The early days of Britain’s National Health Service

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The National Health Service–known to friends and wolves-in-friends’-clothing alike as the NHS–began in 1948, when World War II was over but food was still both scarce and rationed, the economy was just staggering out of a severe recession (no, I hadn’t heard of it either), and the empire was in the process of collapse. 

Introduce anything so ambitious these days and every sober advisor in (and out of) sight would tell you, Get serious. Maybe you could just replace the program with a nice slogan. So how did the prime minister, Clement Atlee, and his minister of health, Aneurin Bevan, manage this little trick?

For starters, the system they introduced didn’t drop from the sky. It had been taking shape since at least 1909. 

 

Irrelevant photo: A camellia–although if you read to the end it becomes semi-relevant since you could argue that it’s deepest pink. Or at least tinged with red.

 

Background

Here at Notes, we–by which, of course, I mean I–can never tell a story without going backward first, so let’s go backward. What happened in 1909 was the publication of the Minority Report of the Royal Commission on the Poor Law, under the leadership of Beatrice Webb. The commission was looking for something that would replace the Poor Law and the punitive Victorian workhouses. The minority report argued for “a national minimum of civilised life . . . open to all alike, of both sexes and all classes, by which we meant sufficient nourishment and training when young, a living wage when able-bodied, treatment when sick, and modest but secure livelihood when disabled or aged.”

Its focus was on preventing poverty rather than providing relief once it was entrenched. But this was a minority report. The majority report argued for individual responsibility and charity. 

What happened? The party in power, the Liberals, tossed both reports into the revolving file, also known as the trash, but Webb and her fellow Fabian socialists printed copies of the minority report and sold 25,000 of them. I’d be happy to see one of my books sell half as well. 

The minority report had far more impact than the majority’s and became  central to the thinking that eventually formed Britain’s welfare state. In some estimates, it led to the Beveridge Report, which leads us to our next subhead.

 

The Beveridge Report 

Despite its name, this was not a misspelled report on what people drank. It was a 1942 report that created the blueprint for a cradle-to-grave social services system. Most importantly for our purposes, it included the idea of a free health service, funded by the state and spreading the cost of healthcare out over the country’s population instead of having it fall on the individual or family unlucky enough to get sick. 

Some 250,000 copies of the full report were sold, along with 370,000 of an abridged version and 40,000 of an American edition. In twelve months. 

Britain’s 2,700 hospitals, at this point, were run by a mix of charities and local governments. National insurance existed, but it only covered people who were working. The number of wounded coming back from the war pushed the system toward bankruptcy, adding to the pressure for a unified, state-run health service.

 

Churchill, Atlee, the war, and the welfare state 

During the war–that’s World War II in case you got lost somewhere along the way–the Conservative and Labour parties governed in coalition. Churchill–a Conservative–was the prime minister, and Labour, the junior partner. pushed for the Beveridge report to be put into practice. Churchill was reluctant to commit the country to hefty new expenses until the postwar economic picture was clear, but he also advocated a “national compulsory insurance for all classes for all purposes from the cradle to the grave.” He didn’t oppose the Beveridge Report but wouldn’t commit himself to implementing it, and privately called Beveridge “a windbag and a dreamer.” 

That left Labour in a position to campaign as the party that would put the report–”the full Beveridge”–into practice, and in the first election after the war Labour won a big honkin’ majority: 393 seats to the Conservatives 197. Labour was a socialist party at this point (it no longer is) and on the first day the new parliament met, its MPs sang (or in some tellings, bellowed) the socialist anthem, “The Red Flag.” 

The link will take you to the song if you can’t go on without hearing it. This version is sung, not bellowed, which is a bit more important than being shaken not stirred.

Once he was prime minister, Atlee threw his weight behind the creation of a welfare state–a huge undertaking, including not just medical care but housing, education, and financial assistance to the unemployed, retired, and disabled.

“We had not been elected to try to patch up an old system but to make something new,” he said. “I therefore determined that we would go ahead as fast as possible with our programme.”

The program also included the construction of housing and the nationalization of key industries. Railroads and coal mines were “so run down,” as the Britannica puts it, “that any government would have had to bring them under state control. In addition, road transport, docks and harbours, and the production of electrical power were nationalized. There was little debate. The Conservatives could hardly argue that any of these industries, barring electric power, was flourishing or that they could have done much differently.”

