by Jeremy Black
Health was even more of a problem for the large number of homeless, which rose, particularly in the 1980s. In part, this rise reflected the decline in the availability of low-cost housing, both public and private, for rent, but the closure of mental homes and the lack of care for ex-servicemen were also important. Each also reflected the serious limitations of the social welfare model of public provision.
Health, therefore, could not be separated from social welfare, and in particular the strengths and weaknesses of the welfare state, the system by which the government provides benefits and services, such as health care and pensions, for all members of society. Existing social welfare had proved unequal to the challenge of the Depression of the 1930s, leading, with the Unemployment Act of 1934, to a stronger conviction on the part of the intellectuals and university-educated public servants who were to become influential in the 1940s, that the central government must have an effective social policy.
The establishment of the National Health Service (NHS) in 1948 proved a far more prominent act by the post-war Labour government than the 1946 National Insurance Act. Inspired by egalitarian ideals, and in reaction to the variations and role of payment in inter-war health provision, the NHS was a system for state care. Its creation reflected the serious problems of the 1930s, when most local authorities did not have enough money for the municipal hospitals, while the voluntary hospitals also suffered from the impact of the Depression.
The solution was to integrate the voluntary and public (municipal) hospitals and to spread resources, and the NHS offered a new system through which central government expenditure could be directed and administered. The Second World War had shown that a regional system of health care and management could work, and the NHS provided this with new regional hospital boards under the Ministry of Health. The Minister of Health, Aneurin Bevan, a Welsh miner’s son and committed socialist who loudly proclaimed his loathing for Conservatives, played the key role in creating the NHS. The creation of a national health service was Labour’s election commitment in 1945, but Bevan, through his own personal pressure, managed to turn this into a commitment to a nationalized health service, a service he later lauded in his book In Place of Fear (1951).
Health care was not only provided free at the point of delivery in hospitals. In addition, the General Practitioner (GP) Service was organized on the basis of a capitation fee paid by the government on behalf of every patient registered with a doctor. The new GP arrangements were an extension of the provisions under the 1911 National Insurance Act. Not all GPs joined the NHS, but the number who retained a private practice was small, and the combined impact of high taxation in the 1940s and the availability of free public treatment was important in limiting private health care, and thus ensuring that Britain took a distinctive health care trajectory, with state provision rather than mixed provision being a central feature.
However, the NHS was flawed from the outset by the classic problems of nationalized entities, including (frequently inconsistent) political intervention, the inflexible national policies that stemmed from centralized state control, funding difficulties in the face of competition for state expenditure, and poor management and labour relations. Moreover, the NHS was harmed by the measures taken to win the consent of interest groups, particularly doctors and dentists, although the British Social Attitudes Survey consistently showed the NHS to be the most popular service of the welfare state.
From the beginning, the NHS suffered from rising expectations of treatment, the greater cost of care that stemmed from an ageing population, and the growing expense of medical treatment. The subsidized availability of drugs under the NHS, with most prescriptions provided free, was both socially progressive and highly expensive, even though the NHS was able to act as a quasi-monopolistic purchaser, and thus to bargain over prices (and wages). The NHS also rapidly encountered problems in dealing with demand for spectacles and dentures, with massive waiting lists reflecting pent-up demand. There was serious political controversy within the Labour government in 1951 over the introduction of charges, with resignations from the government by left-wingers, including Bevan, who saw himself as the government’s socialist conscience.
From the 1970s, moreover, there was declining confidence in the ability of the health system to solve problems, at once the product of a general sense of malaise in Britain, of a decline of faith in modernist solutions, and of specific concerns about the NHS. Whereas the jolly ‘Doctor’ films, beginning with Doctor in the House (1954), had presented a benign image of the NHS (albeit one in which doctors and surgeons treated patients like slabs of meat), Britain was seen as a strike-wracked and run-down NHS hospital in Lindsay Anderson’s depressing satirical film Britannia Hospital (1982).
