In the decades before the National Health Service (NHS), healthcare in Britain was guided by very different ideas. Most of the country’s hospitals were grim Victorian centres for the destitute, derived from workhouse infirmaries established under the Poor Law. An 1834 statute regarded poverty as a moral failing that should be punished with hard labour.
The rich avoided the nightmare of the workhouse infirmary by using private doctors. But for a growing proportion of Britain’s workers and the poor, the infirmary became the norm for hospital care.
When the medical journal The Lancet was given leave to form a commission of examination into the conditions of infirmaries in 1865, it dubbed them ‘a disgrace to our civilisation’. The facilities, it said, ‘sin by their construction, by their want of nursing, by their comfortless fittings, by the supremacy which is accorded to questions of expense, by the imperfect provision made for skilled medical attendance on the sick, by the immense labour imposed on the medical attendants, and the wretched pittances to which they are ground down’.
Infirmaries remained houses of terror for workers, the elderly, the poor, and the disabled until the twentieth century, long after many were taken into state care as municipal hospitals in the wake of the 1929 Local Government Act. Even as state and charitable provision grew, the British healthcare system was guided by a conservative ethos and strictly divided by class.
As historian Charles Webster notes,’ ‘[T]he path to the NHS was by no means inevitable…. [A]ny step towards translation of pious sentiments regarding healthcare into practicable objectives was liable to expose clashes of ideological loyalty and stir up conflict between affected vested interests.’Behind the NHS lies a long struggle against healthcare profiteers and their allies who opposed, at every turn, the effort to decommodify the miracles of modern medicine and provide them to the people as a right.
The Wilderness Years
To describe British healthcare at the beginning of the twentieth century as fragmented would be an understatement. Primary care was predominant and provided by an army of general practitioners (GPs), who were free to operate where they wished and usually concentrated on the affluent areas to the neglect of those with fewer means.
The hospital system was divided between public municipal hospitals, which were descendants of the Poor Law, and a voluntary service run on a charitable basis. A Ministry of Health was established for the first time in 1919, but it couldn’t be said to have had a serious national remit until the Second World War.
Public health legislation followed the Poor Law and focused at first on the eradication of typhus and cholera, but it came to encompass health-adjacent functions such as street cleaning, public laundries, bath houses, and maternity clinics. In healthcare proper, however, growth in public involvement was outpaced by a voluntary sector which established hospitals at a far greater rate. Before the First World War these had mostly been funded by elite philanthropy, but with the interwar slump, endowments gave way to fundraising — often taking the form of ‘flag days’ supported by royals and celebrities.
Doctors in voluntary hospitals were usually volunteers, unpaid for their service and relying either on their private practice or on largesse from the affluent to get by. In the first decade of the century almost all medical care was provided on the basis of contribution or charity, placing it out of the reach of huge swathes of the population.
That changed in 1911, when the Liberal government introduced the National Insurance Act. The Act was extremely limited — it applied only to workers, provided only for GP care, introduced inadequate sick pay, and was tied to the workplace. Its mandatory contributions were also too expensive for the lowest-paid workers and apprentices, with some even going on strike against its passage.
Keir Hardie, leader of the Labour Party at the time, decried the scheme as a ‹porous plaster to cover the disease that poverty causes’. But those worst off were dependents — working-class women and children — who were denied access altogether. This meant that as late as 1938, only 43 percent of the British population was covered by the meagre insurance the Act provided.
In hospitals, where insurance didn’t apply, costs were increasingly loaded onto patients. That led to the rise of almoners, who would conduct interviews with patients on their arrival to ascertain their means. As maternity patient Doris Hoefling recalled to the BBC decades later, the system could often be brutal:
The almoner asked what we earned. She wanted the lot at first. I said, ‘We can’t afford that, we’ll need to get clothes and food for the baby.’ When the baby died, a couple of days later she came up to me in the ward, with a typical caring attitude, and said, ‘Now that you’ve lost the baby maybe you can pay more.’
While state intervention did see health outcomes improve during the interwar years, they remained comparatively poor. Resistance to centralisation and lack of investment in vaccines meant thousands of children died every year from infectious diseases such as pneumonia, meningitis, tuberculosis, diphtheria, and polio.
Surveys showed that up to 80 percent of children in the mining areas of county Durham and the poorest boroughs of London had signs of rickets. Childbirth was an ongoing hazard, with the maternal mortality rate around one in twenty and the same rate for children failing to make their first birthday.
