Читать книгу The Five Giants [New Edition]: A Biography of the Welfare State - Nicholas Timmins - Страница 19

CHAPTER 6

Bevan – Health

The health of the people is really the foundation upon which all their happiness and their powers as a state depend.

Benjamin Disraeli, 1877

This is the biggest single experiment in social service that the world has ever seen undertaken.

Aneurin Bevan, 7 October 1948

In the case of nutrition and health, just as in the case of education, the gentlemen in Whitehall really do know better what is good for the people than the people know themselves.

Douglas Jay, 1937

The Emergency Hospital Scheme was in the short run the financial salvation of the voluntary hospitals, but in the longer term proved a major factor in their post-war nationalization. The scheme illuminated the enormous financial deficiencies of the voluntary hospitals and gave to the public hospitals a more prominent place in the hospital system. For the first time, many of the wealthier and more highly educated members of society became patients in public hospitals and were distressed and eager to reform what they had seen and experienced. Likewise, doctors serving under the EHS had to serve in all kinds of hospitals and were often shocked at what they saw.

Dr Gordon Macpherson in BMA, Health Services Financing, p. 32.

It was the first health system in any Western society to offer free medical care to the entire population. It was, furthermore, the first comprehensive system to be based not on the insurance principle, with entitlement following contributions, but on the national provision of services available to everyone. It thus offered free and universal entitlement to State-provided medical care. At the time of its creation it was a unique example of the collectivist provision of health care in a market society.

Rudolf Klein, The Politics of the NHS, 1983, p. 1

Medical provision before the war depended upon a primitively unstable mixture of class prejudice, commercial self-interest, professional altruism, vested interest, and demarcation disputes.

Arthur Marwick, British Society Since 1945, p. 49

IMPLEMENTATION OF Butler’s Act was to fall to Labour. But the issue which was to cause the biggest welfare state row immediately after 1945 was not to be education, Beveridge’s social security plan, or even housing, though that too was to see its fair share of controversy. It was the National Health Service that took the lion’s share of the headlines, despite proving the most enduring of the 1945 Labour Government’s achievements.

Labour’s 146 majority was the biggest ever known, outstripping by two even Margaret Thatcher’s 1983 victory. Labour MPs horrified the Tories by singing ‘The Red Flag’ in the Commons chamber, and into government came Aneurin Bevan: one of Labour’s great saints or sinners, depending on which part of his career is in view at the time and which section of the Labour Party is making the judgement. He was Attlee’s biggest gamble as a ministerial appointment, one of only two Cabinet ministers who had not served in the wartime coalition. ‘A stormy petrel’ with ‘a magic all of his own’ in the words of Kenneth Morgan, who judged him to be ‘the most hated – if also the most idolized – politician of his time’. The forty-five-year-old ex-miner, however, proved himself at the Ministry of Health to be ‘an artist in the uses of power’.¹

In the 1930s he had been expelled from the party for advocating a popular front. During the war he was a running rebel on the back-benches and was almost expelled again, Churchill once condemning him as ‘a squalid nuisance’.² Macmillan fondly remembered him as an ‘uncontrollable star – perhaps almost a comet’, a man who ‘could not forget and never wanted to forget the sufferings he had seen in the mining valleys of South Wales’. He judged him ‘in many ways the most brilliant and the most memorable of them all’ – the ‘all’ being the 1945–51 Cabinet to which Macmillan gave the accolade of ‘one of the most able Governments of modern times’.³ Just as Butler is remembered for his Education Act, Bevan’s name will always be associated with the NHS.

On 26 July, the day the election result was announced, the British Medical Association was meeting in the Great Hall of BMA House in Tavistock Square, a massive, neo-classical, red-brick building originally designed by Sir Edwin Lutyens for the Theosophical Society with the Great Hall as its temple. The Society had been unable to afford the mighty edifice which came to symbolise all the self-important solidity the medical profession felt was its right – a building where as late as the 1930s the clerical staff were under instruction not to share the lift with the great London consultants who arrived to do their business in top hats and frock coats.⁴

The BMA debate was interrupted by the news that in Labour’s landslide Sir William Beveridge, the man who had demanded a National Health Service three years earlier, had lost the Berwick seat he had taken for the Liberals in 1944. Some delegates broke into a cheer. ‘I have spent a lot of time,’ one eminent Harley Street surgeon said, ‘seeing doctors with bleeding duodenal ulcers caused by worry about being under the State.’⁵ Well before Bevan arrived, the doctors were deeply suspicious about the form any proposed National Health Service would take. That very worry, however, reflected a remarkable consensus which the doctors shared and Bevan inherited: that there was going to be a National Health Service. The question was what form it would take.

Included in Bevan’s inheritance was the Emergency Medical Service, plans for which were drawn up by Chamberlain’s government in the wake of Munich and in fear of what the Blitz would – and did – mean. The creation of the EMS followed surveys conducted in 1937 and 1938 which showed just how deficient hospital services were. By October 1939 the government had provided nearly 1000 new operating theatres, millions of bandages and dressings, and tens of thousands of extra beds in ‘hutted annexes’ some of which remained in use for more than two decades after the war. A national blood transfusion service had been created. As the war progressed, free treatment under the emergency scheme had gradually to be extended from direct war casualties to war workers, child evacuees, firemen and so on, until a sixty-two-page booklet was needed to define who was eligible. Although the elderly and others remained excluded, between 1939 and 1945 ‘a growing section of the population enjoyed the benefits of the first truly “national” hospital service’.⁶ Wartime proved that a national health service could be run.

