The British National Health Service was set up sixty years ago, officially on July 5th 1948. It was one of the greatest political achievements of the Labour Party. A free universal health service, paid for from general taxation rather than on the insurance principle, is a system of as pure communism as you can envisage within a capitalist system. Even the Tories, who opposed it and voted against it, have to pay lip service to the NHS as a popular institution.

Kate Smart (Health services before the NHS) shows that capitalism was incapable of providing adequate health care for the vast majority of the people before the NHS. Barbara Humphries (The fight against private medicine) shows that the NHS was founded in a decisive struggle against vested interests, particularly those represented by the British Medical Association.

The forces of capitalism continue to attempt to undermine and subvert the principles of the NHS. In future issues the Socialist Appeal will be running articles on the threats provided by ISTCs (private health hospitals) and polyclinics. For now we celebrate a great victory for the working class.

Health services before the NHS

By Kate Smart

Before the establishment of the NHS in 1948, the provision of health care was inextricably bound up with religion and controlling the poor. What is clear is that capitalism has never been able to provide health care for working people and they have been forced to rely on charity and philanthropy.

Role of religion

Much of the early care for people who were ill was provided by religious communities where care was provided by monks and nuns attached to monasteries. Some were independent and had their own endowments, usually of property, which provided income for their support. Most hospitals were founded for specific purposes such as leper hospitals, or as refuges for the poor, and it was not until later that hospitals became multi-functional. Not all hospitals cared for the sick and there were establishments to house the dying or infirm but the purpose was not cure or even care but to keep poor sick people off the streets.

The Poor Laws

The 1601 Poor Law created a national system for relief, paid for by levying local rates or property taxes. It was basically to force the poor to work, including children as apprentices, and provide limited relief for those too ill or old to work, the so called 'impotent poor'. Some older people were accommodated in parish almshouses, though these were usually private charitable institutions. Almshouses were religious institutions in existence from the 10th century. In the middle ages the majority of hospitals functioned as almshouses. For the landowners, poor relief provided a way of controlling the 'lower orders' and reinforced a sense of social hierarchy.

The 1834 Poor Law Amendment Act introduced sick wards in parish workhouses. Although intended for the people in the workhouses, the wards soon became full with sick poor people from the parish in general, prompting the state to assess how best this situation could be dealt with. In 1854 there was a report of a Select Committee on Medical Poor Relief and, while much of the evidence given to the Committee favoured extending the medical services of the Poor Law to a much larger section of the population - through schemes such as free dispensaries - this was ignored and the care of ill people was left to a few philanthropists to provide. It was not until 1929 that hospitals were finally transferred from the Poor Law to local authority committees.

The early hospitals

It was not until the eighteenth century that the modern hospital began to appear, staffed with physicians and surgeons. Nine hospitals were established throughout the country but the word 'hospital' was also used for institutions concerned with people and their families who were poor or destitute, as part of the Poor Law provisions. In London, for example, the only medical hospitals in the 1700s were the Royal Hospitals of St Bartholomew and St Thomas. There were other hospitals for special categories, such as Greenwich for injured sailors and refugees, the Magdalen Hospital founded to rescue 'penitent prostitutes' and the Marine Society for Educating Poor Destitute Boys. Between 1719 and 1750 five new general hospitals were founded in London and one of these was Guy's Hospital, founded in 1724, from a bequest by a wealthy merchant Thomas Guy. Guy was a stock speculator investing in government securities, including £42,000 worth of shares in Britain's official slave-trade organisation, the South Sea Company. He amassed a large fortune but was well known for paying his workers a pittance.

Medical care was principally private or voluntary and people had to pay for anything they needed. Medical care tended to deal mainly with serious illnesses. Local authorities of large towns provided municipal hospitals, maternity hospitals, hospitals for infectious diseases like smallpox and tuberculosis, as well as hospitals for the elderly.

19th century medical care

However, due to the social upheaval caused by the industrial revolution, there was a large growth in unemployment and poverty. Sickness became a primary cause of poverty so the Poor Law authorities were forced to develop 'infirmaries' for sick people. Although initially resisted by the state, the number of infirmaries grew very rapidly. At first, in order to access an infirmary, a person had to be a pauper. However, if a person was classified as a pauper then they were also unable to vote. It was not until 1885 that the law which required people to be paupers in order to use the infirmaries was abolished.

There were a few philanthropists and social reformers who tried to provide free medical care for the poor. In 1828, William Marsden, a young surgeon, opened a dispensary for advice and medicines - the 'London General Institution for the Gratuitous Cure of Malignant Diseases'. This four-storey house in one of the poorest parts of the city was conceived as a hospital, to which the only passport should be poverty and disease. Treatment was provided free of charge to any destitute or sick person who asked for it - the demand for his free services was overwhelming. By 1844 his premises, now called the Royal Free Hospital, was treating 30,000 patients a year. Despite consultant medical staff giving their services free of charge, they had to rely on money from legacies, donations, subscriptions and fund-raising events. However, in 1920 it was on the brink of bankruptcy and so forced to ask patients to pay towards their treatment, just like every other voluntary hospital in the country.

