The Foundation of the NHS

Written by James Coker  |  Reporter, European Medical Journal  |  @EMJJamesCoker

The British National Health Service (NHS), a unique healthcare system respected throughout the world, is celebrating its 70^th birthday this week. The occasion has been met with huge celebrations in the UK, with significant praise for the achievements made and the ideals that underpin its existence. Despite structural and organisational changes that have occurred during its lifespan, the institution has retained the fundamental principles that were present at its inception. These are that it is a government-run body, universally available, and free at the point of use, funded almost entirely by general taxation. To mark this momentous milestone, here at the European Medical Group we decided to take a look back at the ideas and events that led to the foundation of NHS through the National Health Service Act of 1946, which came into effect on 5^th July 1948. This includes the build-up, over many years, of public and political support for such a service, the effect that World War 2 had on its inception, and a flavour of the debates and arguments that were made at the time of its creation. While the NHS is an organisation that many in the UK could not now imagine its non-existence, it is important to realise how far public opinion had to shift for it to even be countenanced in the past.

Laissez-faire Economics

The history of the NHS cannot be separated from the history of the welfare state in Britain as a whole, with the idea of government being responsible for the welfare of its citizens evolving gradually. This is a concept that people could be forgiven for taking for granted now, but for a long period it was an alien and even frightening prospect to many. The prevailing philosophy in Britain during the 18^th and 19^th Centuries was for minimal state involvement in the internal affairs of its citizens; this theory is known as ‘laissez faire’ economics, which argues that the freedom of individuals to pursue their goals is the best way of achieving prosperity, and government intervention in internal affairs is not only detrimental but also undesirable, potentially leading to tyranny.¹

Early Welfare State

Britain had long had a tradition of voluntary provision of welfare services to those in need, such as the poor, sick, and elderly, going back to medieval times, but this really grew during the Victorian era of the 19^th Century. This was primarily through bodies like charities and churches, although local administrations did have a role too.² It wasn’t until 1906, however, that central government first assumed a major responsibility for welfare when the Liberal government pushed through what were then considered radical reforms. These were largely implemented in response to the high levels of poverty and poor health that occurred in many areas, which brought embarrassment to the country as well as meaning that a significant proportion of the workforce were unhealthy and uneducated in comparison to other wealthy nations. The reforms included free school meals for the poorest families (1906) and the enactment of old age pensions (1908).³ Importantly, they first established the principle of governmental responsibility for the welfare for its people, and the measures are considered by many to have begun a mindset shift that made the creation of the NHS in 1948 possible. Following the liberal reforms, further welfare measures were enacted by governments in the 1910s, 20s, and 30s.²

Total War

It could be argued that what quickened the march towards the development of the NHS in Britain was the two world wars of the twentieth century, particularly World War 2 (1939–45). In both, the government took complete control of the economy, organising the provision of labour and regulating the lives of its people in a manner never before known. This is referred to as ‘total war’, and among the measures enacted for the war were conscription for military service as well as essential industries on the home front, and rationing for imported food and other items. While this extent of state intervention was necessitated by emergency circumstances of war, it demonstrated to many people that the government was capable of effectively administering vital services and could play a greater role in times of peace. In addition, these war-time periods have been credited with creating a unique community spirit and mentality in the country; a feeling that everyone has a responsibility to help one another.⁴

Beveridge Report

It was during World War 2 that a seminal moment in British history took place, laying the blueprint for the NHS. This was the Beveridge Report, published and presented to the UK Parliament in 1942. In the report, the author Sir William Beveridge identified ‘five giants’ that needed to be slain: want, disease, squalor, ignorance, and idleness. To address these problems, he proposed a new system diametrically opposed to the idea of Laissez-faire government. This was a comprehensive social security system, in which all working people would pay a contribution to the government in return for the payment of benefits to those most in need. In essence, it proposed that the state becomes responsible for the wellbeing of its people ‘from the cradle to the grave’.⁵

National Health Service Act

The Labour government elected in 1945 in the aftermath of the war quickly implemented Beveridge’s recommendations. Amongst a raft of new laws passed was the National Health Service (NHS) Act of 1946, pushed through by the Minister for Health, Nye Bevan, a man inextricably linked with the NHS. Bevan embodied the principles set out in the Beveridge Report by instituting a new, state-run, universal, and free at the point of use health service, which was eventually rolled out in 1948. This unified a fragmented healthcare system under one authority, and crucially it ensured that every person had access to good healthcare, regardless of their ability to pay. Previously, many families would suffer severe financial difficulties when illness struck, or else would simply have to go without care. Access to healthcare free at the point of use therefore removed some of the fear of the problems even relatively minor ailments could cause individuals and families.^6,7