The Emergency Medical Service had itself heavily extended what existed before. On the hospital side just before the war there were 1334 voluntary hospitals and 1771 municipal hospitals. The former ranged from the twenty great English teaching hospitals each with around 500 beds, of which no fewer than thirteen were in London along with nine post-graduate hospitals such as the Great Ormond Street Hospital for Sick Children, to tiny cottage hospitals of ten beds or less. The average was a mere sixty-eight beds. The number of voluntary hospitals, and particularly the number of small ones, had grown sharply after the First World War. Among the older foundations St Bartholomew’s could claim almost 800 years of history, but many such as the Royal Free, whose name encapsulated its aim, had been founded during the great burst of Victorian philanthropy aimed at improving the health care of the poor. This, initially, they did successfully, in as far as medical knowledge then allowed success. In 1891, 88 per cent of the voluntary hospitals’ income came from gifts and investments. By 1938, however, only 33 per cent of their revenue came this way, and less in some cases. Payments from patients had risen from 11 per cent to 59 per cent of their income,⁷ financed either out of patients’ own pockets, by health insurance through, for example, the middle-class British Provident Association, or from factory savings schemes and Saturday Hospital Funds. These last, into which people paid against future treatment, were run by the hospitals themselves. For the less well-off such schemes often bought out-patient but not in-patient treatment. Lady Almoners controlled means-tested access to beds, and substantial donors were often allocated free beds to distribute to the deserving, so a letter of reference from a JP or a councillor or from the local gentry might have to be begged to ensure admission.⁸ Increasingly the voluntary hospitals came to rely on charges and on private patients. The price of survival, as Ruldolf Klein has put it, became ‘to an extent the repudiation of the inspiration which had led to their creation in the first place’.⁹

Despite all these stratagems, flag days, and ‘a begging bowl [always] at the end of the ward; you would not dare to pass that bowl if you visited on those days’,¹⁰ by the late 1930s many of the voluntary hospitals, which accounted for about one-third of the beds, were in deep financial trouble. Even the great teaching hospitals endlessly teetered on the edge of bankruptcy. As early as 1930, the House Governor of the Charing Cross Hospital declared that the hospitals could not rely on sweepstakes and competitions for survival and predicted that within ten years they would be nationalised – state-supported and state-controlled.¹¹ In 1932 out of 145 voluntary hospitals in London, 60 failed to balance their books,¹² and by 1938 the hospitals were pleading with the Ministry of Health for state grants.¹³

Geoffrey Rivett, a senior health department civil servant who was a driving force behind the controversial new family doctor’s contract in the 1980s, records in his history of the London hospital system:

It was said that a hospital need never despair so long as it was bankrupt, but the plaintive cry of ‘funds urgently needed and beds closed’ led in the end to the belief that the voluntary system was not only insolvent, but might not be worth saving.¹⁴

The Second World War and the Emergency Medical Service did save it, but only for a time. In these hospitals, consultants had honorary, unpaid appointments; they made their income from private patients while treating the less well off free. As a result specialist care was only available in parts of the country wealthy enough to provide sufficient private practice to attract specialists. These more prosperous areas were, needless to say, not necessarily those with the greatest need. Elsewhere, surgery and anaesthetics were carried out by GPs (family doctors) working in the hospitals. What this could mean, even after the founding of the NHS, has been illustrated by Dr Julian Tudor Hart, who recalled that just before specialists replaced GPs at Kettering General Hospital where he worked in 1952, a young woman with acute intestinal obstruction was admitted. At Kettering GPs did the surgery,

helped once a week by a part-time consultant who travelled 100 miles by rail from London.

The family doctor opened the abdomen to find multiple obstructions caused by Crohn’s disease. He excised four or five segments along the seven metres of small intestine, leaving the loose ends to be reconnected. Then his troubles began; which end belonged to which? Never having met this unusual condition before, he had waded into the macaroni without planning his return. In those days emergency surgery was still regarded by patients as a gamble with death. If he had confidently reconnected the tubes as best he could, praying he hadn’t created any collisions, dead ends or inner circles, he would probably have been acclaimed whatever the outcome. Being a man of integrity, he persuaded his GP-anaesthetist colleague to keep the patient unconscious for what turned out to be four hours, with a small coppice of metal clamps splayed out from the incision, telephoned the London consultant, and waited for him to come up by the next train to sort it all out. Remarkably, the patient survived. It was the last anecdote of a closing era of GP surgery; the professionals put an end to all that, and not before time.¹⁵

Alongside the voluntaries were the municipal hospitals, many of which had grown up as appendages to the 1834 workhouses: some were still called the ‘Workhouse Infirmary’. Run by local authorities, these were regarded in the main by doctors, nurses and patients alike as grossly inferior to the voluntary hospitals – certainly outside the big cities – and real stigma attached to many. They comprised a mix of old Poor Law institutions, the great mental illness ‘bins’, and the ‘fever’ and ‘TB’ (tuberculosis) hospitals. Most depended on general practitioners to service them. They ranged in quality from the occasionally excellent to the awful. But they had in the decade before the war been supplemented in some cities by a determined expansion of purpose built hospitals. Before 1930 only three local authorities had exercised a right under the 1875 Public Health Act to establish general hospitals. But by 1938, councils in England and Wales provided 75,000 general beds (as opposed to the mental or fever beds they ran) and the London County Council was arguably the biggest hospital authority in the world, rivalling in size the entire voluntary sector. Middlesex developed a hospital service of the highest class, while City hospitals in Birmingham, Bristol, Newcastle, Sheffield and Nottingham set new standards for local authority provision, attracting academics as well as employing specialists and staff doctors. Access to their general hospital beds was means-tested, although on one estimate only about 10 per cent of costs were recovered from patients.¹⁶ None the less, the stigma of the old Poor Law hospitals which made up the bulk of local authority provision still left many reluctant to resort to them: ‘There was a certain sense of shame in being taken there,’ patients recorded.¹⁷ Patients from just over the border in the next authority would often be refused admission to empty beds, and voluntary hospitals dumped patients who failed to respond to treatment on to the Poor Law infirmary for the chronic sick.¹⁸

The two systems thus fought among themselves and against each other. Sir George Godber, who was to become the greatest of the Chief Medical Officers the NHS has seen, helped run the 1937 survey which revealed the appalling physical state of many hospitals and the acute shortage of beds. Run down though they were, he recalled, ‘the physical difficulties imposed by unsatisfactory buildings were less important than the defects in district services resulting from competition, if not overt hostility, between the several hospitals providing them’.¹⁹

The local authorities, who numbered several hundred, also ran a range of other health services. These included the school medical service, some home nursing, a small number of health centres, and ante- and post-natal care: most births were midwife-delivered home births, with a doctor only called if complications arose. One mother in 350 died in childbirth.

