The NHS and the public: a historical perspective

This is the second in our series of guest blogs about the changing relationship between the NHS and the public. Here, Mathew Thomson, Professor of History at Warwick University, looks at the historical context of the public’s relationship with the NHS.

The Britain that sees the NHS approach its 70th anniversary is a very different place to that which welcomed a new National Health Service (NHS) in 1948. Any effort to analyse the relationship between the public and the NHS needs to take this into account. Britain has become a much wealthier society. It is also far more socially and morally liberal. Public expectations have changed radically as a result. There has been a tendency to assume that as a consequence of these changes Britain is also now far more individualistic, and less characterised by social solidarity. But we should be more wary about accepting this change than has sometimes been the case. This is partly because the effects of social and economic change have been uneven. It is also because it may be wrong to assume that material change is necessarily accompanied by a parallel shift in the realm of belief, emotional needs, and values. The current high level of public support for the idea of the NHS is perhaps a case in point.

Histories of the NHS have paid surprisingly little attention to public belief and meaning. We operate with powerful assumptions about what the NHS means now and has meant since its foundation, and we tend to assume this is a story of persistence and therefore continuity of belief, but this is all based on surprisingly fragile foundations. Building a more nuanced history is important if we are to better understand the relationship between the NHS and the public.

What might such a history look like? To begin with, it would need to question the powerful mythology around the coming of the NHS – a completely new system put in place as the result of a social revolution – and instead build up a picture of the relationship between the new service and the public from the ground up. This history would recognise that the public had to learn the NHS. It would also appreciate that relationships associated with pre-NHS medical care and developed over decades would have a legacy.

There is lots of evidence, for instance, to suggest that in the early years of the NHS many people initially and mistakenly thought about their relationship to the new service in the terms and language of National Insurance. This is unsurprising: the British public had experience of that relationship going back to 1911, and it had been at the centre of Beveridge’s much-publicised wartime blueprint for a new welfare state. To add to the confusion, a new and more comprehensive National Insurance system was launched on the same day as the NHS. One finds examples of people talking about having a right to medicines and appliances costing up to the weekly insurance contributions. Other patients explained continuing to use their existing GPs on a private basis on the grounds that they felt it was unfair to expect too much of a doctor who was only being reimbursed through the insurance payment. Others complained about the cost of the ‘compulsory contribution’. The responses varied, but the common factor was the consciousness of a specific sum set aside via National Insurance contributions to fund access to the new system.

The forging of a new relationship in 1948 was also undercut by the fact that in terms of buildings and people so little changed. Perhaps this was why there was less fanfare on the Appointed Day (5 July 1948) than one might expect. The NHS largely took over what was already there. This meant that it inherited a further set of meanings that could not simply be swept away by a change of name. Loyalties and attachments to local hospitals remained powerful and often offered a more concrete object of affection than the abstraction of a national system. Conversely, the distrust and stigma surrounding buildings that had been associated with the Poor Law and asylum system were hard to forget, casting a shadow over NHS care for groups such as older people and people with mental health problems or learning disabilities for years to come.

Equally striking is that the NHS in these early years did not forge for itself the kind of strong, distinctive, new identity that was perhaps presented by the opportunity. The limited funding to support a building programme was a factor, not least in relation to the promised health centres which might have provided a symbol for a new sort of NHS medicine. But so too was the absence of any obvious form of branding. Looking at photographs of the service from the period, or at the popular films that used it as a setting, one is struck by the absence of signals of identity that have now become so uniform and ubiquitous in marking out the NHS. Even the language for describing the service – initially often referred to as the ‘health scheme’ or ‘system’, rather than the ‘National Health Service’ or ‘NHS’ – took time to settle in.

If we accept this proposition that the NHS had to be learnt, we also need to be cautious in assuming that in signing up with GPs registered under the new NHS the public were consciously accepting a new social contract of rights and responsibilities. Whether the state saw it in such terms also merits examination. The legislation talked of the Minister of Health’s duty to promote the Act, not of the rights and responsibilities of patients. In sections of the media and government, talk of using the service responsibly soon followed, but this reflected mounting concern about the danger of the public beginning to treat the service as a right and of the costs this could entail.

The relationship that gradually emerged between the public and the NHS was therefore as much the result of experience as mandate, and was consequently less well defined and more varied than our generalisations have sometimes suggested. Central to the new relationship was undoubtedly the great benefit and, for many, the liberation of having free medical care. However, in practice this was a negotiated relationship, depending on the sanction of a still largely paternalistic and undemocratic medical system, and this modified a sense of rights.

To what extent did the series of social, economic and moral changes outlined at the start of this essay challenge and change that relationship from the 1960s onwards? There are certainly signs of rising public expectations about the quality of care, and about privacy and comfort. One can also trace a history of patients and family carers beginning to organise to represent their views.  In fact, concern about these issues came not just from pressure groups such as patient organisations but also from within the system itself. But transforming such a huge, bureaucratic, and under-funded system to overcome medical paternalism and turn patients from willing recipients of free care into active consumers would be difficult and slow.

Instead, since the 1980s the perception that the right to care was under threat seems to have been significant in turning the public into more active defenders of that right. Here, social solidarity trumped individualism as the insecurities arising from an era of social, economic and cultural change found succour in defence of the social security of free health care for all. In the process, a set of simplified ideas about the relationship of the British people to the NHS going back to 1948 became increasingly powerful and influential. By the 1990s, consciousness of what was to be defended was also helped by the fact that the NHS, which ironically was in many ways becoming much less of a single thing, was now more clearly marked out as the NHS through branding. All of this may help begin to explain why an era which has seen the rise of individualism has also paradoxically seen the British public become more attached than ever to the idea of a National Health Service. Once again, this suggests that the relationship of the British public to the NHS has changed, but perhaps not in quite the way that we often imagine.