July marks the 75th anniversary of the National Health Service. It remains the British working class’s greatest gain – but only just. The NHS is more fragile today than any time since its foundation. Jon Dale looks at the birth of the NHS and where it is heading.
Few now remember life before the NHS. Until 4 July 1948, every visit to a GP or hospital had to be paid for, unless covered by insurance or charity. Workers paid National Insurance but their dependents weren’t covered. Many families couldn’t afford private insurance, weren’t poor enough for ‘charity’, so suffered without health care.
A century earlier, Friedrich Engels described the terrible health of working-class families in his book The Condition of the Working Class in England (see Socialism Today No.248, May 2021). With crowding in insanitary slums, polluted air, and contaminated food and water, they died younger than before the industrial revolution. Cholera, typhus, smallpox and other epidemics regularly swept the country. Even wealthy capitalist families were not immune.
Nineteenth century progress mostly stemmed from public health reforms as capitalism eventually invested in rubbish collection, factory inspection, vaccination and other measures. Confident in the long-term future of their system, Victorian capitalists built sewers and water pumping stations that still survive today. They needed to protect their own families, reduce loss of production from workers’ ill-health, and produce young men fit to defend their empire from other imperialist powers.
Working class growth, developing trade unions, and demands for the right to vote added to pressure for improved living standards and health. Strikes greatly increased from the late nineteenth century until the first world war began. Conservative and Liberal parties represented different wings of the ruling class, pushing trade unions and socialists to form the Labour Representation Committee – becoming the Labour Party in 1906.
Some ruling-class members understood limited reforms could cut across working-class support for socialist change, although others opposed any concessions. The Liberal government introduced National Insurance in 1911. Workers paying their ‘stamp’ could see a GP and get prescriptions without paying, but their families weren’t covered.
War and revolution
The outbreak of war in 1914 only temporarily interrupted the strike wave. Seven times more strike days took place in 1919 than 1918. Workers had had enough of poverty and the horrors of the trenches. Troops and tanks were sent into Glasgow, during a Clydeside general strike, and to Liverpool, when gunboats were also sent during a police strike. Sixty thousand Belfast engineering workers struck for a month.
The Labour Party’s 1918 constitution adopted the socialist Clause Four, calling for “common ownership of the means of production, distribution, and exchange”. Terrified that Russia’s 1917 revolution could spread, Liberal prime minister Lloyd George promised “a land fit for heroes” – without need for revolution.
His government appointed Lord Dawson, a London Hospital doctor, to chair a commission on health system improvement. He was influenced by the new Soviet Union’s ground-breaking progress.
Its Commissariat of Public Health was established in July 1918 to provide a single unified medical service, with state responsibility to protect the health of workers. Medicines were to be freely available. There were plans outlining the organisation of free medical treatment, controlled by workers. Extensive social insurance provision, self-managed by workers with the costs on industry, was to cover work incapacity due to illness, injury, old age, occupational disease, maternity, child labour, orphanage, and unemployment. GPs were to be employed in local polyclinics, with more specialised care in hospitals. But the isolation of the poverty-stricken war-torn workers’ state delayed these advances. Workers’ control ended as Stalinist bureaucracy gained power.
Dawson reported in 1920 that the British healthcare system was inadequate, deteriorating in quality and quantity. He proposed a watered-down version of the plans of the State Medical Services Association, a radical doctors’ group. He recommended replacing disorganised private healthcare with Primary Health Centres staffed by GPs, coordination between these and hospitals, and teaching hospitals for a defined geographical area.
But an NHS was not founded in 1920. Pressure for reforms to avoid revolution lifted after right-wing union leaders called off promised rail and transport solidarity strikes against miners’ pay cuts. Vicious public spending cuts were introduced. Dawson’s plan was shelved.
Poverty and planning
The working class soon recovered. In 1925 a general strike was again threatened against miners’ pay cuts. The Conservative government bought time to prepare to defeat it. Royal Commissions, examining the coal industry and national health insurance, were set up. Extending medical services cover to workers’ dependents was recommended.
