The birth pains of the NHS

The creation of the National Health Service in 1948 is widely celebrated as a glorious chapter in the history of modern Britain. But, argues Mathew Thomson, a mixture of political infighting, middle-class scepticism and a chronic inability to meet demand meant that this was far from a smooth delivery

Listening in: a doctor uses a stethoscope to examine a patient in 1948. (Photo by Popperfoto/Getty Images)

In July 2018, the National Health Service reached its 70th anniversary. The event was marked in a way that is extraordinary for a state institution, including ceremonies at both Westminster Abbey and York Minster. The NHS appears to have become, as former chancellor Nigel Lawson put it, something akin to a national religion. But this was a national religion with a troubled birth.

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By 1946, two years before the NHS came kicking and screaming into the world, it had become clear that Britain stood on the cusp of a new era of state medicine. The National Health Service Act was pushed through parliament that year, spearheaded by the Labour government’s minister of health, Aneurin Bevan. In fact, a radical move in this direction had been difficult to hold back since the Beveridge Report of 1942 had championed the foundation of the welfare state, and a war on the “giant evils” of want, disease, ignorance, squalor and idleness. There was a degree of consensus on the need for change and, in 1944, the wartime coalition government had brought that change ever closer with a landmark white paper that proposed a comprehensive and free health service.

But beneath the calm surface lurked a considerable degree of suspicion and resistance from wide swathes of the public, many of whom baulked at the prospect of the loss of traditional medical cultures – hospitals with proud voluntary traditions and strong roots in the local community – and the meddling of an over-interventionist state. There were also significant differences between the two main political parties over what form the new health service should take. Labour’s remarkable victory in the general election of 1945 owed a lot to the feeling that it was the party more likely to push forward plans for social reform. But with the combative Bevan at the helm, the medical profession proving an obstacle, and the economic fallout from six years of war putting severe constraints on the public purse, it soon became clear that the passage towards the National Health Service would have to navigate choppy political waters.

For many Britons, the advent of the NHS was confirmation of a meddling and over-interventionist state

This mix of optimism and anxiety is evident in The Gleam, a West End hit written by Warren Chetham Strode that opened at the Globe Theatre in late 1946. The story begins in 1946 on the eve of the introduction of the National Health Service. Mr Cartwright, the middle-class father of a family with a history of working in medicine and a son now entering the profession, is an enthusiast, who sees the new service as a beacon of rationalisation and social progress. But when the story leaps forward to an imagined future of 1949, such hopes begin to emerge as naive. The audience are introduced to a series of shortcomings that could emerge under a system of nationalised medical care.

In particular, we enter a world in which doctors are no longer free to make decisions on purely medical grounds, and find themselves penned in by bureaucratic regulation, corrupt officialdom and political interference. As an increasingly miserable character called Dr Boyd puts it: “I’m finding it difficult to retain my own individuality as a doctor… I’m becoming a cog in a none too adequate medical machine.”

But even as the fictional Dr Boyd would surely have conceded, creating this “medical machine” was a massive challenge – one that presented its founders with the huge task of delivering a new health service free at the point of delivery to a nation in the depths of postwar austerity. That they largely achieved this is truly remarkable.

Financial collapse

The transition from a disparate collection of insurance schemes to an integrated national health service was possible because – in the case of the physical fabric of doctors’ surgeries, hospitals and public health clinics – the NHS largely took over what was there already. There were misgivings about the nationalisation of hospitals with strong local identities and links to communities through charity, but in many cases these hospitals were facing financial collapse.

However, when something altogether new was required – most notably a promised network of health centres – the result was an unmitigated failure. This was one of the most visionary aspects of the plan for a national health service, and the one that had exciting prospects in addressing health and not just illness. This had been proposed as early as 1920, and a couple of pioneering centres were built between the wars. But a combination of GP suspicion of the state and limited funds meant that development after 1948 was slow. Just 15 centres opened in the first 17 years of the new service. As for the dilapidated hospital system that the NHS inherited, it included Victorian and former poor-law accommodation. Faced with the challenge of rebuilding a Britain ravaged by wartime bombing campaigns, the nation’s number one priority was housing, not health.

