Feature

Radicalism and compromise

The NHS may be the ‘jewel in the crown’ of Labour’s post-war achievements, but the history of its creation is marked by expedience and compromise. And we are still living with the results of compromises made 50 years ago, argues Steve Iliffe

When Labour won the 1945 general election some of the most ardent advocates of a comprehensive national health service were to be found in Whitehall. The radicalism of key figures in the civil service converged with that of the Socialist Medical Association. Senior civil servants had become convinced of the need for a health service that met people’s needs, without the stigma of the Poor Law. They saw medicine as an honourable profession that should fulfil a social responsibility without recourse to commerce.

Market forces were regarded as the cause of inequality in access to care and had nothing to contribute to reforming medical services. They believed that doctors should be paid salaries, and those in the public service should eschew private practice altogether.

The failure of reform in the inter-war period was a stimulus to such policy makers. In 1911, the National Insurance Act had transformed medical care in Britain, extending free GP care (‘the Panel’) from the five million skilled artisans who were members of friendly societies to fifteen million workers, nearly one third of the nation. Subsequent reform was slow, and a pluralistic system of provision developed, with services provided by ‘the Panel’, local government, charitable (‘voluntary’) hospitals and private doctors.

Separate administrative structures existed to run each type of service, with little or no attempt at co-ordination. Whenever change was sought, the conflicting interests of different bureaucracies, different groups in the population and different ways of thinking within medicine itself formed changing alliances to promote or resist each new scheme. Some changes occurred, nonetheless. Maternity care was greatly-albeit slowly- improved through the expansion of municipal services, but the predominant experience of reformers in the interwar years was one of frustration

There was little solace in the development of Britain’s hospitals. The Ministry of Health, founded in 1919, had little knowledge of the extent of hospital development, and less influence. Municipal hospitals developed without central interference, teaching hospitals received some state funds, channelled through the University Grants Committee not the Ministry, and voluntary hospitals kept at arms length from government involvement, except for contracts with local government to provide TB, cancer and sexually transmitted disease services.

This separation of the Ministry from the hospitals only came to an end in 1938, when the financial problems of London’s teaching hospitals prompted a request for state help. Arguments about the source of funding were resolved by the creation, in May 1939, of an Emergency Medical Service (EMS), within which voluntary, teaching and municipal hospitals were co-ordinated and supported, as part of the preparations for war. The success of the wartime EMS strengthened the enthusiasm of reformers within the Ministry for a centralised health service.

Organised labour was a key player in the war of attrition that characterised the reform process between the wars. While working people had increasing access to the Panel, so that nearly half the population was covered by 1938, access to specialists was much less satisfactory. Panel members could get some free or cheap care, at the price of long waits in the outpatient clinics of the voluntary hospitals, but quicker access depended on payment.

Expert assistance in a matter that concerned the unions, fighting compensation cases where workers’ health had been damaged by their jobs, also came from specialists, and the creation of the EMS had increased access to consultants. When the trade union movement took sides in the debate over a National Health Service, such issues influenced its choice of alliances.

For the middle class, who were excluded from the Panel system and reliant on private medicine, the growth of medicine’s effectiveness meant an increase in personal expenditure whenever illness affected them. The financial problems encountered by the London teaching hospitals were mirrored in the household budgets of affluent homes, making the middle class increasingly interested in state subsidies for medical care. Although, under the NHS, they had to accept paying into the system through National Insurance, they were to receive in services more than half as much again as they paid in premiums. Their post-war affluence was greatly enhanced by free education for their children and free medical care for all.

The specialists were a tiny group largely reliant on private practice, yet also at the forefront of medical development through their honorary work in the voluntary hospitals. The Depression may have done some damage to their private practice income, and their increasing importance in the voluntary hospitals prompted a desire for income from this source, contributing to the financial problems of the hospitals.

Medicine was undergoing great change and the first signs of pharmacological revolution were visible. Medical expertise was needed, in greater quantities than before, and the existing system of isolated centres of excellence staffed by consultants and larger numbers of small cottage hospitals staffed mainly by GPs with limited skills, was an insufficient basis for the next steps in the modernisation of medical practice. Consultants had much to gain from increased funding of the hospital network, and at a crucial stage in the foundation of the NHS they were to trade their influence over the medical profession for favourable terms within the new health service.

