The National Health Service Act of 1946 provided a comprehensive, state-run health service for all British residents, regardless of their ability to pay.
The British National Health Service Act, passed on November 6, 1946, and designed to go into effect on July 5, 1948, was a watershed reform of the nation’s health care system. The legislation, although controversial while in Parliament and especially within its first several years of implementation, eventually received the support of much of the British medical community as well as broad acceptance across partisan lines. The National Health Service (NHS), despite some enduring criticisms, became the most popular feature of the British welfare state.
A commitment by the national government of Great Britain to the principle of medical assistance for the poor extended far back into British history. The Elizabethan Poor Law of 1601, for example, exhibited concern for the physical condition of the destitute. Wholesale reform of the system of poor laws did not occur until poor relief experienced severe stresses brought on by industrialization and urbanization, particularly in the early nineteenth century. The sheer size of the problems of poverty and disease seemed to demand a large-scale solution. The magnitude of poverty and disease were increasingly well documented by a generation of careful gatherers of statistical information such as Seebohm Rowntree and Charles Booth. That a solution should be provided by the national government was argued by a number of groups, including several with a philosophical commitment to state socialism, such as the Fabian Socialists. Advocates of state welfare such as Beatrice Webb often had firsthand experience as social investigators.
In the Victorian era, however, private philanthropy also was advocated as a means of addressing issues of health care and poverty. Although there were tax-supported agencies such as the local poor authorities and medical care facilities such as municipal hospitals, voluntary facilities abounded, with many private charity hospitals having been founded during the first wave of industrialization between 1750 and 1800. Many charitable health care institutions were not only hospitals for the suddenly and critically ill, in the sense of more modern hospitals, but were also designed for the long-term care of certain types of illness or disease. Such voluntary establishments were fitting locations for medical study of unusual cases such as contagious fevers and thus were supported by medical schools and groups of physicians and surgeons. Other private hospitals provided an opportunity for the moral redemption of patients as in the case of hospitals for female sufferers of sexually transmitted diseases.
Several influential Victorian health care reformers such as Sir Henry Burdett saw the future of health care in Great Britain not in nationalization of services but in better coordination between essentially private and localized, but more scientifically managed, facilities. New impetus for reform of systems of public relief, including health care, came on the eve of World War I. Ironically, one argument for state provision of medical services in Great Britain arose from a defense-oriented stance. The health of potential recruits to the British armed services was poor, especially in comparison with German young people, who were much more physically fit as a result of Otto von Bismarck’s state provision of welfare. Britain’s chancellor of the exchequer David Lloyd George was dedicated to the passage of several pieces of legislation that established a minimum standard for physical and financial welfare, including the National Health Insurance Act
A major feature of the National Health Insurance plan was its distribution of payments to employees who were unable to work as a result of illness, through combined contributions from the national government, employers, and employees. That method of financing was widely emulated in other countries, including the United States. Additional pieces of early twentieth century British social welfare legislation, such as old age pensions (which were a precedent for the American social security program), were models for welfare schemes throughout Western Europe.
The 1911 act was not a comprehensive measure, as many middle-class Britons were excluded from its benefits. By the end of the 1930’s, several major criticisms of health care in Great Britain were being expressed by not only the uninsured but also medical professionals and advocates of a more rational organization of state services and health care planning. The health services of the government often overlapped or conflicted with those of private organizations and working people’s groups. The benefits that were available were insufficient to meet the entire medical needs of even those people who were covered. Dental services, for example, were not included. Many groups of persons, including the self-employed, were not eligible for health insurance supported by the state. Particularly during the unemployment and underemployment crises of the 1920’s and 1930’s, gaps in health care provision appeared widespread. In 1930, a British Medical Association report, Proposals for a General Medical Service for the Nation,
World War I and the Great Depression pointed to problems related to health care in Great Britain under the patchwork of offerings after 1911. World War II tested the nation’s health care resources, as well as many other social services, nearly to the breaking point. The heroic efforts of the Emergency Medical Scheme in coordinating the efforts of London hospitals during the Blitz convinced some politicians that state planning of even large medical projects could be successful.
A thorough investigation of state provisions for health care, in tandem with study of other existing state welfare services, was documented in the Beveridge Report
The most important figure in the passage and early implementation of the National Health Service Act was Minister of Health Aneurin Bevan. Bevan’s key problem in securing passage of the legislation and in enlisting support after its passage was the ambivalence of the British medical establishment. Medical professionals, particularly physicians, were committed in principle to the broad provision of health care, especially to the needy, yet they resisted the possibility that day-to-day decisions on medical care might be made by bureaucratic officials. A powerful speaker and effective legislative leader, Bevan and his parliamentary style were characterized as high-handed by some in the medical community.
