IS THE NHS BRITISH? I ask because early one morning recently I tweeted that opinion. Concluding with the bold declaration that a vote for the SNP was a vote to leave the NHS.
The response, by my standards, was dramatic. Some 1800 likes and 1200 comments. If I had posted a video of me kicking a puppy around my garden the responses could not have been more furious; I should be reported to the General Medical Council; my practice should be picketed; the practice address was published and the enraged were encouraged to complain to my innocent practice manager. Many people were thankful someone so ignorant was not their own GP.
Then a senior SNP politician took the opportunity to swim by lazily, like a shark, to denounce my ignorance and encourage the backlash. But a few replies were more considered. Did I not know about the Highlands and Islands Medical Service? We are NHS Scotland, don’t you know?
To be honest I was taken aback by the response. You’re enjoying breakfast and already a mob armed with pitchforks and chanting your name is hunting you down. It was like a scene from The Simpsons. It was time to pause and reflect. Was I wrong? Was my tweet misjudged?
The NHS in Scotland began on the 5th of July 1948. The NHS in England, Wales and Northern Ireland began on the 5th of July 1948. Perhaps it was a coincidence. Further investigation was required.
Much of the information to follow can be found at the Scottish government website www.60yearsofnhsscotland.co.uk The Cabinet Secretary for Health in Scotland in 2008, Nicola Sturgeon, the current leader of the SNP, contributed an introduction. Direct quotes from the Scottish government website are in bold print.
To understand the origins of the NHS in Scotland and the UK it is indeed necessary to go back to the Highlands and Islands Medical Service, HIMS.
“The Highlands and Islands Medical Service was a unique social experiment in Britain long before the NHS.”
Established in 1913 with £42,000 from the British Treasury the HIMS covered half the land mass of Scotland and provided health care to 300,000 people. Prior to the creation of HIMS, medical and nursing services were poor or non-existent in many areas within the crofting counties. Doctors were unable to make a living as the population was sparse. HIMS gave doctors a basic income and fees were set at minimal levels but inability to pay did not prevent people getting treatment.
HIMS was a great success and working in remote communities became an attractive career option for doctors and nurses. Further HM Treasury funding in the 1930s allowed services to extend to hospitals. Stornoway had its first surgeon in 1924, and Wick in 1931.
Scotland can be proud of the Highlands and Islands Medical Service. Directly funded by the state and administered by the Scottish Office in Edinburgh, the Highlands and Islands Medical Service was in many ways a prototype for the NHS, showing the way 35 years before the start of the NHS.
In 1936 The Cathcart report was published. This committee was established in 1933 by the National Liberal Party Secretary of State for Scotland, Sir Godfrey Collins, to review the existing health service in Scotland. Cathcart acknowledged the link between poverty and disease. The report advocated a health service based on the GP and health promotion. The Cathcart report was influential because it provided Scotland with a consensus for how to set up the new NHS in Scotland in 1948. This consensus was missing in England.
In 1937 AJ Cronin wrote The Citadel which was then made into a Hollywood film. The Citadel was very influential in the birth of the NHS. Archibald Joseph Cronin was born in Cardross and studied medicine at Glasgow University. He moved to Tredegar in South Wales and from there to London before returning to Scotland where his writing began. He would later write Country Doctor which inspired the popular BBC drama Dr Finlay’s Casebook.
The Citadel’s message was clear – “Socialised medicine for working people along the Tredegar model was pure and noble but the current system as then practiced in Harley Street was totally corrupt and immoral.”
The film The Citadel, with well-known film stars and King Vidor as director, broke all records. The influence of The Citadel on the creation of the NHS was acknowledged when it was re-released in 1948 at the onset of the NHS.
The Scottish health service benefited greatly from UK spending during the Second World War. In 1939 the Emergency Hospital Service – EHS – began. This was a UK scheme to deal with the expected civilian casualties from air raids. It was also thought that Scotland would become the centre for British resistance if Hitler invaded the south of England.
“Hospital building in Scotland in the 1940s proceeded at a pace scarcely equalled anywhere in Europe, before or since.”
Seven new hospitals were built in Scotland, at Raigmore (Inverness), Stracathro (Brechin), Bridge of Earn (Perthshire), Killearn ( Stirlingshire), Law (Lanarkshire), Ballochmyle (Ayrshire) and Peel (Selkirkshire).
Fortunately the civilian casualties did not materialise, and the Secretary of State Tom Johnston established a range of new specialties including: orthopaedic centres, plastic surgery, eye injuries, psychoneurosis, neurosurgery and the blood transfusion service.