The growing working-class movement made fighting the lack of healthcare access a priority. This took national forms — with both the Labour Party and Trades Union Congress (TUC) adopting policies calling for a national health service decades before its arrival — as well as more local ones, with organisations such as the Workers’ Birth Control Group established by women in mining areas with the slogan ‘It’s four times as dangerous to bear a child as to work down a mine.’
But by far the most important intervention was the establishment of ‘friendly societies’, vast mutual funds organised in working-class communities to provide insurance for healthcare costs. Such was their success that, by the turn of the century, six times as many workers were involved in friendly societies as in the trade union movement.
One of the most successful of these schemes was located in the Welsh mining village of Tredegar. The Tredegar Medical Aid Society was formed by miners and iron workers in the town and grew to offer one of the first comprehensive healthcare provisions available in working-class Britain.
The society extended coverage to women and children, made ophthalmic, dental, and mental health services available for the first time, and even established its own hospital. By the interwar period it covered 23,000 of Tredegar’s 24,000 residents.
The most prominent disciple of the scheme was local miner Aneurin Bevan, whose political career would have a greater influence on the formation of the NHS than anyone else’s. ‘I am determined,’ he said, ‘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.’
Towards the NHS
Britain’s labour movement had grown steadily in the years before the Great War. By 1912 it was organising strikes across the country, most prominently in the coalfields where it had fought for and won the first national minimum wage.
The growing power of labour was also reflected in politics, with Labour’s vote increasing from 300,000 in 1910 to 2.2 million by the 1918 general election. A wave of strikes followed in 1919–20, involving more than two million workers in the docks, railways, and coalfields.
This pressure encouraged attempts at social reform, with healthcare provision prominent on the agenda. In 1920 the newly established Department of Health produced what became known as the Dawson Report, a breakthrough in government thinking on public health.
The report’s conclusion that Britain’s hospitals should be brought together under a national system influenced the debates which were to follow. Six years later the Royal Commission on National Health would go further, advocating public funds to partially cover healthcare costs.
But as the 1920s wore on, the labour movement’s ascent was stalled. First, the ‘triple alliance’ of miners, railwaymen, and transport workers was broken on Black Friday, 15 April 1921. The TUC was formed from the ashes, but its first attempt at a general strike in 1926 was abandoned in failure.
The Labour Party’s vote grew through the decade, but the party leadership also grew more conservative. The first Labour prime minister, Ramsay MacDonald, even left the party to form a national government with the Conservatives after his MPs refused to support budget cuts in the midst of the Great Depression.
All of this frustrated health reform. The 1930s did see the expansion of public health programmes but little by way of structural changes in provision. As the government stalled, outside agitation increased.
Left-wing doctors who had been organised in the State Medical Service Association formed the Socialist Medical Association (SMA) in 1930. The SMA was affiliated to the Labour Party in 1931 and by 1934 had succeeded in placing much of its policies in the party manifesto. Even in the British Medical Association (BMA), a report was produced in 1935 by George M’Gonigle arguing that the government needed to increase healthcare support and welfare payments to the poor to stave off ill health.
But it wasn’t until the Second World War that a major change occurred in government policy. The increased demand on medical services quickly highlighted the insufficiencies of the country’s atomised, anachronistic healthcare system and forced the government to bring it under national control.
The Emergency Hospital Service (EHS) coordinated all hospitals under the Ministry of Health. Their governing boards remained nominally independent, but the central government dictated their function and increasingly took control of their funding. As the war progressed to the Battle of Britain in 1940, with unprecedented aerial bombing of British cities, the EHS expanded to include all medical services as well as responsibility for war-related causalities, both civil and military.
Seizing on the communitarian spirit the war had fostered, the Labour Party pushed for a broad-based review of Britain’s social insurance and allied services. The report, drafted by Liberal economist William Beveridge, was published in November 1942 and became one of the British welfare state’s landmark documents.
Identifying five ‘giant evils’ in society — squalor, ignorance, want, idleness, and disease – it proposed the introduction of ‘a comprehensive policy of social progress’ in which the state would significantly scale up its support for public welfare. ‘A revolutionary moment in the world’s history,’ Beveridge noted, ‹is a time for revolution, not for patching.’But Beveridge’s proposals were far from revolutionary. He favoured a defined contribution social insurance system over one funded by general taxation, far closer to the Bismarck model than to what emerged in the NHS. Beveridge also left open the possibility that workers with more dangerous occupations might be charged more for their healthcare, something he hoped would encourage greater caution.
