Column

A spirit of healthy competition

The fiftieth anniversary of Bevan’s widely welcomed NHS Bill is a good moment to reflect on the scale of his achievement, says Charles Webster

It is worth remembering that the post-war Labour government’s NHS legislation and accompanying white paper were published 50 years ago, on 21 March 1946. Most historical references tend to highlight the 1944 National Health Service white paper produced by the coalition government. But this was a very unsatisfactory scheme, and probably impracticable, largely owing to the complexities introduced in response to pressures from voluntary hospitals and the medical profession.

On taking office, Aneurin Bevan scrapped the coalition’s plans and, with remarkable speed, produced an entirely different scheme, which was accepted by the Cabinet in December 1945. Again with characteristic audacity, Bevan bypassed negotiations with the vested interests, and in March 1946 published his plan for the new health service.

The little-remembered Labour white paper, National Health Service Bill (Cmd.6761), set out the framework for the tripartite administration which survived until the reorganisation of 1974. The most radical feature of the new arrangements was the nationalisation of all hospitals, but equally innovatory was the proposal to locate all family practitioner and community services in health centres. Also important were the proposals to transfer the funding of the new service to general taxation. Remembered with some envy is the provision that, with trivial exceptions, there would ‘be no fees or charges to the patient’.

Bevan calculated that it was necessary to make some compromises alien to socialist thinking. At the Cabinet meeting on 8 March 1946, he acknowledged that Labour supporters would not favour his proposals for pay-beds in NHS hospitals, or the retreat from full-time salaried service for doctors.

He argued that ‘unless pay-beds were provided, some of the best specialists would not be attracted into the NHS and the growth of private nursing homes would be encouraged’; on remuneration, he concluded that ‘under a full-time salaried service, which was advocated by some government supporters, it would not be possible to give freedom in the choice of a doctor’.

As Bevan predicted, these concessions were much disliked within the Labour movement, and were attacked during the debates on the NHS legislation. As peace offerings to the medical profession, they worked better with consultants than with general practitioners.

Politically, Bevan’s conciliatory gestures were helpful in gaining bi-partisan support for his proposals, and for counteracting accusations that, as a socialist politician, he would be doctrinaire and confrontational. Even unfriendly sources acknowledged that Labour’s plan represented a major constructive achievement. The Economist pointed out that the famous Lord Dawson of Penn had concluded that it was impossible to establish a national health service combining socialism in its administration with individualism in its practice. The Economist concluded that Bevan’s plan was a ‘valiant attempt to fulfil Lord Dawson’s formula and looks like doing so much more successfully than any of the previous proposals’ (30 March 1946).

The Times congratulated Bevan for devising a workable solution to the intractable problem of the hospital system likely to ‘permit the rapid development of a well-knit yet flexible hospital service throughout the country, with a spirit of healthy competition between the regions’. Bevan had displayed awareness of the ‘dangers of excessive centralisation and the need to draw all branches of the medical and allied professions into the work of planning and administration’(22 March 1946).

These responses were barometers of the public mood. The Labour plan was accepted as a reasonable compromise. With the additional advantage of Bevan’s inspirational leadership, the new health service rapidly became accepted by health workers and all sections of the community as one of the most successful parts of Labour’s welfare state. All of this is a striking contrast to the present government’s efforts to relaunch the health service according to the ideological determinants of the 1990s.