Social Democracy, Neoliberalism, and the NHS
Andrew Seaton on his award-winning history of the British National Health Service
London 2012 Olympic Opening Ceremony - NHS Section, photo by Shimelle Laine.
Andrew Seaton, a 2022 HPE Project Summer Research Grantee, recently published Our NHS: A History of Britain's Best-Loved Institution (Yale, 2023). We spoke with him about social democracy and neoliberalism in the history of the British national health service.
Andrew Anastasi: What is the NHS, and how was it made?
Andrew Seaton: The National Health Service (NHS) is a universal health system. Although its structure now varies slightly across the constituent nations of the United Kingdom, it is funded by general taxation and provides health care “free at the point of use” without any direct payments or proof of insurance. Founded in 1948 by the postwar Labour government, the institution now stands as the centerpiece of the British welfare state.
I see the NHS’s foundation as the culmination of a longer campaign for a “state medical system” that began in the 1910s. Although these initial demands came from across the political spectrum, the state-centered legislation that founded the service (including nationalizing hospitals and committing to a national network of health centers) reflects left-wing priorities. The architects of the NHS (within the Labour Party and various reforming organizations) conceived of the service as a necessary component of a planned economy based on industry and manufacturing, as well as a response to a falling birth rate.
AA: Your book emphasizes the NHS’s remarkable durability, and you push back on some traditional narratives of neoliberalism, Margaret Thatcher’s tenure, and “crises” in the NHS. How would you characterize your intervention as a historian of political economy? And how is it that the NHS has managed to survive in Britain while mass council housing and public industries have not?
AS: With Our NHS, I wanted to contribute to recent debates about social democracy and neoliberalism. These categories of political economy are contested (as with any category) but have energized fantastic work in multiple geographies. As the History and Political Economy Project shows, they also enable shared conversations. A number of scholars have already questioned the notion of an unequivocal neoliberal “triumph” during or after the 1980s, chiefly by pointing to internal contradictions or its proponents’ inability to translate political priorities into reality. Similarly, other scholars have shown how social democrats actively responded to the economic challenges of the 1970s.
I saw another story that needed to be told: how the structures and principles of social democracy might last or even flourish beyond that hinge point of the 1970s – in other words, the possible endurance of social democracy. My book shows how the efforts of NHS supporters to embed communal practices of welfare in everyday life, defend the institution from free market critique, and present the service as a unique British achievement allowed that to happen. Though outsourcing and the use of private capital to build public facilities undoubtedly reshaped the NHS, I think it is important to recognize where a political economy of social democracy still exists, as well as the unexpected costs of that survival.
AA: Your narrative brings grassroots efforts to the fore. You mention that if Our NHS is not exactly a “people’s history,” it is certainly a “peopled history.” Can you talk about the cultural construction of the NHS?
AS: I’m invested in writing histories that traverse perspectives and forms of experience. This approach was particularly important in capturing the wider significance of the NHS. It is not just a health system – depending on whom you ask, it is an ideal, a reflection of British values, an employer, or something to avoid. One of the driving questions of Our NHS is: Why did a state-oriented medical system become so central to how Britons understood national identity? Today, people regularly tell pollsters that the service is the thing that makes them “most proud to be British.” This outcome was not inevitable; it derived from an active, historical process led by the service’s supporters. The celebrations of the NHS’s “birthday” on July 5, for instance, became a popular tradition in the 1980s because of trade unions. Responding to the marketization policies of Margaret Thatcher’s governments, the labor movement organized family-friendly events with hot air balloons, bands, and beer tents to celebrate the NHS and highlight threats to its future existence. By the millennium, Labour governments scaled up these events to the national level, all in the name of “our NHS.”
AA: Can you explain how you see “welfare nationalism” and “communalism” intertwining and coming into conflict throughout the NHS’s history? How do the end of the British empire, immigration trends, and Brexit feature in your timeline?
AS: The NHS’s left-wing supporters initially conceived of the service as, in the words of one doctor, a model for “all other nations.” This ambition dimmed as few other countries emulated the NHS (although many overseas campaigners took inspiration from it) and as it became the object of sustained critique from foreign conservatives, especially those based in the United States. By the 1970s, the NHS’s British supporters retreated to a more defensive stance and spoke of the institution as a “unique” British achievement. This “welfare nationalism,” as I call it, spilled out into the public realm and provided the NHS with resilience.
As Jennifer Mittlestadt’s work on the “military welfare state” reminds us, investing nationalist values into social assistance programs can enable some initiatives to get off the ground while others flounder. The welfare nationalism around the NHS, though, carried costs, and it could be weaponized against patients and staff from overseas. I show this dynamic in the book by exploring popular engagement with the anti-immigration Conservative politician Enoch Powell during the 1960s and ‘70s and, later, the 2016 Brexit vote. And so I explore the double meaning of “our NHS,” interrogating who gets to claim that sense of ownership, and who does not.
