Two big jobs have dominated the first months of 2016 for me. One was putting the finishing touches to and sending off to the publishers the manuscript for my first sole-authored book, Payment and Philanthropy in British Healthcare, 1918-48. The other was being part of a team at Warwick University setting up and launching the new People’s History of the NHS website.
As someone who has a tendency to say ‘yes’ to too many things, I’m always keen to minimise what I’ve taken on by looking for where they overlap and complement each other. In this case I’ve written a number of short pieces for the new website’s Encyclopaedia about what the NHS replaced and the impact of its arrival on some traditional aspects of the pre-1948 hospital system.
Reform before the NHS and its accompanying virtual museum gallery highlighted the fact that the NHS didn’t come out of nowhere. After the reforms of the Liberal government elected first in 1906, the interwar years can look rather bereft of major government reforms. There was certainly nothing as co-ordinated or on the scale of the wartime Emergency Medical Service or the National Health Service set up in 1948. Yet part of the problem here is the assumption we need to look for big government-run schemes. In this short piece, I drew attention to some of the municipal, voluntary and private initiatives that played an important role in setting the scene for the NHS.
Fundraising and the Coming of the NHS put the spotlight not only on money but on the relationship between the hospitals and their local communities. The two had long been intertwined, though Nye Bevan was eager to separate them as part of a broad – broader than often remembered – understanding of a free health service. He wanted the collection boxes brought in while “a lively local interest” maintained through volunteering in linen leagues and libraries. Asking for donations of time was to be encouraged; not so when it came to donations of money.
Social Work and the Coming of the NHS was the most closely linked to the book I’ve been writing. This looked at what the arrival of the NHS meant for the almoners (as hospital social workers were then known). They had been responsible for the payment schemes in operation in both voluntary and public hospitals before 1948, which my book focuses on. Yet this major element of their work disappeared over night. One almoner recalled saying at the time: “This is a week you pay but you won’t have to pay next week.” What I find remarkable is that in just three years – when prescription and other NHS charges were introduced – they redefined the profession as one for whom dealing with money matters was an inappropriate distraction from their real, social work.
Writing these short pieces has been a nice way of transitioning into the post-1948 research. It’s meant I haven’t had to rush hugely on to new research themes, simply thinking about the impact of the NHS on existing ones. But there is an intellectual danger here – that it could encourage me to re-frame that earlier period as the prelude to the NHS. And this is something historians and social scientists have been rather bad at avoiding.
The ‘appointed day’ when the NHS came into being looms large, perhaps inevitably so, over the history of British healthcare in the early twentieth century. The work I’m currently doing pulls in the opposite direction, by thinking about the NHS in terms of what it replaced. At least this way round I’m comparing with what came before, as those who had lived through the earlier years would have done at the time. The same cannot be said the other way around.
As Barry Doyle has commented recently:
By looking at everything through the prism of the NHS we are failing to see health care systems in their contemporary contexts. In particular, by always measuring them against the gold standard of some imagined NHS we overlook how far provision had travelled in the 20 years after 1918 and how much potential it had to continue to grow.
My worry is not really that I might judge the pre-NHS years too harshly. I have never felt it my job to reach some verdict on whether the various health services operating before 1948 were ultimately a success or a failure – important though that task is. I simply want to understand the past, or at least to better understand it, and hopefully to take a few others with me. So is it really helpful in doing this to repackage my previous work on the earlier period as the road to 1948?
I don’t have an answer, but I feel I can take some comfort from the fact I’m even asking the question. I guess it’s the historian’s duty to be vigilant against anachronism, even in their own work.