124 Evidence submitted by Dr Martin Gorsky
(PPI 90)
SUMMARY
This memorandum describes the historical background
to patient and public involvement in the British health system.
This is not a new phenomenon but extends back
at least to the 19th century, in the form of voluntary sector
governance of GP and hospital services, and in local government
control of health care.
The growing role of the central state in health
provision undermined existing broadly-based forms of patient and
public involvement, which were finally ended with the coming of
the NHS in 1948. However this was unopposed because the goals
of a universal, comprehensive and free service satisfied users'
major requirements of the health system.
Patient consumerism expressed through voluntary
sector activity began to develop from the 1960s. A formal mechanism
of patient and public involvement in the NHS was established in
the 1970s with the Community Health Councils, which for the first
time separated representative from managerial functions.
Consideration of these earlier forms suggests
some inherent features, such as the tendency for power to remain
with medical professionals and administrators rather than users,
the scope for conflict between doctors and representatives of
the public, the possibility that local choices may conflict with
uniform national standards, and the tendency for voluntary representative
bodies to attract those already active in public life.
History suggests that broad issues which policy-makers
need to consider are: the specification of parameters for real
local decision-making by patients and public; and the need to
ensure consistently high levels of public awareness of representative
structures in order to attract a wide range of participants.
Present proposals for strengthening local government's
consultative and community advocacy role could represent a return
to the main direction of policy pursued prior to the NHS, of ensuring
democratic responsiveness of health services through the local
ballot box.
1. INTRODUCTION:
AN HISTORICAL
PERSPECTIVE ON
PUBLIC AND
PATIENT INVOLVEMENT
(PPI)
1.1 The recent series of reforms which replaced
Community Health Councils (CHCs) with new forms of PPI in the
National Health Service (NHS) are apparently driven by two dominant
political assumptions. These are:
(a) An understanding of the citizen as critical
consumer, and no longer the deferential recipient of services.
(b) The premise that welfare states fall
prey to producer interests and that these must be tempered by
user input.
1.2 Although both these assumptions suggest
that PPI in the health system is a new issue, it has an extensive
history, stretching back long before the inception of the NHS
in 1948. Earlier forms of PPI include:
(a) The oversight of general practitioners
(GPs) by friendly societies before the introduction of National
Health Insurance (NHI) in 1911.
(b) Public involvement in the governance
of voluntary hospitals before these were nationalised under the
NHS.
(c) The local democratic processes to which
municipal health services were subject before 1948.
(d) The creation of CHCs as an aspect of
the 1974 health service reorganisation.
1.3 This memorandum provides an historical
perspective on the Committee's second and third terms of reference,
consideration of the different forms of PPI and the background
to the reform process. It will discuss in turn these earlier experiences,
and show why PPI has been weak within the NHS.
2. BEFORE NATIONAL
HEALTH INSURANCE:
PUBLIC OVERSIGHT
OF GPS
2.1 The central state's involvement in primary
care delivered by GPs dates back to 1911 and the coming of National
Health Insurance. Prior to this sickness insurance was widely
provided by non-profit, mutual organisations known as friendly
societies.
(a) Benefits were a cash payment to replace
lost income and GP attendance to certify and treat the sickness.
(b) Membership expanded from the 1850s. By
1911 probably some 40% of all adult males had sickness cover.
(c) Friendly societies had strictly observed
electoral procedures through which working-class members could
serve on management committees.
2.2 GPs were employed locally by friendly
societies to provide services, usually on an annually renewable
contract. The contractual basis of employment meant that management
committees exercised direct leverage over the appointment, conduct
and costs of GPs.
2.3 In the early 20th century friction between
GPs and societies had developed. The bacteriological revolution
raised the status of medicine and GPs resented being subject to
committees of workers.
(a) The British Medical Association (BMA)
instigated the "battle of the clubs". It documented
local disputes and drew up guidelines for members to follow in
dealings with friendly societies.
(b) Conflict was mostly over the question
of remuneration and lack of deference on the part of patients.
(c) But GPs also argued that independent
medical judgement might be sacrificed if they were beholden for
their livelihood to the whims of users, as expressed through management
committees. Examples included over-prescribing of drugs, colluding
with malingerers and unnecessary home visits.
2.4 NHI substantially increased the numbers
of citizens with sickness coverage. It also reconfigured the relationship
between users and GPs in favour of the doctors.
(a) Friendly societies became agents of public
policy as "approved societies" for the administration
of NHI, but without their previous leverage over GPs.
(b) The annually renewable contract was replaced
with a per capita fee for participating GPs serving a "panel"
of patients.
(c) Panel GPs were now answerable to a local
Insurance Committee, in which user representation was diluted.
2.5 Conclusions:
(a) A form of PPI in primary health care
dates back at least to the 1850s.
(b) The "battle of the clubs" demonstrates
that PPI can be a source of conflict between medical professionals
and users.
(c) Behind this conflict there was a status
asymmetry presumed by doctors between themselves and users, founded
on social class and scientific expertise.
(d) The doctors' dislike of PPI cannot be
ascribed solely to self-interest. Concerns that independent medical
judgement should not be compromised by lay people remain current
today.
(e) User power was diminished as a result
of state intervention, though coverage, quality of service and
GP remuneration all improved.
3. BEFORE THE
NHS: PUBLIC INVOLVEMENT
IN THE
GOVERNANCE OF
HOSPITALS
3.1 Prior to 1948 most acute hospital care
was provided in the voluntary sector. The establishment of independent
voluntary hospitals began around the 1750s and their main features
were:
(a) Reliance on voluntary funding sources,
originally philanthropy.
(b) Honorary and unpaid service by hospital
consultants.
(c) Volunteer management by unelected lay
trustees.
3.2 Voluntary hospital management committees
were self-selecting bodies drawn from local industrial and professional
elites and religious activists. Their powers included:
(a) Appointment of doctors, though this was
ceded in the later 19th century to medical committees.
(b) Control of admissions, also increasingly
ceded to doctors in the later 19th century.
(c) Management of income and expenditure.
(d) Regular visiting of the hospital and
oversight of medical care on behalf of patients and donors
3.3 After 1914 the composition of management
committees became more representative of hospital users. This
was because of the changing structure of hospital funding.
(a) From 1914 charity was superseded by user
fees and payments from working-class hospital contributory schemes.
(b) Contributory schemes provided voluntary
insurance against hospitalisation. For a small weekly sum, workers
were exempt from means-tested user fees on admission.
(c) Contributory schemes had strictly observed
workplace electoral procedures allowing ordinary subscribers to
serve on hospital governing bodies.
(d) Trade unionists and friendly society
leaders figured prominently amongst those who took such positions.
(e) Typically these "worker governors"
were in a minority on hospital management committees, with a third
of the seats.
3.4 Despite their minority position the
worker governors exerted some leverage over hospital policy because
contributory income was essential to finance. For example:
(a) They expressed patient concerns over
issues such as waiting times, visiting rights, and medical treatment.
This was a minor part of their work.
(b) They ensured that contribution rates
were kept low relative to local wages.
(c) In some areas they rejected means-testing
and kept the hospital free at the point of use.
3.5 Occasionally worker governors expressed
strong preferences arising from the special interests of local
contributors. This placed them in conflict with doctors and hospital
authorities. For example:
(a) Gloucester 1920s: anti-vaccinationist
governors wanted the voluntary rather than the isolation hospital
to treat smallpox patients. They were overruled.
(b) Sunderland 1930s: worker governors wanted
to sack hospital doctors taking industrial injury cases on behalf
of coal-owners. They were overruled.
(c) Nationally: They supported trade union
actions to improve pay and conditions of nurses and ancillary
workers. Here their dual role as guardians of contributors' funds
meant disputes tended to be resolved consensually.
3.6 Conclusions
(a) A form of PPI in hospital governance
dates back over two hundred years.
(b) Voluntary governing bodies were not directly
representative of users. Initially they were dominated by wealthy
philanthropists. When they became broader, working-class representation
fell to those already active in the labour movement. This tendency
for voluntary representative bodies to attract those active elsewhere
in public life is likely to be repeated today.
(c) Worker-governors were most successful
in defending user interests in respect of equitable funding and
free access to services, both principles later enshrined in the
NHS.
(d) Worker governors were least successful
when they expressed local preferences at odds with medical or
managerial opinion. Ultimately power remained with medical and
professional elites. Localism had clear limits where it was at
odds with national priorities and the same is likely to be true
today.
4. BEFORE THE
NHS: MUNICIPAL HEALTH
SERVICES AND
LOCAL DEMOCRACY
4.1 Prior to 1948 much public expenditure
on health services was made through local government. It came
principally from local taxation, although some services were part-funded
by Treasury grants. The major municipal health services of the
interwar period were:
(a) Isolation hospitals, mental hospitals,
long-stay hospitals (originally the Poor Law workhouses) and by
the 1930s some general acute hospitals.
(b) Environmental services including sanitation,
housing and waterworks.
(c) Tuberculosis (TB) dispensaries and sanatoria.
(d) The school medical service.
(e) The maternity and child welfare (MCW)
services, including midwives, clinics and hospitals.
4.2 These services were overseen by committees
of county borough, county or district councils.
(a) Public health committees were made up
of elected council members, with a permanent public official,
the Medical Officer of Health, acting in an advisory capacity.
(b) Committee structures varied between councils.
In large cities and counties health responsibilities were also
exercised by education, mental health and public assistance (Poor
Law) committees.
