‘The Most Civilised Thing in the World’: The Political Foundations of the NHS

Thursday July 5 marks the 70th anniversary of the establishment of the National Health Service.  On this day in 1948, Aneurin Bevan, as Minister for Health in the post-War Labour Government, launched the National Health Service at Park Hospital in Manchester.  For the first time, hospitals, doctors, nurses, pharmacists, opticians and dentists were brought together under one umbrella organisation to provide services that were free for all at the point of delivery and financed through general taxation.

But it was nearly two years earlier that statutory provision for the NHS was provided, with the passage of the National Service Health Act 1946. This was the result, in part, of an emerging political consensus on the state’s responsibility to provide ‘comprehensive‘ healthcare to its citizens.

 

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How ‘new’ was the New NHS in 1946-8?

The establishment of the NHS was the culmination of attempts by the British State to provide healthcare services to its citizens for at least a century, and arguably even longer.

Beatrice Webb, social reformer and founding member of the Fabian Society, is often credited with the original conception of a comprehensive health service provided by the state, in her Minority Report of 1909 to the Royal Commission on the Poor Law.  In this, she advocated the creation of a ‘public medical service’, or a ‘state medical service’.

Over the following decades, various studies recommended the improvement of health service provision in the UK. There were even suggestions in the 1920s that a new service might have to be funded from general taxation, rather than by an insurance-based model, and the idea of comprehensive and universal health provision, free of charge, gained traction.

In 1934 it became the official policy of the Labour Party, and in June 1942, a British Medical Association draft interim report proposed large regional councils running hospitals, in which consultants would be salaried.

There was, therefore, what the health policy academic Rudolf Klein called a ‘sedimentary consensus’, building over several decades, that some kind of ‘comprehensive’ and universally applied health service should be introduced.

What did the Beveridge Report say about the NHS?

In his famous 1942 report, Social Insurance and Allied Services, William Beveridge proposed the creation of ‘Comprehensive health and rehabilitation services for prevention and cure of disease and restoration of capacity for work, available to all members of the community.’”

This should, Beveridge suggested:

    • Ensure medical treatment for ‘every citizen’
    • Be organised by ‘Departments responsible for the health of the people’
    • ‘Be provided where needed without contribution conditions’ as ‘[r]estoration of a sick person to health is a duty of the State and the sick person’.

How did political parties react to Beveridge’s proposal?

The wartime coalition Government – led by the Conservative Party with Winston Churchill as Prime Minister, but which also included the Labour Party and the National Liberals – came under pressure to implement the Beveridge Report, and Churchill mentioned the prospect of a new health service briefly in his first broadcast on peacetime reconstruction in March 1943.

Although no expenditure could be committed until after an election, the then Minister for Health, Ernest Brown, who was also Leader of the National Liberals, and his replacement, the Conservative Henry Willink, entered into a year of consultations with the medical profession. This resulted in the White Paper, A National Health Service, which was published in February 1944 and based on Beveridge’s principles.

The White Paper proposed the creation of joint boards of grouped local authorities which would manage municipal hospitals and have a contractual relationship with voluntary hospitals.  It also proposed that family doctors should be employed by a Central Medical Board and that GPs would be encouraged to group themselves into health centres provided by local authorities.  Although forced to make concessions to this White Paper, Willink persisted with the idea of universality for a new health service and, by the end of the war, the comprehensive principle was accepted by both sides of the political divide.

Was there a post-war consensus on the NHS?

After the Labour Party’s landslide victory in the 1945 General Election, Aneurin Bevan was appointed Minister of Health.  He concluded that the only workable option for improving healthcare in Britain was to take all hospitals – whether municipal or voluntary – into public ownership. For GPs, Bevan proposed a basic salary, with an allowance for capitation fees, or lump-sum payments based on the number of patients, to act as a top up; and proposed abolition of the sale of practices with an offer of £66 million in compensation.

The Conservative Opposition voted against both Second and Third readings of the National Health Service Bill when it came before the House of Commons in 1946.  They were wary of attempts to end local ownership of hospitals, and were opposed to any notion of a full-time salaried service.

Conservative politicians, nevertheless, made it clear that they did not oppose the principle of a ‘comprehensive health service’, and put such a declaration in their Reasoned Amendments.

What happened next?

The legislation went through Parliament with very little amendment, and received Royal Assent on 6 November 1946.  This by no means created the finished product, however, and Bevan was for months locked in negotiations with the health profession over its implementation.  Final agreement was achieved only weeks before 5 July 1948, and at the behest of the British Medical Association Bevan agreed to amend the Act to rule out the introduction of a salaried service for GPs.

On the ‘Appointed Day’, however, the new service was introduced as “the most civilised thing in the world,” as Bevan termed it, owing to its focus on the “welfare of the sick”.  In the estimation of Rudolf Klein, it was ‘the first health system in any Western society to offer free medical care to the entire population’. Supported by almost all British politicians and parties since, it remains with us 70 years on.

Further reading:

Nicholas Timmins, The Five Giants: A Biography of the Welfare State (2nd ed., London, 1995).

Charles Webster, The National Health Service: A Political History (2nd ed., Oxford, 2002).

Timothy Raison, The Tories and the Welfare State: A History of Conservative Social Policy Since the Second World War (New York, 1990).

Geoffrey Rivett, From Cradle to Grave: Fifty Years of the NHS (1998)

Peter Hennessy, Never Again: Britain 1945–51 (1992)

House of Lords Library, National Health Service: 70th Anniversary, June 2018

 

Andrew Mackley is a Enquiry Executive at the House of Commons Library.