Bevan’s speech to the Institute of Hospital Administrators, 6 April 1946

Mr. President, Ladies and Gentlemen:

I must confess at the outset that my main purpose in asking you to be good enough to postpone the holding of your meeting has not been realised. I had hoped that the Second Reading of the health service proposals would have taken place, and that we should have been able to discuss the proposals in the light of the decision of the House of Commons. However, the time-table has not proved to be so manageable, and as a consequence 1 am in a little difficulty this afternoon. The Bill has been published, the House of Commons has not yet considered it, but nevertheless very considerable debate is going on. It is one of the conventions – not one of the strongest, but nevertheless one of the commonest – of our constitution that a Minister shall make his report to the House of Commons first. Therefore, I am inhibited this afternoon from making many observations on the general principles of the measure, and particularly from making any reply to some of the wilder statements that have been made by men old enough to have been more sensible.

As time goes on and the White Paper is read and the Bill is examined and its contents made familiar, we shall find that many of the speeches that have been made have no relationship at all to what is contained in the proposals. Indeed, one would think, from reading some of the speeches of the more partisan of the controversialists, that they were addressing themselves to proposals which they thought were going to be brought up, and which in fact had not been brought up, and were finding it difficult to make speeches in the new situation.

The medical profession is not an easy one to handle. It is composed of eminent men and women who have devoted themselves and dedicated themselves to it, but who do not appear to bring the same collective sagacity to bear upon the profession as they do upon their individual patients. However, I have no cause for complaint at the general response which has been given to the proposals. On the contrary, there is a wider degree of approval than ever I anticipated. It is bound to be a controversial subject; men and women’s emotions are too deeply involved for them to be able to accept our proposals finally, which have to do with health and with the organisation of our medical services. Furthermore, many devoted people who have given service to our health organisation over the years and have become deeply wrapped up in it are sometimes inclined to mistake their own emotional possessiveness for wisdom. I would much rather have a person kept alive by cold and altruistic efficiency than put to death by warm-hearted sympathy. We must recognise that our hospital service is organised for the service of the patient and not for the purpose of the management board; not even for the good people who give their time and their service to it, and not even for the hospital administrators.

You have recognised in your constitution one of the underlying realities of a hospital service; you have recognised that it is in fact a common service, and your association has anticipated the wisdom of politicians. In your own association you have brought together representatives of the voluntary as well as of the municipal hospitals, and you have therefore, from your day-to-day experience and from your specialist knowledge, realised that the hospital service of Great Britain, if it is to be efficient, must be fully integrated. It is very difficult to integrate hospitals if they are to remain self-governing institutions; it is very difficult to bring voluntary hospitals and municipal hospitals into intimate functional relationship if they are each able at any stage on the road to deny the association. Therefore this integration was regarded by me as an essential first step towards laying the foundation of a great health services scheme in this country. But no one recognises more than does the Government, and certainly no one recognises more than I do, that no legislation, however wisely conceived and however efficiently embodied in an Act of Parliament, can ever give the public a great health service unless the people who administer it want to do it and are enthusiastic in doing it.

The people upon whom the efficiency of the health service will depend are largely represented in this hall this afternoon. I am exceedingly anxious, therefore, that in any proposals I should be able to carry you with me. It is true, as the President said in his most felicitous speech, that you and I cannot, in this relationship, discuss the general principles – that you will do in your capacity as citizens in some other place, perhaps – but what we can do is to consider two features in which we are especially interested.

Staff Representation

Now if there is one thing that I do want to see accomplished throughout the health service, it is the effective participation of the hospital staff in the running of the hospitals. I do not believe that the requirements of democracy are necessarily satisfied by putting a cross opposite somebody’s name every four or five years. I believe that, if we are to have a vital democracy, we can accomplish it only by the daily and hourly participation of the people who are doing the job and the people who are responsible for the administrative policies. Therefore, I hope that, when the hospitals are properly organised, we shall lay out a scheme for the effective participation in the staff organisation, in staff councils and in staff co-operation, not only of the medical staffs of the hospitals but of the domestic staffs as well – because people seem to forget that the domestic staffs are at least as important as the rest.

