Ideology and work in the early NHS

Conventionally understood, work is an economic activity driven by the necessity to eat, clothe and house ourselves and our families. For most historians of work, it is also social, concerned with the relationships between people and society, between capital and labour. We tend to expand on the popular idea of work as an economic activity and talk also of working conditions, hours, productivity, wages, as well as industrial relations, union militancy and job security. Sometimes, we also think about work in cultural terms, considering how different occupations spawn collective identities, shaping our sense of self and of our place in the world.

However, we tend to conceive of the cultural dimension in terms of how the job we do contributes to who we are outside of work. For instance, we discuss how coal miners’ shared experiences of danger and exploitation might have contributed to the formation of class-conscious enclaves in some 20th-Century pit villages, or how the monotony of the production line sometimes generated a sense of alienation amongst manufacturing workers in post-war Britain. But what about the workplace and the work process itself? Identity is not the only sense in which work is “cultural”. People generate “cultures” at work and develop complex ideas about what their work is and how they should behave when doing it. These ideas shape how they do their jobs, as well as the extent to which their employers can win “consent” for productivity.

The variety of ideas that employers and employees have about the work process constitute “ideologies of work” – values and ideas that describe how people think that they and others should act as workers. These ideologies are present in society generally (think of moralistic concepts like “work ethic” or “scrounging”), as well as being coded into particular workplaces. In our concept of the NHS, value-laden ideas about work abound. It’s common to hear people talk about the “dedication” of the service’s staff, as well as invocations of “innovation”, “loyalty”, “self-sacrifice” and “professionalism”. On the other hand, we also hear regularly about concerns over “inefficiency”, “neglect”, “waste” and “resistance to change”.

The early years of the NHS were equally suffused with “ideologies of work”. As the politician most associated with the health service Nye Bevan was one loud voice in determining the cultural meaning of NHS work, reflecting on multiple occasions on the nature of its workforce. His most famous remarks were reserved for doctors, whose reticence about the early NHS threatened to impede its initial establishment. Bevan’s claim to have “stuffed their [consultants] mouths with gold” helped establish the idea of senior doctors as largely financially-motivated and self-interested when it came to public service, an attitude that stood uneasily next to the idea of the NHS as the realisation of “socialist principles”.

Bevan’s affirmations regarding doctors helped create, through criticism of non-believers, the idea that work for the NHS was a great exercise in patriotic socialism and of service to the people, something he reaffirmed when talking to other health workers. Alongside his intense negotiations with the British Medical Association, in his addresses to nurses, Bevan employed them as the best example of the new service’s values. Speaking at a conference organised by the Royal College of Nurses one month before the appointed day, Bevan looked to turn on the charm. “Nurses – I can say this as the doctors are not here – are the most important part of the Health Service”.

Whilst Bevan was imagining a workforce of dedicated health workers engaged in making a “socialist NHS” come to life, newspaper commentary echoed senior civil servants in worrying about the cost of the new service. Rather than a “dedicated” workforce, early reports emphasised the dangers of a spendthrift one. For instance one editorial in The Times (despite the paper being generally sympathetic to the NHS) worried in February 1949 that the infant service was overspending at an alarming rate, perceiving an “internal pressure towards lavish expenditure” by Regional Health Boards.

Such concerns set the terms for the first major inquiry into the functioning of the service, the 1956 Guillebaud Report. Largely written by left-leaning economist Brian Abel-Smith, the report defended the service’s cost-effectiveness, noting in particular the “responsible attitude among hospital authorities” towards the “efficient and economical” use of public funds. The report praised the thoroughness of the service in reducing staff numbers from 1950 onwards. Guillebaud thus simultaneously refuted accusations of “waste”, whilst accepting “efficiency” as a the most pertinent framework for understanding the service.

Debates over its efficiency have recurred constantly since the service was founded. For workers in the early NHS, the ideals that were supposed to drive their work were already a matter for fierce public debate. Arguments over their supposed “profligacy” and “inefficiency” came from parliamentarians, civil servants and from journalists, asserting conflicting expectations around their levels of “dedication” and their twin duties of care to the patient and responsibility for public funds. Much of the agency in these processes was, predictably, projected onto the most powerful groups in the service – hospital authorities and doctors, with nurses and ancillary workers largely absent from these debates. Discussions over their role and their “dedication” would only become more urgent as both the NHS and British workplaces saw more industrial conflict in the form of strikes and protests in the 1970s.

Discerning how far this peculiar public discourse on health work penetrated the actual working lives of the NHS’ workforce and the ideals they brought to their work is difficult, but vital if we are to understand how the “cultural meaning” of the NHS may have shaped the values and behaviour of its employees.

Do NHS staff have “ideals”? Tell us what you think in the comment section, or tell us about your own experiences of NHS work in our life history survey.

