Any assessment of Butler’s Act, however, must concur with Harold Dent’s judgement: for all that it did not provide everything it was ‘the greatest measure of educational advance since 1870, and probably the greatest ever known’. That is not incompatible with one of Butler’s drier judgements on his own handiwork, that it essentially codified best existing practice.24 In resolving some issues, his Act ducked others, leaving open ground that in years to come was to be fought over with all the vehemence of the religious issue that the Act finally settled.
The health of the people is really the foundation upon which all their happiness and their powers as a state depend.
Benjamin Disraeli, 1877
This is the biggest single experiment in social service that the world has ever seen undertaken.
Aneurin Bevan, 7 October 1948
In the case of nutrition and health, just as in the case of education, the gentlemen in Whitehall really do know better what is good for the people than the people know themselves.
Douglas Jay, 1937
The Emergency Hospital Scheme was in the short run the financial salvation of the voluntary hospitals, but in the longer term proved a major factor in their post-war nationalization. The scheme illuminated the enormous financial deficiencies of the voluntary hospitals and gave to the public hospitals a more prominent place in the hospital system. For the first time, many of the wealthier and more highly educated members of society became patients in public hospitals and were distressed and eager to reform what they had seen and experienced. Likewise, doctors serving under the EHS had to serve in all kinds of hospitals and were often shocked at what they saw.
Dr Gordon Macpherson in BMA, Health Services Financing, p. 32.
It was the first health system in any Western society to offer free medical care to the entire population. It was, furthermore, the first comprehensive system to be based not on the insurance principle, with entitlement following contributions, but on the national provision of services available to everyone. It thus offered free and universal entitlement to State-provided medical care. At the time of its creation it was a unique example of the collectivist provision of health care in a market society.
Rudolf Klein, The Politics of the NHS, 1983, p. 1
Medical provision before the war depended upon a primitively unstable mixture of class prejudice, commercial self-interest, professional altruism, vested interest, and demarcation disputes.
Arthur Marwick, British Society Since 1945, p. 49
IMPLEMENTATION OF Butler’s Act was to fall to Labour. But the issue which was to cause the biggest welfare state row immediately after 1945 was not to be education, Beveridge’s social security plan, or even housing, though that too was to see its fair share of controversy. It was the National Health Service that took the lion’s share of the headlines, despite proving the most enduring of the 1945 Labour Government’s achievements.
Labour’s 146 majority was the biggest ever known, outstripping by two even Margaret Thatcher’s 1983 victory. Labour MPs horrified the Tories by singing ‘The Red Flag’ in the Commons chamber, and into government came Aneurin Bevan: one of Labour’s great saints or sinners, depending on which part of his career is in view at the time and which section of the Labour Party is making the judgement. He was Attlee’s biggest gamble as a ministerial appointment, one of only two Cabinet ministers who had not served in the wartime coalition. ‘A stormy petrel’ with ‘a magic all of his own’ in the words of Kenneth Morgan, who judged him to be ‘the most hated – if also the most idolized – politician of his time’. The forty-five-year-old ex-miner, however, proved himself at the Ministry of Health to be ‘an artist in the uses of power’.1
In the 1930s he had been expelled from the party for advocating a popular front. During the war he was a running rebel on the back-benches and was almost expelled again, Churchill once condemning him as ‘a squalid nuisance’.2 Macmillan fondly remembered him as an ‘uncontrollable star – perhaps almost a comet’, a man who ‘could not forget and never wanted to forget the sufferings he had seen in the mining valleys of South Wales’. He judged him ‘in many ways the most brilliant and the most memorable of them all’ – the ‘all’ being the 1945–51 Cabinet to which Macmillan gave the accolade of ‘one of the most able Governments of modern times’.3 Just as Butler is remembered for his Education Act, Bevan’s name will always be associated with the NHS.
On 26 July, the day the election result was announced, the British Medical Association was meeting in the Great Hall of BMA House in Tavistock Square, a massive, neo-classical, red-brick building originally designed by Sir Edwin Lutyens for the Theosophical Society with the Great Hall as its temple. The Society had been unable to afford the mighty edifice which came to symbolise all the self-important solidity the medical profession felt was its right – a building where as late as the 1930s the clerical staff were under instruction not to share the lift with the great London consultants who arrived to do their business in top hats and frock coats.4
The BMA debate was interrupted by the news that in Labour’s landslide Sir William Beveridge, the man who had demanded a National Health Service three years earlier, had lost the Berwick seat he had taken for the Liberals in 1944. Some delegates broke into a cheer. ‘I have spent a lot of time,’ one eminent Harley Street surgeon said, ‘seeing doctors with bleeding duodenal ulcers caused by worry about being under the State.’5 Well before Bevan arrived, the doctors were deeply suspicious about the form any proposed National Health Service would take. That very worry, however, reflected a remarkable consensus which the doctors shared and Bevan inherited: that there was going to be a National Health Service. The question was what form it would take.
Included in Bevan’s inheritance was the Emergency Medical Service, plans for which were drawn up by Chamberlain’s government in the wake of Munich and in fear of what the Blitz would – and did – mean. The creation of the EMS followed surveys conducted in 1937 and 1938 which showed just how deficient hospital services were. By October 1939 the government had provided nearly 1000 new operating theatres, millions of bandages and dressings, and tens of thousands of extra beds in ‘hutted annexes’ some of which remained in use for more than two decades after the war. A national blood transfusion service had been created. As the war progressed, free treatment under the emergency scheme had gradually to be extended from direct war casualties to war workers, child evacuees, firemen and so on, until a sixty-two-page booklet was needed to define who was eligible. Although the elderly and others remained excluded, between 1939 and 1945 ‘a growing section of the population enjoyed the benefits of the first truly “national” hospital service’.6 Wartime proved that a national health service could be run.
The Emergency Medical Service had itself heavily extended what existed before. On the hospital side just before the war there were 1334 voluntary hospitals and 1771 municipal hospitals. The former ranged from the twenty great English teaching hospitals each with around 500 beds, of which no fewer than thirteen were in London along with nine post-graduate hospitals such as the Great Ormond Street Hospital for Sick Children, to tiny cottage hospitals of ten beds or less. The average was a mere sixty-eight beds. The number of voluntary hospitals, and particularly the number of small ones, had grown sharply after the First World War. Among the older foundations St Bartholomew’s could claim almost 800 years of history, but many such as the Royal Free, whose name encapsulated its aim, had been founded during the great burst of Victorian philanthropy aimed at improving the health care of the poor. This, initially, they did successfully, in as far as medical knowledge then allowed success. In 1891, 88 per cent of the voluntary hospitals’ income came from gifts and investments. By 1938, however, only 33 per cent