Mental Health

Mentally ill people and those with learning disabilities were treated even worse than the poor. They were locked away in large forbidding institutions, not usually for their own benefit, but to keep them away from society. The ruling class was happy to foster the view, especially in the 17th century, that if mad people behaved like animals they should be treated like animals. The Bethlem Royal Hospital (also known as Bedlam) was the world's oldest psychiatric hospital, established in 1330. Conditions were consistently barbaric and the care amounted to little more than restraint - violent or dangerous patients were manacled and chained to the floor or wall and it was infamous for the brutal ill-treatment given to 'inmates'. In 1675 it moved to new buildings outside London's city boundary and by the 18th century people used to go there to watch 'the lunatics'. Entry was free on the first Tuesday of the month and for a penny a person could peer into their cells, view the "show of Bethlehem" and laugh at their behaviour, often of a sexual nature or violent fights. Visitors were permitted to bring long sticks with which to poke and enrage those incarcerated there and in one year alone (1814) there were 96,000 visits. Conditions in institutions like Bedlam were so bad that many patients became worse, not better.

In 1773 a Bill passed the Commons to regulate private 'madhouses' but it was thrown out by the Lords. The following year it became essential to produce a medical certificate confirming insanity before rich people could be locked away. For the wealthy there was also the alternative of being an individual private patient of a doctor or clergyman. However, the rights of poor people were totally disregarded and as they were not a useful commodity to the industrialists, they did not want their healthy workers wasting time caring for their family members who might be mentally ill.

General Practitioners

The first attempt to regulate what we now know as GPs was through the 1815 Apothecaries Act. Apothecary was the historical name for a medical person who formulated and dispensed drugs but they also offered general medical advice and a range of services including minor surgery and midwifery. The Act introduced a compulsory apprenticeship and a formal qualification and required individuals to have instruction in a range of subjects including anatomy, botany, chemistry and physics - in addition to six months' practical hospital experience. It also gave the Society of Apothecaries the right to examine and license apothecaries. Soon a licence from the Society became the commonest qualification among GPs, although by 1840 it was estimated that only about a third of those practising medicine were qualified by examination. They sold medicines to surgeons, physicians as well as patients, but for the working class the cost of treatment and care was often out of their reach. In addition to medicines they would also sell tobacco!

Beginnings of a welfare state?

It was not until the 1911 National Insurance Act that basic medical cover for the working population was given. Access to a doctor was free to (male) workers who earned less than £2 a week but this didn't necessarily cover their wives or children, nor did it cover other workers or those with a better standard of living. Hospitals charged for services, though sometimes poorer people would be reimbursed. Even so, it meant paying for the service in the first place, which most could not afford. The need for free health care was becoming widely recognised but the capitalists were not prepared to support it.

Throughout history, health services and the medical profession have been used as a means of social control. Whether it's forced sterilisation of whole sections of the population or as a gatekeeper to services and benefits, the medical profession has always acted to support the interests of the capitalist class.

The fight against private medicine

By Barbara Humphries

This year marks the 60th anniversary of the National Health Service, once described by Tony Benn as the "the most socialist and most popular" of all institutions in the UK. Supported even by a majority of Tory voters over the years, ardent supporters of privatisation such as Margaret Thatcher, was obliged to assure voters that "The NHS is safe in our hands!"

However it is far from truth to say that the NHS had a smooth birth in July 1948, or that it came about as a result of an all-party consensus, resulting from the experience of World War II, which had exposed existing health care arrangements before 1945 for most of the population as being woefully inadequate. The reality is that the Tories, although claiming to support the principle of a comprehensive free health service, in practice voted against every reading of the NHS Bill. Labour, with a large majority in Parliament after 1945 was successful in winning by 261 to 113 votes on the first reading, so it is doubtful as to whether a Tory government would have set up the NHS. Indeed there was some spectacular opposition to the idea of "state medicine".

‘Medical Gestapo'

Terms like "medical Gestapo" and "medical fuhrer" were bandied about by some of the most Conservative members of the British Medical Association and their political allies. At one point the Daily Mail was reported to have poured scorn on the plan with the headline "No future for us in Britain" and "50,000 doctors say the plan won't work". The implementation of an NHS of course required not only the support of Parliament and the British public but the majority of the medical profession. You can't run a health service without doctors. Pamphlets written by some of the doctors such as, "You and the state doctor" and "Don't be doped" illustrate the level of hostility of some of them.

