https://history.blog.gov.uk/2023/07/13/the-founding-of-the-nhs-75-years-on/
The founding of the NHS: 75 years on
On 5 th July 1948 the National Health Service was established in the United Kingdom. Britain was the first western country to offer free at the point of use medical care to the whole population. [1] Seventy-five years on the NHS continues to be a distinguishing feature of the British welfare state.
But how did the NHS come to be? Let us look back to the creation of the National Health Service and how the government of the day led by Prime Minister Clement Attlee set about introducing this transformative reform.
The Second World War led to an immense loss of life and induced considerable hardships. Britons endured rationing (which continued after the war was over), evacuation, destruction or damage to millions of homes and workplaces, air raids as well as the mass pivoting of the nation’s people and resources to meet the vast war effort. The period between the First and Second World Wars had also left its mark. The interwar years were a time of economic depression and social deprivation, there had been no great development of state provision. Attlee and his Cabinet had lived through (and in many cases fought in) both wars and recognised the need for reconstruction and expansion – a comprehensive welfare system was at the heart of this.
During the Second World War, the coalition government led by Conservative Prime Minister Winston Churchill and Leader of the Labour Party Clement Attlee (Deputy Prime Minister from 1942) seized on the need for post war reconstruction. Despite the preoccupation with fighting a world war, the government prioritised planning for this. In June 1941, Labour minister Arthur Greenwood announced to the House of Commons that a new committee had been formed to survey existing social security provision and allied services under the chairmanship of Sir William Beveridge. [2] This became the totemic 1942 Beveridge Report, which identified ‘Five Giants’ that needed to be tackled in order for Britain to succeed economically and socially. The five giants were Want, Disease, Ignorance, Squalor and Idleness. Influential economist and civil servant John Maynard Keynes was also consulted by Beveridge during the making of the report. At his suggestion Beveridge modified some recommendations, thus Keynes believed the plan to be broadly affordable. [3]
The report was published on 2 nd December 1942 and immediately became a best-seller at home and abroad (costing 2 shillings). [4] Some 256,000 copies of the full report, 369,000 copies of an abridged version and 40,000 copies of an American edition were sold in twelve months. [5] The proposals received widespread support across the political spectrum. The recommendations of the Beveridge Report widened the scope set by Lloyd George’s National Insurance Act (1911). Beveridge offered a blueprint for a comprehensive welfare state. In the years after publication, the coalition government worked on plans for turning the recommendations into reality, including producing a White Paper. Full implementation was however not guaranteed. In March 1943, Churchill warned against imposing significant new expenditures without knowing the full post war economic picture; yet he also advocated a ‘national compulsory insurance for all classes for all purposes from the cradle to the grave.’ [6]
On 5 th July 1945 the Labour Party led by Clement Attlee won a landslide victory at the polls, with a majority of 146 seats. [7] After winning the General Election, the Attlee government set about creating a comprehensive welfare state, at the heart of which was the NHS. Indeed Labour had entered the election offering ‘the full Beveridge’. [8] Attlee’s ‘executive efficiency’ would be integral to introducing and implementing such a huge programme. [9] Though Britain and its allies had emerged victorious, the strain of total war had left the country in a desperate state. Yet Attlee reflected:
We had not been elected to try to patch up an old system but to make something new ... I therefore determined that we would go ahead as fast as possible with our programme. [10]
Attlee’s social and political work in the East End of London shaped his view of the role of the state. By the time he was in government, ideas that had seemed very much his own were now part of an emerging consensus. Attlee wrote, ‘I have witnessed now the acceptance by all leading politicians in this country and all the economists of any account of the conception of the utilisation of abundance.’ [11] In 1918 as a soldier in the First World War Attlee expounded his sense of purpose, ‘We live in a state of society where the vast majority live stunted lives – we endeavour to give them a freer life.’ [12]
On arrival in Downing Street, Attlee faced a challenging economic picture. A month into office it got gloomier with the abrupt end of the US Lend-Lease scheme. Subsequently the US made a further loan agreement with Britain however Hugh Dalton, Attlee’s Chancellor of the Exchequer (1945-47) noted that the situation remained ‘desperately difficult’. [13] US Marshall Aid from 1948 until 1951 would also provide critical support for the British economy. Attlee, in assembling his Cabinet, appointed the political firebrand, South Wales miner and trade unionist Aneurin Bevan as Minister of Health. The King’s Speech on 15 th August 1945 outlined an ambitious legislative programme including nationalisation of the fuel and power industries, civil aviation, Bank of England as well as establishing a National Health Service. [14] Chancellor Hugh Dalton worked closely with Bevan to establish the financial foundation for the introduction of the NHS. Dalton found Bevan’s vitality and drive impressive, and Bevan’s biographer credits Dalton as ‘after Bevan … the chief architect’ of the NHS. [15]
