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BMJ No 7124 Volume 316 Editorial Saturday 3 January 1998 1948: a turbulent gestation for the NHS Some things don't change This year is the 50th anniversary of Britain's National Health Service. On 5 July 1948 Aneurin Bevan, minister of health in the postwar Labour government, launched "a unique experiment in social engineering."(1) The experiment continues, but the public has long since judged it a success, even though that success has become tarnished in the 1990s. The NHS's gestation, however, was described by Bevan - in a classic understatement - as "not ... altogether trouble-free."(2) Certainly, the months between December 1945, when the health minister made his first major policy statement to parliament, and the "appointed day" in 1948 were a turbulent period in medicopolitics. The unfolding dramas were faithfully chronicled by the BMJ, and in this opening issue of the anniversary year the journal publishes it first "filler" on the NHS selected from the issues of 50 years ago (p 20). Others will appear during the year, but not necessarily in chronological order because the selections have to be fitted into available spaces. Nevertheless, readers will receive a flavour of the events of a momentous year. In 1948 most doctors probably supported the principle of a comprehensive, state funded health service. After all, the preceding two decades had seen the BMA publish reports advocating a form of national medical service, the wartime Emergency Medical Service had shown the effectiveness of nationally organised hospital care, and William Beveridge's famous 1942 report proposing a "cradle to grave" welfare state had received wide public and political support.(3) The profession was, however, unhappy with the details as they affected doctors as defined in the NHS Act passed in November 1946.(4) So much so that the BMA warned that the independence of medicine was at stake. As a result the BMA and the government spent many months in acrimonious and public confrontation. The differences were most acute over general practice. Hospital doctors, too, were worried: about the nationalisation of voluntary hospitals; the loss of influence by the teaching hospitals; a fair distribution of consultant skills; and private practice. But the presidents of the royal colleges, particularly the physicians' president, Lord Moran, worked behind the scenes to persuade Bevan to make enough concessions to defuse opposition among hospital doctors.(5) General practitioners depended on the political skills of the BMA to achieve their objectives. They feared that the new service would convert them to salaried employees and compromise their clinical independence. General practitioners also saw the NHS as devaluing the financial worth of the goodwill that was bought and sold when they entered or left practices. Plebiscites were held, special representative meetings called, and threats made that doctors would not sign on in the new service. Negotiations dragged on to a stalemate in December 1947. As 1948 dawned, an angry government tried to split the profession, with Bevan savagely attacking the BMA's leaders and accusing them of misleading "a great profession." The profession's answer came soon after in the result of a plebiscite of all doctors by the BMA. Asked whether they would accept service in the NHS, almost 90% of respondents - 75% of the whole profession - opposed joining under the government's terms.This riposte so alarmed the cabinet that Bevan (aided by Lord Moran's informal conciliation(5)) promised an amending act.(6,7) He conceded sufficient ground to the BMA (including specific exclusion of a salaried service for general practitioners) to ensure - after more heated debates and another plebiscite - that doctors would join the NHS on 5 July 1948. The profession's arrival at the starting line may have been at the 11th hour, but Nicholas Timmins, in his admirable biography of the welfare state, described 5 July as "by any standards one of the great days of British history."(8) Events in the remaining months of 1948 showed how much that day meant to the British public. The BMJ of 13 November, for example, noted "the eagerness with which the public has sought to take advantage of a service which, in effect, guarantees the supply, free of direct charge, of everything from wigs to iron lungs.... Doctors' surgeries are crowded out, and the doctors themselves deplore that this heavy pressure of work has made it at times impossible for them to give their patients adequate care and attention."(9) That observation remains pertinent 50 years on. But the important principle was that people could visit the doctor without fear of the financial consequences and when necessary be referred for specialist care. Even in today's cash strapped NHS such access to medical care is cherished by the public. Long may it remain. Gordon Macpherson Former deputy editor, BMJ References 1 Klein R. The politics of the NHS. London:Longman,1983. 2 Bevan A. A message to the medical profession. BMJ 1948;ii:1. 3 Beveridge W. Social insurance and allied services. London: HMSO, 1942. 4 NHS Act 1946. London: HMSO, 1946. 5 Bartrip P. Themselves writ large. The British Medical Association 1832-1966. London: BMJ Publishing Group, 1996:256. 6 Grey-Turner E, Sutherland F M. History of the British Medical Association 1932-1981. London: BMA, 1982:68-9. 7 NHS (Amendment) Act 1949. London: HMSO, 1949. 8 Timmins N. The five giants: a biography of the welfare state. London: Harper Collins, 1995:130. 9 Anonymous. NHS. BMJ 1948;ii:864-5. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline