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Andrew Seaton tackles listener questions about the UK’s National Health Service as it marks its 75th anniversary
How did the British public respond when the NHS was first founded 75 years ago? How have the roles of doctors and nurses changed in the decades since? And was there ever a ‘golden age’ of the National Health Service? In our latest Everything you wanted to know episode, Andrew Seaton tackles listener questions about the UK’s National Health Service, to mark its 75th anniversary. Andrew Seaton is the author of Our NHS: A History of Britain's Best Loved Institution (Yale University Press, 2023) Buy now on Bookshop.org Buy now on Amazon Buy now on Waterstones
How should we see the NHS's history on its 75th anniversary?
On the 75th anniversary of the founding of Britain's National Health Service (NHS), Dr Andrew Seaton considers whether looking back at the institution's history can provide an understanding of where the NHS fits in our lives today…
“I think a lot of present debate about the NHS kind of moves between two poles,” says Dr Andrew Seaton. “On one side, we have a sometimes quite sickly, treacly view of the NHS, which is all rainbows and hearts and the idea of ‘Our NHS’. And on the other side, we have a deeply pessimistic view of the NHS, about the care it produces, and an idea that it's going to collapse any day even though it's lasted 75 years. On the podcast | What was healthcare like in Britain before the NHS? “So I think if we can find a way of using history to move beyond those two poles of conversation, that would be great. And I think once we do, we'll actually find many, many surprising and frankly more interesting things to talk about in the history of the NHS. The fact that it wasn't universally and always celebrated at its inception, [for instance], or the fact that it was deeply implicated in processes of decolonisation and the experience of immigration in Britain. The fact that this state institution could adapt and could be reflexive to social change. The fact that not everything after the 1980s was privatised and slid into disrepair. “And I think that, if we think about the history of the NHS in a different way – if we bring in new voices, [those of] patients, the public, different sets of experts, architects, economists, these kinds of people, as well as cultural figures, the filmmakers, the novelists and so on – I think we'll get a wider and more interesting understanding of where the NHS fits in our lives today.” Dr Andrew Seaton was talking to Matt Elton on the HistoryExtra podcast. Read and hear more about the history of the NHS
Since its faltering launch in 1948, the National Health Service has become a cherished part of British society. Andrew Seaton explains how it attained that status
As Britain’s National Health Service celebrates its 75th anniversary this July, two topics look set to dominate the extensive media coverage. The first is the sense of crisis stalking the NHS, illustrated by sky-high waiting lists, troubling financial shortcomings, exhausted staff and extensive industrial action. The second is the NHS’s enviable reputation as arguably Britain’s best-loved institution. In 2022, some 62 per cent of people surveyed by polling organisation Ipsos stated that the service was the thing that made them “most proud to be British” – an increase of 12 per cent from 2016. The fun-runs, tea parties and other events marking the NHS’s ‘birthday’ on 5 July speak to its standing in British public life. It’s an institution that appears to be part of the furniture – and, at the same time, on the brink of collapse. No other part of the welfare state attracts the same level of admiration. People do not bake cakes to commemorate the introduction of child benefit payments. Nor do they attend street parties to mark the construction of council estates. Even among Britain’s international peers, there are few countries that view their health system as emblematic of their ‘national’ values. True, Canadians might cite their country’s guarantee of universal healthcare as a point of pride to lord over their US neighbours to the south, but Canada does not celebrate its health service to the same degree as we do in Britain. Clearly, despite its many and vocal critics, the NHS is widely beloved. But from where did this public support stem? And to what extent have the difficulties facing the service, and the persistent sense of ‘crisis’ they’ve engendered, shaped this sentiment over time? Public affection for the NHS had to be actively nurtured. It was not inevitable that any state-organised universal health system founded after the Second World War would eventually attract such a degree of popular support. Achieving such an outcome took both effort and time. Supporters of the concept and its implementation – who sat predominantly, though not exclusively, on the political left – furnished the institution with a caring and egalitarian image, helped embed its communal modes of care in everyday life, defended its principles against free-market critique, and established new traditions to celebrate its achievements and history. These efforts – by assorted activists, campaigners, trade unions, experts, cultural figures and the Labour Party – helped ensure the status of the NHS in Britain today. In turn, they also contributed to the survival of the institution when so many other parts of the welfare state and public industries fell away from the 1970s under Margaret Thatcher and her successors. State medicine During the interwar years, the British public relied on health services that stemmed from government, charitable and private initiative. For example, patients