During the Second World War, the scope of health insurance had been extended but it covered just half of the population and did not include hospital and specialist services, dental, optical, or hearing services. [16] Universal provision regardless of ability to pay was at the core of the Attlee government’s new reforms. Minster of Health, Bevan set about building on the Beveridge Report and the coalition government’s White Paper. In October 1945, Bevan outlined his vision for a National Health Service. In December, he explained to Cabinet that this was ‘an opportunity, which may not recur for years, for a thorough overhaul and reconstruction of the country’s health position.’ [17] Prime Minister Attlee drew on a cricket metaphor to express his approval, Bevan had done well “on a pretty sticky wicket”. [18] Provisions would include hospital care, ambulance services, GP services, maternity care, prescriptions as well as optical care and dentistry. [19]
Turning the NHS from principle to policy required significant structural change and thus extensive negotiations with the medical profession, local authorities, committees, Parliament and with other Cabinet ministers. It was an arduous process to say the least. What’s more, the NHS was one of a series of reforms which formed the welfare state. How the state would pay for these reforms was a huge matter for the government of the day. Keynes had told the War Cabinet in May 1945 that Britain faced a ‘financial Dunkirk’. [20] The 1946 National Insurance Act [21] extended the contributions of working age people (except married women) in order to contribute to funding the provisions of the welfare state.
Given its foundational status for the whole welfare programme, Attlee focused his attention on ensuring the passage of the National Insurance Bill. In the House of Commons during the first and second readings, Attlee reflected on the historical battle for social reform and credited earlier pioneers. [22] The Prime Minister also acknowledged the significant financial cost:
The question is asked – can we afford it? … Supposing the answer is “No”, what does that mean? It really means that the sum total of the goods produced and the services rendered by the people of this country is not sufficient to provide for all our people at all times, in sickness, in health, in youth and in age ... I cannot believe … that we can submit to the world that the masses of our people must be condemned to penury. [23]
The National Health Service Act received Royal Assent on 6 th November 1946. This however marked the beginning of a deeper, more protracted phase of negotiations in the run up to so-called “Appointed Day” on 5 th July 1948 – when NHS provision would begin. As such 1,143 voluntary hospitals (90,000 beds) and 1,545 municipal hospitals (390,000 beds) were taken over by the NHS in England and Wales. [24]
Historian Pauline Gregg recounted how nail-bitingly close it got:
Six months before the Appointed Day it looked as though the whole edifice might crash through lack of support from the medical profession; but a near-last-minute agreement saved the structure. [25]
Up to this point the medical profession exercised a significant degree of autonomy and so the creation of a National Health Service would lead to some loss of freedom as well as increased bureaucratic demands. Bevan recognised this and stated:
Any health service which hopes to win the consent of the doctors must allay these fears. … There is no alternative to self-government by the medical profession in all matters affecting the content of its academic life. … It is for the community to provide the apparatus of medicine for the doctor. It is for him to use it freely in accordance with the standards of his profession. [26]
The Minister of Health however was also determined to deliver his mission:
No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means. [27]
Bevan secured the support of Cabinet to table a debate in the Commons on 9 th February 1948, which confirmed the government’s determination to begin NHS provision on Appointed Day. [28] In the February debate, Bevan detailed the ‘wholesale resistance to the implementation’ the NHS Act from the professional bodies. [29] Over the proceeding months, Bevan made concessions and gave assurances to the medical profession on clinical freedom. [30] By Appointed Day, a majority of GPs had applied to enter the NHS and three quarters of the population had registered with the NHS. [31] As the river of NHS provision began to flow, Bevan turned to his Parliamentary Private Secretary Barbara Castle and said:
Barbara, if you want to know what all this is for, look in the perambulators [prams]. [32]
Dr Michelle Clement is Lecturer and researcher on government reform and delivery at The Strand Group, King’s College London and Researcher in Residence at No.10 Downing Street. @MLClem @TheStrandGroup
[1] R. Klein, The New Politics of the NHS (Radcliffe Publishing, 2006), p.1.
[2] P. Gregg, The Welfare State (George G. Harrap & Co, 1967), p.18.
