The NHS: Nye’s Simple Idea
The creation of the National Health Service, which Beveridge thought essential to his wider vision, was an angrier task. Britain had had a system of voluntary hospitals, raising their own cash, which varied wildly in size, efficiency and cleanliness. Later, it also had municipal hospitals, many growing out of the original workhouses. Some of these, in go-ahead cities like London, Birmingham or Nottingham, were efficient, modern places whose beds were generally kept for the poor. Others were squalid. Money for the voluntary hospitals came from investments, gifts, charity events, payments and a hotchpotch of insurance schemes. Today we think of ward closures and hospitals on the edge of bankruptcy as diseases of the NHS. The pre-war system was much less certain and wards closed for lack of funds then too. By the time the war ended most of Britain’s hospitals had been brought into a single national emergency medical service. The question was what should happen now – should they be nationalized or allowed back to go their own way? A similar question mark hung over family doctors. GPs depended on private fees, though most of them also took poor patients through some kind of health insurance scheme. When not working from home or a surgery, they would often double up operating in municipal hospitals where, as non-specialists, they sometimes hacked away incompetently. And the insurance system excluded many elderly people, housewives and children, who were therefore put off visiting the doctor at all, unless they were in the greatest pain or gravest danger. The situation was similar with dentistry and optical services, which were not available to anyone without the cash to pay for them. Out of this Labour was determined to provide the first system of medical care, free at the point of need, there had been in any Western democracy.
Simplicity is a great weapon. Nye Bevan’s single biggest decision was to take all the hospitals, the voluntary ones and the ones run by local councils, into a single nationalized system. It would have regional boards but it would all come under the Ministry of Health in London. This was heroic self-confidence. For the first time, a single politician would take ultimate responsibility for every hospital in the land, bar a tiny number of private ones. Herbert Morrison, the great defender of municipal power, was against this nationalization but was brushed aside by Bevan.
A more dangerous enemy by far were the hospital doctors. What followed was the most important, most difficult domestic fight of the post-war Labour government’s life. The doctors, organized under the Conservative-leaning leadership of the British Medical Association, had it in their power to stop the NHS dead in its tracks by simply refusing to work for it. They were worried about their standing in the new system – would they be mere state functionaries? And they were suspicious of Bevan, quite rightly. He had wanted to have the doctors nationalized too, all employed by the state, all paid by the state, with no private fees allowed. This would mean a war with the very men and women trusted by millions to cure and care for them. But Bevan, the red-hot socialist, turned out to be a realist and diplomatist. He began by wooing the top hospital doctors, the consultants. The physicians and surgeons were promised they could keep their lucrative pay beds and private practice. Bevan later admitted that he had ‘stuffed their mouths with gold’. Next he retreated on the payment of the 50,000 GPs, promising they could continue being paid on the basis of how many people they were treating, rather than getting a flat salary. This wasn’t enough. In a poll of doctors, for every one who said he would work in the new National Health Service, nine said they would refuse to take part. As the day for the official beginning of the NHS drew closer, there was a tense political stand-off. Bevan continued to offer concessions while also attacking the doctors’ leaders as ‘a small body of politically poisoned people’ sabotaging the will of Parliament. Would the old Britain of independent professionals, with their cliques, status and fees, accept the new Britain of state control? They did, of course. More concessions and more threats brought them round. In the end, Bevan was backed by a parliamentary majority and they were not. But it had been a long, tight, nasty battle.
When the NHS opened for business on 5 July 1948, there was a flood of people to surgeries, hospitals and chemists. Fifteen months later, Bevan announced that 5.25 million pairs of free spectacles had been supplied, as well as 187 million free prescriptions. By then 8.5 million people had already had free dental treatment. Almost immediately there were complaints about the cost and extravagance, the surge of demand for everything from dressings to wigs. There was much anecdotal evidence of waste and misuse. There certainly was waste. The new bureaucracy was cumbersome. And it is possible to overstate the change – most people had had access to some kind of affordable health care before the NHS, though it was patchy and working-class women had a particular difficulty in getting treatment. But the most important thing it did was to take away fear. Before it millions at the bottom of the pile had suffered untreated hernias, cancers, toothache, ulcers and all kinds of illness, rather than face the humiliation and worry of being unable to afford treatment. There are many moving accounts of the queues of unwell, impoverished people surging forward for treatment in the early days of the NHS, arriving in hospitals and doctors’ waiting rooms for the first time not as beggars but as citizens with a sense of right. If there was one single domestic good that the British took from the sacrifices of the war, it was a health service free at the point of use. We have clung to it tenaciously ever since and no mainstream party has dared suggest taking it away.