These days, the UK's national health system, the National Health Service (NHS), had its 75th anniversary. It is about time to write about it. Especially as the state of the NHS is an ongoing topic not only amongst our doctor friends, but among all Britons, even more so in the media.
From the discussions I followed, it quickly emerged that opinions on the state of the NHS could not be more conflicting. On the one hand, many Britons are proud of their system. After all, it is one of the best in the world, or rather it IS the best in the world, as one well-meaning study or another concludes [1] (typical of Britain, see my post onn British ways). Others, however, believe the NHS is in a devastating state and getting worse every day.
NHS funding has been used for propaganda to leave the EU, see the Brexit bus. And at protests during a Trump visit in 2019, one saw many banners in the crowd calling for a better budget for the NHS.
The discussions are surprisingly emotional to an outsider. But the importance of the NHS to Britons is hard to overestimate, and not just on healthcare issues. Therefore, I would like to dedicate several posts to the NHS, starting with the question of where the outstanding importance for many Britons comes from. To understand the background, it is again necessary to look at history, especially recent history.
In my excursion into the colonial era, I traced the present-day self-perception of the British back to the power and status of the Empire. However, this is only the perception in comparison to other countries. In terms of identity "at home", the rise and crisis of the Labour Party, as well as the two world wars, are decisive.
In the 19th century, British politics was still shaped by the interplay of conservative and liberal forces. This dynamic came to an end with electoral reform in the wake of World War I. Before, it was hardly possible to speak of universal suffrage. In the 18th century, only a few percent of adult citizens were entitled to vote: Men who had a certain amount of property or income.
Small changes to the electorate occurred over the next hundred years, but it was not until the Great War that pressure became sufficient enough to allow all sections of the population to participate in the electoral process. Workers had given their lives for Britain on the battlefields in France. And women were heavily involved on the "home front". From 1918, all adult men and women were granted the right to vote [2].
The electorate more than doubled. It was now poorer and more female. As a result, the Liberal party disappeared into insignificance. From now on, socialists and conservatives alternated in government. The state took more care of its citizens, or rather interfered more in their lives, depending on the point of view.
A development that reached a climax after World War II. Not only was the state forced to take on more tasks, but the grievances of the time brought the nation closer together and a new sense of community emerged.
Out of this, the Labour government of the post-war period developed Britain's welfare state. It followed a socialist utopia in which the whole of society was to be administered centrally and according to plan. Most schools and universities, the main sectors of the economy, social security and health care were now in public hands. From the cradle to the grave, the British were to be cared for by the authorities. The comprehensive role of the state was not shaken in the decades to come. The so-called post-war consensus had a large majority among the population.
The NHS, or the various services of the individual British countries, are a child of this period and were formed 1948. Until 1969 the Welsh service was part of the English NHS. The Service in Northern Ireland was formed under a different name: Health and Social Care (HSC).
Anyone who needed medical help was to receive it without complications. The services were and are not paid for by patients, but by society as a whole, through tax revenues. Accordingly, there is no public health insurance (but there are private ones that cover more or additional services).
The welfare state had its own problems to contend with, such as overly strong trade unions or the typical inefficiency of planned economic structures, yet the post-war consensus held. Labour was not interested in a withdrawal of the state anyway and the Conservatives did not think they could push through any changes.
This was still the case during the first Thatcher government at the end of the 1970s. Privatisation of state institutions had made it into the Conservative party programme, but they did not dare to start it.
In general, the Conservatives assumed they would have little chance of re-election if they did implement them. And the next Labour government would simply reverse the privatisations, not to mention problems with trade unions. Therefore, also investors were hardly interested in takeovers.
In the early 1980s, however, conditions changed. The unions had fallen out and Labour had split. For the left political camp, this was a disaster, given the British electoral system: In this, each citizen has only one vote, to determine an MP in the home constituency. It is a first-past-the-post-system.
If a Labour candidate had previously received 60% of the vote and the Conservative candidate 40%, the Socialist would have entered parliament with a clear lead. But with two candidates on the left, it was likely that neither could match the Conservative candidate's approval. Although the left still had an overall majority in the constituency, it would be represented by a Conservative MP in the House of Commons. And since there is no second vote in the British system to apportion parliamentary majorities according to the popular vote, this could lead to disproportionate majorities for the Conservatives.
In other words, even if the policies of a Conservative government met a strong opposition in the population, Labour's divisions combined with the electoral system ensured a change of government was unlikely. (The absurd British electoral system will be discussed in more detail later).
This opened a window of opportunity for Thatcher and Co. to realise the privatisation of the welfare state after all. And the Conservatives took advantage of it. In the next few years, British Aerospace, British Telecom, Britoil, British Gas, British Coal, British Steel, British Petroleum (BP), British Airways, National Power, British Rail, Rolls Royce and Jaguar, among others, were privatised.
This was accompanied by rapid structural change. Many of the companies turned out to be not profitable. They were broken up or trimmed for efficiency. The coal industry almost completely disappeared. In contrast, the service sector flourished, especially the financial industry. Modern, neoliberal Britain was born.
Today, part of British society virtually idolises Margaret Thatcher. She not only created modern Britain, and made the profiteers of her policies incredibly rich, but gave the country a new faith in itself after the relative decline of the post-war years.
The other part of society demonises Thatcher. Deindustrialisation caused many workers to lose their jobs. At the same time, with the withdrawal of the welfare state, many social programmes were scrapped. The cohesion of society was lost. The new Britain is well summed up in a quote by Margaret Thatcher herself: "There is no such thing as society" [3]. Society took a turn back to the naive liberal order of the 19th century.
After Thatcher, the welfare state and its principles were largely history. New Labour accepted the new reality; after its election victory in 1997, no company was nationalised. Instead, the party initially relied on public-private partnerships, for example in local transport, schools and the healthcare system.
In the new millennium, however, Labour also pushed ahead with privatisation (although banks were nationalised for a short time in the wake of the financial crisis.) The following Conservative governments did not change the policy. In 2013, Royal Mail was one of the last state-owned companies to be privatised.
Today, the public health system is the most significant and almost the only remnant of the welfare state. More than that, the NHS is one of the few remaining unifying elements of British society at all (along with the armed forces). The rest has been broken up, privatised, abolished.
Any debate about its future is therefore not only about healthcare for the population, but about British identity and self-esteem. Just how much is shown, for example, by a YouGov survey from 2018, in which Britons were asked which event evoked the greatest pride in their country. The creation of the NHS came in first, ahead of the signing of the Magna Carta, the size and impact of the British Empire, the abolition of slavery and the fight against Hitler (and that's saying something!) [4].
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[2] In the first years only women at the age of 30 or older were allowed to vote. 1928 the voting age was reduced to 21, the same as for men.
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