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Securing the reluctant assent of general practitioners (GPs) was one of Labour health minister Nye Bevan’s most difficult tasks in founding the NHS by July 5 1948.
The events behind this have been the subject of two new plays in the west end of London: one by Michael Sheen, the other by Lucy Kirkwood. The events themselves are even more dramatic than Sheen and Kirkwood’s plays. Bevan’s eventual compromise with the doctors’ union representing GPs, the British Medical Association (BMA), still casts its shadow over health services today.
Bevan became minister on August 5 1945, inheriting a legacy of attempts to create a health service during the second world war. His Conservative predecessor, Henry Willink, failed in his negotiations with each of the different groups of doctors needed to work under a new health service. These different groups of doctors were the hospital specialists and consultants, local authority medical officers and GPs.
Where Willink failed, Bevan succeeded through a tactic of divide and rule.
To win over hospital specialists and consultants Bevan, in an infamous and perhaps apocryphal phrase, “stuffed their mouths with gold”.
Before nationalisation, hospital specialists and consultants had honorary contracts with prestigious philanthropic voluntary hospitals, earning most of their income through lucrative private practice. These private earnings rested on the reputation doctors had in their specialist field through their honorary hospital appointments.
Bevan’s bargain allowed hospital specialists and consultants who agreed to contracts with the new health service to continue their private practice. They also secured a shadowy system of distinction awards on top of generous salaries determined independently of government. Their resistance soon withered away.
Local authority medical officers were the least troublesome group of doctors to Bevan. They worked in local authority public health departments and municipal hospitals – effectively former workhouses – on a salaried basis.
With lower status and income than their specialist and consultant counterparts, they wanted all hospitals to be brought under local authority control. This was wholly unacceptable to hospital specialists and consultants who prized their independence and professional position.
Bevan squared this circle through the nationalisation of all hospitals: municipal and voluntary. These were controlled by new bodies that answered to the minister and government.
This satisfied hospital specialists and consultants while alienating local authority medical officers, ironically one of the biggest losers under the NHS, as they were the group who supported state intervention the most.
Troublesome
While Bevan bought hospital specialists and consultants and sold out the ideals of local authority medical officers, GPs remained troublesome throughout negotiations, right up to the day the NHS began.
Although today we see GPs as family doctors, before the NHS they were primarily workers’ doctors. Reforms in 1911 expanded access to GP services by ordinary working men through an insurance system, although this did not extend to their wives and children as dependants.
GPs reluctantly accepted the 1911 reforms, although pay for most became reliable if poor as part of a compromise agreement between the BMA and the government over the extent of state regulation.
GPs remained independent doctors who ran their own surgeries, maintaining their own list of patients. Poor pay from the 1911 reforms meant lists were bloated for GPs to remain afloat, especially in deprived areas. When negotiations began under Bevan, he was – in the words of the official historian of the NHS, Charles Webster – “entering a house haunted with the ghosts of 1911”.
GPs wanted improved pay, which looked derisory compared with the gold received by hospital specialists and consultants. Like their hospital counterparts, they wished to maintain their independence and were fiercely opposed to the salaried service.
They also wanted better conditions to reduce patient list sizes – which were promised but slow to materialise. It was these issues which meant that in January 1948, 84% of GPs in the BMA voted against the NHS.
What changed between January and July 1948 to make the NHS a reality? Time meant Bevan was forced to compromise more than he wanted, although most of the negotiations with the BMA were actually handled by Lord Moran, president of the Royal College of Physicians.
First, GPs maintained their independence. They avoided nationalisation. As part of this, they were permitted to continue buying and selling their surgeries and lists of patients which came with them as GPs moved in and out of business.
Second, they obtained formal representation at all levels of NHS decision-making concerned with GPs and primary care. This prevented any further far-reaching reform without their involvement.
Third, they were allowed to keep some hospital beds within the nationalised system, particularly in rural areas, or those which struggled to attract hospital specialists and consultants. Together, these last-minute concessions meant the NHS launched to much fanfare in Park Hospital, Trafford, by Bevan on July 5 1948.
Legacy
The consequences of these bargains can be felt today. As Nick Timmins, a former health correspondent and senior fellow at the King’s Fund (a health thinktank) argues, a point rarely acknowledged in public debate about the NHS is that it is not one big thing, but many small ones.
Despite recurrent rounds of reforms over the intervening decades, GPs remain mostly independent doctors contracted to provide certain services rather than salaried workers.
Subsequent reforms have weakened professional representation and the presence of GPs in hospitals. Despite these losses, the basic professional model that GPs fought hard to retain in 1948 – one dating back to 1911 – remains recognisable today.
Michael Lambert has received funding from the Economic and Social Research Council, Wellcome Trust, and National Institute for Health Research.
