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The State and Medical Care in Britain

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The State and Medical Care in Britain THE STATE AND MEDICAL CARE IN BRITAIN: POLITICAL PROCESSES AND THE STRUCTURING OF THE NATIONAL HEALTH SERVICE A Dissertation Submitted to the Faculty of Economics and Politics in Candidacy for the Degree of Doctor of Philosophy by Keith William Lowe Wolfson College University of Cambridge July 1981 © K. Lowe 1981 Abstract The creation of the National Health Service is treated, analytically and historically, as a planning process involving major changes in the social organisation of health as a part of the larger set of social and economic reconstruction policies undertaken by the wartime Coalition and postwar Labour governments. Definitions of 'health' are considered as relative both to social expectations and ideology, and to theoretical models of the organisation of health services. These models are identified with certain socio-political agents or interests in the providing and consuming of health services: professional groups, public and private authorities, non-professional workers, and the public. The models of the health service advocates and of the medical profession are considered as reference points. A framework is presented for the analysis of the representation of these interests, by the state, in the planning and operation of the NHS, and as beneficiaries of its services. Through a detailed historical consideration of internal health service planning documents of the major interests, including the medical profession, the health service advocates representing the Labour party and trade unions, and recently released documents of the Ministry of Health and the Coalition and Labour Cabinets, the interaction of the interests with the two governments and with each other is traced, and the reconciliation by the state of the health service models proposed by them is analysed. It is argued that the changes wrought in the social organisation of health in Britain can be described according to certain principles of the organisation of pre- and post-NHS health services: principles of public access, structure of services, structure of administrative control and structure of planning representation. Tne major interests were represented differentially by the state with respect to each of these criteria; similarities and differences between the approaches of the two governments to the representation of interests are examined, and it is concluded that, although the health service advocates and the public benefited from a free and universal scheme, the public and non-professional health workers enjoyed considerably less representation than the medical profession in the particular services provided by the NHS and in its planning and administration. i Acknowledgements The author wishes to acknowledge the assistance provided by a number of individuals and institutions in the preparation of this dissertation. Staff members of the libraries of the British Medical Association, the Department of Health and Social Security, the Trades Union Congress and the Labour Party were of great assistance in making documentary and archival materials available; Mrs Irene Wagner of the Labour Party Library facilitated the arranging of appointments with a number of contemporary political figures. The late Dr David Stark Murray generously arranged to make materials of the Socialist Medical Association available. In Cambridge, thanks are due to the members and staff of WOlfson College for their warm encouragement and hospitality, and to Mr Ray Jobling, St Johns's College, for his supportive supervision through the early formulation and research stages, and his forebearance in dealing with manuscripts submitted from Canada. Dr Alan Boulton, Director of Psychiatric Research, Saskatchewan Department of Health, is due special thanks for his enthusiastic encouragement and assistance to a doubly-occupied researcher during the drafting and editing of the dissertation. The research was supported by a Doctoral Fellowship from the Social Science and Humanities Research Council of Canada. Typists Louise Powell and Louise Bors made contributions far beyond the normal call of duty. This dissertation is the result of the author's own work and includes nothing which is the outcome of work done in collaboration. ii List of Abbreviations BHA British Hospitals Association BMA British Medical Association COHSE -- Confederation of Health Service Employees DHSS -- Department of Health and Social Security GMC -- General Medical Council GP -- General Practitioner KERF -- King Edward's Hospital Fund for London MP -- Member of Parliament NALGO National and LOcal Government OffIcers' ASSOCIatIon NCL -- National Council of Labour (of the Labour Party, Tue and Co-operative Congress) NEC -- National Executive Committee (of the Labour Party) NHS -- National Health Service NUPE -- National Union of Public Employees PEP Political and Economic Planning PLP Parliamentary Labour Party PRO Public Record Office SMA Socialist Medical Association TUC -- Trades Un~on Congress iii ._. ---_ ... ---- - ....-- .. -----.-.--------.----------.~-.---~--~-------~---~-.- --~.-- ------~-----~---------~~~ .-._-.- -_.------_ .•.- --- .. ----.-----.------------~-- ---- --- --- ---- -----.----.-~.- ---_. -~. - --~- --- Table of Oontents Abstract i Acknowledgements ii List of Abbreviations iii Table of Contents iv 1. Introduction: Historical and Theoretical Approaches to the Study of the NHS 1 2. From the Poor Law to National Health Insurance and the Inter-War Debates 64 3. Health Services in War and Reconstruction 109 4. The Advocates of a National Health Service: Groups and Is·suesintheEarlyPlanningPeri6d - -144 5. Government Planning After Beveridge: Health Minister Brown, the Medical Profession, and Wider Consultations 181 6. Advocacy and Response: The Challenge of the White Paper 214 7. 1942 to 1945: The Long Negotiations and Revisions, to the Last Word of the Caretaker Government 250 8. The Health Service Proponents: The Search for a Socialist Health Plan 291 9. The Government, 1945 to 1949: Continuity and Change in the Final Stages of Establishing the NHS 334 10. Conclusion: Structural Interests in the Planning of the NHS 377 Selected Bibliography 399 iv CHAPrER 1 INTRODUCTION: HISTORICAL AND THEORETICAL APPROAC~~S TO THE STUDY OF THE NATIONAL HEALTH SERVICE Themes of the Study The National Health Service is rightly seen as a most significant element .. of British postwar· social policy, a landmark in the transformation of social and economic relations accomplished under the aegis of the state. It bears important structural similarities and differences to schemes for the provision of medical care undertaken by several western nations as part of their planning during the Second World War for postwar construction. It bears equally important similarities and differences to alternative model schemes advocated in Britain in the same period by representatives of the organised medical profession and, on the other hand, by representatives of the socialist and labour movements. This study is concerned, historically and theoretically, with the formation of state policy leading to the implementation of the National Health Service (NHS) in Britain in 1948. The processes involved in this policy formation, it is suggested, are essentially political. They may be analysed through a variety of approaches, from the empirical and historical to the abstract and theoretical, from particular debates and negotiations over health policy to the more general imperatives, based 1 on the nature of a mid-twentieth century capitalist economy and society, toward state intervention in the creation of major health and social service systems. The concern here is to locate and analyse debates, campaigns and negotiations over the main principles and structures of the NBS within the context of the political dynamics of an advanced capitalist society, in particular within the context of the wartime reconstruction of economic and social relations in Britain. The analysis can be seen as a contribution to the ongoing discussion of the welfare state. Most of the main historical accounts of the genesis of the NBS focus upon the conflict between the British Medical Association (BMA) and the two governments. Both the theoretical and the historical intent here is to shed some light upon what might be thought of as the other side: the advocates of a state health service who took their position on behalf of the public as consumers of health services and on behalf of the large number of non-professional workers in the health services. These groups held, as part of their overall political or ideological position, that only a state-provided, fully comprehensive and co-ordinated health service, open to all without financial or other eligibility barriers would be an adequate replacement of the chaotic and class-biased system then in existence. Democratic organisation, the rights of health workers and the addressing of preventive and occupational health issues were especially emphasised. This position was taken as part of the reform programme of the labour movement, and by socialists as part of the programme for the transition to a socialist Britain. This position has not, as yet, received a great deal of attention in the literature on the history of the NBS; nor has the relationship of 2 the health service advocacy campaign to the government policy making process, and to its outcome, the NHS Act and its amendments. It is hoped the study will make a double contribution to the welfare state discussion, first through its specific historical approach,
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