More generally, histories written prior to the mid-1970s tended to adopt an optimistic note about the expansion of publicly provided social welfare, although, in practice, many of the social problems of the 1930s had eased rather because of post-war economic expansion which greatly reduced unemployment. Moreover, economic growth helped state provision by providing the wealth for higher levels of taxation, which was why, when the economy ceased to grow in the 1970s, many on the right of politics began to argue that Britain could no longer afford a welfare state grounded on universalism, as opposed to means-testing. The percentage of the GDP taken by tax rose from 30 per cent in 1937 to 32 per cent in 1960, but then, in a period largely under Labour government, to 43 per cent by 1980.
The sustainability of this seemed highly unlikely to commentators. In addition, the desirability of targeting resources at the really needy, in order to reduce the escalating welfare bill, of moving from universal provision to ‘residualism’, also proved a thorny subject for Labour, with some politicians moving in this direction during the Blair and Brown governments (1997–2010).
Government spending on health care rose above the rate of inflation under both the Conservative and Labour Parties, and there was less direct private contribution to individual health care than in France and Germany, let alone the US. Concern about creeping privatization in the NHS led Blair to make electoral capital in 1997 with his pledge to ‘Save the NHS’ (which was not in fact in danger). Expenditure on the NHS rose under Blair and Brown, and Cameron felt it necessary to promise that it would be safe under him. The NHS was, and is, Western Europe’s largest employer.
Such expenditure affected the government funds available for other activities. In particular, spending on health (and other aspects of social welfare) reduced the state’s capacity to spend on economic investment, transport infrastructure and military expenditure. To American critics, the last was a key aspect of a more general facet of European politics and society. Ironically, expenditure on health care in Britain in 2007 was only 8.4 per cent of GDP, compared to 16 per cent for the US, and there were 8.2 MRI (magnetic resonance imaging) scanners per million people in Britain compared to 25.9 in the US: it was social welfare that took more in Britain. Yet, despite less spending in Britain, health outcomes were better than in the US.
Improved health care played a role in longer life expectancy and in major changes in the causes of death. Whereas infections and parasitic diseases were a major cause of death for the entire population in the first half of the century, today infections and parasitic diseases generally only kill people who are suffering from associated disorders and who are at the extremes of life. Respiratory diseases have also declined in importance.
Instead, late-onset diseases, especially heart disease and cancers, are now far more important, and help encourage the government role in discouraging smoking and drinking to excess. Cancers were responsible for 25.6 per cent of all deaths in England and Wales in 2001, followed by ischaemic heart diseases (19.9 per cent) and strokes (11 per cent). Death rates from heart disease are among the highest in the world. In September 2009, the European Heart Network reported that, of sixteen European countries, Britain had the sixth highest death rate for coronary heart disease among men under sixty-five and the
fourth highest for women under sixty-five. Lifestyle is a major issue, with much of the population clinically overweight or obese, which partly helps explain the high rates of heart disease. Climate may also play a role, notably in higher rates in Scotland, although diet is also cited as a factor there.
Moreover, the British people are literally changing shape, becoming broader and taller and having more fat. Between 1951 and 1999, the average female bust size increased by 2 inches (5 centimetres), while women grew taller by about half an inch (12 millimetres) and heavier by 6.6 lbs (3 kilograms) each decade. Average shoe sizes rose from 4 to 5½ (37 to 38½), and waist sizes from 25½ to 28 inches (65 to 72 centimetres). There were similar changes for men. The cult of exercise had little impact on these trends. Another change linking social trends with health was that of the marked rise in sexually transmitted diseases. Between 1998 and 2007, chlamydia increased by 150 per cent, herpes by 51 per cent and gonorrhoea by 42 per cent.