The Trades Union Congress (TUC) leaders did nothing to plan the general strike, while the government prepared hard behind the Royal Commissions’ cover. Despite the 1926 general strike growing stronger daily, TUC leaders called it off after nine days with nothing gained. The Royal Commission’s recommendations were then scrapped. A national health service was not founded in 1926.
The Great Depression followed the 1929 stock market crash. Unemployment reached twenty percent – 75% in the worst-hit areas. Half the claimants were denied meagre benefits under the humiliating Means Test. Avis Hutt, a radical nurse in London’s East End in the 1930s, recorded a large proportion of the illnesses she treated were caused by patients actively avoiding hospital care “because of the financial thing”. Workers were afraid to take days off work if ill or injured. They could not afford to lose pay and feared losing their job.
The Workers’ Birth Control Group argued: “It’s four times more dangerous to bear a child than to go down a mine”. At least one third of the population could not afford a healthy diet. Over 80% of children in London and Durham showed symptoms of rickets, easily preventable with Vitamin D. Scurvy – another vitamin-deficiency disease – and tuberculosis were rife in the poorest areas.
At the outbreak of war in 1939 existing services were completely inadequate to cope with military and civilian casualties and maintain workers for factory and food production. ‘Voluntary’ hospitals were mostly bankrupt. Middle-class people, including health workers, were shocked by Dickensian workhouse conditions in many local authority hospitals.
The government created the Emergency Medical Service, planning hospital services for the first time. Beds and staff were counted, with staff able to move between different hospitals according to need. Public health laboratories, regional blood transfusion depots, ambulance and transport services were developed. Privately owned companies had not provided these, with no profit to be made. The advantages of planning were clear.
Ironically, health improved with wartime food rationing. Infant mortality fell and life expectancy rose – excluding deaths from military causes. Everyone had access to a basic diet with enough vitamins. Prices were controlled. Pregnant women got subsidised milk. Two thousand local authority restaurants served basic three-course meals for nine pence (9d – £1.75 at today’s prices).
The Beveridge report
The capitalist class lacked confidence that they had mass support during the war. Calls to defend ‘king and country’ and ‘the British way of life’ failed to inspire workers after the hungry thirties. The army’s ‘Morale Committee’ observed: “The nearest thing that the ordinary soldier has to a conscious ‘war aim’ is to make sure that he will have a home and a job and what he regards as a fair deal after the war”.
More far-sighted government ministers understood they had to offer real change. Sir William Beveridge was commissioned to produce plans for social welfare. Massive queues formed to buy his ‘Report on Social and Allied Services’, published in late 1942. Within two weeks, nine out of ten adults wanted it implemented. Beveridge proposed universal social security, with unemployment and sickness benefits, family allowances, pensions and a national health service.
The Daily Telegraph denounced the plan as “halfway to Moscow”. But the Manchester Guardian warned: “Parliament must never forget the enormous psychological effect the Beveridge Plan has produced in the country. There was no parallel to it in the last war, even with ‘homes for heroes’ and if the people’s hopes should be dissolved in cynicism the consequences will be revolutionary in a very different sense from that of Sir William Beveridge’s mild ‘British Revolution’.” Tory MP Quentin Hogg warned fellow Tories, “if you do not give the people social reform, they are going to give you social revolution”.
Labour’s 1945 election manifesto stated, “The Labour Party is a Socialist Party and proud of it… the best health services should be available free for all. Money must no longer be the passport to the best treatment”. Only the name is shared by Starmer’s Labour!
Winning a huge majority put pressure on to ensure it delivered. Former Welsh miner Aneurin Bevan became Minister of Health. He was influenced by his home town’s miners’ mutual aid. Workers contributed a penny a week to Tredegar Medical Society, in return receiving medical care free at the point of use and other benefits, covering 95% of local people.
