medicine and the state - bmj

MEDICINE AND THE STATE

The evolution of the NHS

Frank Honigsbaum

Britain has a record of parliamentary governmentnoted for its conservative tendencies, yet it hasproduced the most radical and comprehensive publichealth service in the world. How did this happen?Were health needs greater in Britain than elsewhere?Was the private sector less able to cope? Did the publicpress more strongly for state aid? Was the nation betterable to afford it? None of these questions seem to pointin a satisfactory direction; the main forces behind thedevelopment of the National Health Service have to belooked for elsewhere.

The dreaded poor lawState intervention in health care began almost

accidentally, as a result ofthe establishment of the poorlaw in 1601. That statute required the "necessary reliefof the lame, impotent, old, blind and such other amongthem being poor and not able to work."' Thereafter arudimentary system of medical relief arose underwhich those who were too poor to pay were suppliedwith physic by a parish doctor. This systema wasnever intended to spread beyond the ranks of thepoor. Indeed, in 1834 an attempt was made to curbpauperism with the introduction of a workhouse test:those wanting relief had to enter a hated workhousebefore they could receive it. Two years earlier a morefrightening deterrent had been posed.with the passageof the Anatomy Act, making the corpses of the poorliable to dissection.2 Though the sick were exemptedfrom the workhouse test and could still be treated athome, the system became stigmatised. No one soughtpoor law relief if it could possibly be avoided.The public did not feel the same reluctance to use the

municipal health services that arose in the nineteenthcentury. Throughout the period, local authority effortswere concentrated on environmental reform but,

starting with the provision of asylums for the mentallyill and isolation hospitals for those with infectiousdisease, municipal attention shifted increasingly topersonal care. What drove local authorities on were thepersistently high maternal and infant mortalities thatdisturbed the nation.3 Something had to be done, andmedical officers of health found the public receptive tothe free maternal and child welfare services theyoffered.

This movement led some to think that the time hadcome to reform the poor law and put all public healthservices under the care of local authorities. By 1909 theFabian socialists Sidney and Beatrice Webb hadbecome the leading exponents of this idea. Workingclosely with Sir Arthur Newsholme and other medicalofficers they made it the key to their campaign to breakup the poor law; even government officials whoadministered the system had begun to wonder whetherthe principles of "deterrence" and "less eligibility"should be applied to health care.

Local Government ActHad this programme carried it is doubtful whether a

universal service would have emerged. The Webbs hadbeen so anxious to placate their critics that they evenexcluded the higher paid workers from the publicsector. They wanted to unify the public health servicefirst and to worry about its extension later. Not until-1929 was their goal realised with the passage of theLocal Government Act, which abolished the boards ofguardians who administered the poor law and gavelocal authorities the chance to convert Poor Lawinstitutions into municipal hospitals, thereby makingindoor as well as outdoor medical relief more readilyavailable.4 To placate the doctors and voluntaryhospitals who feared the loss of patients a means test

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London W2 5BSFrank Honigsbaum, PHD.associate research fellow ofKing's College, London

BrMedJ 1990;301:694-9

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still had to be applied, and all who could afford to paywere expected to do so. Though the procedure was notstrictly enforced, it did slow the growth of municipalservices. Women, children, the unemployed, andothers who had been excluded from the health careprovided under National Insurance applaudedmunicipal efforts and looked forward to the develop-ment of a comprehensive service, but those who lostincome from the process were determined to frustratethem.The strongest opposition came from the medical

profession. Before the 1930s doctors had been moreconcerned with threats to their position under thepanel system-the method by which medical benefitwas provided through National Insurance. But as thatdanger subsided the profession turned its attention tothe growth of municipal services, aroused by sharpclashes between general practitioners and medicalofficers of health in the years between the wars. Therewas a particularly important clash in Croydon in 1937,where the medical officer ofhealth failed to consult localdoctors during the course of an outbreak of typhoid,.which resulted in 42 deaths before he was ableto diagnose the cause. This gave medical leadersthe chance to condemn the absence of consultativemachinery throughout the country. Throughout the1930s the leading figure in the British Medical Associa-tion, Sir Henry Brackenbury, had sought to forge anaccommodation with public health workers in the hopeof finding a suitable place for private practitioners inthe framework of municipal care. But by the timediscussions on the postwar health service began in 1943the profession wanted nothing to do with the proposal.General practitioners and consultants alike weredetermined to keep their distance from medical officersof health.

