The forgotten Tory blueprint for the NHS
Before the Attlee government of 1945, Henry Willink MP had a plan
It seems the Tories can do no right by the NHS. Despite successive governments throwing ever greater amounts of money at the service, the party repeatedly stands accused of starving it of much-needed funds and seeking to privatise NHS services wherever possible.
After 12 years of Conservative government, the NHS is plagued by lengthy wait times, high rates of excess deaths, a lack of medical staff and emergency services on the brink of collapse. Yet these problems are not new, and have been exacerbated by the effective shutting down of the health service during the Covid-19 pandemic.
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In the face of accusations that their incompetence — or worse, deliberate malice — is destroying the NHS, it is striking that so few Conservatives seem willing to discuss the role the party played in its creation.
In a March 1944 speech, Prime Minister Winston Churchill said that the “discoveries of healing science must be the inheritance of all”. With this notion in mind, and aided by the recommendations made in the Beveridge Report of 1942, it fell to the Conservative MP Sir Henry Willink, the Minister of Health in Churchill’s wartime coalition government, to draw up the first detailed blueprint for a national health service. It was Willink who declared the service should be “free at the point of delivery, according to need not ability to pay”, and his ideas which were advanced by Aneurin Bevan in Clement Attlee’s Labour government of 1945.
Indeed, the proposals put forward by Willink are arguably superior to those subsequently implemented by the Attlee government. The 1944 Willink White Paper outlines a system of public and private hospitals working for the NHS. Autonomous “voluntary hospitals”, provided they met national conditions of care and standards, would be contracted by the NHS to perform services for patients. The voluntary hospitals would receive payments from both central and local funds, and the patient would access the treatment they required for free at the point of need. Instead, Bevan opted for a fully nationalised and regionalised national health service.
Willink’s proposals would likely have meant the NHS evolved into a model similar to the universal health coverage provided by Germany and other nations, with a more decentralised and independent system allowing for greater healthcare innovation. For context, according to research by the Institute for Economic Affairs, if British patients with the four most common types of cancer (breast, prostate, lung and bowel) were treated in Germany rather than in the NHS, more than 12,000 lives would be saved each year. This data is from 2018, before cancer services were disrupted by the Covid lockdowns. There is a considerable likelihood that mortality rates have worsened since, although the full impact of the pandemic may not be seen for some time.
Beveridge anticipated that “the development of health and rehabilitation services would lead to a reduction in the number of cases requiring them”. In other words, the cost of the health service would reduce over time as the population became healthier. To date, this has proved to be far from true. The NHS has seen average annual budgetary rises of 3.7% since it was established in 1948, and the share of GDP attributed to healthcare was around 11.9% in 2021 — a significant increase from 9.9% in 2018. Given population increases, demographic changes, healthcare demand and inflation, there is little doubt the overall NHS budget will rise further still in future. Enoch Powell was correct in referring to Beveridge’s expectation as “a miscalculation of sublime dimensions”.
In his announcement of the government’s plan in 1944, Willink spoke of “a service that will provide the best medical advice and treatment to everyone, every man, woman and child in this country.” Yet the NHS of today falls short of this aim and is in desperate need of reform.
For the Conservative Party, remembering of its role in the founding of the NHS could help to change the popular narrative that Tories seek its demise and help bolster the political courage desperately needed to implement change.
There was a good episode of “Who do you think you are” recently where the actress Ruth Jones learned about the work of her grandfather as the administrator of a voluntary insurance funded hospital trust in South Wales before 1945, who found his organisation dismantled and his expertise frozen out by the newly nationalised NHS. It demonstrated that there was a pre-existing viable model for providing affordable healthcare, which was dismantled on ideological grounds. Interestingly even Jones either didn’t understand of what she had learned, or didn’t want to.
Yes, it’s not generally appreciated that Britain had a cooperative model of healthcare insurance prior to 1945: the Friendly Societies which by 1910 covered 75% of manual workers in Britain. It is absurd to imagine that the NHS provided a system of healthcare where none previously existed: it merely nationalised a system that already worked.
And now, of course, it doesn’t work.
A return to community based system will be a good thing. That will require us take an active interest in our local societal entities and stop blaming central government. Both funding and accountability must be devolved to local communities. Poorer area can have some central fund to help but most of the weight should fall locally.
Only municipal and voluntary hospitals were nationalised in 1948. NHS GPs, dentists, dispensing pharmacists and opticians are, and always have been, profit making businesses both sides of the border.
