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It's a wonderful NHS? A counterfactual perspective on the creation of the British National Health Service

It's a wonderful NHS? A counterfactual perspective on the creation of the British National Health... INTRODUCTIONThis paper explores a major critical juncture and counterfactual in the creation of the NHS. Counterfactuals have featured in many books and film (e.g., the title is drawn from the 1946 Frank Capra film ‘It's a Wonderful Life’). Counterfactual history has a long history (e.g., Ferguson, 1998; Evans, 2013; Black, 2015). Tetlock and Belkin (1996: 3) opened their book by stating that ‘there is nothing new about counterfactual inference. Historians have been doing it for over two thousand years’. Historians who have made forays into counterfactual history include Edward Gibbon, and G.M. Trevelyan (in 1907) (in Ferguson, 1998). However, a number of eminent historians over the years have dismissed it. For example, A. J. P. Taylor stated that ‘a historian should never deal in speculations about what did not happen’, while according to M. M. Postan, ‘The might‐have‐beens of history are not a profitable subject of discussion’ (in Fearon, 1991). Michael Oakeshott argued that counterfactual history ‘is not merely bad or doubtful history, but the complete rejection of history … a monstrous incursion of science into the world of history’ (in Levy, 2015). More bluntly, opponents have regarded it as a ‘parlour game’ or ‘red herring’ (Raymond Carr) or ‘mere … unhistorical shit’ (E. P. Thompson) (in Ferguson, 1998; see also Evans, 2013; Black, 2015). The most recent major critique is from Evans (2013) who like Antony in Shakespeare's Julius Caesar, came not to praise counterfactual history but to bury it (Rosenfeld, 2014). However, Evans (2013) has himself been critiqued (e.g., Rosenfeld, 2014; Sunstein, 2016, below). Counterfactual analysis has appeared in many academic disciplines (e.g., Black, 2015; Fearon, 1991; Sunstein, 2016). While counterfactual analysis has been argued to be a vital element in many academic disciplines, it appears to be little explored in social policy and health policy (but see Emmenegger, 2011).This article examines the debate on counterfactual history, and discusses criteria for ‘good counterfactuals’, before focusing on the highly cited criteria of Tetlock and Belkin (1996). We then discuss the development of health services in the road to the NHS before considering a range of candidate critical junctures in the creation of the NHS in the period in the years immediately preceding the NHS (Table 1). Our chosen critical juncture is the decision in the Labour Cabinet between the local and national path, as it seems both decisive and the closest to the Tetlock and Belkin (1996) criteria of good counterfactuals (Table 2). This is followed by exploring our chosen counterfactual of ‘Morrison's NHS’, with a number of possible ‘forks in the road’ for a NHS based on local government, which illustrates some of the arguments for a national or local health service (cf Powell, 1998).1TABLECritical junctures in the creation of the NHS.SourcePathCritical juncture?Second world warSpeeded up planningHitler and the Ministry of Health between them had accomplished in a few months what might have taken the British Hospitals Association twenty years to bring about (Webster, 1988: 22);Political and Economic Planning (PEP) (1941, p 3) ‘the bombing plane … has forced on us a transformation of our medical services’ (in Powell, 2011).Emergency hospital service/Emergency medical serviceNational planningEMS was ‘crucial’ for providing a model and for making the voluntary hospitals dependent on government funding (Addison, 1975);EMS marked ‘a secular shift towards a nationally planned and rationalised health service’ (Webster, 1988: 22).Hansard (1941)National hospital serviceCommitment to comprehensive National Hospital ServiceBeveridge report (1942)Comprehensive NHSBeveridge report as ‘the Steamroller Effect’ (Earwicker, 1982)Assumption B was a commitment that it would be very difficult for any administration not to honour (Webster, 1988: 35)Willink Ministry of Health (1944)PrinciplesTwo principles of a comprehensive and free NHS were to remain the foundation of Labour's 1946 Act (Klein, 2013: 7–8)Labour victory in 1945 general electionLabour policy on NHSLabour party had most radical proposals on health care (Webster, 1988: 24).Bevan appointed as minister of healthNationalisation of hospitalsAttlee pencilled in Bevan at education with Ellen Wilkinson at health, before changing his mind and swapping them (Thomas‐Symonds, 2014); ‘Founder of the NHS’; the ‘architect’; his creation’ with NHS ‘synonymous with Bevan’ (Rintala, 2003)Bevan versus Morrison cabinet debateNationalisation of hospitals‘the key clash’ (Thomas‐Symonds, 2014); ‘a classical confrontation’ (Harold Wilson, in Rintala, 2003: 30)Bevan's ‘biggest battle – the most crucial in the whole fight for the Health Service, even though it was fought behind closed doors‐ occurred in the Cabinet’. (Foot, 