The Bevan legacy

At the conclusion of the second world war Britons wanted a new order of things. Medical care had made big advances in the war, and soldiers had been offered a higher standard of care than they were likely to encounter after demobilisation. Civil servants and politicians discerned these currents long before the war ended.

Following the war, therefore, Britain would almost certainly have created a national health service without Aneurin Bevan, and even without a Labour government. Bevan had to work with the conditions he inherited and he accepted much that had been planned during the wartime coalition government. He made relatively few big decisions, but those that he made have had a profound effect on the way the service has developed.

Bevan held fast to the principle of a service funded by the taxpayer, and essentially by no other source, and his resignation from the cabinet on the issue of health charges had the effect of raising that principle to the status of a dogma. That has been an important cause of the strain experienced by the health service ever since. It has been refused sufficient funds from the taxpayer, and has never had anywhere else to turn for money. Worse, sensible discussion of alternatives has been made almost impossible ever since Bevan turned the National Health Service into a party political battleground.

Summary points

• After the war Britain would probably have created a national health service without Aneurin Bevan. He made relatively few big decisions, but those he did make had a profound effect on the way the NHS developed

• His decision to nationalise the hospitals led to the government supplying virtually all health care as well as paying for it

• His biggest principle was that the NHS should be funded entirely by tax. This has led to underfunding

• Bevan also politicised the NHS in a way that has locked politicians in a perennial dread of change

Aneurin Bevan: the man and his decisions

Few politicians are as well, or as affectionately, remembered 50 years on as Bevan, and rarely is a politician’s name so inextricably linked to a particular achievement as his is to the creation of the NHS. This is especially remarkable, because at the time Bevan was far from popular. He had long been viewed by many—even in his own party—as a wild man, who had risen in part thanks to the intemperance of his invective. He was a fierce critic of his party’s leadership and had got himself expelled from the party in 1939. During the war, while his senior Labour colleagues held leading positions in Churchill’s coalition cabinet, Bevan railed against the prime minister and the conduct of the war in tirades that even his colleagues felt were close to treasonable. When he entered the Attlee cabinet as minister of health in 1945, he could count on the hostility of the deputy prime minister, Herbert Morrison, the chancellor, Hugh Dalton, and the foreign secretary, Ernest Bevin—and he developed more enemies as he went along.

So, as Bevan set about making the decisions that were to shape the NHS, several of his colleagues were looking out for reasons to accuse him of making a terrible mess of the preparations. Bevan supplied them with ammunition, first by refusing to discuss his plans with the medical profession until after first reading of the parliamentary bill and subsequently by becoming involved in a bitter and protracted feud with the BMA, which seemed to risk failure for the whole project.

Luckily Bevan retained a high opinion of himself, and this was largely shared by the civil servants working for him. He impressed them by an early display of decisiveness, when he nationalised the country’s hospitals. Previously, there had existed municipal hospitals, which tended to be quite good, and voluntary hospitals, which were of varied quality and already overwhelmingly dependent on taxpayers’ money. All the wartime plans made before Bevan’s appointment had assumed that the local authorities would take over all hospitals; indeed it was assumed that local authorities would be the foundation of the health service as a whole, employing general practitioners and supplying community health services too. However, those planners had not worked out how they would overcome the voluntary sector’s predictable protests at being absorbed by the local authorities. Bevan solved that problem by bringing all the hospitals under the control of national government.

Bevan’s decision to nationalise the hospitals provided an early demonstration of independent thought and display of power, which left him free to be unexpectedly flexible in other respects. He was convinced that he needed the hospital consultants on his side and so gave them the right to have private patients and allowed pay beds in NHS hospitals.

To general practitioners he conceded something which had not been on offer from Bevan’s wartime Tory predecessor, Henry Willink: their self employed status, with payment mainly through capitation fees. Nevertheless, the BMA waged a long campaign and extracted further concessions. The bad publicity which that campaign caused Bevan gave the government the first warning that the BMA can seriously damage a minister’s political health. But it also gave his own party the impression that he was determinedly implementing socialist policies, when in many ways he was not. With all his concessions Bevan created a health service which was less socialistic than that planned by his Tory predecessor. Bevan was prepared to make so many concessions because he cared about a central principle and was willing to cede territory elsewhere to protect it. The principle was a free health service available to all. For Bevan, that meant that it should be funded from taxation.