Majority of patient contact with NHS is, and always has been, with private contractors, not state employees.
It was the same in Scotland. Nearly all our hospital were “Royal” (free) hospitals and heavily endowed. These endowments were “stolen” by the government, the word used by a medical working in one.
Over the centuries, patients “willed” money to their local hospital in differing amounts but who is going to donate money to a faceless bureaucracy?
The majority of hospitals in Scotland, as in England and Wales, were municipal.
Ruth Jones’s grandfather was the Secretary of a mutual aid society in Neath that employed GPs under Lloyd George’s National Health Insurance Scheme (NHIS), not a “voluntary insurance funded hospital trust”.
Just a point which is often overlooked. When the NHS was set up the primary cause of ill-health was disease. Children in particular suffered from terrible diseases like polio.
Today we have been successful in removing serious diseases of childhood so people can now live longer and longer and longer…
So the NHS is now mainly concerned with problems of old age. In a way this is not really fair because we are penalising the young for a few extra weeks on the average life expectancy.
This lack of focus means that NHS employees are now strongly concerned with ‘diseases’ of the young like mental issues.
That is an excellent point and one that I hadn’t appreciated before.
As well as vaccination programmes stopping terrible childhood diseases, the NHS is good at preventing the health problems of middle age – hypertension, high cholesterol and diabetes can all be spotted early with simple tests and controlled with cheap medication.
You could argue that as a system to prevent life-threatening diseases in the non-geriatric population, the NHS works pretty well and the problem is that the scope of “healthcare” has massively increased (geriatric care, mental health etc).
Not sure where that leaves us but it is an interesting perspective.
I have no suggestions for how to address the NHS mess. But it seems to me there are four principal reasons why it is failing so badly:
 Since 1980 the population of the UK has increased approximately from 50 million to 80 million without a noticeable, corresponding increase in infrastructure and revenue funding to deal with some 30 million extra people demanding access to free health services.
 Tony Blair’s government introduced the new GP contract that absolved them of out-of-hours work and paid them significantly more! Patients have resorted to A&E departments as a consequence.
 The rise of embedded, rampant managerialism within the public sector, the NHS no less, where well paid managers and bureaucrats wield power and set the agendas.
 Cameron’s governments that placed cutting public service budgets as the principal policy objective (an end in itself ultimately, rather than a means to an end) that decimated operational budgets (e.g. Home Secretary Theresa May who cut some 30,000 police jobs) in the NHS and elsewhere.
Is it any wonder that the NHS, and other public services, have been so damaged by such useless politicians, insulated from the impact of their governance by virtue of their personal wealth?
“1] Since 1980 the population of the UK has increased approximately from 50 million to 80 million without a noticeable, corresponding increase in infrastructure and revenue funding to deal with some 30 million extra people demanding access to free health services.”
Actually from 56 to 67 million – an increase of 20%
Whilst Dept of Health and share spending has gone up 400% – in real terms, over the same period.
Moreover, the health services are not free, by paid for by taxes, which presumably go up with population rise….
That 400% cannot possibly be a real terms figure. Your last sentence is also a bit of a quibble, the term generally used is ‘free at the point of delivery’, which however could be achieved on other ways than by a monolithic nationalised health service.
Of course everyone accepts that health services must be paid for by SOMEBODY, the Left would argue by increasing taxes still more on the ‘wealthy’ and corporations.
I used to work as a clerical assistant in my local hospital in the early noughties and was shocked at how antiquated and wasteful the admin systems were.
I could not understand why we were posting out via snail mail hundreds of appointments without ever consulting the patients.
Of course this created phonelines jammed with callers desperate to change the appointment. But we had filled the diary.
Complete madness and appalling customer service.
Not to mention insane sums wasted on headed paper, envelopes, printing and postage and vast quantities of expensive printer ink.
Don’t get me started on fax machines! In the 21st century!
In an age when most have mobile phones, email and Internet why were we still using 19th century technology?
A paper letter is not more secure than an email. It can be lost, stolen and opened by the wrong person.
Our patient database was full of errors and double registrations because we used names and dates of birth to identify the patient instead of their unique NHS number.
I could go on.
The time and money wasted can only be guessed at.
Not to mention all the inaccurate information entered onto the system.