Bevan made this government’s responsibility, also nationalising 3,000 voluntary and municipal hospitals. He proposed salaried GPs more evenly distributed to poorer areas, with health centres, free medical and dental consultations, free treatments, free opticians’ examinations and glasses.
Facing opposition from the British Medical Association leadership, Bevan conceded NHS consultants could keep beds for private practice in NHS hospitals. GPs could remain self-employed, contracting their services to the NHS. There was no local democratic or workers’ control. Nevertheless, a few councillors on local hospital boards were more than exists today.
Capitalist concessions
The 1945 Labour government’s biggest concession was leaving capitalism in place. Only bankrupt vital industries and hospitals were nationalised. Most of the economy remained privately owned, concentrated into giant monopolies as years passed.
Profitable pharmaceutical and medical supplies industries have grown enormously as medical research – often publicly funded – progressed. The total cost of medicines and medical devices in England was £17.8 billion in 2021/2022 – nine percent of Department of Health and Social Care spending. A socialist government would nationalise these industries, with compensation only where genuinely needed, integrating them with the NHS. It would appeal to workers across the world to take similar measures, as these are global industries.
It was not long before big business pushed back against reforms it had been forced to give. Labour introduced charges for dentures and glasses in 1951, prompting Bevan’s resignation from government. The Tories brought in prescription charges in 1952 which Labour abolished in 1965, before reintroducing them in 1968 during a currency crisis.
But the Tories did not seriously threaten the NHS during its first thirty years. It was incredibly popular, and with low unemployment during the post-war economic boom, it helped to keep workers fit. Instead, the 1950s Tory government doubled National Insurance and did not invest in needed new hospitals, health centres and community services. Pay remained low resulting in staff shortages, partly filled by overseas workers. A national NHS strike by low-paid ancillary staff took place after the first post-war global recession in 1973.
Workers’ militancy rose in the early 1970s with many national strikes, a call – under great pressure from below – by TUC leaders for a 24-hour general strike against the jailing of dockers’ shop stewards, and the ousting of the Tory government during the 1974 miners’ strike.
Between 1975 and 1978 the Labour government, supported by union leaders, achieved what the Tories could not and held pay down. Inflation reached 27% in 1976 with NHS workers suffering a 19% drop in real pay, pushing many even deeper into poverty. They fought back with a national demonstration and strikes in early 1979, alongside council workers.
Thatcherism
Margaret Thatcher won the election that May, determined to weaken unions and reverse public ownership, rolling back what she called the “frontiers of socialism”. The 1980 global recession, triggered by a sharp rise in oil prices following the Iranian revolution, led sections of the capitalist class to turn from the post-war acceptance of a ‘welfare state’, to cuts to public services, privatisation and attacks on trade union rights, in an attempt to restore profitability at the expense of the working class and the historic social gains they had won. Chilean dictator General Augusto Pinochet was the trail-blazer, with the US president Ronald Reagan and Thatcher the most determined following this new path.
In 1982 her cabinet discussed compulsory private medical insurance and more NHS charges, according to papers released in 2012. The discussion was leaked and, under pressure from most of her cabinet, Thatcher retreated. Although ahead in opinion polls months after the Falklands/Malvinas war, Tory ministers were not confident of keeping support if they attacked NHS core principles. Labour’s left wing – including Militant, forerunner of the Socialist Party – was still strong, and the prospect of a left Labour government under working-class pressure could not be ruled out.
“Of course we welcome the growth of private health insurance”, Thatcher then told the 1982 Tory conference, but was forced to add: “There is no contradiction between that and supporting the National Health Service. It brings in more money, it helps to reduce the waiting lists, and it stimulates new treatments and techniques. But let me make one thing absolutely clear. The National Health Service is safe with us”.
Ferdinand Mount, her policy adviser, then proposed freezing rather than directly cutting public spending, tax relief for private medical insurance, and opening ancillary services – cleaning, laundry, catering – to privatisation. The government claimed to be making the NHS more ‘business-like’, supposedly increasing efficiency. Privatisation crept in the back door, rather than marching through the front door with flags and drums. Hospital infections increased.
