How Britain fell in love with the NHS

No other part of the welfare state attracts the same level of admiration. People do not bake cakes to commemorate the introduction of child benefit payments. Nor do they attend street parties to mark the construction of council estates. Even among Britain’s international peers, there are few countries that view their health system as emblematic of their ‘national’ values. True, Canadians might cite their country’s guarantee of universal healthcare as a point of pride to lord over their US neighbours to the south, but Canada does not celebrate its health service to the same degree as we do in Britain.

Clearly, despite its many and vocal critics, the NHS is widely beloved. But from where did this public support stem? And to what extent have the difficulties facing the service, and the persistent sense of ‘crisis’ they’ve engendered, shaped this sentiment over time?

Public affection for the NHS had to be actively nurtured. It was not inevitable that any state-organised universal health system founded after the Second World War would eventually attract such a degree of popular support. Achieving such an outcome took both effort and time.

Supporters of the concept and its implementation – who sat predominantly, though not exclusively, on the political left – furnished the institution with a caring and egalitarian image, helped embed its communal modes of care in everyday life, defended its principles against free-market critique, and established new traditions to celebrate its achievements and history. These efforts – by assorted activists, campaigners, trade unions, experts, cultural figures and the Labour Party – helped ensure the status of the NHS in Britain today. In turn, they also contributed to the survival of the institution when so many other parts of the welfare state and public industries fell away from the 1970s under Margaret Thatcher and her successors.

State medicine

During the interwar years, the British public relied on health services that stemmed from government, charitable and private initiative. For example, patients needing hospital care accessed treatment in either ‘municipal hospitals’ (often refurbished Poor Law institutions from the Victorian era, now run by local councils) or ‘voluntary hospitals’ (which ranged from smaller cottage hospitals to prestigious teaching establishments such as the Royal Infirmary of Edinburgh, and were funded by patients’ payments, fundraising and endowments). Yet, as surprising as it may appear, in the 1940s public responses to proposals for a ‘National Health Service’ were mixed.

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In the Second World War, when the ‘reconstruction debates’ about the nation’s future reached their height, pollsters asked Britons what they thought about potential government organisation of medical care. The results were equivocal. Many respondents welcomed the idea, perceiving it as an improvement on the existing services that left considerable gaps in coverage, particularly for women and children. (For instance, the National Insurance system that provided millions of Britons with access to a GP did not cover ‘dependants’, thereby excluding the family members of those who were insured through their employment.) Others were ambivalent. Significant numbers believed that such plans would lead to a bureaucratic and impersonal system under government oversight – one in which local doctors and hospitals lost their familiarity with and detailed knowledge of individual patients.
As one woman questioned by the social-research organisation Mass Observation remarked: “I hate anything which is controlled by the government.” Critical letters to local newspapers decried “state medicine” as a “deadly threat to personal liberty”. At the heart of these statements lay an older view that the state should not coordinate something as personal as medical care.

Having secured a landslide victory in the 1945 general election, Clement Attlee’s Labour Party needed to address these concerns. The new minister of health, Welsh socialist Aneurin Bevan, oversaw the legislation for what would become a nationalised medical system, predominantly funded by taxation and free at the point of use. Although Bevan’s tussles with the British Medical Association are often invoked when narrating the drama that surrounded the creation of the NHS, another sort of battle was fought to win the hearts and minds of the British people. Recognising the apprehensions about ‘state medicine’ voiced during the war, the government worked hard to portray the NHS as a caring, egalitarian service that would support families.

Such an image was advanced through the production of films including 1948’s Here’s Health, a live-action drama depicting a fictional working-class family’s struggles to afford care in the months before July 1948. This film’s exposition of the benefits of the NHS to those previously excluded from government help with medical costs emphasised the new offer to families. Similarly, government posters, radio broadcasts, speeches and travelling exhibitions affirmed the service’s humanitarian credentials, distinct from earlier critical interpretations of government medicine.

Transforming lives

Of course, this promotion was not the only reason for the growth in the NHS’s popularity. Following the launch of the new service on 5 July 1948, hospital treatments and doctors’ appointments, now available to all free of charge, transformed many people’s lives and garnered significant appreciation. Nonetheless, cultural output also played a role in grounding the service. The language of ‘state medicine’ declined in popular use, becoming voiced predominantly by the service’s organised political opponents. The NHS was a single body that people could thank for the care they received – in a way that hadn’t been possible with the disaggregated medical system of the interwar years, and which had been discouraged by the critical views of government medicine invoked during the war.

However, in the first two postwar decades, the NHS suffered as a result of small budgets and a lack of prioritisation by both Conservative and Labour governments. Far from being a golden age of the welfare state, in the late 1940s and 1950s spending on social services stagnated, health languished below the likes of education in government priorities, and funding for new hospitals and general practice facilities was scarce. It wasn’t until the 1960s that a significant wave of new hospitals began to appear in towns and cities, a legacy of the financial support offered by the 1962 Hospital Plan.