needing hospital care accessed treatment in either ‘municipal hospitals’ (often refurbished Poor Law institutions from the Victorian era, now run by local councils) or ‘voluntary hospitals’ (which ranged from smaller cottage hospitals to prestigious teaching establishments such as the Royal Infirmary of Edinburgh, and were funded by patients’ payments, fundraising and endowments). Yet, as surprising as it may appear, in the 1940s public responses to proposals for a ‘National Health Service’ were mixed. Read more | An appointment at the house of death: the horror of the early Victorian hospital In the Second World War, when the ‘reconstruction debates’ about the nation’s future reached their height, pollsters asked Britons what they thought about potential government organisation of medical care. The results were equivocal. Many respondents welcomed the idea, perceiving it as an improvement on the existing services that left considerable gaps in coverage, particularly for women and children. (For instance, the National Insurance system that provided millions of Britons with access to a GP did not cover ‘dependants’, thereby excluding the family members of those who were insured through their employment.) Others were ambivalent. Significant numbers believed that such plans would lead to a bureaucratic and impersonal system under government oversight – one in which local doctors and hospitals lost their familiarity with and detailed knowledge of individual patients. As one woman questioned by the social-research organisation Mass Observation remarked: “I hate anything which is controlled by the government.” Critical letters to local newspapers decried “state medicine” as a “deadly threat to personal liberty”. At the heart of these statements lay an older view that the state should not coordinate something as personal as medical care. Having secured a landslide victory in the 1945 general election, Clement Attlee’s Labour Party needed to address these concerns. The new minister of health, Welsh socialist Aneurin Bevan, oversaw the legislation for what would become a nationalised medical system, predominantly funded by taxation and free at the point of use. Although Bevan’s tussles with the British Medical Association are often invoked when narrating the drama that surrounded the creation of the NHS, another sort of battle was fought to win the hearts and minds of the British people. Recognising the apprehensions about ‘state medicine’ voiced during the war, the government worked hard to portray the NHS as a caring, egalitarian service that would support families. Such an image was advanced through the production of films including 1948’s Here’s Health, a live-action drama depicting a fictional working-class family’s struggles to afford care in the months before July 1948. This film’s exposition of the benefits of the NHS to those previously excluded from government help with medical costs emphasised the new offer to families. Similarly, government posters, radio broadcasts, speeches and travelling exhibitions affirmed the service’s humanitarian credentials, distinct from earlier critical interpretations of government medicine. Transforming lives Of course, this promotion was not the only reason for the growth in the NHS’s popularity. Following the launch of the new service on 5 July 1948, hospital treatments and doctors’ appointments, now available to all free of charge, transformed many people’s lives and garnered significant appreciation. Nonetheless, cultural output also played a role in grounding the service. The language of ‘state medicine’ declined in popular use, becoming voiced predominantly by the service’s organised political opponents. The NHS was a single body that people could thank for the care they received – in a way that hadn’t been possible with the disaggregated medical system of the interwar years, and which had been discouraged by the critical views of government medicine invoked during the war. However, in the first two postwar decades, the NHS suffered as a result of small budgets and a lack of prioritisation by both Conservative and Labour governments. Far from being a golden age of the welfare state, in the late 1940s and 1950s spending on social services stagnated, health languished below the likes of education in government priorities, and funding for new hospitals and general practice facilities was scarce. It wasn’t until the 1960s that a significant wave of new hospitals began to appear in towns and cities, a legacy of the financial support offered by the 1962 Hospital Plan. Nonetheless, even without new facilities, governments and reformers spearheaded a number of changes to the way the NHS worked on an everyday level. These efforts further expanded the service’s popularity in its early years. Partly, they improved flexibility in the face of social changes that included an increasingly affluent population, shifting attitudes to gender and sex, and growing ethnic diversity. For example, hospitals gradually extended their visiting hours: whereas in the 1940s patients might have been allowed just one or two hours a week to enjoy the company of relatives and friends, by the 1970s some hospitals permitted one or two hours’ visiting each day. Similarly, in response to changing ideas of masculinity, hospitals increasingly allowed fathers to attend the births of their children. There were limits to the extent of such changes, but they still reflected well on a public welfare service that – compared with many other institutions founded in the 1940s – largely escaped widespread denigration as monolithic or unwilling to adapt to social change. A cultural force The cultural prominence of the NHS also