JUNE 5 2018 is the 70th anniversary of the National Health Service – the jewel in the crown of the British Labour Party and the welfare state.
But the celebrations are tempered by the knowledge that the NHS is mired in the biggest crisis of its history, one that threatens the survival of a health system that is universal and free at the point of use.
Labour and the trade unions reaffirmed their unwavering commitment to defending the NHS. But fine words aside, neither put up a series struggle against former Health secretary Andrew Lansley’s Health and Social Care Act, or the further reforms of his successor Jeremy Hunt. Unison, the largest health care union, did not call a single strike or demonstration during the entire five years of David Cameron’s government.
Despite the deliberate underfunding, and the chaos caused by decades of Tory and New Labour reforms which imposed an internal market and creeping privatisation, the NHS remains so popular that only the most doctrinaire free market ideologues dare attack it openly.
But the enemies of the NHS are determined to disrupt, privatise, and dismantle the final remnant of the working class’ postwar gains. Defending the NHS today means not only resisting encroaching privatisation, but a political offensive to refound a truly universal welfare and healthcare system, the fulfilment of tasks Labour left incomplete in the 1940s, and making these reforms permanent by placing them under the democratic control of the working class.
Ken Loach’s 2013 documentary The Spirit of ’45 revived interest in the post-war Labour government, remembered as the founder of Britain’s welfare state. The film presents testimonies from workers who suffered from the fear and the reality of impoverishment that illness and injury guaranteed in the 1920s and 1930s.
Interviews with nurses and doctors recall the enthusiasm which greeted the new service. Loach recalls the massive use of the new services as people got glasses and dentures, and which the Tory press then sourly presented as freeloaders exploiting the new services, rather than millions who desperately needed them but who could not afford them before.
A further spur to re-examining the achievements of the 1945 government was Labour’s new leader Jeremy Corbyn and shadow chancellor John McDonnell’s ambition of emulating the achievements of Clement Attlee and Aneurin Bevan for the 21st century.
But the NHS has a long prehistory. In the 1920s and 1930s a series of city, town and London borough councils were won by Labour. In the days before the Tories progressively stripped local government of many of its powers and responsibilities, these had considerable resources and deployed them to make significant reforms for working people – parks, public health measures, slum clearance and publicly owned housing, transport, power generation, schools, and local hospitals.
In the capital the London County Council under Herbert Morrison built or extended a series of local authority hospitals, which provided free services, funded from local rates. These included maternity hospitals, hospitals for widespread infectious diseases like scarlet fever, smallpox and tuberculosis, plus providing homes for the elderly, the physically and mentally, handicapped to remove them from the dreaded workhouses sanctioned by the Poor Law. Of course, access to these services was a postcode lottery since the Tories, then as now, were eager to keep down rates and taxes and were great believers in the moral value of private enterprise in health as in all other aspects of human life.
During the war a coordinated Emergency Health System was set up to deal with the devastating mass bombing raids expected in a new era of total war. When Churchill replaced Neville Chamberlain as prime minister he brought Labour ministers, including Clement Attlee, Ernest Bevin, and Herbert Morrison into the cabinet. They were given a large role in war production and in what was known as the Home Front. Part of this they insisted was raising the morale of a skeptical public that this war and its outcome would be different from World War One.
During WW1 then Prime Minister David Lloyd George had also promised expanded welfare and “homes fit for heroes”, but these had all been reneged on in the following decades. Something more definite had to be promised. Sir William Beveridge, a Liberal (though a social rather than a free market one), was tasked with drawing up a report on postwar social reconstruction. Before the war he had worked closely with the Fabians and Clement Attlee researching social problems at the LSE.
The report envisaged the creation of what came to be called a welfare state, with a universal, compulsory unemployment and sickness insurance system, the aim of full employment, child allowances and, last but not least, a comprehensive health service free at the point of delivery. Beveridge picturesquely called this “slaying the Five Giants – Want, Disease, Ignorance, Squalor and Idleness”. His report stated that “a comprehensive national health service will ensure for every citizen there is available whatever treatment he (sic) requires, domiciliary or institutional, general, specialist or consultant.”
The extortionate costs of healthcare before the war and the misery this inflicted on millions thanks to mass unemployment and the public assistance means test, made the Beveridge Report massively popular reading in wartime Britain. Published on December 1 1942, it sold 100,000 copies within a month, and a cheaper mass edition was distributed to the armed forces.