[3] J. Harris, William Beveridge: A Biography (OUP, 1977), p.412.
[4] P. Gregg, The Welfare State (George G. Harrap & Co, 1967), p.19.
[5] P. Gregg, The Welfare State (George G. Harrap & Co, 1967), p.19.
[6] M. Gilbert, Winston S. Churchill: Road to Victory 1941-45 (Heinemann, 1986), p.367.
[7] The first overall majority for the Labour Party.
[8] P. Hennessy, A Duty of Care: Britain Before and After Covid (Penguin, 2022), p.5.
[9] R. Burridge, Clement Attlee (Cape, 1985), p.204
[10] C. Attlee, As It Happened (Sharpe Books, 2019), p.165.
[11] J. Bew, Citizen Clem (Kindle edition, riverrun, 2016), p.578.
[12] J. Bew, Citizen Clem (Kindle edition, riverrun, 2016), p.579.
[13] H. Dalton, High Tide and After: Memoirs 1945-1960 (Muller, 1962), p.xi.
[14] The King’s Speech, Hansard, Vol. 137, 15 August 1945.
[15] B. Pimlott, Hugh Dalton (Papermac, 1986), p.495.
[16] P. Gregg, The Welfare State (George G. Harrap & Co, 1967), p.49.
[17] CAB/129/5 ‘Proposals for a National Health Service’, 13 December 1945, The National Archives,
http://filestore.nationalarchives.gov.uk/pdfs/small/cab-129-5-cp-45-339-39.pdf
[18] J. Bew, Citizen Clem (Kindle edition, riverrun, 2016), p.567.
[19] In 1951, under the Attlee government, charges for dentistry and optical care were introduced. The following year the Churchill government brought in prescription charges.
[20] P. Hennessy, A Duty of Care: Britain Before and After Covid (Penguin, 2022), p.7.
[21] Which built on the 1911 National Insurance Act.
[22] J. Bew, Citizen Clem (Kindle edition, riverrun, 2016), p.573.
[23] P. Hennessy, Never Again: Britain 1945-51 (Cape, 1992), p.119.
[24] G. Rivett, “1948-1957: Establishing the National Health Service”, Nuffield Trust , 2014,
https://www.nuffieldtrust.org.uk/chapter/1948-1957-establishing-the-national-health-service
[25] P. Gregg, The Welfare State (George G. Harrap & Co, 1967), p.51.
[26] A. Bevan, In Place of Fear (Kindle edition, Lume Books, 2020), Loc 1605-1630.
[27] A. Bevan, In Place of Fear (Kindle edition, Lume Books, 2020), Loc 1353.
[28] K. Harris, Attlee (Weidenfeld and Nicolson, 1982), p.423.
[29] House of Commons ‘National Health Service’ Debate, 9 February 1948,
https://api.parliament.uk/historic-hansard/commons/1948/feb/09/national-health-service
[30] R. Lowe, The Welfare State in Britain since 1945 (Palgrave Macmillan, 2005), p.179
[31] P. Gregg, The Welfare State (George G. Harrap & Co, 1967), pp.62-63.
[32] P. Hennessy, Distilling the Frenzy: Writing the History of One’s Own Times (Biteback, 2012), p.10.
Sharing and comments
Share this page.
Comment by John posted on 13 July 2023
Enlightening.
Related content and links
History of government.
This blog gives insights into the history of government – its development, its departments and some of the roles and people involved. Find out more .
Contributors include:
- The No 10 Guest Historian series
- The Cabinet Confidential series
Sign up and manage updates
- The National Archives on Twitter
- The National Archives on Facebook
- FCDO historians on Twitter
- History & Policy on Twitter
Recent Posts
- Filling ‘the hole in the centre’: The No.10 Policy Unit – 50 years on 2 May 2024
- The founding of the NHS: 75 years on 13 July 2023
- Visiting the secret state: Margaret Thatcher and Intelligence 21 December 2022
- What the Butler saw: Britain and the Abadan Crisis, 1950-51 7 December 2022
- Curzon's comeuppance 25 November 2022
Comments and moderation
The birth of Britain's National Health Service
On 5 July 2018, Britain’s National Health Service celebrated the 70th anniversary of its founding. Discover how an abstract ideal was made reality by the determination of a postwar Labour government.
