BMJ  2008;336:1216-1218 (31 May), doi:10.1136/bmj.39582.501192.94

Analysis

NHS at 60

Founding principles

¹ BMJ, London WC1H 9JR

Inthe first in a series ofarticles marking the 60th anniversary of the foundation of the NHS, Tony Delamothe examines what drove its formation

Britain’s National Health Service (NHS) came into existence on 5 July 1948. It was the first health system in any Western society to offer free medical care to the entire population. It was, furthermore, the first comprehensive system to be based not on the insurance principle, with entitlement following contributions, but on the national provision of services available to everyone.1

To the founding principles enumerated in this quotation should be added quality and equity. Presenting his National Health Service Bill to parliament in 1946, health minister Aneurin Bevan said "not only is it available to the whole population freely, but it is intended . . . to generalise the best health advice and treatment."² The intention was to make the same, high level of service available to all, according to need.³ In other words, the new service could be seen as responding to the old Marxist rallying cry, "From each according to his ability, to each according to his need" and a more familiar enthusiasm for uniform, national standards of excellence.¹

Universal, equitable, comprehensive, high quality, free at the point of delivery, centrally funded—how does the NHS look 60 years after it came into existence? In the next five articles I will be examining how its founding principles have fared. In this article I look at how the socialist dream came to be dreamt in the first place.

Roots

Much has been written about the effects of the second world war in galvanising social change,⁴ but historians agree with the government’s white paper that "The idea of a full health and medical service for the whole population is not a completely new one, arising only as part of post-war reconstruction."³ As far back as 1909, the socialist reformer Beatrice Webb had called for a public or state medical service in her minority report to the Royal Commission on the Poor Law. David Lloyd George’s health insurance scheme for breadwinners (although not their dependents) looks quaint now, but was an important milestone for its time (1911). A decade later, Lord Dawson of Penn argued that "the best means of maintaining health and curing disease should be made available to all citizens." In 1930, the Socialist Medical Association was set up to campaign for a national health service, and its proposals for a comprehensive, free, and salaried medical service run by local government became official Labour Party policy in 1934.⁵ Throughout the 1930s, the British Medical Association made supportive noises, but funding models remained a sticking point.

The crucial shove came from William Beveridge, who had been asked by the government to chair an interdepartmental committee on the coordination of social insurance in June 1941. Published in December 1942, his report focused firmly on postwar Britain. It identified the "five giants on the road to reconstruction" that needed to be slayed: want, disease, ignorance, squalor, and idleness.⁵ "A revolutionary moment in the world’s history is a time for revolutions, not patching," he wrote.

Through some judicious listening, Beveridge showed himself more in step with popular feeling than Winston Churchill’s coalition government. Queues formed outside government offices to buy the report, which contained 300 closely printed pages and cost two shillings (10p). Total sales of the report and a brief official summary eventually exceeded 600 000 copies. Within two weeks of publication, 19 out of 20 people had heard of the report and nine out of 10 believed that its proposals should be adopted.⁴

"The purpose of victory is to live in a better world than the old one," exhorted Beveridge, and Britain’s war weary population agreed. Within a few months of the report’s publication 57% wanted to see "great changes" in their way of life after the war.⁶ It was the report’s assumption that a comprehensive national health service would be set up that most caught the public’s attention.⁴ Various surveys showed the "very strong and in some cases unanimous" feeling that "in the future, the best possible medical, surgical, and hospital treatment should be available to everyone."⁶ In war, all had suffered together; in peace, all would benefit together.

War is over; the battles begin

Despite Churchill being credited with winning the war for Britain, almost the first postwar act of the British people was to elect a Labour government by a landslide majority. Clement Atlee was installed as prime minister, with Aneurin Bevan as minister of health. By then, the Beveridge report had been an important influence on the drafting of the white paper, A National Health Service (1944). It underpinned the National Health Service Bill (1946), which preserved Beveridge’s aspiration for "a national health service for prevention and comprehensive treatment available to all members of the community."⁵

The devil, however, was in the detail, and battles raged over the reconfiguration of the nation’s hospitals and general practitioner services and of its doctors’ remuneration. In some respects the war had made things easier. In anticipation of massive air raid casualties, the Emergency Medical Service had brought the country’s municipal and voluntary hospitals into one umbrella organisation, showing that a national hospital service was possible. According to the NHS’s official historian, Charles Webster, "The Luftwaffe achieved in months what had defeated politicians and planners for at least two decades."⁷

On 5 July 1948—less than six years after Beveridge’s report—the NHS came into being.

Defending the principles

The battles that were fought to defend the underlying principles of the NHS while it was still coming into existence are instructive. They indicate what its architects thought was too important to compromise on.

Universality
According to historian Arthur Marwick, Labour policies of the time "were hitched to the star of ‘universality.’" Labour politicians knew of the bitterness felt by unemployed men who were thrown off unemployment insurance once their claim on the system was exhausted, the "means test" before employment assistance was forthcoming, and the humiliation over different standards of service for "panel" and private patients.⁸ In Marwick’s opinion, Conservatives would probably have aimed lower—at selectivity—which was what the BMA argued for. It wanted the new service limited to those below a certain income level; covering upper income groups was unnecessary because they could provide for themselves (not to mention provide some doctors with an attractive living).⁶ But Bevan was prepared to face down any special interest groups whose demands cut across proposals with strong public support.