(c) Local health policy and expenditure levels
were therefore subject to local democratic procedures and committee
makeup largely determined by party composition.
4.3 There was considerable variation between
local authorities with respect to levels of health spending and
the comprehensiveness of services.
(a) Spatial variation is now criticised as
a "postcode lottery", but government in the 1930s regarded
it as a desirable manifestation of local choice in action.
(b) It sought to aid disadvantaged areas
by refining the central grant mechanism, so that greater Treasury
support for health expenditure went to poorer authorities with
greater need.
(c) None the less geographical unevenness
remained on the eve of the NHS.
4.4 There is no clear research evidence
that local choice expressed in the ballot box directly influenced
local health policy.
(a) A key determinant was wealth: richer
areas spent more on health, poorer areas spent less.
(b) There was a weak positive correlation
between Labour representation on councils and greater expenditure
on TB and MCW. However these services were those sustained by
Treasury grants which privileged poorer areas likely to return
Labour councillors. There may therefore be no causal link with
party policy.
(c) Another measure of "progressive"
health policy was the degree of improvement of Poor Law hospitals.
Councils led by all political parties undertook this. Party programmes
were not the key determinant.
4.5 Conclusions
(a) Another form of PPI with which Britain
experimented before 1948 was the situating of health services
within local government, thereby making them subject to local
democracy.
(b) In practice local choice influenced committee
make-up although more specific democratic influence on health
policy is hard to detect. Health was only one among many issues
on which voters made their choices at local elections.
(c) Local policy was therefore determined
largely by the resource base and by public officials.
(d) Localism led to uneven provision. It
was, and perhaps still is, inherently at odds with the goal of
universal high quality services.
5. THE COMING
OF THE
NHS: WHAT HAPPENED
TO PPI?
5.1 The NHS Acts of 1946 and 1947 ended
all these arrangements.
(a) The Insurance Committees overseeing GPs
were replaced by Executive Councils with a similar lay/professional
mix.
(b) Both voluntary and municipal hospitals
were nationalised and placed under the control of Regional Hospital
Boards (RHBs) and local Hospital Management Committees. Their
members were appointed by the Minister of Health.
(c) Most personal health services were removed
from local government, leaving only environmental health, domiciliary
care, school medicine and some maternity care subject to local
democracy.
5.2 There was no significant political opposition
to these changes.
(a) The Labour Party had previously favoured
a local government-run NHS, but this proved politically difficult
due to the objections of the BMA. The nationalisation and regionalisation
scheme was a pragmatic alternative.
(b) The contributory scheme movement accepted
its demise, although existing worker-governors strenuously protested
their exclusion from the new hospital management structures.
(c) Aneurin Bevan, architect of the NHS,
assumed that democratic control of health services would be enhanced
through ministerial oversight and parliamentary scrutiny. He had
had first-hand experience in South Wales of earlier forms of PPI,
through his positions in a local Medical Aid Society, and as a
voluntary hospital governor. Bevan did not lament the loss of
these structures.
5.3 In contrast to earlier arrangements
there was no direct user representation on the RHBs.
(a) In practice RHBs were dominated by doctors,
local politicians, academics and the professional and industrial
elites previously active in voluntary hospital management.
(b) There was a preponderance of elderly
males on these boards.
(c) There was no structural provision for
the retention of existing worker governors.
(d) The new system of ministerial appointment
led to the under-representation of the labour movement. Bevan's
reluctance to appoint trade unionists was probably a concession
of to pacify opponents of the NHS.
5.4 The absence of PPI was not deemed problematic
in the 1950s and 1960s, and it is only in the last 30 years that
a new concept of "patient consumer" has emerged.
(a) Opinion poll evidence from the 1950s
showed very high levels of public satisfaction with the NHS.
(b) Voluntary sector groups representing
health care users were initially few in number and did not exert
pressure on policy.
(c) Only with the arrival of the Patients
Association (1963) can the first signs of the health consumerism
of today be clearly identified.
(d) Patient groups linked to specific diseases
or to public health issues began to proliferate in the 1970s and
1980s. Their emergence was an aspect of a broader consumer movement
in industrialised societies, with a focus on consumer rights and
standards of services.
5.5 Conclusions
(a) The advance of state agency in health
provision terminated existing arrangements for PPI.
(b) This had no significant opposition because
the goals of a universal, comprehensive and free service satisfied
users' major requirements of the health system.
(c) The managerial structures bequeathed
by Bevan privileged the interests of providers—doctors and
administrators—over those of patients.
(d) Therefore the NHS was poorly equipped
to accommodate the emergence of the patient consumer from the
1960s.
6. THE COMMUNITY
HEALTH COUNCILS
1974-2003
6.1 As yet there has been no detailed historical
evaluation of the CHCs, although there has been limited contemporary
policy research.
6.2 CHCs were established in the 1974 NHS
reorganisation.
