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episodes within the app

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It said that war makes the state and

0:23

the state makes war and

0:25

here on the warfare podcast We spend

0:27

a lot of time focusing on how nations

0:30

start wars and fight battles But

0:32

much less on the lasting impact

0:34

of those wars on society and

0:37

this week is a special week It's the 75th

0:39

anniversary of the NHS that

0:42

vital social welfare net that brought

0:44

health care to all Free at the point

0:46

of use after the Second World War in

0:48

the United Kingdom But how did the

0:50

Second World War impact and spur on

0:53

the creation of a National Health

0:55

Service of the NHS? Well, I'm

0:57

your host James Patton Rogers This is warfare

0:59

and to explore how the brutality of war led

1:01

to a cross Political effort to improve

1:04

the health of a nation. I'm joined by

1:06

my friend colleague and expert historian

1:08

Gareth Millwood Gareth is a historian

1:10

of the welfare state of the NHS and

1:13

the author of sick note a history of

1:15

the British welfare state published by

1:17

Oxford University Press Together

1:19

we sat down in my office to explore

1:21

this fascinating history of how

1:23

war makes a state how the Second

1:25

World War made the NHS enjoy

1:35

Gareth welcome to warfare. How

1:37

you doing? I am very well. Thank you. It's good to be here

1:39

It's great to have you on the podcast So I'm sure you're

1:41

not very often invited onto podcasts

1:44

that are to do with war and military history That's

1:46

not because you're not an amazing speaker and a fantastic

1:49

expert academic But you are a historian

1:51

of the welfare state of the NHS Some

1:54

people might think that the two don't go together exactly

1:57

more of a post-war historian than anything

1:59

else, but I guess if

3:59

during the war when a lot of the plans for

4:02

a national health service are being formulated,

4:05

they are on the basis that we are fighting

4:07

this total war on the home front and

4:09

the soldiers are fighting in foreign lands.

4:12

Eventually they're going to be fighting for

4:14

something and we're going to provide something to those people

4:16

who fought so hard. That is part

4:19

of the story and I think we'll get into a few more

4:21

parts where maybe that's not so true and we'll get into

4:23

plenty of other myths about the way the NHS

4:25

was founded. There's another war of course

4:27

that's part of this story and I would say this

4:30

as the post-war historian and that's the Cold

4:32

War. Of course. And the NHS is part of

4:34

this large attempt to plan

4:36

the economy, to invest in human

4:39

capital as a way of showing that

4:41

liberal democracy is an alternative to authoritarian

4:43

fascism

4:43

and communism. So there is still

4:45

a war element to this that we probably

4:47

ought to discuss. I see so when we're looking at that

4:50

post-war world we're

4:52

actually looking at a gigantic global

4:54

political struggle, an ideological struggle

4:57

that is still taking place. There

4:59

are lots of worries going on at this time that fascism

5:02

might spread. I remember at this point the

5:04

French are trying to frame the uprisings

5:07

in Vietnam as being tantamount to

5:09

Hitler at this point, trying to draw the Americans

5:11

in and then they change and say actually it's all about

5:13

communism. Are these the sort of narratives that

5:15

are going on in Britain as well? To

5:17

an extent yeah and the Labour Party is

5:20

explicitly a capitalist social democratic

5:23

party. The welfare state is one of the ways that

5:25

they're able to show that we are not communists, we are capitalists.

5:27

Of course because Churchill's gone. He's ousted

5:30

by this point. We're into a Labour government so the

5:32

country is looking to a peacetime

5:34

leader. Absolutely

5:36

and the NHS is part

5:38

of that much bigger change

5:40

that's not just happening in Britain, it's happening all across

5:42

Western Europe including in West Germany

5:45

and the Scandinavian states obviously take this and run

5:47

with it in the Nordic model of welfare that

5:49

has been lauded in so many different places

5:52

but also the United States and when we think of that as a place

5:54

that doesn't really have a welfare state but we're coming off

5:56

the back of the new deal, social security

5:59

becoming a thing in the United States.

5:59

States as well. All of the Western

6:02

democracies are realising that yes,

6:05

we are capitalists, but maybe

6:07

we need to interfere a little bit in the economy

6:10

in order so that we can all benefit overall.

6:13

Whatever that laissez-faire thing was in the 20s

6:15

and 30s, that clearly didn't work.