swelled in the postwar decades. Though the slew of art, films, television programmes, novels and music featuring the service was not always straightforwardly supportive, it did help cement the service’s status as a pivotal part of British life. At the cinema, the NHS provided the background for the risqué and slapstick humour of Carry On Nurse (1959) and Carry On Doctor (1967) – and in 1975, the prog rock band National Health named themselves after one of their frontmen’s spectacles, which were provided by the service. Cultural material also passed comment on the universal principles behind the NHS. In her 1974 novel Second-Class Citizen, Nigerian-born novelist Buchi Emecheta captured the experience of using the service as a person of colour. The protagonist, Adah, feels marginalised because of her class and race on a London maternity ward where everyone else is white. As in real life, gossip spreads easily on communal wards. Yet, for all the challenges she faces, Adah expresses gratitude for the companionship that such spaces could engender in the NHS. The convivial atmosphere of a maternity ward, where women “seemed to have known each other for years and years”, encourages Adah to adopt a “new code of conduct” and gain the confidence to leave her abusive husband. Emecheta’s novel spoke to the connection between decolonisation and the NHS. When the service was launched, Britain’s colonies were beginning to secure independence, including India and Pakistan in 1947, Malaya in 1957 and Nigeria in 1960. Thousands of people from the nations of the reimagined ‘New Commonwealth’ journeyed to Britain to work and build lives, and the NHS employed and cared for many such immigrants. In fact, the service’s guarantee of universal healthcare would not have been possible without them: thousands of doctors, nurses, technicians, cooks, porters and cleaners from overseas performed essential tasks during the postwar labour shortage. By the start of the 1970s, for example, almost a third of all NHS doctors had trained overseas, most in India and Pakistan. Despite their invaluable contributions, such employees were sometimes subjected to racism from colleagues and patients. In rare cases, patients sometimes even asked to be treated by a white doctor or nurse instead of someone of colour – and, shockingly, on occasion NHS hospitals acceded to such requests. As patients, some people from the Commonwealth were met with hostile refusals of their ‘right’ to access NHS services, regardless of their status as British citizens. And in his infamous 1968 ‘Rivers of Blood’ speech, Conservative MP and former minister of health Enoch Powell claimed that hospital beds – along with council housing – were being overrun by Commonwealth immigrants. As the NHS became increasingly understood as a distinctly ‘British’ achievement, discussions about who belonged in the service and who did not became more sharply polarised. The idea of ‘our NHS’ built support for the institution – but could also lead to the exclusion of those who were not white or who had arrived from beyond Britain’s borders. Shock to the system The NHS, along with other parts of the welfare state and public industries, faced serious challenges during the economic and political turbulence of the 1970s and 1980s. The oil crisis of 1973 shook the industrialised world, resulting in record fuel prices, soaring inflation and job losses. Successive Conservative and Labour governments struggled to get a grip on the economy in the years that followed, and various political projects migrated from the fringe to present new solutions. The politics of neoliberalism – characterised by a belief in free markets and competitive individualism – gained greater purchase on debate and policy, with politicians, businesses and intellectuals advancing free-market priorities. By the 1980s, Margaret Thatcher’s government was following this political approach. But the prospect of privatising the NHS – which now rivalled pensions as the largest recipient of government welfare spending – represented a major challenge. Indeed, the size, practices and values of the health service comprised an enduring emblem of social democratic politics. The fact that the institution’s prominence wasn’t successfully undermined was not due to a lack of desire or effort. The prime minister’s famous 1982 remark that the service was “safe with us” obscured a longer history of opposition to the NHS. During the 1960s, Thatcher and key members of her government had belonged to important health policy groups within the Conservative Party that advocated marginalising or even abolishing the health service. On the eve of the 1979 general election, one such group stated that the NHS was “better discarded altogether and a fresh start made in light of knowledge accumulated and experience gained”. In line with free-market principles, this group maintained that a health system based on private health insurance would encourage greater choice and self-reliance, raising more money to spend on medical care in general. In the early years of Thatcher’s government, an internal committee in the Department of Health and Social Security explored such ambitions. They met little success, though, because of the difficulties of replacing a system as large as the NHS, instability within the private health insurance market, and soaring popular support for the existing nationalised system as a uniquely ‘British’ achievement. For the champions of markets within healthcare, reforming the internal structures of the service – rather than its total removal – seemed a viable alternative option. If fortress NHS could not be besieged from without, then perhaps it could be compromised