Scotland’s health service was transformed by the Emergency Hospital Service, and it set up Scotland well for the start of the NHS.
“In total the EHS provided an additional 20,500 beds – an astonishing 60 per cent increase on Scotland’s existing provision. Of these, 13,000 were later incorporated into the NHS.
From severe pre-war bed shortages, Scotland by 1948 had a relative abundance – 15 per cent more beds per head of population than England and Wales. It also had 30 per cent more nurses and was better resourced for GPs.
The Treasury funding formula for the NHS incorporated the EHS hospitals and their staff. This was a significant benefit for Scotland.”
In 1942, Englishman “Sir William Beveridge set out his vision of a post-war Welfare State to banish from Britain the five evil giants – want, ignorance, squalor, idleness and disease.”
The Beveridge report was instrumental in paving the way for the NHS.
His report became a best seller because of its breath-taking vision and passionate language. The fiery rhetoric was inspired by weekends in Scotland with the Scottish Jessy Mair.
Mair was Beveridge’s close confidante and companion for many years and they eventually married.
“His biographer, Jose Harris, highlights her influence on him during his visits north of the border where she was staying with relatives in Scotland:
“Much of his report was drafted after weekends with her in Edinburgh and it was she who urged him to imbue his proposals with a ‘Cromwellian spirit’ and messianic tone. ‘How I hope you are going to preach against all gangsters,’ she wrote. ‘who for their mutual gain support one another in upholding all the rest. For that is really what is happening still in England’. . . .”
Prior to the NHS, the health service in Scotland was in poor shape.
“Staff shortages, long waiting lists, cash crises and hospital infections were all evident in Scotland long before the NHS.”
By 1939 only around a half of all Scots had a GP. It was mainly women and children and the poor who did not have a GP.
“Aneurin Bevan (1897-1960) was the charismatic Labour politician who created the National Health Service”.
This is true but it is a little-known fact that the NHS was first proposed by the Conservative Party when English Tory Health Minister Henry Willink produced his White Paper, “ A National Health Service”, in 1944. Conservative, Labour and Liberal politicians in the wartime government had all agreed to meet the need, as identified in the Beveridge Report in 1942, for health care to be free for everyone at the point of use.
Winston Churchill in 1944, speaking as Prime Minister and leader of the Conservatives said, “Our policy is to create a national health service, in order to ensure that everybody in the country, irrespective of means, age, sex or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”
All three parties included the pledge in their manifestos after the war. The landslide victory for the Labour Party in 1945 meant it fell to Aneurin Bevan to found the NHS.
Welshman Bevan had lived in the mining community of Tredegar South Wales in 1921, at the same time as AJ Cronin was working for the Tredegar Workmen’s Medical Aid Society. It seems unlikely they were unaware of each other although there is no evidence they met in the two years they shared in Tredegar.
Bevan had close links with Scotland and was married to a Fifer, Jennie Lee.
“Bevan’s vision for the NHS was for the whole of Britain. It was a monumental administrative and political challenge.
In three years he succeeded in delivering a universal service for all the people – “in place of fear”, as he described it.”
The NHS began across the whole United Kingdom on the 5th of July 1948.
The impact of the new NHS in Scotland was immediate:
“For the first time everyone in Scotland now had access to proper medicine on prescription. Those plagued with rotten teeth were able to see a dentist for the first time. Previously-deaf people could hear with new aids.
“The new NHS had to be seen to be believed. Half a million Scots (one tenth of the entire population) were able to have free spectacles within four months of its inception. Half a million also got free dentures in the first year.
“The first year of the NHS provided the biggest single improvement in the everyday health and well being of the people of Scotland – before or since”.
The influence of Scotland and the Highlands and Islands Medical Service on the NHS is clear, and the NHS and the UK was good for Scotland too:
“Scotland had provided prototypes for the NHS. The UK structure brought advantages in return. Services were available across Britain. National Health Service staff had common salary scales which gave a relative advantage to Scottish health workers whose wages were generally lower than elsewhere”.
The Scottish government website is clear that the NHS is a United Kingdom-wide health service, while highlighting the perennial issue of funding:
“From this time the focus was on the wider UK NHS family. It was the new welfare state which helped lay the foundations of the post-war British state. The NHS not only operated across the United Kingdom – it was a modern representation of it.
Money was to be a constant cause of friction and major decisions would mostly be made in London not Edinburgh.”
