The NHS ‘founding myth’: It never happened in the way we think it happened
4 December 2015
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Economic Theory
Healthcare
Lifestyle Economics
15 November 2024
Every 14 July, France commemorates the storming of the Bastille, which kick-started the French Revolution. ‘Bastille Day’ is not just a bank holiday. It is part of France’s national story, the great founding myth of French Republicanism. It is a powerful story of ordinary people rising up and overthrowing an oppressive elite.
But it is not a true story. The history that is ‘remembered’ on Bastille Day is only very loosely based on actual events. The historical storming of the Bastille was pointless (the building was almost empty at the time), and the French revolution ended in well-known failure.
And yet, if a historian pointed this out on Bastille Day, they would be rightfully dismissed as a pedant and a bore. Bastille Day is a founding myth, so judging it by how historically accurate it is would completely miss the point. The point of a founding myth is not to understand what happened in the past, but to foster a ‘team spirit’ here and now. It is irrelevant whether it is a true story, as long it is a shared story, which helps to create a group identity.
In the UK, it is the National Health Service which has acquired features of a founding myth. It is a story of ordinary people getting together, putting their differences aside, and deciding to organise healthcare collectively. A nation rose above itself, and created a healthcare system run by the people, for the people. As columnist Owen Jones puts it:
“The welfare state, the NHS, workers’ rights: these were the culmination of generations of struggle, not least by a labour movement […] set up […] to give working people a voice.”
RAF veteran Harry Leslie Smith even became a minor political celebrity by recounting his version of the NHS founding story at a party conference:
“It was an uncivilised time [before the NHS] because public healthcare didn’t exist. Back then, hospitals, doctors and medicine were for the privileged few. Because they were run by profit […] Sadly, rampant poverty, and no healthcare, were the norm for the Britain of my youth. That injustice galvanised my generation, to become, after the Second World War, the tide that raised all boats. […] Election Day 1945 was one of the proudest days of my life. […] I voted […] for the creation of the NHS”.
It is a powerful story that arouses strong feelings. But like the popular version of Bastille Day, it is also almost completely untrue. The creation of the NHS had nothing to do with pressure ‘from below’. The health service was, at least initially, a brainchild of social elites, not a product of ‘People Power’. The general public never demanded a government takeover of healthcare.
This is well documented in a paper in the English Historical Review, entitled “Did We Really Want a National Health Service? Hospitals, Patients and Public Opinions before 1948”, which reviews contemporary survey evidence. To quote from a contemporary summary of various surveys:
“[T]he evidence before us seems to indicate a fairly large amount of resistance to State interference in the field of medicine […] roughly half the population was opposed to any major change on the health front, a quarter disinterested and a quarter in favour”.
The author of the paper concludes:
“[I]t is clear that little evidence exists to support those seeking to claim an inclusive popular mandate for radical reform as a justification for implementing contentious policy”.
A paper in Studies in American Political Development, which examines the political factors behind the emergence of publicly funded healthcare systems in different countries, also finds:
“the overwhelming evidence is that these early programs were promulgated by government elites well in advance of public demands”.
It is equally a myth that the NHS opened up the benefits of modern medicine to everybody, while under the preceding system only the rich had access to healthcare. Of course there were substantial improvements in health after the creation of the NHS – but there were also substantial improvements in health before the creation of the NHS. In long-term time series of population health data, the impact of the introduction of the NHS is not discernible. Pre-NHS trends and patterns, positive and negative ones, mostly continued.
Does any of this matter? People love the NHS today, so who cares about ancient history?
Unfortunately, there is a massive difference between the French and the British founding myth. Bastille Day refers to an abstract event in the distant past; the way we interpret it today has no tangible impact on contemporary politics. There is therefore no reason why people in France should not remember this event in an idealised way.
The NHS, in contrast, is not just a founding myth. It is also an actual healthcare system that treats actual people, here and now. There is nothing wrong with sacralising a historic event, but there are big problems with sacralising a health system, especially if it means that even well-founded criticism is treated as heresy (or in the best case, misrepresented as an attack on individual doctors and nurses).
And it is about time for a bit more honesty about the NHS’s shortcomings. As I show in my new IEA Discussion Paper ‘Diagnosis: Overrated’, the NHS is falling behind comparable health systems in a lot of respects, and this is about more than just a lack of money (although that is a factor). The NHS derives much of its sacrosanct status from its founding myth story. If we want a more honest debate about the future of the health service, shedding some light on its mythical past is not such a bad way to start.
Dr Kristian Niemietz is the IEA’s Head of Health and Welfare, and a Research Fellow at the Age Endeavour Fellowship (AEF). He is the author of the IEA Discussion Paper ‘Diagnosis: Overrated – An analysis of the structural flaws in the NHS’, released today.
But it is not a true story. The history that is ‘remembered’ on Bastille Day is only very loosely based on actual events. The historical storming of the Bastille was pointless (the building was almost empty at the time), and the French revolution ended in well-known failure.
And yet, if a historian pointed this out on Bastille Day, they would be rightfully dismissed as a pedant and a bore. Bastille Day is a founding myth, so judging it by how historically accurate it is would completely miss the point. The point of a founding myth is not to understand what happened in the past, but to foster a ‘team spirit’ here and now. It is irrelevant whether it is a true story, as long it is a shared story, which helps to create a group identity.
In the UK, it is the National Health Service which has acquired features of a founding myth. It is a story of ordinary people getting together, putting their differences aside, and deciding to organise healthcare collectively. A nation rose above itself, and created a healthcare system run by the people, for the people. As columnist Owen Jones puts it:
“The welfare state, the NHS, workers’ rights: these were the culmination of generations of struggle, not least by a labour movement […] set up […] to give working people a voice.”