from within. The policies that followed this shift in approach included outsourcing work such as hospital cleaning or laundry to private companies, the introduction of management principles in the NHS that were comparable to the private sector and, in 1990, the implementation of an ‘internal market’ to ensure greater competition. Premature diagnosis? This marketisation of the NHS’s functions from the 1980s escalated an atmosphere of crisis. For many, the legislation that enabled companies to take over catering contracts, or the slick managers employed to help the service follow ‘business principles’, marked a betrayal of the service’s founding values. The government’s stringency with the NHS’s budget increases during the 1980s compounded concerns over its capacities. To be sure, these policies never went as far as anticipated by their neoliberal promoters in think tanks and businesses. At the start of the 21st century, most of the NHS’s workers remained employed in-house, and it still delivered the overwhelming majority of healthcare to Britons. For all of the newspaper headlines heralding a private sector ‘takeover’ of the nationalised service, companies often struggled to make headway because of the difficulties involved in complex procurement processes, or the pro-NHS campaigners who quickly seized upon any of their perceived failings. Nonetheless, due to this process of marketisation, predictions of the NHS’s actual or imminent demise became ever more common. In a typical example of this sentiment at the end of the 20th century, one protester at a march against budget cuts carried a small coffin emblazoned with the slogan: “NHS died 1985 – RIP”. These claims of crisis focused public attention on the service, and helped build further support for the institution. The 1970s and 1980s represented the transition point in the public standing of the NHS – the moment when it became most central to politics and understandings of British identity. The service’s prominent place in the popular psyche was demonstrated by a boom in events celebrating its birthday on 5 July. During the 1980s, trade unions established ‘NHS Day’ as a popular tradition, with family-centred events such as donkey rides and galas combined with protests and petitioning. Such events marking the service’s anniversary encompassed both a celebration of its principles and a push back against what trade unions described as ‘privatisation’ under Thatcher’s government. When Tony Blair’s New Labour came to power in 1997, it smoothed out some of the more radical elements of this cultural practice, and made it a national phenomenon. For the NHS’s 50th birthday in 1998, commemorative 50p coins were issued, a garden party was held at Buckingham Palace, a ceremony was staged at Westminster Abbey, and government-sponsored exhibitions took place, confirming the ascent of a popular cultural tradition originally framed by a sense of crisis. Again, the involvement of trade unions, campaigners and the Labour Party underlined how building wider support for the NHS required the active involvement of its supporters. It wasn’t inevitable that the service would retain its prominent place in British life. It was the result of fierce struggles between those who advanced social democratic and neoliberal politics in healthcare, as well as a context of crisis during the 1970s and 1980s. Alarming prognosis At least in public, leading politicians in all main political parties now support what they regularly describe as ‘Our NHS’. This trend became obvious in the aftermath of New Labour and its escalation of the NHS’s cultural significance in British public life. For the service’s 60th anniversary in 2008 David Cameron, then leader of the opposition, even visited the ‘first’ NHS hospital in Manchester to praise the institution. None of his predecessors in his party had undertaken such an act, yet it now seemed natural for him to do so. Even so, today the NHS again faces serious challenges. Depending on the NHS Trust, these financial difficulties could be made worse by longer-term debts from New Labour’s Private Finance Initiative (PFI), which used private capital to build facilities as part of long-term contracts with construction companies, management consultants and private equity firms. The Conservatives initially continued PFI but abandoned it in 2018 due to a lack of cost-effectiveness. In the wake of the 2008 financial crisis, the government restricted the annual budget increases for the NHS. And since 2010, funding for the service has seen its largest sustained reduction relative to overall GDP since the 1950s. Without annual budget increases – needed for any health system to keep pace with the rising costs of medical care and the growing demand for services – older facilities have not been upgraded, and thousands of vacancies have remained unfilled. On an everyday level, patients’ access to NHS services became more restricted as waiting times and lists ballooned. During the 2010s, the number of people waiting for hospital treatment rose from 2.5 million to 4.6 million – the highest number ever – in England alone. From 2020, the Covid pandemic compounded these difficulties as appointments were postponed and, once government restrictions were eased, exhausted staff struggled to meet demand. The NHS is not unique in facing these troubles. Most health systems worldwide are experiencing related problems, and their patients express similar concerns. According to an Ipsos 2022 survey of more than 23,000 people in 34 countries around the world, three out of five respondents believed that their own health system was seriously overstretched. Moreover, the NHS has faced moments of serious crisis before, and recovered. It is not impossible that the service – and the wider social democratic principles it represents – might rebound in the future. And the history of the NHS suggests that, in order to address internal difficulties, it will need its supporters among the British public. Read and hear more about the history of the NHS This article was first published in the August 2023 issue of BBC History Magazine
