Nye Bevan and the Doctors: Interrogating the Mythology of the Founding of the NHS
Chris Locke | 3 June 2024
◇ British History | History of the NHS | Modern History
The currently depressed state of the National Health Service (NHS) is already featuring in the campaign rhetoric of political parties vying for power in the forthcoming UK general election. As the NHS approaches its 76th anniversary, interest in the man popularly credited as its principal architect, Labour health minister Aneurin (Nye) Bevan, has been boosted recently, thanks to his portrayal by celebrated Welsh actor Michael Sheen in the play Nye, which transferred recently from London's National Theatre to the Millennium Centre Cardiff.[1] The rapturous reception greeting recent performances of this in the Welsh capital are as much an indication of the public’s appreciation of Bevan’s legacy, and its enduring affection for the NHS, as they are for the play and its performers. While allowing the play’s author, Tim Price, a measure of artistic licence in bringing the life of this charismatic but controversial figure to the stage so entertainingly, the play may have left audiences with some key misconceptions regarding the origins of the NHS and Bevan’s role in it. Foremost among these is, that, were it not for Bevan, there would have been no NHS, and second, that the medical profession, while unquestionably the strongest obstacle to his plans, was in general opposed to the concept of the NHS itself.
Undeniably, the shape of the NHS was determined to a large extent by Bevan's personal vision and principles. These were conditioned, as demonstrated in the play, by his familial experience of ill health, unemployment, and deprivation in the mining communities of South Wales in the interwar years. As much as any of his colleagues in the Labour Party at that time, Bevan understood what the public needed in the way of health services, and he was unwavering in his determination to deliver it, overcoming all opposition, including some from within his own party. His principal opponents, the play makes clear, were the medical profession, led by its powerful representative organisation, the British Medical Association (BMA). However, the play glosses over the considerable part played by others in preparing the platform for Bevan's triumph and ignores the fact that, despite its opposition to his plans, the medical profession itself had been actively and openly campaigning for a National Health Service over several decades.
Doctors belonging to the left-leaning State Medical Services Association had been calling for a National Health Service as early as 1912 when the health insurance provisions of Lloyd George’s National Insurance Act were being debated.[2] The BMA was at that time opposed to the Liberal government's proposals, though not the principles behind them. In the 1920s, following the publication of the Dawson report, the BMA's Insurance Acts Committee began calling for an extension of the scheme to include the families of insured workers and for the scope of medical treatment provided to include hospital and not just GP services, and in 1930 the BMA published its vision for a more comprehensive range of health services in a report titled A General Medical Service for the Nation.[3] The parlous state of the British economy at that time forced it to conclude, however, that such plans were for the time being ‘beyond the scope of practical politics'.[4]
In 1937 the influential report into the British health services by the independent think tank Political and Economic Planning accurately diagnosed the inadequacies of prevailing health services and made a compelling case for a National Health Service which many within the medical profession readily accepted. [5] The outbreak of the second world war cemented belief in the NHS idea when, in preparation for mass civilian casualties, the hospital services were unified, and were seen to operate efficiently, under central government control.[6]
Many were surprised when, in 1941, a time when prospects for the nation were at their bleakest, the BMA made the bold and surprising decision to establish an intra-professional consultative body called the Medical Planning Commission to determine what a National Health Service should comprise and the best means of introducing it when hostilities had ended. The ideas it subsequently circulated to the profession for discussion were described as ‘striking and revolutionary’ and seemed to abandon principles the profession had previously considered sacrosanct.[7] The comprehensive new NHS, they suggested, should cover 90% of the population, excluding only the most affluent. But, at its meeting later the same year, the BMA’s Representative Body voted by a narrow majority to extend coverage to 100% of the population. [8] Public interest in the idea of a National Health Service was boosted by the publication in 1942 of Beveridge’s Report on Social and Allied Services. Public expectation surrounding this, and the need to offer British people some morale-boosting hopes for a better future in the event of victory, forced the wartime coalition government to begin negotiations with the medical profession. This resulted, after a protracted period of discussion and argument, in the 1944 NHS White Paper. [9]
When Nye Bevan was revealed as the unexpected choice of health minister following the Labour Party’s landslide victory in the general election of 1945, he was therefore embarking on a well-trodden path marked out for him by his predecessors. He was also free to select or reject from a range of previously negotiated proposals those most attuned to his, and his party's, political preferences. Having formulated a new NHS Bill, Bevan irked the BMA by initially refusing to negotiate its details. When meeting them in person, he impressed its representatives with his intellectual acuity and wit, but his sometimes-impolitic public utterances alienated many doctors, for whom he became something of a socialist bogeyman, characterised hysterically as a would-be medical ‘dictator’.[10]
Bevan eventually succeeded in winning over a large proportion of the Consultants, aided by the conciliatory efforts of the president of the Royal College of Physicians, Lord Moran, by allowing them to continue their private practice in parallel with work for the NHS. [11] But he failed to satisfy the GPs, who remained fearful of being forced to give up their independent contractor status and of being subordinated to local authority control. Bevan announced a series of measures aimed at alleviating their concerns. In summarising these, however, the play's author makes one glaring error, when Bevan is heard to announce that GPs ‘will be allowed to continue to buy and sell their practices’. In fact, Bevan remained firmly opposed to this idea. In a debate in the House of Commons he asked how it could it be right for a doctor to succeed to a practice, ‘not on account of his professional qualifications but on the size of his purse’.[12] Thus, while GPs were still permitted to sell the buildings they operated from if they owned them, the NHS Act took away their right to sell the goodwill of their practices. This prohibition was enforced by a new Medical Practices Committee, and it was the new NHS Executive Councils who alone determined who succeeded to vacant NHS GP practices.