Family doctor or GP services remained based on Lloyd George’s ‘Ninepence for Fourpence’ National Health Insurance, and 43 per cent of the adult population was covered for a ‘panel’ doctor by 1938.²⁰ Ninety per cent of GPs took at least some part in the scheme. Non-working wives and children, the self-employed, higher income earners and many of the elderly, however, remained excluded. Hospital treatment was not covered, and the Approved Societies which ran the scheme offered wide variations in ‘extra’ cover for dentistry, spectacles (which many people bought for 6d. [2.5P] at Woolworths) and sometimes some hospital care. Schoolchildren and the poor could get free treatment, subject until 1942 to the humiliating ‘family means-test’ in front of the Relieving Officer, and some queued at the ‘casualty’ or ‘dispensing’ departments of the voluntary hospitals seeking treatment for illnesses that ranged from the minor, which really needed only a GP’s attention, to the horrifyingly major.

An Aberdeen woman quoted in Margaret Whitehead’s compilation of pre-NHS memories, recalls getting rheumatic fever on top of scarlet fever when her mother took her to the dispensary because they could not afford a doctor. ‘I took scarlet fever … and I was ill for a few days and my mother took me to the dispensary. We had to walk to the dispensary because it was free there, we couldn’t afford to pull in a doctor. ‘Cos my mother would have had the doctor in the house maybe … well, at least twice a week, ’cos she had eight of us. And you know what it is, there’s always something wrong with one. And it had to be serious before she took in a doctor because she couldn’t afford to pay for it.’²¹

Some GPs only saw their panel patients at lock-up surgeries, receiving private patients in their homes; others took the private patients through the front door, the panel being relegated to a side ‘surgery’ door. As with the voluntary hospitals, the need to supplement panel income with private practice concentrated family doctors’ services more heavily in wealthier areas. But even for the middle classes and for those who were not poor, doctors’ fees with the cost of medicine on top could be crippling, not to mention the possibility of hospital bills. Muriel Smith of Chelmsford recalled:

We were married in October 1937 and if we ever needed to see the doctor, the fee was one guinea … we had to be really ill to consider facing up to this. The men did if they were not well enough to go to work, but the women very rarely bothered. My weekly household money was one pound and my husband’s total salary was three pounds. When my son was born in 1946, the bill for the nursing home was £22 and the ambulance came to £1 5s. It is quite remarkable the difference between those long ago days and the ease with which we were able to cope with my husband’s illnesses after the war – a hernia operation, piles operation, three weeks in hospital after a slight heart attack and constant free care from then until his second heart attack three years later, when he died in Guy’s.²²

Of course, many GPs played Robin Hood, waiving fees when they could, for the poor and for the middle class. My mother remembers her rather austere family doctor in Hull in 1947 refusing to send a bill for treating a recurrent bout of the malaria my father (by then a Methodist minister) had acquired as an infantryman in Burma. ‘I don’t charge the cloth,’ he said, explaining that in return GPs referred to the church those who needed pastoral not medical care. But there were limits to such charity and inter-profession trading. Many GPs outside the more prosperous private patient areas were far from well off. Nationally only about one-third of GPs’ income came from panel patients.²³ They supplemented panel income with work in municipal hospitals, or for factory owners, or occupational health work under the eagle eye of the local authority medical officer whose punitive attitude to payment and control helps explain the doctors’ deep distrust of either a local authority-run service or any suggestion that they should be forced to become ‘civil servants’ employed by the state.

Against this background, it is hardly surprising there was a powerful movement for reform. Beatrice Webb is usually credited, in her minority report of 1909 to the Royal Commission on the Poor Law, with the first call for a ‘public medical service’ or ‘state medical service’, but much else had happened before Bevan took office. To highlight just some of the many streams which combined into the flood that made a national health service inevitable, 1920 saw a committee established by the Ministry of Health under Lord Dawson which argued that ‘the best means of maintaining health and curing disease should be made available to all citizens.’ In 1926 a Royal Commission foreshadowed a tax-funded NHS by observing that ‘the ultimate solution will lie, we think, in the direction of divorcing the medical service entirely from the insurance system and recognising it along with all other public health activities as a service to be supported from the general public funds’.²⁴

By 1930 the British Medical Association was backing ‘a general medical service for the nation’ though on the basis of extending national insurance to include hospital care. Rather surprisingly, the BMA foresaw the whole being managed by the larger local authorities.²⁵ In 1933 the Socialist Medical Association was seeking a comprehensive, free and salaried medical service run by local government and in 1934 this became the official policy of a Labour Party crippled by the split over Ramsay Macdonald’s National Government.

The growing importance of local government services reinforced the perception that insurance no longer provided the answer, and by 1938 the planning of the Emergency Medical Service was turning Ministry of Health minds to how a permanent national health service might be created. Less than three weeks after the outbreak of war, Sir Arthur MacNalty, the Ministry of Health’s Chief Medical Officer, offered a counter to a paper by Sir John Maude, the Ministry’s deputy secretary. Sir John had foreseen either ‘the gradual extension of National Health Insurance to further classes of the community and by new statutory benefits, or the gradual development of local authority services’. MacNalty provided a third option – that the hospitals should be administered ‘as a National Hospital Service by the Ministry’. Such a system was already practically established through the Emergency Medical Service, he argued. It would be ‘difficult and in many cases impossible for voluntary hospitals to carry on, owing to the high costs of modern hospital treatment and the falling off of voluntary subscriptions after the war’. He judged that the voluntary hospitals and local authorities would resist, as might the medical profession, ‘but I am certain they [the doctors] would, for the most part, welcome national control in preference to being controlled by local authorities’. It was, he suggested, ‘a revolutionary change, but it is one that must inevitably come’.²⁶

Such an approach – the one Bevan eventually adopted – would mean ‘a radical change in the policy of the ministry. Hitherto, we have always worked on the assumption that the Ministry of Health was an advisory, supervisory and subsidising department, but had no direct executive functions.’ And that remarkably prescient sentence foresaw many of the battles to come in the 1980s as the issue of how to manage as opposed to administer the NHS finally reached centre stage.

