Dan Snow's History Hit - The Creation of the NHS

Episode Date: July 4, 2023

75 years ago this week, the National Health Service was born. Launched by Aneurin Bevan on the 5th of July, 1948, it revolutionised healthcare in the UK by providing free medical treatment for all. Today, it is one of the country's most beloved yet divisive institutions. But how did the NHS come into being in the first place? And how has it shaped our lives in the 75 years since?Dan is joined by Jenny Crane, a lecturer in Health Geography at the University of Bristol to tell us about how the NHS was created, and the key characters who shaped it along the way.Produced by James Hickmann and edited by Dougal Patmore.Discover the past on History Hit with ad-free original podcasts and documentaries released weekly presented by world-renowned historians like Dan Snow, Suzannah Lipscomb, Lucy Worsley, Matt Lewis, Tristan Hughes and more. Get 50% off your first 3 months with code DANSNOW. Download the app or sign up here.We'd love to hear from you! You can email the podcast at [e-mail] can take part in our listener survey here.

75 years ago this week, the National Health Service, the NHS, was born. From that point forward, healthcare in the UK would be provided free at the point of delivery, irrespective of people's ability to pay. And today, 75 years on, we're still talking about the NHS nearly every single day. 75 years on, we're still talking about the NHS nearly every single day. It's nearly always cited as the primary reason for people to cast their votes in elections. It is something that every single person in the country has used, has interacted with. It is something that everybody has got strong feelings on. Dr. Jenny Crane is a lecturer in health geography at the University of Bristol. She is a fellow of the People's History of the NHS project. She's explored how the NHS has shaped

our lives, what its legacy is, how popular it is, the challenges it faces. She's come and tell me about how the NHS came into being. And it is a fascinating tale. It takes us from philanthropic Victorian and Edwardian healthcare provision through to the massive effort of the Second World War and the utopian government that came to office after it. She also helps us all to understand how so many of the issues, so many of the things that we talk about within the NHS that were debated, that contested, are actually baked into the DNA of the organisation. They are the result of compromises, of decisions that were made when the NHS was born 75 years ago. This is such interesting and important historical context

for something that is so important in modern Britain, healthcare, but also plays such a huge role in our political discourse. It's a great one. Enjoy. T-minus 10. Atomic bomb dropped on Hiroshima. God save the podcast. Thank you for having me. So what happens if you or I get sick in 1930? Well, it would be very different if it was you or I. So assuming you are a working male in 1930, I don't know what your working hours,

maybe you're a cleaner, maybe you work in a shop. Jenny, I don't want to get into it, but I think I'm kind of an admiral actually. Then you will definitely be getting better healthcare than I will. So let's say we're both working people, normal jobs, median income. Okay. I think I'm much less likely to be working. I think I'm probably classic housewife, stay at home mother. So if you were an admiral or maybe a minor, quite a different job, you would be covered most likely by insurance for your job.

Whereas if I was a woman, I sometimes would be covered by partner's insurance, but quite often wouldn't. And then would be reliant on local healthcare, on going to a panel board and finding a voluntary hospital. It's just this huge mismatch that really, really depends. Like we talked about the postcode lottery today, but that's nothing on, well, it's very serious as well, but on 1930, it will entirely depend on where you live and what local insurance you have. So maybe you'll be getting operated on, although obviously, probably with less anesthetics today, with less antibiotics, but I might be left without treatment. And so it could be a web of philanthropic local governments. You could get lucky, live next to some wonderful supported hospital, but potentially left completely alone,

unless you come up with payment yourself. Yeah, you can always pay yourself. But yeah, absolutely a web and a mesh and a very precarious, stressful thing to navigate that would lead to people making different healthcare choices, probably not approaching the doctor if they felt ill. Yeah, unimaginable. And no surprises, therefore, that maternal mortality was much higher and life expectancy much lower and all that kind of stuff. What are the debates going on through the first half of the 20th century about how to provide healthcare? Presumably there are voices saying we shouldn't provide any at all through the state, and there's voices talking about universal healthcare. Yeah, there's definitely this long-term movement towards the NHS. So I think the first kind of call for a national health service

