‘Next week, the British Government will launch the greatest experiment in social reform ever embarked upon by the British nation.’
The formation of the National Health Service (NHS), instituted by the post-war Labour government seventy-five years ago today, was characterised at the time by Tribune as a providential moment. ‘The Great Experiment’ to which the publication’s 2 July 1948 headline referred, represented, for it, the culmination of a long socialist struggle for universal public healthcare, free at the point of use, as a social right.
Aneurin Bevan MP, the socialist minister of health and principal architect of the NHS, had been closely involved with Tribune since the beginning, helping found the publication in 1937 and steering it through the war years as co-editor. Throughout his tenure, Tribune’s pages constituted an important intellectual seedbed for the radical vision of social reform that would enter government in 1945 — when Bevan departed for the Ministry of Health carrying the blueprints of the NHS with him.
For the majority of people in Britain at the time of Tribune’s founding, access to decent, reliable healthcare was limited, if not wholly out of reach. With no integrated national health system, working people were forced to rely upon a regionally disparate archipelago of fee-charging doctors’ practices, municipal hospitals, and cash-strapped voluntary hospitals. In working-class areas, where preventable diseases claimed thousands of lives annually, families were subject to the whim of charity, means-testing interrogation from almoners, and the stretched capacity of ‘friendly societies’.
Even when the 1911 National Health Insurance Act introduced primary care for employed workers, it was limited and expensive, leaving most women and children, as well as hospital care, outside its remit. As Britain was plunged into the Depression of the 1930s, the lack of adequate healthcare led to squalor, desperation, and death for millions; rectifying this situation became a leading focus of working-class politics.
Against ‘piecemeal’ provision, and its socially disastrous consequences, calls for national health reform appeared in Tribune. Writing four months before the outbreak of war, Labour MP and co-founder of the Socialist Medical Association Dr Edith Summerskill argued,
[T]he whole machinery of the medical services needs overhauling, and a more comprehensive State-controlled system introduced, which will supply medical treatment to every individual in the community, and make it as easy as access to elementary education is today.
The Locomotive of History
The bombardment of Britain’s cities by Hitler’s air force prompted emergency national measures, including in healthcare. The resistance to centralisation — especially in hospital care — was overcome, clearing the way for more radical and progressive solutions in the years to come.
In 1942, the publication of Liberal reformer William Beveridge’s report — Social Insurance and Allied Services — captured popular attention. Beveridge’s diagnosis of the severity of social underdevelopment of the country — represented by the ‘five giant’ ills of want, disease, ignorance, squalor, and idleness — set the tone of public debate.
Tribune received the Beveridge Report as a clarion call for social transformation. In a leading editorial, ‘Beveridge Manifesto’, Bevan described Beveridge as ‘a social evangelist of the old Liberal school’; not a socialist, but one whose honest commitment to disclosing facts and drawing policy recommendations from them, rather than from orthodoxy, had produced a report with far-reaching implications. ‘The mouse has been in labour,’ he said, ‘and has brought forth a mountain.’
The ‘novelty’ of Beveridge’s report, which sought to ‘establish a tolerable minimum standard of security for every citizen’, the editorial argued, was in his having ‘set down with the authority of a statistician and on government notepaper the conditions which must be satisfied if this modest ambition [was] to be achieved’. Rather than assuming that ‘social service should be made up of the crumbs which fall from the industrial feast’, Bevan noted, Beveridge had begun from the following question:
How many crumbs … make a decent meal? The disabled worker must have that and nothing less. He fixed the figure, and, if the figure is to stand, we cannot help suspecting that he will overturn the table.
For Tribune, Beveridge’s report implied that, with regard to the country’s poor, ‘to keep their bodies healthy, to ease their minds, to release their souls … are the first claims on the State. The claim of property must come second.’ Bevan’s conclusion was optimistic: ‘It will still be a battle, but we must thank Sir William for a weapon. And if it be asked how it happens that a reformer so sedate has been able to fashion a weapon so sharp, and how a Government so timid should have presented materials for its fashioning, we must answer in the famous words of Karl Marx that “war is the locomotive of history”.’
Now Win the Peace
Beveridge’s recommendations, wrote Bevan subsequently, had generated ‘overwhelming enthusiasm’ among the British people: ‘Not since the six point Charter of the Chartist Movement stirred Britain from end to end has the mind of our people been so moved.’ The question now, however, was ‘[From] where [was] the leadership to come which [would] give expression to the awakened social aspirations of the British people?’
