The British National Health Service

State Intervention in the Medical Marketplace, 1911-1948

Sharon Schildein Grimes

• Publisher: Taylor & Francis
• Year: 2016
• Print ISBN: 9781138204508
• eBook ISBN: 9781315469195
• Edition: 1
• Topic: Histoire
• Subtopic: Histoire du 20ème siècle

First published in 1991, this book charts the inception of the British National Health Service from 1911 to 1948. It pays specific attention to the struggle of doctors to achieve work control in the medical marketplace during this turbulent time. With particular focus on the medical profession, it discusses key themes such as restrictions to the inception of the Health Service under David Lloyd George's government and the relationship between the Beveridge report and the National Health Service Act in 1946. In its final analysis, the book asks what, if any, gains were made by the medical profession in the creation of Labour's crowning achievement.

This book will be of interest to those studying the history of the British welfare state, social welfare and healthcare.

Chapter I
The National Insurance Act of 1911: The Confrontation with State Intervention

Throughout 1938, British experts waited for the confirmation of their grim predictions of a full-scale aerial attack by the Luftwaffe. The estimate of 50 casualties per ton of bombs dropped gained credibility when the figures from the March 1938 raids on Barcelona were considered. Afterwards, revised statistics by the Air Raid Precautions Department fixed a higher ratio of 72 casualties: for each ton of bombs 24 persons would be killed, 24 persons seriously injured, and 24 slightly injured. Of the injured, 36 would require treatment in a hospital. Material damage would be considerable: 500,000 houses would suffer total destruction, while 1 to 2 million would be extensively damaged.¹ Anticipated mental strain among civilians alarmed officials: a report presented to the Ministry of Health in 1938 estimated that psychiatric casualties would surpass physical casualties by three to one.²

A dark picture of a panic-stricken, homeless mass of refugees devoid of food or shelter emerged. Preparing for a catastrophic war, the government created the Emergency Medical Service, which anticipated services which would actually be needed in wartime. Civilians struggled to cope with the inconveniences of black-outs and evacuation schemes. And it was the latter, unsuccessful though they were, which shocked the nation and awakened a dormant social conscience. When the tempest of explosive warfare failed to materialize in the early days of the war, the press filled its scant columns with accounts of evacuees who were spirited from the city to the countryside where cultural shock reverberated with undiminished frequency. Rural foster mothers were puzzled by children whose staple diet seemed to consist of white bread smeared with margarine or jam or a cache of chips, who viewed soup, green vegetables, stewed fruits and puddings with suspicion or hostility. And the public became alarmed by tales of children infested with scabies and vermin. Government departments began to sift through what meager prewar statistics they possessed concerning the conditions of the bud of the nation.

While the sensationalism of press accounts relieved the public's temporary boredom and frustration, it served a far greater purpose in the long run. For when the initial outrage was spent, the larger questions remained: what could be done? What environmental changes could be effected without usurping parental responsibility? Did the state have a duty to intervene on behalf of a citizen? Did a citizen bear a responsibility to the state to maintain his health and well-being?

Public opinion concerning the state of the health of evacuees in 1939 closely paralleled the mood of the nation following the Boer War when it had been confronted with the supposed deterioration of the British race. In dealing with the earlier crisis, the government under David Lloyd George's persuasion had committed itself to a limited national health service-limited in the sense that it excluded spouses and children of the wage-earning public. Yet it was precisely this segment of the population which now aroused the nation's sympathy and concern.

When the phoney war became the people's war and the spirit of Dunkirk began to permeate every aspect of British life, postwar planning became a topic of universal importance. Discussions among total strangers sharing a firewatch or an evening's shelter in a tube station would focus on common aspirations for the future. A people who had shared the perils of war should also participate in the rewards of peace. Empty promises of homes fit for heroes were inappropriate in a nation which had exchanged the uncertainties of the Slump for the realities of war.

The public's vague prescriptions for social reform found articulation in a report submitted by the Inter-departmental Committee on Social Insurance and Allied Services published in December 1942. The committee's chairman, Sir William Beveridge, an economist whose reputation as a manpower expert was well known, had been kicked upstairs by Ernest Bevin, then Minister of Labour. Denied the appointment that he coveted as Director-General of Manpower, Beveridge (at the request of Arthur Greenwood, Minister without Portfolio) began a rigorous eighteen-month critique of the entire social welfare system. Aided by a team of civil servants which he clearly dominated, Beveridge steered the course of investigation into a radical analysis of policy that overstepped the bounds of the committee's terms of reference. Consisting of three hundred tightly spaced pages, the report provided a roadmap for a national journey on the road to freedom from want, attacking disease, ignorance, squalor and idleness. Beveridge advocated the provision of children's allowances; the creation of a comprehensive national health service available to every citizen and providing both curative and preventive services; and, the underpinning of such a scheme, the maintenance of full employment and the prevention of mass unemployment. Each citizen would contribute at a flat rate and receive a uniform rate of benefit. Citizen contributions would be supplemented by payments from both employers and the state.