(a) This aimed to tackle the unsatisfactory
"tripartite structure" of the NHS by creating new tiers
of area and district health authorities. CHCs were created at
the district level.
(b) They were not initially a policy response
to the new consumerism in health but were proposed during the
consultation process to compensate for further reduction in the
role of local government.
(c) However in the parliamentary debates
they were championed by consumer interests, which lobbied strongly
for their autonomy.
(d) Government reluctantly conceded greater
financial and political independence for the CHCs from area health
authorities. Thus for the first time a representative mechanism
was created which was separate from the health system's managerial
structure.
6.3 The structures and functions of CHCs
were as follows:
(a) They consisted of nominees of local government
(1/2), voluntary organisations (1/3) and regional health authorities
(1/6).
(b) This method produced a membership which
was a "distorting mirror"[74]
of the population, being disproportionately middle-aged, male
and middle class, and already active in other areas of public
life.
(c) However, the voluntary sector membership
brought in new people, particularly from health related associations,
and later from new movements, such as women's and minority groups.
(d) The CHC's role was to act as community
watchdog (overseeing services and assessing local needs) and patients'
advocate (providing assistance and advising on complaints), and
to participate in health planning (through consultation procedures).
(e) The detail of how CHCs would carry out
these activities was largely unspecified and no criteria for assessing
their effectiveness were developed. CHCs interpreted their roles
in different ways, with some more passive than others.
6.4 CHCs subsequently had a long, but insecure
existence and were abolished in 2003.
(a) The Thatcher government considered their
abolition in 1982 during its purge of quangos, but pulled back
fearing a defensive outcry.
(b) The coming of the internal market undermined
their status, both because it provided a new mechanism for assessing
patient demand, and because consumer protection was now directed
to the individual not the community.
(c) There is some evidence that CHCs were
easily disregarded. In 2002 the vast majority of CHC referrals
to the Secretary of State were over cases of inadequate consultation
with health authorities or trusts.
(d) Labour was a staunch defender of the
CHCs in the 1990s. However once in power it proposed their abolition
on the grounds that they were outdated, lacked teeth and suffered
from low public awareness.
(e) One leading historical assessment of
this volte-face claims that government sought to appease provider
interests by removing an oppositional body and replacing it with
the weaker Patient Advocacy and Liaison Service. [75]
7. GENERAL CONCLUSIONS
7.1 Historical perspectives on forms of
PPI
— Although current debates about PPI
are framed as a response to contemporary health consumerism, the
involvement of patient and publics in the organisation of health
services has a long history in Britain.
— Like today earlier forms of PPI sought
to represent the interests of those who paid for and consumed
health services, to those who provided them: doctors and administrators
in the public or voluntary sector.
— Under these earlier forms of PPI
power and authority in the British health system tended to remain
with provider interests rather than users.
— At every stage the advancing role
of the state reduced the power of PPI structures, although the
achievement of universal access, comprehensive provision and equitable
funding in 1948 meant that this was uncontested.
7.2 Historical perspectives on the design
of PPI
— Provider interests (eg "club"
doctors, voluntary hospital administrators) have tended to be
wary of PPI (friendly society committees, worker governors) as
a potential source of opposition.
— However this may not simply be a
case of professional or bureaucratic monopolisers protecting self-interest.
Localism has in the past been inimical to medically optimal policies,
to rational resource allocation and to uniform national standards.
Policy makers need to specify clearly at the outset the scope
for real local decision-making by PPI bodies.
— In the past, participants in voluntary
forms of PPI have been self-selecting, likely to represent special
interests or to be drawn from limited social constituencies defined
by age, gender and social class. Given contemporary evidence for
high levels of passive citizenship (poor local election turnout,
low levels of voluntary association membership) the same is likely
to be true today. Mechanisms are needed for ensuring consistently
high levels of public awareness of PPI structures in order to
attract a wide range of participants.
— The alternative approach was to use
the ballot box, and there are some current indications that local
government may again take a larger role. In addition to the establishment
of local authority Overview and Scrutiny Committees there are
moves towards greater joint working between the NHS and local
government on health and social care. Present proposals for strengthening
local government consultation and community advocacy[76],
could represent a return to the main thrust of policy before the
NHS, of ensuring democratic responsiveness by situating health
services within local government.
Dr Martin Gorsky
Centre for History in Public Health
London School of Hygiene and Tropical Health
January 2007
74 R Klein and J Lewis, The politics of consumer
representation: a study of Community Health Councils, Centre
for Studies in Social Policy, London, 1976, p29. Back
75
Charles Webster, The National Health Service a political history,
Oxford, 2nd edition 2002, p245. Back
76
Department of Health, Our health, our care, our say: a new
direction for community services, Cm 6737, The Stationery
Office, January 2006, pp 158-61. Back
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