Many patients used the NHS for free medicine, while retaining private doctors. In short, they worked the system

Another herculean task facing the NHS’s founders was winning the hearts and minds of the British public, and persuading them to register with the new service. Look in any local paper across the month of June 1948 and you’ll probably find a government exhortation to sign up, usually based around the urgent, capitalised message: “CHOOSE YOUR DOCTOR NOW.”

Endless stamp-licking

A large proportion of the population had already in effect chosen their doctors. Since 1911, thousands of working-class men had registered with a panel doctor under the National Health Insurance scheme, and were simply moved over to the NHS. They didn’t have to sign up to anything. But their wives and children did – as did the middle classes.

In fact, if one section of the population was particularly sceptical of the promised merits of a National Health Service, it was the middle classes. This was the constituency that needed reassurance that Britons would still be able to choose their own doctor – and that there would be no disruption to existing doctor– patient relationships. Unfortunately, this was also the constituency most likely to be exposed to the scaremongering coverage published by newspapers such as The Sphere. Here, the arrival of government publicity into the sanctity of the private home was taken as a sign of the end of times, a harbinger of endless “stamp-licking and form-filling” in which Britons would be “permanently enslaved”. It was preferable, opined The Sphere, “to resign oneself to the prospect of extinction”.

The general public evidently didn’t agree, because the speed of people signing up was spectacular. By the end of 1948, the vast majority of the population had effectively become NHS patients. Clearly, for most British people the attraction of a free service was enough to overcome any misgivings about an overbearing state. When the social research organisation Mass-Observation looked into the issue in the first year of the service, it found that even those who remained ambivalent, and stayed with their existing family doctors on a private basis, invariably also signed up with an NHS-registered doctor as a way to access free medicines. They used the private doctor for diagnosis, and the NHS for free prescriptions. In short, they worked the system.

And where middle-class patients did use an NHS doctor, they widely expressed their relief at discovering that the experience wasn’t so very different. Some even expressed a sense of guilt that they were now getting the service free of charge when others might need it more. Particularly attractive was the prospect of free hospital care. As Mr Oakton, the house governor of Worthing Hospital, put it, the middle classes in some ways had the most to gain from the proposed change. Hospital care, he argued, had always been “available free to the necessitous poor and millionaires”. It was the “black coated worker” who had often been deterred or crippled by the cost.

The success of the government’s sign-up drive had solved one problem, but it created another: that of meeting public demand for NHS prescriptions. This encompassed everything from free medicine and elastic stockings to trusses and surgical sundries. (The local press was filled with advertising from chemists reminding the public that they could turn to the NHS doctor for such prescriptions). But if there was one item that came to symbolise the NHS’s inability to meet exploding patient demand, it was glasses.

In the past, many people had continued with an old prescription, used poor-quality over-the-counter alternatives, or simply gone without. Now they ordered their glasses from the new service. Such was the clamour that, in September 1948, the Arbroath Herald and Advertiser joked that the whole population must be going blind.

The growing waiting lists for glasses soon became something of a cause célèbre, and was mirrored in parallel debates about access to dental care. Having a national system made all of this visible: the press dedicated countless column inches to debating the latest figures on the escalating provision of glasses, pharmaceuticals and medical appliances.

For some, the fact that this debate was taking place at all was good news – a symbol that the new NHS was remedying previous neglect. As one Cheltenham optician put it: “One gets a certain amount of satisfaction from the fact that many old-age pensioners are today taking advantage of the scheme. Their gratitude on securing their spectacles does a lot to recompense one for the extra work required to cope with the demand.”

But, for the NHS’s critics, the supply ‘scandal’ was an opportunity to question whether free provision on such a scale was really possible, and whether people could be trusted not to abuse this new privilege.