But Beveridge did not invent the NHS. The Socialist Medical Association, founded in 1930, and affiliated to the Labour Party, had already come forward with a series of proposals. Headed by the doctors Sommerville Hastings and David Stark, it called for a fully nationalised health service, with a salaried medical profession and the gradual elimination of private practice. The SMA argued for local health centres, which would include a dental and industrial injuries service and see the integration of GPs and their practices into the hospital system, including visits from hospital consultants.
In 1943 the the Labour Party issued a pamphlet ‘A National Service for Health’ which had wide circulation, and the SMA held a Health Workers’ Convention at Conway Hall which included hundreds of delegates from health workers unions.
In March 1944 Henry Willink, a Tory health minister issued a White Paper called A National Health Service which stated:
“The Government have announced that they intend to establish a comprehensive health service for everybody in this country. They want to ensure that in future every man and woman and child can rely on getting all the advice and treatment and care which they may need in matters of personal health; that what they get shall be the best medical and other facilities available; that their getting these shall not depend on whether they can pay for them, or on any other factor irrelevant to the real need – the real need being to bring the country’s full resources to bear upon reducing ill-health and promoting good health in all its citizens. “
This shows that a health service available to everyone regardless of ability to pay was now a common position of all the parties. Even the Tory election manifesto stated: “The health services of the country will be made available to all citizens. Everyone will contribute to the cost, and no one will be denied the attention, the treatment or the appliances he requires because he (sic) cannot afford them.”
Labour’s 1945 general election manifesto Let Us Face the Future, was published in April. Thanks to the agitation of Aneurin Bevan who led a rank and file revolt against the timidity of the original draft from the National Executive, it included substantial nationalisation and declared the Labour Party was “socialist and proud of it.” It even declared that Labour had as its “ultimate purpose… the establishment of the Socialist Commonwealth of Great Britain – free, democratic, efficient, progressive, public spirited, its material resources organised in the service of the British people.”
Let Us Face the Future’s central pledge alongside the nationalisation of coal, electricity, steel, the railways, road transport, etc., was to implement the Beveridge Report in full. Curiously for what became Labour’s most enduring achievement, the manifesto’s health pledges only amounted to a couple of paragraphs:
“By good food and good homes, much avoidable ill-health can be prevented. In addition the best health services should be available free for all. Money must no longer be the passport to the best treatment. In the new National Health Service there should be health centres where the people may get the best that modern science can offer, more and better hospitals, and proper conditions for our doctors and nurses. More research is required into the causes of disease and the ways to prevent and cure it.”
Health and Housing Minister Aneurin Bevan, a former Welsh miner and left winger, who had been expelled from the Labour Party before the war and during it was a merciless critic of Churchill in the House of Commons, proposed a plan for a completely nationalised hospital system with 14 regional boards, appointed by the minister of health and local management committees.
His first opponent was none other than Herbert Morrison who resisted the “destruction” of the health service the London County Council had built up in the 1930s. There was an immediate outcry against Bevan’s system as hyper-centralised. But it was his initial suggestion that GPs should be salaried employees which roused the biggest uproar.
As soon as the NHS Act was passed in 1946, a furious struggle to block and sabotage the new system was launched by the doctors’ organisation, the British Medical Association, backed in its own inimitable style by the Daily Mail. GP’s practices were private businesses which they could sell at will: many gained a large part of their incomes from wealthier patients concentrated in middle class areas. They feared if they were to become salaried employees of the NHS they could be directed to move to poor areas without an adequate number of doctors by the Ministry of Health. They repeatedly threatened to boycott any new system that put them under “political”, i.e. democratic, control, pleading their professional independence.
Articles and letters in the British Medical Journal described Bevan as “a complete and uncontrolled dictator”, “medical Führer” and called the NHS “the first step, and a big one, towards national socialism”.
But such nonsense played into the Welshman’s hands and he waged a skilful campaign to split the hospital consultants and the Royal College of Physicians from the GPs and the BMA. He also had to struggle against the municipal authorities and the charities, which resented the nationalisation of their hospitals.
Two days before the NHS came into force, Bevan, addressing a public meeting made the comment that instantly made him the object of ruling class hatred and working class admiration for the rest of his life. Recalling the unemployment and illness his own family, and many others in the mining communities and industrial areas had suffered, he said:
“That is why no amount of cajolery, and no attempts at ethical or social seduction, can eradicate from my heart a deep burning hatred for the Tory Party that inflicted those bitter experiences on me. So far as I am concerned they are lower than vermin. They condemned millions of first-class people to semi-starvation.”