Britain’s postwar government worked hard to portray the NHS as a caring, egalitarian service

Nonetheless, even without new facilities, governments and reformers spearheaded a number of changes to the way the NHS worked on an everyday level. These efforts further expanded the service’s popularity in its early years. Partly, they improved flexibility in the face of social changes that included an increasingly affluent population, shifting attitudes to gender and sex, and growing ethnic diversity. For example, hospitals gradually extended their visiting hours: whereas in the 1940s patients might have been allowed just one or two hours a week to enjoy the company of relatives and friends, by the 1970s some hospitals permitted one or two hours’ visiting each day. Similarly, in response to changing ideas of masculinity, hospitals increasingly allowed fathers to attend the births of their children. There were limits to the extent of such changes, but they still reflected well on a public welfare service that – compared with many other institutions founded in the 1940s – largely escaped widespread denigration as monolithic or unwilling to adapt to social change.

A cultural force

The cultural prominence of the NHS also swelled in the postwar decades. Though the slew of art, films, television programmes, novels and music featuring the service was not always straightforwardly supportive, it did help cement the service’s status as a pivotal part of British life. At the cinema, the NHS provided the background for the risqué and slapstick humour of Carry On Nurse (1959) and Carry On Doctor (1967) – and in 1975, the prog rock band National Health named themselves after one of their frontmen’s spectacles, which were provided by the service.

Cultural material also passed comment on the universal principles behind the NHS. In her 1974 novel Second-Class Citizen, Nigerian-born novelist Buchi Emecheta captured the experience of using the service as a person of colour. The protagonist, Adah, feels marginalised because of her class and race on a London maternity ward where everyone else is white. As in real life, gossip spreads easily on communal wards. Yet, for all the challenges she faces, Adah expresses gratitude for the companionship that such spaces could engender in the NHS. The convivial atmosphere of a maternity ward, where women “seemed to have known each other for years and years”, encourages Adah to adopt a “new code of conduct” and gain the confidence to leave her abusive husband.

Films, TV shows and novels helped cement the NHS’s status as a pivotal part of British life

Emecheta’s novel spoke to the connection between decolonisation and the NHS. When the service was launched, Britain’s colonies were beginning to secure independence, including India and Pakistan in 1947, Malaya in 1957 and Nigeria in 1960. Thousands of people from the nations of the reimagined ‘New Commonwealth’ journeyed to Britain to work and build lives, and the NHS employed and cared for many such immigrants. In fact, the service’s guarantee of universal healthcare would not have been possible without them: thousands of doctors, nurses, technicians, cooks, porters and cleaners from overseas performed essential tasks during the postwar labour shortage. By the start of the 1970s, for example, almost a third of all NHS doctors had trained overseas, most in India and Pakistan.

Despite their invaluable contributions, such employees were sometimes subjected to racism from colleagues and patients. In rare cases, patients sometimes even asked to be treated by a white doctor or nurse instead of someone of colour – and, shockingly, on occasion NHS hospitals acceded to such requests. As patients, some people from the Commonwealth were met with hostile refusals of their ‘right’ to access NHS services, regardless of their status as British citizens. And in his infamous 1968 ‘Rivers of Blood’ speech, Conservative MP and former minister of health Enoch Powell claimed that hospital beds – along with council housing – were being overrun by Commonwealth immigrants.

As the NHS became increasingly understood as a distinctly ‘British’ achievement, discussions about who belonged in the service and who did not became more sharply polarised. The idea of ‘our NHS’ built support for the institution – but could also lead to the exclusion of those who were not white or who had arrived from beyond Britain’s borders.

Shock to the system

The NHS, along with other parts of the welfare state and public industries, faced serious challenges during the economic and political turbulence of the 1970s and 1980s. The oil crisis of 1973 shook the industrialised world, resulting in record fuel prices, soaring inflation and job losses. Successive Conservative and Labour governments struggled to get a grip on the economy in the years that followed, and various political projects migrated from the fringe to present new solutions. The politics of neoliberalism – characterised by a belief in free markets and competitive individualism – gained greater purchase on debate and policy, with politicians, businesses and intellectuals advancing free-market priorities.

By the 1980s, Margaret Thatcher’s government was following this political approach. But the prospect of privatising the NHS – which now rivalled pensions as the largest recipient of government welfare spending – represented a major challenge. Indeed, the size, practices and values of the health service comprised an enduring emblem of social democratic politics. The fact that the institution’s prominence wasn’t successfully undermined was not due to a lack of desire or effort. The prime minister’s famous 1982 remark that the service was “safe with us” obscured a longer history of opposition to the NHS.

Thatcher’s remark that the NHS was “safe with us” obscured a longer history of opposition

During the 1960s, Thatcher and key members of her government had belonged to important health policy groups within the Conservative Party that advocated marginalising or even abolishing the health service. On the eve of the 1979 general election, one such group stated that the NHS was “better discarded altogether and a fresh start made in light of knowledge accumulated and experience gained”. In line with free-market principles, this group maintained that a health system based on private health insurance would encourage greater choice and self-reliance, raising more money to spend on medical care in general.