John Major’s Tory government’s NHS and Community Care Act (1991) introduced an internal market with a ‘purchaser-provider split’, forming NHS trusts, adding a corporate management structure, and the principle of competition. In 1992, the Private Finance Initiative (PFI) began, saddling new hospital building with expensive debt and guaranteeing corporations big profits.
Creeping privatisation
During its years in opposition, Labour’s right-wing leaders transformed it into a capitalist party, shutting down trade unions’ influence, expelling socialists, particularly Militant.
The collapse of the Soviet Union and the ideological ‘victory’ of capitalism reinforced this process, with Tony Blair abolishing Labour’s socialist Clause Four. In government, after 1997, New Labour escalated PFI. They contracted out routine surgery, diagnostic tests, laboratories, mental health services and more, signing a ‘Concordat’ with private health companies in 2000.
Foundation Trusts were created in 2003, described by Health Secretary Alan Milburn, as a “middle ground within public service and between state-run public and shareholder-led private structures…”. These reinforced the trend towards commercialisation, selling off publicly-owned land, closing ‘uneconomic’ services and hospitals. Nevertheless, strong community opposition, with big local demonstrations and rallies, often delayed or halted cuts.
Milburn, Patricia Hewitt and other Labour health ministers moved to lucrative jobs in private health companies after Labour lost the 2010 election.
Jeremy Hunt, now Tory chancellor, in 2005 proposed “breaking down barriers between private and public provision, in effect denationalising the provision of health care in Britain”.
Commentators noted that the Tory-Liberal Democrat coalition’s 2012 Health and Social Care Act “proposals do represent, to a great extent, an evolution of the NHS market, and do share some similarities with New Labour’s market reforms”. Tory Health Secretary Andrew Lansley wanted more market competition between Foundation Trusts and private health companies.
Trusts were regulated by Monitor – set up by Blair’s Labour. Of its 337 staff, only 21 had an NHS operational background and only seven a clinical background. Its chair, David Bennett, had been a senior partner in McKinsey’s management consultancy company. He said: “We did it in gas, we did it in power, we did it in telecoms. We’ve done it in rail, we’ve done it in water. So, there is 20 years of taking on monopolistic monolithic markets and providers and exposing them to economic regulation”. A speech that has not aged well!
By 2016-2017, 7.7% of Department of Health spending went to the private sector, compared to 2.8% in 2006-2007. Big business has taken over more since then, always shielding behind the NHS logo.
Simon Stevens, NHS Chief Executive, ex-Blair health adviser and ex-director of US corporation UnitedHealth, committed to finding £22 billion ‘efficiency savings’ between 2015-2020. Years of low funding increases, which mythical ‘savings’ could not plug, left the NHS perilously weakened by shortages of staff, beds, and service when Covid-19 struck in 2020.
The current crisis
The situation now is a desperate vicious cycle. An estimated 10,000 staff in England and 2,600 in Scotland are off work with Long Covid. Overloaded staff in unsafe conditions led to half-a-million working days lost in January due to mental illness. Waiting lists lengthen as staff fall sick, making patients more seriously ill, disabled, and needing more complex treatment.
The Health and Care Act (2021) accelerated money flowing into private companies. Forty-two US-style Integrated Care Boards (ICBs) now control local NHS spending. Contracts for prescriptions management have been awarded to companies like Optum, owned by UnitedHealth. Rather than selling insulin for $20 (although it cost less than $2 to produce) as manufacturers did in the 1990s, in Arkansas Optum charged $300-700 in recent years.
An Optum subsidiary bought EMIS in 2022 – a digital records system widely used in general practice, pharmacies and community care. Controlling health data is a potential goldmine for profit-seeking corporations.