Australian Labor’s “Medi-scare”

Recent weeks have seen campaign buses emblazoned with contested slogans about healthcare touring two countries on opposite sides of the world. In the run-up to Britain’s referendum on its European Union membership, the Electoral Commission declared Vote Leave’s £350million per week slogan to be ‘misleading’. Certainly some voters decided to vote ‘leave’ in the mistaken belief this was a promise extra funding for the NHS. A week later Australians went to the polls. Even before the final result was known, the incumbent Liberal Party had reported the opposition Labor Party to the police for one episode in what is being dubbed, by some, their “medi-scare” campaign.

“Mr Turnbull’s plans to privatise Medicare will take us down the road of no return. Time is running out to Save Medicare”, read a text message sent out on election day by Queensland Labor but appearing to be sent by ‘Medicare’. This was the reported provocation, but it was only part of a larger campaign strategy described by the Deputy Prime Minister, Julie Bishop, as a “monstrous lie”. As in the UK, this came under the spotlight in the wake of a surprising result. While the UK narrowly voted to leave the EU, the widely-predicted comfortable re-election of Australia’s centre-right Liberal/National Coalition turned into a shockingly close contest, leaving PM Malcolm Turnbull waiting more than a week for confirmation he would have enough MPs to remain in office.

buses

So, what is Medicare? This universal health insurance scheme was originally called Medibank when introduced in the 1970s, before being reaffirmed and rebranded with the Medicare name borrowed from the US in the 1980s. It was one of the Whitlam government’s progressive reforms blocked by the conservative Senate in a stand-off only resolved by a rare double dissolution, prompting elections for all seats in both the House of Representatives and Senate. While Coalition governments have repeatedly encouraged private insurance opt-outs, at the heart of the system remains the mechanism of bulk billing. This means the doctor accepts a slightly reduced rebate from Medicare (covering 85% for outpatients and 75% for inpatients) and cannot charge any additional charges to the patient, but equally they avoid the hassle and cost of billing and debt collection. This was the Whitlam government’s way to incentivise extensive coverage without establishing an Australian NHS. The current rebate freeze (introduced by Labor in 2013 but set to continue until at least 2020) makes that incentive less attractive, with Australian GPs warning they might abandon bulk billing altogether as costs rise and move instead to charging patients perhaps a $25 fee for each visit. Labor ran hard on the message that government policies would make it more costly to see the doctor.

ALP medicare cardLabor managed to set the agenda as they took their Medicare campaign online and associated it with local hospitals in marginal seats. As they promised to end the rebate freeze and broadened out to funding for hospitals and drugs, the Coalition found themselves having to uncomfortably defend a whole host of complex policies from the simple charge of ‘privatisation’. Their position was made harder by the fact their health policies have been changing even faster than Australian Prime Ministers in recent years. In less than three years, the Coalition government’s policy proposals and u-turns have included making patient co-payments ranging from $5 to $15 a condition of bulk billing and cutting medicare rebates by more than half. Meanwhile, policies they have introduced and kept included maintaining the rebate freeze and calling for private sector expressions of interest in taking over the entire Medicare and Pharmaceutical Benefits Scheme. It turns out  that “outsourcing is not privatisation” is a less successful campaign slogan than “Save Medicare”.

It’s not the place of a British historian to take sides in this debate. Liberal spokespersons are not lying when they say they have (now) no policy to make doctors charge patients or to disband the medicare system. However, neither are the Royal College of Australian GPs when they say the government’s policies will have the effect (intended or otherwise) of discouraging bulk-billing and encouraging them to increase charges. Whether or not this can fairly be described in the way the Australian Labor Party has is for a matter for Australia’s voters today and her historians tomorrow.

labourshealthservice-1What I can offer is some comparison of the way healthcare plays in Australian and British election (and referendum) campaigns. Indeed, much looks remarkably similar. In speeches, on placards and even emblazoned on a banner attached to a plane flying around Perth, the ALP has been running hammering home the simple message: Vote Labor, Save Medicare. This has been a common theme in British Labour campaigns. Since the very early years of the NHS, election posters reminded voters that the Conservatives had voted against its creation and suggested the party could not be trusted with it. Even the Labour Prime Minister least associated with social welfarism, Tony Blair, came to power with the rallying cry on the eve of the 1997 election that the British people had “24 hours to save the NHS”.

And this is not just opportunism at election time. Healthcare reform has an important part in the folk history of both parties. For British Labour, the NHS has become an emblem of the postwar welfare state established under Clement Attlee in just six years – more familiar and tangible than reforms to social security or the like. Its continuing popularity (greater than that of the Monarchy or the BBC) gives Labour a place in a comforting national story, while the Conservatives will perhaps always be seen by many as the ‘natural party of government’. For Australian Labor, wheeling out 1980s Labor Prime minister Bob Hawke reinforces this sense of history. Indeed, the foundation of Medibank/Medicare is bound up with the even-shorter-lived progressive government of Gough Whitlam, one of a number of long-lasting reforms passed in less than three years before the government was dismissed by the Governor General in the most dramatic and controversial episode in Australian political history.