Class and Economy
Average changes were played out through major social and regional variations, a situation readily seen in the 1930s. An instructive contrast from 1936 was that between the unemployed Jarrow shipworkers who drew attention to their plight with a march on London, and the new Carreras cigarette factory opened at Mornington Crescent in London and employing 2,600 workers. This regional contrast ensured that it continued to be unhelpful to think of a common working-or middle-class experience, and this situation obviously inhibited the development of class consciousness. The gender dimension was also significant.
Social differences had a regional component throughout the period, with ownership of electrical goods, as well as of cars and telephones, and electricity consumption, higher in the south east than in poorer areas, such as South Wales. Whether defined in terms of income or occupation, the middle class were proportionately far more important in London and the south east than in any other region.
The Second World War, however, encouraged an inclusive idea of nationhood resting on shared experience and common purpose. An emphasis on the Home Front made social distinctions seem unacceptable, and the rationing of food, clothes, petrol and much else rested on a theory of equality. Although the extent to which, during the war, the classes mingled, for example in work, should not be exaggerated, such mingling was stressed as a desirable goal and was more extensive than before the war.
The war was followed by a degree of collectivism under the Labour governments of 1945 to 1951. The welfare state built up under Labour was seen as an aspect of the continued process of state control over society and economy, while nationalization of much of the economy consolidated the trend towards national control, planning, products, conditions, pricing and wage settlements. These collectivist aspirations were to be contested, however, not only by political opponents, but also, notably from the 1960s, by the rise of an individualist culture and one in which class categories were affected, indeed undermined, by a new and more vocal interest in youth, gender, and race (see p. 271–3, 276–8).
Nevertheless, class remained an important dynamic, although not the anticipated rise of the working class but, instead, a major expansion of the middle class. In 1900, 75 per cent of the labour force were manual workers; by 1974, 47 per cent and, by 1991, only 36 per cent. In contrast, in 1971, male employment in administrative, professional and other service occupations was below 25 per cent in only three counties in England and Wales: Montgomery, Radnorshire and Carmarthen, all agricultural counties in Wales. The trend in employment reflected the extent to which heavy industries were hit hard by economic change. The expansion of the late 1940s, which led, for example, to the massive and modern Port Talbot steelworks, opened in 1951, was succeeded by closures and massive lay-offs. In Wales, the Ebbw Vale Steelworks closed in 1975–6, the Shotton steelworks following in the 1980s. Moreover, London ceased to be a city in which manufacturing was a central element of the economy.
This de-industrialization was a dramatic change on the situation in the 1850s when Britain was the ‘workshop of the world’. As with many other trends covered in this book, this was not one unique to Britain. Instead, there were problems general to heavy industry, coal-based manufacturing and the European economies. Yet Britain fared worse than the other economies of Western Europe, and it was not only heavy industry that was hard hit in Britain. The reasons for industrial problems were much debated among economists but included very poor labour relations, notably in the 1970s, frequently indifferent management, incoherent government policy and a fiscal environment that was not focused on industrial production.
A good example was provided by shipbuilding, in which Britain led the world until 1955 when it was supplanted by Japan. In the late 1940s and early and mid-1950s, British shipyards benefited from rising world demand, but by the 1960s they were losing orders to the lower charges of foreign yards. In addition, the latter were able to promise earlier and more reliable delivery dates, a result of the lack in Britain of modern yards able to offer flow-line production and, therefore, higher productivity. This absence reflected problematic labour relations and a lack of investment, born of short-term attitudes and limited planning for the longer term.
As the market became more competitive from the 1960s, the decline of British competitiveness in this sphere hit hard. Business was lost and shipyards were closed, so that, whereas the UK had delivered 12.4 per cent of the ships that entered service in the world in 1962, by 1971 the percentage was down to 5.1; although, in terms of tonnage, there had been an increase. The Suez Crisis of 1956 exposed a particular problem in British shipbuilding capacity, as it led to a shift towards supertankers, designed to take oil from the Middle East round Africa rather than to go through the Suez Canal, a challenge that British yards, with their limited facilities on narrow rivers such as the Clyde and the Tyne, could not meet.