The coalition government, which commissioned Beveridge’s report, could not be relied upon to implement its conclusions. Britain’s ‘governing classes [would] not go one single step further than they are compelled to go,’ Tribune argued, and without ‘organised pressure’ Beveridge’s recommendations would ‘remain on paper’. With the effective confirmation soon afterwards that ‘the hoped-for Beveridge Plan in its entirety’ had ‘been rejected out of hand’ by Churchill’s government, the ‘main hope for now for saving the Beveridge Report’ was ‘to rouse the country’ in preparation to remove the Conservatives from power.
Instead of adopting the ‘Beveridge Plan’, Bevan predicted that the coalition administration would introduce a ‘number of separate measures … on which it is hoped that public opinion will focus’. These included a commitment to some manner of health reform, ultimately realised with Minister of Health Henry Willink’s February 1944 White Paper, entitled A National Health Service, following the publication the previous year of the Labour Party’s own paper, The National Service for Health.
Responding to the White Paper, Hugh Ferguson, a regular Tribune commentator on medical matters, was cautiously optimistic. The promised scheme was ‘very obviously a product of compromise’ with conservative voices within the government and medical establishment, but it nevertheless appeared ‘in accordance with those outlined in the Labour Party’s plan … and with what the Socialist Medical Association [had] been demanding for a long time’.
Its limitations, including the maintenance of the private buying and selling of doctors’ practices, ‘preservation of voluntary hospitals as autonomous units, free to remain outside the service’, and inadequately unified administrative structure, represented ‘concessions … to the more reactionary elements in the medical profession at the expense of the consumer’. The realisation of the paper’s promise would ‘depend on what we make of it, and how deeply public opinion can be roused not only to prevent it from being watered down’.
Proposals for healthcare reform were continuously hampered by the hostility of the then deeply conservative British Medical Association (BMA). Seeking to maintain the social status and independence of private and charitable medical practice against a nationally administered state system, this professional body was determined ‘to avoid every step forward that can possibly be avoided’. In his prescient 1943 piece, ‘Tory Doctors’, Ferguson wrote,
In the struggle for a free and complete health service for the whole people the progressive section of the medical profession will need the full and active support of all the progressive elements in the country against those who under the cloak of liberty are trying to maintain a fictitious independence which means drudgery, economic insecurity and professional backwardness for the ordinary doctor, and class medicine for the people.
By June 1945, Tribune wrote, ‘the White Paper plan’ had been ‘mangled beyond recognition’ by the BMA’s backroom intransigence. With major climbdowns over democratic oversight of hospital administration, remediation of coverage disparities, health centre provision, and measures against ‘the buying and selling of public medical practices’, it was ‘plain’ that ‘Mr Willink [had] sold out to the medical reactionaries’.
With the war over, it was ‘conclusive’ — such had been Willink’s retreat — ‘that the very idea of a National Health Service’ would be ‘discredited if a Tory Government is allowed to come into power and carry out what has already been prepared behind the scenes’. To salvage what remained of Beveridge’s vision, and undertake the necessary steps beyond its envisaged insurance model, would require a transformative Labour government and a minister of health bold enough to act as a pioneer. Aneurin Bevan’s time had come.
Bevan’s background, rooted in the Welsh town of Tredegar, prefigured his unshakeable commitment to socialised medicine. Tredegar’s idiosyncratic Medical Aid Society, fostered by the local workers’ movement into a scheme supporting tens of thousands, essentially constituted a national health service in miniature: furnishing resident workers and families with comprehensive healthcare.
Bevan would draw upon Tredegar’s experiment in his plans as health minister following Labour’s landslide election victory in the summer of 1945. Departing Tribune for Whitehall, Bevan summarised his ambitions in his declaration ‘to extend to the entire population of Britain the benefits we had in Tredegar for a generation or more. We are going to Tredegarise you.’
Tribune expressed a positive outlook on the new Labour government’s social agenda, but it recognised that popular support would rely on tangible improvements in workers’ daily lives. ‘Health will be one of the first subjects by which the Labour Government will be judged,’ Socialist Medical Association grandee Dr David Stark Murray contended. ‘The socialist conception of a new health service is one which would liberate both patient and doctor and provide for all the needs of both…. The quality must be of the highest, the service must be complete, and it must cover every citizen.’
