Views & Reviews Medical Classics

The National Health Service Act 1946

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d6346 (Published 05 October 2011) Cite this as: BMJ 2011;343:d6346
  1. John Lister, senior lecturer in health journalism, Coventry University
  1. arx226{at}coventry.ac.uk

Some good things come in small packages: and this compact document changed the world. Its proposals opened up the possibility of modern medicine, sweeping away economic barriers to healthcare that had excluded up to half the population.

There is also a beauty in simplicity, and even in the dry parliamentary language of a bill that in its first few paragraphs sets up the first ever universal and comprehensive tax-funded healthcare system, free to all at point of use.

This is more poignant in light of the current debate over attempts to reword the first few paragraphs in a new Health and Social Care Act. The architect of the 1946 act, Aneurin Bevan, makes it absolutely clear in the very first paragraph that it is the “duty of the Minister” to “provide or secure the effective provision of services” that “shall be free of charge.” Paragraph 3 also states simply that it is the minister’s duty to provide hospital accommodation, medical, nursing, and other services, and the services of specialists.

Bevan’s solution to the problems of a broken and bankrupt network of teaching, charitable, and municipal hospitals was also beautifully simple. Instead of subsidies to prop up flagging structures one by one, in one step he nationalised the whole network, (paragraph 6). This was to be a publicly provided service, as well as publicly funded.

The nationalisation made it possible for the first time to ensure that the various hospitals—many of them very small—could begin to work together, to share expertise, and develop clinical teams, and to plan the allocation of health resources according to needs. These later developments were not spelled out in the bill, but emerged as it was implemented.

The bill reflected aspirations of the postwar electorate that had thrown out the backward looking wartime leadership and given Labour a massive mandate for radical change. It won the support of junior doctors who saw the chance of a career structure and a national training scheme.

But it also reflects the backwardness of sections of the medical profession, who clung tenaciously to their private practice and their right to offer superior services to those with money to pay. Bevan’s compromise—conceding pay beds in NHS hospitals—is set out in paragraph 5. His later 11th hour compromise, allowing GPs to remain independent contractors is not here: it was not agreed until 1948.

The new NHS was incomplete, lacking mental health, preventive, community health, maternity, and ambulance services, which were all controlled at first by county councils. Some of its language— “lunacy” and “mental defectives”—has long ago been dropped. But it was a seed boldly planted, that grew and bore fruit. It’s history in the making.

Notes

Cite this as: BMJ 2011;343:d6346

View Abstract