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. 

 

 

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.