The problem of goalpost moving for what constitutes “health” will continue to ensure costs rise. This is true across the west, until we are all immortal, there is no clear point at which the desire to create more health will end. The idea that better health care and prevention should save a lot of money makes sense, right up until we remember that every patient will degenerate and die in the end, and that is very often the most expensive phase of a persons life for the health services.
However, if we look across most other industries and activities over the past 30 or so years, the effect of technological advances (computing in particular where we can do more each year at decreasing real cost) has been to enable huge increases in productivity and unit cost.
We should be asking ourselves why we have not seen these same savings in healthcare. I have a strong sense that the opportunties here have not been fully realised and there’s a boatload of excess cost and inefficiencies that can still be taken out, given sufficient will, competence and lack of obstruction by vested interests resisting change.
I raised the issue of the cap on doctor’s training places in an earlier article on the NHS last week.
Interestingly, my local MP spoke in a debate yesterday where he opened his speech (in support of greatly expanding doctor training places in the UK) with a question. “What is the main nationality of Bulgarian doctor’s coming to the UK ?”. It’s British. Not Bulgarian.
Our “system” is so messed up that we’re turning away straight A medical school applicants in this country. I applaud those with the inititate and drive to train in Plovdiv or Sofia and then return here.
But frankly, that such as situation has been allowed to accumulate and be tolerated for decades tells me that the upper management of the NHS is at least as bad as the politicians. They’ve had ever expanding real term funding and spent the money on other things. They clearly cannot understand what their real priorities are.
When is someone going to hold any NHS “leaders” to account ?
National healthcare systems were possible in 1942; medical interventions were limited and not particularly expensive. Today we can keep a brain dead person alive indefinitely, at tremendous cost though.
Modern medicine is so expensive it must be rationed somehow. If you’re not going to use price to do it (as Willink says above, “free at the point of delivery, according to need not ability to pay”) you have to use something else. In the ideal technocratic model of national health care, that “something else” is trained panels of experts evaluating the probability of success for a treatment. In the real world, that “something else” is long waiting periods that cause the sickest (and most expensive) patients to die before they get treatment at all.
” … you have to use something else. In the ideal technocratic model of national health care, that “something else” is trained panels of experts evaluating the probability of success for a treatment.”
Well we have had NICE in the UK to do just that since 1999. Some controversies but it does attempt to bring some evidence based uniformity to treatment recomendations and does remind health professionals that they are actually in a business, paid for by the great British taxpayer.
It in interesting that they called it the national HEALTH service and that Churchill’s words were ‘‘discoveries of healing science must be the inheritance of all’‘
Note that he used the word ‘healing’. Modern medicine is not into healing people, it tries to fix people, using a medicine created by the industry, hence based on revenue rather than social outcome. The logic economical outcome is that more people need more services which serves the investment of the industry.. and it works…
But nowadays you are called (or thought off as being) ‘fluffy’ when you use the word healing. ….
Well, if society prefers to use the model of repairing cars to fix people, it is the choice society makes…. but cannot afford any more.
it is not the organisation of the NHS that is the main problem: it is the type of medicine it prefers. Oh, I am not saying that we have not made enormous progress, we have. In acute illness and in diagnostics we are amazing…. in healing people ….. mmmmmm
The issue was whether Local Authorities could oversee the voluntary sector, as Willink had suggested. Bevan concluded they couldn’t and weren’t big enough to take on this management. He also wanted it to be very clearly be a ‘national’ service. So there were both ideological and practical considerations. Bevan was a pragmatist when he needed to be to get it done – hence much of what we’ve inherited on doctor remuneration.
Churchill of course blocked Beveridge and Willink’s plan until after the war, and then campaigned against both. His thumping election defeat in 45 shows people knew then something we’ve forgotten about our Winnie, but that’s another story.
The issue for sustaining the Voluntary sector was it was going to become reliant on government funding, and then would need baling out if organisational failure. Bevan wanted the ability to control to avoid this.
Now whether we could get back to a more mixed economy as regards providing health services (whilst retaining free at the point of use) may still depend on the total amount we are prepared to invest in health services via the payment for services mechanism. The more mixed approach works where the total expenditure is higher and risk of organisational failure therefore less – France, Germany etc. Investment therefore flows more easily. Hospitals/clinics aren’t like MOT centres. We notice immediately if they go bust and close. For example look at what happens to Care Home residents when their provider goes bust.
Except it’s no longer true that we spend a lower proportion of GDP on health than the typical European figure. We spend as much and get worse outcomes.
