Bevan’s speech to the Executive Councils Association 7 October 1948

“When I received the invitation to address this Conference I responded with alacrity because I am most anxious, certainly in these, the early months of the operation of the National Health Service Act, to meet those people who are mainly responsible for the local administration, and to confer with them in their capacity as shock-absorbers between the general public and the central administration.

“Yesterday afternoon I addressed, for some time, the people responsible for hospital administration, the Governors of the Teaching Hospitals, the chairmen of the Regional Hospital Boards, and the chairmen representatives of the Hospital Management Committees, and this afternoon I am addressing those who are mainly responsible for the General Practitioners’ side of the scheme and for the services connected with the Ophthalmic Opticians, and with the dentists and with things of that kind. The third partner in the scheme, the Local Welfare Authorities, have, of course, got their own means of articulation which they are not slow to exercise. It is, therefore, all to the good that the Executives have found it wise to form an Association, of which this is the first annual conference, because unless you can establish effective contact with each other you will have no means of learning from each other’s experience, and, what is as important to you, you will have means of effectively checking the behaviour of the central authority because if you have no means of inter-communication he will be the only person who will know what is happening over the whole thing and he will have you at a disadvantage. Speaking on behalf of myself, and, I am sure, future Ministers of Health, we would much rather that you were possessed of a complete picture of what is happening in the country as a whole so that out of your experience you can advise me, than for me to be the sole repository of what is happening over the whole thing. Therefore I say at once that I welcome the formation of the Association, and indeed, when I spoke here before at the winding-up of the Insurance Committees’ Association, I welcomed the suggestion that you should continue in another form.

I would like, first of all, to express, on behalf of the Government and on behalf of myself, our deep gratitude to the members of the Executive for the devoted work they have been recently doing. We know what an enormous burden has devolved upon you, and if the opening months of the new Service have been accompanied by less friction and difficulty than we at first feared it is very largely because the various bodies that have been established have taken such an enormous burden upon their shoulders. I know how busy you have been, I know how busy the officers have been, I know how busy they are going to be, and therefore I take advantage of this opportunity of saying how grateful we are for what you have done. I have been hard put to it in the last few months to explain to visitors from other parts of the world the set-up of the National Health Service in this country, because they have a habit of referring to it colloquially as “nationalised medicine.” This is a phrase I don’t like at all because it has nothing to do with the facts, and when I try to explain that the administration of this great organisation is reposed in the hands of voluntary people they just cannot understand it. And I can understand their bewilderment, because I doubt very much whether there is any nation in the world with so large a body of experienced and dedicated voluntary workers as we have in this country. We have long experience of the administration of social services of various kinds and we have been able to call upon that experience not only in, shaping, not only in the structure, but in the administration of the Service when it came into existence. Indeed, one of my chief embarrassments in the last year has not been to find people to come forward to do this work, but to select from out of a large number who were ready to do it. Many good people have been disappointed that their services have not been called upon. So we have in this country not a dearth but a plethora of individuals who are willing and able to carry out work of this kind.

“I believe that it will be universally agreed that so far things have gone reasonably smoothly. The service has been enthusiastically received by the vast mass of the population. Of course, some things have gone wrong – not much – but they have gone a bit wrong. The difficulties that we anticipated have not been realised and those that we never anticipated happened, but, of course, we must always expect the unexpected.

“There has been a very considerable rush for some of the facilities that we are able to provide. It seems to me that a most extraordinary proportion of the population has got bad sight. I had never anticipated that we would have such a rush for the services of the Ophthalmic Opticians as we have had, and I note that there are some people writing for the newspapers who have been very cynical about this fact, although, as I have said before, why the newspapers should complain I do not know, unless it is that they are discovering a new industry I have never seen in them up to now.

“But it is undoubtedly a fact that a large number of people are making use of the free service and for a while we shall have a great rush, but I am fortified in my belief that what we are doing is worth while when I reflect upon the very large number of sick, and especially of old people, who are now having their eyes properly seen to for the first time. I know of a case of an old lady of 98 years of age who went for her spectacles in the normal way and got them quite easily and now she is overjoyed. So simple and efficient is the service with which you are provided.

