The National Health Service has been around for 75 years and run by Conservatives for 48 of them. Next month, when Labour celebrates the anniversary of its proudest achievement it will do so, as usual, in opposition.
At the next general election, Keir Starmer will, as usual, warn the country not to trust the Tories with the NHS. Rishi Sunak, knowing how that charge resonates with voters, will swear allegiance to state-run, collectivised healthcare although it is an affront to many of his party’s sacred beliefs.
It is a ritual dance displaying a peculiarity of British politics. The country that led global trends in privatisation of state assets and whose most electorally successful party makes a fetish of free-market enterprise finds itself also home to one of the world’s most popular and durable socialist institutions.
A rising tide of liberalising capitalism has sluiced the NHS but somehow not dissolved its collectivist foundations. That makes it a miraculous bastion or an infuriating relic depending on which end of the ideological spectrum you ask. For most people in the middle it is just there, an immovable feature of the landscape, like a mighty river or majestic forest. It might be vulnerable to spoilage and neglect, but no one imagines it could be erased and no politician who wants to get elected will be caught suggesting such a thing.
How Britain fell in love with socialised medicine, and whether the relationship can endure, is the subject of two books published to coincide with the service’s 75th birthday. In Fighting for Life, Isabel Hardman arranges the history into 12 themes, defined as the “battles that made our NHS”.
First is the struggle to get the whole thing set up. It was done with astonishing speed in the face of financial constraint, resistance from much of the medical establishment and the Conservative party. The Tories were notionally on board for some kind of nationwide healthcare expansion, but not on the scale or in the form that Nye Bevan, health secretary in Britain’s postwar Labour government, brought to the Commons.
Fast-forward 75 years and we reach the 12th of Hardman’s battles – the struggle, on multiple fronts, to protect Britain from the ravages of Covid, which also became a struggle to protect the NHS itself from falling apart under the strain.
Hardman describes how the problems inflicted on the health service by the pandemic – trauma for staff equivalent to wartime; colossal expense; disruption of systems and cancellation of routine procedures – are unrelenting and existential. “The NHS continues to operate at a pace and level of stress that it simply has not seen in its entire history,” she writes. The resultant danger is that “patients are starting to lose faith with it in an unprecedented way, too”.
A poll in May last year found the health service top of the list of things people thought were best about Britain, beating the nation’s countryside into second place. But idolatry doesn’t stop growing numbers of people turning to the private sector when they can’t get GP appointments or when the wait for operations is too long to bear. That is only an option for those who can afford it, or rather, the few who can afford it plus increasing numbers who can’t but are driven by despair to incur the expense anyway. This fractures the moral foundations of a service that embedded itself so deeply and so quickly in popular affections precisely because it banished the fear of ill health that a billing service imposed.
That is especially true for women and children, who had previously depended on the indulgence of husbands and fathers for access to medicine. Battles fought on that front – for safe maternity care; for reproductive rights – provide some of the most compelling passages in Hardman’s deftly constructed and powerfully told narrative. They are also among the most shocking scenes. Well into the 1970s, unmarried mothers were compelled to give up babies for adoption on the grounds that their condition was proof of moral depravity. Doctors and midwives would sermonise mid-delivery, denying young women pain relief and abusing them for their wickedness.
Hardman is a meticulous journalist with a gift for storytelling. She doesn’t let her admiration for the NHS as both a political achievement and a healthcare provider impede the exposition of its flaws. She modulates her tone with subtle precision, using controlled fury for scandals born of callous neglect and ironic detachment when transporting the reader into cabinet discussions where a health secretary’s vanity conflicts with a chancellor’s parsimony.
The colour palette is less varied in Andrew Seaton’s Our NHS, which is a more academic, but still accessible survey of health service history. Seaton, a research fellow at St Anne’s College, Oxford, applies a wide-angle lens, taking in more of the international context that has shaped the health service. He is insightful on the ways that American conservatism, and its grotesque distortions of what state-funded medicine involves, have fed a British defensiveness that insulates the NHS from some of the more aggressive privatising impulses in the Tory party. “Free-market medicine was daubed with the Stars and Stripes,” he observes, “which could not compete with the Union Jack draped over the NHS.”
Seaton also charts an interesting grey zone where patriotic enthusiasm for a unique, beloved institution shades into “welfare nationalism” and resentment of foreigners gaining unearned access to a precious, limited resource. He and Hardman are in agreement on the vital role that immigration has played in keeping the health service functioning. Both are nuanced in mapping the contours of a public response that shades between welcoming foreign doctors and nurses, wary acceptance and flagrant racism.
The two authors are aligned in their analysis, covering much of the same material and identifying many of the same recurrent patterns: the constant pressure for innovation provoking fear of core NHS principles being abandoned; tension between a consumer culture that increasingly expects customised choice and a system that functions by pooling resources on a principle of collective solidarity; the challenge of imposing minimum standards without the perverse, unintended consequences that rigid targets generate; the simple fact that there is never enough money, but also that more cash is not always the answer and Treasury pockets are not infinitely deep.
Both books describe party political wrangling without overt partisanship, although Seaton’s leftward tilt becomes increasingly clear in later chapters. It is explicit in his conclusion – that the tenacity of the NHS in fending off marketisation might serve as a model for the resurgence of egalitarian, social democratic politics in Britain.
In Fighting for Life, Hardman is less concerned with ideological frames and gloomier about the future. Specifically, she warns of the slide into a two‑tier system, where medical excellence is on tap for the rich, while the rest wait in lengthening lines, making do with whatever they are given. It is an all too plausible scenario, hardly conducive to festivity on the eve of the NHS’s 75th birthday, but necessary reading in order to understand the reasons for that longevity and why it is imperilled.
• Fighting for Life: The Twelve Battles That Made Our NHS, and the Struggle for Its Future is published by Viking (£20). Our NHS: A History of Britain’s Best Loved Institution by Andrew Seaton is published by Yale (£20). To support the Guardian and the Observer buy them at guardianbookshop.com. Delivery charges may apply.