Maintaining Traditions

In order to avoid some of the defects that might arise from a too highly centralised service, the structure of the Bill provides for a very great deal of decentralisation. I am conscious that in carrying out a great reform we might have the benefit of the innovations and yet lose some of the advantages of the present system. What we must strive to do in Great Britain is to maintain a continuity of those qualities arising out of the reform itself. We are a very old country with great traditions, our procedure in many respects is very complex. We have accumulated in our passage through history, like an old ship on a long voyage, a considerable accretion of barnacles. It is our purpose to try to cut out the barnacles without mutilating the traditions.

The Teaching Hospitals

You will have seen from the proposals how we propose to accomplish that in the case, for example, of the teaching hospitals. The teaching hospitals are very busy institutions. They are going to maintain their own traditions, they are going to maintain their own identities, but they are going to retain them in such a fashion as to enable them to be fitted into the general hospital system. The teaching hospitals, although they will have their self-governing boards and a special charter, will be expected to discharge their services within the general hospital service, and will not be expected to reject certain cases because those cases have not got specially interesting qualities about them – something of which you have heard now and again, I have no doubt. If the medical graduates are to be trained properly in our teaching hospitals they can only be trained if they are brought into contact with the widest possible diversity of patients; and therefore the teaching hospitals will be expected, in return for their charter, in return for the payments which will be made to them, to provide their proper share in the general hospital service itself.

Academic medicine is going to be wholly free, and left outside the interference of the State. Academic medicine is going to be what it ought to be, an entirely self-governing force. That is as it should be. I myself would not only hesitate, I would refuse to accept the obligation of determining the shape of academic medicine. The medical profession has shown itself on more than one occasion fully able to create resistance to change without being reinforced by the Government. Therefore, academic medicine is to be left fully free.

Finance of Teaching Hospitals

Furthermore, we have striven, Mr. President, to keep the hospital service at the regional level free from what may be called the restriction of the balance sheet. These great hospitals will be spending big money, and it is one of the great problems of State intervention in any form of activity, and especially in this one, for the State to provide all the money and to hold those who spend the money to accountability for the expenditure without paralysing the service by interfering too much with particular items of expenditure. That is one of our great problems, and we have striven to solve it, and I believe that if the proposals are imaginatively and sympathetically examined they will be found to have gone very far to remove the hand of the accountant from the administration itself.

The teaching hospitals will receive from the Ministry of Health their annual budget, a global sum based on the assumption of what they will require to spend to provide the services that we shall need from them, and within that global sum they will have plenty of elbow room in disposing of it over particular items of expenditure. Furthermore, they will be able to receive grants from the University Grants Committee for all purposes for which those grants are permissible – and they are very wide indeed- for experimentation, for exchange of doctors and surgeons between countries – and I do most earnestly hope that with an international health service there will be very much more interchangeability between Great Britain and the rest of the world than there was before the war in regard to health services. Furthermore, so as to serve as an additional shock absorber between the Ministry of Health and the teaching hospitals themselves, they are to retain their endowments and be free to spend them for whatever purposes they desire. So far as I can see, Mr. President, the teaching hospitals are going to be better off than ever they were before, they will receive what monies they need for their general hospital expenditure, and they will no longer find it necessary to spend their own endowments either on day-to-day necessary administration or on capital expenditure. I could have taken no more steps to have ensured the freedom of action of the teaching hospitals than I have done, consistent with their integration in the general hospital service.

No Civil Servants

When you come to the hospitals in the country generally, the same principles have been followed. The civil rights of the staffs and of the doctors generally are being preserved; because you will not be Civil Servants, you will be in contract with the Regional Boards and, being in contract with the Regional Boards, you will be fully free to conduct agitation and vote against the Ministry of Health at any time you care. There will be no limitation at all upon the civil liberties of the persons working in the National Health Service. Indeed, Mr. President, it does not seem to have been grasped by many of those who have been rushing into print that the Bill does not create an additional civil servant; on the contrary, the structure has been so devised as to leave civil rights entirely undisturbed; and indeed, in the case of those who are now in the employ of municipal authorities their civil rights should be enlarged rather than diminished.

