Below is your study resource for GCSE and Advanced Level History courses.
‘The best health services should be available free for all. Money must no longer be the passport to the best treatment’
Let Us Face The Future, Labour Party, 1945
David Lloyd George’s 1911 National Health Insurance Act covered low paid workers for treatment by a panel doctor. Hospital treatment was excluded. Cover only applied to the insured worker and not their dependants.
As a result many didn’t receive proper healthcare as it was too expensive.
Local Authorities were responsible for a number of public health services such as maternity care and child welfare.
Hospital treatment was provided by voluntary and municipal hospitals.
The voluntary hospitals ranged in size from the large teaching hospitals with around five hundred beds, to the small cottage hospital with only a handful.
Many of the voluntary hospitals had originally been established to treat the poor, relying on charitable donations for their funding. By World War II they were in financial difficulties and a greater proportion of their income now came from charging patients.
Municipal hospitals were run by Local Authorities and the quality of medical care varied widely. Most had been founded under the Poor Law, so for many they were associated with the stigma of the workhouse.
They competed with the voluntary hospitals and there was no coordination of services. Access to beds was means tested and most patients were refused treatment if they lived outside the area.
Access to treatment was not evenly distributed.
Specialist consultants were concentrated in the more prosperous regions. They gave their services for free in the voluntary hospitals, but relied on income from private patients. In the smaller voluntary and municipal hospitals, surgical procedures would often be carried out by a General Practitioner.
Poorer areas, which often had the greatest need, lacked enough doctors as there was less opportunity for private practice.
In Scotland, the Highlands and Islands Medical Service had been established in 1913 to provide medical care to the more remote areas of the country. It was state funded and administered by the Scottish Office. The cost of treatment was set low.
In the 1930’s the service was extended to include hospital care and an air ambulance.
Paupers were entitled to free medical treatment under Scotland’s 1945 Poor Law Act.
The Emergency Medical Service was set up to deal with the expected civilian casualties from air raids. It was put into operation as soon as war was declared in September 1939.
New hospitals were built and annexes constructed to extend the capacity of existing hospitals. New operating theatres were set up and medical supplies were stockpiled. The ambulance service was extended and a national blood transfusion service established.
The Government directed the allocation of medical resources and determined the number of beds voluntary and municipal hospitals had to provide for EMS patients.
Those eligible under the EMS scheme would receive free medical treatment. At the beginning these were mainly service personnel and civilian war casualties.
The scheme was extended as the war went on to include more categories of patients, such as firemen, munitions workers and evacuees.
The EMS demonstrated the feasibility, and public approval, of a national hospital service run by the Ministry of Health.
There had been calls for some form of national health service since at least 1909, when Beatrice Webb advocated a ‘state medical service’ in the Minority Report of the Poor Law Commission.
In 1920 the Dawson Report argued that ‘the best means of maintaining health and curing diseases should be made available to all citizens’.
In the 1930s the British Medical Association had produced its own proposals for a General Medical Service for the Nation. This included the extension of National Health Insurance to cover more medical services, such as hospitals, and the dependants of insured workers.
While it was widely recognised that there was a need for healthcare reform, opinions differed as to how such a system would be administered and financed.
There was strong resistance from the medical profession over any suggestion that GPs should become full-time salaried employees of a state medical service.
It was the 1942 Beveridge Report which popularised the idea of a free, national health service available to everyone.
In Social Insurance and Allied Services William Beveridge made three assumptions which were essential to his plan for social security. Assumption B was the introduction of a comprehensive national health service.
Ideally this would provide ‘full preventative and curative treatment of every kind to every citizen without exceptions…and without an economic barrier at any point to delay recourse to it’.
Like the 1920 Dawson Report, Beveridge advocated a healthcare system that was as much about preventing ill-health as treating it. For Beveridge, improving the health of the nation had benefits from both a humanitarian and economic standpoint.
The popularity of the Report led the wartime Coalition Government to publish the White Paper, A National Health Service, in February 1944. This proposed that everyone should have access to a comprehensive healthcare service.
The 1944 White Paper on the National Health Service was based on compromise. It took into account the policies of the Labour and Conservative members of the Coalition Government as well as other interest groups, such as the medical profession.
The result was a plan for a national health service which satisfied no one.
Henry Willink, the Conservative Minister for Health, drafted a revised proposal. This was accepted by the Cabinet of Churchill’s caretaker government in June 1945. It made so many concessions to the different vested interests that Aneurin Bevan would reject it as unworkable.
By 1945 there was agreement on the need for a national health service. Both Labour and the Conservatives were promising its introduction in their election manifestos. However, there was no consensus on how this would be put into practice.
‘no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means’ Aneurin Bevan, In Place of Fear 1952
1945 saw the Labour Party win a General Election with their biggest ever majority. Clement Attlee appointed Aneurin (Nye) Bevan Minister of Health, giving him the responsibility of establishing the NHS.