I am bound to admit that the rush for spectacles has been so great that it has exceeded our productive capacity, and therefore we can expect, in some respects, a little delay.

“The general mass of the population have signed up with their doctors to a degree which is extremely satisfactory. Over 90 per cent. of the population has already signed up with a local General Practitioner, and the figures are being added to day by day, and I confidently expect that by the end of the year virtually one hundred per cent. of the population will be in. This is remarkable, having regard to the fact that, of course, signing is not compulsory, although some people may think it is, because there are still large numbers of people who confuse the Health Act with the National Insurance Act and who believe that the benefits of the Health Act are in respect of insurance contributions, when we, of course, know that is not the case, and that the expenses of the Health Act are borne by the Exchequer as a whole and do not fall upon the Insurance funds. Furthermore, having regard to the heated controversies which appear to be inseparable from any reform of the Health Services, it is extremely gratifying to know that practically all the active General Practitioners in the country have joined the Service. The last figure I had was 18,165, and this after we have made every single effort to weed out figures of duplication. As I said earlier, of the population of about 42.5 millions about 90 per cent. have signed up. The number of dentists taking part in the Service is growing; they are now over 80 per cent. 1 know that in some quarters these figures are not accepted, but I can assure them that these are the facts: 8,039 dentists out of a possible 10,000 – and more of them are joining up day by day as the benefits of the Service become known to the members of the profession. At first, of course, we are all aware that the dentists were not kindly disposed towards the scheme, and there was some difficulty in obtaining the co?operation of one or two of their organisations, but 1 am happy to say that the dentists themselves are now sufficiently appreciating the benefits of the scheme as to join up. Up to the 17th September, a little over two months after the scheme had started, the Dental Estimates Board had received over one million Dental Estimates Forms for the first time for authoritative payment, and some for prior approval. In that short time, in other words, over one million people had had treatment under the scheme.

“The number of prescriptions dispensed is phenomenal. It is at a rate approximately twice that of the National Insurance Scheme. If this is maintained it will mean that 140 million or 150 million prescriptions a year will be dispensed under the Service. Many chemists, as a result, are adding to their dispensing facilities with the help we are giving them for building licences.

I need hardly tell you that the work of the Executive Councils touches the population most intimately. Every man, woman and child in the population will at some time or another establish contact with the Executive Council and with its officers. Therefore, it is of the utmost importance that the efficiency of the executive machinery should be maintained at the highest level. We were fortunate in the fact that we were able to obtain from the officials of the old Insurance Committees, a very fine staff to start us off.

We started off this Service on July 5th with all the resources that we had at our disposal before July 5th. We had not any more. There were some who said, ‘Why don’t you postpone the date until you have got all the resources that you need?’ and I answered by saying, ‘What are all the resources we need?’ because what we need in the Health Service is anybody’s guess. It depends on what society is prepared to lay aside for that purpose. It depends on the actual technical resources of the medical profession. It depends upon our physical resources in the way of buildings. I was satisfied that if we had postponed the starting of the Health Act to some mythical date when we would have at our disposal all the resources about which nobody could agree we would never start at all.

“But, nevertheless, one very great revolution did start on July 5th, and that was, that whatever we have got to give, those who needed them most got them without respect of income. That was the first important revolution, and as time goes on we will be able to add to our resources, to refine our machinery, to simplify our administration, and therefore to improve what we are doing a very great deal.

“Now the Executive Council, because it is the administrative body responsible for the General Practitioners’ Service and for the Ophthalmic Opticians and Dentists and Chemists has a very important function to perform in raising and retaining the highest standard of ethical conduct amongst these professions. I have been exhorting the general public in the last few weeks to make use of this National Health Service prudently, intelligently and morally, because if too great a strain is placed upon it at the beginning it might break down, and because things are free is no reason why people should abuse their opportunity. This is a very great test of the maturity of the British people ? that we put at their disposal, insofar as they are available, all the resources of the medical profession without charge, and if the people abuse it, if those who don’t really need it demand it, then they will be merely standing in the way of those who need it more. And so we should, in all our separate places, with all the contacts that we have at our disposal, exhort people to use this thing as though it were their own – because it is in fact their own – and that when any individual abuses it he must reckon with the sum total of abuse, which might add up to a sum very grievous to carry and very difficult to continue to provide.