Dr Andrew Seaton of the University of Oxford considers the question of a 'golden era' of Britain's National Health Service, founded in 1948…
“This is an important question, because it frames and underpins our idea of crisis and decline," says Dr Andrew Seaton. “This idea that there was a golden age for the NHS, and that now we’re no longer in a golden age. So history is very important to our present understandings of 'decline and crisis', these kinds of phrases that are used around the NHS. “There was no such thing as a golden age for the NHS. Often what you'll see, particularly from the [political] left, is the postwar decades presented as a golden era of the welfare state: the supposed generosity of Clement Attlee’s government and their support for welfare services, the supposed golden era of harmony on the wards, respect for the matron, this kind of stuff. It's just not true. It's a fantasy. If we look at funding levels, the Attlee governments actually spent more money on imperial commitments and overseas military commitments than they did [on] the welfare state. That’s the first point to make. There were social divisions on the wards, too. It wasn't that everyone had respect for matrons in the past. [And] if you were a woman or a working-class person or someone who wasn't white, you might be condescended to [for instance]. These kind of social cleavages existed in the postwar years. “So I suppose in that sense, if we're thinking about golden eras or high-water marks for the NHS, it really depends what we're thinking about here. If we're thinking about funding, then the most generous point is under New Labour in the late 1990s and during the 2000s. That is the point when the UK, for the first time in the postwar era, came up to the level of its international industrialised peers in terms of spending on healthcare. So it depends what lens we’re looking [through]. “And I would argue that it isn't necessarily in the deep, deep past that we could find the high-water marks of the NHS. It could be surprisingly recent. In 2010, 2011 and maybe even 2012, the Commonwealth Foundation (which is an independent health care think tank based in New York) put the NHS as the number-one healthcare system in terms of efficiency and giving the most access to patients. So it’s in the surprisingly recent past that it was achieving those kinds of metrics. “This is all to say that it's not impossible that it might achieve those kinds of metrics again in the future. And, of course, for very, very good reasons, there's a lot of concern and pessimism about the state of the NHS. But I think if we think historically about it – and we don't even have to go that far back in the past – we can challenge and maybe even puncture some of that sentiment.” Dr Andrew Seaton was talking to Matt Elton on the HistoryExtra podcast. Read and hear more about the history of the NHS
Founded to give free healthcare to all, the National Health Service is one of the UK’s most beloved institutions. But since it was founded in 1948, it’s faced a slew of demanding challenges, from ballooning costs to lethal epidemics
Before the National Health Service (NHS) came into being, Britain’s healthcare – and the health of its people – left much to be desired. Pre-Second World War, infectious diseases including diphtheria and tuberculosis were rife, and infant mortality rates were high. Healthcare was something of a postcode lottery, with those who lived near to institutions like the St London teaching hospital in London most likely receiving a higher standard of care than people whose closest port of call was a cottage hospital with few beds. And, of course, people had to pay for their healthcare: in the 1930s, one doctor’s visit was approximately three shillings and sixpence – an eye-watering cost that even the middle classes struggled with. Officials had recommended that a free national health service should be introduced in England as early as 1920. However, it wasn’t until 1942 and the release of the Beveridge Report, which set out a system of free healthcare funded by taxes, that it seemed possible such an ambitious project could become a reality. Read more about life in Britain before the 'free' NHS When did the NHS begin? On 6 November 1946 Aneurin ‘Nye’ Bevan, the Minister of Health in Clement Attlee’s Labour government, oversaw the passing of legislation that brought the service into being: the National Health Service Act for England and Wales (there was separate legislation produced for Scotland and Northern Ireland). But, as the country was still economically reeling from the Second World War, the service was not formally founded until 1948. In the early days, Bevan faced opposition from doctors who were worried that working for the service would limit their independence and hamstring their income. But he eventually persuaded them to join the NHS, later claiming that he had “stuffed their mouths with gold”; he agreed that consultants could keep their private practices and thus retain their financial freedom. On 5 July 1948, the day the NHS officially launched, 85 per cent of doctors had signed up with the service. Blowing the budget On that first day, the service took control of 480,000 hospital beds, 125,000 nurses, 5,000 consultants – as well as scores of