MacNalty’s was far from the only model being kicked around in the Ministry of Health at the time. Sir Arthur Rucker, who was to become the deputy secretary, argued for yet another option – more of a mixed economy. Joint hospital boards should plan both municipal and voluntary hospital services, he argued, financial support for the voluntary hospitals being dependent on their co-operating and providing agreed services under contract.

As the Ministry of Health pondered, the British Medical Association came back into the game. In August 1940 it set up a Medical Planning Commission of no fewer than seventy-three members drawn from the BMA, the medical Royal Colleges, and the Society of Medical Officers of Health (the local authority chief doctors), along with observers from the health ministries. The Commission’s ‘draft interim report’ emerged in June 1942 as Beveridge was working on his report. Among much else, it again foresaw large regional councils, though loaded with medical representation, running hospitals in which consultants would be salaried. They would choose between being ‘whole-timers’, or part-timers who would retain the right to private practice. For GPs, the commission proposed a mix of basic salary, capitation fees (a fee for each patient on the doctor’s list), and payment for services not covered by capitation. The sale of practices – nominally for ‘goodwill’ – would cease. This report in large measure was drafted by Dr Charles Hill, then the BMA’s deputy secretary but already known to the public as ‘the radio doctor’. The BMA report was remarkable in foreshadowing the way both GPs and consultants would operate in future, although not before a full-blown war had been fought between Bevan and the Association which until the eleventh hour appeared to threaten the very establishment of the NHS.

At the BMA’s annual representative meeting in July, the report received a muted reception. It was, however, not only passed, but the meeting also agreed by ninety-four to ninety-two votes that, while still insurance-based, the scheme should cover the whole community, not just 90 per cent of the population with the remainder forced to continue under private practice.²⁷ The implication of this decision, which the BMA was to restate (though with a qualification) in May 1945 before Bevan’s appointment, were huge, although it appears not to have been entirely recognised at the time. For if 100 per cent of the population could join, family doctors were bound to become dependent on public funds. If the service proved popular with the public, private general practice was bound to wither.

In December, Beveridge delivered his Assumption B: that a comprehensive health service would underpin his social security recommendations. His report caused unease at BMA House, according to Dr Elston Grey-Turner, then a young assistant secretary who went on to become the BMA’s secretary and its official historian. The storm signal, he says, was an aside suggesting that under a national health service, ‘the possible scope of private general practice will be so restricted that it may not appear worthwhile to preserve it’.²⁸ If private practice went, family doctors would become dependent for all their income on the state, whether through local or national government. The spectre of state control, of doctors being civil servants, was raised. As yet, no one was saying when anything would actually happen. But as pressure to implement Beveridge mounted irresistibly, Churchill’s March 1943 broadcast finally allowed plans for a national health service to be drawn up, even if no expenditure could be committed before an election.

Ernest 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

In practice and theory the Royal Colleges were members of the thirty-strong committee that the BMA had set up to negotiate with Willink. The Royal Colleges’ presidents, however, were careful to keep their own channels of communication with Bevan open, while Bevan, in line with the constitutional position he had long held as a back-bencher, refused to negotiate with the BMA until the Bill was published. That did not prevent him talking to people, and dinners at Prunier’s with Moran along with other meetings shaped crucial parts of the deal that made the NHS. Moran related to Michael Foot a conversation with Bevan:

BEVAN: I find the efficiency of the hospitals varies enormously. How can that be put right?

MORAN: You will only get one standard of excellence when every hospital has a first-rate consultant staff. At present the consultants are all crowded together in the large centres of population. You’ve got to decentralize them.

BEVAN: That’s all very well, but how are you going to get a man to leave his teaching hospital and go into the periphery? [He grinned] You wouldn’t like it if I began to direct labour.

MORAN: Oh, they’ll go if they get an interesting job and if their financial future is secured by a proper salary.

BEVAN (AFTER A LONG PAUSE): Only the State could pay those salaries. This would mean the nationalization of the hospitals.⁴³

The college presidents also convinced Bevan that he would have to allow part-time consultants to continue private practice in NHS ‘pay beds’. Without that concession there was a real risk that specialists would refuse to join the health service, and would, in Bevan’s words, set up ‘a rash of private nursing homes all over the country’⁴⁴ which would undermine the very comprehensiveness of the service Bevan was seeking to establish. In addition, Lord Moran talked Bevan into merit awards, on top of basic salary, for those doctors whom their peers judged worthy. A decade later, Bevan at a private House of Commons dinner was to boast wryly in one of his most famous asides, ‘I stuffed their mouths with gold.’ The remark was not given currency until 1964 by Brian Abel-Smith, when it provided one small element of the growing resentment over private practice that exploded in Barbara Castle’s great pay beds row.⁴⁵ At Prunier’s, as Professor Abel-Smith has put it:

The top doctors obtained á la suite terms in the Health Service: part-time payment for loosely defined sessions, the secret disposal of Treasury funds to those of their number whom Lord Moran and his two colleagues thought more meritorious, the lion’s share of the endowments of the teaching hospitals to pay the costs of their researches, and the right to private practice – much as before. The consultants had gained regular remuneration without any loss of freedom and were being trusted to use this freedom responsibly.⁴⁶

Labour’s left wing, whence Bevan came, proved far from happy with this deal. But, as Michael Foot has put it, ‘to get the specialists into the hospitals and to keep them there as regularly as possible was crucial to the whole enterprise’.⁴⁷ In the long run, the concessions split the medical profession and put the Royal Colleges, with the powerful voices of Webb-Johnson and Moran, on Bevan’s side. Without that, it is doubtful if the NHS would have been born at all; and the steady spread of consultants across the country, which did so much after 1948 progressively to improve standards of care outside London and the big cities, would not have occurred. The mighty battle which was still to be fought with the BMA, despite some of the ballot results to come, was to be between Bevan and the GPs rather than Bevan and all the doctors.

