Aneurin Bevan’s long shadow over 70 years of the British National Health Service

Introduction

The years approaching the 70th anniversary of the British National Health Service (NHS) (https://www.england.nhs.uk/nhs70/) have seen some re-assessment of the role of the Labour party in general, and Minister of Health, Aneurin Bevan in particular, in the creation of the NHS. According to Hugh Byrne, ¹ a NHS hospital consultant in London, it is great Labour party myth that before Aneurin Bevan in 1948, nothing resembling the health service that we have today existed, as previous reforms included the 1906 Liberal government’s initiatives, the Beveridge Report of 1942 and 1944 White Paper ‘A National Health Service’ from the Conservative Minister of Health Sir Henry Willink, in the wartime Coalition Government, which called for the creation of a free universal healthcare system. He concludes that ‘Bevan was neither its father nor the midwife – he was at best an obstetrician, arriving when much of the hard work was done and taking most of the glory’. Health Secretary Jeremy Hunt told the 2017 Conservative Party Conference that ‘Nye Bevan deserves credit for founding the NHS in 1948. But that wasn’t him or indeed any Labour minister’. He pointed to the importance of the Conservative Health Minister, Sir Henry Willink, whose, 1944 White Paper announced the setting up of the NHS. ²

However, these issues are far from new. In the 1946 Parliamentary Debate, ³ the Conservatives stressed that they were in favour of a free and comprehensive NHS and that they voted against Bevan’s Bill because that they differed on means while agreeing on ends. This claim has been repeated in many of the NHS debates since then (e.g. Minister of Health, Derek Walker-Smith, ⁴ c1400; Secretary of State, John Moore, ⁵ c916; Shadow Health Secretary, Andrew Lansley, ⁶ c216). Labour politician, and Bevan’s biographer, Michael Foot ⁷ (1975) mischievously suggested that ‘Future generations may learn that Aneurin Bevan did not make the NHS; he inherited it from that much underrated social visionary Sir Henry Willink’. In an article for the 50th anniversary of the NHS, conservative politician Michael Portillo ⁸ wrote that following the war, Britain would almost certainly have created a national health service without Aneurin Bevan, and even without a Labour government. However, it is clear that a Conservative Health Service would have differed from Bevan’s NHS in fundamental ways.^9,10

It is clear that Bevan casts a long shadow over the NHS. Bevan headed the Health Service Journal’s ‘Diamond’ list of the most important people in the 60 years of the NHS (HSJ, 30 June 2008). According to Berridge, ¹¹ invoking Nye Bevan is a cottage industry among health ministers. Portillo (2008) wrote that few politicians are as well, or as affectionately, remembered 50 years on as Bevan, and rarely is a politician’s name so inextricably linked to a particular achievement as his is to the creation of the NHS. Bevan has a Commission (www.bevancommission.org/), a Foundation (www.bevanfoundation.org), a website (www.nyebevan.org.uk/), as well as a number of biographies.

Berridge used the term ‘history as invocation’. ¹¹ We can see that Bevan can be invoked in different ways. Put another way, different Bevans cast a variety of shadows. We now present four invocations or different shadows, before concluding by suggesting a new invocation for the 70th anniversary of the service.

Bevan as the embodiment of the NHS

In this sense, with little further explanation, Bevan is equated with the NHS, or almost reified: for example, as in the ‘end of Bevan’s vision’ ¹² (although Bevan does not feature beyond the title). However, there are a number of problems with this approach. First, it is not clear if Bevan’s NHS is associated with his values or principles, or the structure or the institutional bricks and mortar that build on these principles to form the 1948 NHS. After many years of debate, Bevan’s principles are difficult to pin down as they are multiple, vague and sometimes in tension. ⁹ As Portillo ⁸ put it, Bevan was prepared to make so many concessions because he cared about a central principle, of a free health service available to all, funded from taxation, and was willing to cede territory elsewhere to protect it. Attempting to piece these concerns together from sources such as Cabinet Papers, Hansard Debates (especially, 1946, ³ Bevan’s resignation speech in 1951 ¹³ and the 10th Anniversary Speech of 1958), ⁴ and ‘In Place of Fear’ ¹⁴ broadly suggest the comprehensive and redistributive principles. The comprehensive principle is associated with a number of evocative phrases in Bevan; for example, ‘No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means’ (p. 100) and ‘A free health service is pure Socialism’ (p. 106). ¹⁴ The redistributive principle suggests that the NHS should be financed by taxation (rather than flat rate or ‘poll tax’ contributions) or charges. However, there are many other ways of interpreting the ‘comprehensive’ and ‘redistributive’ principles, let alone other possible principles such as ‘universal’ or ‘equal’. ⁹

Second, the original 1948 structure was a compromise, shaped by path dependency and the ‘art of the possible’, including some defects and concessions such as ‘pay beds’, GPs paid by capitation, Merit Awards, and the ‘democratic deficit’, some of which were viewed as ‘repugnant’ by the Labour left including Bevan himself. ¹⁰ For example, Bevan stated that ‘election is a better principle than selection’, and considered the possibility that the NHS could be run by a reformed local government. ¹⁴

Third, it is more difficult to see ‘Bevan’s NHS’ as we move further from 1948. For example, it can be argued that the principle of a free NHS was either still born (with certain charges allowed) or died in infancy (for example, in charges by the 1950 Labour Government, which led to Bevan’s resignation from the Cabinet). Put another way, the term ‘Bye Bye Bevan’ ¹⁵ could arguably have been used at many points during the NHS’s history. In his resignation speech, Bevan termed the cuts to the NHS budget and the imposition of charges as ‘mutilating’ the NHS and the ‘arithmetic of Bedlam’. ¹³ To adapt a phrase from Bevan’s fellow Welshman Dylan Thomas, after the first breach of principle, there is no other.

