Lessons from the history of British health policy: past and present

Alex Mold , Virginia Berridge | 03 June 2024

Health policy is never really off the contemporary political agenda, but as Britain approaches its first General Election since 2019, it is a key issue for politicians and the public alike. What can be learned from British health policy in the past for those trying to improve it in the present? This question is central to a report we co-edited for the British Academy, Lessons from the History of British Health Policy.

Considering the societal, cultural, political, and scientific drivers of health policy over the last 175 years helps us to understand some of the challenges facing health policy today. In the report, we cover the period from 1848 to 2020.  We analyse four distinct phases:

• 1848-1919, beginning with the 1848 Public Health Act, and ending with the establishment of the Ministry of Health in 1919, when health policy making was pluralistic, with both local and central government playing a role. 
• 1919-1948, when the central state’s role in health policy expanded. 
• 1948 -1974, when health policy was primarily (although not solely) directed towards the establishment and development of the NHS. 
• 1974-2020 beginning with the reorganisation of the NHS in 1974 and culminating with the COVID-19 pandemic, saw the proliferation of ‘health policy’, and the tensions between policymakers, politicians and experts became more prominent. 

Health policy in any place and at any time was never solely about ‘health’ but needed to consider a range of political, social and economic considerations too. The shape and scope of health policy in Britain over almost two centuries has changed, but this history also highlights some significant ongoing challenges.

What were some of the persisting policy challenges?

The changing nature of population health over the last two centuries presented its own difficulties, as policy makers and service providers adjusted to the decline of infectious disease, the rise of chronic disease and an aging population. The funding of health services was perhaps the most permanent headache. Costs increased, and there were never any easy answers as to who should foot the bill (of course a common problem in all democratic countries). Variation in service provision and quality was also a persistent issue, and one that did not go away with the creation of the NHS. The organisation (and re-organisation) of health services was a matter of perennial debate, something which picked up additional speed in recent decades. The boundaries of ‘health policy’ were always unclear, with public health and social care fitting awkwardly within systems and politics that often focused on a narrower set of objectives.

What are some of the key lessons?

1. Structural problems may require structural solutions that lie outside ‘health’ policy

Improvements in population health were only partly related to improvements in health services.  Increases in life expectancy and the epidemiological transition from infectious to chronic disease took place before the establishment of universal health coverage under the NHS. Measures which addressed the social determinants of health, such as the environment, economic development, and education, were just as, if not more, important than the technicalities of health service expansion. The health service focus has consistently meant that other areas important for health such as housing or water supply, have been neglected.

There are several parallels here for contemporary policymakers. Policies which focus on the environmental drivers of ill-health, such as low emission zones, sit awkwardly between health, transport, and environmental policy domains, but both the late-Victorian example and today’s Great London Authority demonstrates that change is possible if the political will is there. Likewise, tougher regulation of contemporary public health ‘nuisances’, such as fast-food outlet density or minimum unit pricing for alcohol, may result in improved population health if these measures can be made palatable. Policymakers may need to act counter to public opinion, or at least ahead of it.

Infrastructural development is also likely to be necessary, not only in the form of better sanitation (the crumbling Victorian network undoubtedly needs an upgrade) but in greener, quality housing and in more effective digitisation of health services, systems, and information. Putting such measures in place will require popular as well as political support. 

2. Health policy is more than NHS policy, and ongoing issues can only be addressed by taking a more holistic view of health policy

Since its establishment in 1948, the NHS has come to dominate the health policy field. This is understandable, given the importance of health services for individual and collective health, to say nothing of the NHS’s increasing economic and political salience. But despite Bevan’s aim for the NHS to be ‘comprehensive’ it never was (or perhaps ever could be). The elements that were left out of the original structure of the NHS such as social care, public health, and democratic representation, have presented policymakers with some of the longest-running headaches. It is those issues which also need to be addressed.

3. The centralisation of health policy has advantages and disadvantages, but is most effective when core and periphery work together

Before 1948 health policy was often made at the local and regional level. The centralised nature of the NHS and its funding from general taxation allowed policymakers to deal with issues in a coordinated way. Political control of the health service enabled successive governments to decide how much resource to put into services, but also how to shape and structure them. But there were disadvantages. Variation in access to and the quality of services was a feature of the pre-NHS system, and despite its architects’ greatest hopes, inequalities did not disappear with the coming of the NHS (for instance the historic much greater endowment of hospital beds per head of population in London remains the case today).

At the same time, while British health policymaking appears to have become more centralised, beneath the surface localism remained important. Devolution and regional variation have come to the fore. It was probably always true that there was no ‘national’ health service, but a series of health services that differed quite significantly between England, Wales, Scotland, and Northern Ireland, as was obvious with the differences in the changing rules announced during lockdown. This has become even more the case as national devolution gathers pace. Local government has resumed some of its nineteenth century role with the return of public health responsibilities to local government following the Health and Social Care Act in 2012.

What can a contemporary policymaker take from this complex picture?  Perhaps they would do well to emulate the Victorian reformers who managed to achieve change by getting central and local actors to work together. Coordination has long been a challenge, and the centralised nature of the NHS should not obscure the need to maintain a dynamic and constructive relationship between the Westminster government and elected, provincial authorities.

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• Berridge, Virginia
• Medicine and public health

About the author

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Alex Mold is Professor of Public Health History at the London School of Hygiene & Tropical Medicine. Her research focuses on the history of public health in Britain since 1945.  With Virginia Berridge, she co-edited a report for the British Academy on the Lessons from the History of British Health Policy.

 

Virginia Berridge is Professor History and Health Policy at the London School of Hygiene & Tropical Medicine.  Her research encompasses both epidemic and chronic disease histories of public health. With Alex Mold, she co-edited a report for the British Academy on the Lessons from the History of British Health Policy.