6:18

And I think the war is one of

6:20

those big events that actually shows

6:23

how much planning on a large scale

6:25

really can benefit you and still be,

6:28

to a large degree, democratic. And so it's this alternative

6:31

to maybe these other forms of government

6:33

that haven't quite worked or they

6:35

feared might not work. That's fascinating.

6:37

And you've mentioned the 1920s and 30s here. And for all those who live

6:39

in the UK,

6:42

it must be quite hard to think of a

6:44

Britain before the NHS. I

6:46

certainly can't think about that. And all it's done for

6:48

my family over the years and friends

6:50

and sisters, and I'm sure all of our listeners

6:53

in the UK will have family members

6:55

that probably wouldn't be around if it wasn't for the

6:58

NHS.

6:58

But what was life

7:00

like in the UK before

7:02

the NHS? Take us back to those 1920s and 1930s, before

7:06

the war. We paint a kind of apocalyptic

7:09

picture. I guess when I think of that, I'm probably

7:12

misremembering and looking more at kind

7:14

of Victorian squalor and people

7:16

paying to fall asleep on ropes and

7:19

anyone with a health condition throwing themselves off

7:21

a bridge because they can't live with the pain anymore. Was

7:24

it as bad as that by the 1920s and 30s or do we misremember?

7:28

Some of those stories are not massive exaggerations.

7:32

But I think one of the things

7:34

that is very difficult when we're talking about this

7:36

time, and we're talking about health systems

7:38

is first of all,

7:39

the amount of things that are invented over the

7:41

1940s, 50s and 60s have completely changed what health

7:44

care

7:45

is. The world that you're talking about

7:47

is pre-penicillin. It's

7:50

pre a lot of the pharmaceutical drugs

7:52

that really help to manage pain, chronic

7:54

conditions, all of those other kind of things. And lots of the technical

7:56

innovations that happen during the Second World War

7:58

exactly to treat pain.

8:00

Absolutely. And war being a very big driver

8:02

of this kind of medical science, as we know from,

8:04

again, from antibiotics, but also plastic

8:06

surgery and various other things came out of the First World War. A

8:09

lot of it going on in the Second World War as well, trying

8:11

to treat malaria, various other things. Anyway, that's

8:13

one of the things to remember is the health system was very different.

8:16

The other thing to remember is that

8:19

British healthcare in the interwar

8:21

period was world leading,

8:23

if you could get it. Okay. And

8:25

I think we have to remember, especially both

8:27

of us sitting in this room now are British, and we

8:30

are at least right now living in Denmark.

8:32

We are, yes. We're not only British

8:35

and so therefore probably a little bit biased about

8:37

the importance of the NHS, but we're

8:39

sitting in a Scandinavian country which

8:41

prides itself entirely

8:43

on its investment in a welfare state and

8:45

up to 50% tax. Yep, which

8:48

of course we're very happy to pay. Of course. But

8:50

I think it is also worth saying that

8:53

the horror stories that we hear today

8:55

about the American healthcare system, again,

8:58

are not lies, but there

9:00

are a lot of people that do have access to healthcare

9:03

in the United States. What are leading healthcare in so

9:05

many ways? In so many ways. So this

9:07

is not to either defend the American system or

9:09

defend the British system, but again, just to, before

9:11

I launch into this, be very clear that there

9:14

are elements of this that are true,

9:16

but there's also other things that we need to take into account.

9:19

So this pre-war health system,

9:22

I think you can break it down to three different

9:24

parts, because these are the three different parts that effectively

9:26

make the modern NHS. The first

9:29

is public health,

9:30

which is things like building sewers,

9:33

vaccination programs, preventing infectious

9:36

disease, reporting infectious disease, those

9:38

sorts of things. That was the responsibility

9:41

of the local council and remained

9:43

the responsibility of the local council up until the

9:45

1970s. So this wasn't part of the NHS when it was originally

9:48

set up, but that is a big part of any

9:51

national health system anywhere in the world. You

9:53

have to

9:54

prevent diseases from happening in the first

9:56

place. One of the ways you do that is you collect bins

9:59

and you fax them.