Cal Flyn average reading time 7 minutes 21 June 2018
O ver the past seven decades the NHS has weathered two monarchs, 15 prime ministers, 29 health secretaries, countless changes in policy, and controversies and crises of all kinds – during which time it has come to occupy a unique position in national culture and identity.
It is more popular than any other British institution – more so than the royal family, the armed forces or the BBC – and for the grand majority of those now living, the NHS has been a constant presence throughout their lives. It has assisted in their birth, nursed them through ill health and will tend them on their deathbed.
Formation of the NHS
The NHS as we know it today grew out of a government report composed during the darkest days of World War II. Written by the economist Sir William Beveridge, this 1942 report reimagined the role of the state in a postwar nation, setting out to combat the five “great evils” of society: want, disease, ignorance, squalor and idleness.
“A revolutionary moment in the world's history is a time for revolutions, not for patching,” wrote Beveridge. To a country ravaged by war – a “bankrupt nation”, in Winston Churchill’s words – it was a bold and distant vision of a better future.
This dramatisation of the work of a GP, made two years before the NHS was created, reflects some of the attitudes towards approaching change in healthcare.
Healthcare before the NHS
In 1945, shortly after the war in Europe had drawn to a close, Clement Attlee led the Labour Party to a shock landslide victory over Churchill’s Conservatives, and set about transforming Beveridge’s vision of a welfare state into reality. A major component of this was the creation of a universal health service, available to all and for free. Aneurin Bevan, a prominent socialist and the son of a miner, was tasked with spearheading its creation.
Up until this point, healthcare had consisted of an uneven patchwork of services that varied widely by region.
‘Voluntary’ hospitals, aimed at the ‘sick poor’, provided the bulk of emergency care and relied largely on charity. They were staffed by physicians and surgeons who donated their time and expertise while making a living from their private practice. Municipal hospitals, a vestige of the old workhouse hospitals created under the Poor Laws, were run by local authorities.
Upper- and middle-class patients were barred from these public wards on the basis that it was an abuse of charity, and expected to pay. In return they received greater privacy and a higher standard of care. Some hospitals ran more successfully than others, but by the 1930s hospitals across the country were facing financial crisis and growing waiting lists.
The cover of A J Cronin’s book The Citadel , which contrasted private Harley Street medical practices with the socialised system in the mining town of Tredegar.
A hunger for change
Public hunger for change was building. Back in 1937, the bestselling novel The Citadel had presented a searing indictment of prewar health provision, based on the author A J Cronin’s experiences as a doctor in London and the mining villages of south Wales. In it, he contrasted the corrupt, immoral private practices of Harley Street with a socialised system he had worked for in Tredegar, Blaenau Gwent. The book’s enormous success has been credited with laying the groundwork for a universal health system in popular opinion.
There were other cases from across the country that gave some indication as to how a national health service might function. In Scotland, an ambitious state-funded health service had served the dispersed, rural population of the Highlands and Islands since 1913. Then, during World War II, the government had taken unprecedented control of hospitals under the Emergency Medical Service in anticipation of tens of thousands of air-raid casualties. Both systems demonstrated how much could be achieved when health services were centrally administered.
For Aneurin Bevan, however, the inspiration would come from closer to home.
A plaque commemorating the Tredegar healthcare system and the National Health Service it inspired.
Aneurin Bevan and the NHS
Bevan himself was born in Tredegar, and was intimately aware both of the efforts his local community had made to preserve themselves in ill health, and the danger of going without adequate care. One of ten siblings, of whom only six had survived into adulthood. he had also lost his father to pneumoconiosis (‘miner’s lung’) in 1925.
The Tredegar Workmen’s Medical Aid Society, where Cronin had worked and where Bevan’s father had been treated, had been formed in 1890 by a merger of local benevolent societies. It was intended to provide medical benefits and funeral expenses to miners, steelworkers and their families – and later the whole community. Members made weekly financial contributions, which collectively enabled them to employ doctors, a surgeon, and to maintain a hospital.
This would become Bevan’s model as he worked on the National Health Service project. As he would explain to the country in 1948: “All I am doing is extending to the entire population of Britain the benefits we had in Tredegar for a generation or more. We are going to Tredegarise you.”
Around this time Bevan made clear the key principles that underpinned this new service: it must “universalise the best”, not simply provide a safety net for the poorest; it must be “free at the point of delivery” – that is, the patient does not pay at the time of treatment; and it must be provided according to need, not the ability to pay.
This cartoon features the character Charley, who has the workings of the NHS explained to him and uses some of its services.