And I think a western European comparison probably a better reference point – France, Germany, Netherlands.
I look forward to having a look at the data source you share, but for argument let’s pretend that in 22-23 we have moved to the western European average. How long does it take to attract and train doctors and and nurse? 3 years for a nurse, 5yrs+ for a doctor. Point being needs to be sustained for good number of years.
The UK spends around 20% less than the Germans, and this was as high as 33% less only 5 years ago. Te Germans also spent treble the UK on hospital infrastructure between 2015-2019 to increase capacity
Well, Germany is overall a richer country than the UK, which notably concentrated on a rigorous building up of its economic base after World War 2, rather than prioritising the creation of a welfare state, and of course at that stage spending much less on the military.
It s the very fact of an entirely taxpayer-funded system that causes such a huge and ever growing problem for the UK. Everyone wants to pay higher taxes all the time, right? If it were so easy to ratchet up spending by 20 or 30,% as you seem to suggest, why haven’t successive Labour governments done so? New Labour of course did raise spending significantly, with a rather large proportion of the increase going into doctors pay. Left of centre opinion in general: We must always spend MORE (from wherever we happen to be) on health, education, railways, welfare, and I struggle to find a single area they don’t argue for this. We’ve just blown the nation’s finances in an absurd panicked overreaction to a respiratory virus, and at every stage the Left wanted longer lockdowns and more spending.
Health outcomes are not all about spending, as the current abysmal situation in Scotland seems to show. A state monolith with bits of pieces of crypto private provision seems very unlikely to provide the best structure for health provision, which is why it hasn’t been adopted by any similar country. Israel has an excellent insurance-based health service: it has four major providers and a significant degree of patient choice.
Let me get this straight. It’s OK to have local authorities managing schools. But not hospitals.
You don’t see any contradiction in that ?
Thankfully we didn’t make the same mistake with centralising all education and enforcing a “one size fits all” model so that everyone gets equally poor service (because that’s “fairer”).
No I think it’s worth exploring. The point was back in 48 that was the conclusion.
The upside is potentially better local decisions and full ownership of the discharge pathway into social care.
The downside is LAs need to be given additional powers if taking this on that the Treasury might object to. We also then need to untangle medical and nurse training and national workforce planning. So it’s not straightforward, but as you say we do it for education, largely.
Furthermore though if one wants to reduce some of the politicisation of the NHS it’s not clear opening this up as a local councillor issue will aid that. Making regional capacity decisions could get more difficult, but perhaps that can dovetail with more regional autonomy to match.
Interestingly Tories in the 90s and last 13 years haven’t promulgated this. One suspects because of antipathy to local government more generally.
Thanks. I’ve been struggling to agree with you on anything for many days !
You’ve helpfully opened up an interesting point here about central vs local management and I think it is worth thinking about. I’m not sure what I think here yet – I just found the differences in approach to health and education interesting. Local government management of education has not been without its challenges though. And education isn’t truly local – most of the funding is raised nationally and we end up with massive regional inequalities in funding per pupil (as we well know in Cambridgeshire, where it’s been well below average – when costs are well above average).
I’ve made a separate comment on doctor’s training (“awaiting approval” !).
Very interesting discussion, gentlemen! This is exactly the sort of civilised, intelligent discourse which is so lacking in the nation’s life generally. Thank you for your reasoned and balanced conversation.
Some points in passing:
Prior to the NHS most of the public hospitals were run locally with strong local authority links. Many of the great regional hospitals were built in this pre-NHS era.The concentration of taxation powers in central government and its redistribution to county, district and unitary councils via the Rate Support Grant (or whatever it is called today) has massively undermined the authority and power of local government. When I retired from a top management position in a county council some 12 years ago, the government grant represented approximately 85% of local council income, with the Council Tax making up a proportion of the balance.But it is not only through controlled LA budgets that central government in the UK exercises power over local councils. It do so also through the imposition of policies and associated actions that have to be implemented in order to secure much of that central government funding. This is why there is such a numbing uniformity of policy across the local government/public service landscape, whether Tory or Labour controlled. The enormous power of civil servants in London is not really understood by the general public.Some would argue that this is about achieving fairness across the board – the same for all. Much of the central government imposed policy relates less to service delivery than the requirement to meet central government policy development – i.e. local councils have become the delivery mechanisms for central government, which is less interested in the specifics of libraries, country parks, trading standards, planning, or whatever, than delivering equity, inclusion, diversity and so forth.It seems to me that the NHS has, over the decades of its existence, become a bureaucratic and managerialist behemoth that is beyond repair. I wonder if any UK politician has the courage and integrity to tackle the issue – and whether the public will be able to break away from the brainwashing they’ve absorbed over decades about how wonderful and amazing is the NHS. Compare it, for example, with the Australian or Canadian models and we look as though we are still crashing about in the darkness of our caves!