11:59

probably invest in this system. So there's a capitalist

12:02

drive behind this to soothe

12:05

communist ambitions? I think so,

12:07

definitely. And to keep the human cogs of labour

12:09

turning? Absolutely. And I think this is

12:12

also a time where we've just come

12:14

out of the Boer War, where it's been very

12:16

clear that a lot of recruits are nowhere near fit enough

12:18

to actually be able to fight. So

12:20

again, if you improve the health of the nation, you

12:22

have healthier workers, healthier soldiers,

12:25

and hopefully healthier mothers having healthier children

12:28

who can then go on to be healthy mothers, children, and soldiers.

12:30

There's a real sort of logic to the way that this whole thing is built

12:32

up in empire and built up in the way of state building in

12:35

the late 19th, early 20th century. And a war making

12:37

industry. Absolutely. Absolutely.

12:40

So it's all part of this kind of machine. So when does it start

12:42

to transition to a system that

12:45

is free at the point

12:47

of use? That is really

12:49

inspired by the war. There is a real

12:52

sense of, okay,

12:54

we're going to have to have something again to placate people

12:57

once this is over. But there's also a sense of,

12:59

okay, what happened in the 1920s and 1930s with the Great Depression and

13:03

with the massive inequalities and the big issues

13:05

to do with the slums and various other social

13:08

issues in Britain in the 20s and 30s that this

13:10

can't go on. There has to be some kind of alternative

13:13

to this. That's where we move away

13:15

from just having GPs available

13:18

to people who have insurance, but

13:20

the idea being that the entire population ought

13:22

to be covered by this comprehensive

13:24

national health service, because we've not moved

13:26

on to the third pillar yet, which is the hospitals.

13:29

Oh, okay. And that's the big thing that

13:32

is so difficult to deal with because these hospitals

13:34

are massive institutions worth millions

13:36

of pounds, even at 1939 prices. So

13:40

being able to nationalize all of those or almost

13:43

all of those and make those available to

13:45

the entire population,

13:47

that's the big challenge. So hospitals in

13:49

the 1930s were private entities

13:52

where if you're rich enough and probably

13:54

higher class, you can pay you for the best healthcare

13:56

that you want. I would that it was so simple. Okay.

13:59

So this is where being a historian

14:02

is a blessing in the curse and that you have to spend months of your

14:04

life trying to understand how this political system works.

14:06

So

14:08

there were world leading private institutions

14:11

that if you were rich enough to be able

14:13

to just write the cheque or hand over

14:15

the cash, yes, you could go and you

14:17

could get treatment for your mental health

14:19

issues or for if you needed surgery,

14:22

you needed palliative care, any of that kind of stuff.

14:24

You could just pay. What else? I

14:26

don't know why. Yeah,

14:29

why not? Gout. If you

14:31

need a bit of hospitalisation for gout, you can

14:33

pay and you can do that. If you're

14:35

slightly less than the mega rich,

14:37

you

14:38

might have a private insurance company that you

14:40

are able to pay premiums to and then

14:42

they might be able to cover all those

14:44

costs and you can have your choice

14:46

of whichever hospital you want to go with. Within

14:48

reason, obviously, there's geographical issues that

14:50

might come up. But say you're quite rich and

14:52

you live in London, you have access to all these world

14:55

limiting hospitals and you can pay.

14:57

So that's quite simple. Kind of

14:59

one over on there. Where it starts to get more difficult

15:01

is through people who are

15:04

reliant upon wage labour, the middle

15:06

and the upper working classes,

15:08

who are reliant really on two

15:11

separate systems.

15:13

One at the bottom level

15:16

is the poor law. So when we're thinking about

15:18

workhouses and we're thinking about those old Victorian

15:20

asylums, they're all part of

15:22

this poor law system that is administered by local

15:25

councils. It's paid for through local

15:27

rates or taxes. And

15:30

that provides the very bare minimum care

15:32

to people who in return

15:35

for getting that care are considered paupers,

15:37

which has all sorts of legal implications.

15:39

I'm not an interwar or a Victorian

15:42

legal expert, but things

15:43

like if you went into the workhouse, it

15:46

could result in losing your right to vote.

