Review: Our NHS. A History of Britain's Best Loved Institution

At a special service at Westminster Abbey on 5 July 2023 to mark the 75th anniversary of Britain's National Health Service, Keir Starmer—then Leader of the Opposition—read from the Bible, taking as his text a passage from Revelations, which envisions a New Jerusalem descending from heaven to remove pain and suffering. A powerful analogy but, as Andrew Seaton suggests at the opening of his new history, the NHS is ‘akin to a religion’. An opinion poll of 2023 ranked it ahead of the monarchy, the Union Jack, the pub and the BBC as an icon of Britishness. And whilst there have been many histories of the NHS, Seaton's is the first to explore how public health and national identity have become so intertwined.

In an extensively researched and wide-ranging book, Seaton charts the evolution of the NHS from a shaky start in austerity Britain through the heyday of ‘welfare nationalism’ in the 1960s and 1970s and onto its survival into the millennium. Whereas other parts of Britain's postwar architecture of social democracy have been dismantled—particularly public utilities, council housing and nationalised industry—the NHS has seen off its critics, especially the free marketeers. To explain its resilience, Seaton offers a close and, at times, overly polemical reading of the political history of the NHS since 1948, alongside an account of how, as an institution, it shed its bureaucratic origins, becoming more humane and ‘communal’.

Offering medical provision ‘from the cradle to the grave’—Winston Churchill was the first politician to use the famous phrase—the NHS took time to find its place as a national treasure. Seaton shows how the patchy Victorian system of health care, although inefficient, left many people resistant to the state taking over. Moreover, Clement Attlee's government could fund a massive expansion of staffing—soon the NHS became one of Britain's largest employers—but no new hospitals were built in the first decade. A huge propaganda effort, led by Aneurin Bevan (depicted in the book admiring the posters), encouraged the nation to register for the new services, and exercise restraint in using them. Social justice was not the only driver behind the new NHS. Our NHS brings out how Bevan and others were concerned about a declining birth rate. They were also keen to export best practice overseas, but this never happened. Despite some early admirers in the USA, there were no takers there. And across the Commonwealth, where other parts of the new welfare state were being transplanted, the NHS instead exerted a huge drain on local labour forces, recruiting heavily in the Caribbean, South Asia and sub-Saharan Africa.

Two chapters in the book describe the transformation of practice across the first few decades of the life of the NHS. Aimed more at the male breadwinner in its early years, hospitals, GPs surgeries and new health centres gradually became more user-friendly. Men were allowed in on baby deliveries, parents accompanied hospitalised children and visiting hours were extended. Much of this came about as patient groups organised to lobby for change. Distinctive open-plan wards—speeding up treatment—also made hospitals spaces which cut through class divisions, although private beds remained. The NHS scored many hits. It rolled out polio vaccination, free contraception and family planning, cataract surgery, hip replacements and MRI screening. Seaton mentions some of this but might have banged the drum more. Other aspects of healthcare it did not do so well. Preventive medicine took longer than other countries to kick in. Seaton doesn't discuss long-term care for the elderly sick, provision for which did not seem to occur to NHS planners in 1948, and has never been a statutory priority—unlike in other countries such as Germany—and, as Covid showed up, social and racial inequalities persist in treatment of certain illnesses and in access to resources.

At the heart of this book is a somewhat partisan claim that the NHS is an ‘achievement of the left’. Not only insofar as it is the postwar Labour Party's finest hour, but also in that the survival of the NHS has been in the face of concerted opposition by the Conservative Party and its ‘neoliberal’ allies. Seaton devotes a lot of attention to right-wing plans to privatise health insurance and open health care to commercial companies (particularly cleaning contractors). The Labour party, on the other hand, are credited with always upholding the principles of the NHS. This doesn't really stand up to scrutiny, not least because the Conservatives have been in power for longer periods of the NHS's existence. Surprising as it may seem, it was a Conservative Minister of Health, Enoch Powell, who introduced the ‘Hospital Plan’ of 1962, the largest NHS building programme of the era.

Even well-known enemies of welfarism, such as Margaret Thatcher, never really took on the NHS—Seaton's only telling evidence for her antipathy comes from her famous eye surgery in a private hospital in 1983, and a breezy sentence in her memoirs of 1993. By way of contrast, Our NHS—the phrase was coined by Labour leader, Neil Kinnock, in 1988—argues that Labour has been an agent of ‘modernisation’, not privatisation. That is a questionable interpretation. Seaton doesn't mention Tony Blair's breakfast meeting with private-sector healthcare executives of 13 May 2003, during which he declared that ‘[w]e are anxious to ensure that this is the start of opening up the whole of the NHS supply system’, but it underlines surely how New Labour embraced extending Primary Care Trusts, ‘patient choice’ and Private Finance Initiative (PFI) for new hospital buildings.

A highly original chapter on NHS anniversaries, which closes out the book, points to a different take on Labour's relationship with the NHS. They have just so been much better at claiming it as their own.

Our NHS sees off some myths about the history of the NHS, at the same time as it perpetuates others, notably Labour's ownership of the story. Other countries have similar national health systems to the UK—notably Italy, Spain and Sweden—yet somehow, they manage to do without contested arguments about in whose hands it is safest.

Our NHS. A History of Britain's Best Loved Institution, by Andrew Seaton, Yale University Press. 374 pp. £11.99