Nevertheless, the Beveridge Report met widespread approval among the British public and became synonymous with the idea of a welfare state, garnering great moral appeal. This forced the wartime coalition government to respond, and by 1943 it was producing plans to build a permanent national healthcare system.
The Conservatives’ proposals were modest — scaling up of the local authority bodies under a national leadership, an expansion of insurance, and a contract system to bring all doctors into the pay of the state. But under pressure from the voluntary hospitals — that feared the confiscation of their assets — and the leadership of the BMA, the government retreated and watered down even these proposals.
The Labour Party meanwhile produced its own document, ‘The National Service for Health: the Labour Party’s Post-War Policy, in 1943. Though it did not commit to the abolition of fees or the insurance system, nor to the nationalisation of hospitals or full centralisation, it did propose a significant increase in the proportion of healthcare to be funded by general taxation, as well as fully salaried status for doctors.
For those on the party’s socialist left, it didn’t go far enough, but it was nonetheless a strong foundation for the party’s 1945 general election manifesto, an election Labour was to win by a landslide.
The 1945 British general election was a momentous political event. Against a backdrop of the highest trade union membership since the 1910s, Winston Churchill, hero of the battle against Hitler, was unceremoniously dumped out of office, with his Conservative Party losing almost two hundred seats. It was a watershed moment for the working class and a profound blow to the capitalists.
For Aneurin Bevan, it brought to mind Marx’s description of the Crimean War: ‘As exposure to the atmosphere reduces all mummies to instant dissolution,’ he quoted, ‘so war passes supreme judgment upon social systems that have outlived their vitality.’Bevan had been a thorn in the side of British governments from the parliamentary backbenches during the Second World War. An early supporter of the Republican cause in Spain, which led to his key role in building Tribune, Bevan proposed a more left-wing basis to the struggle against fascism.
He argued for a popular front with other parties on the Left, and even for an Anglo-Soviet pact, stances which saw him temporarily expelled from the party. Bevan consistently called for nationalisation of strategic sectors of the economy during the war and bitterly condemned the Tory government for placing ‹private property rights before the needs of the nation’.
These comments led Churchill to condemn Bevan as a ‘squalid nuisance’. Bevan preferred Churchill to Chamberlain’s appeasement, but nonetheless recognised that any alliance with the Tory leader could only be temporary. Churchill’s rhetorical interventions may have stirred a spirit of determination in the face of the Wehrmacht, but ‘What he [Churchill] did not do, and what he could not do, was to summon the future. For Mr Churchill is the spokesman of his order and of his class, and that class and that order is dying.’ It was a mark of the socialist left’s power inside and outside Parliament that a backbench politician who had been such a vociferous critic became the youngest member of Clement Attlee’s cabinet. Far from seeing this as an opportunity to moderate, Bevan was determined to take his socialist principles into the construction of the National Health Service, something he declared would be opposed to the ‘hedonism of capitalist society’. But Bevan’s path to success was not straightforward. On arrival into the ministry he was warned against radical proposals by his permanent secretary, who pointed out that the previous administration had performed an embarrassing climbdown when it attempted more modest reforms.
Bevan nonetheless persisted, aided by the clarity of his vision. He was opposed to the insurance system in principle, seeing the buying and selling of patient goodwill as something which ‘dehumanised’ both doctor and patient. He also rejected the idea that healthcare should be denied in any circumstance to those who couldn’t afford it.
‘You can’t have different treatment in order of contribution,’ he argued, continuing that it would be impossible to ‹perform a second-class operation on a patient if [they] weren’t paid up’. Instead, healthcare should be funded through general taxation and be free at the point of access, a radical proposal which would remove it from the predations of the market.
He also insisted, against Labour Party policy, on the full nationalisation of Britain’s hospitals. In the case of the voluntary sector, which amounted to one-third of the facilities at the time, he proposed to achieve this by appropriation of private property, something the Tories condemned vociferously when his bill reached Parliament.
