The National Health Service and the Endurances of British Social Democracy, 1948 to the Present

Why do political settlements last? The National Health Service and the Endurances of British Social Democracy is a social, political, and transnational history of Britain’s National Health Service (NHS) and argues that even the most seemingly inevitable policy successes require constant support to mature beyond their foundations.

The NHS has been famously called “the closest thing the English have to a religion.” Founded in 1948, today it is the world’s fifth largest employer and enjoys support across Britain’s political spectrum: from the progressive narrative showcased at the Opening Ceremony of the 2012 London Olympics, to the “Leave” campaign’s promise to save “Our NHS” during the 2016 Brexit vote. How did this universalist institution survive decades of well-funded and organized attacks to become the jewel in the crown of Britain’s welfare state in the late-twentieth century?

Existing scholarship prioritizes “path-dependence,” a concept borrowed from economics and political science. According to this approach, the resilience of institutions like the NHS results from the difficulties involved in shifting large administrative structures and their inbuilt resistance to change. Yet, these interpretations obscure wider developments. I argue, by contrast, that nationalized medicine’s persistence resulted from an active and historical process. Through research in thirty-five archives on both sides of the Atlantic, I show that the NHS endured by adapting to changing social norms, outmaneuvering ideological opponents, and amassing public support. I uncover a range of perspectives, including activists, hospital volunteers, economists, architects, filmmakers, radio broadcasters, novelists, playwrights, doctors, nurses, receptionists, and the women, men, and children who received care in its clinics and hospitals.

I begin the dissertation with the origins of a “National Health Service” in the Edwardian period and its introduction under a Labour government in 1948. Left-wing reformers worked to persuade a public skeptical of impersonal “state medicine” by presenting the NHS as a humanitarian institution that safeguarded gendered ideals of the family. It then maps the postwar modernization of the service through hospitals and health centers. Unlike accounts that focus on modernization as a bureaucratic and technocratic process, I recast it as a social phenomenon by centering patients’ changing experiences of health care. Class, gender, and race shaped these interactions. Nonetheless, the institution’s balance of communalism with individualism helped secure it from the critiques that undermined other parts of the welfare state. From the intimate spaces of the hospital ward and doctor’s surgery, I pan out to consider the NHS in a transnational context. In doing so, I illuminate how the service became imbued with “welfare nationalism.” In the 1940s and 1950s, the British left cooperated with allies in the U.S. to try and pass a form of national health insurance. However, the failure of these American efforts, followed by sustained critiques of the NHS by U.S. conservatives, forced the British left into a defensive position. They began to draw distinctions between the NHS and the inequities of the U.S. health system. Yet this process of associating the service with nationally-framed “British” values unwittingly created racialized boundaries for the tens of thousands of its employees who originated from the former empire. I conclude by showing how neoliberal ambitions to replace nationalized medicine with private health insurance failed to overcome the developments of the previous decades. The NHS’s adaptability rebutted critiques in the 1970s and 1980s that painted all facets of the welfare state as unresponsive to public demand. Moreover, increasingly seen as inequitable, discriminatory, and “American,” private health insurance could not dislodge the NHS’s place in the national imaginary.

Moving from the efforts of local government and hospital boards to design health care facilities, to everyday experiences of treatment, to international health care debates and the movement of workers and experts across former imperial boundaries, I offer a new interpretation of the welfare state, transnational health politics, and political change. By charting the history of the NHS from its origins a century ago to the present day, I make the case for the endurances of social democratic structures and values beyond the standard periodization of a “rise and fall” between the 1940s and the 1980s. Solidaristic settlements require constant vigilance to ensure their longevity in the face of shifting ideological currents.