As the National Health Service reaches its 60th anniversary, it's time to look back and explode some myths about who created it, and why...
The NHS at 60: not given to us by Labour, but fought for and won by workers
WORKERS, JULY 2008 ISSUE
The National Health Service came into being on 5 July 1948, and has played a major part in the quality of our lives ever since. Most people in the UK have known no other way of providing medical care. The NHS faces many threats and challenges despite all its successes. The alleged need to improve patient choice is pushing many changes, not all of them welcomed by patients and health workers.
Medical care has advanced beyond belief compared to 1948. The NHS today employs 1.3 million workers, with an annual budget of over £100 billion. It is organised into many different trusts, which compete for patients and funds. Some will soon have "foundation" status with even greater independence. Financial performance is as important as clinical in deciding which trusts have resources.
The government promotes the Private Finance Initiative (PFI) and private/public partnerships (PPP) in the belief that "the market" is the best way to exercise financial control. But it does not talk about the huge future costs these entail, or the effect on clinical decisions.
When the NHS was created, patients were promised "your own doctor". Superficially the promise of greater choice is a progression from that promise. But it's worth looking in more detail at the reasons for creating the NHS. Two days before the NHS came into being Health Minister Aneurin Bevan wrote the following in the British Medical Journal:
"On July 5 there is no reason why the whole of the doctor-patient relationship should not be freed from what most of us feel should be irrelevant to it, the money factor, the collection of fees or thinking how to pay fees – an aspect of practice already distasteful to many practitioners.
"The cost of ill-health is a burden on the community and a burden on the family, and the startling advances made by Medicine in the past 25 years have steeply increased this cost. There is, therefore, a logical case for spreading it over the whole of the community so that those who are fortunate enough to remain in good health may help those who temporarily fall out of the ranks.
"The price Britain will have to pay for this new service is high, but the fact that the country is prepared to pay this high price shows that it is well aware that on the crude economic level an efficient and complete medical service will pay a good dividend in health, happiness, and efficiency in work".
The NHS was not a creation of the Labour Party, given out of generosity. Lord Beveridge, whose report recommended setting up a national health service, was anyway a prominent Liberal. The NHS was fought for and won by pressure from workers. Health provision was one of the reasons a Labour government was put into power in 1945 (and again in 1997).
The impetus for providing standardised comprehensive health care services came in the wake of the industrial revolution. Britain was transformed with great rapidity from an agrarian, rural nation into an industrial, urban one in the late 18th and early 19th centuries. People congregated in towns and cities, which produced an explosion of disease, industrial injuries and destitution. Lack of clean water, drainage and refuse disposal were major contributory causes of disease, particularly of cholera outbreaks.
Royal Commission
A Royal Commission was convened in 1832 under the stewardship of Edwin Chadwick, to examine the problems of urban poverty. This gave rise to the establishment of a Public Health Board, with him as Chairman, following the passage of the Poor Law Amendment Act in 1834. He subsequently produced a paper entitled "Report on the Sanitary Conditions of the Labouring Population of Great Britain", which was the chief stimulus behind the Victorian Public Health Movement. The first Public Health Act went onto the statute books in 1848; from then it became generally accepted that the health of the population was the responsibility of society as a whole.
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November 2007: Marching in London for the National Health Service in a demonstration called by Unison.
Photo: Workers |
Health services in Britain emanated directly from industrialisation and the needs of the manufacturing base. It is not a question of chicken and egg. Wealth creation and health are linked inextricably.
The National Insurance Act of 1911, passed under Lloyd George, represented the most important direct intervention by the state into health care prior to 1948. It introduced a compulsory system of contributory health insurance for a major section of the manual workforce. It was known as the "10 pence for 4 pence scheme". At the outset 11.5 million workers were covered, rising to 20.3 million by 1938, which was 43 per cent of the population. The income limit for participation was extended from £160 a year to £250 in 1920. In addition to a weekly receipt of sickness benefit, members and their families were eligible for adequate medical attendance and treatment, without further payment, from their chosen "panel" doctor. By 1938, 90 per cent of all active general practitioners were involved in the scheme. Hospital treatment was excluded, except for tuberculosis.
After the 1914-18 war, Lloyd George, under pressure to create a "home fit for heroes", commissioned the Dawson Report. This proposed the need for a nationally organised comprehensive health system with primary and secondary health services, specialist services for infectious diseases and mental illness, and teaching hospitals with medical schools.
The first Ministry of Health was established in 1919 with a doctor, Christopher Addison, at its head. During the interwar economic depression, Neville Chamberlain was minister from 1924-1929, and briefly also in 1929 and 1931. He was forced by the electorate to support a whole series of laws comprising 25 Acts of Parliament which brought all Health and Poor Law services into a single scheme, and extended access to health insurance and pensions. The 1929 Local Government Act is of particular significance.
At the outbreak of war in 1939, there were 3,000 hospitals in England and Wales of which 1,000 were voluntarily supported, with excellent standards and high calibre medical staff.
Of those, 300 hospitals specialised in a particular branch of medicine such as paediatrics, orthopaedics or ophthalmics. The remaining 700 were small cottage hospitals staffed by general practitioners.
In addition 2,000 local authority hospitals comprising the Poor Law Infirmaries provided a very basic standard of care for the elderly and chronically sick. There were 300 large hospitals for the mentally ill and about 50 infectious diseases hospitals established under 19th century sanitary legislation.
Between 1939 and 1946 events moved rapidly towards a proposal for a central government-directed and structured national health service. The Beveridge Report of 1942 promulgated the concept of comprehensive public protection for all individuals from "the cradle to the grave" against sickness, unemployment and poverty. Ernest Brown was Minister in 1942. The state, he said, will provide free medical care and pensions, family allowance, insurance against unemployment, improved housing and basic public health services. One-sixth of the cost would be met from National Insurance Contributions, five-sixths from the Exchequer.
No longer tolerable
Though differences existed between him and the doctors, the profession as a whole were no longer prepared to tolerate a situation whereby people hesitated to seek medical advice for fear of the cost that might be entailed by the discovery of a serious illness. No major operation or prolonged medical investigation could be allowed to impose a financial strain at a time when a family might be least able to bear it.
As we've seen, Bevan wanted to take money away from the relationship between patient and doctor. Labour wants to take the NHS in the opposite direction: monetary considerations are to the fore with direct and indirect privatisation of parts of the service and the increase of enterprises in health care with no purpose except to profit. But it's not only Labour – all parliamentary parties have similar views on "what we can afford".
The challenge for the working class in Britain is once again to assert the importance of the NHS to our health and to fight as much to maintain it as we did to create it and revive it. In the end it's us who will decide the future for NHS by taking action or failing to do so.