An unusual NHS

The idea of an NHS paid for almost exclusively by the taxpayer has so deeply penetrated our national psyche that it is worth remembering that it was not inevitable. The most obvious alternative was one based on compulsory national health insurance. This principle had been established by the Lloyd George reforms at the beginning of the century and was the model endorsed by the Beveridge report, the foundation of most postwar welfare reforms.

Labour welcomed the Beveridge report on its publication. But Bevan had always opposed the contributory principle. He thought that a free health service should be accompanied by a redistribution of wealth through the tax system. Bevan’s way of proceeding was also in marked contrast with practice elsewhere. According to Rivett, “few other countries, outside the Eastern bloc, followed the same route” that Britain took.¹ Yet Britain embarked on an uninsured health service with apparently little debate about the principle involved, or its sustainability.

It was a decision of inestimable significance, which owed nothing to previous British practice or experience, was little discussed at the time, and has been rarely queried since. Bevan convinced the British people that the NHS was the best system in the world. You might say that ever since then vested interests have tried to convince us that underfunding has made it the worst. But in both cases we have tended to be insular: few know about other countries’ systems.

Following the creation of the NHS, there was almost immediately debate about what was meant by a “free health service.” The issue of health service charges was to lead to Bevan’s resignation from the cabinet. His adversary was the new Labour chancellor, Hugh Gaitskell, who believed that Bevan had taken too far his idea of a free health service, that it should not extend to providing things like spectacles and false teeth which were not linked to illness, and that prescription charges were needed in order to suppress unnecessary demand. The cabinet even considered charges for hospital stays.

At the time of his resignation, Bevan had failed to convince either the cabinet or the left wing of his party of the matter of principle which mattered enough to him to sink his own career. In an extraordinarily bad tempered speech he increased resentment against him by referring to “my health service.” According to Tony Benn’s diaries, “He shook with rage and screamed....The megalomania and neurosis and hatred and jealousy he displayed astounded us all.”

Such reports make it really quite surprising that it did become widely accepted that Bevan was the father of the NHS, that his resignation had been on an important matter of principle, and that a completely free service was the defining principle of the NHS.

I think the explanation for that change is partly that the 1945-51 Labour government, despite all its reforms, was a disappointment to the Labour party itself. The government lost momentum and compromised more than its zealots would have wished. Following the split in the party Labour mythology built up the NHS as the outstanding socialist achievement.

A sacred, and underfunded, NHS

The effects of that mythology have been with us ever since. The principle of a free health service has not since been breached any more deeply than it was by the cabinet that founded the NHS. Charges to patients today make up less than 3.5% of NHS revenue. By his political martyrdom, Bevan made the NHS sacred in the form he had created it.

In the years since Bevan, there has been an important development in Labour’s general political outlook which logically should have led it to rethink its stand on the NHS. Labour has abandoned its commitment to redistributive taxation. We are thus left with a commitment to fund the NHS almost exclusively out of taxation, without any policy to increase the amount of tax available to pay for it.

The paradox is that the Bevan model has led to very tight restriction of health expenditure. There has been little to choose between the political parties. Over the years the treasury has kept the lid screwed down tightly, and the NHS has had nowhere else to turn for money. The signs are that our low level of expenditure is not just a demonstration of our efficiency: Britain is actually spending too little on health.

Too much weight on a single back

I am not saying that Britain would do better if it had a different healthcare system. My point is that while there is ultimately only one source of money in a society—its people, who end up paying one way or another—it none the less helps to raise revenue in a variety of ways. Putting nearly all of the burden on taxation makes it difficult to bear, especially since many more people on low incomes pay income tax now than in Bevan’s day. Another change is that both the main political parties now favour low taxation. And governments may favour other programmes such as education ahead of health.

Some combination of taxation, private capital, national insurance, charges, and private insurance might made the burden on the public more tolerable, enable the nation to spend more on health, enable people to be treated more quickly, and provide the NHS with more secure sources of funding.

In the Netherlands nearly 68% of total health expenditure comes from social health insurance and nearly 14% from private insurance. Only about 10% comes from taxes. In Germany just 14% comes from the government. In the United Kingdom 85% of health spending comes from public expenditure.

Logic and concern might dictate that we should pursue every avenue to increase the monies available for health care. But we don’t, because to suggest any private contribution or any change in funding produces a hysterical reaction.