GPs, opticians, pharmacists, dentists and more. Setting the budget for such a large service had not been an easy undertaking, and it soon became clear that demand far exceeded supply. The budget for optical services, for example, was £3.5 million for the first year – the actual cost came to a staggering £15 million. And dentists were swamped, too, as Britons who had previously avoided getting their teeth seen to – pre-NHS, people who needed dental work had to travel to a teaching hospital and often pay for services – flocked to see dentists in their droves. In the first year alone, 33 million pairs of dentures were given out. Dentists who had formerly seen 15 or 20 patients a day were now treating up to 100. Although some people were at first reluctant to use the service, often worrying what their neighbours would think of them for taking something for free, others took advantage of the free assistance on offer. For instance, one doctor was flummoxed by a patient’s continual requests for free prescriptions of cotton wool. When he finally asked him what he needed it for, he was stunned to discover the man had been using them to wash his greyhound. With the budget left in tatters, charges were introduced – the first being for dentures, in the early 1950s. Prescription charges soon followed, initially per prescription before it increased to per item. These charges were later removed by Harold Wilson’s Labour government in February 1965, but they gradually crept back in from 1968 onwards. Many exemptions were put in place, though, and a great deal still exist: in 2016, 89.4 per cent of prescriptions were issued free of charge. Listen | Susan Cohen discusses the highs and lows of the NHS, from its creation in 1948 to the challenges it faces today Changing attitudes Throughout the service’s history, attitudes towards care – particularly in the case of family planning and mental health – have altered dramatically. Originally family planning was never covered in the service’s remit, but when the contraceptive pill was introduced in the 1960s, this was no longer the case. NHS doctors were able to prescribe the pill from the early 1960s onwards – but there was a catch. Only married women were eligible for these prescriptions, and in most cases, they were given out to older women who wanted to stop having children rather than women who didn’t want children at all. Unmarried women resorted to subterfuge to secure their access to the pill, slipping on wedding rings in the waiting room to convince their doctors they had husbands. Later in the decade such charades became unnecessary, as the pill was available through the Family Planning Association. Meanwhile, attitudes to LGBT+ patients came to the fore in the eighties, when the AIDS crisis ravaged England. Following actor Rock Hudson’s death from an AIDS-related condition in 1985, UK headlines foretold a plague and stirred up prejudice. The NHS and the department of health were very slow to respond, launching their health campaign about the virus in 1987. With the slogan “Don’t die of ignorance”, the campaign was meant to raise awareness of the disease and hammer home how dangerous it was: a film commissioned for the campaign prominently featured a tombstone. Contact tracers were also sent out into the community to speak with those who had had relations with AIDS sufferers, and a succession of large-scale campaigns about HIV and safe sex followed. Treating mental health has changed greatly during the service’s history, too. The early NHS inherited a collection of ‘asylums’ that were in a terrible state. In the 1970s, these asylums were closed down and sold off, and the onus for mental health care was moved towards the community and smaller, local hospitals, with varying levels of success. A raft of new drugs were introduced too, to help treat psychosis and depression, and – particularly in recent years – attitudes towards mental health have largely improved. Vaccinating the nation The NHS has carried out several high-profile immunisation drives throughout its history – most notably the vaccination campaigns for polio, measles, and of course the current push to vaccinate the country’s population against Covid-19. Less than a century ago, polio – a debilitating disease that can cause paralysis – was feared across the world. In 1955, a British version of the US vaccine was successfully developed and rolled out across the country. And by 1962, a version of the vaccine that could be administered on a sugar lump was pioneered, which made vaccination even simpler. However, the public response to the polio vaccination drive was initially rather poor. In the 1950s, epidemics of the disease were breaking out in the Midlands and Northern Ireland. These two spikes in cases helped persuade people to get vaccinated, as well as the surprise death in 1959 of a 29-year-old footballer called Jeff Hall, who had died within a fortnight of being diagnosed with the disease. The race for a cure: how we found vaccines for 4 of history’s most dangerous diseases Once people were convinced of the need to be vaccinated, the program was rolled out very quickly, and the virus was eventually eradicated in the UK (the last polio outbreak in the country happened in the late 1970s). But for those who weren’t vaccinated in time and who had to be treated by the NHS for polio, their experiences were often horrible. Children recalling their treatments spoke about being kept in iron lungs (machines to assist with breathing which were akin to large metal coffins), and they were rarely allowed to see their parents. Once they were allowed home, they often had to sleep in cold plaster casts and wear callipers (leg braces). However, the polio immunisation drive pales in significance when compared to the race to vaccinate the UK’s population against Covid-19 – and treat those who are suffering from its effects. In the words of historian Susan Cohen, “the service has responded absolutely remarkably” to this unprecedented strain on their resources and staff. Cohen says: “They’ve put their lives on the line to save other people, and that’s what the NHS has always been about.” Dr Susan Cohen is a historian with a special interest in British social history. She was talking to Rhiannon Davies, BBC History Magazine sub editor, on an episode of the HistoryExtra podcast This article was first published on HistoryExtra in 2021
