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Did we really want a National Health Service?

By Nick Hayes

For most today, it’s difficult to imagine a British hospital system where treatment is not ‘free’ at the point of delivery, paid for out of national taxation, because in our imagination, the alternatives conjure pejorative images of the Americanisation of health. Those today opposed to decentralisation also echo the concerns of earlier health reformers like Dr Stark Murray, who thought the pre-nationalised hospital system simply disparate and chaotic. Others contemporaries drew attention to the “gloomy and depressing” hospital buildings, the “crowded, un-hygienic waiting rooms”, and the “unsympathetic and inhuman atmosphere” that pervaded public hospital wards. Public disquiet, it is widely suggested, drove forward demands for radical reform. Lawrence Jacobs, for example, argues that widespread dissatisfaction with existing standards of treatment, a strong public dislike of voluntary hospitals and their flag day systems of financing, and an aversion to workhouse-turned-municipal-hospitals pressured policy-makers into taking action. For Charles Webster the newly elected post-war Labour government simply “responded to public demand by decisively breaking with the gradgrind [utilitarian] health polices of the past.”

From the annual reports of Leicester Royal Infirmary.

But what do we really know, rather than think we know, about what ordinary people thought about hospitals before the NHS? Was there a strong demand for state nationalised medicine? Or were people generally satisfied with an already rapidly expanding but essentially localised service administered by voluntary hospitals, underpinned by a robust system of broadly based community fundraising activities and 2d per week mutualist contributory funds, and council-controlled public hospitals?

The Beveridge Report. Image courtesy of Nick Hayes.
In 1939 the British Institute of Public Opinion asked 1,523 men and women the question: “1,092 hospitals in Britain are dependent on charity for their support. Do you favour continuing this system, or should hospitals be a public service supported by public funds?” Seventy-one per cent favoured the latter. When later told about Beveridge’s “outstanding proposal that doctors’ and hospitals’ services should be extended, free of charge, to every person” — not surprisingly 88% thought it to be a good idea. Most thought a state-run medical service would benefit the nation, although surprisingly few knew why this might be. But most, too, felt old age pensions and family allowances the “most important” welfare concerns, while employment and housing, rather than health, consistently dominated questions on reconstruction priorities.

From the annual reports of Leicester Royal Infirmary.
The social survey organisation, Mass Observation, in conducting more detailed studies, shed a more nuanced light on public attitudes. It concluded that the “majority of people” were “satisfied with the available hospital services and treatment,” although maybe the “time was ripe for some changes on the hospital front.” Street collections, for example, unlike other forms of fundraising activity, were generally unpopular. As one factory manager commented: “I loathe flag days and resent the whole idea. I give to these because I am afraid to be rude to the vendor.” Many thought that essential services like hospitals should be state financed but not necessarily state run. Yet others simply offered an unreserved backing to voluntary provision. For one elderly working-class man voluntary hospitals were “exceptionally good. I don’t know what we would do without them places.” Others feared, reasonably or unreasonably, that state-run hospitals would be overcrowded — or depersonalised: “you won’t get the same interest taken in you.” Questioned about voluntary hospitals, “one person in two expressed unqualified approval, the greatest measure of support coming from working-class people in general and working-class women in particular.” Asked whether hospitals should remain as voluntary institutions, be run by a public authority or become partly voluntary and partly public, forty-two per cent supported a public system, but an equal number favoured wholly or partly retaining voluntary provision. Moreover, only a minority of the public (some 20%) wanted to see the hospitals funded directly through tax and/or the rates. Half of the people questioned opted instead for an improved form of state insurance, and a full 35 per cent wanted a system based on mutualist contributory payments.

Where does this leave us? A number of recent studies have argued against notions of a wartime radicalisation, stoking demand for widespread social reform. Contemporaries surveying wartime public opinion, such as Mass Observation, similarly noticed such a reticence for change in health reform. It concluded:

On the surface, the evidence before us seems to indicate a fairly large amount of resistance to State interference in the field of medicine…. roughly half the population was opposed to any major change on the health front, a quarter disinterested and a quarter in favour of State intervention. But probing below the surface, we find that much of the feeling is simply in favour of no change, a fear of any change and feelings that existing conditions aren’t so bad after all, or that a change might be worse.

This poses the question as to why resistance to change by such a large margin should be dismissed simply as timidity, rather than as a positive vote for existing provision? Why should favouring the status quo be reconstructed in such a way? What we hear here are echoes of the progressive reformer’s voice at work; a voice that trumpets that “no less than three out of every seven questioned’ favoured the government taking over the hospitals,” while conveniently ignoring the fact that the other four did not. It was the same voice that asked such loaded questions in 1939, or prompted positive responses later. And it is this voice that still wrongly dominates our understanding of contemporary popular opinion of pre-NHS provision.

Nick Hayes is a Reader in Urban History at Nottingham Trent University. Having previously worked on post-war re-construction, and on civil society and voluntarism, he has recently focussed on the relationships between local hospitals and communities. He is the author of “Did We Really Want a National Health Service? Hospitals, Patients and Public Opinions before 1948” in The English Historical Review, which is available to read for free for a limited time.

First published in January 1886, The English Historical Review (EHR) is the oldest journal of historical scholarship in the English-speaking world. It deals not only with British history, but also with almost all aspects of European and world history since the classical era: it covers the history of the Americas, including the foreign policy of the USA and her role in the wider world, but excludes the internal history of the USA since Independence, for which other scholarly outlets are plentiful.

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  1. […] National Health Service just before and after its inception deserved more recognition this year. “Did we really want a National Health Service?” asks questions that people think they have answers to, all wrong. Perhaps that’s […]

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