If we say this to the general mass of the population it is equally true of the professions themselves. The General Practitioner has a very great responsibility. Over-prescribing can be as bad as underprescribing. Those of us who have had experience of the administration of a National Health Insurance Scheme will know that some General Practitioners are very conscious of the impressiveness of long lists in prescriptions on the psychology of the patient. If they wish to impress the patient with the fact that they are having a very good bottle of medicine merely by the number of items in it, if it is merely psychological results they are after, I hope they are going to give very cheap prescriptions in that respect.

‘We do not want to interfere, on the contrary, we want the General Practitioner to prescribe what he considers necessary for his patient and to put nothing at all in his way, but we do want to impress upon him that it is not a good thing to evoke merely psychological response from the patient by the prescribing of expensive drugs. The same thing is true about the general conduct of the General Practitioner. There are the local committees that consist of representatives of the professions and of the Executive Councils, who are concerned with the general conduct of the professions in their local behaviour, and we hope that these committees will realise their responsibilities because, although it might be a cliché I would like to say it, the Health Act has not come into existence for the sake of the doctor or of the Ophthalmic Optician or of the dentist or of the chemist, but it has come into existence for the benefit of the patient. The professions are able to organise pressure groups of various kinds, and to make their demands articulate, but the general mass of the patients has to depend upon you, and has to depend upon the House of Commons, and has to depend upon the Ministers for the safeguard of their position. Therefore, the highest possible standards of ethical conduct must be demanded from the professions concerned in the administration of the Health Act. It is far, far better to start off being strict and later on to be lenient than to start off being lenient and then try to be strict, because it is much more difficult to weed out bad practices than to prevent them from arising, and therefore we look to the Executive Councils and to the disciplinary machinery that has been set up under the Regulation to try and improve the administration as much as possible.

“Now I know there are some instances where the shoe pinches, I may be told, for example, that the conditions of service for the staffs of Executive Councils ought to be looked at. I know, but there is the Whitley machinery for that purpose. There is plenty of machinery available now under the Health Act for every section concerned to have its point of view stated. There is no reason why Conferences of this sort should be used for that purpose, because they have got agencies at their disposal through which they can express themselves, and we shall not look unsympathetically at any reasonable claims that are put forward, but, of course, we must always keep a balance between the claims of one section and the claims of another.

“I know also that there have been some complaints about the delay in payments, and I hope that you will look at this immediately so as to try and make payments as promptly as possible, and certainly as promptly as your machinery will permit, because there are many professional people who are accustomed to receiving payment at the time the operation was performed and have now to wait a little longer for their bills to be paid.

“We have made, on the whole, as I said earlier, a very good start, but we have yet a long way to go, and I would like to conclude by impressing upon all of us, not only those who are here but those who might read what I say outside, our collective responsibility for the administration of this great Service. It is, I think, correct to say that what we are doing is now being watched by the whole world. This is the biggest single experiment in social service that the world has ever seen undertaken. It is, I think, a great tribute to the vitality and the genius of the British people that we are able to undertake a task of this complexity and magnitude within three years of the end of a great war. It shows that the British people have still got the principles of innovation, and renovation, running through them yet, and that we can pioneer in many directions for the rest of the world to follow. But if we are able to start these things we are being watched as they develop, and the rest of the world will decide whether they are going to imitate us by the extent to which we make a success of what we are doing.

“As I said at the beginning, we are having visiting us now from different countries people who are watching what we are doing, and therefore we have a responsibility not only to the patients, not only to the British nation, but a responsibility to the other nations who are looking to us to set them a good example.

“Therefore, I wish your Association every success. I thank you for the co-operation you have already given; I implore you to continue it and even to increase it, so that in a few years’ time we shall be able to look back upon a good job well done, and be able to hand down to future generations the best instrument of social welfare that the genius of mankind has yet been able to devise.”

Source: Executive Councils Association (England) National Health Service, Record of Proceedings at the First Annual Meeting, October 7th and 8th, 1948 (Preston, Executive Councils Association, 1948).