In a particularly dramatic moment in the play Bevan is heard to say repeatedly that the NHS will start on the ‘appointed day’, 5 July 1948, ‘with or without the doctors’. Bevan knew there could be no NHS without the doctors but was confident that they would capitulate. This was because in the high stakes game of poker he was playing with the BMA he knew he had an ‘ace in the hole’. When the NHS Act became law the previous system of National Health Insurance under which many GPs received the bulk of their patient income would cease, and the capitation fees attaching to the 90% or more of patients expected to sign up for NHS services would accrue only to those signing up to serve them as NHS GPs. Moreover, only those signing up before the appointed day were guaranteed a share of the £66 million which Bevan had persuaded the Treasury to set aside as compensation for giving up the right to sell the goodwill of their practices. As Dr Guy Dain, the GP chairman of the BMA’s Council acknowledged, ‘The GP is in a cleft stick, that is if the Act starts, and he has not come in he loses the right to compensation’. [13] This was something GPs could not readily forego, given that most started out in practice with sizeable debts, due to loans taken out to purchase their practices. Those not signing up before the appointed day risked their practice purchase money, usually the equivalent of two years’ income, never being repaid. Another memorable quote from Bevan in the play is his boast that he would make the doctors ‘the most well-paid profession in the country’. That may, arguably, have been true for a while as far as the Consultants were concerned, but it was not to prove so for the GPs. Within two years of the appointed day, they were threatening to resign en masse, citing evidence before a government-appointed arbitrator that their incomes had fallen significantly compared with both their Consultant colleagues and other professions.[14]
In the final analysis, the medical profession's concerns about the NHS Act proved largely groundless and they soon counted themselves among its most enthusiastic advocates. There is no doubt that Bevan's clear sighted and determined approach proved decisive in bringing the NHS into being. But, given the previous investment of successive governments, ministers, civil servants, and the medical profession itself, in efforts to create it, it seems likely the NHS would eventually been introduced in some form even if Bevan had not been appointed health minister, or had not succeeded with his plans. The portrayal of the medical profession in the play as ‘villains of the piece’ is understandable as the reasons for their opposition are too complex and difficult to explain in the course of a dramatic performance. Yet many commentators have been in no doubt as to the important contribution they made in developing and popularising the idea of a National Health Service. Among these was Michael Foot, an admirer and protégé of Bevan’s who became leader of the Labour Party in the 1980s and who witnessed these events first hand. In his biography of Bevan, he generously endorses a statement made in a contemporary editorial in the British Medical Journal which read: ‘The historian who will be able to view these events dispassionately in the future may come to the conclusion that after 1911 the principal architect of the National Health Service was the medical profession itself’. [15]
Chris Locke is an honorary research fellow in the History department at the University of Sheffield. His book, GPs, Politics and Medical Professional Protest in Britain, 1880-1948, was published last year by Routledge as part of their Studies in Modern British History series.
References
[1] Nye, a National Theatre and Wales Millenium Centre co-production 2024, written by Tim Price, directed by Rufus Small, and starring Michael Sheen.
[2] See John Stewart, The Battle for Health: A Political History of the Socialist Association, 1930-1951 (Aldershot, 1999) p.20.
[3] BMA Archive, B/177/1/1, A General Medical Service for the Nation (London, 1930).
[4] BMA Archive, B/203/1/24, minutes of the Insurance Acts Committee’s Dependants Subcommittee meeting on 5 May 1932, p.9, item (10).
[5] Political and Economic Planning, Report on the British Health Services (London, 1937).
[6] See Charles Webster, The National Health Service: A Political History (2nd, edn, Oxford 2002) p.6.
[7] See Charles Hill, Both Sides of the Hill: The Memoirs of Charles Hill (Lord Hill of Luton) (London, 1964, p.32)
[8] British Medical Journal, 26 September 1942, Supplement p.33.
[9] A National Health Service, Government White Paper, HMSO, London February 1944. See also British Medical Journal, 26 February 1944, Supplement pp.3-36 and 293-295.
[10] See John E. Pater, The Making of the National Health Service (London,1981) p.132. Frank Honigsbaum, Health, Happiness and Security: The Creation of the National Health Service (London, 1989) p.98.
[11] John Campbell, Nye Bevan: A Biography (London, 1987) p.168.
[12] Hansard, HC, 9 February, col.40.
[13] British Medical Journal, 10 July 1948, pp. 59-60.
[14] See Geoffrey Rivett, From Cradle to Grave: Fifty Years of the NHS (London, 1997) pp.112-115.
[15] Michael Foot, Aneurin Bevan, 1897-1960 (abridged edn edited by Brian Brivati, London 1977) p.360.