- The Health Services since the War. Vol. I: Problems of Health Care: The National Health Service before 1957 by Charles Webster
HMSO, 479 pp, £27.50, April 1988, ISBN 0 11 630942 3
At a time when British national identity appears more fragile than it has been for a very long time, the National Health Service bids fair to become the only major national institution that expresses the unity and commands the undivided loyalty of all but a tiny minority of the people living in this country. Shorn of empire, of economic pre-eminence, of religious certainty and racial separateness, many of them have nevertheless come to see the NHS as something peculiar and intrinsic to the British way of life: a sort of utilitarian church, mediating the beliefs and presiding over the rituals of a society incapable of advancing any more metaphysical conception. For the past thirty years foreign observers cited in Charles Webster’s study have perceived the NHS as an ‘integral part of the total pattern of the British state’, as an ‘altogether natural feature of the British landscape’, and ‘almost a part of the Constitution’. In contemporary British mythology the NHS is perhaps the last institutional survivor of the fabled ‘Dunkirk spirit’. Even in Mrs Thatcher’s Britain most of us take comfort from the thought that, though individually we are required to be competitive and self-regarding, nevertheless somehow and somewhere our collective organic self is being caring and altruistic on our behalf.
Such an institution clearly deserves study in its own right, as a complex of the things that history is all about: money and power, birth and death, science and civil rights, patronage and dependency. But it deserves study also for a different and more functional reason: namely, that false assumptions about the historic character of the NHS seriously distort current debate about patterns of health care and levels of spending on NHS facilities. Thus defenders of the NHS often imply that any infringement of the principle of free care would mean the end of civilisation – even though it is possible to think of many countries no less civilised than our own where health care except for the very poor has never been free at the point of consumption. Similarly, when the NHS is portrayed by its critics as a vast financial albatross crippling the economy, its apologists tend simply to wring their hands and intone that the sacred cow must be fed – rather than pointing out that Britain’s expenditure on health care since the Second World War has been consistently lower than that of most of her major competitors. Within this debate, both sides make impassioned appeals to the authority of the recent past: a past within which means tests and prescription charges, Bevanism and Butskellism, visionary utopianism and new realism, all churn together in the popular imagination. Charles Webster’s The Health Services since the War, which translates the folklore of the NHS into carefully documented historical analysis, could not have appeared at a timelier moment.
Dr Webster’s study is the latest in a series of ‘peacetime histories’ published by HMSO, whose authors are given privileged access to ‘closed’ official documents. It traces the evolution of the National Health Service from its earliest beginnings in the Poor Law, public health and national insurance legislation, through the Beveridge era of wartime reconstruction, to the introduction of the National Health Service under the aegis of Aneurin Bevan in 1946-8. It then analyses the structural development of the hospital, GP, local authority and ancillary services, and focuses upon the major dilemmas and flashpoints of NHS policy from its inception up to 1957. This latter date coincided, not with any major new departure, but with a period in which the NHS seems to have become generally accepted in all quarters as an irreversible bulwark of the new post-war Britain.
Though the story is told with almost exaggerated restraint and detachment there are few signs here that this is an ‘official’, government-inspired history in any pejorative sense. Indeed, one of the most striking things about Dr Webster’s study is the small comfort that it gives to cliché-ridden, portmanteau versions of Britain’s recent history, whether emanating from government or opposition, right or left. Both major parties are shown to have played a large part in the planning and inception of the service (though the Conservatives muffed the opportunity of fully proclaiming their commitment in 1945). Both major parties are shown to have been historically associated with policies diametrically opposite to those which they now espouse. Conservatives, for example, were strongly opposed in the Fifties to greater insurance funding of health provision, while Labour gave short shrift to the claims of local authorities. Aneurin Bevan promised industrial democracy to health service workers, but in fact gave it only to consultants (whose salaries and status he protected much more vigorously than his Conservative successors). Opposition to prescription charges, that later litmus-test of socialist purity, was as prevalent among ‘one nation Tories’ as among dissident Labourites, and Bevan himself initially approved such charges, less as a fund-raiser than as a puritanical rationing device: ‘I shudder to think of the ceaseless cascade of medicine which is pouring down British throats.’