In the early years of Thatcher’s government, an internal committee in the Department of Health and Social Security explored such ambitions. They met little success, though, because of the difficulties of replacing a system as large as the NHS, instability within the private health insurance market, and soaring popular support for the existing nationalised system as a uniquely ‘British’ achievement. For the champions of markets within healthcare, reforming the internal structures of the service – rather than its total removal – seemed a viable alternative option. If fortress NHS could not be besieged from without, then perhaps it could be compromised from within. The policies that followed this shift in approach included outsourcing work such as hospital cleaning or laundry to private companies, the introduction of management principles in the NHS that were comparable to the private sector and, in 1990, the implementation of an ‘internal market’ to ensure greater competition.

Premature diagnosis?

This marketisation of the NHS’s functions from the 1980s escalated an atmosphere of crisis. For many, the legislation that enabled companies to take over catering contracts, or the slick managers employed to help the service follow ‘business principles’, marked a betrayal of the service’s founding values. The government’s stringency with the NHS’s budget increases during the 1980s compounded concerns over its capacities.

To be sure, these policies never went as far as anticipated by their neoliberal promoters in think tanks and businesses. At the start of the 21st century, most of the NHS’s workers remained employed in-house, and it still delivered the overwhelming majority of healthcare to Britons. For all of the newspaper headlines heralding a private sector ‘takeover’ of the nationalised service, companies often struggled to make headway because of the difficulties involved in complex procurement processes, or the pro-NHS campaigners who quickly seized upon any of their perceived failings.

Nonetheless, due to this process of marketisation, predictions of the NHS’s actual or imminent demise became ever more common. In a typical example of this sentiment at the end of the 20th century, one protester at a march against budget cuts carried a small coffin emblazoned with the slogan: “NHS died 1985 – RIP”. These claims of crisis focused public attention on the service, and helped build further support for the institution. The 1970s and 1980s represented the transition point in the public standing of the NHS – the moment when it became most central to politics and understandings of British identity. The service’s prominent place in the popular psyche was demonstrated by a boom in events celebrating its birthday on 5 July. During the 1980s, trade unions established ‘NHS Day’ as a popular tradition, with family-centred events such as donkey rides and galas combined with protests and petitioning.

Such events marking the service’s anniversary encompassed both a celebration of its principles and a push back against what trade unions described as ‘privatisation’ under Thatcher’s government. When Tony Blair’s New Labour came to power in 1997, it smoothed out some of the more radical elements of this cultural practice, and made it a national phenomenon. For the NHS’s 50th birthday in 1998, commemorative 50p coins were issued, a garden party was held at Buckingham Palace, a ceremony was staged at Westminster Abbey, and government-sponsored exhibitions took place, confirming the ascent of a popular cultural tradition originally framed by a sense of crisis.

Again, the involvement of trade unions, campaigners and the Labour Party underlined how building wider support for the NHS required the active involvement of its supporters. It wasn’t inevitable that the service would retain its prominent place in British life. It was the result of fierce struggles between those who advanced social democratic and neoliberal politics in healthcare, as well as a context of crisis during the 1970s and 1980s.

Alarming prognosis

At least in public, leading politicians in all main political parties now support what they regularly describe as ‘Our NHS’. This trend became obvious in the aftermath of New Labour and its escalation of the NHS’s cultural significance in British public life. For the service’s 60th anniversary in 2008 David Cameron, then leader of the opposition, even visited the ‘first’ NHS hospital in Manchester to praise the institution. None of his predecessors in his party had undertaken such an act, yet it now seemed natural for him to do so.

Even so, today the NHS again faces serious challenges. Depending on the NHS Trust, these financial difficulties could be made worse by longer-term debts from New Labour’s Private Finance Initiative (PFI), which used private capital to build facilities as part of long-term contracts with construction companies, management consultants and private equity firms. The Conservatives initially continued PFI but abandoned it in 2018 due to a lack of cost-effectiveness.

In the wake of the 2008 financial crisis, the government restricted the annual budget increases for the NHS. And since 2010, funding for the service has seen its largest sustained reduction relative to overall GDP since the 1950s. Without annual budget increases – needed for any health system to keep pace with the rising costs of medical care and the growing demand for services – older facilities have not been upgraded, and thousands of vacancies have remained unfilled. On an everyday level, patients’ access to NHS services became more restricted as waiting times and lists ballooned. During the 2010s, the number of people waiting for hospital treatment rose from 2.5 million to 4.6 million – the highest number ever – in England alone. From 2020, the Covid pandemic compounded these difficulties as appointments were postponed and, once government restrictions were eased, exhausted staff struggled to meet demand.

The NHS is not unique in facing these troubles. Most health systems worldwide are experiencing related problems, and their patients express similar concerns. According to an Ipsos 2022 survey of more than 23,000 people in 34 countries around the world, three out of five respondents believed that their own health system was seriously overstretched. Moreover, the NHS has faced moments of serious crisis before, and recovered. It is not impossible that the service – and the wider social democratic principles it represents – might rebound in the future. And the history of the NHS suggests that, in order to address internal difficulties, it will need its supporters among the British public.

Read and hear more about the history of the NHS

This article was first published in the August 2023 issue of BBC History Magazine