adequate continuance of the British race’, Beveridge declared.
Women might have been pouring into the wartime workforce, building bombs, delivering Spitfires, staffing up industry. But only one in eight married women had worked before the war, and it was to be the early 1960s before all companies and professions ceased to require women to give up work on marriage. The school leaving age was 14. In percentage terms, hardly anyone went to university. Tax rates and thresholds were spectacularly different from today. Britain still had an empire. The economy was not remotely global, and banks were not what they are now. Life expectancy at 65 was around 12 years, not the 20-plus of today. There were fewer than 200,000 people aged over 85 against 1.5 million today. And so on and so on.
He would recognise the NHS as the fulfilment of his famous ‘Assumption A’ – that to make his new social security system work there had to be ‘a national health service for prevention and comprehensive treatment available to all members of the community’ and ‘without a charge at any point.’
He would recognise, just about, the current state pension system. But he would be horrified when he looked at the rest of social security – a structure that politicians of all parties now demeaningly and misleadingly dub ‘welfare.’ Beveridge built his social security system around national insurance – a ‘something for something’ society.
'But he would be horrified when he looked at the rest of social security – a structure that politicians of all parties now demeaningly and misleadingly dub ‘welfare’.'
‘Benefit in return for contributions, rather than free allowances from the State, is what the people of Britain desire,’ he declared, noting ‘the strength of popular objection to any kind of means test.’ These days, the link between National Insurance paid and benefits received has become almost vanishingly small, with National Insurance effectively just another tax, and a jobs tax at that. Working age benefits are overwhelmingly means-tested, even if the tax credits are much more generously means-tested than in Beveridge’s day.
And he would – as the past couple of decades’ history show – not find the task of marrying the largely free at the point of use NHS care to social care that is both heavily needs-tested, and then heavily means-tested, an easy one.
'For many people, free at the point of use health care is sacred.'
For many people, free at the point of use health care is sacred – even if there are in fact some charges, for prescriptions and dental treatment for example. These days they raise a little more than 1 per cent of the budget, though they have in the past raised as much as 6.4 per cent. It also remains sacred despite the history of the past 30 years, which has seen significant parts of what was NHS activity – billions of pounds worth of it – shifted across to the means-tested social care sector. For example, a significant percentage of those now in nursing or residential homes, and thus subject to both a needs test and a means test, would in the past have been housed, or even warehoused, in the often grim but nonetheless free, long-stay wards – the so-called ‘back wards’ – of NHS hospitals. The fact that this issue remains alive today is illustrated by the repeatedly moving boundary of what counts as NHS ‘continuing care’ and how far it should remain an NHS responsibility. And even if one were to adopt the idea of social care itself becoming ‘free at the point of use’ – a genuinely expensive option in terms of public spending – knotty issues remain about how to charge for accommodation as opposed to care within that.
Beveridge, if his report is anything to go by, would instinctively look for a national insurance, or social insurance, solution. But he might recoil from it. These days a full switch to classic social insurance is an unappealing answer. General taxation provides the widest possible tax base and is cheap to collect. Classic social insurance involves contributions from employees and employers, with some additional contribution from the state. But that has the effect of switching the cost of health (and of social care in a merged system) on to the working age population, thus raising the cost of employment. In an increasingly global economy, the aim should be to make jobs as cheap as possible to create and then to tax the income and wealth they produce. It is for precisely for that reason that, in so far as there has been a shift in mainland Europe’s social insurance systems, it has been to introduce more general taxation.
And even if Beveridge managed to sort the funding out, there remains the immensely important question of how to organise the newly integrated service. You only have to read his chapter on how a national health service might work – it bears very little relation to what Aneurin Bevan eventually did – to know that in this area he was better at finding funding answers than organisational ones.
It might be heresy to say it, but he might find it all too difficult. There are sections in his mighty report where he sort of gives up – for example, over ‘the problem of rent’ (a fair way to help people with housing costs). A problem, currently called housing benefit, with which we still live.
'To get to a fully integrated health and care system requires a painful trade-off.'
But he might just conclude – seeking to use ‘experience in a clear field’ to pinch one of the phrases in his report – that to get to a fully integrated health and care system requires a painful trade-off. Namely, that if English politicians and the English electorate are not willing to fully fund a jointly free health and social care system, then some new NHS charges may be needed in return for a better funded but fully integrated health and social care approach. Given his love of insurance, he’d probably seek to devise those charges (for a GP visit, outpatient attendance, or hospital stay, for example) in a way that made them insurable.
He would not be as popular as he was when his original report was launched – queues formed down Kingsway to buy it, and no government paper outsold it until the Profumo report in the 1960s. But he might decide that was the best way to sort out a bad job. What is certain as certain can be at this distance in time, is that he would see it as an issue that had to be tackled.
The views expressed in this article are those of the author and are not presented as those of The King’s Fund. We have commissioned external authors to write for ‘The NHS if’ series as a way of presenting different perspectives on the future of health and care. We welcome a diversity of views on this issue and encourage you to leave us your feedback.