A memorandum from the Ministry of Health spelt out the objections to selectivity: "however good [the service] might be, a 90 per cent service would be prejudiced from the start, since it would inevitably be regarded as something provided cheaply for the lower classes only, and not good enough for the well-to-do."⁶

Marwick sees a twofold purpose in Labour’s emphasis on the principle of universality: "Only by making the state services open to all could it be ensured that the highest standards would be available to all; only by having a universal service could the stigma be removed from those who had to make use of state services."⁸

Free at the point of delivery
Voluntary hospitals opposed the policy of removing all economic barriers to health care, including patient charges, warning that a free service would lose the public’s active interest and support. In the end, the government rated this as a lesser evil than relying on fear to stimulate the public’s charitable contributions and introducing what would be resented as another form of means test. ⁶

Equity
As already noted, the Emergency Health Service provided a possible blueprint for postwar hospital provision, and supporters of both voluntary and municipal hospitals each argued strongly that their service should take over the other. But Bevan rejected both options in favour of a single nationalised hospital system. His objections to voluntary hospitals were that they had been established "often by the caprice of private charity" so were "badly distributed throughout the country." Endowments left to hospitals in affluent parts of the country exacerbated the inequality in provision. Nearby voluntary hospitals duplicated specialist services, while some areas lacked them entirely. By contrast, many local authorities had been too poor or too small to exercise their hospital powers properly. They had inherited their hospitals from the Poor Law, many of them "monstrous buildings, a cross between a workhouse and a barracks."

Bevan concluded that if the government was to fulfil its contract with the people to "universalise the best" and to provide them with the same standard of service this couldn’t be achieved by local authorities dependent on local taxation for income. Any such system would have produced better services in richer areas and worse ones in poorer areas.¹ Only a nationalised and regionalised scheme could provide the social and geographical equality he sought.⁷

Wouldn’t the continued existence of private practice threaten any notion of equity? The white paper was explicit that it could continue side by side with a new national health service. Patients wouldn’t be compelled to use such a service; nor would doctors be compelled to work for it. It seems that Bevan genuinely believed that his new NHS would offer such uniformly high standards of care that no one would choose private health care on grounds of quality alone.

Paid for by central funding
Although the 1944 white paper said that the costs of the new service would be borne "partly from central funds, partly from local rates and partly from the contributions of the public under any scheme of social insurance which may be brought into operation,"³ two of these three potential sources had failed the equity test by the time the NHS Bill came to be drafted.

Contributions from rates (local taxes) were excluded for reasons set out above. Bevan’s reason for rejecting an insurance based system was that treatment should not have to depend on the contributions made (holding out the prospect of second class operations being performed on patients not quite paid up).¹

Together we are strong?

As these examples suggest, the founding principles of the NHS seem mutually reinforcing. Abandoning one without adversely affecting at least one of the others would be difficult. Could this interdependence at least partly explain their resilience?

As the following articles in this series will show, the "ends" of the NHS have survived largely unscathed over the past 60 years while the "means" have been in constant flux.¹ But none of the arguments over the founding principles of the NHS have ever been decisively "settled." They seem likely to be contested, indefinitely. Next week I will look at how the principles of universality, equity, and quality have fared, 60 years on.

Health care before the war1 5 7 8 Panel doctors provided what we would describe today as primary health care for low paid workers (but not their families). Payment was in the form of the "health stamp"—a deduction from the weekly pay packet. Private patients paid fees to private doctors Hospital care was provided by two conflicting systems: the independent voluntary hospitals and the municipal hospitals, which were administered by local authorities. Among England’s voluntary hospitals were 20 teaching hospitals, 13 of them in London Hospitals charged those who could afford to pay and provided free care to those who could not. By the end of the 1930s many voluntary hospitals were in serious financial difficulties Historian Arthur Marwick characterised health care before the war as depending on "a primitively unstable mixture of class prejudice, commercial self-interest, professional altruism, vested interest, and demarcation disputes"

Aneurin Bevan 5 9 Appointed Minister of Health in Atlee’s postwar Labour government, Bevan had a chequered past. A former miner, he "could not forget and never wanted to forget the sufferings he had seen in the mining valleys of south Wales." Twice expelled from his party, his eventual legacy was the NHS, "the greatest Socialist achievement of the Labour Government," according to his biographer, Michael Foot. He persuaded his colleagues, the House of Commons, and ultimately the medical profession, which stood to lose materially by his reforms, that the reforms were sound and practical. A BMA council member was quoted as saying: "The first thing I noticed was the fiend was beautifully dressed. We were surprised to discover that he spoke English." He proved to have "the finest intellect I ever met."

---

This is the first of six articles marking 60 years of the NHS

In the preparation of this article I have greatly benefited from discussions with Rudolf Klein, Nick Timmins, and Virginia Berridge.

Competing interests: None declared.

References

1. Klein R. The new politics of the NHS: from creation to reinvention. Abingdon: Radcliffe, 2006.
2. National Health Service Bill. Official Report of House of Commons (Hansard) 1946 April 30:cols 45, 49.
3. Ministry of Health, Department of Health for Scotland. A National Health Service (Cmd 6502). London: HMSO, 1944.
4. Calder A. The people’s war: Britain 1939-45. London: Granada, 1971.
5. Timmins N. The five giants: a biography of the welfare state. London: Harper Collins, 1995.
6. Jacobs LR. The health of nations: public opinion and the making of British and American health policy. Ithaca, Cornell: 1993.
7. Webster C. The National Health Service: a political history. Oxford: Oxford University Press, 2002.
8. Marwick A. British society since 1945. Harmondsworth: Penguin, 1982.
9. Pater J. The making of the National Health Service. London: King Edward’s Hospital Fund for London, 1981.

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