People who make provision for insurance themselves have received little encouragement. That is curious since even Bevan himself saw that private practice could make some small contribution to funding the NHS. He allowed hospital consultants to earn money beyond their NHS salaries as a way of securing their services in the public sector without having to pay them private sector fees. It brought the NHS quality at a cheap price. The private patient was recruited to subsidise the NHS one.

Because relatively so little health care is available in Britain, we have a disgraceful situation where how rich you are really does make a difference to the health care that you receive. Our queues and our queue jumping are no cause for pride or complacency, nor any reason for us to patronise other countries. The shortages and inequality are a paradoxical outcome of one of the most socialist looking systems in the world. But the answer to queues and queue jumping is not to cut back on private insurance, but rather to increase by every means what the nation spends on health care.

Private capital

Bevan’s decision to nationalise the hospitals produced an effect that was not challenged for many years. It meant that not only would the government, using taxpayers’ money, pay for health care, it would also be responsible for supplying it all. We take that for granted now, but it was not inevitable: it was an unexpected choice and it is not what a number of other countries chose to do. In Britain, the independence of the municipal and voluntary hospitals was put to an end. The decision brought advantages of integration, but uniformity is the enemy of innovation. Diversity can lead to the emergence of novel good practice which can then be learned by others.

It is perfectly possible for government to pay for services—so that they remain free at the point of delivery—without owning those services. If the government did not own all the facilities from which it buys services, it would not need to find capital for their construction and improvement.

Recent attempts to introduce private finance into the NHS have met with only limited success. Fundamentally this is because as part of the Bevanite legacy we cannot detach ourselves from the idea that the government should control the hospitals as well as pay for them.

The NHS in three parts

Bevan’s decision to take all the hospitals, voluntary and municipal, under government control also had the effect of creating a health service in three parts: hospitals, general practitioners, and community health. Since then these three have existed in separate columns like silos that have almost nothing to connect them. Bevan was right to believe that the local authorities were in no condition to take on such heavy responsibilities. But the NHS has lived with this lack of integration ever since. In particular, it has proved difficult to develop a cadre of bright professionals who think about and drive policy for the NHS as a whole, rather than just for their silo.

Political football in the NHS

A political development of lasting significance was the decision by Bevan to make party political capital out of the NHS. In 1948 the prime minister, Clement Attlee, proposed to make a broadcast to the nation about the NHS hailing it as a national (rather than a government or party) triumph. Bevan was incensed and persuaded Attlee that since the Conservatives had voted against the bill at second and third readings, he should claim the credit for Labour and use the NHS as a stick to beat the Tories.

In party political terms I am sure that this was sensible. The Labour party has had a permanent advantage over the Conservatives ever since, and although much more of the NHS’s extraordinary advance and development has occurred under Conservatives than Labour (since Conservatives have been in office a good deal longer) still the NHS is associated with the Labour party, and the slogan that the Tories cannot be trusted with the NHS continues to resonate with the public.

So Bevan was politically shrewd. But the politicisation of the NHS has been greatly to the harm of the service itself. Rational debate has become very difficult. Every sort of change, including the replacement of old hospitals by new ones, has been presented as an attack on the service. It has made the Tories timid about reform—and it has made the Labour party cling to the Bevanite dogma of a health service financed only from taxes.

It is not just politicians who politicised the NHS. The BMA campaign against Bevan used a number of lies about his intentions designed to scare the public and embarrass him. We have seen similar campaigns since. Since the earliest days, most groups in the NHS have thought it in their interests to depict the NHS as being on the brink of collapse in order to obtain more money from government. Again this has become so much an accepted part of the scene that we have to remind ourselves that most service organisations do not try to paint the worst possible picture of themselves to their staff and customers.

Conclusion

At the end of the NHS’s first 50 years, we can be proud that people in Britain do not live in fear of medical bills they cannot afford. We can congratulate those many thousands of health professionals who have given brilliant service to the sick and pushed so wide the boundaries of medical care. We can celebrate longer life and healthier living.

But we cannot give three cheers when so many who work in the service are themselves depressed. Our celebrations must be tempered by the thought of all those who suffer because they cannot have today, or perhaps even this year, the treatment that would bring them relief from pain and a better quality of life.

The gap between what we spend on health care today and what we “ought” to spend is large, and no party is going to make it up from taxation. That the parties are so coy in speaking about health is mainly down to Nye Bevan. He made the NHS sacred and untouchable. He may have freed the patient from fear of medical bills, but he has locked the politician in perennial dread of change.

Figure.

Bevan turned the NHS into a party political battleground