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