Here was a revolution with no clear precedent in England. Whatever G. K. Chesterton may have believed, the monasteries and friaries of pre-Reformation England were not ‘the inns of God where no man paid’. Similarly, those who drew up the Tudor poor laws and established the parish system of relief had no conception of universal healthcare. Victorian refinements to those laws taught the lesson that sickness should be understood as the consequence of feckless living. Even the comparatively enlightened provisions of the 1911 National Insurance Act were confined to working men.
Rationing might have slimmed the nation down, but it had done nothing to avert disease. Tuberculosis, ‘the white plague’ of the Victorians, was still abroad, with few X-rays available to detect it. Diphtheria could cause a child to choke. Rickets and polio crippled the young as surely as they had a century before. Measles could be fatal. Scarlet fever, smallpox and influenza were as widespread as ever. Furthermore, the nation was simply run-down. The faces of the poor showed concave cheeks, chap-fallen jaws, grey, stubby teeth, and a nutcracker profile. As if poor sanitation, overcrowding and unsympathetic elements were not enough, children were still subject to Victorian notions of nutrition, being fed on starchy breast milk substitutes. Indeed, artificial feeding could be as dangerous for children as lack of hygiene. At a time when diarrhoea alone could kill a small child within days, it was common for a hospital administrator to spend half her day filling out death certificates. The imbalance of provision between rich and poor was dark and ugly. There was one GP for 18,000 people in the East End, while in the suburbs ‘it was one for every two hundred and fifty’. Money had to be put on the shelf for the doctor in case anyone fell ill; if there was no money, people would pay in kind, with eggs perhaps, or vegetables.
Medicine was, in every sense, a private affair. Even funding for hospitals was secured by charity parades or private benefactors. The doctor himself was a breed apart. You did not visit him – he came to you. Pre-eminent in that world was the consultant, tailed by his subordinates in the hospital as a king by his courtiers. Any love he or the general practitioner had for the sick might have been considered incidental. Yet the reason for what seems like a rather mercenary approach is simple enough. Before the NHS existed, a GP bought his practice. Like any other professional, he sought to enlarge his business, improve it, and perhaps sell it on at a profit. He had a capital investment in his work and sought to preserve it.
Nye Bevan, for one, did not see why matters should remain so. His own father had ‘died from dust’, in miners’ parlance. Bevan himself had started working in the pits of Tredegar at the age of twelve. He spoke of how food on the plate became a family’s calendar: you knew it was the weekend when there was almost nothing. ‘My heart is full of bitterness,’ he wrote, ‘when I see … the ill and haggard faces of my own people … There must be another way of organising things.’ There was, and it lay nearby. The Tredegar Medical Aid Society had been founded at the end of the previous century as a means of providing the local workers with healthcare they could not otherwise have afforded. Workers put in ‘thruppence a week’ of their earnings and received free medical, dental and optical care. It was, as one resident recalled, a ‘miniNational Health Service’. Bevan took it as his template.
The National Health Service Act had been passed along with the rest of the welfare legislation, but the other bills would not need quite such lavish preparation. The Conservative party under Churchill was opposed to Bevan’s proposals on the basis of cost. Bevan wanted a truly national health service, invested in by the employee but sustained by taxation. But this, its opponents argued, would be costly, unwieldy, ineffective and, given the high levels of taxation required, would necessitate a threat to English liberties. Surely such matters could be devolved to the regions. But the population wanted social change; for what else had the war been fought?
On 3 January 1948, Bevan offered his pledge: free healthcare for all, to be delivered on 5 July of that year. In a speech he reflected that ‘there is a school of thought, you know, that believes that if a thing is scarce, it ought to be dear … But this is not an orthodox government, and I am not an orthodox Minister of Health.’ It was an assessment shared by his most implacable opponents, the nation’s doctors, represented by the British Medical Association.
Members of the BMA had already become known as the ‘shock troops’ of the middle class. For the BMA, the proposed reforms were tantamount to an invasion of medicine by the state. The objection was not as disingenuous or self-interested as it appears: teachers would later display similar concerns about national curricula. And how would lawyers react if they were told to become servants of the state? Medical science had become a true science by the early Forties, and doctors were rightly proud of what had been achieved.
Dr Charles Hill, the leader of the opposition to Bevan, had been the ‘Radio Doctor’ during the war, dispensing homely advice to 14 million people in a voice as warm as a freshly baked loaf. Now, speaking on television against the reforms, his voice was grim and dour as he raised the old Tory shibboleth of freedom. ‘We all want better healthcare, better treatment … But in organising them, let’s make sure that your doctor doesn’t become the state’s doctor, your servant, the government’s servant.’ For all that Hill came from Islington, he acquired a slight West Country accent for this occasion, reassuringly bluff and English.
On 13 January 1948, the BMA called a plebiscite of its 35,000 members. ‘Our independence,’ it insisted, ‘will have been sacrificed to a soulless machine.’ An openly vituperative press campaign was launched, with Bevan satirized as ‘fuhrer’ in letters to the nation’s newspapers. The whole project was denounced as a ‘socialist plot’. On 9 February, Bevan presented his bill for an unprecedented fourth time; while in Newcastle, London and Liverpool, the BMA’s efforts bore fruit and the NHS was rejected outright by doctors. In Brighton, the ratio of rejection was 350 to 1.
Amidst all this, a subgroup emerged: the Socialist Medical Association, composed overwhelmingly of students, led what support there was for the NHS, in the face of hostility and ridicule. It was not uncommon for members of this group to be pointed out as ‘communists’ in the middle of a lecture. It was of a piece with the BMA’s language. They were convinced that with assimilation would come regimentation. Doctors would be forced to ‘march up and down’. The word ‘totalitarian’ was ubiquitous.
On 18 February 1948, the results of the BMA’s plebiscite came in. Thirty thousand had voted against, 86 per cent of the membership. Outwardly Bevan contrived to appear at once unbendable and good-humoured, but in private he confessed to a growing desperation. He consoled himself by trying to recall what first provoked his mission. ‘When I hear the cacophony of harsh voices trying to intimidate me, I close my eyes and listen to the silent voices of the poor.’ The man who it was said could make others believe that ‘their dreams were realisable’ was beginning to doubt. The bill had been passed but could not proceed. With victory in sight, the BMA felt it could begin to patronize its foe. Bevan was compared to ‘a very difficult patient’, self-willed but powerless.
Now at last the nation spoke. On 1 March 1948, a Gallup poll showed 87 per cent of the people in favour of the NHS, yet even this endorsement could not end the impasse. The National Health Service had a head but as yet no body, and if doctors chose not to work within his system Bevan had no means of compelling them. And so, unable to persuade the middle men of medicine, Bevan determined to woo its aristocracy. On 10 March he paid a visit to Lord Moran, president of the Royal College of Physicians and former doctor to Churchill. Moran headed the nation’s consultants and they in turn controlled the great charity hospitals: Barts, St Thomas’s, the London Hospital. These mighty institutions had reached financial extremis; in their vulnerability lay Bevan’s advantage.