Agnes Arnold-Forster and Caitjan Gainty | Renewal 29/4
The NHS occupies a peculiar position in the British political imagination. The devotion it inspires is unusual by both international and historical standards. This privileging of sentiment over scrutiny is dangerous; it obscures structural failings and precludes progressive reform.
In 2018, to mark the hundredth anniversary of the Spanish Flu pandemic, Public Health England told audiences that the tragedy of a century ago was entirely a thing of the past. They confidently asserted that, together, the government, the NHS and Public Health England ‘stand equipped and ready to respond with a plan in place for every stage of a future outbreak’, promising that the plan would, ‘ensure that minimal disruption of daily society occurs whilst we protect the health of the nation’.1
Fast forward to 2021, as we consider the damage already done by the Covid-19 pandemic and what its future may still hold, it is clear that the plans Public Health England touted in 2018 were seriously flawed. As of August 2021, nearly 130,000 people have died from Covid-19 in the UK, and still counting. This is a statistic that puts the country in the top 10 of worldwide Covid mortality tables. The UK has not been alone in its general unpreparedness for pandemic, nor has it been exceptional in its inability to predict how the course of the pandemic would run. The nations of the global north are well-represented in the mortality tables, and the translation of (sometimes conflicting) scientific data into the real world, real-life application of policy has been a notable problem the world over. Like virtually all of the pandemic preparedness plans of the world’s wealthier nations, the UK’s was based on flu. Public Health England’s Spanish Flu retrospective, oozing with what has turned out to be misplaced confidence, is not, then, a sign of a uniquely British failing, but a sign of a wider inability to even contemplate, much less rationally prepare for, the appearance of other non-flu viruses. With perhaps some minor exceptions, it is not an overstatement to say that the pandemic – whether by haplessness, by poor planning, or even by outright denial – has not been handled well by anyone.
But what is unusual about the British situation is the extent to which, at least in the public mind, the National Health Service has been given a free pass in terms of its responsibility for these failings. Public Health England has been effectively abolished on account of its role in pandemic unpreparedness, with its end date set as October 2021. The British government has taken at least some of its share of flack as well. But rather than hold the NHS as also responsible, we have instead celebrated its workers as our heroes, early on in the pandemic dutifully clapping for them every Thursday evening – as though to compensate for the repeated exposure to a deadly virus that the NHS’s own poor planning had forced onto them, not least in the way of meagre supplies of personal protective equipment.
The past eighteen months have seen the strengthening of a not unfamiliar rhetoric. As Boris Johnson put it, the NHS is a ‘national asset’: one that will allow us to ‘defeat this coronavirus’. Why? Not because of its preparedness or ability to mobilise quickly. No, it is for the far hazier reasons that the ‘NHS [i]s the beating heart of this country’. ‘It is unconquerable’ and ‘powered by love’.2 That is a bizarre thing to say about a health service. It is also no mere artefact of the specialness of our pandemic times. Instead, it is well-worn rhetorical territory for British politicians and their voters. Even in more regular circumstances, there is probably no other British institution that is supposed to better encapsulate the British spirit than the – or ‘our’ as it is personalised – NHS. It is difficult to think of any other country that has burdened its health care delivery system with as much emotional and historical import as has Britain. While doctors and nurses are nearly universally lauded professionals, the place the NHS – the entire health system – occupies in the British national imagination is unparalleled abroad, even in countries that have comparable healthcare systems that are free at the point of use, tax-funded, and generally regarded as more effective and efficient, as in Denmark, New Zealand and Canada, for example.
The current view of the NHS is not only very different from the way that health systems are perceived around the world; it is also a far cry from the way the NHS was perceived at its inception over seventy years ago. In the 1940s, after all, the NHS was far from unique. It was one example among many of the healthcare rationalisation programmes that emerged over the 1930s and 1940s, to combat economic depression and, later, the ravages of war. The emotional relationship between the British public and its health service did not, then, emerge fully formed in July 1948. So why do we tend to project back the foundation of the NHS as a singular sign of Britain as the world-leading healthcare exception? And what are the perils of such a historical positioning?
In this article, we chart the historical rise of the NHS to its current vaunted position as the country’s ‘beating heart’, and explore what has been lost and misunderstood in the development of this exceptional, sentimentalist devotion. This is not a critique of the health service itself. It offers instead a reconsideration of how and why our devotion to the NHS came to be. We argue that this reconsideration might offer a basis from which a new and more constructive relationship with our health service might emerge.