Between the time of the passage of the act and its implementation about a year and a half later, two polls of the medical profession were taken. The first survey of opinion indicated several fears by doctors, among them that the NHS would diminish competition within medical ranks and that it would require physicians to move to certain areas of the country to provide health care. Despite his personal unpopularity with physicians, Bevan reassured health care providers that within the NHS they would have considerable scope for choosing how they should be remunerated and would be allowed to retain private patients. When a second poll was conducted, in the spring of 1948, opposition to the NHS within the medical profession was significantly milder. By the middle of the 1960’s, more than 98 percent of the general practitioners in Great Britain were associated with the NHS and only 5 percent of the population availed themselves of the right to consult private physicians.
The NHS legislation itself was praised within a number of quarters as comprehensive, necessary, and well written. The NHS appeared less a measure associated with socialism (after the massive state planning of World War II made state coordination and even ownership a patriotic feature) than a method of rationalizing and coordinating the provision of health care services. Such rationalization already had existed on a more piecemeal basis.
In the earliest years of the operation of the NHS, it faced a pent-up demand for medical services, especially as a result of the recent war, which had caused many people to forgo nonemergency treatment. The NHS was overwhelmed, for example, with demands for dental care, which previously had not been covered as a health care service. In its first years it had to revise scales for the payment of dental services as well as trying to recruit more dentists. Despite a huge cost overrun of about one-third of estimated expenses in fiscal year 1949, even the Conservative opponents of Labour legislation extending NHS funding decided not to voice their misgivings publicly. The NHS did begin to make nominal charges, however, for prescriptions, eyeglasses, and dentures.
The NHS was successful and popular largely because of its inclusion of a number of people who previously had been outside any health insurance scheme. Less than half the British population had had any form of health insurance prior to 1946. In the 1950’s and 1960’s, major reports from Parliament and by the medical profession indicated general approval by physicians and the public of the structure, goals, and administration of the NHS.
Several issues associated with the NHS remained divisive, including the question of the amount and type of reimbursement for participating physicians and the lack of commitment to building new hospital facilities and clinics. The economic downturn in Great Britain in the 1970’s forced a reassessment of the NHS’s planning mechanisms. Despite a 1974 reorganization, the NHS continued to struggle with rapidly escalating medical costs and the problems that increased costs caused in apportioning health care. Although the Conservative government of Prime Minister Margaret Thatcher recommended cutting social services, the number of physicians and nurses employed by the NHS increased, as did governmental expenditures on health during the Thatcher years.
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Eckstein, Harry. The English Health Service. Cambridge, Mass.: Harvard University Press, 1964. A discussion of the historical origins of the NHS, with emphasis on the twentieth century. Argues that the basis of the NHS lay in a call for rationalization, rather than a wish for socialism or statism, by the Labour Party. -
Fox, Daniel M. Health Policies, Health Politics: The British and American Experience, 1911-1965. Princeton, N.J.: Princeton University Press, 1986. A comparative study of health care politics in Great Britain and the United States, critical of the idea that the United States ought to follow the British example. Contains a detailed bibliographic essay. -
Prochaska, F. K. Philanthropy and the Hospitals of London: The King’s Fund, 1897-1990. New York: Oxford University Press, 1992. Written with the aim of establishing the importance of voluntarism in British health care. Prochaska reviews the history of the King’s Fund, a major source of funding for London hospitals in the early twentieth century, noting its close connections with monarchy and its success despite the nationalization of health services. -
Sked, Alan, and Chris Cook. Post-War Britain: A Political History. 4th ed. New York: Penguin Books, 1993. A survey of modern British politics, including discussions about social services and the NHS that characterized periods of economic stress. Argues for the efficiency of the NHS as an institution, especially in contrast with health care systems in other nations. -
Southwick, Arthur F. The Doctor, the Hospital, and the Patient in England: Rights and Responsibilities Under National Health Service. Ann Arbor: Bureau of Business Research, Graduate School of Business Administration, University of Michigan, 1967. A discussion of the legal basis of the NHS, the statutory and judicially imposed obligations on medical and administrative personnel, and the legal rights of patients. -
Webster, Charles. The National Health Service: A Political History. 2d ed. New York: Oxford University Press, 2002. A history of the National Health Service in Great Britain from the time of its start in 1948 to the attempts at reform near the end of the century.
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