Bevan as rhetoric

In a speech in Manchester on 4 July 1948, Bevan stated that

The eyes of the world are turning to Great Britain. We now have the moral leadership of the world and before many years we shall have people coming here as to a modern Mecca, learning from us in the twentieth century as they learned from us in the seventeenth century.

The next day, on his visit to Park Hospital on the ‘Appointed Day’, he described the birth of the NHS as ‘the most civilised step any country has ever taken’ (http://www.nyebevan.org.uk/quotes/). Ten years later, he made a similar claim that the NHS was ‘regarded all over the world as the most civilised achievement of modern Government’ (c 1398). ⁴ This has led to the NHS being labelled on countless occasions as ‘the best in the world’ or ‘the envy of the world’. However, the British public no longer believes that, and neither should it. ¹⁶ It is important to differentiate the ideal of the NHS or its principles with its sometimes flawed performance.

Bevan as trust

In 1948, Bevan persuaded Prime Minister Clement Attlee that the NHS must be regarded as a party rather than a national triumph. Claims that Labour created the NHS, and the Conservatives voted against it convey the message that you can’t trust the Tories on the NHS, show that the NHS is a ‘Labour property’ and provide a strong electoral card, which continue to resonate with the public. ⁸ Bevan (c1386) ⁴ stated that Conservative Members voted against the NHS on every conceivable occasion and for every conceivable reason. This has been repeated many times, for example, by Shadow Health Secretary, Robin Cook, ⁵ c908; former Labour Leader and Bevan biographer, Michael Foot, ⁵ c922–3; Health Secretary, Alan Johnson, ⁶ c226). However, by the same logic, you can’t trust the medical profession on the NHS, as the BMA twice voted against serving in Bevan’s NHS in the 1940s.

In 1997 Labour claimed just before the General Election that there were ‘14 days to save the NHS’. Labour Health Secretary, Frank Dobson ¹⁷ (c796) presented his

proposals to renew and modernise the national health service, which our party founded … This Government were elected to save the heath service… Our plan is to give our country a modern and dependable health service that is once again the envy of the world.

Bevan as reassurance

The politics of reassurance saw New Labour anchoring itself in Old Labour. The White Paper ‘The NHS. Modern. Dependable’ ¹⁸ contained a Foreword by Labour Prime Minister Tony Blair that stated that ‘creating the NHS was the greatest act of modernisation ever achieved by a Labour Government’. Berridge notes that Health Secretary Alan Milburn’s speeches in about 2003 had many references to how Bevan’s aspirations were still needed, but needed modernisation. ¹¹ In one sense, this has similarities with the Conservative argument about means and ends: Old Labour Bevanite principles were to be delivered by New Labour means. In a ‘Nixon goes to China’ fashion,

Labour secretaries of state have got away with introducing private-sector providers into the NHS on a scale which would have led the Labour Party onto the streets in demonstrations if a Conservative government had ever tried it. In the late 1980s I would have said it is politically impossible to do what we are now doing. (Former Conservative Health Secretary, Ken Clarke) ¹⁶

Conclusions

Aneurin Bevan has rightly cast his long shadow over the 70 years of the NHS. However, it is important to recognise the different reference points of Bevan as the embodiment of the NHS; Bevan as rhetoric; Bevan as trust; and Bevan as reassurance have been used by different people at different times for different purposes. For example, Bevan as trust tends to represent an offensive political discourse used by politicians claiming the mantle of Old Labour: you can trust the party that created the NHS, but the Conservatives voted against the NHS. On the other hand, Bevan as reassurance tends to represent a defensive political discourse by New Labour: don’t worry if we are changing the NHS as we belong to the same party as Bevan. The other two invocations of Bevan as the embodiment of the NHS and Bevan as rhetoric are more problematic in academic debates as they tend to confuse or even prevent any rational argument on the NHS: how can anyone argue against Nye’s vision? However, there is one surprising omission in the invocation of Bevan in academic circles. The comparative health systems literature often contrasts ‘Beveridge’ and ‘Bismarck’ systems, with the Beveridge type defined as a tax-based national health system that ensures more equitable access, as it is universal in coverage and tends to minimise the problems of risk selection and cost shifting by healthcare providers and insurers. ¹⁹ This terminology is puzzling in that in comparison to Bevan, Beveridge had a very limited role in determining the structure of the British NHS, essentially only arguing that a ‘comprehensive’ service was a necessary assumption in order to make his social insurance system work. As a present to the NHS on its 70th birthday, perhaps it is time to rename this type as a ‘Bevan’ system?