I should probably stop here and say what will be obvious to some people and not at all to others: there’s no single definition of socialism that all socialists agree on. I think a fair summary of this version is that key industries were nationalized and the state was responsible for supporting people’s overall welfare. It was a form of socialism that coexisted with capitalism.

But let’s go back to the end of the war. The country was well past its eyeballs in debt and Keynes had warned earlier that the country faced a “financial Dunkirk.” It had borrowed massively to fund its role in the war (a lot of it from the US), and wartime industries like aviation were bigger than it now needed while basic industries like coal and railroads needed serious repair–which is to say, investment. As the Britannica (again) puts it, “With nothing to export, Britain had no way to pay for imports or even for food.”

Loans from the US and Canada helped the country get through a short stretch. The Marshall Plan got them through another stretch of time. But food continued to be rationed, and the fifties were a pretty gray time for the country.

In that situation, how were they going to pay for this massive investment in a welfare state? At least part of the answer was the National Insurance Bill–an extension of a system put in place before World War I–which had working-age people paying in every week specifically to support the benefits everyone in the country could draw on. (Married women who worked didn’t pay in, but don’t worry, they suffered enough inequalities to more than make up for it.)  

 

The NHS

In 1948, the National Health Service was launched, under the leadership of Aneurin–called Nye–Bevan, the minister of health. 

Bevan had started work as a miner at 13 and chaired his miners’ lodge at 19. He also chaired the local Medical Aid Society, a system that had members paying in and getting healthcare in return. Initially, this didn’t include miners’ families. During his tenure, membership expanded to include non-miners,until 95% of the town was eligible. This became his blueprint. 

“All I am doing is extending to the entire population of Britain the benefits we had in Tredegar for a generation or more,” he said. “We are going to ‘Tredegarise’ you.” 

The NHS was set up to help everyone, and care would be free and based on need, not ability to pay. “A free health service is pure socialism,” he said, “and as such is opposed to the hedonism of capitalist society.” 

Opposition came from the Conservative Party, the British Medical Association, and the right-wing newspapers.

Okay, historians argue about whether the Conservatives belong on the list. Their 1945 manifesto backed health services available to all citizens but didn’t commit to it being free. At any rate, they voted against Bevan’s version of the NHS and compared it to Nazism. That probably makes it fair to say they opposed it.

No one argues over whether doctors opposed the plan, at least as a group. Bevan claimed he won them around by “stuffing their mouths with gold”– allowing consultants to treat paying patients privately and still work inside the NHS. He later claimed he’d been “blessed by the stupidity of my enemies.”

 

And now?

I’d hoped to take you through a bit of more recent NHS history, but I dipped a toe into that water and just about drowned. Now that I’m back on the couch, safe and dry, I’ll risk nothing more than the most superficial of summaries. The NHS is immensely popular–basically, it’s the national religion–and most people find the idea of medicine for profit both shocking and counter-intuitive. But profit has crept into the system, and for the moment at least, socialism has been pushed to the political fringes. 

I’ve lived in Britain for 18 years and seen the NHS reorganized in assorted ways, all of them disastrous. Huge chunks have been privatized so one corporation or another could make a profit by running it as cheaply as possible, all in the name of efficiency, but somehow, magically, it all gets less and less efficient. At the moment, the NHS is suffering from years of underfunding. Waiting lists are long, jobs can’t be filled, and nurses and doctors are leaving the system to work somewhere–anywhere–else. 

With the next election predicted to return a huge Labour majority, I’d like to think the problems will be fixed–or at least addressed in some way that serves the public interest–but I’m doubtful. The current party leadership has been telling us we can’t expect much from them and I’m inclined to think they’re telling the truth. 

Still, for all its problems–and they’re many–the NHS is a magnificent thing: a system that makes healthcare free at the point of delivery, as the saying here goes. I’m originally from the US, so I’ve seen what the alternative looks like. A for-profit system is primarily interested in, um, making money, so what matters is whether a person can pay. US healthcare can and does bankrupt even the comfortable and well insured. It neglects the poor and milks the rich and–oh, hell, I could go on but you get the point. Both systems have their problems, but I much prefer the problems of a socialized system.

