The Five Giants [New Edition]: A Biography of the Welfare State. Nicholas Timmins
![The Five Giants [New Edition]: A Biography of the Welfare State - Nicholas Timmins](limg_read341088.jpg "The Five Giants [New Edition]: A Biography of the Welfare State - Nicholas Timmins")
Brown, the leader of the National Liberals and Minister of Health in the coalition government, opened discussions with a tentative suggestion that doctors might be salaried local authority employees. Hill exploded. He warned a mass meeting of doctors to be ready ‘for a fight… [against] the translation of a free profession into a branch of the local government services’.29 In November, Brown was replaced by Henry Willink, and after the best part of a year of consultations, chiefly with the medical profession, the voluntary hospitals and the local authorities, the White Paper A National Health Service emerged in February 1944.30
Its opening statements were both noble and crystal clear: that everybody ‘irrespective of means, age, sex, or occupation shall have equal opportunity to benefit from the best and most up-to-date medical and allied services available’; that the service should be ‘comprehensive’ for all who wanted it; that it should be ‘free of charge’, and that it should promote good health ‘rather than only the treatment of bad’. It was now certain that a National Health Service, largely tax-financed, free at the point of use, and comprehensive, covering family doctors, dentists, hospital services and more, would arrive. Its precise form, however, remained far from clear. For Willink’s document was a compromise. It proposed some thirty joint boards of grouped local authorities who would take over the municipal hospitals, while Rucker’s suggestion resurfaced that voluntary hospitals should be free to make a contractual relationship with the boards ‘for the performance of agreed services set out in the plan’. Here in the most embryonic of forms was an outline of the internal market that the Conservatives finally introduced into the NHS in 1990.
Family doctors, the White Paper proposed, should be employed by a Central Medical Board, which would have the power to prohibit new doctors practising in over-doctored areas. GPs, who overwhelmingly worked single-handed, would be encouraged to group themselves in health centres provided by local authorities. While the precise methods of payment remained unclear, the White Paper said there was ‘a strong case for salary’ in health centres.
‘Like all compromise proposals designed to reconcile multiple and conflicting objectives, the White Paper left most of the actors involved feeling dissatisfied,’ Rudolf Klein has recorded.31 Local government hospitals had escaped nationalisation, but many local authorities would lose control of their hospitals, while the voluntary hospitals believed they would suffer ‘a mortal blow through the cessation of income from patients’. The GPs had escaped council control and retained the right to private practice (despite strong objections from Clement Attlee during the White Paper’s drafting); but they had no clear form of payment offered save the hint of salaries.32
The BMA’s council saw in the proposals ‘the thin end of the wedge of a form of service to which it is overwhelmingly opposed – a State-salaried service under local authorities’.33 The British Medical Journal, under its fierce, and fiercely independent, editor Dr Hugh Clegg, warned that if the ideas went through it was hard to see ‘how private practice as we know it today can survive as much more than a shadow of itself’.34 Willink’s White Paper went out to consultation. Well over a year later in June 1945, after Labour had left the coalition government but with the general election still to be held, he proffered a string of further compromises. These were approved by Cabinet and conveyed to the BMA in private, but not made public. The Central Medical Board and its powers disappeared. Health centres were to be experimental. Doctors both in them and outside were to be paid by capitation fees, not salary. Concessions were also offered to the voluntary hospitals. The new joint authorities were to be planning, not executive bodies, and the existing multiplicity of local authorities would retain control over their existing hospitals – a recipe for a dog’s breakfast if ever there was one. John Pater, a Ministry of Health civil servant at the time and future NHS historian, judged it a system ‘of almost unworkable complexity’, one which it was ‘just as well’ did not survive.35
This was the state of play when Bevan arrived. What Rudolf Klein has termed a ‘sedimentary consensus’ existed, built up over many years, that a National Health Service would be introduced. It was a consensus, however, marred by a profoundly suspicious body of doctors fearful of state control, plus a collection of other interests none of which were satisfied by what was proposed. ‘By the end of the war,’ Charles Webster, the official historian of the NHS has judged, ‘all the government schemes lay in ruins, while the powerful interest groups were more divided than ever they had been.’36
Bevan’s first act was to sink into the well-upholstered chair in his new ministry – and then banish it. ‘This won’t do,’ he declared, ‘it drains all the blood from the head and explains a lot about my predecessors.’ His second was to charm all around him. ‘He sold himself to the Ministry within a fortnight,’ Sir Wilson Jameson, the Chief Medical Officer, told Bevan’s biographer, Michael Foot. Sir William Douglas, according to Foot a natural Conservative who was nearing retirement, was transferred in as Permanent Secretary only to tell a friend a few days after Bevan’s appointment that he thought him ‘a terrible fellow. I’ll never forgive him for all those attacks on Churchill during the war. I made it clear that I would carry on only for three months until they’d got someone else.’ A few months later the same friend asked again what he thought of Bevan. ‘What are you driving at?’ replied Douglas. ‘He’s the best Minister I ever worked for. I’ve made it clear that while Bevan’s there, I’ll stay.’ The same charisma worked initially on the BMA council. ‘We expected to see a vulgar agitator,’ Dr Roland Cockshut, who was to become one of Bevan’s most fierce opponents, said. ‘… However, the first thing I noticed was that the fiend was beautifully dressed. We were quite surprised to discover he spoke English.’ He proved, Cockshut concluded, to have ‘the finest intellect I ever met’. He told the doctors he intended to do the job for five years when no previous health minister had lasted longer than three.37 The meeting ended with an ovation, and only the next day did council members start pinching themselves and asking ‘what the hell were we doing, cheering him yesterday?’ The British Medical Journal warned its readers that the Welsh Aneurin from whom he took his name was ‘both a bard and a warrior’.38
Bevan’s third act was to draw up the proposals that in March 1946 were to form the National Health Service Bill. Within his first month he reached the fundamental conclusion that Willink’s revised plans for the hospitals would not work. In his own words, he judged that Willink had ‘run away from so many vested interests that in the end he had no scheme at all’.39 His answer to the hospital problem was to take the lot, municipal and voluntary, into public ownership – the idea floated by the house governor of Charing Cross in 1930 and revived in 1939 by MacNalty as ‘revolutionary’ but ‘inevitable’, though it had never formed part of any government or party proposal. Sir John Hawton, the deputy secretary in charge of hospitals who in the 1950s became Permanent Secretary and who was for ever a Bevan fan, told Michael Foot:
At our very first full discussion, Bevan put his finger on the hospital arrangements devised by Willink as the greatest weakness. And, of course, he was right. They would never have worked. I came away that night with instructions to work out a new plan on the new basis he proposed.40
In this, Bevan made his biggest break with all that had gone before.
Bevan’s other key piece of business in the autumn and winter of 1945 was to strike up a close and, it was to prove, life-saving relationship with the Presidents of the three main Royal Colleges – the surgeons, physicians and obstetricians. Of the three, Sir Alfred (later Lord) Webb-Johnson of the surgeons and Lord Moran of the physicians were to be the pivotal figures. Webb-Johnson came to address Bevan in correspondence as ‘My dear Aneurin’.41 Moran, the former Sir Charles Wilson, was already an almost mythical figure. Distrusted in BMA circles as ‘Corkscrew Charlie’, he was Churchill’s personal doctor and was president of the physicians for a near-record nine years. Politically sinuous, vain, immensely able and determined to spread specialist care across the country, Moran told Michael Foot that he initiated the approach to Bevan because ‘the service was inevitable, so it at once became important, if the doctors were to have any say in things, that Bevan, as Minister for Health, should look upon them as allies and seek their advice’.42
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