On 5 July 2015, the British National Health Service will celebrate its 67th birthday. The same date in 1948 was the ‘appointed day’ on which a whole raft of the postwar Labour government’s reforms came into force. These included reforms to pensions, social security and – most famously – the inception of the NHS. Health Minister Anuerin “Nye” Bevan marked the day by opening Trafford General Hospital in Manchester (pictured above). So this is a good time to think about how we remember the NHS and the impact it made to British society.
Left-wing campaigner Harry Leslie spoke at the 2014 Labour party conference about what life was like before the NHS. The video below is difficult viewing for anyone – the heart-wrenching stories of poverty and sickness in a ‘barbarous time’ could fail to move only those with the stoniest of hearts. But it also makes difficult viewing in another way – difficult for those who have studied this subject and might find a few of the claims rather odd.
At this point I should make two things absolutely clear. First is that Harry Leslie’s memories and his story are not invalidated if they sit uncomfortably alongside the historical record. Even if the pre-NHS health system(s) appear rather different once you’ve read through the government reports, doctors’ records, newspapers and all the other available fragments of the time, his experience is an equally important aspect of the past to be recovered and recorded. There are often tensions between the views from above and below even without the passage of time. Recognising the different experiences of the same time and place is why you’ll often hear historians talking about histories in the plural these days.
The second is that by questioning the wider accuracy of some of how Harry Leslie has recounted the pre-NHS history of British healthcare, I am in no way seeking to discount the value or positive impact of the National Health Service. The simplification of that history into the dark days before 1948 and the glorious age of civilisation thereafter is a powerful myth in the British psyche, but it is also wildly inaccurate. In order to truly appreciate the good done by the NHS, we must first separate the history from the myth. Doing so will also help us to identify those far too numerous times when politicians claim their reforms to be true to the founding principles of the NHS, but are actually often very wide of the mark.
It is not right to say that in Harry Leslie’s childhood “public healthcare didn’t exist”. It had simply not been nationalised. What did exist was a patchwork of public hospitals providing care for certain sections of the population, run by local government. They might treat the poorest in infirmaries that previously served as sick wards for the workhouse. Whether a change of ownership after legislation in 1929 really amounted to anything more than a change of the name over the door in many cases is a matter of severe doubt. However, they did exist. Equally, there were local hospitals for infectious diseases. Tuberculosis sanatoria were in fact one of the main aspects of developing public hospitals from the end of the nineteenth century, which leaves the historian wondering what circumstances meant Harry’s sister was so tragically excluded from the care that was available at the time.
What Harry Leslie’s testimony makes abundantly clear is that the services on offer before the Second World War were woefully inadequate at reaching those who needed them most. Public healthcare did exist, but was too often targeted at sections of the population with different providers for each service, leaving far too many to fall through the cracks. The easy narrative here is that the NHS unified the services that were being provided and therefore made the best healthcare available to all. However, that is not quite true either. The campaign for co-ordination had been under way throughout the interwar years. By the end of the 1930s public health campaigners, the medical profession, local authorities, the not-for-profit voluntary hospitals, organisations such as the King’s Fund and the Nuffield Trust, and many others besides, collaborated on numerous local plans up and down the country to unify the services being provided. For leading Labour politicians such as Ernest Bevin, the policy objective was to replicate the best local schemes across the country, importantly keeping control of all health services at the local level. This is quite different from the nationalised hospital service introduced by his near-namesake Nye Bevan.
Perhaps then the real change of the NHS was in abolishing the dreaded profit-motive from healthcare? This has long been an assumption – indeed, it was my assumption when I began working in this area. Only what I found was rather different. Running services for a profit was a strikingly marginal activity, in even the elite of British hospitals – and I’ve given over a chapter of the book I’m writing to explaining just how marginal it was. But surely the NHS brought about ‘free’ access to medical care for the first time? Well, actually no.
The most dramatic change the NHS made to most people’s everyday lives was not to provide them with medical care free at the point of use. Before 1948 hospitals had arrangements in place for this to be guaranteed to anyone for whom paying would cause financial hardship; and beyond the hospital it was not uncommon for a doctor’s conscience to render him (or occasionally her) unable to charge poor patients. Across working-class communities many who would have been expected to pay something turned to mutual aid schemes to ensure doctor’s visits or hospital stays without a bill, while from 1911 national insurance made a similar arrangement compulsory for workers in certain industries. Neither did the NHS open up greater provision. No new hospitals were built for more than a decade and the ‘appointed day’ did not herald the end of the dreaded waiting list. What the NHS changed was that it removed entirely both questions of payment and the moral implications of charity from the doctor-patient encounter. Moreover, it enshrined within commonly-held notions of British citizenship that this should be so.
The NHS was part of a wider reform movement that deserves some share of the credit for delivering us from the “uncivilised time” that came before. Recognising where one ends and the other begins is crucial for understanding specifically what it is about the NHS that should be preserved. What exactly does that mean? Well, I’ll be blogging about that as my colleagues at Warwick University and I explore these issues further over the next few years.