is 1909. It's a minority report to report about the poor law. That talks about should we have a national service? Should we have some consistency? And the London County Council, who's providing more healthcare across London, are talking about if this needs to be made more broad. There's various policy reports from the Fabians, from the Webs in the 20s and the 30s. And this really escalates hugely in the context of World War II. The idea of soldiers recreating a new world, deserving something better than the current system. And then there's famously the Beveridge Report, 1942, by somebody who becomes a Liberal MP. An eccentric character like Bevan that calls

to attack the five giants of want, ignorance, squalor, idleness. And a lot of that report actually focuses on social security, but other parts focus on national healthcare, because the idea is that we can't have a decent social security system unless we have full employment, so people are working and paying into it, and also unless we have a healthy population. So the idea is that we need a national healthcare system for this. And famously, that sells about 600,000 copies to members of the public. So obviously, as well as these policy debates from think tanks and MPs, there is this generalised moment of excitement. You would never see a policy report selling these numbers today.

People say there were queues, this generalised moment of excitement from the public. You're obviously facing like women can't see, they need glasses, they need dentistry. The nation is not in a good state. That was also revealed by evacuation, actually, another impact of the World War II. You know, people in the villages taking city children and they're shocked by the fact they have rickets, nits, bedbugs, bed wetting, this whole range of health issues they might not have been brought into contact with before. And to see it in children is quite shocking. It's interesting that you're talking about this. And I think the context of World War II feels so

important. Obviously, there's sort of altruism here and everyone ought to have healthcare and it's a reflection of, I guess, a democratisation of British society. But it also sounds like it's sort of, we're in a big national endeavour, people need to be fixed, they need to get down the mines. There's a sort of Team UK fit for work vibe here, which no doubt, does that come from this kind of enormous spasm of national effort that the Second World War entailed? Yeah, I completely agree. There is this human capital aspect and it becomes part of the feminist critique of the welfare state in the 1970s that it's, you know, just intending to make people fit to work, to make Britain more and more

productive. And the welfare settlement is kind of under question in the 70s. There's that moment. And actually a recent chapter, Roberta Bivens, who's a historian, she found this memo from the BBC from 1948 that said the government really wanted to use the NHS to project a new vision of Britain as a strong power, as a moral state. And it says that a lot of people think Britain's been economically crippled by the war. And obviously it's a major reception of the Marshall Plan. They want to really project an image of the NHS to combat that and actually really project leadership in this moment of the start of the end of empire as well. So definitely huge human capital concerns, huge positioning of Britain in the world. It's not just pure

philanthropy or altruism, as you say. And is that why, although we will come to the Labour Party and the establishment of the NHS, is that why it was quite attractive to conservatives, even very old-fashioned conservatives, in the late 1940s? Yeah, and I think I should mention for conservative listeners, Henry Willink did a report in 1944, which also called for a National Health Service. And who was he? He was in the coalition wartime government and a Conservative figure. I think more recently, and especially since the 1980s, campaigning tries to take it as a sheer left-wing cause, but actually it's a lot of cross-party consensus in the wartime period.

And partly maybe because of these human capital concerns, but I think also people have just been shocked by the welfare of the population. People have been shocked by the high number of civilian deaths in World War II, which is obviously so much larger. So it's 70,000 World War II in the UK, like 2,000 in World War I. People have just been shocked by the state of the nation. And that crosses parties. Beveridge becomes a liberal. Everyone is supporting the idea of an NHS. But then the question is how it will be realised, how much you'll pay for it, what the limits will be, who should be prioritised. So there's huge significance in that detail, even if there's cross-party support for a generalised idea of a national health service. And also the idea at the start is that it will be cheaper,

you know, that it will start paying for itself because the nation will get really healthy and it will be a health service, non-ill health service, and healthy population won't need it as much. So there's an economic efficiency argument there as well, which we don't really realise because of the growing costs of treatments. Although actually we have been hearing that I think more recently haven't we with people leaving the job market early and retiring and we are hearing quite a kind of conservative or certain sort of commercial case for specific sort of people in their third quarter of life receiving special attention to keep them working for longer. Got to keep working and we've had to bring retired doctors back, haven't we, to cover shortages due to industrial unrest from younger

people. There's more recent research on generational attitudes that I've been looking at and how younger people are very, very, they're more likely to be cynical about the idea of saving the NHS because they're questioning the position it's in. They're more aware of industrial strife, whereas the older generation are more likely to come back from retirement to look after it or protect it because they were born within it and they're a lot more attached to the current system. Let's talk about Nairin Bevan. He's a Labour politician who's often credited as sort of the founder of the NHS. Let's talk a little bit about his background first, but then we'll talk about him being swept into office and actually being in a position to do something about it. It's a shock for everyone. Such a rebel firebrand, people say, don't they?