15:48

So these are institutions that are

15:50

not funded particularly well for

15:53

the most part. They also carry a stigma

15:55

with them. And the idea being that you would not rely

15:58

on these institutions if you had absolutely

15:59

any other. And you wouldn't want to rely on them. These

16:02

are like the most basic safety net

16:04

you could ever imagine for society. So you

16:06

go in, you share a

16:08

room probably with tens if not

16:10

hundreds of other people in a poor house

16:12

in a work house. You have to do work

16:15

while you're in there and you get the basics

16:17

you need to live and then hopefully you can get

16:19

yourself out of the poor house. Absolutely. And if you're

16:22

in the poor law infirmary because you need

16:24

some kind of operation or you need

16:26

some kind of long-term residential

16:28

care or whatever else, you

16:29

might not be forced to work, but you are still

16:32

having those very

16:33

bad conditions imposed upon

16:35

you. This is starting to

16:37

get better in some parts of the

16:39

country, particularly London, by

16:41

the 1920s and 1930s as people are starting to realise that

16:44

actually providing healthcare is probably a

16:47

wider good. But even

16:49

if you were a relatively progressive leaning

16:51

council, the chances that you actually have the

16:53

resources to be able to invest in a good

16:55

hospital are quite slim. The quality

16:57

of care in these places was quite poor and for

17:00

anybody that had grown up in that environment,

17:02

they would immediately associate that hospital

17:04

with poverty and not want to be involved.

17:06

So you want to avoid these places at all costs. And

17:09

that's part of the Edwardian and Victorian idea

17:11

that you deliberately make public services

17:13

terrible to try and make people not

17:16

rely on them. So that's the way that they approach unemployment.

17:18

It's the way that they approach poor health.

17:29

I'm Tristan Hughes, host of The Ancients

17:31

from History Hit, where twice a week, every

17:33

week, we delve into our ancient

17:36

past. I'm joined by leading

17:38

experts, academics and authors who

17:41

share incredible stories from our distant

17:43

history and shine a light on

17:45

some of antiquity's great questions. Was

17:49

the Oracle of Delphi really able to see

17:51

into the future? What can be discovered from

17:53

lost civilisations? And was King

17:55

Arthur actually real? You can

17:58

expect all of this and more

17:59

from the ancient

21:49

and

22:00

maybe in certain circumstances with

22:02

the wind blowing in the right direction, if you happen

22:05

to live in an area that actually has a good charitable

22:07

hospital in the area, which is the other problem, maybe

22:10

you can get access to care. So it's not

22:12

just based on your ability to pay, it's where

22:14

you live,

22:15

it's what kind of schemes you happen to be a member of. It

22:18

can be your gender or your age that can

22:20

affect whether you have access. So you've basically

22:22

got this mess of these different types

22:24

of hospitals,

22:25

GPs who are

22:27

technically private contractors, but if they

22:30

live in a poor area, they're completely reliant

22:32

on their income from the national insurance bodies, so

22:34

they can never make enough money to really have any

22:36

kind of prestige or anything else. So

22:39

rich people are getting a completely different level of care

22:42

if they live in the right area, and yeah,

22:45

the whole thing is a complete mess, and this is one of

22:47

the reasons why,

22:48

by the 1940s, every major party goes, look,

22:52

we need some kind of national coordination

22:54

on standards, on provision. This

22:56

system is just a complete mess

22:58

that has grown because there's been no national coordination,

23:01

it's just been

23:02

where a private enterprise thinks it can make the most profit,

23:05

where a charitable organization has enough

23:08

donors in the local area, or where the

23:10

local council maybe has enough money

23:12

to provide good enough care for the people

23:14

who can't afford any of these other different situations. It

23:16

sounds like absolute chaos, Gareth. Absolutely

23:18

chaos. And when you think about the fact that you had

23:21

Luftwaffe bombings of major towns

23:23

and cities, not just London,

23:25

all across the United Kingdom, but

23:28

you don't have a national health service, then all

23:31

of these variables, to

23:33

put it nicely, means that so

23:35

many people must have fallen through the system. So

23:37

you can see why there is this massive

23:39

push then to try and do something about this.

23:42

Who is it who leads the charge? That

23:44

depends really on your political kind

23:46

of persuasion. Of course. So there's

23:48

this conservative doctor, Hugh Byrne, who

23:51

wrote on Conservative Home a few years ago, and

23:53

this has been quoted by NHS historian

23:55

Martin Powell, talking about Aniran

23:57

Bevan, the

23:58

person that he's credited with creating.

23:59

creating the NHS because he was the health minister

24:02

at the time that the laws were passed through

24:05

and he really was the kind of person that led the negotiations

24:07

with the hospitals and with the doctors to create

24:09

the NHS. Yeah, that's who I've heard of. This is

24:11

Nye Bevin, this is the origins of the NHS, this is

24:14

the person that led the charge. Yeah, this is the

24:16

person that led the charge and that's certainly the story that

24:18

is told by the Labour Party and it's definitely

24:20

told by the left of British politics and we'll get onto,

24:23

we already talked about the Blitz spirit being maybe a myth.