We have known the NHS so long it is easy to take it for granted but we should not forget what a monumental achievement it was:
“5 July 1948 was the second of Britain’s finest hours in the brave and high-minded 1940s. Like the Battle of Britain it was a statement of intent, a symbol of hope in a formidable, self-confident nation. That should not be forgotten…when the trials and tribulations and the often fractious politics of health care are given their due place in the post-war history of the United Kingdom. The NHS was and remains one of the finest institutions ever built by anybody anywhere”.
Historian Peter Hennessy Never Again, Britain 1945-1951
“It was the first health system in any Western society to offer free medical care to the entire population.”
Rudolf Klein, The New Politics of the NHS, 2006.
The founding principles of the NHS are still a guide and an inspiration.
That it meet the needs of everyone.
That it be free at the point of delivery.
That it be based on clinical need, not ability to pay.
If any British citizen becomes ill or breaks their arm they know they can attend a hospital wherever they are in the United Kingdom, with no difficulty.
Although the NHS covers all the United Kingdom, it required separate legislation in the constituent legal jurisdictions to bring the NHS in to existence. England and Wales was covered by the National Health Service Act 1946, accountable to the Secretary of State for Health. Scotland was covered by the National Health Service (Scotland) Act 1947, accountable to the Secretary of State for Scotland and Northern Ireland was covered by the Health Services Act (Northern Ireland) 1948.
The first use of the term National Health Service is attributed to a physician from Liverpool, Dr Benjamin Moore in 1910 in his book, The Dawn of the Health Age. But what exactly do we mean by the term NHS? The Institute for Government explains that the NHS is the umbrella term for the four health systems of England, Scotland, Wales and Northern Ireland. Between 1948 and 1999, the health systems of Scotland and Northern Ireland were managed by UK government departments – the Scottish Office and the Northern Irish Office respectively.
In Northern Ireland the NHS was merged with the broader social care system in 1973 and called the Health and Social Care System, rather than the NHS. In 1969 the NHS in England and Wales was separated and the Welsh NHS was run by the Welsh Office, a UK government department.
Devolution in 1999 transferred control of the NHS in Scotland from the Scottish Office to the Scottish Parliament and the health system in Scotland is known as NHS Scotland. The Cabinet Secretary for Health and Sport in the Scottish Government has responsibility for health matters in Scotland and so Scotland has a distinctively Scottish version of the NHS. For example, new GP contracts in Scotland were agreed with the BMA in 2004 and 2018 and therefore GPs in Scotland have a different contract to England. Also Scotland has free prescriptions, whereas prescriptions cost £9.15 in England, for those required to pay.
The funding for NHS Scotland benefits from the pooling and sharing in the UK. Scotland’s deficit in 2020 was £15.1 billion. Public spending in Scotland is £1,633 per person more than the UK average. In 2020, Scotland spent £14 billion on health. The Institute for Government calculates spending per head of population on the NHS is more in Scotland at £2,396, than England at £2,269. We are able to spend more on our health service in Scotland. This is because of the generous Block Grant we are apportioned by the Barnett formula increases, as part of the UK.
So is there a separate Scottish NHS after all? Mibbes aye, mibbes naw. It may be argued Yes in terms of autonomy, but No when it comes to history, institutional framework and funding. Thanks to devolution, the NHS in Scotland is both Scottish and British. Just as it was at the time of its inception, the NHS is still a modern representation of the United Kingdom. The Scottish Parliament has the power and ability to shape Scotland’s health service as it wishes, while retaining the spending power it has as part of the UK. It can choose to increase spending on the NHS (or reduce it, for that matter). It is a good arrangement.
Our lives have all been dominated recently by Coronavirus. Across the UK, we have been encouraged to stay at home and protect the NHS. At the start of the pandemic we were all encouraged to clap on our doorsteps for the NHS. If you live in Scotland and you were out on your doorstep clapping, who were you clapping for? Did your appreciation of the NHS screech to a halt at Gretna, or did your solidarity with NHS staff extend to Newcastle and London, Wrexham and Cardiff, Coleraine and Belfast?
And so, after due diligence, research and contemplation, my conclusion?
The NHS began on the 5th of July 1948 as a United Kingdom-wide health service. Devolution in 1999 has allowed the development of a well-funded, distinctive, Scottish version of the NHS. If Scotland voted for independence then, by definition, Scotland would have its own completely separate health service, which would no longer be a part of the United Kingdom NHS organisation – with its UK-wide reach and benefits