Yeah, Nye Bevan, born 1897 in Tredegar, which is a Monmouthshire on the border, just on the Welsh side. Six of 10 children, four of them die before they make adulthood, which is common at that time, but obviously incredibly tragic for every family. His father's a miner and he goes down the pit at 14 as well, incredibly common in that part of the world. It's a surprise to people that he reaches the cabinet because he's so outspoken, but in a way it's also very plausible because he's always, he studies history, economics and politics at the Central Labour College. He joins the Independent Labour Party. He serves in the South Wales Miners' Federation local branch. He's very political. And then the Nye Bevan Society, there's a lot of love for this

man. And also historians as well say, is it significant that his dad died, they say, in Nye's Arms, which is very poetic, of a lung disease related to mining in 1925? And is that something that really drove his later passion for health and for universal healthcare so he's part of the kind of build-ups the general strike not a penny off the pay minute on the day he goes to monmouthshire county council age 31 he enters parliament which is very young isn't it to enter parliament as the labour party member for ebba vale which near trudeau in the valleys and he just has these incredible rhetorical skills, which you just don't always see today in parliament, but which makes him a really interesting person to research.

So he said, I have some good quotes. He said that Winston Churchill was a man suffering from petrified adolescence. Churchill says he's a squalid nuisance. So the feelings go both ways. On that, he says that Chamberlain, the worst thing I can say about democracy is that it's tolerated the right honourable gentleman for four and a half years. Not pleased with Chamberlain, helps to oust him. And he famously says the Conservative Party are lower than vermin. So he's got some views. He gets expelled from the Labour Party because of his opposition to intervention in the Spanish Civil War. He's expelled from the House for disrespecting the chair. He's a bit of a rebel. He's not your typical kind of figure that you'd expect to put in the cabinet because of this fear

that you might not be toeing the line, I think, but nonetheless appointed. And he was happy to criticise the performance of the British Army and various things during the Second World War as well, so incredibly outspoken. So outspoken, yeah. And then also marries Jenny Lee, another Labour Party member from Fife in Scotland, who's similarly outspoken. And she writes a book about their marriage. And it's amazing to see they must have had this hugely feisty, intellectual left-wing marriage. She later helps to found the Open University under Wilson, but Bevan doesn't see X.E. Daly's in 1960. Labour swept to office in 1945, somewhat unexpectedly. It's seen as one of the great change elections in British history. Were they intended to be as radical as they were? Did they absolutely go into this thinking, we are going to remake British society?

Yeah, that's a good question. Hard to say, because if you read the manifesto, it's maybe more boring. It's available online. it might be a bit more dull than you'd expect but then if you look at their posters it was saying that they would cover everyone and healthcare would be for free i guess it also leads to the question historians are raising about did they actually reform society was it an evolution of these previous healthcare systems that we talked about because it had so many limits was it a revolution so i'm not sure but I think that's an interesting question. I think Bevan was looking to do some serious reform and as health and housing, as his brief, that's the most incredible combination. Housing was really seen as the

key issue of that election rather than health. Maybe the health reform took people by surprise a bit more, I think. But housing, the housing stock had been so desecrated by bombing. Does he oversee like a million more houses by 1950, which we see all the time today in these postal council estates? So yeah, maybe they surprise themselves a bit more with health, but maybe some people try and be radical.

So Bevan is Minister for Health, at least Prime Minister, and Bevan, does he surprise people with his radicalism? Because this is universal healthcare. And today we still talk about the fact that it's one of the more, how should we describe it? One of the more expansive models in the Western world. Lots of other democracies, even social democracies have elements of insurance and things, but here there's some very clear guidelines, I guess, set up by Bevan.