Freedom in Local Hospital Management

The Regional Boards also will receive their global budget. There will be an assessment of what the hospitals expenditure will be in the regional area, and that sum will be given to the Regional Board and it will be free to be expended on the services that it is to provide to the public. There will therefore be elbow room left in that way. It will not be required to seek the approval of the Minister of Health or of the officials of the Ministry of Health to any particular item of expenditure. The Regional Boards will be free to do the same thing for the Hospital Management Committees in the local hospital service, and I hope that full advantage will be taken of that liberty, because not only is it necessary that a Regional Hospital Board should have freedom of movement, it is also necessary that the Management Committees should not be tyrannically controlled by the Regional Board; at all points of the service it is necessary that improvisation, experimentation, individuality should be allowed, consistent with the provision of the service. Therefore, there will be no attempt to make the hospital service of the future a purely scholarship service. In fact – as you know very much more than I do – hospital management today is a highly professional and technical job, and whilst we want the help of the amateur with very great hospital experience in the management of our hospitals, we do not want in any way to undermine the highest professional performance.

Furthermore, we have left the hospitals with the funds which have been provided by endowments. It is proposed, as you know, under the Bill, to assemble all the endowments which have been made to the voluntary hospitals at the Ministry of Health and then allocate them to the Regional Boards, so that the Chancellor of the Exchequer will not put a sacrilegious hand upon a single ha’penny of the money. It is a very sizeable sum; it will be in the nature of free money, pocket money for the hospitals. Once it is allocated, the Regional Boards can spend it just as they wish. And remember, it will be in addition to the money which will be provided for the hospital service itself. Furthermore, the Regional Boards and the Management Committees will be able to receive additional endowments, if people want to make them.

Charity and State Legislation

It does not seem to me that there is anything very wrong with it. There will be people who, in the course of time, will still want to leave benefactions in order to supplement the State service. What we desire to do, by the health service, is to universalise and make available to every citizen a service which the generosity of some has made available to some. That is always the progress of legislation in this country; it starts off by voluntary effort, it starts off by empirical experiment, it starts by improvisation, it then establishes itself by merit, and ultimately at some stage or other the State steps in and makes what was started by voluntary action and experiment a universal service. When that is done, experiment does not cease, voluntary effort does not end. Charitable inspirations are not inhibitive; they start at a higher level and push the State forward again, and then some day somebody else will be meeting here and gathering that harvest and the results of voluntary effort will attain a higher level still. So ft is foolish to say that because the object of pity has become the care of the State, therefore the impulse of pity is going to be dried up; it will find new objects, new purposes, a new direction. The Regional Hospital Board will have the greatest freedom of action.

Mental Treatment

I was delighted, Mr. President, that in your speech you made reference to the new relationship of the mental hospital to the general hospital service. The isolation of the mental hospital from the general hospital service is an outrage upon medical practice. The Lunacy Acts have never been properly carried out. It ought to be possible for persons suffering from acute mental anxiety and mental disturbance to be able to get clinical advice at a general hospital without having to undergo what may be the embarrassment of going to an institution dealing with more advanced cases. 1 think that a great deal of mental disorder could be prevented from developing in its earlier stages if people were able to walk into the same institution for advice on mental disorder as for a corn on the foot.

Reservoir of Administrative Ability

I said at the outset that I was inhibited rather from making general observations upon the health service as a whole, as a consequence of the fact that we meet in difficult times. I believe that there exists in this country a very general body of support for the main principles of the health service. That is a matter with which I shall have to deal later, but what gives me greater self-confidence than I might otherwise have is, not only that there exists a great volume of political support, but that in this country – and especially in you – there resides an almost illimitable reservoir of administrative knowledge and experience to carry out the scheme when Parliament has adopted it. We are a very happy country in this respect, and we have more administrative experience, skill and knowledge than any country of a similar size in the world. We are able to carry out these great reforms just because we have those qualities. Therefore, when the argument is over, when the decisions have been made, when the shape of the new health service has had the imprint of His Majesty’s signature, I hope to have the advantage of many consultations with you in order to bring practical benefit to every person in the land.

Source: The Hospital, May 1946, pp. 179-83.