The 5th of July 2023 marks 75 years of the National Health Service, a major part of the UK’s welfare state.
The beginning of the welfare state in the UK can be traced back to the beginning of the 20th century and Lloyd George’s liberal government. In power between 1905 and 1916, this government passed most of the legislation that became the foundation of the later welfare state. The Liberal party was the Conservative Party’s main political rival in the 19th and early 20th century. But an internal split involving Lloyd George led to a divided party which gradually lost most of its former power to the Labour Party. Lloyd George was the last liberal prime minister.
One of the key pieces of legislation introduced was the 1911 National Insurance Act. This provided sick benefit and some free medical treatment to all workers earning under £160 a year (approximately £20,000 today). This compulsory scheme took 4 pence a week from workers, 3 pence from the employer and 2 pence from tax. The workers were entitled to 10 shillings (approximately £60 today) for the first 13 weeks of sickness. By 1913 almost 15 million UK workers were insured.
In 1930 The Council of the British Medical Association (BMA) produced a Proposal for a general medical service for the nation¹. This proposed an extension of national insurance to dependents. This was one of several attempts to extend welfare services during the inter-war period. But the estimated costs of extending the scheme beyond the workers was too large a barrier. The profound societal change required to take such a major step needed an equally profound impetus. This was supplied by the second world war.
In July 1939, just before the outbreak of WWII the Civil Defence Act was passed. This enabled the Ministry of Health to create the Emergency Medical Service which developed medical services in the UK in preparation for war, including building new hospitals. RCP fellows were involved in all medical planning initiatives. On 18 March 1940, in his presidential speech, Sir Robert Hutchinson stated:
“the Royal Colleges have not been backward in asserting their rightful positions as advisors of the Government in these matters”
Lord Dawson (RCP president 1931-7) had been on the committee which planned what would become the WWII Emergency Medical Service. During the war, the RCP was represented on the BMA Medical Planning Committee by Sir Charles Wilson (Lord Moran) (RCP president 1941-8), Dr Henry Tidy, Dr John Ryle, and Dr Harold Himsworth. Dr Archibald Clark-Kennedy represented the College on the Central Medical War Committee.
The main impetus for serious discussion about developing a welfare state, including comprehensive medical care, came from the Beveridge Report published in 1943. This was the report of the inter-departmental committee on social insurance and allied services, chaired by William Beveridge, an economist. It famously identified five "giant evils" in society: squalor, ignorance, want, idleness and disease. The report proposed widespread reform to social welfare to address these. It formed the basis for the post-war Welfare State, which included the creation of the NHS.
Although the report had huge public support, there was a great deal of debate in Parliament. The conservatives wanted:
- voluntary hospitals and private practice to remain
- freedom of choice for doctor and patient
- no direction of doctors
- no more private practice,
- salaried service
- direction of doctors
RCP fellows discussed the report in committees during 1943, particularly the proposal that the local authorities should be in charge. Fellows were against control by the local authorities and distrusted political interference in professional areas. However, they supported the idea of availability for all, if private practice continued also.
The Beveridge report led to a Committee of the same name, which tackled the issues involved in establishing a comprehensive medical services. Lord Moran (Chair), Sir Harold Boldero, and Lord Cohen represented the RCP. The Committee submitted its report in October 1943. It was in favour of a comprehensive medical service, but with the option for practitioners to work in private practice.
In internal meetings during1944, RCP fellows approved resolutions to ‘ensure that the practice of medicine as a free and liberal profession should be safeguarded’ while supporting the principles of a comprehensive medical service. In January 1945 a document which was almost certainly written by Lord Moran was produced:
“In the long history of the College it has often influenced the government of the day..The time is at hand to negotiate with the Ministry of Health….The College does not desire to oppose the government’s intention to make available to the whole population a Comprehensive Medical Service.”
The National Health Service Bill was published in 1946. In the Lords three RCP fellows spoke on the bill, including Lord Moran, who stated his belief that when it became law the whole medical profession would unite to make it work, despite the differences in views and support for various aspects. In April the RCP fellows approved the principles of the bill.
“For the first time one of the principal organisations of the profession has made a public statement on the National Health Service which emphasises support rather than objections…..In associating itself with this proposal for effective reform the College has shown both a sense of realities and a spirit of cooperation which will strengthen public confidence in the profession.”
(Lancet, 1946: I; 786)
The Bill received Royal Assent in November 1946. The medical profession faced with an Act which was going to come into force in 20 months started taking positions in a bitter struggle over aspects of its implementation. In January 1947 Lord Moran and other Royal College presidents wrote an open letter to the Minister of Health:
“The opposition of a substantial part of the medical profession to any renewal of discussions with the Government regarding the National Health Service is causing us concern…. it may lead to an impasse… We believe that behind the opposition of members of the profession is the fear that to enter into discussions would compromise their positions by implying their approval and acceptance of the main provisions … Among specialists … The whole profession regard it as essential that independent practice should continue and that independent practitioners should have the necessary facilities for the treatment of their patients”
The Minister, Mr Bevan, replied:
“I believe that some, at least, of the opposition on the part of the profession to discussions is due to a misunderstanding of the proposals … Every doctor will have to decide for himself … whether or not he should take part in the new service … The issue for the medical profession today is … whether they will accept or forgo the opportunity to influence its shaping ... The function of the General Medical Council … remains unaffected. … It is a basic principle of the new Service that there should be no interference with the clinical freedom of any doctor.”
This exchange broke the threatening impasse and on 15 Jan 1947 the Council of the BMA passed a resolution in favour of opening negotiations. But during 1947 relations deteriorated again. Lord Horder, a prominent fellow, was active in opposing the entrance of consultants until agreement was reached with the whole profession. He was also competing with Lord Moran for the presidency of the RCP. But Moran had the backing of the younger fellows. Shortly before the Act became law, in May 1948, the BMA recommended that practitioners accept service in the new NHS and continue negotiations.
The National Health Service officially began on 5 July 1948. It was structured into regional areas, as favoured by Lord Moran, considered one of the architects of the scheme; a system which is still in place today. It was one of the first comprehensive healthcare systems in the world. Today the NHS treats 1.3 million people a day in England alone, and no one in the UK can imagine life without it.
Pamela Forde, Archives Manager
¹ BMJ (1930) 1, Suppl. 165.