On the one hand, he surprises people and that's reflected in the kind of take up afterwards. So people are surprised that they're actually able to get these mundane medical technologies for the first time. And there's stories of women in particular just queuing out the door. They get 27,000 hearing aids, you know, in the first year of the NHS, which is incredible and shows how many people were just walking about death. They get 164,000 surgical medical appliances, 6.8 million dental treatments, 4.5 million pairs of glasses. So clearly people were surprised and maybe worried it would be taken away is what I read from that, or that they were just living in ill health. But then on the other hand, there was some research that would suggest that maybe people were not only not surprised by the NHS, but that they just weren't really that aware of it. So Roberta Bivens, a historian at Warwick, did an analysis of the front pages of media on the appointed day, the 5th of July, when the NHS opens. And she found that actually there was much less coverage than you'd think. She says it's silent as much as celebrated. that actually there was much less coverage than you'd think. She says it's silent as much as celebrated. And another historian, Nick Hayes, he looks at social surveys and interviews from

the inception of the NHS. And again, he finds that was there this radical demand and he finds that people take this pride in not knowing about welfare reform. Most people in Manchester, who the social survey has talked to, just don't know about it. So that would suggest it doesn't take people by surprise. But then kind of conflicts with the idea of the Beverage Report selling 600,000 copies. So it's very contested historically. Did it surprise people or not? Well, we've got a clip here produced by the government, a promotional cartoon from 1948, implying that they did a bit of work to do in telling people about the NHS and what it meant. Let's take a listen. In the past we've had all sorts of public health services

such as main drainage and water supply. Everyone makes another of these services. And so is street cleaning. These are all public health services, but the new Health Act proposes to organise personal health services in the same way. There have been many personal health services, but different kinds of financial arrangements. Some people could afford them, others could not. Some places were well off for hospitals, others were unlucky. This new health service will be organised on a national scale as a public responsibility. The cost of the service will be met from rates, taxes, and national insurance, and so everyone will pay for it, and everyone will benefit from it. When you're ill, you won't have to pay for treatment.

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Follow America's story from the first Native people to footprints on the moon on American History Hit, a podcast by History Hit, with new episodes every Monday and Thursday. Follow us wherever you get your podcasts. To be continued... Talking Vikings, Normans, Kings and Popes, who were rarely the best of friends, murder, rebellions and crusades. Find out who we really were by subscribing to Gone Medieval from History Hit, wherever you get your podcasts. what is the nhs did they take this weird web and network of surgeries and hospitals all over the country and just sort of nationalize it all go now from issue them with an id card and go right you're all the nhs now what is it yeah we need to learn it so matthew thompson this historian says the public needed to learn it through these kinds of videos, mass leafleting campaigns.

And likewise, we need to learn it as well, I think. So they do basically just nationalise, as you say, this existing hodgepodge system that you still see today. People will notice sometimes your GP surgery is this old, crumbling Victorian building. Sometimes it's a huge PFI building. They just basically nationalize some 5 000 hospitals in england and wales overnight which is a pretty crazy move and there's no i think there's no new

hospitals built at the start of the nhs and there's not substantial hospital building program until the 1960s so it really is nationalizing and that's why the postcode lottery continues because it reinforces these long-standing inequalities by region. And then there's continual reports looking to reform this in the 60s and 70s. It's very difficult because that always involves hospital closures or consolidations. Rural populations might be more affected if you're closing small cottage hospitals. The public are more likely to have an attachment to those kinds of small sites. So it's a very, very hard thing to rationalise because of just nationalising it overnight. Bevan gets the symbolic keys to Park Hospital in Trafford

to symbolise that he now kind of manages all of these as Minister of Health. The hospital administrators just bill the government, do they? They just send the bill to someone else? Yeah, so it's, yeah, centralised. Instead of sending it to this hodgepodge, they just kind of, following the money as always. Yeah, a good way of saying,

what's it actually mean that it's been nationalised? So, so-and-so's come in for a hearing aid and rather than them getting a bill, it's sent to Bevan. Sent to Bevan's desk in Waterloo. Well, there's the thing that might be a misquote that he said. What is it if a bedpan drops in Tredegar Hospital, where he's from, he wants to hear it in Westminster. And that is the idea of him wanting everything to be super, super centralised.