*

Now that Labour’s taken distance from any suggestion of socialism, I wondered if it had also taken distance from its old song, “The Red Flag.” Apparently not. Its 2022 party conference made headlines when the delegates sang it. The song opens with the words, “The people’s [or “workers’,” depending on the version you choose–and probably your politics] flag is deepest red / It’s shrouded oft our martyred dead.” A parody runs, “The people’s flag is deepest pink / It’s not as red as you might think.”

And with that I’ll leave you for the week. Stay well out there, people. It’s not safe to get sick.

27 thoughts on “The early days of Britain’s National Health Service”

  1. The rot set in with the introduction of competition (purchaser : provider split) by Margaret Thatcher. The NHS isn’t a business and employing an army of administrators to make it run like one was a disaster. Blair’s focus groups influenced policy, prioritising quick access to GP care, rather than continuity of care. This was misguided, but Blair did pump more money into the system (increased the percentage of GDP spent on health to match European spend). But with 14 years of Conservative government austerity, the service has been run down, staff pay has not kept up with inflation, maintenance of buildings neglected, etc. The population is getting older and sicker. Social care is inadequate (problems recruiting lower paid carers), so hospital patients can’t be discharged when they are recovered. And as you have said, frequent reorganisations have made matters worse. Morale among health workers is at rock bottom. We need another Nye to get the service working properly again.

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    • We do, and I’m afraid we won’t find one in Starmer’s orbit, although I’d love to be wrong about that.

      When I set out to write the post, I meant to get into the purchaser/provider split and Blair’s little accounting trick–PPsomething; the initials escape me just now–that hid the cost of construction and left the service with debts, shoddy construction, and no one around anymore to be accountable for it. And all the rest of that mess. But summarizing it in some readable way, not to mention being amusing and not turning homicidal–turns out to be beyond me. I ended up narrowing my topic so I didn’t have to abandon it completely.

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  2. Private Finance Initiative – Gordon Brown’s fudge to get companies to build/improve hospital infrastructure then to rent it back to the NHS at exorbitant rates for 20 years, at which point, the private companies still own the building. It moved expenditure from capital to recurrent, which improved the national credit rating or something. Disastrous for hospital trusts struggling financially as a result.

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  3. Fascinating- thanks for taking on the task of describing the rise of the NHS. Historical perspective is essential for any understanding of complex situations! Greetings from Portugal which also has a struggling NHS.

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    • Sorry to hear yours is struggling as well. A health service is so important, and while there’s money to be made from destroying them, I’m afraid they’ll continue to be under attack. The vultures are circling.

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  4. I worked in a PPE funded building in the East of England near Cambridge. A diagonal crack ran through the outer wall to our surgical unit as the building slid slowly down the hill. It is also worth mentioning, in the interests of fairness, that the NHS is a victim of its own success as we are all living long enough to die of much more interesting, expensive and previously untreatable diseases.

    Kind regards, Chris.

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    • That’s a horrible–and not at all surprising–story about the building.

      We are living longer, and as medicine gets clever it also gets more elaborate and more expensive. Both were predictable, but reading the reasoning of the people underfunding the NHS, you’d think both were a complete surprise–something they couldn’t possibly have planned for.

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    • I think Nye Bevan & co assumed that only those who couldn’t afford private medical treatment would use the NHS. Instead, everyone uses it – which is fair enough. And new treatments are being developed all the time – which is wonderful, but expensive.

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      • Interesting possibility, one I haven’t seen raised but certainly possible. One theory making the rounds is that if a program is open to all, society will put pressure on it to work well. If it’s means tested and so open only to the poor, it will become “poor service for the poor,” since they’re the group least likely to have the power to press for good services. By being open to everyone, the NHS avoided that–for a time.

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  5. I appreciate this overview, but I’m still a bit puzzled how the economics worked out. If we were already in debt and then nationalized a bunch of things, built houses and all the other stuff, did that reduce the national debt eventually at all, or break even or what? I ask because it’s just the sort of magic money tree we could do with now. Maybe the investment in industry meant we had stuff – steel? – to export.

    I skimmed Wiki on The Marshall Plan, and realised that as well as that very significant injection of cash, a lot of the economic recovery came from removing trade barriers across Europe, modernising transport, and so on. We’ve been bashed by Brexit, but perhaps one positive noise from Labour is that they are intending to borrow to boost the economy, which might be the only way to get out of the slump. On much else, they seem like Tory Lite – love the “people’s flag is deepest pink”.