Before the Bill could be published, however, Bevan had to sell it to the Cabinet and in October he sought a decision on ‘one big question of principle’ – whether to nationalize the hospitals. His argument was simple: the voluntary hospitals were dead. In this he had the backing of the magnificently named Sir Edward Farquhar Buzzard, a former President of the BMA and Regius Professor of Medicine at Oxford, who had publicly delivered the same diagnosis to the press a year earlier.⁴⁸ To keep them going, Bevan told the Cabinet, around 80 or 90 per cent of their revenue under any national health service would have to come from public funds and ‘I believe strongly that we must insist on the principle of public control accompanying public financing.’ In this the teaching hospitals and postgraduates would be given special status on three grounds: their quality and standing; because ‘it is a good thing in itself to keep separate a field for independent experiment in method and organisation’; and because the state should not dictate the medical curriculum. The local authority hospitals too should be nationalised, he said. The great bulk of local authority areas were too small to run good ones, the rates could not bear the full cost of the service, and complex cross-financing arrangements would be needed if rich areas were not to have better services than poor ones. The ‘voice of the expert’ (chiefly the doctors) had to be brought into the planning and running of the services. There was thus a powerful case for ‘starting again with a clean slate’.⁴⁹ Bevan acknowledged the proposal would mean ‘extinction’ for most voluntary hospitals and would ‘provoke an outcry’ both from them and from local authorities. The attitude of the doctors, he conceded, was uncertain. But again, probably unconsciously, he echoed MacNalty: ‘if the choice were before them between a primarily local government service and primarily nationalised service, the overwhelming majority would prefer the latter’.

In a tantalising aside, he acknowledged that if local government were reorganised into regions (a Labour policy) then the hospitals might revert to regional government. Given that an experiment loosely on these lines is underway at the time of writing – ‘Devo-Manc’ – it is worth exploring the reaction. His memo brought Herbert Morrison, Lord President of the Council, leaping to the local authorities’ defence. Morrison had made his name as leader of the London County Council in the 1930s, when local government, at least in terms of breadth of function, was in its heyday.

‘We should be cautious about any step which will weaken local government,’ Morrison argued. The government’s nationalisation plans were already likely to remove gas, electricity, probably passenger transport and possibly water from them. And Bevan, he complained, was ‘on the horns of a dilemma’. If the proposed appointed regional hospital boards were ‘subject to the Minister’s directions on all questions of policy, finance, establishments and so on, then they will be mere creatures of the Ministry of Health, with little vitality of their own’. Yet under a nationalised state system ‘it is difficult … to envisage the alternative situation in which, in order to give them vitality, they are left free to spend Exchequer money without the Minister’s approval and to pursue policies which at any rate in detail may not be the Minister’s, but for which he presumably would be answerable’.⁵⁰

Local government ran a better hospital service than Bevan gave it credit for, he said – adding in a touch of raw politics that the health minister would be launching a war with local authorities ahead of council elections in November and the spring. He offered, however, no solution to the voluntary hospital problem, admitted he had no ‘conclusive argument against nationalising the hospitals’, conceded that a nationalised system might be inherently more efficient, and opened with the courtesy of describing Bevan’s paper as ‘brilliant and imaginative’.

Four days later, desperate for a decision to get ahead with his plan, Bevan hit back, arguing that putting the voluntary hospitals under local government would ‘rouse a tornado compared with any passing thunderstorm my scheme may provoke’. He added: ‘any scheme which leaves responsibility for the hospital service with local authorities must be unequal in its operation. This would be unjust to the public who will pay equal contributions.’ The regional boards ‘would be the agents (though not, I hope, in any derogatory sense the creatures) of my department’ with ‘substantial executive powers, subject to a broad financial control’. If the scheme was sound, the political consequences need not be feared, and if Morrison described it as imaginative: ‘is not that exactly what we were returned to be?’ Neither of the present systems – municipal or voluntary – would do. Such a chance to make the health services ‘the admiration of the world … comes but once, perhaps, in a generation … if it is not done now it will not be done in our time.’⁵¹

The row went to Cabinet two days later, where Morrison reiterated objections that hospital nationalisation was not in the party manifesto: indeed, municipalisation had been Labour’s policy. Local pride and voluntary enthusiasm mattered, Morrison argued, and there would be ‘a very large transfer of liability from the ratepayer to the taxpayer’ under Bevan’s plan. He was backed by Chuter Ede, now Home Secretary, and some others. But Arthur Greenwood, chairman of the Cabinet’s social services committee, Ellen Wilkinson the education minister, and Emmanuel Shinwell, Minister of Fuel, backed Bevan as did George Buchanan, the Scottish health minister. Lord Addison, once Lloyd George’s Minister of Health, an anatomist who was ‘easily the most distinguished doctor ever to enter politics’ and who had effectively founded the Medical Research Council, did the same. The seventy-six-year-old Addison, now leader of the Lords, argued that nationalisation would greatly assist medical education. Attlee summed up strongly in Bevan’s favour.⁵²

What Morrison half hinted at, but which never in the 1940s became quite the core of the argument, is that in practice there are profound difficulties in having an elected body, which will almost inevitably come under party political control, disposing of purely central government funds – an argument that was to become even stronger in the 1980s when cash limits were introduced. Without their own funds the local politicians will blame all failures on lack of central government cash. They may even refuse to implement government policy, as was to happen with health authorities in the 1980s when local government had influence on them (though not control). Given the tendency of political control of local authorities to move against the government of the day, such a recipe is one for conflict rather than creative tension between the centre and the periphery. Only if elected bodies raise at least some of their own funds can the responsibility for running the service – and raising more from their electors if more is judged to be needed – be safely entrusted to them. It is a case, if conflict is to be avoided, of ‘no representation without taxation’.