Companies accredited to provide procurement services to integrated care boards control multi-million pound local NHS budgets. Many have already failed to deliver decent services or been found to have overcharged. From July to December 2022, 2,000 private companies received over £2 billion. The biggest winner, Circle Health Group Ltd, received over £116 million despite its failed takeover of Hinchingbrooke Hospital. Circle is now owned by Centene, a $135 billion a year US health insurance and ‘managed healthcare’ corporation.
‘Managed healthcare’ is “intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay… selective contracting with health care providers; and the intensive management of high-cost health care cases”. (US National Library of Medicine)
This leads to treatments on the NHS being withdrawn but ‘increased beneficiary cost-sharing’ – the patient pays for private treatment – is always an alternative. ‘Selective contracting’ will funnel more NHS funds into big-business coffers.
Thirty-nine percent of NHS hospital eye procedures – mostly cataract operations – and 31% of orthopaedic procedures, particularly hip and knee replacements, were carried out in private hospitals in 2022. With more private hospitals in wealthier areas, those in poorer areas find they have to wait even longer.
The working class needs its own party to fight for the NHS. Labour’s health spokesperson, Wes Streeting said: “Labour would use the spare capacity in the private sector to get patients seen faster, free at the point of use. The last Labour government showed this is an effective tool in bringing down NHS waiting lists”.
He’d pump NHS money into private hospitals already benefiting from an £8 billion subsidy, as they contribute nothing to training the 17,500 doctors working in them. Staff shortages, which private hospitals worsen, are the main reason for NHS waiting lists. Their facilities should be taken over and integrated into the rest of the NHS, without compensation unless there is genuine need.
The decades before 1948 and the 75 years since show decent healthcare for all needs working-class action. When capitalism felt under threat from an organised working class it granted reforms, only to try removing them when pressure eased or their economy hit new crises. The NHS will not survive without action on a mass scale, led by trade unions, and a new political vehicle for the working class, a new mass workers’ party.
As well as massively increased NHS funding, ending privatisation and scrapping PFI debt, it must be democratically run by health workers and the community as a whole, planning to meet needs and integrated with social care.
A socialist society would build decent homes, ensure good working conditions, shorter hours and end low pay. Everyone could enjoy a good diet, access to leisure facilities and community centres. Cutting air pollution with green energy and free public transport and other measures would all prevent much physical and mental illness – as vital as treating them.
Dental crisis a warning for the future
Dental services are a grim warning for the future of general practice and hospital care, if current trends continue. In 1948, Britain’s dental health was worse than in defeated and occupied Germany. Three quarters of adults only had false teeth. After dental care became free there was a huge increase in demand. From 15-20 patients a day, dentists were seeing over 100.
But in 2022, over eleven million people’s dentistry need was unmet – a quarter of adults in England. NHS dentists have almost vanished from many areas. It’s getting worse – 74% of dentists intend to reduce the amount of NHS work they do, with 42% likely to change career or retire early due to inadequate NHS funding. (British Dental Association, 6 March 2023)
The government plans to cut a further 10% off England’s dentistry budget to plug other holes in NHS spending. “This will push dedicated NHS practices to the wall or to the private sector and leave whole communities with no options”, says the BDA.
Private health care is growing, not only in dentistry. Many are driven to it unable to bear relentless pain, fearing worsening disability or loss of work. Five hundred and fifty-one people have gone blind or had their eyesight irreparably damaged since 2019, due to long waiting lists for specialist appointments and treatment.
Over seven million people are waiting for scans and treatment in England. Lengthening hospital waiting lists are leading to record numbers of private patients – 272,000 in the UK used their own money in 2022 (199,000 in 2019 pre-pandemic). Including those covered by insurance, a total of 820,000 paid for private hospital care last year.
Despite grim news reported almost daily, the NHS still has enormous public support. Ninety percent agree the NHS should remain free at the point of delivery; 89% agree the NHS should provide a comprehensive service to everyone; and 84% that it should be funded by taxation. But less than two in three expect these will still apply in five years. (The Health Foundation opinion poll, November 2022)
If the NHS is to survive, lessons from history need to be studied by trade unionists, NHS campaigners and socialists.