While there are differences between the Australian federal insurance system and the nationalised health service in Britain, this issue of who pays the doctor has some similarities. In particular, GPs are not salaried employees of the state, which means arrangements for paying them to see Medicare/NHS patients is a perennial headache for policymakers. But does that regularly spill over to become an election issue? It is tempting sometimes to consign NHS prescription charges as a political issue to history – being put to rest when Harold Wilson’s 1960s Labour government reversed its own abolition of them – but that overlooks the vast exemptions introduced after 1997 and their abolition by devolved administrations in Wales (under Labour in 2007), in Northern Ireland (under the power-sharing Executive in 2010) and in Scotland (under the Scottish National Party in 2011).

While prescription charges may be a live issue, and the six years of David Cameron’s Coalition and Conservative governments have been dogged by controversial structural reforms of the NHS and the ongoing contract dispute with the junior doctors, any notion of paying to visit the doctor has been kept firmly off the agenda. In this sense, although the NHS may have been reformed beyond recognition from that founded by Health Minister Aneurin Bevan in 1948, it is still committed to the “collective principle” he outlined in his 1952 book In Place of Fear:

“The collective principle asserts that the resources of medical skill and the apparatus of healing shall be placed at the disposal of the patient, without charge, when he or she needs them; that medical treatment and care should be a communal responsibility that they should be available to rich and poor alike in accordance with medical need and by no other criteria. It claims that financial anxiety in time of sickness is a serious hindrance to recovery, apart from its unnecessary cruelty. It insists that no society can legitimately call itself civilized if a sick person is denied medical aid because of lack of means.”

The fact that Australian Labor’s “medi-scare” struck such a chord suggests both that the electorate was ready to believe the worst. The Conservatives may equally find the British people are ready to believe the worst about them, with Theresa May’s warning from fifteen years ago, that many see them as “the nasty party”, still echoing as they set about the task of establishing a post-Brexit vision of Britain. In fact, the Deputy Chairman of the party recently warned that “working people” see them as “the party of BHS and not the NHS – by BHS I mean the corporate, awful revolting people like that Phillip Green and the dodgy guy he sold it to”.

As she enters Downing Street, however, one of Theresa May’s many challenges is to unite the moderates in her party with the typically more right-wing Brexiteers. They may have brandished half-promises of extra funding on the side of their campaign bus, using the NHS as a national rallying cry, but they tend to be from the traditionalist wing of the party where antipathy towards the NHS is not hard to find. Former Conservative Prime Minister John Major memorably highlighted this during the referendum campaign:

“I mean the concept that the people running the Brexit campaign would care for the National Health Service is a rather odd one. I seem to remember Michael Gove wanted to privatise it. Boris wanted to charge people for using it. And Iain Duncan Smith wanted a social insurance system. The NHS is about as safe with them as a pet hamster would be with a hungry python.”

Yet the conventional wisdom is that high-profile jobs need to be found for prominent Brexiteers as Theresa May puts together her first government. Should anyone with such sympathies be considered for a stint at the Department of Health, she would do well to learn from the Abbott/Turnbull government’s hard-learned lesson that even dabbling with the idea of charging patients opens you up to accusations against which it can prove difficult and costly to defend yourself.

My thanks to Evan Smith and Chloe Ward for their Australian history and politics readings tips.

The ‘Appointed Day’: Celebrated or Silent?

With all the tumult that continues to surround the recent EU Referendum and its results, it seems likely that yet another anniversary of the National Health Service’s first day of operation will pass with little notice this week. It is now 68 years since the National Health Service officially opened its doors on 5 July 1948, the so-called ‘Appointed Day’, designated by the National Health Act of 1946. The first NHS baby, Aneira Thomas – born at one minute past midnight on the Appointed Day in the Amman Valley cottage hospital (see its now-abandoned and decaying maternity wing here), not far from Bevan’s own birthplace in Tredegar where a workers’ health cooperative inspired the all-encompassing remit of the NHS – is now herself a pensioner, retired from a life serving the NHS as a mental health nurse. Her sisters and daughter too have lived NHS lives, working as nurses and paramedics.

As an adult, Thomas has expressed great pride in her role, her namesake, and the NHS itself. But when did her unique claim to fame become meaningful to Thomas? Interviewed in 2008, as part of the ‘NHS at 60’ celebrations, she observed that as a child, ‘I never understood what the significance of it was… I just kept saying I was the first national health baby and didn’t understand what it meant.’ And indeed, historical evidence suggests that the significance of the NHS, and thus of its annual anniversary emerged rather slowly for many patients, and service users, and for politicians, professionals and ‘media-types’, too.