Ministry of Health officials found it hard to acceptthis view. From the moment the panel system began in1913 Sir Robert Morant and the civil servants whoadministered it had longed for the day when it could becombined with municipal care under the direction of

medical officers of health. That, in their view, was thelogical way to organise public health services, andpoliticians from all parties agreed with them. The planthe ministry presented to the profession in 1943 calledfor all care to be organised under local authoritydirection, and general practitioners were to beemployed in health centres and receive a salary. Thesystem long desired by that doyen of the public healthworld, Sir Arthur Newsholme, was at last to berealised: health services were to be consolidated undermedical officer of health control.Had the ministry stuck to this conception it is certain

that the postwar service would not have taken the formit did. Instead of a comprehensive service open toeveryone the department would have had to restrictcare to those below an income limit just as the Webbshad done in 1909. The profession would never haveaccepted the 100% principle in that form. Indeed, asit turned out, the doctors forced the removal ofmunicipal direction from all but a limited array ofcommunity services, and even those were taken awaywhen the National Health Service was reorganisedin 1974.5 At that point medical officers of healthdisappeared as well, their place being taken bycommunity physicians or public health officers, whoserole was to plan or evaluate services rather than providethem.

Crucial role of club practiceIf neither poor law nor municipal developments

were sufficient to produce a universal service wherethen did the movement towards a national healthservice come from? The most likely source lies in thenature of club practice, which was started by friendlysocieties in the nineteenth century and which, by theintolerable conditions it imposed, made a frustratedmedical profession that was unable to produce reformson its own and was receptive to state intervention.Ironically, this made the doctors themselves thedriving force behind the development ofa wider publicservice. The system of general practice that existstoday still bears the earmarks of the rudimentaryarrangements that were clumsily erected in the 1820s.Club practice began innocently enough. As the

industrial revolution proceeded working men found itdesirable to protect themselves against adversity andrecourse to the hated poor law; they formed friendlysocieties like the Manchester Unity of Oddfellows toprovide, among other benefits, cash support when ill.But how could the societies be certain that memberswere really incapacitated? Doctors were needed toensure the payment of legitimate benefits, addingwhatever care they could provide in their surgeries torestore patients to health. Because at that time mostdoctors did their own dispensing they were expected toprovide drugs. For this service the societies generallyoffered payment in the form ofa capitation fee as it waseasier to administer. The amount, when club practicebegan, was about two to three shillings a year, and by1911, when parliament intervened, it had risen only tofour shillings despite the increasing cost of drugs.

Doctors nevertheless saw the work as a usefulsupplement to private practice that brought withinreach the wives and children who were generallyexcluded from the clubs. In an age when orthodoxmedicine had little to offer club practice also affordedprotection against competition by unqualifiedpractitioners. Parliament formally endorsed thearrangement in 1858 with the passage of the MedicalAct, which not only established a register of qualifieddoctors but also restricted club and public practice tothose who were on it.But the profession could live with club practice only

so long as it assumed modest proportions. By the end of

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the century friendly societies had grown to the pointwhere they covered one third of the working class.Countless others were organised into clubs thatfollowed the example of the friendly societies so that anever increasing number of doctors were drawn into thework, with some four or five thousand being soinvolved that they depended on club income for theirsubsistence.Nor was low pay the only problem: the clubs were

controlled by laymen, and doctors had no voice inadministration. Some medical men suffered severeindignities, including interference in clinical work. Atone club in Birmingham only one minute was allowedfor consultations, and if the practitioner exceeded thattime "a loud knocking at the surgery door brought theconsultation to a close." A J Cronin, in his classic novelThe Citadel, has left us with a graphic account of theharsh treatment handed out to doctors in clubs run bycoal miners in south Wales.6

Need for state interventionFrom the middle of the nineteenth century doctors

in some places made sporadic attempts to reformclub practice, but they failed. The profession wasovercrowded, and practitioners from other places wereall too ready to take the appointments abandoned bylocal men. National organisation was needed, and theBMA supplied it in the wake of the "battle of the clubs"that began in 1895. An account of this struggle, writtenby a special commissioner, appeared in the Lancet overa period of 20 years, while the BMJ published anextensive study of the economic conditions of contractpractice in 1905.7

Despite the Herculean efforts of medical leaders theprofession could not secure appreciable reform. TheBMA itself was split by the conflict, with leadingconsultants resisting the efforts of general practitioneradvocates to secure the trade union powers needed foreffective action. It soon became apparent to BMAofficials like Drs James Smith Whitaker and AlfredCox (then secretary and deputy secretary respectively)that state aid was needed to free the profession from thecontrol of the friendly societies.