    I wonder whether an equivalent modern Tredegarizing might be in the form of universal basic income replacing all the hodge-podge of benefits. There’s some evidence from small-scale studies using UBI that it can boost the economy, because poverty in our current system acts as a trap, disincentivizing people from training, starting businesses, even meeting other people, so they become isolated and dejected and the only extras they can afford come from fiddling the system or more serious crime. With a secure income guaranteed, they are freed to generate additional income and economic growth generally for the society.

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    • I’d love to explain the economics of the era but it’s beyond me. Keynes was an active force in all this, I believe–certainly in the Beveridge report–and the economics of it were Keynesian. Certainly, they invested in the infrastructure, making trade and business easier. They invested in the workforce (otherwise known as human beings and the lives they led) in the form of housing, education, welfare support, and health. I haven’t double checked this, but I’ve heard they either established or raised the minimum wage. According to Keynes–and I think I’ve got this more or less right–that sort of borrowing brings growth; it’s the borrowing that doesn’t create jobs that’s problematic. As governments have moved away from Keynesianism and declared war on government debt, many of them have, ironically, run up more debt that the parties they accuse of overspending.

      Sorry, can’t give you a link on that. I see figures occasionally but don’t want to go searching for them.

      A universal basic income does sound like it would be worth trying. The current system is not only trapping people but is so damn punitive, working on the assumption that anyone getting support from the state must be up to something bad.

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  6. The pre First World War Liberals introduced national insurance, which gave entitlement to a range of what would now be called benefits, and old age pensions. And the Webb report came well after the Booth report and the Rowntree report … although it was more the poor health of people volunteering to fight in the Boer War that prompted the Liberal reforms. No-one threw anything “in the trash”!

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    • Thanks. The Booth and Rowntree reports are new to me. A bit of history I’d like to dig into one day. That’s the problem with history–everything connects to everything, and you can’t possibly get hold of it all. But you can have fun trying.

      One of the assorted articles I read, and I can’t tell you which one anymore, did say that the government–Liberal at the time–didn’t act on their the Webb report of the majority report, which is what I translated into throwing them in the trash. Maybe an overstatement but a footnoteable one.

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      • The economic fudge at the time was that investment in free medical care would mean a reduction in costs once the accumulated backlog of treatable ill-health was dealt with. Don’t forget that at that time antibiotics (miracle drugs – and cheap!) were just coming in, no-one quite understood the dangers of smoking, or anticipated the pace of growth in expensive high-tech medicine. And after a decade of rationing, obesity was hardly an issue! The sort of public health interventions most people saw as priorities were better housing and fewer industrial accidents.

        One important phase in the debate was the position of GPs: their organisation resisted and resisted until practically the last minute. Bevan settled for their central position as gatekeepers/access points to the system, and for their remaining self-employed contractors with the NHS, with a guaranteed income from a capitation fee per registered patient. That was enough to attract them into the system, and very soon they were it staunchest supporters.

        On previous reform: I’m reading a massive history of the 20s and a 30s, from which I learn that an awful lot of active reforms to welfare systems, including the end of the last relics of the old Poor Law system, is credited to …. Neville Chamberlain.

        Oh, and another version of the Red Flag is

        “The working class can kiss my arse,

        I’ve got the foreman’s job at last

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        • Now that you remind me, yes, I do remember that version of “The Red Flag.” I think I heard it before I knew what it was parodying.

          Neville Chamberlain, of all people? History’s an endless surprise. Sort of like a grab bag. You reach in and there’s no telling what you’ll pull out.

          Good points all about the ways medicine has expanded. I don’t know how much you’ve followed the economics of US healthcare, but I suspect you’d have fun being horrified by it all.

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    • My partner worked in managed care–boy, what a phrase that is–before she retired (and before Roe v. Wade was overturned), so I’ve got a semi-inside view of the problems with American health care. But what’s happened to women’s health since the political pile-on–. My hope is that the right wing over-reached with that and that it’ll turn and bite them in the ass.

      That’s a mixed metaphor, isn’t it? Oh, well. Squint as you read it and you’ll barely notice.

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