Morrison lost the argument in October, but continued the fight, leaving Bevan to ‘damn and blast’ him to his wife Jennie Lee when he returned home at night. In December, however, the issue was finally settled in Bevan’s favour.⁵³ For years afterwards Morrison would refer sourly to ‘Nye’s precious health service’, particularly after its launch when Bevan succeeded in extracting ever-growing sums for it despite the extreme financial difficulties Labour then faced.⁵⁴

When the Bill and accompanying White Paper⁵⁵ were published in March 1946, however, it was not the idea of nationalising the hospitals but Bevan’s proposals for GPs which nearly sank the whole scheme. Ironically, these differed in substance not at all from the ideas the BMA’s own Medical Planning Commission had put forward three years earlier. But Dr Charles Hill, the scribe of that report and now the BMA’s Secretary, appeared to have forgotten everything.

Bevan proposed that family doctors should be paid a basic salary, and capitation fees on top. The sale of practices would be abolished and £66m was offered in compensation – a sum that even the BMA admitted was fair.⁵⁶ On this Bevan was adamant. He was to tell the Commons: ‘I have always regarded the sale and purchase of medical practice as an evil in itself.’⁵⁷ It was ‘inconsistent with a civilized community … for patients to be bought and sold over their heads. When I am told that all they desire is that patients should have the best medical treatment, how can that be argued when a doctor succeeds to another doctor’s panel not on account of personal qualifications but on the size of his purse?’⁵⁸ In addition, he proposed that GPs should be encouraged to work in partnerships in health centres provided by local authorities. Bevan’s only substantive departure from the BMA’s own 1942 proposals was that he revived the controls, which Willink had dropped, to prevent new GPs entering over-doctored areas.

The BMA exploded. Doctors argued that the plans would lead to a full-time salaried service under either the state or local government. Doctors would be reduced to civil servants, clinical independence and freedom of speech would be threatened, and Bevan himself as Minister of Health would have enormous powers to direct them. Some of the language used now seems incredible. Dr Alfred Cox, a former secretary of the BMA, wrote to the British Medical Journal declaring: ‘I have examined the Bill and it looks to me uncommonly like the first step, and a big one, towards National Socialism as practised in Germany. The medical service there was early put under the dictatorship of a “medical Fuehrer”. This Bill will establish the Minister of Health in that capacity.’ Dr Cox was far from alone. At a meeting of 1000 doctors in Wimbledon Town Hall shortly after the Bill was published, Bevan was called ‘a dictator’ and ‘an autocrat’. ‘This Bill,’ declared one doctor, ‘is strongly suggestive of the Hitlerite regime now being destroyed in Germany.’ Another denounced the hospital proposals as ‘the greatest seizure of property since Henry VIII confiscated the monasteries’.⁵⁹

What Bevan proposed for the GPs was in the end what happened. And given both that the BMA had itself outlined remarkably similar proposals and that the doctors’ fears simply failed to materialise, an explanation of their apparently paranoiac reaction and the lengths to which they took the argument is needed. It falls in three parts. The first lies in the structure, history and some of the personalities of the BMA – particularly in the structure, which was to cause the association similar problems once a decade between the 1960s and the 1980s over various virulent disputes about doctors’ contracts. Second, the doctors’ fears were genuine and they had evidence to support their view that a full-time salaried service was the final goal. And third, the dispute about their contract was played out against the background of the hospitals being nationalised – a revolutionary departure which left plenty of room for argument about its implications.

The BMA was in some ways the very model of democracy, but it was an unwieldy democracy. Its nominal governing body was and is the representative body, normally called together at the annual representative meeting. It could take binding ‘decisions of the association’ by two-thirds majority. Below that was the council, a large body of some seventy members. The day to day work, however, was undertaken by the chairman, the secretary and his staff (at this time the BMA had no executive) and through the ad hoc negotiating committee. The chairman was one Dr Guy Dain, a pocket battleship of bristling energy, a strong believer in individualism whose motto was that ‘responsibility is the salt of life’. (He had it translated into Latin when he was knighted.) He had become convinced ever since Ernest Brown’s suggestion of a salaried service in 1943 and since the report of ‘that old blighter Beveridge’ that the ministry wanted to turn doctors into civil servants. John Pater, a civil servant at the time, judges he became ‘increasingly emotional’ in his belief that he was defending the freedom of the profession.⁶⁰ Dain and Hill, however, while they could negotiate as spokesmen, could not agree terms without reference back to the representative body.

Anything the BMA’s negotiators came back with had to be manoeuvred through these conferences and meetings. And the plain fact for the BMA was and is that it is always easier to make an impassioned speech against any proposal than a reasoned, and possibly complex one, for it. Dr Charles Hill, thirty years after the event, conceded:

It is undeniable that emotional outbursts in public at critical times, inevitable in a large body at times of crisis, did sometimes embarrass the profession’s spokesmen by the headlines they stimulated and the somersaults of policy they encouraged … Furthermore, the Representative Body did declare itself – in advance of any Government plans – in favour of many features of a health service which it subsequently rejected. It did tend sometimes to ignore such gains as its representatives had secured and immediately to switch its attention to the points on which it had not won, however important or unimportant they were. Balance sheets of gains and losses are not always judged dispassionately in large assemblies, where oratory and emotion prevail. Tactics are better devised in private by the few than publicly by the many.⁶¹

Thus, not to be overthrown, BMA negotiators have often on platforms to sound at least as militant as the most militant of the voting doctors before them – people who were no mere cannon fodder but articulate and almost by definition individualistic men and women. More than once in the next fifty years, the association was to paint itself into corners in this way.

