Making and Breaking

Nobody could call Frank Honigsbaum’s book ‘user friendly’. Some reasons for its indigestibility are inherent in the topic: the moves, some effective, most frustrated, by civil servants and politicians, towards the creation of the British National Health Service. But there are also self-inflicted handicaps to ready comprehensibility: the author has done his best to impede communication. His structure means that he tracks through the period 1936-48 several times and with the year not always discernible, for he takes the plans of civil servants for general practice as one story, for hospital services as another, and then looks at the discussions of the financial issues. Much of the writing is in the form of initials, and the table of these given is not comprehensive. A further shorthand leads to the suppression of many of the small words that ease communication, the ‘the’s’, ‘that’s’ and ‘to’s’, so that at times the prose reads like headlines. Some sentences have got away with hanging participles, mistakes in number or misuse of subjunctive tenses. This is hard going.

This is a pity because the story has real and contemporary interest. It would have more if it were more complete. The author assumes an acquaintance with the main aspects of medical aid and welfare between the wars, and so does not set them out. The party politics are also taken for granted. The nearest models to the later health service are ignored: there is not mention of the medical service for schools, and only a casual glance at the Highlands and Islands service with partly salaried practices. There seems to be a misunderstanding of the main features of inter-war welfare, for the author states that many unemployed had no resource but the disablement benefit once they had exhausted unemployment insurance. This view is remarkable considering the amount of Parliamentary time devoted to the variously christened assistance by which the great bulk of the unemployed was sustained. Has the author not heard of the ‘dole’?

The first part of the book shows the persistent efforts of the Civil Service to widen the so-called National Health Insurance system which covered only the employed adult workers, into a really national provision under local government control, and the equally persistent refusal by the doctors of two basic parts of this package, salaries and local government control. The doctors were not totally against salaries: if large enough, they would have been acceptable. But any effective form of local government authority was rejected. Many months of planning went into a White Paper in 1944 which the British Medical Association turned down flat. Yet some sort of agreement had to be reached, for a health service really national in scope had been one of the pre-conditions of the Beveridge Report, and the Government was pledged to realise the principles of that report. The Government had also explicitly promised a national hospital service, but discussions with the Royal Colleges of Surgeons and Physicians were even more difficult than with the BMA. There were rivalries between the Colleges, between the London hospital consultants and those elsewhere, and most of all between the prima donna figure of Lord Moran and everybody else. But the hospitals could not survive as they had been. There was no likelihood that the voluntary ones could go it alone because the level of taxation was high enough to preclude the charity they would need. Collecting silver paper would not see them through. Also there simply were not enough trained consultants in existence, so that hospitals were not neatly cut off from general practice. This book gives many examples of the consultants’ hostility to the general practitioners who also acted as surgeons, but does not note the view of some medical men of the time that though their surgical death rate may have been too high, they were often, as GPs, very good diagnosticians.

The voluntary hospitals were of all sizes and all qualities, and among their élite the teaching hospitals provided an additional problem of to which department the cost of their teaching belonged. It was not just the location of costs that provided puzzles. Nobody knew what a more uniform and adequate general practitioner care would cost. The civil servants suggested that the equipment for a practice could be bought for £10 while the Government actuary said £200. Even less was known about what would have to be paid to dentists if the great bulk of the population, which had opted for toothlessness rather than restorative work, was to change its mind.

The story here shows the traditional way in which legislation was built up normally. Civil servants planned changes and consulted with the interests concerned. Committees, carefully picked, were set up to advise. Gradually some piece of ameliorative change would be made ready for the statute book. But when a drastic and rapid transformation is required this method is useless. For one thing, the interests consulted are not the public interest, but the vested ones. Some of the schemes proposed by the civil servants here would have drastically reduced the national aspect of provision. The wartime party truce prevented reconstruction plans from having a head of political steam. It was not until Labour was in power and the health service project had been handed to Bevan that the public interest could become effective.

Honigsbaum brings out well the mixture of flexibility and firmness with which Bevan handled the vested interests. Not least among these was his Cabinet colleague Herbert Morrison, fiercely protective of the hospital system built up by the London County Council. Bevan, facing the main division within the medical profession, bought off the two parts with different compromises. The general practitioner was not to be a salaried employee, the consultant could add private practice to salaries already generous. In addition, the somewhat disreputable system by which doctors in secret allot themselves handsome supplements as ‘distinction’ or ‘merit’ awards was set up. But Bevan stood firm on forcing the existing institutions into the service. The sale of practices was to end, and the hospitals were nationalised. The result was that primary medical care became available for the 70 per cent or so of the population who had not been within national insurance, the families of wage-earners, and that less secure but still important access to secondary care in hospitals was also available. For the first time young adults who needed spectacles or tooth repair could get it free.