The NHS
On 5 September 1945, the Minister of Health Aneurin Bevan attended a dinner at the Savoy Hotel in London. He gave a speech, brimming with emotional energy, about the need for a new medical service. He invited the co-operation of the healthcare professions and acknowledged their misgivings. He called for their ‘devotion’ to this project that would make Great Britain ‘the envy of all the other nations of the world’. The new medical service Bevan was describing was the NHS. Less than three years later, and after successfully navigating the suspicions and oppositions of doctors and political rivals, ‘our NHS’ was brought into being.3
Despite Bevan’s own expressed emotional commitment, most people were not exactly wowed by the new scheme. In 1949, Mass Observation, a social research organisation, conducted surveys in which they asked the population for their views on the new health service. The sheer number of completed questionnaires by people who simply did not care about the introduction of the health service might come as some surprise to readers today. When asked about her opinion of the new scheme, one woman wrote, ‘I can’t say really, because I haven’t been to my doctor lately’.4 A man who was also surveyed agreed: ‘It hasn’t affected me any different to what it used to be. If ever I get laid up I should go to the doctor just the same’.5 Mrs W. Parsons was even more blunt, ‘The scheme is all right’.6 The value of the NHS is now so embedded in our national psyche that it can be difficult to imagine a world where its introduction was met by anything other than euphoric gratitude.
Gratitude in response to free-at-the-point-of-use healthcare was slow to develop. After the lukewarm and occasionally fractious (on the part of doctors) reception of the late 1950s, the subsequent two decades have traditionally been painted as a period of political consensus about the new national health service. However, as one researcher put it, the history books are relatively silent on the ‘ideological criticism that reverberated throughout the NHS’s founding years’.7 In his 1942 report, William Beveridge estimated that state medicine would cost £170 million. Some of the earliest attacks on the health service claimed that this was dangerously inaccurate, and used the supposed error to advance anti-NHS arguments. In 1949, a critical doctor writing in the medical press lamented: ‘At the present rate of expenditure … it will involve us in national ruin’.8 Right-wing publications such as The Spectator shared these fears, reporting on their own anxieties about the fiscal sustainability of the health service. Various writers and critics published books and articles challenging the affordability of state medicine. Groups like the Fellowship for Freedom in Medicine, who had objected to the service since before its inception, continued to forcefully advance anti-NHS politics through pamphlets, bulletins, research articles, national meetings, lobbying politicians, and urging support for private health insurance. At a meeting they held in 1957, one member ‘took strong exception’ to the ‘constantly repeated assertion, by politicians and propagandists, that the National Health Service is “the envy of the world”’. He insisted that there was ‘no justification whatsoever for this assertion’, noting as evidence the (accurate) observation that no other country had yet attempted to base their health service on the British system.9
Groups like the Fellowship for Freedom in Medicine were influential, shaping the scope and nature of public debate about the health service. However, they and their fellow anti-NHS activists never managed to achieve their goal – the replacement of state medicine with private health insurance. The few historians who have looked at this ideological opposition argue that this failure was partly because anti-NHS activists lost the ‘battle of ideas’ over British healthcare and failed to shift popular opinion on the service. One of the reasons for this, paradoxically, was the indifference to the service among ordinary people. The emotional intensity of anti-NHS activists’ writings – their vision of a ‘totalitarian nightmare’ that destroyed the covenant of trust between doctor and patient – simply did not match up with people’s everyday experiences of their medical treatment or the professionals they encountered, if they encountered any at all.10 The continuation of the NHS was more a product of indifference than passionate defence.
Over the second half of the twentieth century, the emotional relationship between the NHS and Britain’s population shifted. From the end of the 1950s onwards, cultural representations of the NHS became increasingly popular. The Mills & Boon ‘Doctor-Nurse’ romances sprang up over this period as did the Carry On films. The Doctor in the House TV series emerged in the late 1960s. These books, films, and TV programmes traded in, and made popular, stereotypes about hospital settings and healthcare professionals. They cultivated affection through comedy and romance and built enduring myths about the NHS and its employees. Some of this cultivation was deliberate, stemming from the longstanding media tradition of using culture to shape public opinion. But whether deliberate or not, the 1950s and 1960s witnessed an up-tick in pro-NHS propaganda, and the NHS – and medicine more largely – was reimagined through the melodramatic lens of film-makers, artists and authors who mined medicine for its drama, pathos, humanity, humour and romance. Though in many ways these representations were thoroughly unlike the day to day of medical practice, the images stuck. Medicine had found its aesthetic place in our cultural imagination.