Opposition

There was still significant opposition to the law in the build up to it being passed. These came from a variety of sources, including a number of health professionals. With doctors suddenly facing the prospect of new employers, this seismic change was not universally popular. In particular, the British Medical Association (BMA) were strongly opposed at the time. Among the counter-arguments made were fears that the system would allow the state too much control and lead to tyranny. Another was the fear that the system would absolve individual responsibility. Long-term affordability of the system was also an issue raised by opponents.⁶

Challenges

The fact that the NHS still stands strong today is testament to the fact that these fears have, in general, been unfounded. It should not be denied that there have been challenges, particularly in regard to funding, which is becoming an increasingly prevalent issue. Additionally, successive governments in recent decades have implemented changes that some have viewed as having loosened the founding principles of the service to an unacceptable degree. Examples of these are the introduction of a market and competition within the NHS and the contracting out of services to private companies.⁸

Successes

Despite these issues, there can be little doubt that, overall, the NHS has improved the overall health of the UK population. In 1948, the year in which the NHS was first created, life expectancy for males was 66 years and for women it was 71.⁹ This has now increased to 79.5 and 83.1 years for men and women, respectively.¹⁰ Diseases such as polio and diphtheria have virtually been eradicated,¹¹ and pioneering new medical procedures, such the world’s first IVF baby, have been delivered in NHS hospitals.¹²

Whilst it is too simplistic to say such improvements are solely the credit of the NHS, the fact that everyone can access the major advancements there have been in medical treatments over the last 70 years is surely a major factor. This has been reflected by the virtually unwavering public support there has been and remains for the NHS and its founding principles.¹³

Reflection

To some extent, the successes of the NHS, such as helping to improve life expectancy in the UK, have brought up major challenges, for example in regard to funding the care of an increasingly elderly population. In our next blog we will look at the future of the NHS, and how these long-term issues can be tackled. Yet for all the discussion on its future, it is important to spend time reflecting on how and why the institution was created to help us better understand the present situation.

REFERENCES

1. Encyclopaedia Britannica. Laissez-faire economics. Available at: https://www.britannica.com/topic/laissez-faire. Last accessed: 19 June 2018.
2. Field F. The Welfare State – Never Ending Reform. 2011. Available at: http://www.bbc.co.uk/history/british/modern/field_01.shtml. Last accessed: 19 June 2018.
3. The National Archives. Britain 1906–1918: Achievements of Liberal Reforms. Available at: http://www.nationalarchives.gov.uk/education/britain1906to1918/g2/background.htm. Last accessed: 19 June 2018.
4. BBC. The Home Front. Available at: http://www.bbc.co.uk/history/home_front. Last accessed: 19 June 2018.
5. The National Archives. The welfare state. Available at: http://www.nationalarchives.gov.uk/pathways/citizenship/brave_new_world/welfare.htm. Last accessed: 20 June 2018.
6. Spartacus Educational. The National Health Service Act. Available at: http://spartacus-educational.com/Lhealth48.htm. Last accessed: 20 June 2018.
7. Berridge V. The NHS: what can we learn from history? 2009. Available at: https://www.historyextra.com/period/modern/the-nhs-what-can-we-learn-from-history/. Last accessed: 20 June 2018.
8. Rivett G. National Health Service History. Available at: http://www.nhshistory.net/shorthistory.htm. Last accessed: 20 June 2018.
9. Independent. The Birth of the NHS. 2008. Available at: https://www.independent.co.uk/life-style/health-and-families/features/the-birth-of-the-nhs-856091.html. Last accessed: 20 June 2018.
10. NHS England. NHS England – Board Paper. 2018. Available at: https://www.england.nhs.uk/wp-content/uploads/2018/03/09-pb-29-03-2018-scene-setter-on-current-trends-health-inequalities.pdf. Last accessed: 20 June 2018.
11. NHS England. Background. Available at: https://www.england.nhs.uk/nhs70/about/background/. Last accessed: 20 June 2018.
12. NHS Choices. The history of the NHS in England: The NHS in the 1970s. Available at: https://www.nhs.uk/NHSEngland/thenhs/nhshistory/Pages/NHShistory1970s.aspx. Last accessed: 20 June 2018.
13. Ipsos MORI. What do the public think about the NHS? 2017. Available at: https://www.ipsos.com/ipsos-mori/en-uk/what-do-public-think-about-nhs. Last accessed: 20 June 2018.