The situation before 1945 was hopelessly inadequate for most people. Whilst the wealthy had access to the best doctors and hospitals for which they paid, only one third of the population had any kind of health insurance which entitled them to medical care. The Liberal Government in 1913 had introduced a health insurance act, but this was limited to those in certain occupations earning below a certain amount. This excluded women, the majority of whom were not in paid employment in the 1930s, and children. Those receiving poor law relief did have some free health care.

Poor Law relief

Those registered under the state insurance scheme were known as "panel patients" for whom doctors received a capitation fee. Doctors, however topped up their salaries from private patients. Inevitably these received better treatment than "panel patients" as doctors needed the money. If the situation was bad for patients, it was also unsatisfactory for most doctors - Harley Street doctors working in specialist hospitals in London could make a lot of money. Many doctors however would have found themselves in areas of high unemployment, working for very little money - they often carried out home visits for no fees at all, to see a child for example. General practitioners had to buy a practice from a retiring doctor - often borrowing money to do this. If there was inequality in primary health care, the situation with hospital treatment was even worse on a national scale. There were half as many doctors per head of the population in South Wales as in London and in many parts of the country there were no hospitals to speak of.

BMA

The main professional opposition to the setting up of the National Health Service came from the British Medical Association. Why were they so much against a salaried and national health service, which would have given doctors a good salary and more security? Ostensibly, the "leaders of the BMA" claimed that "state medicine" would undermine their professional independence and the sacred 'Hippocratic oath of care' between the doctor and the patient, whereby the doctor's sole judgement would be to act in the best interest of the patient. But what independence was there when many doctors were dependent on the fees of very wealthy patients? It was the money and class interests, which lay behind private medicine which motivated the scale of opposition of the BMA. One of the most outspoken opponents of the National Health Service plan was a physician to eminent patients such as the Royal Family, the leader of the Tory opposition and newspaper proprietors. As Michael Foot, biographer of the architect of the NHS Nye Bevan, wrote "fundamentally it was a class question". Wealthy patrons, who could afford to pay, were getting treatment at the expense of the rest of the community and the argument that this funded a trickle down effect of the best medicine in the world ran fairly hollow. Those of us who have seen the Michael Moore film "Sicko" about private health care in the US, can see that private health care does anything but guarantee medical independence for doctors. In fact many doctors are simply finding ways to avoid life saving treatment for patients in order to save insurance companies money!

Nye Bevan

Nye Bevan, the Minister for Health in the 1945 Labour Government, was a key player in the establishment of the NHS. He was the son of a miner who had died of pneumoconiosis and had seen for himself the lack of health care for working class people. However in his home town of Tredegar, there had existed a working men's medical aid society which gave him the inspiration for the NHS. As a local councillor he had served on the local hospitals committee which had given him an insight into the medical profession - an invaluable aid to dealing with the BMA. In 1945 health was not the priority for Labour - full employment and housing were. The Beveridge Report which set out a plan for a welfare state in Britain, also did not have details for a national health service. It was Bevan's plan. Bevan had been expelled from the Labour Party in the 1930s for his left-wing views. He still faced enemies in the 1945 Labour Cabinet - right-wingers such as Ernest Bevin the Foreign Secretary and Herbert Morrison, former leader of the London County Council. The LCC as a local authority had been one of the largest health authorities in the world but Bevan rejected the idea that local authorities should run the health service. All hospitals would be nationalised, under government authority and it would be funded mainly through taxation, not insurance. This was very radical but he won the backing of the Labour cabinet.

GPs

Resistance from the BMA crumbled during the course of 1948, as by July 5th - the inauguration day for the NHS - 90% of GPs had signed up to work for it. Within 2 months 93% of the population had signed up as patients. Even the Tory press was abandoning its support for the BMA's 'referendum'. Did they expect more concessions? Bevan claimed that he would not "negotiate with the BMA". There were other professional organisations such as the Royal College of Physicians. However important concessions were made in the NHS plan - no doctor would be compelled to join, GPs would receive a capitation allowance per patient as well as a salary, and most critically doctors working for the NHS would be allowed to have private patients who could be treated in NHS hospitals. It was hoped that this would wither away as the NHS could be seen to provide for everyone, but the elimination of private pay beds from NHS hospitals has never been achieved including by successive Labour governments.

The other weakness in the foundation of the health service was that it was a "sickness service" - there was no provision for preventative medicine. Notably public health however had long been in the public domain. As a result of this diseases such as cholera - rampant in the 19th century - had long disappeared. The guarantee of a clean water supply could not be left to private capitalism!

Socialism works!

Nevertheless the NHS remained one of the best and comprehensive healthcare systems in the world - the jewel in the crown for the 1945 Labour Government. It has also been noted that its success indicates that "socialism would work"!