24:25

Okay. And it's the socialist myths over

24:27

the creation of the NHS. But here's a conservative

24:29

one. He says about Bevin and the NHS,

24:32

Bevin was neither the NHS's father

24:35

nor the midwife. He was at best

24:37

an obstetrician,

24:38

arriving when much of the hard work was done

24:41

and taking most of the glory. Oh,

24:43

so if you were to have perhaps

24:45

more of a centre right, Leaning, who

24:48

would you say is the midwife

24:50

of the NHS? There's plenty of different

24:53

figures that we can go into and I think Dr

24:55

Byrne here needs to be put in a bit of context. This

24:57

is a more recent attempt by the Conservatives

25:00

to show that they can be trusted with the NHS.

25:02

There's been a lot of negative publicity about the way

25:04

that conservatives have run the NHS, particularly

25:07

since the coalition government took charge. There's been a lot

25:09

of underinvestment in certain areas of the NHS.

25:11

I think that's relatively safe to say without

25:14

political neutrality hat on. When

25:17

you look at Michael Portillo, for example,

25:19

who for your international listeners, would we

25:21

describe him as not a socialist, Michael

25:23

Portillo? Yeah, I think so. He's not a socialist.

25:26

He thinks that Bevan was the father of the

25:28

NHS as well and talks in quite long terms, or at

25:30

least he did in the 1990s, maybe his opinions have changed.

25:32

And Michael Portillo was a former MP,

25:35

former minister, and was a

25:37

conservative Tory MP. Yeah, and an arch

25:38

statuaryte as well. Really big on small estate

25:41

spending, but even he was no, Bevan is the

25:43

architect of this and did quite a lot of good work in the 1940s. So

25:46

this is part of a very particular issue that's

25:48

going on now with the Conservative Party. The

25:50

history is being rewritten. The history is being rewritten by

25:52

the Conservative Party. However,

25:55

there were key Conservative figures during

25:57

the war who were in favour of

26:00

a free at the point of use health

26:02

system. Okay. As there were liberals

26:04

as well.

26:05

One of the letters that's always stuck with me

26:07

when I was doing my research for the last

26:10

research project and book that I was working on, which is about

26:12

doctors' sick notes. Doctors hate

26:15

writing sick notes because they see it as bureaucracy

26:17

when they could be doing important stuff like curing

26:19

people or helping them or these other kind of things. And

26:22

they were really worried when the NHS was about

26:24

to start that, oh no, we're going to be government employees,

26:26

we're just going to be writing government forms for the rest

26:28

of our lives, rather than doing proper in

26:30

scare quotes. I'd be worried about that. Absolutely.

26:33

Yeah. And I think we all are. Whenever people start

26:35

meddling

26:35

with systems like, oh, who's in charge now? What

26:37

are they going to want? But anyway, he talked about

26:39

the NHS and about social security in this post-war

26:42

settlement. And he said that the plan

26:44

was produced by a liberal, taken

26:46

up by the conservatives and actuated

26:48

by the socialist. No party

26:50

could allow this luscious plum to fall

26:53

outside its vote catching ambit.

26:56

So all three of the major parties, obviously,

26:58

the liberals aren't a major party after 1945, but

27:00

all three of the major parties in the interwar

27:02

and war era are all advocating

27:05

for

27:06

an NHS. Okay, so we

27:08

understand with Bevin where the Labour Party

27:10

can put its origins to the NHS, and

27:12

the Liberal Party much earlier on laid the foundations

27:15

for this. So how can the conservatives say

27:17

they have a claim to the NHS? The conservatives

27:19

also bought into this idea that, yes, the nation

27:22

needs some kind of health system.

27:25

They'd seen the mess that was the interwar hospital

27:28

system and said, yeah, we need some kind of coordination.

27:31

So they bought into the idea that, yeah, probably

27:33

we do need a system that is free at the point of use

27:36

for

27:36

people to have. And

27:38

so there was a plan put forward for a thing

27:40

called a National Health Service

27:43

in 1944 by the wartime health

27:45

minister, Henry Willink,

27:47

who provided this plan for a

27:49

National Health Service.