Lloyd George gave the doctors the opportunityto move towards state control in 1911 with his

National Insurance Bill, and Dr Cox used an extremeConservative member of parliament, Sir Henry Craik,to make the following ringing declaration during acrucial debate on an amendment to the bill:

If you do not now place the administration of the medicalrelief under some public body ... you will place the profes-sion of medicine in perpetuity under the heel of privatesocieties.... The doctors ... desire to be brought into imme-diate contact with the State whose servants they are.

Parliament only partly complied; the societies weretoo firmly entrenched to be completely displaced.They, along with the other "approved societies"admitted to the act, were given a 60% majority on theinsurance committees created to administer medicalbenefit. This, among other provisions, led the doctorsto oppose a measure that their more perceptive leadershad welcomed. But Lloyd George was determined topush the reform through. Above all else he wanted toend the custom that required doctors to supply drugs;henceforth, except in rural areas, chemists wouldsupply them-at least as far as the Insurance Act wasconcerned. The panel system began in 1913 with onlygeneral practitioner care provided, but the way wasopen for insured people to benefit from the wonderdrugs that appeared thereafter.Though they opposed the act, the doctors soon

learnt to like it. Whatever lingering dissatisfaction theyfelt they had to admit that the conditions of panelservice were far superior to those in club practice. Butstill the societies exerted too much influence formedical comfort, and in 1922 they tried to extend itfurther by offering to pay the excess costs of medicalbenefit from the surplus funds they had accumulatedunder the Insurance Act. In the midst of this disputeDr Cox again made the profession's preference clear:I would rather see the State provide the money. Our CivilService is incorruptible. I would rather see the Governmentstanding between the insured persons and the medicalprofession than the approved societies, some of which wantthe Government to stand aside.

Even the rival Medical Practitioners' Union-then athorn in the side of BMA leaders-shared the sameview: "The danger is not that we may have more Stateinterference with our work but that we may have less."8

The growing municipal threatThe dispute, which ended with a "glorious victory"

for the doctors,9 proved to be a turning point in thedevelopment of medical benefit. Thereafter societyinfluence waned and the profession turned its attentionto the growing threat from the municipal sector. Localauthority clinics were spreading fast, and hospitalservices were expected to follow in the wake of theLocal Government Act 1929. As women who did notwork and children were excluded from medical careunder the Insurance Act medical officers of healthconcentrated their efforts for them. Practitionerseverywhere became alarmed by the way maternity andchild welfare clinics were "stealing" their patients.The profession's way of meeting this threat was to

call for more state intervention. It wanted the panelextended to cover "dependants and specialists"-that


1860s* 1866: Thomas Clifford Allbutt develops the

modern clinical thermometer* 1867: Joseph Lister publishes his

description of antiseptic surgery, which hehad been practising for two years

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is, the wives and children of insured people and themedical services provided by specialists. In that wayindependent practitioners could absorb the work doneby local authority clinics. In 1929, when the BMA firstpublished the plan, the doctors were willing to acceptmunicipal administration, but nine years later, when itwas reissued, they felt it safer to stick with insurancecommittees. Clashes with medical officers hadled them to fear municipal rule more than societyinterference.

BMA and TUC alliance and the Beveridge reportBMA leaders ideally wanted to free the profession

from both municipal rule and society interference, andthe trade unions gave them the opportunity. By the1930s the unions had become alarmed at the way theinsurance industry was influencing social policy. In1912 the industrial insurance offices had been admittedto the Insurance Act along with friendly societies, tradeunions, and other bodies; but whereas the insuranceoffices managed to enrol half of the insured peoplethe unions secured only 11%, and even that smallproportion fell to 8% by 1938. From the time theInsurance Act began spokesmen for the insuranceindustry proved more astute than friendly societyleaders, and by the 1930s they were bringing greatpressure to bear on social policy. In 1932 an actwas passed that, owing to growing unemployment,threatened 200000 insured people with the loss ofmedical benefit, thereby leaving them, in the words ofone friendly society critic, "crucified on the cross of theinsurance principle."Even worse for the unions was the way that casualty