So maybe he would indeed want to personally be signing those cheques. And that sounds today kind of socialist or something, but in a way it's again born from the lessons of World War II, is that there were these ministries of aircraft production and the government had taken over the British economy almost, hadn't it? And decided how many vehicles to produce and shells and ran factories and ran enormous industrial enterprises. So this kind of concentration of power in Whitehall is perhaps not as strange as I suppose it could seem in a different context. He had these sort of principles, didn't he, on which he wanted the NHS to be founded upon? He writes several books. He has one in place of fear, which the NHS is there in place of fear,

from 1952. He says no society can legitimately call itself civilised if a sick person is denied medical treatment because of a lack of means. So he wants it to be free. He wants it to be universal so you can turn up with whatever condition you want to your GP, who will be the gatekeeper to hospital services or to accident and emergency. And you will get treated regardless of if you're rich or poor, male or female, young or old. That's a really radical idea. The change is how people use healthcare massively. That all sounds lovely, but there is resistance to it, isn't there? In fact, the resistance, it harks back to an earlier part of our conversation. People call him a dictator,

and this is almost comparing it to kind of Nazism. Yeah, is that the British Medical Association's leader at the time, Charles Hill, writes in the British Medical Journal that Bevan is a complete and uncontrolled dictator, indeed. And the American Medical Association, similarly across the sea, are saying it's very dangerous. It's a Soviet threat. It's communism. Also some critique of it, maybe spending some of the Marshall Plan funding, so they're funding it. The British Medical Association are concerned about that centralization. They're concerned about losing independence, which is a model that they've grown up with and worked with. And they're also a bit concerned about their fixed salaries

and if that will reduce their income, which is why Bevan famously says in the end that he stuffs their mouths with gold. Right until the last minute, it's not clear if the doctors are really going to be on board with the NHS. He has to kind of split them off, manage them. Eventually says they will retain capitulation, being paid for a registered patient. Yeah, stuffs their mouths with gold. So much resistance. And the American resistance is very interesting as well, that the American Medical Association would take such an interest.

And Life magazine, they send journalists to take photos of the early NHS and they see people getting hearing aids for the first time or looking after the elderly. But what they focus on and what they publish is when they can find like shabby window frames or kind of bomb damage, peeling paint in the wards, because they want to say that this isn't an option for America. It's not good quality and the money should be spent. They say in the Life magazine, how much socialised medicine equals how many guns? This could be spent on defence with the Soviet threat rather than on healthcare. And even if it is spent on healthcare, they're saying it's not that effective anyway.

It's not that good a service. So there's a lot of people invested in undermining the NHS. And the way you've described its genesis, which is a kind of a mix of wartime contingency and radical progressive thinking, and also just needing to keep groups like doctors happy. contingency and radical progressive thinking and also just needing to keep groups like doctors happy it does explain why we are always talking about reforming the nhl like i'm now really like like you know getting rid of small hospitals which anyone who lives in the uk will in rural uk in particular will know it's an issue of consolidation of hospitals is so important i've always assumed that's because there was a sort of blueprint laid down in the 1940s which is now aging but actually so much of this dates from

before the NHS. There was never a clean slate and just a network of hospitals built and a service provided. It feels that we're still trying to solve some of the challenges that were there in the original DNA of the NHS. And that's why it's contested and that's why we are constantly arguing about how we should pay for it and what form it should take. Yeah I really agree. Yeah the 1961 hospital plan by Enoch Powell, he was Minister of Health at the time, that was really an attempt to rationalise it, create a certain number of district hospitals, large concentrated hospitals per certain number of areas. There's been attempts to do this since the 70s, 80s, 90s. But it's so weird that was not done at the beginning. There was no plan for that at the beginning. It was just, yeah, that's fascinating.

