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Ideology and work in the early NHS

by Jack Saunders

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.

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