Britain’s merchant marine also declined, with, again, a major implication for the nation’s once close relationship with the sea. In 1900, the UK owned about half of the merchant shipping afloat, and in 1914 39.3 per cent. Thereafter, there was a serious decline, to 29.9 per cent in 1930, 26.1 per cent in 1939, and, after the wartime destruction of other merchant navies, a rise to 32.4 per cent in 1948. By 1960, the share was down to 16.3 per cent. This was due not only to the growth in the shipping of other countries, but also to serious problems in the British industry, especially labour disputes, anachronistic working practices, poor management and under-investment: labour problems hit profits, ensuring limited investment, which in turn affected British shipbuilding.
Although Britain’s merchant fleet was not to reach its post-war peak until 1975, in 1967 it lost its position as the world’s leading shipper to Liberia, which operated as a flag of convenience for the US, helping to provide American-owned shipping with lower taxation and cheaper crews. Merchant shipbuilding was in terminal crisis by the 1970s. As with the car industry, the Labour government of 1964–70 went for larger groupings, rather than the reform of working practices. In 1977, Labour nationalized the industry, which by 1978 was launching only 5.2 per cent of world output. Trading losses and a lack of support from the Conservative government and the European Union compounded the problem, and by 1992 the relevant percentage of world output was 1.2, while most British shipyards had closed.
More generally, the manufacturing base declined, and notably as a source of employment, as the nature of much of the work in it became more skilled, restricting opportunities for the less skilled, and the service sector grew. Average incomes for those in work rose appreciably, ensuring that, whether they thought of themselves as working class – as in the case of John Prescott, Labour’s deputy leader from 1994 to 2007 – or not, much of the working population could afford a lifestyle associated with middle-class occupations. Commentators discerned embourgeoisement among Luton car workers from the 1960s. The rise in home ownership, the decline of trade union membership, and the creation of ‘New Labour’ in the 1990s, with its conscious breach from the trade unions, were all as
pects of this change.
The rise in the service sector was linked to a growth in consumerism that reflected the increase in prosperity, but also owed something to a major extension of personal borrowing that was partly a product of technological development, not least in the shape of credit cards and, later, internet purchases. Thanks to the state provision of free or subsidized health care, education, council housing, pensions and unemployment pay, rising real incomes fed through into consumption, although, for many, rising incomes led to expenditure on forms of private welfare, such as private and occupational pensions, school fees, private medicine and, increasingly, private housing. Indeed, the last became a key aspect of expenditure.
Government action was important. Purchase tax on consumer durables was cut from two-thirds to half in 1953, as the Conservatives, who had gained power in 1951, replaced Labour austerity with consumer demand. As a result of a surge in consumption, the number of households owning a washing-machine rose from 25 per cent in 1958 to 50 per cent in 1964 and 88 per cent in 1991, so that going to the laundrette became a minority activity. For cars, ownership by 25 and 50 per cent of households was reached in 1956 and 1965, and for fridges in 1962 and 1968. Thus, for many, the 1960s meant the affluent society in the shape of washing-machines, cars and fridges, rather than pop music and drugs.
The transition to the service economy was true even of traditional centres of heavy industry. In 1901, 15 per cent of the inhabitants of Newcastle were employed in shipbuilding and engineering, but by the late 1970s the largest employers were the City Council, the Department of Health and Social Security, the Area Health Authority, and the university. More generally, social structures and practices were remoulded across Britain with the decline of industry, and traditional assumptions of, and about, class were altered. Both middle-and working-class assumptions about behaviour – their own and that of others, and how it placed people socially and exemplified different values – were challenged. In John Osborne’s biting play Look Back in Anger (1956), what made the central character, the anti-hero Jimmy Porter, so angry were the limits to social mobility in class-ridden Britain. Despite his university education, Jimmy would never be able to escape his working-class background and, as a result, he chose to run a stall, rather than accept a form of employment which his educational qualifications would allow him to undertake.