The political changes within British society presented the medical profession with a significant new challenge to add to its traditional struggle with the spectre of local government control. The Depression and the Second World War had generated a shift to the left that intensified the medical profession’s anxiety about its power to determine developments in medical care. The profession had no choice but to seek a compromise with the Labour Party that preserved as much of its autonomy as possible.

The NHS is often seen as a socialist institution because of its foundation by a radical Labour government, and because of the long campaign for it on the Left. But its dominant characteristics arose from the compromises required to bring it into being.

There is no doubt that the NHS relieved the discomfort and distress of millions of citizens, offering better quality dental and optical care than most had ever experienced, spreading specialist medical services across the country, and dealing with a backlog of medical problems (especially in areas such as gynaecological surgery) that would otherwise have remained neglected.

The benefits that the NHS brought to Britain are clear. Less obvious, at least to the Left, are the losses that Britain experienced by evolving its health service in the way that it did. Forty five years later we are feeling those losses, as successive Conservative governments move the NHS into the marketplace with astonishingly little resistance from the political opposition, the trades union movement or the public.

Bevan’s legacy was a fine balance of power between capital, professionals and the people, and a centralised structure for the NHS that together epitomised the weakness of British socialism. In 1948 it was accepted that the revolution in modern medicine was led by scientists and doctors, with hospitals as their natural bases. The new hospitals were not like old cottage hospitals, but were the factories of a brave new medical world, run by the socially-responsible professional men so much desired by Whitehall’s enlightened civil servants.

In creating the NHS, Labour created a nationalised industry which was only nominally owned by the people of Britain. There was no effective way in which citizens could influence the development of the NHS without recourse to campaign politics. A trickle of local government representation on NHS management bodies was halted in 1974, at the beginning of a phase of unending managerial reform. Opportunities for trade unions to influence the NHS indirectly through Community Health Councils (established in the same round of reforms) were rarely taken. Change from ‘outside’ the NHS did occur, but was uncommon and difficult.

For the most part, medical care was something provided for people by experts. The perception of health as the product of expert interventions has had more serious consequences, for it turns medical care-and health too-into marketable commodities. When the politics was taken out of the NHS by the foundation of a health service run by quangos, the social origins of illness and health, and the long history of popular struggle for better health and better medical care began to be forgotten.

And by taking the NHS out of politics, and in particular out of local government politics, Bevan and the Labour government lifted a weight from the back of the trade union movement, which had had to struggle for decades to achieve improved medical care for working people. It also greatly relieved the medical profession, which did not want to be controlled by anyone, least of all the ‘local state’.

The profession’s defence of its autonomy had a lasting consequence in general practice. GPs were brought into contract with the NHS, but have never been employed by it. In 1948 Britain’s GPs were enrolled in a public sector franchise network, and the subsequent development of general practice from solo lock-up shop to group practice in medical centres has demonstrated how effective a system franchising can be. By providing their own buildings and absorbing some staff costs themselves, general practitioners have also demonstrated how cheap franchising can be for government. This lesson was not lost on the Thatcher government, which in effect moved hospitals onto a franchise basis by creating trusts and a so-called internal market.

The political and economic problems temporarily resolved in 1948 resurfaced 40 years later, but with different players in a changed game. Had the NHS not been constructed on the cheap, and had the British economy not continued its long-term decline despite the post-war boom, the apolitical health service might not have experienced its current protracted crisis, with the public that uses it relegated to walk-on roles in demonstrations while the staff who run it oscillate between gesture politics and demoralisation.

None of this diminishes the achievement of the post-war Labour government in creating the NHS, nor does recent history suggest that any alternative system would have had greater durability. The National Health Service was certainly an expression of progressive modernisation, but was not the pinnacle of civilisation that its uncritical adherents sometimes imagine.

As it is forced into a commercial framework, the political issues of under-funding and public powerlessness long buried in the formerly centralised structure of the NHS are now returning to the public domain, where they rightly belong.

This article is based on a paper presented at the Remembering 1945 conference, held at the Museum of London in July 1995.