Department of Epidemiology, Center for Social Epidemiology and Population Health University of Michigan, USA. E-mail: jwlynch{at}sph.umich.edu
For readers already well informed about the origins of the National Health Service (NHS), this book is a good read from which they will probably learn a lot. For readers coming to this subject for the first time, however, I have reservations.
The flyleaf describes it as:
the first book to explain the creation of the British NHS as the result of a private alliance between Aneurin Bevan, Minister of Health, and Charles Wilson, Lord Moran, President of the Royal College of Physicians.
Marvin Rintalas drama includes two other principal characters, Lord Horder as disappointed contender for leadership of the Royal College of Physicians and conspirator with Bevan, and Charles Hill as Secretary of the British Medical Association. He adds vivid sketches of David Lloyd George as initiator of the NHS 36-year gestation from industrial coverage by State Insurance to universal coverage by State medical care in 1912, and of Sir William Beveridge as initiator of comprehensive State insurance in 1942.
The flyleaf also states Rintalas main interest as the intersection of the political and the personal in history. His honesty in declaring his particular observer bias is helpful. Though this intersection is indeed of great interest, we must look elsewhere for the main story.
What wasand still isthat main story? It has two distinct themes, interwoven and interdependent. First, development of the idea of social solidarity: the necessary and self-interested duty of well people to care for sick people, and to organize the whole of society for this purpose. Second, development of medical care from almost wholly illusory professional trade to increasingly effective applied human biology. Brought together, these two themes have been synergistic: separated, they have led into blind alleys of tight-fisted charity on the one hand, and tinkering body repairs on the other. Popular ideas of social solidarity which have weakened in other fields like manufacture, the arts, and education, remain vigorous in health care. As a former Conservative finance minister ruefully remarked, For most people in Britain, the NHS is the nearest thing they have to religion. Less obviously, balanced development of medical science was hugely assisted in the UK by the universality of NHS investment, and by gift rather than trading relationships in the NHS economy: and was hugely impeded in USA because it lacked such an economy.
If Rintala is interested in big historical stories at all he would probably accept at least some of this onemore, at least, than most US medical professionals still wistful for the days when health care was their business, not that of some giant corporation. Without some such understanding historians can make some very silly mistakes.
Such a mistake, of monumental proportions, appears on 1518. He paints an original, convincing, and to me unexpectedly unattractive portrait of Sir William Beveridge. He rightly sweeps aside other historians who have blandly assumed that because the Beveridge Report of 1942 became revered as the foundation for the postwar British welfare state, it must have been welcomed by Churchill as Prime Minister, and by Clement Attlee as leader of the Labour Party in the wartime coalition. In fact, though Churchill had vigorously supported Lloyd Georges National Insurance Act when he was a Liberal Minister before the First World War, he did his best first to bury the Beveridge Report, and when that proved impossible, to postpone its implementation at worst until after the war ended, and at best indefinitely. This hostility was shared by Attlee and the other Labour leaders in the coalition government, Herbert Morrison and Ernest Bevin. As Rintala says, none of this was surprising; Beveridge was arrogant and overbearing, with no talent for making political allies, and was also a Liberal, a dying party which neither Conservatives nor Labour were interested in reviving.
So without any powerful friends, why didnt the Beveridge Report disappear into the dusty archives of historical footnotes? Things may be made to happen in history either by the powerful few, or at moments of exceptional unity, by the otherwise powerless multitude. Having excluded the powerful, Rintala dismisses the multitude; Few Britons, he says, read Beveridges report.
Well, well. On the night before its publication on 1 December 1942 there were queues to buy it from the HMSO bookshop in Kingsway, and the first 60 000 copies were sold out in a few days. Sales topped 100 000 within a month and 200 000 by the end of 1944. Together with a later shortened version, total sales eventually reached over 635 000, a record for any government publication. Within two weeks, the National Council of Labour, representing the whole Labour Party not just MPs, endorsed the report and called for legislation before the war ended; and a Gallup poll showed 95% of people had heard of it and 90% favoured its implementation. Because of this mass interest, and because through BBC World Service broadcasts the report had for the first time provided British soldiers and their families with positive war aims which became a principal theme of Army Bureau of Education discussions throughout the forces in all theatres of war, all government attempts to emasculate the report failed. When it was first debated in parliament in February 1943, Churchill and his cabinet, including Attlee, Morrison, and Bevin, all refused to consider legislation before the wars end, or to make any promises to implement it later. Led by Arthur Greenwood and Aneurin Bevan from the back benches, 119 MPs, including 97 Labour MPs (all but one of those not holding office in the coalition government) defied the Party whips and a threat by Ernest Bevin to resign, and voted against the government. This backbench revolt, backed by a full issue of Picture Post in 1943, did as much as anything to bring about the Labour landslide of 1945.1 It also ensured that Attlee would include Nye Bevan in his cabinet; better pissing out of the tent than into it.
If Rintala is trying to show that personalities matter more than the social frames within which they operate, his own book refutes him. Despite Beveridges ugly personality, his report became a mighty social force, far greater than its author. Lord Horder, whom Rintala shows to have been just as much (and as superficially) committed as Lord Moran to a grand social function for the NHS, so long as he could be seen as its author, was simply the weaker of two very similar overlarge egos, typical of the dominant teaching hospital consultants of their day. Having failed to become Bevans principal assistant, Horder tried to become his principal opponent, by forming the Fellowship for Freedom Medicine. In this also he failed, leadership in that ignominious struggle going to Charles Hill. And Hill failed to stop the NHS not because of his personal attributes, but because Bevan had a better grasp of how social forces can operate, and had the whole working class and most of the middle class behind him.
The consultants were, at that time, the principal agents of effective clinical medicine, and unlike GPs, needed skilled teams and costly buildings and equipment to do their work. When Bevan nationalized the hospitals, the consultants had nowhere else to go. Like it or notand most of them didntthey needed means of production only the State could provide. To negotiate this to their own best advantage, they needed a realist like Corkscrew Charlie Moran rather than a romantic like Horder.
As for Nye Bevan, without the South Wales miners, their valley communities, and their long traditions of locally organized mutual aid, he would have been nothing, and well he knew it. It was that conscious dependency that made him effective and of lasting historical interest, but of this Rintala clearly knows little.
Never mind, it is well and boldly written, and perhaps none the worse for so obviously requiring critical reading.
Reference
1 Calder N. The Peoples War: Britain 19391945. London: Pimlico, 1969, p. 31.