27:51

But he was more focused on the idea that people

27:53

should have access to health care. He

27:55

wasn't so bothered necessarily with

27:57

how that was provided. So he was a...

27:59

bigger proponent of keeping

28:02

private hospitals, keeping the voluntary hospitals,

28:05

because his argument was these should be community

28:07

things. And this was this conservative idea of locally

28:10

run community things where everybody knows each

28:12

other will be much more efficient than a state

28:14

run cold system

28:16

that doesn't really care about these sorts of things. And

28:19

also fears that a state run system would

28:21

end up costing loads of money and being controlled by bureaucrats,

28:23

all this other kind of stuff. So he wanted to keep the

28:26

local grandees in charge of good

28:28

sorts, in charge of the hospitals,

28:29

but provide free care

28:32

for everyone. And this is the reason why

28:34

the conservatives vote consistently against

28:37

the NHS acts in the 1940s.

28:39

Their argument is, no, we agree with you.

28:42

Everybody should have free access to health care. We

28:44

fundamentally disagree with the way you're going about

28:46

it. So in this sense, when the conservatives

28:49

argue that no, we would have had the NHS too,

28:52

and we wanted to make sure that people would have

28:54

free care, they're right in

28:56

the sense that yes, an NHS

28:59

would have probably come about under the conservatives,

29:01

but it probably wouldn't have been as comprehensive.

29:04

And ultimately, it wouldn't have had that reforming

29:07

ethos that brought everything under a national

29:09

umbrella, which got rid of some

29:12

of those inequalities of access and also

29:14

made it easier for the nation as a whole to

29:16

plan where things go. And that

29:18

was one of the success stories of the vaccination

29:21

campaign that we saw through COVID. It was

29:23

the fact that we had a nationalized health service, and everything could

29:25

get out very quickly and very coordinated. When

29:27

you look at somewhere that's more federal, like Germany,

29:30

for example, they had a much more mixed

29:32

kind of story on a national level, at least than

29:34

we did here in the UK. It is really interesting

29:36

looking at the different parties, because it shows probably

29:39

why they have the fault lines we do in terms of the

29:41

NHS today,

29:42

but you have the liberals almost provide

29:44

the ideological ethos and foundations,

29:47

you have Labour that provide the

29:49

NHS as we know it today, and

29:51

then you have the conservatives that provide the name,

29:54

but would have probably been a very different NHS

29:56

had it come about. And who knows, depending

29:58

on who will continue in power.

31:59

are the liberal William Beveridge

32:03

and the conservative Henry Willink.

32:06

So people probably heard of

32:08

the Beveridge report, this report that's written

32:10

in 1942, I believe, and is a kind of a blueprint

32:15

for what the state should look like

32:18

once the war is over. He'd been

32:21

deliberately brought in by the government to build

32:23

these plans because they thought it would be a morale boost,

32:25

it would give people a sense of what they might be

32:27

fighting for, but it would also for

32:30

some kind of inquiry with Ferris

32:32

Differint and what we now probably call in management

32:34

speak, stakeholders

32:36

in the policy making environment about

32:38

what might be possible

32:40

once the war was over.

32:42

And Beveridge comes up with this plan, the Beveridge

32:44

report, which goes all around the

32:46

capitalist world as a potential option for

32:48

people who's very popular in Scandinavia and

32:50

inspiration for some of the things that they did after

32:53

the war. And Beveridge's idea

32:55

is that the welfare state ought to provide

32:57

a bare minimum for all citizens, and

33:00

it ought to do that because that is what citizens

33:02

deserve as being citizens of Britain.

33:05

So this is a national idea of

33:07

Britishness and Britain and for

33:10

the national good so that everybody

33:12

ought to have access to

33:14

good enough unemployment benefit because

33:16

unemployment isn't entirely the fault of the individual.

33:19

It's in fact almost always not the

33:21

fault of the individual. It's a societal issue

33:23

that happens when economies collapse or when certain

33:25

sectors lose money, geographical

33:28

issues. And so you provide people with a good

33:30

enough care for when they're unemployed, they

33:32

won't get into deep poverty, they won't get into

33:34

those kind of major issues. Thinking about modern examples, you're

33:36

not going to lose your home, those sorts of things which can compound

33:39

all sorts of issues. He also had

33:42

these five giants that he wanted to tackle

33:44

through this

33:44

minimum standard. So he wanted to get

33:46

away from want, so he wants to get rid of poverty.