Furthermore, then more than now, those doctors who attended the representative body and the council were not necessarily representative of the profession as a whole. In the 1940s, the BMA was much more GP-dominated than it was to become. The Royal Colleges, whose role strictly is to supervise education and standards, not pay and rations, also played more part in medical politics than they did in later years. Harry Eckstein, an early chronicler of the founding of the NHS who also produced a detailed study of the BMA as a pressure group, observed that to partake in medical politics doctors needed money and time. At a time when many GPs in poorer areas were low earners, the representative body meetings were ‘inevitably weighted in favour of age, affluence, private practice and the suburb’. In other words, those who had least to gain as doctors from a National Health Service were more likely to be those who voted at the BMA’s very public and well reported meetings, and the decisions of those meetings were strongly reflected in the interpretation of events and advice that BMA leaders then put to doctors in the rash of plebiscites between 1946 and 1948. Bevan found, as Lloyd George had put it in 1911, that ‘a deputation of doctors was a deputation of swell doctors’.⁶²

Dain, Hill and the members also remembered history. Lloyd George had, to an even greater extent than Bevan, refused to negotiate with the medical profession over the National Insurance Act. In 1913 the BMA had assembled 27,400 signed pledges from family doctors refusing to participate until its terms were met. Ironically, in a position that was reversed in the 1940s, it had then been the consultants, who were unaffected by the measures, who largely orchestrated the opposition.⁶³ When the 1911 Act came into force, however, GPs fearing they would lose potential patients to rivals, suddenly signed on in droves, leaving the association routed, divided and humiliated. This time, Dain and Hill, desperate to maintain the doctors’ unity and preserve the BMA, repeatedly consulted the troops, calling special representative meetings and holding plebiscites which only helped give publicity to the more furious opponents of the proposals.

The doctors also had good grounds for their suspicion that a full-time salaried service was the ultimate goal. Ernest Brown, a National Liberal, had proposed it; it had been Labour policy since 1934; and as recently as April 1943 the party had reiterated the proposal for all doctors, not just GPs, in A National Service for Health. That document had included a bar on private practice for those employed by the state.⁶⁴ Bevan had formally rejected this part of party policy. Michael Foot records that he ‘desperately wanted the patient to have free choice of doctor. He saw it as the best safeguard against poor service from the general practitioner.’⁶⁵ He was to tell the Commons that to make doctors salaried would mean allocating patients to doctors and vice versa. Capitation, on the other hand, encouraged the doctor to provide a good service in order to attract and keep the patient who could move if dissatisfied, but he also wanted a small basic salary to allow young doctors to keep body and soul together while they built up a practice.

If Bevan rejected a salaried service, that still left him with his own back-benchers to placate for dropping party policy. Twice in the second reading debate in April 1946 he remarked that the profession was not ripe for a salaried service, adding: ‘There is all the difference in the world between plucking fruit when it is ripe and plucking it when it is green.’ Arthur Greenwood only compounded their suspicions by declaring in the wind-up to the debate: ‘What was published by my party in 1943 … we of course stand by.’⁶⁶ The BMA and its leaders heard only those sentences, not Bevan’s repeated assurances that there would be no full-time salaried service. In addition Grey-Turner, the BMA’s official historian, concedes there was ‘an emotional, even political,’ undercurrent to the dispute. ‘When [in 1945] Churchill in his own words was “immediately dismissed by the British electorate from all further conduct of their affairs”, many in the middle classes were uneasy.’ Statements by Labour ministers such as ‘we are the masters now’ and Shinwell’s declaration that he did not care ‘a tinker’s cuss’ for the middle classes only compounded that feeling. In the middle of the dispute Willesden Borough Council attempted to force all its employees, its medical officers included, to join a trade union. (The BMA at this stage was, jealously and proudly, not one.) Doctors did not have to be paranoid to see that as another straw in the wind.⁶⁷ Such attitudes and actions ‘provoked resentment and belligerence in professional people,’⁶⁸ and doctors, if anyone did, considered themselves professionals.

Thus throughout the dispute-wracked months between April 1946 and 5 July 1948 – vesting day for the National Health Service – the argument was repeatedly heard that Bevan’s plans for GPs were ‘the thin end of the wedge’ and ‘could lead, sooner rather than later’ to a full-time salaried service with ‘doctors becoming a branch of the civil service’. The consultants were told that would be their fate too, once they took salaries in the nationalised hospitals, despite the distinctly favourable terms Bevan had contrived for them. Given that no one quite knew what a nationalised hospital meant, even though the Emergency Hospital Service had provided a national system for seven years, the fears may have been groundless. That did not at the time make them as ludicrous as they later appeared to be.

The BMA, let alone the profession, was in practice of course never united. Webb-Johnson for the surgeons described the Bill as ‘bold and statesmanlike’.⁶⁹ Moran repeatedly defended it, accusing opponents of distorting the arguments and resorting to slogans. The surgeon Henry Souttar, the immediate past president of the BMA who had chaired the Medical Planning Commission, pronounced it ‘exceedingly good’.⁷⁰ Professor Johnstone Jervis, President of the Society of Medical Officers of Health, declared it ‘incontestably the greatest thing that has ever been done in social medicine in any age and country’.⁷¹ And while the British Medical Journal bitterly attacked Bevan, The Lancet argued for the plan. Many newspapers sided with the doctors and the Tories in their objections. But the then more numerous Labour-supporting papers backed Bevan, and The Times and the Economist both gave the plan a consistently favourable press.

The detailed and tortuous course of the battle between Bevan and the doctors has been well told elsewhere⁷² and a number of issues other than the central one of whether doctors would become full-time salaried civil servants and thus denied clinical freedom and free speech, wove in and out of the dispute. But the Bill achieved its Royal Assent in November 1946, at which point a BMA plebiscite showed 54 per cent of doctors opposed to entering detailed discussions on NHS regulations (including pay) with Bevan.

The three Royal College presidents intervened. In January 1947 they wrote to Bevan seeking assurances and clarification on key issues including the basic salary. Bevan was proposing this should be £300 pa – enough to get a young doctor started, hardly enough to make him a state employee. The presidents’ action, the equivocal ballot result, and Bevan’s conciliatory reply cornered a special BMA representative meeting into starting talks.⁷³ These dragged on through 1947 to break down at a meeting in December when Bevan, who had been all milk and honey throughout the year, exploded. According to Dr Solly Wand, ‘he threatened us and raved at us. He waved his finger in the air and said that if, as a result of anything the profession did, the number of patients who signed on was much less than 95 per cent, he would make serious reductions in capitation fees.’⁷⁴ The breakdown came because the BMA was still demanding such extensive changes that fresh legislation to construct a new and very different Act would have been needed. Bevan declared that Parliament decided the law, not doctors, and refused to let them dictate to the government.

