BEVAN: I find the efficiency of the hospitals varies enormously. How can that be put right?
MORAN: You will only get one standard of excellence when every hospital has a first-rate consultant staff. At present the consultants are all crowded together in the large centres of population. You’ve got to decentralize them.
BEVAN: That’s all very well, but how are you going to get a man to leave his teaching hospital and go into the periphery? [He grinned] You wouldn’t like it if I began to direct labour.
MORAN: Oh, they’ll go if they get an interesting job and if their financial future is secured by a proper salary.
BEVAN (AFTER A LONG PAUSE): Only the State could pay those salaries. This would mean the nationalization of the hospitals.43
The college presidents also convinced Bevan that he would have to allow part-time consultants to continue private practice in NHS ‘pay beds’. Without that concession there was a real risk that specialists would refuse to join the health service, and would, in Bevan’s words, set up ‘a rash of private nursing homes all over the country’44 which would undermine the very comprehensiveness of the service Bevan was seeking to establish. In addition, Lord Moran talked Bevan into merit awards, on top of basic salary, for those doctors whom their peers judged worthy. A decade later, Bevan at a private House of Commons dinner was to boast wryly in one of his most famous asides, ‘I stuffed their mouths with gold.’ The remark was not given currency until 1964 by Brian Abel-Smith, when it provided one small element of the growing resentment over private practice that exploded in Barbara Castle’s great pay beds row.45 At Prunier’s, as Professor Abel-Smith has put it:
The top doctors obtained á la suite terms in the Health Service: part-time payment for loosely defined sessions, the secret disposal of Treasury funds to those of their number whom Lord Moran and his two colleagues thought more meritorious, the lion’s share of the endowments of the teaching hospitals to pay the costs of their researches, and the right to private practice – much as before. The consultants had gained regular remuneration without any loss of freedom and were being trusted to use this freedom responsibly.46
Labour’s left wing, whence Bevan came, proved far from happy with this deal. But, as Michael Foot has put it, ‘to get the specialists into the hospitals and to keep them there as regularly as possible was crucial to the whole enterprise’.47 In the long run, the concessions split the medical profession and put the Royal Colleges, with the powerful voices of Webb-Johnson and Moran, on Bevan’s side. Without that, it is doubtful if the NHS would have been born at all; and the steady spread of consultants across the country, which did so much after 1948 progressively to improve standards of care outside London and the big cities, would not have occurred. The mighty battle which was still to be fought with the BMA, despite some of the ballot results to come, was to be between Bevan and the GPs rather than Bevan and all the doctors.
Before the Bill could be published, however, Bevan had to sell it to the Cabinet and in October he sought a decision on ‘one big question of principle’ – whether to nationalize the hospitals. His argument was simple: the voluntary hospitals were dead. In this he had the backing of the magnificently named Sir Edward Farquhar Buzzard, a former President of the BMA and Regius Professor of Medicine at Oxford, who had publicly delivered the same diagnosis to the press a year earlier.48 To keep them going, Bevan told the Cabinet, around 80 or 90 per cent of their revenue under any national health service would have to come from public funds and ‘I believe strongly that we must insist on the principle of public control accompanying public financing.’ In this the teaching hospitals and postgraduates would be given special status on three grounds: their quality and standing; because ‘it is a good thing in itself to keep separate a field for independent experiment in method and organisation’; and because the state should not dictate the medical curriculum. The local authority hospitals too should be nationalised, he said. The great bulk of local authority areas were too small to run good ones, the rates could not bear the full cost of the service, and complex cross-financing arrangements would be needed if rich areas were not to have better services than poor ones. The ‘voice of the expert’ (chiefly the doctors) had to be brought into the planning and running of the services. There was thus a powerful case for ‘starting again with a clean slate’.49 Bevan acknowledged the proposal would mean ‘extinction’ for most voluntary hospitals and would ‘provoke an outcry’ both from them and from local authorities. The attitude of the doctors, he conceded, was uncertain. But again, probably unconsciously, he echoed MacNalty: ‘if the choice were before them between a primarily local government service and primarily nationalised service, the overwhelming majority would prefer the latter’.
In a tantalising aside, he acknowledged that if local government were reorganised into regions (a Labour policy) then the hospitals might revert to regional government. Given that an experiment loosely on these lines is underway at the time of writing – ‘Devo-Manc’ – it is worth exploring the reaction. His memo brought Herbert Morrison, Lord President of the Council, leaping to the local authorities’ defence. Morrison had made his name as leader of the London County Council in the 1930s, when local government, at least in terms of breadth of function, was in its heyday.
‘We should be cautious about any step which will weaken local government,’ Morrison argued. The government’s nationalisation plans were already likely to remove gas, electricity, probably passenger transport and possibly water from them. And Bevan, he complained, was ‘on the horns of a dilemma’. If the proposed appointed regional hospital boards were ‘subject to the Minister’s directions on all questions of policy, finance, establishments and so on, then they will be mere creatures of the Ministry of Health, with little vitality of their own’. Yet under a nationalised state system ‘it is difficult … to envisage the alternative situation in which, in order to give them vitality, they are left free to spend Exchequer money without the Minister’s approval and to pursue policies which at any rate in detail may not be the Minister’s, but for which he presumably would be answerable’.50
Local government ran a better hospital service than Bevan gave it credit for, he said – adding in a touch of raw politics that the health minister would be launching a war with local authorities ahead of council elections in November and the spring. He offered, however, no solution to the voluntary hospital problem, admitted he had no ‘conclusive argument against nationalising the hospitals’, conceded that a nationalised system might be inherently more efficient, and opened with the courtesy of describing Bevan’s paper as ‘brilliant and imaginative’.
Four days later, desperate for a decision to get ahead with his plan, Bevan hit back, arguing that putting the voluntary hospitals under local government would ‘rouse a tornado compared with any passing thunderstorm my scheme may provoke’. He added: ‘any scheme which leaves responsibility for the hospital service with local authorities must be unequal in its operation. This would be unjust to the public who will pay equal contributions.’ The regional boards ‘would be the agents (though not, I hope, in any derogatory sense the creatures) of my department’ with ‘substantial executive powers, subject to a broad financial control’. If the scheme was sound, the political consequences need not be feared, and if Morrison described it as imaginative: ‘is not that exactly what we were returned to be?’ Neither of the present systems – municipal or voluntary – would do. Such a chance to make the health services ‘the admiration of the world … comes but once, perhaps, in a generation … if it is not done now it will not be done in our time.’51
The row went to Cabinet two days later, where Morrison reiterated objections that hospital nationalisation was not in the party manifesto: indeed, municipalisation had been Labour’s policy. Local pride and voluntary enthusiasm mattered, Morrison argued, and there would