“I need not remind you that what we get into scrapes for is not for saying what nobody believes and everybody says, but for saying what everybody believes and nobody says.”
Florence Nightingale. Letter to Sir John McNeill,1857.
Ideas about a National Health Service have been around ever since the French revolution. The Jacobins predicted an end to all disease as soon as everyone was well fed, housed and educated, as they believed would occur soon after the world became ruled by reason. Like all revolutionaries, they saw remote ends more clearly than immediately feasible means, but their perception that most disease and premature death was rooted in poverty has provided the rational foundation for public health policy ever since.
In the Victorian era, Sir John Simon tried to set up a unified national medical service, not just to tinker with disease, but to maintain public health. He was easily isolated by his clinical colleagues, who lived from sale of their skills, real or imagined, not from enlightened government. A main function of all trade unions was mutual assistance in times of illness, often with some elementary provision for prepaid medical care on the club system. These two elements, State-funded Public Health from above and ad hoc general practitioner (GP) care from below, eventually became the main points of origin for the NHS.
The idea got going again in the 20th century, when the South African war revealed that few British working men had been well enough fed to make good soldiers. The intoxication of empire, and new confidence that doctors might become men of science rather than shopkeepers, led to demands for health services to maintain the British race where God apparently wished it to be; firmly on top of everyone else. This ugly set of ideas attracted not only imperial Tories, but many medical intellectuals convinced they could design a more perfect human race in their own image. It ended in Auschwitz, but British doctors contributed to its origins, showing that medical professionalism, at least as traditionally understood, was no guarantee of humane thought and action.
The first modern proposals for a State Medical Service were presented by Fabians Sydney and Beatrice Webb in their Minority Report on the Poor Law in 1909. Churchill’s description of Beatrice as a lady determined to scrub working class women into healthy behaviour had some justification. The Webbs shared some of the imperial and authoritarian delusions of their time, which may have helped to make them uncritical of Soviet communism in 1935. They showed little of the warmth and compassion of that other eminent Fabian, George Bernard Shaw. His description of the gap between teaching hospital theory and social reality has never been bettered :
“The only way [a doctor for poor people] can preserve his self respect is by forgetting all he ever learnt of science, and clinging to such help as he can give without cost merely by being less ignorant and more accustomed to sick-beds than his patients. Finally he acquires a certain skill at nursing cases under poverty-stricken conditions, just as women who have been trained as domestic servants in some huge institution with lifts, vacuum cleaners, electric lighting, steam heating, and machinery that turns the kitchen into a laboratory and engine-house combined, manage, when they are sent out into the world to drudge as general servants, to pick up their business in a new way, learning the slatternly habits and wretched makeshifts of homes where even bundles of kindling wood are luxuries to be anxiously economised.”
That description still fitted the situation I, and thousands of other young GPs like me, found in inner-London practice when I qualified in 1952.
By 1911, Lloyd George was on his way to becoming the most cunning and effective prime minister our ruling class ever had since Disraeli. He saw that industrial workers, till then the mass base of the Liberal Party, were moving toward socialism and the new Labour Party, and similar changes were accelerating all over the world. In Germany, Chancellor Bismarck had tamed revolutionary socialism by introducing State medical insurance. Lloyd George took a look, and came back with similar proposals for Britain. His 1911 Insurance Act was the origin of the Welfare State, and his nationalisation of club medicine and local insurance in 1912 was the progenitor of the NHS in 1948 .
The heart of this service was not medical care, but cash benefits to breadwinners during episodes of sickness or injury, to keep families from pauperism and maintain a viable labour force for industry. From the point of view of the State, GPs were involved mainly as judges of entitlement to benefit; any medical care they gave was an incidental bonus. To the extent that effective medical science was applied at all, it was assumed to exist only in hospitals, an attitude that continued well into the 1960s.
In the same year of 1912 the State Medical Service Association was formed, to press for the Lloyd George Insurance Act to be further developed into an NHS, including hospital care in a comprehensive service. In 1929 it renamed itself the National Medical Service Association, and in 1931 it became the Socialist Medical Association, affiliated to the Labour Party. From then on it campaigned first to establish, later to maintain and defend “a Socialised Medical Service, both preventive and curative, free, and open to all”. In 1982 it again renamed itself as the Socialist Health Association. Many different forces influenced the NHS we actually got in 1948, but the SHA was certainly one of them.
BIRTH OF THE NATIONAL HEALTH SERVICE
The war in the West became serious in 1940. On the brink of defeat and all-too- possible Nazi occupation, Britain was forced to look at itself honestly. Like other important national industries, hospitals were found to be grossly underfunded, unplanned, uncoordinated, irrationally distributed, and underequipped. Few had laboratory or X-ray services, and most relied on GP-surgeons plus a few unpaid consultants who worked free, in exchange for a secure base for private practice.
Rightwing Conservatives, the Thatcherites of their day, had admired the fascist dictators’ success in suppressing independent trade unions and socialist ideas. This underlay Chamberlain’s policy of appeasement. Together with years of mass unemployment, the undeniable consequences of appeasement of fascism marginalised the Conservative right for an entire generation. Alliance with the USSR, which bore the brunt of the fighting, and the excellent results of State planning for British war industry, created a wider social base for socialist ideas than ever before or since.
Swept along on this tidal wave of commitment to a new and better postwar world, in 1944 the British Medical Association (BMA) collaborated in government plans for a future National Health Service. It was a high point in popular resolve never to return to pre-war laissez faire economic policies and their consequent high unemployment and social division, finally expressed in the landslide election of 1945 and Britain’s first majority Labour government. By then the BMA and Conservative Party were in full retreat from NHS plans they had endorsed a year earlier. Without a Labour government, no comprehensive NHS would have been born; at best, we would have had a two-tier service, with private insurance at the top and poor care for poor people at the bottom.
Birth of the NHS required not just a Labour government, but a socialist vision of the future. Almost single-handed, Aneurin Bevan was the architect of the NHS. He grew up in a coal-mining village, where people learned through bitter experience to share forms of wealth that were indivisible, and to respect values that were unmarketable. He wrote only one short book on his ideas about socialism, In Place of Fear. The fears he had in mind were those the 1945 Labour government tried to delete from British society: of losing jobs, homes, health, and personal dignity, fears which threatened and often blighted the lives of most working people between the two world wars.
Despite huge advances in medical care, we still fear the natural consequences of ill- health with good reason; but for more than 40 years since 1948, nobody in Britain has had to fear its unnatural consequences in a market economy; mounting bills from doctors and hospitals, and insurance premiums that rise with risk, and never cover all the most serious contingencies, and the unspeakable question hovering over every commercial transaction – is this to help me or to help him ?