In the end the Bevan wore down the doctors’ resistance. But in doing so he made serious concessions to both the GPs and consultants. The consultants were won over by conceding their right to continue private practice using NHS hospitals. GPs were to be paid a capitation allowance for each patient as well as a £300 p.a. NHS salary, and still owned and could sell their practices. They were also allowed to have private patients who could be treated in NHS hospitals too. This left the GPs practices as distinct small businesses not fully integrated into the service.
Bevan famously boasted, when asked how he defeated the BMA’s boycott threats : “I stuffed their mouths with gold.” But paying Danegeld to the doctors had political as well as financial consequences. The nationwide network of local health centres never appeared, since without the GPs’ involvement as NHS employees, their practices were excluded from centralised or local planning. And it left a Trojan horse of private medicine within the walls of the NHS; one that over the past two decades New Labour and the Tories have used to marketise the health service on the road back to privatisation.
So, although provision free at the point of use might seems like an “island of socialism”, in fact an NHS operating within a market economy, where inputs are subject to providing profits for the pharmaceutical, medical equipment and construction industries, and where the GPs and consultants remain in part petty capitalists, is only a form of state capitalism. It is one, like a nationalised transport system, that the working class needs to defend in its own immediate interests. Moreover it can also be a launching pad for measures transitional to socialism taken by an anticapitalist workers’ government.
The explosion of pent up demand for treatment, especially by dentists and opticians, accumulated during the decades of neglect under the private system, meant costs soared over the next three years. To give just one example, the £1 million budget for providing spectacles in the first year ballooned to a £27 million bill (£1 billion in today’s money). This became a major campaigning issue against the NHS by the Tory press. By 1950 the NHS was costing £358 million a year and the decision to enter the Korean War presented the government with a choice which they resolved by abolishing the free-at-the-point of use principle when it came to prescriptions for medicine and charges for dentures and spectacles.
The Korean Civil War had broken out in June 1950, but it developed into a proxy conflict between the USA and the Soviet Union, with China involved in on the ground fighting US and British troops. The United States pressured the Labour Government, already financially in hock to them, to vastly increase its defence spending. Chancellor Hugh Gaitskell proposed a rearmament programme of £4,700 million. Bevan criticised this but was most alarmed by the cuts that Gaitskell proposed to balance the budget.
This precipitated a government crisis as Gaitskell squared off with Bevan. The increasingly right wing cabinet leaders, led by Herbert Morrison, were determined to pay for and participate in the Korean War and thus be able to hold on to the still substantial remnants of the British Empire in Africa and the Far East. Bevan personally detested Gaitskell, whom he later alluded to as “a desiccated calculating machine”, but the cabinet supported the rising star of the right and Bevan resigned and returned to the backbenches as a critic of the government.
In 1951, a tired Attlee, returning from illness, decided to renew Labour’s reduced 1950 general election majority of five seats, and seek a new mandate. Although Labour won the popular vote, the vagaries of the British electoral system delivered a Tory majority, which they held onto for the next 13 years.
The history of the NHS since has been one of Tory attempts to undermine it by stealth; introducing market forces wherever they could, hiving off subsidiary services to the private sector, starving it of funds, reforming away its central coordination with hospital trusts and putting these under GPs’ control. But rarely if ever have they dared to attack it directly. Indeed when in trouble, as Theresa May is today, they even throw money at it – though of course much of this finds its way back into private business.
Although New Labour did substantially increase funding to the NHS, they not only refused to reverse the internal market trialed by the Tories, but took it several steps further. The “defence of the NHS” by the unions has been feeble in the extreme.
Even under Jeremy Corbyn Labour’s promises on the NHS don’t approach anywhere near the commitments necessary to reverse the damage, let alone unleash its full potential.
A genuine socialist policy would be to return to the model of an integrated national plan that Labour left-wingers advocated at the outset.
The PFI deals must be cancelled, privatised services brought back in house, and the pharmaceutical industry nationalised without compensation. A nationwide system of local clinics and social care infrastructure must be established to relieve pressure on hospitals and strengthen communities. All GPs, consultants, dentists, opticians etc. must become fully salaried employees of the NHS. In addition we need to ensure that health workers of all grades and specialisations are trained in far greater numbers. This means reversing the steady decline in real wages and conditions.
Last but not least the Tories and New Labour’s organisational reforms must be repealed and a new charter of NHS governance drawn up which includes democratic oversight by representatives of health workers and patients. In this way the full promise of 1948 can be realised, the ground lost recovered, and an advance to a genuinely democratic, and socialist society be realised.