Bevan was an outspoken, left wing backbencher and his appointment came as a surprise to many. At forty seven years old, he was the youngest member of the Labour Cabinet.
Having got the National Health Service Bill passed by Parliament in 1946 (1947 for Scotland), Bevan then fought to win the cooperation of the medical profession.
‘The essence of a satisfactory health service is that the rich and the poor are treated alike’ Aneurin Bevan, In Place of Fear, 1952
The National Health Service was founded on three key principles.
–Everyone should have equal access to treatment
– It should be free at the point of use
– It should be based on healthcare needs and not the ability to pay
Everybody was eligible for free medical care. This included British citizens and foreign visitors.
Bevan had to integrate and coordinate all the existing medical institutions and health care providers into one comprehensive, National Health Service.
The NHS was set up as a tripartite structure under the Minister of Health. In Scotland, this was headed by the Secretary of State.
Hospitals
Voluntary and municipal hospitals were nationalised so that patients would have access to the same standard of care.
They were organised into Regional Hospital Boards, with fourteen in England and Wales, and five in Scotland. The day to day running of the hospitals was overseen by local Hospital Management Committees.
Teaching hospitals were nationalised. In England and Wales they were administered by their own Boards of Governors directly under the Minister of Health.
General Practitioners, opticians, dentists and pharmacists
Their services were administered by local Executive Councils with which they had NHS contracts. They retained their self-employed status. GPs were the first point of contact for NHS patients who could then be referred, if necessary, to the appropriate NHS service.
Local Health Authorities
Local Authorities provided services such as maternity care, health visitors, child welfare, ambulances and vaccinations. Bevan also hoped that they would provide Health Centres.
The NHS was to be financed out of general taxation. Bevan thought schemes based on contributory health insurance were costly to administer and inherently unfair.
Although in favour of a comprehensive health service, the Conservatives objected to the proposals put forward by Bevan. They voted against the Health Service Bill on its second and third readings.
There were also concerns from within the Labour Cabinet. Herbert Morrison, a former leader of London County Council, argued against the weakening of local government.
It was the General Practitioners, represented by the BMA, who raised the loudest objections and threatened non-cooperation. The BMA thought that Bevan’s eventual aim was to make GPs full-time, salaried government employees. In February 1948 BMA members voted overwhelmingly not to support the NHS.
Bevan had to make concessions to win their support and a compromise was eventually reached.
Over ninety percent of doctors joined the NHS in the first year.
Consultants would be salaried but they could also carry on in private practice. Pay-beds would be allocated for private patients in NHS hospitals. Bevan later commented ‘I stuffed their mouths with gold’.
Doctors would be involved in the planning and running of the NHS, serving on the Regional Boards and Hospital Management Committees.
Bevan promised legislation ruling out a salaried service. Instead GPs were to be paid by capitation fees (i.e. based on the number of registered patients).
The buying and selling of practices would be abolished, but doctors would receive compensation for this.
‘It shall be the duty of the Minister of Health…to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness, and for that purpose to provide or secure the effective provision of services’ Part I, National Health Service Act 1946
The National Health Service Act was given Royal Assent in November 1946. A separate Act covering Scotland was passed in 1947.
The Labour Government set the ‘appointed day’ for its commencement as the 5 July 1948.
The Minister for Health Aneurin Bevan officially launched the NHS at Park Hospital in Davyhulme, Manchester (now Trafford General). The first patient to be treated on the NHS was 13-year-old Sylvia Diggory, whom Bevan met at the launch.
The new NHS proved exceedingly popular. By the end of 1948, an additional 21 million people had registered with a GP. Prescriptions for over 5 million pairs of spectacles were given out in the first year. There were long waiting lists for dental treatment. In 1947 doctors issued 7 million prescriptions per month. By 1951 this had risen to 19 million per month.
The rise in demand was mostly down to people coming forward with long standing complaints or seeking treatment where previously they couldn’t have afforded to.
Even before its launch Bevan had stated that ‘expectations will always exceed capacity’.
The cost of the NHS was significantly higher than forecast. In 1949 Bevan had to agree to legislation allowing for prescription charges, though not their actual introduction. Under pressure from the Treasury, Bevan agreed to an expenditure cap.
In 1951 the Chancellor of the Exchequer Hugh Gaitskell brought in charges for dentures and spectacles. Bevan believed this went against the principles of the NHS. It would only save £13 million out of a total NHS budget of £400 million. The government had also just committed billions to a program of rearmament for the Korean War. On the 21 April Aneurin Bevan resigned over the issue, as did Harold Wilson.
In 1952 the new Conservative Government introduced a 1s prescription charge and charges for all dental treatment.