As the century progressed, a new era of NHS activism and NHS devotion emerged. Partly as a product of economic pressures through the 1970s, campaigners sought to ‘influence and contest the redistribution of NHS resources’, and NHS staff undertook their first industrial action over pay, spending and safety. As historian Jenny Crane has argued, however, campaigns around the NHS in the 1970s were predominantly focused on local and individual hospitals. In contrast, the national movement in defence of ‘the’ or ‘our’ NHS, as it increasingly became known, only developed in the 1980s and had to be ‘constructed, forged and fought for’. This conceptualisation of the NHS as a quasi-abstract entity or proper noun, one that required a degree of emotional investment in order to best protect its interests and existence, ‘did not emerge organically’.11 It was only after Margaret Thatcher, and partially in response to her government’s policies, that the NHS’s current identity as the ‘prized symbol of Britain’s national status and modernity’ was cemented.12
At the very least, this history undermines the assumption that the NHS is loved simply because the service is, by its very nature, lovable. Devotion to the service is a historical phenomenon, something that has been made and can, therefore, be unmade.
‘Our’ NHS
Pointing out the historical contingency of NHS devotion is not, of itself, an argument to unmake this devotion. Rather, the problem is what this devotion to the NHS has created. Currently, any deviation from full-throated support is viewed as tantamount to damning indictment. And this binary has not only helped to reify pre-existing political echo chambers; it has also, and perhaps more problematically, made any kind of change, never mind the thoroughgoing reform the pandemic has suggested it could use, difficult to imagine, much less talk about. The faulty alignment of national ideals with the NHS, which in utilitarian terms is just a healthcare system, has forced out of public discourse any criticism of the NHS, and thus also the opportunity for meaningful reform.
This observation has probably never been truer than today. Those who critique the NHS outright, or dare to say another health service might have coped with the pandemic better, are likely to find themselves confronted by a torrent of nationalised indignation. This is particularly true among people who identify as politically left-leaning. In such circles, critique of the NHS is tantamount to an expression of support for Conservative Party politics or ideologies. This is an ahistorical association. Scepticism about the medico-industrial complex and critiques of healthcare systems were, at least until the 1970s, a fundamental strand of left- not right-wing political life and activism.
But the right has also had to toe this party line, demonstrating at least a baseline of practical and emotional allegiance to the service. When Thatcher aimed to radically reform (or gut, depending on your perspective) the NHS, she knew enough at least not to downplay its significance in British life, promising, at the 1982 Conservative Party Conference, that the NHS ‘is safe with us’.13 Reflecting his commitment to this same sentiment in 2015, David Cameron expressed indignation that anyone could doubt his loyalty to the service. ‘My love of the NHS, my respect for the NHS, my commitment to the NHS runs through every sinew of my body’, he declared.14
Despite this reductive public discourse, in private, stories of incompetence and failure proliferate. Women, people of colour, and the disabled have for a long time reported systematic failings on the part of healthcare professionals, and there is much to learn from these experiences about how we might do healthcare better. However, those critical narratives that do reach the public realm have generally shared a tendency to disguise their criticism of the NHS as criticism of, say, a rogue bad doctor or hospital, or, more frequently, politics and politicians; economic policies (austerity in particular); the private, Americanised, companies that have crept their way into this beloved public system; or a conveniently elusive ‘management’ that has let the public down. Critiques of the health service are almost always caveated with an acknowledgment that the service is under unique and particular pressures, despite the fact that the NHS has been in a state of near-perpetual crisis since the mid twentieth century.
Emblematic of these tendencies is Adam Kay’s widely-read and well-received This is Going to Hurt, which uses humour to defuse the litany of failings, frustrations and errors he observed over his six years as a doctor. Though Kay criticises healthcare working conditions, the mishandlings of medical management and the daily tragedies that accompany hospital life, his book never deviates from his expressed commitment to the NHS’s ideals, its value, or the fundamental necessity of its existence. Such accounts emphasise that the NHS is not to blame (not our NHS) but rather the nefarious or bumbling few who have failed in the sacred work entrusted to them.
Indeed, in addition to disallowing critique, the tendency to avoid pinning blame on the NHS, and the preference instead to pin it on any and all passers-by, has begun to make it difficult to ascertain where the contours of the NHS even lie. The NHS’s passage from a rationalised healthcare service that echoed a postwar reboot of social welfare systems to an amorphous symbol of British national identity has done it no favours. It is probably best defined now as a project and an ideology, evidence of the country’s supposedly vaunted global position. This has added another way in which critique of the NHS becomes unacceptable: pointing out the failings of the NHS seems dangerously close to pointing out Britain’s increasingly precarious place in the world.
The post-pandemic future?
The current pandemic has finally presented an opening for more numerous and louder voices of NHS dissent. Encroaching into public discourse finally are the same themes – of systematic, institutionalised racism, and grossly unequal experiences of healthcare that flourish under the cover of an ancient rhetoric of egalitarianism – that have erupted in the public sphere, not infrequently positioned as resulting from Britain’s abiding nostalgia for its erstwhile empire.