In early 1946, Bevan brought his proposal for a National Health Service to Parliament. Starting out his work, Michael Foot later recounted in his biography of Bevan, the new health minister had ‘quickly concluded not merely that the supposed results of the secret Willink discussions were unsatisfactory but that the White Paper itself was in certain vital respects unworkable’. Bevan’s National Health Service Bill was in significant part his own.
Tribune’s response to the announcement of Bevan’s vision, ‘A People’s Medical Service’, was celebratory. ‘If it is implemented in the spirit in which it is drawn up, it should make Britain’s public health service a model for the world.’ Bevan’s proposals would enact ‘a completely new situation’ in British healthcare: ‘Medical care and ability to pay will no longer be connected. Every man, woman and child in the country will be entitled to a complete medical service, without charge.’ Far from the diffuse, uneven coverage of the past, ‘medical care’ under the NHS would ‘become a public responsibility’, with ‘medical resources … fairly distributed, planned in accordance with need and paid out of public funds’.
‘In two important spheres’ especially, Tribune noted, the bill went ‘further in the changes it proposes than any former plan’ — the ‘outright nationalisation of all hospitals’, and the mandating of local authorities to ‘provide and maintain general health centres’. Cutting through ‘a Gordian knot, which other plans have tried in vain to undo’, Bevan’s measures would fold ‘both voluntary and municipal hospitals … into a national hospital service’.
This forthright approach naturally in- censed conservatives in Westminster, Fleet Street, and the BMA leadership. The co- founder of a publication most well known for its anti-fascism, Bevan was nonetheless routinely subjected to accusations of harbouring totalitarian ambitions — the British Medical Journal would infamously dub him a ‘Medical Führer’.
This barrage of anathema, despite good-faith concessions Bevan had granted over salaries and capitation fees, betrayed an intense hostility on the BMA’s part to ‘the whole arrangement’ of a National Health Service. ‘Like its big brother, the Tory Party,’ Tribune wrote, ‘it considers freedom of business an essential condition of the liberty of the subject.’ Despite these displays of hostility, however, the day was already as good as won for the cause of socialised medicine. Tribune commented on the successful Third Reading of the bill in July 1946:
A great deal of the credit for this must go to Bevan himself…. Of course, he has been aggressive, but always at the right time. Perhaps better than anyone else in the House, he knows when to use a sledgehammer. But he has also shown that he knows the point on which to be accommodating; and as this Parliamentary skill has been combined with first-class administrative ability, his Health Bill has not only had a smooth passage through the House but seems likely to have a smooth inauguration when it comes into force.
‘The National Health Service Act,’ wrote Ferguson that November, ‘is now on the Statute-book as the last of the Beveridge-trilogy.’ There was still a long way to go ‘towards the achievement’ of the Act’s ‘great objectives’, of course, but there was much cause for optimism: the new NHS, once established, would grant citizens for ‘the first time … a right to get the best that medicine has to offer unconditionally’.
In a January 1947 interview with Tribune commemorating the tenth anniversary of its founding, the minister of health described his ‘work for Tribune as the Socialist activity of which I am most proud’. Giving his prognosis on the construction of the NHS, and welfare state more broadly, Bevan confided,
We labour against immense difficulties, for we inherit not only post-war problems but the hang-over from a Tory past. I think we have made a good start. 1945 was the year of opportunity; 1946 was the year of preparation; 1947 will be the year of achievement; 1948 the year of the first fruits; and thereafter the harvest will be as rich as we care to make it.
The First Fruits
The interregnum between the passage of the National Health Act in 1946 and the foundation of the NHS two years later was a difficult slog. Following the BMA’s decision to refuse negotiations with the minister over the implementation of the Act, hoping to force him to capitulate as his predecessors had done, Tribune urged Bevan to stand firm: ‘The BMA’s demands are incompatible with a public service for the whole population and no Minister of Health could accept his responsibilities under the National Health Act if they were conceded.’
In the end, a handful of sweetening concessions, coinciding with a deterioration of rank-and-file support for the BMA leadership’s hardline approach, allowed for the establishment of the NHS with the vast majority of doctors participating. As Bevan would later acknowledge, he had ‘ultimately’ judged it necessary to ‘stuff their mouths with gold’.