insurance companies and employers administeredthe public workmen's compensation programme.Workers with industrial injuries found themselvesforced to accept miserly lump sum settlements that leftno recourse but the poor law after the money wasexhausted. Some doctors-particularly orthopaedists-shared the unions' concern, and in 1935 the BMAissued a report on fracture treatment that severelycriticised the insurance industry.'0By this time the profession had also become

concerned by the industry's influence on maternitypolicy. The cash maternity benefit paid under theInsurance Act was the most popular the statute had tooffer, and industrial insurance agents found it a readysource of finance for the purchase of life policies. In1929 when that benefit was under threat the insuranceoffices cleverly managed to avoid a cut with a schemethat called for the expansion of municipal services,justifying their plan with a severe criticism of the waythat general practitioners provided antenatal care.The moment was ripe for an alliance between the

doctors and the unions. In 1936 the BMA formed ajoint committee with the Trades Union Congress tofacilitate cooperation. While the congress endorsedthe BMA's maternity policy the BMA condemnedthe practices of the insurance industry and employersbefore government committees investigating work-men's compensation and rehabilitation from industrialaccidents. The combination was too strong for thegovernment to ignore. While in 1936 England andWales adopted a maternity act based on municipalprovision in 1937 Scotland adopted a different statute,which made room for general practitioners as the BMAwanted. Then, in 1938, the government created a royalcommission with a core of union supporters to studythe whole question of workmen's compensation.Though the outbreak of war gave employers an

excuse to boycott the commission's proceedings andforce its suspension, the movement started by theBMA and Trades Union Congress proved too strong tostop. It" was reinforced by the formation of theEmergency Medical Service in 1939 to deal with theexpected civilian casualties of bombing raids andwhich led to the radical reorganisation of hospitalservices during the second world war. In 1941, afteradditional pressure from the Trades Union Congress,the government created a committee headed by SirWilliam Beveridge to consider not just workmen'scompensation but the whole field of social policy. Nordid Beveridge disappoint the unions: when his reportappeared in 1942 it endorsed nearly all of the congress'spolicies. Beveridge called not only for the removal ofthe insurance industry from state administration butalso for the abolition of the approved society system.

Impact of the Medical Planning CommissionMeanwhile, the doctors were not silent. In 1940 they

had formed a Medical Planning Comnmission, which inJune 1942 produced an interim report calling for thecreation of a comprehensive health service covering90% of the population. Though this amounted to littlemore than an endorsement of the extension proposalspublished by the BMA in 1929 and 1938, it carriedgreater weight because the scheme now had thesupport of the prestigious consultants who led the royalcolleges.The profession's report came five months before

Beveridge's appeared, and that made it easy forBeveridge to add an assumption to his plan that calledfor the creation of a comprehensive health servicecovering the nation as a whole. As the secretary ofthe Beveridge Committee later disclosed, the proposalhad a strategic purpose-it "provided the mainargument against the Approved Society system." Bothrecommendations were subsequently accepted by thegovernment.

At that point (November 1942) it looked like thedoctors would slip easily into a service that was open toeveryone; indeed, at its annual representative meetingtwo months earlier the BMA had approved the conceptby a small majority. But throughout the period theprofession made it clear that it would not acceptmunicipal control, and the civil servants at the


Cartoon by David Low, whichappeared in the "EveningStandard," 3 December 1942.Such cartoons helped to diffuseinformation about theBeveridge report

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When the smoke had clearedrepresentatives voted-to acceptconditional cooperation in the NHS(28 May 1948)

Ministry of Health failed to heed the warning. Onlyrepeated medical resistance forced the department tomodify its plan, and it took a pragmatic Labour

-minister, Aneurin Bevan, to remove the last vestige oflocal authority control in 1945.

Thereafter other objections arose and Bevan had tomake further concessions before the NHS began inJuly, 1948. But once in it the doctors learnt to like theNHS just as they had come to support the panelsystem. By 1989, in the face of a radical reorganisationproposed by a Conservative government, theyhad become the ardent defenders of a nationalisedstructure that was foisted on them by a socialistminister in 1948. Consultants, like general practitionersbefore them, found refuge in the doctrine of centralcontrol. Just as panel practitioners favoured nationalcontracts to free themselves from the approved societymajority on insurance committees, so consultantswelcomed regional appointments and uniform terms ofservice to avoid interference from local authorities.And now not only had the approved societies gone butso had the spectre of municipal control.Nor was that all: as with club practice and the

panel system before it (with minor exceptions) onlyregistered practitioners were admitted 'to the newservice, thereby extending the profession's protectionagainst unqualified practice to the nation as a whole.Clinical freedom was enlarged as well: doctors nolonger had to worry about a patient's ability to paybefore deciding what treatment to give. The profession

enjoyed greater freedom than it had experienced at anytime since club practice began in the 1 820s.