RAF veteran Harry Leslie Smith even became a minor political celebrity by recounting his version of the NHS founding story at a party conference:
“It was an uncivilised time [before the NHS] because public healthcare didn’t exist. Back then, hospitals, doctors and medicine were for the privileged few. Because they were run by profit […] Sadly, rampant poverty, and no healthcare, were the norm for the Britain of my youth. That injustice galvanised my generation, to become, after the Second World War, the tide that raised all boats. […] Election Day 1945 was one of the proudest days of my life. […] I voted […] for the creation of the NHS”.
It is a powerful story that arouses strong feelings. But like the popular version of Bastille Day, it is also almost completely untrue. The creation of the NHS had nothing to do with pressure ‘from below’. The health service was, at least initially, a brainchild of social elites, not a product of ‘People Power’. The general public never demanded a government takeover of healthcare.
This is well documented in a paper in the English Historical Review, entitled “Did We Really Want a National Health Service? Hospitals, Patients and Public Opinions before 1948”, which reviews contemporary survey evidence. To quote from a contemporary summary of various surveys:
“[T]he evidence before us seems to indicate a fairly large amount of resistance to State interference in the field of medicine […] roughly half the population was opposed to any major change on the health front, a quarter disinterested and a quarter in favour”.
The author of the paper concludes:
“[I]t is clear that little evidence exists to support those seeking to claim an inclusive popular mandate for radical reform as a justification for implementing contentious policy”.
A paper in Studies in American Political Development, which examines the political factors behind the emergence of publicly funded healthcare systems in different countries, also finds:
“the overwhelming evidence is that these early programs were promulgated by government elites well in advance of public demands”.
It is equally a myth that the NHS opened up the benefits of modern medicine to everybody, while under the preceding system only the rich had access to healthcare. Of course there were substantial improvements in health after the creation of the NHS – but there were also substantial improvements in health before the creation of the NHS. In long-term time series of population health data, the impact of the introduction of the NHS is not discernible. Pre-NHS trends and patterns, positive and negative ones, mostly continued.
Does any of this matter? People love the NHS today, so who cares about ancient history?
Unfortunately, there is a massive difference between the French and the British founding myth. Bastille Day refers to an abstract event in the distant past; the way we interpret it today has no tangible impact on contemporary politics. There is therefore no reason why people in France should not remember this event in an idealised way.
The NHS, in contrast, is not just a founding myth. It is also an actual healthcare system that treats actual people, here and now. There is nothing wrong with sacralising a historic event, but there are big problems with sacralising a health system, especially if it means that even well-founded criticism is treated as heresy (or in the best case, misrepresented as an attack on individual doctors and nurses).
And it is about time for a bit more honesty about the NHS’s shortcomings. As I show in my new IEA Discussion Paper ‘Diagnosis: Overrated’, the NHS is falling behind comparable health systems in a lot of respects, and this is about more than just a lack of money (although that is a factor). The NHS derives much of its sacrosanct status from its founding myth story. If we want a more honest debate about the future of the health service, shedding some light on its mythical past is not such a bad way to start.
Dr Kristian Niemietz is the IEA’s Head of Health and Welfare, and a Research Fellow at the Age Endeavour Fellowship (AEF). He is the author of the IEA Discussion Paper ‘Diagnosis: Overrated – An analysis of the structural flaws in the NHS’, released today.
4 thoughts on “The NHS ‘founding myth’: It never happened in the way we think it happened”
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There is, of course, nothing necessarily wrong about elites leading the way in social changes — indeed I dare say that is how changes often come about. But what I really value is not change but competition. That’s where the NHS falls down. It’s a state monopoly (or, as I prefer to say, ‘monoparechy’ — single supplier’, rather than ‘single seller’). We taxpayers all have to pay (a lot) for the NHS, and most of us would rather not have to pay twice if we choose to go private. That’s why some form of voucher scheme always seems very attractive. It retains the NHS for those who want it, but allows the rest of us an alternative option. Why won’t the politicians allow us to go down that path?
Maybe the NHS is now, along with other state run health systems a product of it’s own ‘success’ insofar that it is an easy target for the big drug manufacturers.
Who could imagine the drug companies raking in the huge price of some drugs if the target was the punters themselves.
Of course we will never know but it would seem that the cost of drugs would come under greater scrutiny by Joe Public if he were able to lower his insurance premium cost by electing to become self insured in some instances.
Maybe we would have a quite different health system and a more affordable system and, maybe a generally more user friendly system.
After all how much would another six months of life be worth in realcost terms rather than in NICEcost terms and, more importantly, would we each be willing to pay for it
Given the fact that the NHS is the third largest employer in the World and the two largest serve nations more than ten times our own population, I would endeavour to suggest that the NHS doesn’t provide value for money; this along with facts such as the requirement of the NHS to undertake some activities which are not core to its raison d’etre; the constant dissolution of objective argument being drowned out in choruses of subjective banter; the constant politicising of the entity to grab votes by all parties and the reliance of the nations’ increasing dependency upon the NHS as a mainstay of the “Illfare State” means there will never be sensible debate or discussion upon its future or indeed, as to whether we feel we can afford it any longer.
One problem I see is that the concept of private healthcare, or similarly, private schooling, is conflated totally with expensive, posh, for the rich, in the minds of the public. When a state version of a service exists, people forget that the idea of poor people, even not-poor-but-not-rich people, buying a private service is even slightly plausible. Ask them whether the poor use private supermarkets and they’ll be baffled – the question doesn’t make sense. When there isn’t a state version, the private service isn’t thought of as private, it’s just… normal. When there is a state version, the private alternative is called private, and private means shutting people out, means for the rich only.
Status quo bias is a powerful thing. Everywhere in the world, people can only imagine things working how they currently do in their own society, and think it would be absurd for them to work any differently.