But this emerging public criticism has not yet been enough to challenge wider perceptions. By and large, the NHS remains untouchable. Nowhere has this been more evident than in the prominent slogan early on in the pandemic to ‘stay home, protect the NHS, save lives’. This introduced the British variant of the ironic notion, circulating in many places, that it should be the people’s responsibility to protect healthcare, rather than, as in normal times, healthcare’s responsibility to protect us. But, more than that, it drew on the NHS’s status as a manifestation of Britishness to inject a nonsensical feeling of pride in this ‘world-leading’ system – even though it was so immediately overrun by the pandemic that it became, and has to some degree remained, largely inaccessible for the last eighteen months. These paradoxes need to be called out, not for the sake of political gain or global embarrassment, but for the purposes of growth and change.
Highlighting the failings of the NHS is different from an indictment of those who work within it. Indeed, critique of the NHS ought to be done in large part on behalf of its workers, who arguably suffer the most from these critical failings, living day in and day out with the obligation to do exactly that which they cannot: provide a world-leading, effective, inclusive service in a system that is discriminatory even to those who work within it.
Calling out the failings of this service is also not an attack on the value of healthcare more largely. Not to have love for the NHS ‘run through every sinew’ of one’s body is not a sign of diminished appreciation of the role medicine plays in keeping us healthy. Healthcare does not have to be loved to be effective, efficient, inclusive and therapeutic. Instead of love, we need to take a good, long critical look as a nation at where our healthcare system stands. Is a discriminatory service that runs its workers ragged really what we want? Is private grumbling over the shoddiness of one’s own experience, coupled with a Polly-Annaish ‘everything’s fine’ public persona, really better than a stand for real and inclusive
healthcare reform?
The pandemic presents us with an opportunity. Over the course of the past eighteen months the UK has experienced high levels of Covid-related morbidity and mortality, and the shut-downs of all but Covid care that have been catastrophic for many – in short, the problematic failure of the health system to cope with a national health emergency. This should press us to reconsider both our healthcare system and the disservice we have done it by constantly turning a blind eye toward its failings. Rather than allow this exceptional opportunity for growth to pass us by, we need to finally face the realities of an aging, poorly structured, non-inclusive, overwhelmed healthcare system, with underwhelming health outcomes, so that we can do the work required to fix it.
Agnes Arnold-Forster is a Research Fellow at the London School of Hygiene and Tropical Medicine and the author of The Cancer Problem: Malignancy in nineteenth-century Britain (Oxford University Press, 2021).
Caitjan Gainty is a historian of health and healthcare at Kings College London.
Together, Caitjan and Agnes run the Healthy Scepticism project.
Notes
1 Public Health England, ‘Spanish Flu a hundred years on: Lessons from the most deadly flu pandemic in history’, 2 March 2018: https://publichealthengland.exposure.co/spanish-flu-a-hundred-years-on.
2 Peter Stubley, ‘Coronavirus: Boris Johnson praises NHS as country’s greatest national asset after saying “he could have gone either way”’, Independent, 12 April 2020: https://www.independent.co.uk/news/uk/politics.
3 Aneurin Bevan, ‘Speech to the Royal Medico-Psychological Association’, 5 September 1945, reprinted at https://www.sochealth.co.uk/national-health-service.
4 Interview with Mrs Amelia Anne Probart, 19 April 1949, Interview 02/149, Mass Observation Archive.
5 Interview with Mr W. Grove, 19 April 1949, Interview 02/167, Mass Observation Archive.
6 Interview with Mrs W. Parsons, 19 April 1949, Interview 02/136, Mass Observation Archive.
7 Andrew Seaton, ‘Against the “Sacred Cow”: NHS Opposition and the Fellowship for Freedom in Medicine’, Twentieth Century British History, Vol 26 No 3, 2015, p427.
8 Ffrangcon Roberts, ‘The Cost of the National Health Service’, British Medical Journal, 19 February 1949, pp293-7.
9 ‘Fellowship for Freedom in Medicine’, British Medical Journal, 7 December 1957, pp187-S188.
10 Seaton, ‘Against the “Sacred Cow”’, p448.
11 Jenny Crane, ‘“Save our NHS”: Activism, information-based expertise and the “New Times” of the 1980s’, Contemporary British History, Vol 33 No 1, 2019, p52-74.
12 Roberta Bivins, Contagious Communities: Medicine, migration, and the NHS in postwar Britain, Oxford, Oxford University Press 2015, p13.
13 Margaret Thatcher, ‘Speech to Conservative Party Conference’, 8 October 1982, https://margaretthatcher.org.
14 ‘David Cameron “The NHS is safe in my hands”’, ITV News, 18 May 2015, https://www.itv.com/news/update/2015-05-18/david-cameron-the-nhs-is-safe-in-my-hands/.