In the process the public benefited, too, in-receivinga service that, in the words of the Archbishop of Yorkin 1946, promised to "bring a health, happiness andsecurity to millions in a way which no previous Acts ofParliament ever have done." Though no organisedgroup spoke for patients during the debates of the1940s, it was doubtful whether the doctors would havesucceeded if their interests had not coincided withthose of consumers. The BM7 reported Dr Cox'saddress to a conference for local medical and panelcommittees nearly sixty years ago:

He [Dr Cox] had had one principle underlying all his work-namely, that the Association would never be successful unlessat the back of it all was a sincere desire to further the interestsof the public. If the Association could not convince the publicthat in addition to looking after the interests of the profession,as it was bound to do, it had a great desire to make the medicalservice better, then it would never get the results it ought toachieve. He begged them to hold fast to the principle that theywere out first and foremost for the interests of their patients.Capitation fees were important, but they were not the mainthing.""

Today medical freedom is again under'threat, thistime from a government that is determined to makedoctors accountable for the work they do. Freedom forthe profession, it feels, has gone too far, producingwhat Sir John Brotherston (before 'he, became chiefmedical officer of the Scottish Department of Health)


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once called a system of "syndicalistic anarchy" in theadministration of the health service. Somehow,the government believes, a balance must be struckbetween organisation and freedom.

Is this demand reasonable? The final answer nodoubt rests with the public. If patient care suffers inthe process then the nation may decide that therestraints imposed are not worth the savings theyproduce. Today, as in 1911 and 1948, it is the publicinterest that will predominate.

Material in this paper is taken mainly from the following:

Honigsbaum F. Health, happiness and security. The creation of the National HealthService. London: Routledge, 1989.

Honigsbaum F. The division in British medicine. A history ofthe separation ofgeneralpractice from hospital care, 1911-1968. London: Kogan Page, 1979.

Honigsbaum F. The struggle for the Ministry ofHealth, 1914-1919. London: G Bell,1970. (Occasional papers on social administration No 37.)

Other sources are numbered in the text:

1 Webb S, Webb B. The state and the doctor. London: Longman, 1910.2 Richardson R. Death, dissection and the destitute. London: Routledge, 1988.3 Frazer WM. A history of English public health 1834-1939. London: Bailliere,

Tindall and Cox, 1950.4 Wilson N. Municipal health services. London: Allen and Unwin, 1946.SLevitt R. The reorganised health service. London: Croom Helm, 1976.6 Cronin AJ. The citadel. London: Gollancz, 1937.7 Anonymous. BrMedJ 1905;ii(suppl): 1-96. Report on contract practice.8 Anonymous. "How it strikes us." Medical World 1922 July 28:507.9 Anonymous. Insurance: the court's award. BrMedJ 1924;i:205-6.10 British Medical Association. Report of the committee on fractures. Br Med J3

1935;i(suppl):53-.62.11 Anonymous. Annual panel conference. BrMedj 1931;ii(suppl):256.

Playing at Doctors (1863)Frederick Daniel Hardy (1826-1911;British)Frederick Daniel Hardy has connections with thefirst artist in the series, Thomas Webster (p 687).Hardy studied with him, subsequently became amember ofthe Cranbrook Colony, and, like hismaster, went on to specialise in scenes ofchildren atplay. These pictures sold well andprovided him witha comfortable living, an ambience reflected in thispicture, which shows privileged children in a cosymiddle class setting. Seemingly a straightforward

representation ofa children's game, does "Playing atDoctors" have a deeper meaning? The clue to thismay lie in the two women in the doorway; one is.middle aged, the other elderly. Possibly, then,Hardy is showing us three stages oflife-and thegame in progress refers to the frailty ofold age.Hardy's strength lies in his accurate observation andattention to detail, particularly ofcontemporaryVictorian interior decoration; his pictures have even

been used by specialists as an authentic source ofinformation.

CLASSIC OF THE DECADE

1865: Claude Bernard's Introduction aI'Etude de la Medecine Experimentale.Paris: J B Bailliere.

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