Apologies for the poor arrangement of my post above. All of my bullet points were removed and I was prevented from editing these! Most annoying!!
It is indeed annoying. But your comment was still easily readable. And more importantly, very helpful.
I also suspect that the increased use of external consultants in the public sector has drained the sector of talent and also some self-confidence. It’s hard to believe that public sector bodies like London Underground once produced original and outstanding station designs. I’m just guessing here, but the rigidity of public sector pay scales might have something to do with it ? You will certainly know far more about this than me. But I just don’t see why anyone who wants to do new and innovative things would want to work in the public sector these days – the best people (not everyone) can earn more in private industry and be less encumbered (but not free from) the “non core constraints” of diversity, etc. i.e. the stuff that gets in the way of actually getting stuff done.
Agree and further illuminates why Central Govt, and esp the Treasury, won’t be suggesting healthcare devolution to LAs anytime soon.
But they really can’t duck the social care problem much longer. Personally I can’t see a way round it longer term without an additional insurance we all take out, and risk pooling will be essential which drives it towards a national/state system.
I would add though Australia and Canada do spend significantly more per capita. Younger demographic too, as least for the moment. Still things we can learn, but not entirely a like for like comparison.
Nonetheless the current crises has to prompt serious thought on whether we can do this better.
“The issue was whether Local Authorities could oversee the voluntary sector, as Willink had suggested”
Perhaps you should actually read the 1944 NHS white paper, rather than repeating what you have read on Facebook. The white paper proposed that hospitals municipal and voluntary should be co-ordinated regionally as hospitals in London had been in a highly effective manner by the London County Council before the war. Voluntary hospitals were not the ‘voluntary sector’, but institutions such as Barts and Guys etc.
Churchill did not campaign against the NHS.
Very interesting, but there’s one observation I’d make in that the system of public/private provision mooted by the 1944 report may well have been dodged by the subsequent Attlee government, but very similar measures have been taken since, notably in the New Labour years when GP practices were privatised and the use of private trusts to offer services to the NHS was expanded.
It’s possible therefore that this strategy as a means of reforming the NHS could be said already to have been tried and to have failed.
GPs have always been independent contractors and not employed by the NHS since it’s foundation, though not many people are aware of the fact. They do however provide their services almost entirely on behalf of NHS and paid (very well!) by it, ie the government.
So if it has been ‘tried and failed’ that applies to the entire period since 1948.
National Health Service GPs have been profit making contractors since 5 Jul 1948.
In that NHS GP contracts were largely a continuation of National Health Insurance Scheme GP contracts, effectively since c 1913.
NHS GPs, dentists, dispensing pharmacists and opticians are, and always have been, profit making businesses both sides of the border.
The majority of patient contact with NHS is, and always has been, with private contractors, not state employees.
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Let’s think about politicians who have wrecked the NHS. Let’s start with Sir Keith Joseph, move on to Kenneth Clarke, then glossing over John Major and Tony Blair before arriving at Andrew Lansley. It’s a catalogue of morons imposing reforms with no attempt to assess their impact. Why don’t we look at what works both here and abroad, and devise a completely new system? That’s not ignoring the fact that healthcare worldwide is in crisis.
“Free at the point of service” sounds good but is fatally flawed in practice. The centralised payer (be it government or insurance company) becomes the customer to be pleased, not the patient. Over time, it builds a culture of bloated administration tails wagging the caregiver dog. That is the fundamental reason the NHS (or American Healthcare, for that matter) is an expensive poorly serving mess.
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The 1944 NHS white paper was “Presented by the Minister of Health and the Secretary of State for Scotland” i.e. Henry Willink (Con) and Tom Johnston (Lab)? It helps to have read at least the first line of a document you refer to.
Liberal National leader Ernest Brown was Minister of Health in early 1943 when the coalition government committed to implementing Beveridge. Willink only became Minister of Health in November 1943 (reshuffles following Chancellor Kingsley Wood’s sudden death.). It was Brown and Johnston who worked out most of the practicalities of the National Health Service.
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