The book closes with the legislation, and does not, therefore, discuss the timeliness of the whole achievement. Chemotherapy was then still confined to two effective drugs; many more were to follow in the Fifties, and and at vast cost. Complicated new lines in surgery still lay in the future. If the unknown, but in fact moderate, cost of the service was a problem in the Forties, it is horrific to think what sort of hurdle this would have made twenty years later.

How relevant today are the lessons of this story? The reader has to raise as well as answer this question, for it is not set out in the book. Our present government has no use for the traditional way of building legislation by consultation with the interests – the nearest it gets to communication with the doctors is to offer insults – and it feels it necessary to evaluate all services primarily in terms of cost. The ‘reforms’ to be pressed on the medical system are much less drastic than the changes of the Forties, and the structure within which legislation will have to work is much simpler. The Health Service has a fairly uniform administration; it is no longer a mass of local anomalies. The nursing and medical professions are organised more coherently, and if negotiation were to be allowed, have bodies well placed to speak for the mass. The big difference between today and the immediate postwar era is that the public, the body of clients or consumers, is aware of the benefits the Health Service confers and regards them as a right. Consumers are easily reached by propaganda from the doctors, and the propaganda, naturally, is directed specifically at those who go to the practices – that is, at those who have medical needs. The rest of the voting public can be reached by government propaganda supporting the ‘reforms’, but many among this section may still be happily thinking that health problems are for others. The mass of the electorate is also aware that it is paying for the Government’s propaganda by taxation, while getting that of the profession as a gift. It is by no means clear that alterations to the Health Service, certainly easier to achieve than was Bevan’s task, will be without electoral cost.

Marina Warner’s pamphlet is about the sad state of many children under our present government. It is a pleasant change from Honigsbaum, for she sees it as part of the author’s job to be readable. The work is an elegant and moving description of the life of the poor, showing how those looking after children, usually their mothers, on a small income are treated as less than citizens. Their children not only have a narrow physical and cultural existence but also receive some of the frustration and resentment engendered in their parents.

There is a serious branch of social demographic thought discussing the similarities between babies and consumer durables. The rich buy washing-machines, as do the poor, but they buy more expensive models: so with children. Family size does not vary much between classes, but investment in children does. There is the issue of whether one buys a tumble dryer or a dishwasher; does one go for a new car or a third child? Which will give more satisfaction and pleasure? Which will involve longer expense? I suspect that Ms Warner, if she had read this literature, would be horrified, because the concepts involved are dehumanising. But it forces home the fact that recently, and doubtless in other ages, we have tended to treat children as commodities, not as individuals living their own lives, sometimes their own tiresome and inconvenient lives. In talking or writing about children at large, about their needs, their safeguarding, even their rights if the recent United Nations Convention is to be taken seriously, we ignore them as people. We also sentimentalise.

The process of bullying and bossing the mothers of small children took a major step forward in the so-called Children’s Act of 1908, which, among other things, made it criminal to take an infant into your bed after drinking alcohol. This was not so much from concern for the child’s view of life, for children probably preferred to be warm in the bed rather than cold in a sparsely furnished cot, but for manpower: ‘the nation cannot afford the likely loss of life’ was the note in Parliamentary debate. The process of restricting what mothers might do went on after women got the vote. In Sweden it has got to the stage of making the stray slap illegal. But it is not illegal here for parents to be squeezed into bed and breakfast hotels, put at the top of buildings without lifts, obliged to wriggle through turnstiles with push-chairs, unable to afford shoes for their children. Marina Warner’s vivid description of the stresses experienced by many mothers is welcome, except that it implies that children should in some way be immune from the unpleasant experiences of life. If cruelty to children is unacceptable so, also, should be cruelty to the old. If children have rights, it is because all human beings should have them. Marina Warner says that childhood should mean freedom from pain: it would be better to make that ‘unnecessary pain’. Both physical learning – what not to bump into or fall off – and social learning – what not to say or do – involve pain. It is one of the strengths of the great novelists of the 19th century in handling childhood that they show us vividly the pain of social learning. To propose childhood without it is sentimentality.