Susan Cohen discusses the highs and lows of the NHS, from its creation in 1948 to the challenges it faces today
Historian Susan Cohen discusses how Britain’s National Health Service has changed over the decades since its landmark creation in 1948. She explores the challenges of providing ‘cradle-to-grave care’ for all Britons, and discusses some of the biggest issues that the service has faced, including discrimination in the ranks, AIDS and Covid-19. Read more about the history of the NHS
The birth pains of the NHS: how Britain's National Health Service was created
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
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. 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. Paying for healthcare: life in Britain before the ‘free’ NHS 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. 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. How did Spanish Flu get its name? 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. A bite-sized history of dentistry 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. 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”. 5 "bloody brilliant" 20th-century women 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. 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
What was healthcare like in Britain before the NHS?
The National Health Service was launched on 5 July 1948 by the then minister of health, Aneurin Bevan, to provide healthcare that was free at the point of delivery. But what was life like for the sick and injured before Britain had a ‘free’ health service? Here, Dr George Campbell Gosling explores what it was like to be asked to pay for healthcare, and explains the profession that was established to handle such money matters…
They are little remembered now, but before the introduction of the NHS in 1948, some 1,000 women at hospitals across the country policed the boundaries of medical charity, public and private healthcare. It was the job of these ‘lady almoners’, as they were known, to interview patients and decide an appropriate rate. They increasingly also helped to make sure patients received the support they needed when they left the hospital (this had become their primary role by the 1960s, when they officially rebranded themselves as ‘medical social workers’). During Victorian times, the hospital was an institution that meant very different things for people of different classes. Associated in the public psyche with poverty, those who could afford a private doctor stayed away from the hospital at almost any cost. All hospitals – whether a workhouse infirmary or an elite voluntary hospital – were institutions founded and funded by the middle and upper classes to serve the medical welfare needs of the working-class population without charge. Despite a complete lack of evidence, there was widespread fear in the 19th century that the system was being abused. This led to the first almoner being appointed at London’s Royal Free Hospital in 1895; one Miss Mary Stewart had the task to assess those coming to the hospital for treatment. Some were to be told they were too well-off, so should be treated privately. Others were told they should make some financial contribution to the hospital. The remainder received treatment for free but were advised to join a community savings scheme to ensure they could pay their way in future.This system was copied in a number of other London hospitals and, after the First World War, was rolled out across the country. In challenging economic circumstances – when the latest treatments were becoming more expensive to provide and demand for them was increasing – the hospitals reluctantly turned to the patients themselves as a source of income. <img src="https://images.immediate.co.uk/production/volatile/sites/7/2018/08/GettyImages-463913111-a303f47.jpg" width="3677" height="2850" alt="Associated in the public psyche with poverty during Victorian times, those who could afford a private doctor stayed away from the hospital at almost any cost. This illustration from The Illustrated London News depicts a ward in the Hampstead Smallpox Hospital, c1871. (Photo by Oxford Science Archive/Print Collector/Getty Images)" title="Associated in the public psyche with poverty during Victorian times, those who could afford a private doctor stayed away from the hospital at almost any cost. This illustration from The Illustrated London News depicts a ward in the Hampstead Smallpox Hospital, c1871. (Photo by Oxford Science Archive/Print Collector/Getty Images)" /> Hospitals didn’t appoint financial clerks or debt collectors to administer this new system. Instead they turned to almoners, who took into account an individual’s social background and family set-up when determining the appropriate amount that they should pay. For this reason it was understood to be a distinctly female role. While the nurses could care for the sick and the midwife would guide the mother through birth, the almoner could advise on the