Of course, in 1948 – even more than today – the residents of Great Britain faced change on an overwhelming scale. Not only the NHS but a whole raft of services, benefits, and charges came into being between 1944 and 1948: in 1944, the Education Act introduced free secondary education; in 1945, the Family Allowances Act offered families financial support while the National Insurance Act extended a benefits safety net beneath the unemployed and the sick; in 1946, the Industrial Injuries Act gave yet further benefits to those injured at work, and in 1948, the Children’s Act mandated council provision of good housing and care to all children ‘deprived of a normal home life’, while the National Assistance Act came into force, providing ‘the last defence against extreme poverty’ (in the words of the Times newspaper) in the form of benefits available to anyone in need. Whole industries were nationalized, New Towns mushroomed, and existing towns and cities saw massive building – albeit newly constrained by a tightened belt of legally-protected green land. As the Daily Mail’s editorial put it on 3 July 1948,

‘On Monday morning, you will wake up in a new Britain – in a State which “takes over” all citizens six months before they are born, provides cash and free services for their birth, for their early years, their schooling, sickness, workless days, widowhood, and retirement. Finally it helps defray the cost of their departure. … You must begin paying next Friday… Everyone, from duke to dustman, earl to errand boy, must pay, even if they decline the free services or scorn the cash allowances.’

With so many new services, and the reshaping of an entire society, it is perhaps unsurprising that the NHS Appointed Day in 1948 prompted little media fanfare; while some national and local papers carried stories announcing the ‘birth’ of the NHS, few made it front page news, or included pictures to grab readers’ attention. This was not due to any shortage of photos: as well as an extraordinary wealth of news photography documenting the day, the Ministry of Works itself generated a substantial visual archive of the new services and their staff. These are the photos with which we have now become so familiar via celebrations of key NHS anniversaries: its 50th, 60th, and 65th birthdays, for example. But almost none were published in the national press on 5th July 1948. Instead, the front pages carried the usual selection of celebrities, crimes, advertisements, ministerial handshakes and the like. In Manchester, for example, chosen as the site for Bevan’s inaugural tour of his new NHS, the city’s main newpaper gave scant coverage to local events on the day, including a large thanksgiving ceremony honouring the advent of the NHS in the city’s cathedral. It did print a picture of Bevan’s July 5th visit on the inside pages a day later — but it titled the photo ‘The Transfer of the Hospitals’, a title which emphasised loss of local control and resources rather than the advent of a new universal health service. Nor was the Manchester Guardian alone in relegating news of the ‘Appointed Day’ to its inside pages, despite praising the NHS as a symbol of ‘the advance of equalitarianism’. After all, as the paper’s editor noted, ‘the new system of social security’ provided by the Ministry of National Insurance also came into effect on the 5th, and ‘unlike … the National Health Service, will make itself felt at once’, not least through higher taxes.

The Guardian (again, like many others, including the Daily Mail at the other end of the political spectrum) marked the first anniversary of the NHS not at all. Service users, at least, certainly had good cause to celebrate: in its first year, the new NHS had provided patients with 27,000 hearing aids; 164,000 surgical and medical appliances; 6,800,000 dental treatments; and 4,500,000 pairs of glasses – and these figures did not even include items supplied through general practice, hospital dental treatments, or the hospital eye services. Ilford, a photographic supply company, even bid for an additional £1,000,000 in new capital on the back of the National Health Service’s voracious appetite for x-ray films.

However, little more than a year after its birth, the NHS was already facing criticism. For example, some complained that it was a ‘National Ill-Health Service’, too focused on ‘the free provision of corsets, free wigs, and false teeth to all and sundry’, and caring for the unhealthy ‘at the expense of the healthy’. The NHS was, according to some, already encouraging ‘social parasitism’ (Manchester Guardian, 9 August 1949). Others grumbled about ‘abuse’ of the health service by ‘foreigners’ — claims that our own on-going debates about access to the NHS echo all too accurately, of course.

Perhaps in a climate of radical social change, environmental reconstruction, anxiety and seemingly permanent austerity (yes, I am still talking about 1949 here – though viewed from the midst of our current moment of change, it may be hard to tell), the chaos was simply too great to focus on celebrating what had been achieved. Or perhaps in ‘interesting times’, the urge to cynicism, scaremongering and sometimes bitter complaint serves as a vent for wider anxieties. As the 5th of July comes around again this week, we at the People’s History of the NHS will scan the papers for clues about the current meanings of NHS anniversaries – but we won’t be surprised if comments are scanty (or negative), and celebrations muted or absent altogether.