This year marks the 60th anniversary of the
National Health Service, once described by Tony Benn as the “the most socialist
and most popular” of all institutions in the UK. Supported even by a majority
of Tory voters over the years, ardent supporters of privatisation such as
Margaret Thatcher, was obliged to assure voters that “The NHS is safe in our
hands!”
However it is far from truth to say that the NHS had a
smooth birth in July 1948, or that it came about as a result of an all-party
consensus, resulting from the experience of World War 2, which had exposed
existing health care arrangements before 1945 for most of the population as
being woefully inadequate. The reality is that the Tories, although claiming to
support the principle of a comprehensive free health service, in practice voted
against every reading of the NHS Bill. Labour, with a large majority in
Parliament after 1945 was successful in winning 261 to 113 votes on the first
reading, so it is doubtful as to whether a Tory government would have set up
the NHS. Indeed there was some spectacular opposition to the idea of “state
medicine”. Terms like “medical Gestapo” and “medical fuhrer” were bandied about
by some of the most Conservative members of the British Medical Association and
their political allies. At one point the Daily Mail was reported to have poured
scorn on the plan with the headline “No future for us in Britain” and “50,000
doctors say the plan won’t work”. The implementation of an NHS of course
required not only the support of Parliament and the British public but the
majority of the medical profession. You can’t run a health service without
doctors. Pamphlets written by some of the doctors such as, “You and the state
doctor”, “Don’t be doped” illustrate the level of hostility of some of them.
The situation before 1945 was hopelessly inadequate for most
people. Whilst the wealthy had access to the best doctors and hospitals for
which they paid, only one third of the population had any kind of health
insurance which entitled them to medical care. The Liberal Government in 1913
had introduced a health insurance act, but this was limited to those in certain
occupations and earning below a £420 a year. This excluded women, the majority
of whom were not in paid employment in the 1930s, and children. Those receiving
poor law relief did have some free health care. Those registered under the
state insurance scheme were known as “panel patients” for whom doctors received
a capitation fee. Doctors, however topped up their salaries from private
patients. Inevitably these received better treatment than “panel patients” as
doctors needed the money. If the situation was bad for patients, it was also
unsatisfactory for most doctors – Harley Street doctors working in specialist
hospitals in London could make a lot of money. Many doctors however would have
found themselves in areas of high unemployment, working for very little money –
they often carried out home visits for no fees at all, to see a child for
example. General practitioners had to buy a practice from a retiring doctor –
often borrowing money to do this. If there was inequality in primary health
care, the situation with hospital treatment was even worse on a national scale.
There were half as many doctors per head of the population in South Wales as in
London and in many parts of the country there were no hospitals to speak of.
The main professional opposition to the setting up of the
National Health Service came from the British Medical Association. Why were
they so much against a salaried and national health service, which would have
given doctors a good salary and more security? Ostensibly, the “leaders of the
BMA” claimed that “state medicine” would undermine their professional independence
and the sacred ‘Hippocratic oath of care’ between the doctor and the patient,
whereby the doctor’s sole judgement would be to act in the best interest of the
patient. But what independence was there when many doctors were dependent on
the fees of very wealthy patients? It was the money and class interests, which
lay behind private medicine which motivated the scale of opposition of the BMA.
One of the most outspoken opponents of the National Health Service plan was a
physician to eminent patients such as
the Royal Family, the leader of the Tory opposition and newspaper proprietors.
As Michael Foot, biographer of the architect of the NHS Nye Bevan, wrote
“fundamentally it was a class question”. Wealthy patrons, who could afford to
pay, were getting treatment at the expense of the rest of the community and the
argument that this funded a trickle down effect of the best medicine in the
world ran fairly hollow. Those of us who have seen the Michael Moore film
“Sicko” about private health care in the US, can see that private healthcare
does anything but guarantee medical independence for doctors. In fact many
doctors are simply finding ways to avoid life saving treatment for patients in
order to save insurance companies money!
Nye Bevan, the Minister for Health in the 1945 Labour
Government, was a key player in the establishment of the NHS. He was the son of
a miner who had died of pneumoconiosis and had seen for himself the lack of
health care for working class people. However in his home town of Tredegar,
there had existed a working men’s medical aid society which gave him the
inspiration for the NHS. As a local councillor he had served on the local
hospitals committee which had given him an insight into the medical profession
– an invaluable aid to dealing with the BMA. In 1945 health was not the
priority for Labour – unlike full employment and housing. The Beveridge Report
which set out a plan for a welfare state in Britain, also did not have details
for a national health service. It was Bevan’s plan. Bevan had been expelled
from the Labour Party in the 1930s for his left-wing views. He still faced
enemies in the 1945 Labour Cabinet – right-wingers such as Ernest Bevin the
Foreign Secretary and Herbert Morison, former leader of the London County Council.
The LCC as a local authority had been one of the largest health authorities in
the world but Bevan rejected the idea that local authorities should run the
health service. All hospitals would be nationalised, under government authority
and it would be funded mainly through taxation, not insurance. This was very
radical but he won the backing of the Labour cabinet.
Resistance from the BMA crumbled during the course of 1948,
as by July 5th – the inauguration day for the NHS – 90% of GPs had
signed up to work for it. Within 2 months 93% of the population had signed up
as patients. Even the Tory press was abandoning its support for the BMA’s ‘referendum’.
Did they expect more concessions? Bevan claimed that he would not “negotiate
with the BMA”. There were other professional organisations such as the Royal
College of Physicians. However important concessions were made in the NHS plan
– no doctor would be compelled to join, GPs would receive a capitation
allowance per patient as well as a salary, and most critically doctors working
for the NHS would be allowed to have private patients who could be treated in
NHS hospitals. It was hoped that this would wither away as the NHS could be
seen to provide for everyone, but the elimination of private pay beds from NHS
hospitals has never been achieved including by successive Labour governments.
The other weakness in the foundation of the health service was that it was a
“sickness service” – there was no provision for preventative medicine. Notably
public health however had long been in the public domain – as a result of which
diseases such as cholera – rampant in the 19th century had long
disappeared. The guarantee of a clean water supply could not be left to private
capitalism!
Nevertheless the NHS remained one of the best and
comprehensive healthcare systems in the world – the jewel in the crown for the
1945 Labour Government. It has also been noted that its success indicates that "socialism would work" !