practical family and financial implications of sickness. As the secretary of one hospital told a King’s Fund committee in 1912, “the Almoner’s work is ladies’ work” – but added that “ladies are usually better if they are suited for the work. I mean ladies who are really ladies”. These class assumptions usually went unspoken. But it was assumed that the person making decisions and offering guidance over the financial aspects of treatment for working-class patients should be a respectable, educated, unmarried middle-class woman. The first generation of these women came from the world of charity work, usually from the notoriously moralistic Charity Organisation Society. However, two-year courses were soon established that combined practical experience with social and economic studies at university. The almoners’ payment system began in the more prestigious voluntary hospitals, but soon spread to public hospitals also. With its introduction came the separation of middle-class patients, often into a few private rooms within the hospital. These would often be on a different floor to the ordinary wards – or perhaps in a different building entirely, sometimes taking over a section of the nurses’ block. This ensured that provision for the sick poor was not being crowded out while also preventing the two classes of patients from having to ‘rub shoulders’. The payment system was now echoing and formalising the social hierarchies and class distinctions of healthcare beyond the walls of the hospital. Private medicine was a marginal activity of the hospitals, but private surgeries were far more common. Doctors used the prestige of hospital work to build their credentials for lucrative private practice. For most people, however, the doctor’s fee of around sixpence (let alone the cost of any medicines prescribed) would have been beyond reach. As a result, two schemes provided an alternative for working-class patients. One was the health insurance element of National Insurance, introduced in 1911 by Liberal Chancellor of the Exchequer David Lloyd George and expanded throughout the 1920s and 1930s. This was a compulsory insurance scheme for workers in certain industries, though it generally did not cover family members. The insurance granted access to a doctor from the local panel when needed, but usually didn’t stretch as far as hospital treatment. The other scheme was membership of one of the various community-owned mutual aid funds and medical clubs, into which working people could pay while times were good. They would receive access to a doctor, medicines and sometimes hospital treatment without having to see the almoner, by means of paying in advance. <img src="https://images.immediate.co.uk/production/volatile/sites/7/2018/08/GettyImages-3249247-bfeb543.jpg" width="3084" height="2100" alt="Nurses distribute tea at St Bartholomew's Hospital, London, in 1939. The almoners payment system in early 20th-century hospitals ensured that provision for the sick poor was not being crowded out, says George Campbell Gosling. (Photo by Kurt Hutton/Picture Post/Getty Images)" title="Tea Time At BartsNurses distribute tea at St Bartholomew's Hospital, London, in 1939. The almoners payment system in early 20th-century hospitals ensured that provision for the sick poor was not being crowded out, says George Campbell Gosling. (Photo by Kurt Hutton/Picture Post/Getty Images)" /> There were also some health insurance schemes available to middle-class individuals, helping them to meet what could be a substantial cost for treatment – whether in the private room of a hospital, a private nursing home or in their own home. Unlike the working-class medical clubs, these organisations survived the creation of the NHS in 1948 by covering the fees for services that fell beyond the scope of the NHS, and for private hospital wards, which were kept as ‘pay beds’ for those who wanted to go private in NHS hospitals. So, while we tend to think of the NHS’s defining feature being its delivery of a free health service, private wards were one element of payment that continued within the NHS. Plans to phase them out, championed in the 1970s by Labour MP Barbara Castle, were finally abandoned followed the Conservative election victory in 1979. The idea, when Aneurin Bevan first introduced his new health system in 1948, had been to abolish most forms of payment. It was, however, an ambition that was not shared by all – even some within his own Labour party opposed it. We sometimes imagine the NHS as being at the heart of a post-war consensus in British politics. But if there was a consensus over the NHS, it began not in 1948 but in 1951. Not with the realisation of Bevan’s vision, but with his resignation in protest at the introduction of charges for dentures and spectacles, and with the door opened for an incoming Conservative government to introduce prescription charges as well. One of the junior ministers who resigned alongside Bevan was the future prime minister Harold Wilson. A year after he came to Downing Street in 1964, a second three-year stint of free NHS prescriptions began, designed to ensure that the new system of prescription charges included exemptions for the poorest and that sickness did not result in financial hardship – the same priorities that had guided the pre-NHS hospital almoners. In the 21st century, under devolution, Scotland, Wales and Northern Ireland have all returned to a version of Bevan’s universalist health system by abolishing prescription charges. Yet in England we have a compromise of a free health service with elements of payment, rooted in traditions that go back even further than 1948. This article was first published by HistoryExtra in 2018