33:49

He wants to get rid of disease, which is public

33:51

health and the hospital system, which we're about to

33:53

talk about. Ignorance, he felt that

33:56

the world is becoming more complicated. People

33:58

needed a higher and higher level of education.

33:59

to deal with that complexity, and that should be something

34:02

the state should be actively investing in. Squalor,

34:05

so getting rid of the slums and all the bond

34:07

sites and various other things that were a product of

34:09

the pre and during the war, and

34:12

idleness, which was unemployment. The idea that, yes,

34:14

there are some people that are unable

34:16

to work because of economic issues, but

34:18

there's also, in his view, a group

34:20

of people who will do everything they can

34:23

to avoid work, and so you need to find ways of encouraging

34:25

them to work and providing different opportunities

34:28

for them to work. So you didn't lack ambition?

34:29

Didn't lack ambition, no. This

34:32

entire blueprint of how to change, basically,

34:34

capitalist democracy. And his argument is

34:36

the way that you fund that is through a combination of

34:38

direct taxation, so things like education

34:40

should be free, things like hospitals ought to be free.

34:43

The reason you do that is because educated,

34:45

healthy people are happier,

34:47

able to work longer, and are more

34:49

productive. So it's a sort of a national

34:51

investment, and this is the reason why the state's businesses

34:54

and individuals should be paying in through their taxes to

34:57

benefit all of us. But he also

34:59

holds on to that liberal idea of insurance.

35:02

So he says that the way that you encourage people to

35:04

work is that you only provide them with

35:06

full unemployment benefits if they built

35:08

up national insurance contributions. You

35:10

only provide them with a full pension at the end of their life

35:13

if they've been paying into the system. So it's an encouragement

35:15

for people to work as long as they possibly can so that

35:18

they end up with something at the end. Now

35:20

modern historians and modern politicians will make

35:22

all sorts of arguments about how that disadvantages

35:25

women because they're not able to work as long because

35:27

often they're the ones with the care and duties, maternity,

35:29

all those other kind of things. It doesn't help immigrants

35:32

or people from ethnic minority

35:34

backgrounds where they are more likely to be

35:36

discriminated against in the workplace or they're less

35:39

able to work for the 30, 40 years

35:41

that they're supposed to work before they get their pension. And

35:43

disabled people particularly who can't necessarily

35:45

work constantly or at a high rate, it

35:48

does affect what they're able to take from

35:50

the system. But this was the kind of the liberal

35:52

idea of this should work for the vast majority of people. If

35:54

it works for the vast majority of people, therefore it is good. We're not

35:57

going to go into the politics of all of that.

35:59

But that's the general.

35:59

liberal framing of how this should work. His

36:02

other argument was

36:03

the state should provide a good level of service

36:06

because we need healthy workers, we need educated

36:08

workers, but those who are willing

36:10

to spend more or are willing to

36:12

save more for their retirement or their healthcare

36:15

or their education

36:17

should be able to access a private level that

36:19

is above the bare minimum.

36:21

And that was his kind of idea that all

36:23

of this stuff would improve the economy so much people

36:25

would be able to make choices about what healthcare they had,

36:28

what education they had, all these other kind of

36:30

things and what unemployment protections they had.

36:33

So this is the liberal kind of approach and he

36:35

said, yes, we need a health service free at

36:37

the point of use because we need healthy workers

36:40

in order to

36:41

be more productive, but also healthy

36:43

workers don't take sick pay. So in the long run,

36:45

we'll save money. That was his argument.

36:48

It turned out that's not what happened with the NHS. But

36:50

the argument was that healthier workers will

36:53

work more,

36:54

they won't take as much sick pay, they'll also

36:56

get their knee done early so they don't need

36:58

major reconstructive surgery, which in the long run

37:00

will save us more money. So this is really interesting.

37:02

So out of all of these principles, then, because

37:05

I can already see that many of them don't

37:07

translate through to a modern NHS

37:10

or even the NHS that's established in 48,

37:12

which ones do translate through and how

37:15

does it change? I think the ones

37:17

that do translate through are the idea

37:19

that we should provide free healthcare,

37:22

free at the point of use healthcare

37:24

to the population because they

37:26

are citizens. This is a national

37:28

health service. This is a British health service. This is nationalism.

