A difficult birth: Nick Thomas-Symonds on the creation of the NHS
A healthcare system based on need, not wealth? It may enjoy almost universal support in Westminster now, but passing the National Health Service Act in July 1948 was not an easy task, as Labour MP and Nye Bevan biographer Nick Thomas-Symonds reports
On 4 July 1948, the night before the National Health Service came into existence, Nye Bevan, Labour minister of health and housing, declared that Britain had assumed the “moral leadership of the world”.
Bevan’s vision of a universal standard of healthcare, free at the point of delivery, had become a reality. Every household in the country was sent a leaflet that captured the immediate impact of the new system: “It will relieve your money worries in time of illness”. Millions of people have benefited – both at the time and since. Healthcare based on need, not wealth, was a great liberating principle that enabled people to live more fulfilled lives.
The creation of the National Health Service has also changed the nature of the debate on healthcare in this country. Bevan made healthcare an entitlement people came to expect. On 21 March 1949, Time magazine set out that Bevan had stood “amid the tall, black blocks of Bolton’s cotton mills in Lancashire and told the assembled workers: ‘homes, health, education and social services – these are your birthright’.”
In contrast, healthcare in the United States is still seen as a commodity. Barack Obama’s Patient Protection and Affordable Care Act 2010 attempted to extend healthcare coverage by introducing a ‘penalty’ for those who did not take out insurance. The controversy it generated was based on the idea of freedom: for individuals in choosing whether to take out health cover, and for states in choosing whether to participate in federal programmes. Though, even on this analysis, it is a freedom severely limited by ability to pay.
On this side of the Atlantic, Bevan established the key role of government in providing healthcare for all its citizens. The National Health Service Bill was clear about its purpose by creating a duty upon the minister of health to promote the establishment of “a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness and for that purpose to provide or secure the effect of provision of services” (Section 1(1)). The National Health Service (Scotland) Act 1947 created a similar duty on the secretary of state for Scotland for healthcare in the region.
Yet, the National Health Service Bill did not have an unopposed passage through the House of Commons. On 30 April 1946, Nye Bevan opened the second reading debate with a bold statement of ambition, declaring that the Bill would: “place this country in the forefront of all countries of the world in medical services … I believe it will lift the shadow from millions of homes. It will keep very many people alive who might otherwise be dead. It will relieve suffering. It will produce higher standards for the medical profession. It will be a great contribution towards the wellbeing of the common people of Great Britain.”
Richard Law, responding for the Conservatives, opposed the Bill in strong terms, stating: “It is surely a most extraordinary thing that the right honourable gentleman the minister of health, who has absolutely no administrative experience of a great government department, and who has no great knowledge, either practical or theoretical, of the very important subject matter with which this Bill is dealing, should have set his own intuition and judgment against all those best informed in the medical profession and in the hospital services outside the house. In fact, the right honourable gentleman has done just that. The British Hospital Association and the British Medical Association are opposed to this Bill.”
The partisan rhetoric made little difference. The Labour government had a large majority after the party’s landslide election victory in 1945 and secured the passage of the Bill through second reading on 2 May 1946, winning the division by 359 votes to 172. However, rather than mark the end of the struggle for the National Health Service, the vote was only one of a series of key events.
The first of these had already happened. Henry Willink, the wartime coalition minister of health from 1943 to 1945, had produced a white paper in 1944 on comprehensive healthcare provision, but proposed leaving hospitals in the control of the voluntary sector and local authorities. Bevan’s cabinet colleague, Herbert Morrison, lord president of the council, had led the London county council from 1934 to 1940, and the city had benefited from a successful local authority health service during that time.
Morrison favoured local authorities owning hospitals. Bevan favoured nationalised hospitals to guarantee a universal standard of provision and to ensure central government responsibility for funding. Drawing on his own experience on the Tredegar urban district council and Monmouthshire county council, Bevan was concerned that cuts to funding for local councils would affect healthcare provision, with the government able to lay the political blame at the doors of town halls if the spending taps were turned off. This argument was won by March 1946: Bevan’s scheme was simpler and had the backing of Prime Minister Clement Attlee.
In comparison to this swift victory in cabinet, Bevan spent the best part of 18 months in negotiations with the medical profession. Doctors, represented by the British Medical Association, reacted against the idea that their historic professional freedom should be sacrificed for them to become what they saw as full-time salaried civil servants.
The Labour cabinet stood behind Bevan, sticking to an implementation date of 5 July 1948. As the deadline approached, Bevan was acutely aware of the fact that the British Medical Association would not want to be the reason why people did not achieve access to free healthcare. Thus, he offered late concessions to the doctors themselves, including the ability for consultants to continue private work, and generous compensation for the value built up in GP practices where doctors now joined the National Health Service. In his own words recalling how he dealt with the doctors, he “stuffed their mouths with gold”.
Thus, Bevan was able to secure his moment of triumph in July 1948. It was the culmination of a battle in cabinet, in parliament, and with the medical profession. In winning those battles with a combination of philosophy and pragmatism, Bevan created an institution that was built to last.
When the director Danny Boyle produced a showcase of our nation for the 2012 London Olympics opening ceremony, the National Health Service was a centrepiece illustrating that this great institution is now part of our national fabric.
Nick Thomas-Symonds is Labour MP for Torfaen and chair of the Aneurin Bevan Society
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