Such an account should not, however, be seen as lending support to the familiar view that the NHS was the product of a unique political consensus produced by the Second World War. On the contrary, Dr Webster concludes that, although there was growing support for the principle of a free universal service, ‘concerning the mechanism for extending provision and bringing greater order into the chaotic assemblage of health services there was remarkably little unity of outlook.’ From the start of its history the NHS was a cockpit for conflicting views on such basic issues as the proper unit of public administration (local, regional or central), the proper relationship between doctors and government, and acceptable levels and methods of public finance. From the beginning, the structure of the NHS (based on regional hospital boards and private contracts with GPs) was powerfully determined by medical syndicalism, and by the determination of doctors not to become the salaried employees of local (or central) authorities. Within two years of its foundation, the service was beset with what proved to be chronic financial crisis and controversy: to such an extent that Herbert Morrison at one stage feared a collapse of confidence in the Labour Government comparable with that of 1931. Such issues were rarely reducible, however, to simple issues of party politics. Disputes over funding divided, not just Labour from Conservative, but those who thought that health finance required rational forethought from those like Bevan who thought that it could be left to find its own ‘natural level’. In both parties there were those who protested against the ‘mutilation’ of local government by the vast policy-making and patronage powers conferred by the National Health Service Act on the Minister of Health. Hostility to the principle of public medicine came not so much from Conservative backwoodsmen (though there was some of that) as from a powerful rump of BMA physicians who skilfully linked professional privilege with defence of personal freedom (‘Bevan or Belsen’, in the language of the BMA’s secretary, alias the BBC’s ‘Radio Doctor’, Charles Hill). Both parties were sensitive to libertarian arguments and both parties tried to grapple with the complex issue of pharmaceutical profiteering. Throughout the period under review organised labour, women and minority groups were grossly under-represented on regional boards and hospital management committees: but this stemmed less from any conscious gerrymandering on the part of Conservatives than from the generally conservative structure and temper of post-war society. Bevan himself strongly opposed any more direct expression of labour interests, believing that Parliament was the only indispensable democratic institution and that the TUC was primarily significant as the spokesman for a large body of health service ‘consumers’.
The result was very far from being either the repository of socialist values or the model of advanced rational bureaucracy envisaged by utopian planners during the Second World War. Although the new service was rapidly to become the largest employer in Europe, virtually no thought was given to the management of its personnel and resources (senior management at regional level consisting entirely of unpaid voluntary notables mostly over the age of sixty). The opening of the new service in 1948 left administrators and doctors reeling before a tidal wave of patients coming forward for treatment after years of neglect, and for more than a decade the keynote of NHS thinking was not forward planning but desperate improvisation. Concessions to vested interests and medical paranoia created an unwieldy and anomic tripartite structure, in which hospitals, GPs and local authority services had few contacts with each other, and chains of financial accountability were almost non-existent. In spite of continually rising expenditure, capital replacement in the hospital sector throughout the Fifties ran at something like 50 per cent below the level of twenty years before. Moreover, in spite of various symbolicbreaks with the past, there was much continuity of old services, and particularly in the mental health sector the change was largely one of name rather than kind. As Charles Webster points out of the service in general, ‘adaptation of this ramshackle and largely bankrupt edifice into a rational, modern and humane hospital structure to serve the whole population was inconceivable without revolutionary reorganisation and a secular increase in capital and revenue expenditure.’ Such changes were not on the agenda of any political party during the period under review.
Is this an example of the new ‘tory’ history, identified by David Cannadine and others, in which the systematic dismantling of the epic events of yesteryear both symbolises and contributes to British national decline? Perhaps, but I do not think so. Though Dr Webster’s account is more complex and less heroic than partisans might wish, the story that he tells is not an ignoble one: nor is it lacking in historical lessons for those who care to read them. Readers on the left will not find here a vision of the NHS which can join Chartism and the Levellers in the proto-socialist pantheon; nor will they find a golden age in which management of the NHS was conspicuously superior to that of the present day. But they will find an encouraging account of how a society much poorer than our own managed to cobble together the world’s first democratically-approved system of state medicine. Readers on the right will find that, in spite of continual anxiety about rising levels of expenditure, the NHS from its early days was good value for money. (The Guillebaud Committee, set up in 1953 to expose NHS extravagance, reported instead that it had ‘found no opportunity for making recommendations which would either produce new sources of income or reduce in a substantial degree the annual cost of the Service. In some instances ... we have found it necessary, in the interests of the future efficiency of the Service, to make recommendations which will tend to increase the future cost.’) Readers of all complexions will be struck by the sheer difficulty, complexity and imponderability of many of the issues under review: issues which largely defied any clearcut solutions, either of a ‘market’ or a ‘socialist’ kind. For the social and political historian, perhaps the most fascinating feature of the whole story is the way in which the NHS apparently almost by accident rapidly came to assume a central role in reinforcing and legitimising modern political culture and the extension of state power. The British people, notoriously ungrateful to their rulers for defence and public order, nevertheless felt grateful to government and to their fellow citizens for keeping at bay the pains of disease and death. Even if health services had been wildly inefficient and extravagant (and little in these pages supports the view that they were so), the NHS might be judged worth keeping on the same grounds as the monarchy – as a potent symbol of one-nationhood. British Conservatives, who for two hundred years have excelled at taking over, taming and transforming institutions invented by their opponents, might ponder the advantages of doing the same in the case of the NHS.