AA: The US health care system (or lack thereof) makes more than a cameo appearance in your narrative. Can you explain how the US served as a negative example for pro-NHS voices in the UK? And, conversely, how have US activists looked to the NHS for inspiration or support?
AS: Many Americans visited the UK to study the NHS as part of their support for, or opposition to, greater health coverage back home. This engagement drew on earlier links between welfare reformers, as documented in Atlantic Crossings (1998) by Daniel Rodgers. Once aspirations of national health insurance faltered in the US and the insurance model became entrenched through Medicare/Medicaid in the 1960s, the British Left found it much more useful to paint the American way of health as the antithesis of the NHS. In the 1980s, Britons began to comment more regularly on the inequity of US health care. The political Right often expressed frustration that their own proposals – especially around supporting private health insurance – became linked with US practices. Today, Britons still tend to think of the US when they reflect on other medical systems, rather than, say, France. That specific comparison has both a history and lasting consequences.
AA: You mention that, at the turn of the 21st century, the NHS was one of the world’s largest employers, in league with the Chinese People’s Liberation Army and McDonalds. It seems that the making of “our NHS” has also been a labor struggle, both for those employed in its ranks, and for those workers who with the NHS gain an independence not afforded to, for example, the legions of US workers whose healthcare is tied to employment.
AS: The NHS remains one of the world’s largest employers in company with an eclectic range of organizations. Accordingly, nearly everyone in the UK will know someone who has worked for the service. My own mother was a cleaner in the NHS before she retired. Like any health system, the conditions or work and pay are highly stratified across the workforce – with consultants at the top and “ancillary staff” like cleaners or porters at the bottom. As a result, the NHS has long featured in critical studies of what it means to work for the state.
In the 1970s, the NHS began to see mass industrial action for the first time. Ancillary staff went on strike for higher pay in 1972. By the 1980s, neoliberal think tanks like the Adam Smith Institute suggested that outsourcing their work to the private sector would save money and also prevent strikes. The Thatcher government agreed and promoted outsourcing through administrative changes. As Quinn Slobodian has shown, neoliberalism expands markets and protects them from external influence – in this case, largely for the benefit of private companies involved in contract cleaning or catering. Today, most work is still undertaken by the NHS’s own employees, showing the limits of outsourcing. But I did want to highlight how these policies harm workers in specific areas like cleaning, driving down conditions and pay within a public institution.
AA: If the NHS has been the result of a unique, perhaps unrepeatable historical process, does its story contain any lessons for movements to realize democracy anew, in a postneoliberal context? In other words, which aspects of the NHS project are replicable today, and what should be avoided?
AS: There are aspects of the NHS’s history that one would not want to replicate. The service was often justified through patriarchal assumptions about women’s roles as caregivers and mothers. Similarly, there is a long history of women’s pain being ignored or trivialized. And there are various medical scandals, many of which resulted from a lack of a patient voice within the NHS’s structures. That being said, these issues are far from unique to Britain and it is important to also recognize how the service has long been admired for its commitment to delivering universal health care through a public system.
Promoting the NHS in cultural terms can be a model, especially in how these efforts challenged critical interpretations of “state medicine” among the public. I was excited to see Our NHS discussed by Adam Gaffney, David Himmelstein, and Steffie Woolhander in their recent NYRB piece on the future of US health care. As proponents of a national health program, they are drawn to the communication efforts of NHS supporters as well as the British service’s example of a planned, publicly-financed and -owned health system that avoids runaway costs. For those invested in a future for social-democratic politics, then, the past provides examples of what to avoid as well as what could still be done.
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Andrew Seaton is a historian of modern Britain who writes about politics, social history, medicine, and the environment. He is currently a Leverhulme Early Career Fellow at University College London (UCL). Andrew's first book, Our NHS: A History of Britain's Best-Loved Institution, was published by Yale University Press in 2023, and it was supported by an HPE research grant. Our NHS won the American Historical Association's Morris D. Forkosch Prize and was shortlisted for the Wolfson History Prize, the UK's leading historical award. Andrew is currently researching a new book, provisionally titled The Ends of Coal.
Andrew Anastasi is the Postdoctoral Fellow of the History & Political Economy Project. His current book project is The Other Anti-War Movement: The New Left in and against the War on Poverty (under contract, University of Minnesota Press). Andrew holds a PhD in sociology from The Graduate Center, City University of New York, and has been a visiting professor at Barnard College.