These nationalised hospitals were also to be brought under a centrally planned system. This idea met with opposition in the Labour Party and Labour-run municipalities, which lobbied hard for a more localised structure. But Bevan was unconvinced. ‘I would rather be kept alive in the efficient-if-cold altruism of a large hospital,’ he replied, ‘than expire in a gush of warm sympathy in a small one.’This desire to ensure the best care for all people was also a standout feature of Bevan’s NHS. Public healthcare was to be comprehensive and universal — modelled not on the Poor Law infirmary but on the elite provision available in the private wing of the voluntary-sector hospitals.
This meant universalising specialist and consultant services, making mental health, dental, and ophthalmic medicine available to many for the first time, and finding a way to ensure regulation and equal distribution of GPs across the country.
Bevan’s legislation faced considerable opposition both before and after its passage in 1946. The British Medical Association (BMA) threatened a boycott by the country’s doctors. In the letters page of the British Medical Journal, Bevan’s reforms were compared to Nazism and the minister was dubbed a ‘Medical Führer’.
The president of the BMA, Bernard Docker, charged the government with ‘mass murder’.
Amid much consternation, Bevan was forced to make a number of concessions: the hospital system would be run on the basis of regional boards, with only the minister having centralised powers; consultants would be allowed to retain a part-time private practice as long as they did not establish pri- vate facilities; and GPs would be permitted to remain semi- independent.
It took only two years from the passage of the legislation for the NHS to be launched on 5 July 1948. By then opposition from doctors had melted away and more than 90 percent of the population had been enrolled into the system. Queues formed around the block in cities across England and Wales as people sought information on their new entitlements.
The NHS was the first healthcare system in the world to provide free medical care to the entire population. It was also the first to provide comprehensive care on the basis of general taxation rather than insurance.
In the decade after the establishment of the NHS, many Western nations sought to introduce public healthcare — but none provided it so widely, so effectively, and as a right to so many.
It would be wrong to paint the beginnings of the NHS as smooth, however. Opposition from the Conservative Party and Labour’s right wing continued. Even Bevan hadn’t expected the extraordinary uptake in usage for the NHS in its early years as millions who had been denied decent care sought to make up for a lifetime of neglect.
The cost of managing the NHS, which the Labour Party had said would be £170 million in 1943, had reached £465 million by 1951. Bevan’s opponents successfully whipped up panic about overruns in the system which had seen Attlee introduce a cap on expenditure.
When the Labour government sought to introduce charges for dental services and eye care in 1951, Bevan resigned from the cabinet. Direct charges were anathema to his beliefs, but they were to be extended further in the NHS when the Conservative government introduced prescription charges shortly afterwards.
Despite its limitations, the NHS was an extraordinary achievement and success. Surveys after its establishment found that the NHS enjoyed 89 percent approval. The 1952 Guillebaud Report, an independent study commissioned by the Conservative government on NHS spending, tvindicated Bevan — finding no strong evidence of waste, disputing the need for medical charges, and calling for greater investment.
In these early years, the NHS radically improved the lives of millions — ensuring that developments in antibacterials, anticoagulants, blood transfusions, anaesthetics, X-radiation, and cardiology were available to all.
In 1954 NHS medical researchers were the first to link smoking to lung cancer; in 1958 a national programme was launched to vaccinate everyone under 15 against polio and diphtheria; in 1960 an NHS hospital performed the UK’s first kidney transplant; and in 1961 the contraceptive pill was made available through public clinics.
By 1964 around one in five people visited the hospital at least once a year, a sixfold increase since 1948. Within twenty years the infant mortality rate in England and Wales had halved, with the maternal mortality rate reduced by two-thirds. Deaths from infectious disease declined 90 percent by 1970 for both men and women. The National Statistics office found that premature deaths among those aged 15 to 44 halved within a decade of the NHS being established, and for those aged 1 to 14 it fell by more than 60 percent.
When Aneurin Bevan died in 1960, a Conservative MP wrote in the Evening Standard:
He was the last of the demagogues. In the coalfields from which he came, Marx and Engels have been supplanted by Marks & Spencer, and the sound of class war is being drowned by the hum of the spin-dryer. There will be no more Aneurin Bevans.
But Bevan’s politics didn’t die with the industries that made him, nor did the necessity for the free, comprehensive, and universal healthcare system he introduced. As a new generation faces the realities of class war waged from above, the NHS offers a reminder of what can be achieved when the tides of history are turned back in the other direction.