A Punch cartoon illustrating the doctors' defeat by Bevan.
Opposition to the NHS
Bevan faced a big job. Not only was a huge proportion of the country’s hospital stock war damaged, but many doctors were still in army service. Of those who remained, a large proportion was still to be convinced. Many of them had established practices and were resistant to change.
Between 1945 and the launch of the NHS, Bevan engaged in furious battle with the British Medical Association (BMA), the doctors’ union, over the terms of service offered to doctors – specifically the issue of whether they should be directly employed on set salaries.
In 1947, the BMA threatened to boycott the new service and the row became increasingly public: one letter in the British Medical Journal described Bevan as “a complete and uncontrolled dictator” and cooperative doctors as “quislings” (after the head of the puppet government in Nazi-occupied Norway). For his part, Bevan accused the BMA of engaging in “a squalid political conspiracy” and “organising sabotage of an Act of Parliament”.
Finally a deal was brokered in which GPs would retain the power to run their practices as small businesses, and consultants could both work for the service and retain their private patients. As Bevan put it bluntly, he “stuffed their mouths with gold”.
Introducing the National Health Service
Pamphlets explained the workings of the new National Health Service and answered questions such as "What is it? How do you get it?"
Leaflets were produced for different areas – this one advises how the NHS would work in Scotland.
The new NHS was explained through diagrams such as this one, advising patients to "choose your doctor now".
The “appointed day”
Britain’s National Health Service came into existence on 5 July 1948. It was the first universal health system to be available to all and financed from taxation. It was also, Bevan admitted, “the biggest single experiment in social service that the world has ever seen”.
Ethel Armstrong, now aged 88, was then a student of radiology at the Royal Victoria Infirmary in Newcastle. “It was just unbelievable. You couldn’t believe that whatever it was that you needed, that required medical attention, was going to be given to you totally free of charge. Before then, it was very much a two-tier system. If your parents had money, you could pay for care. Large families were struggling… Today we take everything for granted.”
Ethel had a high-flying career in radiodiagnosis and radiotherapy, retiring in 1990 only to immediately join the NHS Retirement Fellowship, a charity that supports retired NHS workers – “the small cogs which turn the big wheel that is our NHS”. She is now a life patron. In March she was awarded a MBE recognising 70 years’ service that have spanned the length of the health service itself. “My passion, enthusiasm and commitment to the NHS have never waned,” she says.
Faces of the NHS: 1940s
Ethel Armstrong recalls her interview to go and work for the NHS: "I walked through the oak-panelled doors with Queen Victoria's portrait standing at the front, with my shiny shoes and half a crown in my pocket. Until then, I had never, ever, walked through the door of any hospital... because it was not a free service until 5 July 1948, so you had to pay for your care, so I did not know what to expect."
Peter Tonks first began work as a hospital clerk in 1946, before the NHS. He remembers, "When I went for the interview... there were two patients scrubbing the floor on hands and knees." Under the NHS, he said, "We realised that we could improve the environment for the benefit of the patients." One of the improvements Peter made was to introduce paid domestic staff.
Joyce Thompson was training as a nurse when the NHS was created. Joyce said, "I decided to go into nursing, I feel, through my father, who was a big St John's Ambulance man. When I was little, there was no such thing as the NHS, and there were doctors' bills to pay... there was always knocking at our front door for father to look at cuts... he did a lot of that kind of work and I always went to the door behind him to see what was happening."
Ethel is not alone in her strong feelings for the NHS. Historian Jenny Crane from the People's History of the NHS project observes that: “Over the late 20th century, members of the public, campaign groups, and politicians alike have positioned the NHS as fundamentally entwined with and imbued by 'British values'.”
By one means or another, the NHS cares for us in sickness and in health, from the cradle to the grave, in the home, clinic and hospital.
About the contributors
Cal Flyn is a writer and reporter from the Highlands of Scotland. She writes across the British press, including the Guardian, the Sunday Times, the Daily Telegraph, Prospect and New Statesman. Her first book, ‘Thicker Than Water’ , was published by William Collins in 2016, and selected by the Times as one of the best books of that year.
Stay in the know
Sign up to our newsletter to find out what’s on, read our latest stories and get involved.
All our newsletters
Tick this box if you’re happy to receive other emails about Wellcome Collection, upcoming events and exhibitions and/or other relevant opportunities.
By clicking subscribe, you agree to receive this newsletter. You can unsubscribe any time. For information about how we handle your data, please read our privacy notice .
IMAGES