Tribune sat down with its former editor three days before the formation of the NHS for a ‘Special Interview’ to discuss ‘July 5th and the Socialist Advance’. Asked about the relationship of the new NHS to the cause of socialism, Labour’s health minister explained its purpose clearly: ‘The most important feature of the social services of Great Britain is the advance which they make possible on the distributivist front — what Marx called the “withering away” of wages by the reward according to people’s needs.’
The National Health Act does this much more effectively than any other part of the social service system, because it is not based on contributions. It is on the financial side a vast redistribution of national income. On the active and administrative side, it brings to the individual citizen all the battery of modern medicine, irrespective of the individual’s means.
It would be ‘not only distributivist’, he continued, but also ‘perfectly democratic’ — asserting that public healthcare ‘democratises the social consumption of the recent advances in medicine’, destroying ‘the money barrier which inevitably existed in orthodox capitalist societies between the doctor and his patient’. The ‘main line of advance’ for socialists, Bevan concluded, was in its contribution to ‘withering away the disabilities of the wages system’. ‘[I]t can be regarded in any respects as the most revolutionary feature of the British Socialist programme.’
The launch of the NHS, Tribune reported later that year, was an immediate success: ‘[T]he national health service, now entering its fifth month, has caught the imagination of the people more than any other single piece of legislation since 1945.’ The paper’s pages featured a cartoon depicting Bevan as an optician directing a squinting Churchill to an eye-test chart that read, ‘THE GREATER THE COST OF NATIONAL HEALTH INSURANCE THE GREATER THE INDICTMENT OF TORY GOVERNMENTS FOR THEIR NEGLECT OF THE HEALTH OF THE PEOPLE.’
‘Today,’ reported Ferguson on the first anniversary of Bevan’s health system, ‘95 per cent of the population, 89 per cent of the doctors and 92 per cent of the dentists are participating in the National Health Service.’ The new comprehensive public health system, to achieve which Tribune’s longtime editor had marched through a storm of abuse, was ‘so universally popular that its enemies hesitate to attack it — except to demand more’.
This moment of achievement was, probably, the greatest political conquest in the history of the British working class. People who had suffered privation and illness through the Depression, Blitz, and reconstruction now at last had recourse to reliable, quality healthcare provision, not as recipients of charity, but as a right. The legacy of the post-war Labour government is complicated to say the least, but the foundation of the NHS was transformative for millions of people across generations.
The Fight Continues
But Bevan had concluded his July 1948 interview in Tribune with a warning. The ‘National Health Service,’ he stressed, ‘is an attempt at the introduction of egalitarianism through the medium of a society which is certainly not egalitarian, either in its structure or in its inspiration.’ It had only been down to the ‘powerful authority of the Labour Government, and its massive support among the people as a whole’, that the NHS had not been strangled in its cradle.
Bevan hoped that the new service would ‘develop a tradition of its own’ to help it survive in a society beset by hostile commercial forces, but argued that ‘It must be clear, however, to everybody in the Labour Movement that we are not going to obtain from the National Health Service the best results possible, except by the utmost vigilance on the part of the whole Socialist, Co-operative and trade union movement.’
The rearguard struggle to defend the principle of universal public health coverage reached a climax for Bevan in his 1951 resignation from the Labour government, following its decision to introduce NHS service charges for dental and eyecare treatment to help finance Britain’s military budget during the Korean War. Having taken a stand against the sacrifice of socialised medicine on the altar of militarism, Bevan returned to Tribune’s pages with an article condemning the cynical calculation that ‘the arms programme is to be partly financed by raids on the social services’.
Such vigilance against backsliding from the principles of 1948 is today a task of existential importance for defenders of the NHS. Through chronic underfunding, internal marketisation, and privatisation, our once world-leading universal public healthcare system has been corroded almost to the point of collapse.
It will not be restored through Tory government or, sadly, a Labour Party committed to plastering over the cracks with private healthcare. As Tribune and Bevan argued in the 1940s, genuine public and universal healthcare can only be won through the ‘organised pressure’ of the workers’ movement. Tribune today stands with the nurses, junior doctors, and ambulance workers taking strike action, just as it once did with the bold socialist reformer who knew that the NHS would last only so long as its supporters defended it.