Despite its debt to Liberal individualism through the maintenance of the compulsory insurance principle, the Beveridge Report appealed to the public as a revolutionary document. A jubilant nation refreshed by the recent success of El Alamein came to associate the report with this victory and pressed harder for postwar planning. Publicity was well organized with considerable help from the press, the B.B.C., and the report's author himself. Within two weeks of publication a poll conducted by the British Institute of Public Opinion found that 19 out of every 20 adults had some knowledge of the report's contents. While 90 percent of its subject matter dealt with the detailed mechanics of the insurance scheme, it was the other 10 percent that captured the spirit and imagination of the people. Beveridge's arresting catch phrases were quite suitable for quotation either in the local pub or in the corridors of Whitehall.

The reaction to the Beveridge Report within government circles was less euphoric. Within two days of its issue, the Army Bureau of Current Affairs withdrew a summary prepared by Beveridge himself as part of a pamphlet series for distribution to servicemen. As Sir James Grigg (Secretary of State for War) informed the House of Commons, he was afraid that the Beveridge summary might be interpreted as settled government policy, which it certainly was not. To decide precisely what was feasible, the government appointed an official committee on the Beveridge Report under the chairmanship of Sir Thomas Phillips, a cautious critic of Sir William's ever since their early days at the labour exchanges.

The cabinet tackled the issue in January and early February 1943 in the absence of Churchill. But the prime minister left no margin for error in interpreting his position. Although agreeing to the preparation of the necessary legislation, he refused to bind the hands of any future parliament or prime minister by implementing it. Sir Kingsley Wood, Chancellor of the Ex-chequer, questioned the availability of the necessary financial resources in the British postwar economy.³

When the subject was finally brought to the House floor on February 16, the report was welcomed in principle but with such a lack of enthusiasm that impatient backbenchers staged a revolt, voting against the government, demanding "Beveridge now." The medical profession, which along with the approved societies and voluntary hospitals was destined to be most directly affected by the plan, reacted cautiously. Initial criticism focused on what was to become the "100 percent proposal." The British Medical Association, which would emerge as the leading spokesman of the profession, regretted the absence of an upper income level. While willing to concede that 90 percent of the population should receive free and comprehensive health care, they wished to preserve the remaining 10 percent for remunerative private practice.

Discussions with the Ministry of Health began in March 1943 with the appointment of a representative committee from the various medical bodies. Following numerous consultations and extensive testimony gathered from concerned interest groups, the government published the fmdings in February 1944, a year which Beveridge designated as the Great White Paper Chase. Despite the document's basically conservative nature, the B.M.A. 's reaction bordered on hysteria. The proposed health centers would mean nothing less than the introduction of a full-time salaried medical service, they declared, and that they had opposed ever since Lloyd George had advanced it in 1912. Thus, between February 1944 and May 1945 the Minister of Health, Henry Willink, placated a hostile medical profession by toning down as many of the offending recommendations as possible. Had the White Paper on a National Health Service containing Willink's concessions been drafted into law, the doctors would have had little to criticize. But the end of the coalition and a general election which returned a Labour government committed to more radical changes prevented its initiation.

After the election the medical profession hoped that they would begin at the beginning, a favorite delaying tactic. But their opponent, Aneurin Bevan, the new Minister of Health, was impatient to forge ahead with Labour's vision of a new society. Within a year he would place on the statute books the bare bones of legislation known as the National Health Service Act of 1946. Filling in the flesh would be a more complex issue. Questions that had been left unresolved following the passage of the 1911 National Insurance Act were to be settled decisively. The elaborate system of approved societies which David Lloyd George had created to soothe vested insurance and friendly society interests was to be dismantled with little ceremony. Nor would another monument to the spirit of self-help remain unchanged, as voluntary hospitals across the land would be joined to their local authority counterparts as part of a nationalized system. The successful experience of wartime coordination of civilian hospitals and the financial benefits gained through this alliance would make its reversal impossible.

During this period of rapid ideological change and heightened social consciousness two forces were in conflict: an evolving and expanding state intervention in an increasingly complex society against powerfully entrenched vested interests whose internal dynamics had been conditioned by their own peculiar historical evolution. In 1911-1913 the British Medical Association failed to exercise sufficient control of its membership. Rank and file militancy permeated the medical profession just as it did in industry where laborers struggled to obtain that sine qua non, power and authority. The same challenge to employer authority arose within medicine as g.p.s attempted to protect their economic position and establish a satisfactory d...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Original Title
• Original Copyright
• Dedication
• Contents
• PREFACE
• CHAPTER I — THE NATIONAL INSURANCE ACT OF 1911: THE CONFRONTATION WITH STATE INTERVENTION
• CHAPTER II — INERTIA THROUGH POSITIVE DEVELOPMENT: THE TRIUMPH OF EXTENSION OVER UNIFICATION
• CHAPTER III — THE BEVERIDGE REPORT: REFORM FEVER
• CHAPTER IV — THE WHITE PAPER ON A NATIONAL HEALTH SERVICE: A PYRRHIC VICTORY?
• CHAPTER V — THE 1945 GENERAL ELECTION: BROKEN ELECTORAL PROMISES
• CHAPTER VI — OYSTERS AND OLIVE BRANCHES
• CHAPTER VII — REVOLUTION OR RESOLUTION?
• CONCLUSION
• BIBLIOGRAPHY
• INDEX