37:31

This is the nation coming together

37:33

and protecting its own and itself.

37:36

That definitely follows through.

37:38

I would also say the idea of national productivity

37:42

isn't the thing that we talk about so much

37:44

now, but I think it's the underlying assumption

37:46

behind why a lot of the stuff to do with the

37:48

welfare state remains is this idea that actually

37:52

this is costing us quite a bit of money, but the alternative might

37:54

actually end up costing us more. And I think that's another

37:56

reason why there's a lot of investment in this. But

37:58

those ideas, I think.

39:59

longer respiratory issues, so

40:02

all of this comes together. But I've never thought about the

40:04

failures of the post First World War

40:06

world leading into the NHS we have

40:09

today. So it's the World Wars period

40:11

that helps in some ways to produce

40:13

the NHS. I would absolutely agree with that. I think

40:16

you can't look at the way that veterans

40:18

were, or at least the national narrative that is

40:20

remembered the way that veterans were failed after

40:23

the First World War. You also see in

40:25

the 20s and 30s isolated

40:27

attempts to try to overcome

40:29

some of those kind of issues. So London

40:32

County Council for example tries to do a lot more

40:34

of coordinating its various voluntary

40:36

hospitals and public hospitals in

40:38

the 20s and 30s and the standard of care

40:40

there does start to improve. It becomes

40:43

the blueprint for the very first NHS

40:45

in the world in New Zealand. They look at what

40:47

London has done and they take that and have their

40:49

free at the point of use health system set

40:51

up. The other kind of organisation that's

40:54

often talked about in this way is

40:57

the Highlands and Islands Medical

40:59

Service

40:59

which was brought about by

41:02

the Scottish Office because health is

41:04

a devolved issue in Scotland and has been

41:06

since

41:07

time in Lomorow where they

41:10

had realised this geographical problem of

41:13

you cannot encourage

41:15

private hospitals or private

41:17

GPs to set up practice in an area

41:19

where they're going to be spending more money on petrol

41:22

just driving around from place to place than

41:24

they're ever going to be able to make from the fees that you're going

41:26

to be able to charge people who live in poor, you

41:29

have to subsidise that. Exactly. So

41:31

they coordinate all of that and subsidise

41:33

it to try and bring costs down to pay for things

41:35

like petrol travelling costs, understanding

41:37

that because of that travel a doctor's

41:39

not going to be able to see as many patients in

41:42

as much time because they're having to jump all

41:44

over the place and so that's not necessarily

41:46

the thing that provides the entire inspiration

41:48

for the NHS but it does show the logic

41:51

behind actually there

41:52

are some areas that the market can't service

41:55

even if it was working perfectly and that there does need

41:57

to be some kind of collective response.

41:59

these issues and that's another thing that comes from the 20s

42:02

and 30s. That is absolutely

42:04

fascinating. It's been an absolute pleasure

42:06

to talk about the NHS and

42:08

its origins as we mark this massive

42:11

milestone, 75 years

42:14

of the NHS. May it continue for 75

42:16

years more. Depending on how well it does, I'm not sure

42:19

me and you will still be here to be able to talk about this.

42:21

We'll be into our hundreds by then, but if we

42:23

are we'll have you back on the podcast. Absolutely,

42:25

that'd be great. But you've got to tell us, where can

42:27

we read more about your research on

42:29

the NHS? You can read more about my research

42:32

through, I guess, my

42:33

books which are available open

42:35

access thanks to funding from the Wellcome

42:37

Trust. One of them is called Vaccinating Britain

42:39

and it's about the childhood vaccination service and how

42:41

that grew from wartime vaccination

42:44

of children to try and prevent diphtheria

42:47

and how that became the modern vaccination service

42:49

that we know and love today. And my other

42:51

book is called Sick Notes which is about

42:53

sick notes and about how that nickname

42:56

became a thing and medical certification.

42:58

I promise it's more interesting that it would sound from

43:00

the get-go. It sounds very interesting and I'll explain exactly

43:02

why it's so hard

43:03

for any of us to get sick notes. Absolutely.

43:05

Garris, thank you so much. We'll put a link into the show

43:07

notes and you're always welcome on the Warfare

43:09

podcast. I'd like to come back. Thank you very much.

43:15

Thanks for listening, but before you go, a reminder

43:17

that you can now follow along online on Twitter

43:20

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43:22

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43:27

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