The elusive staff

Then there was the problem of staffing the new NHS. Winning over the medical profession to cooperate with the new scheme had been one of Bevan’s outstanding achievements. But coping with the extra demand unleashed by a free service would be possible only if the hospitals had the nurses and auxiliary staff to provide the care. Here, expansion came up against the problem that, in order to support the new welfare state, Britain also had to get manufacturing production up to full capacity. This would take time, so hospital wards remained empty, without the staff to man them, and waiting lists grew longer still. Soon the government would look to immigration for a partial solution.

From empty wards and shortages of reading glasses to the middle-class panic over an intrusive state, the NHS faced enormous challenges in its early years. But, for all that, it rapidly won support across the board. That’s why, when the Conservative party returned to power following the 1951 general election, it concluded that the health service was far too popular to abandon. The new service would survive infancy.

But the scale of those challenges had raised concerns over cost and efficiency – and it had dampened expectations. (Labour acknowledged as much when it introduced charges for some dental treatments and glasses in 1951 – a trigger for Bevan’s resignation.) If the Conservatives could persuade the electorate that they weren’t an existential threat to the service, they could capitalise on being seen as better managers of limited resources.

By 1951, the birth pains of the NHS had not so much been cured as accepted, through a compromise over expectations from the main political parties. The tensions this created would haunt Britain’s brave new world of health provision for years to come.

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A regional health check

How the nascent NHS was received in communities around Britain

Nottingham

In the wake of the NHS’s birth, the Nottingham Journal noted the collapse of the area’s school dental service as demand from the population drained it of qualified staff. The paper also pointed out that local authority services had long preceded the NHS, and that it was “the long-term sum of these services that has given us our great advances in health”. By 1953, though, the same paper was reporting that the public had become more understanding of minor irritants; there was “less scepticism”. The NHS had, it seems, won hearts and minds by delivering real benefits.

 

Gloucestershire

Across the county, there was evident pride at the NHS’s ability to meet patient demand. The NHS was now “generally speaking, already working smoothly”, reported the Gloucester Citizen in 1949: double the number of patients were already signed up compared with the old National Insurance panel system. Meanwhile, the Gloucestershire Echo ran a story about the first ‘Bevan Baby’ born at the Sunnyside Maternity Home in Cheltenham.

 

Edinburgh

In February 1949, the Edinburgh “Wee Jessie’s ‘Specs’”. Four months previously, this 12-year-old Edinburgh girl had broken her spectacles. Her mother had taken her for an eye test under the NHS scheme and the application had been sent off to the makers that day, but months later she was still waiting, had been off school and had missed her exams. Her local MP and the Scottish secretary, the Post_ reported, had now been drawn into the case.

 

Essex

In November 1948, the prospective Conservative candidate for Chelmsford, Hubert Ashton, made waves in an Essex Newsman story bearing the headline “National Health Service Costs Going Up …Up …” “There is more than a tendency today,” warned Ashton, “to look on the state as a milch cow.” The Conservatives did support the new social services, but people needed to realise that the cost of the new services was going to be very high, Ashton argued, whereas “socialists would have you believe that they are free”.

Sussex

Sussex certainly doesn’t appear to have been a hotbed of enthusiasm for the NHS, with some people fearing that the system was open to abuse. These fears were stoked by reports in 1949 of an optician sending NHS glasses to a Greek lady now living in Italy. She had been prescribed the glasses on a visit to the area, and the optician had sent the order off to the manufacturer as a priority case and had then dispatched the spectacles to Italy. A meeting of the NHS Executive Council for East Sussex was clearly of the view that this was a step too far.

Mathew Thomson is a professor of history at the University of Warwick. His books include Lost Freedom: The Landscape of the Child and the British Post-War Settlement (OUP, 2013). He is part of a team working on a cultural history of the NHS, in conjunction with the Wellcome Trust. The team contributed to the forthcoming People’s History of the NHS (BBC Four)

This article was first published in the July 2018 edition of BBC History Magazine