In January 1948, with Hill insisting that the months of negotiation had made it ‘absolutely clear that these proposals mean and are intended to mean a whole-time salaried service under the state’, another plebiscite was held.⁷⁵ The doctors were told that the independence of medicine was at stake. The British Medical Journal declared that Bevan’s refusal to amend the Act, ‘strengthens this belief’.⁷⁶ The BMA council’s message to the membership stated that the issue was not money or compensation, but ‘the intellectual freedom and integrity of the profession’. If a majority voted against the service, including 13,000 of the 20,000 GPs, the BMA would advise the profession not to join the NHS.

The result was overwhelming, and stunning for the government: 84 per cent of doctors voted, and 86 per cent of those (including 17,000 general practitioners) were against accepting service under the Act.⁷⁷ Bevan, who had been under growing pressure for months from Morrison and others who had seen the whole enterprise as likely to end in tears unless the doctors were placated, refused to waver. He issued a terse statement. ‘The Act will come into operation on 5 July in accordance with Parliament’s decision.’⁷⁸

Some newspapers, the Observer and the Glasgow Herald included, called for his resignation. Between the February ballot result and the end of March there was complete deadlock. It was the Royal College presidents, led by ‘Corkscrew Charlie’, who rode once again to the rescue. In late March after private consultations with Wilson Jameson, the Chief Medical Officer,⁷⁹ Lord Moran wrote to Bevan suggesting that he introduce amending legislation. It would stipulate that a whole-time salaried service could not be introduced by regulation, but only by a full Act of Parliament. Webb-Johnson and Mr William Gilliatt, now the obstetricians’ president, backed him. On 7 April, Bevan told Parliament he would do just that – pointing out for good measure that if doctors really believed they would be turned into civil servants by the basic salary which would now apply only for the first three years, they could hand it back. It was the decisive intervention. If the NHS Act was Bevan’s baby, the Royal College presidents were its midwife. Moran’s intervention, Bevan told him in a private letter, was ‘the most helpful thing said by any doctor in the whole of this business’.⁸⁰

In substance, given his repeated assurances that he did not intend a full-time salaried service and the clear reasons he had outlined as to why he opposed one, Bevan had given away little. But his offer to embody those assurances in legislation received an enthusiastic reaction in both Parliament and the media.⁸¹ The battle in fact was over. The BMA, however, did not yet realise that, any more than did the British Dental Association which as late as June 1948 was still trying to organise a boycott of the service.⁸² Furious doctors who had already been condemning the Royal College presidents as ‘Quislings’⁸³ for their earlier interventions renewed the charge and relations between the BMA and the Royal Colleges were never to be quite the same again. The effect of the intervention echoed down the succeeding years: the heinous ‘betrayal’ by the Royal Colleges was one of the first stories told me by a BMA doctor when I became a health correspondent in 1974. These strained relations were to have further ramifications in the NHS’s history.

The association’s leaders put fourteen questions to Bevan, including continued worries about free speech, rights of appeal to the courts over dismissal, and objections to the ban on selling practices. Bevan replied, promising a right to speak out in patients’ interests which he enshrined in doctors’ terms and conditions of service. That right was only to be undermined not by a ‘National Socialist’ Labour minister as the doctors feared, but by Kenneth Clarke, a Conservative health minister, and the nearest the Tories have produced to a Bevan of their own in his intransigent determination not to be dictated to by the doctors.

At a deeply divided council meeting, the BMA decided once again to go to a plebiscite telling the members that, despite gains, not all fourteen of their queries had been answered satisfactorily and that on balance ‘the freedoms of the profession are not sufficiently safeguarded’. Seventy-four per cent of the doctors voted. They split 52 per cent against joining the NHS to 48 per cent in favour. But the number of GPs refusing to join was now only 9588 out of the 20,000 – far short of the 13,000, or two-thirds, that the BMA had said was necessary to make the Act unworkable. Doctors on the ground were finally beginning to believe the great Welshman’s word. In addition, ‘the great and natural fear of many general practitioners was that enough of their colleagues might join the service on the appointed day to make it workable, and so would take away the bulk of the patients,’ Grey-Turner records.⁸⁴ The events of 1913 were repeating themselves.

There had been warning signals. A mere 6000 doctors had contributed to an independence fund the BMA set up in April to finance continued opposition, and in March it had become apparent, according to Grey-Turner, that there was ‘no clear cut plan as to how doctors were to carry on their practices, and earn their incomes, if they refused to join the National Health Service’.⁸⁵ Dr Alfred Cox, who had originally condemned Bevan as a Fuehrer and the Bill as ‘National Socialism’, and who had been the association’s secretary during the 1911–13 dispute, now wrote to the BMJ warning that then the leaders had fought on when doctors, satisfied by Lloyd George’s concessions, had flocked to join the panel scheme. ‘Is history to repeat itself ?’ he asked.⁸⁶

The BMA’s council opened talks with Bevan on the final details of remuneration for doctors, and on the package of amending legislation. By the end of May at the final special representative meeting, Dain had to announce that 26 per cent of GPs in England and more than 36 per cent in Scotland and Wales had already signed up. Solly Wand told the meeting that whether the representatives liked it or not, their army ‘had started to go home’.⁸⁷ A frantic last-ditch manouevre to get the BMA to fight on was defeated,⁸⁸ and a mere five weeks from the launch of the NHS the doctors formally agreed to take part. Like Waterloo, however, it had been a damn close-run thing. On 18 June, seventeen days before the Appointed Day, Dain finally promised that ‘the profession will do its utmost to make the service a resounding success’.⁸⁹