Yeah, that's so true. I think they just went from the stint of health in the nation, making a radical change rather than wiping it and starting all over again. But you're right, it does mean if you want to understand the state of the NHS today, you have to look back to the 1930s, the Victorian period, while at the same time it's expanded and expanded. So many new treatments, the health of the nation has not improved as the early architects really hoped, unfortunately. Yes, that's one of the saddest aspects probably of that early utopian thinking, that preventative healthcare, the idea that we'd live better, healthier lives. I mean, of course, well, we are in so many ways, but and yet we have got these new challenges around, you know,

obesity and longevity that mean that it isn't saving us money, I guess, right? No, I don't think so. Although I think that's very contested as much as it's so political, but I think some analyses say that it is a good value system for money and for what it does. And then there's arguments about would it keep people in better health if it had more funding and could be a national health service rather than national ill health service. But at the same time, debates can't ignore the sheer inequalities that we have in the NHS today. I was really shocked by the stat from Claire Bambra, health geographer, that there's a nine-year life difference between some English local neighbourhoods and obviously two-year between the north and the south of England. There's obviously huge inequalities, black women

five times more likely to die in birth than white women. Just hideous. Hideous inequalities remain, which could be a cause for calling for significant reform, I think, should be. So let's finish up by looking at how pop you think it's been sort of through its history. As you've said, actually, at the beginning, it wasn't necessarily universally celebrated right at the beginning. Lots of people will tell you, and the Olympic opening ceremony in London suggested it was something incredibly close to British people's hearts and identity. Is that just an attack in this never-ending battle for opinion on the NHS? Do you think that's true? How's that arc of acceptance and popularity gone

through the 75-year history of the NHS? I always argue that people were happy to be getting medical treatment and they were attached to their local hospitals, providers, more likely to have a family doctor in the late 40s, 50s, 60s. And that actually, it was only in the 1980s when people felt that the NHS was under threat, that people particularly started to love it when people were scared of losing it. So reforms by the Thatcher government around bringing in a purchaser-provider split and contracting out services like cleaning and catering and laundry, campaign groups, but also members of the public were just really, really concerned that the NHS would break down. And there was some intergenerational family memories when you

interview campaigners, members of the public, they've been told by their grandparents that they had to pay to give birth to their first five children, but not to the sixth, or that they had to have an operation without anaesthetic because they couldn't afford it. So I think at that point in the 80s, the generational memory of life before the NHS and the family stories are there, and the feeling that the NHS is under attack is there. And that's really when the public love kind of builds up. And then I think it's amped up further in the late 90s, as the NHS is actually in a relatively good period then, it's getting further funding. And the NHS logo is also brought in in 1999, that gives people something further to kind of coalesce around. And obviously, you see this in the Olympics opening ceremony. The NHS also becomes more represented on TV and culture,

which I think adds to the idea that it's an object and something that can be celebrated, builds up from there. But then today, because of recognition of these inequalities and because of austerity and relatively poor provision, unequal cancer outcomes, cancelled operations, public opinion is a bit more kind of wavering on the NHS today, I think. Is it the Health Foundation recently said that 57% think the general standard of care in the NHS has got worse in the last 12 months. 69% think the standard of social care has deteriorated. And increasingly in surveys, people are really worried about the condition of the NHS for the next five to 10 years. Really, really concerned. And you also hear when I do public engagement

work, you hear so frequently people saying, love the NHS but and then they tell you the most horrific stories of things that they've experienced in health so I think at the moment that love is really bound up with criticism and stress and angst about services future perhaps like all of us at 75 years old we have challenges health challenges facing us do you think the sort of simplicity of an Iron Baron's vision for the NHS, that it's just free for everyone, irrespective of need, do you think that can endure? I'm just a little idealist. I have hope for it. Too often, as compared to the American system, which positions us to feel grateful for having any kind of universal healthcare,

that if we look at the Scandinavian social democratic models instead, we see that people are getting healthcare free at the point of use or based on limited social insurance that they pay according to means. I think that it is a model that can work. I think that it's something that should be prioritised in terms of public spending. I think that these health inequalities could be addressed. I do believe in it. Jenny Crane, thank you very much indeed. Tell us what your book is called

that you published last year. It's called Posters, Protests and Prescriptions, Cultural Histories of the NHS in Britain. It's got lots of different essays by different historians who look at TV and the NHS, the American Medical Association response, campaigners, why they love the NHS, different spaces. It's based on archives, interviews, surveys. Well, thank you very much for coming on and talking all about it. Thank you. you