1975: 132)Nationalisation of all hospitals may have been the most decisive governmental action regarding hospitals ever taken in a Western nation (Rintala, 2003: 49)Bevan NHS Act (1946)Comprehensive NHSTwo critical junctures in British Health policy: NHI and the creation of the NHS Hacker (1998: 87)Bevan versus the doctorsMedical veto?Doctors disliked nationalisation less than municipalisation (e.g., Pater, 1981: 109; Klein, 2013: 5–6)Appointed day (1948)Comprehensive NHSTwo critical junctures in British Health policy: NHI and the creation of the NHS (Hacker, 1998: 87)2TABLECounterfactual criteria for cabinet decision.CriteriaClarityClear condition is that Attlee sums up in favour of MorrisonLogical consistencyCabinet decision leads to Minister of Health developing plans, which are then passed by ParliamentEnabling counterfactuals should not undercut the antecedentThere is no obvious enabling counterfactualHistorical consistency (Minimum rewrite)Minimum‐ rewrite summing up in favour of Morrison, which was more in line with party policy, and more expected in period before 1945Theoretical consistencyWhile there are no relevant theories, the counterfactual is plausible, and in line with Labour party policy and Ministry of Health expectationsAvoid the conjunction fallacyThere do not seem to be any compound counterfactuals or multiple counterfactual stepsRecognise the interconnectedness of causes and outcomesWhile surgical counterfactuals may be unrealistic as causes are interdependent and have important interaction effects, this seems to be reasonably ‘surgical’ in that there appear to be few interaction effectsConsider second‐order counterfactualsThere is a possibility that subsequent developments will return history to the course from which it was initially diverted by the antecedent. It is possible that under our pessimistic scenario (below) a local government service would fail, and nationalisation may have been consideredCOUNTERFACTUALS AND CRITICAL JUNCTURESSome scholars have pointed to the necessity of counterfactual analysis. For example, Cowan and Foray (2002: 542) argued that counterfactual conditionals are ubiquitous in science. They can be, and are, used to express causal relations (see also Black, 2015; Capoccia & Kelemen, 2007; Emmenegger, 2011; Rosenfeld, 2014; Sunstein, 2016; Tetlock & Belkin, 1996). Similarly, Sunstein (2016: 440) claimed that ‘historical explanation is inevitably a form of counterfactual history’ (see also Black, 2015).Capoccia and Kelemen (2007) claimed that the role of counterfactual analysis is enhanced in the critical juncture framework. They identified contingency as the key element of critical junctures. During critical junctures change is substantially less constrained than it is during the phases of path dependence that precede and follow them. Only by taking counterfactual analysis seriously can contingency be studied (p. 368). In the context of the study of path‐dependent phenomena, they defined critical junctures as relatively short periods of time during which there is a substantially heightened probability that agents' choices will affect the outcome of interest (p. 348).Evans (2013) pointed out that there are several theoretical and reflective considerations of the problems counterfactual history, ranging from the ‘highly critical to the carefully justificatory’ (p. 12). He noted that counterfactuals come in many guises, with his particular targets appearing to be ‘exuberant’ or ‘long range’ counterfactuals, or those (like Ferguson, in his view, below) who break their own ‘sane and workable rules’ by taking ‘speculations too far up the stream of time, or by descending into a morass of politically motivated wishful thinking (p. 150).Sunstein (2016: 436) agreed with Evans (2013) on the problems of some forms of counterfactual analysis such as those which are hopelessly speculative, because they depend on wildly elaborate causal chains, those that suggest that some apparently trivial change may lead to large consequences (“the butterfly effect,”), especially those that require a large number of contingencies to come to fruition He noted that much of Evans's exasperation is reserved for these narratives. Sunstein continued that it is possible to dismiss counterfactual history when it is based on’ false historical claims, wildly elaborate causal chains, or all‐bets‐are‐off changes. But what if it is vulnerable to none of these objections? Evans does not give a satisfactory answer to this question’ (p. 437). Moreover, Sunstein (2016: 434) set out a ‘fundamental objection to his ultimate conclusion: For those who seek to venture historical explanations, including Evans himself, counterfactual history is inevitable, because any causal claim is an exercise of counterfactual history. Historians are pervasively counterfactualists.’ Rosenfeld (2014: 451) discussed Evans' ‘perceptive but flawed critique’, arguing that his overall critique can be summarised in three words: plausibility, politicisation, and popularity. However, in Rosenfeld's view, this was a partial one that neglects countervailing evidence (p. 453).WHAT MAKES A STRONG COUNTERFACTUAL ANALYSIS?A number of scholars have suggested criteria for counterfactuals. In what is sometimes considered as one of the first and best‐known counterfactual history texts, Ferguson (1998: 86) suggested that ‘we should consider as plausible or probable only those alternatives which we can show on the basis of contemporary evidence that contemporaries actually considered’. He insisted that we consider only those counterfactual scenarios that contemporary actors considered and committed to paper or some other form of record that is accepted by historians as a valid source. He continued that in order to understand how it actually was, we need to understand how it actually wasn't, but how, to contemporaries, it might have been. This is even more true when the actual outcome is one which no one expected – which was not actually thought about until it happened. That narrows down the scope for counterfactual analysis down considerably (p. 97). However, this has been criticised for being too narrow (e.g., Lebow, 2000; Mackay, 2007).The most comprehensive, and most cited, set of criteria are Tetlock and Belkin (1996). They set out six criteria for judging counterfactual arguments: clarity, logical consistency or contenability; historical consistency (‘minimum rewrite rule’); theoretical consistency; statistical consistency; and projectability (see below), but noted that they were subject to some interpretation, with some contributors to their edited book regarded them as ‘impossible’, ‘undesirable’ or ‘irrelevant’ (p. 17). This list was modified by writers such as Lebow (2000) and MacKay (2007). For example, Lebow (2000) modified the list of Tetlock and Belkin (1996) to set out eight criteria for plausible‐world counterfactuals, where numbers 1, 2, 4, and 5 are drawn from or are variants of the Tetlock‐Belkin list, number 6 was recently proposed by Tetlock, and numbers 3, 7 and 8 are his:Clarity. Good counterfactuals should also specify the conditions that would have to be present for the counterfactual to occur;Logical consistency or co‐tenability. Every counterfactual is a shorthand statement of a more complex argument that generally requires a set of connecting conditions or principles;Enabling counterfactuals should not undercut the antecedent. Counterfactuals may require other counterfactuals to make them possible;Historical consistency. Plausible counterfactuals should make as few historical changes as possible on the grounds that the more we disturb the values, goals and contexts in which actors operate, the less predictable their behaviour becomes;Theoretical consistency. It is useful to reference any theories, empirical findings, historical interpretations, or assumptions on which the causal principles or connecting arguments are based, thus allowing the plausibility of the counterfactual to be assessed;Avoid the conjunction fallacy (an error in judgement that occurs when people overestimate the likelihood of two events happening at the same time). The laws of statistics indicate that the probability of any compound counterfactual is exceedingly low.Surgical counterfactuals are unrealistic because causes are interdependent and have important interaction effects;Consider second‐order counterfactuals (subsequent or ‘follow up’ counterfactuals in the causal chain).Capoccia and Kelemen (2007) pointed out that the literature included a wide range of criteria for counterfactuals to be plausible, including clarity and logical consistency, the most important criterion was perhaps theoretical consistency. They cited Mahoney (2000) who explained that analysts should focus on ‘a counterfactual antecedent that was actually available during a critical juncture period, and that, according to theory, should have been adopted’. They continued that historical consistency (or the ‘minimal‐rewrite rule’) was also critical, suggesteding that legitimate counterfactuals include ‘only policy options that were available, considered, and narrowly defeated by relevant actors’ (cf Ferguson, above). This would rule out ‘miracle counterfactuals’ such as the one considered in an ‘alternative history’ by Niemietz (2023) who set out of a Commission set up by the Conservative‐Liberal Democrat government in 2010 which led to the replacement of the NHS by something similar to the Dutch system of ‘an almost completely privatised healthcare system’.Sunstein (2016) pointed out that Evans (2013) seemed to approve of two rules in particular: the “minimal rewrite” rule, which says that a chain of counterfactual consequences should not extend beyond a certain logical point; and the concept of ceteris paribus, which says that a counterfactual must only make one change in the causal chain and leave everything else the same as it was in reality (p. 453). Summing up Tetlock and Belkin (1996), Sunstein (2016) argues that they stressed the importance of well‐specified antecedents and consequents, of logical consistency among connecting principles, of avoiding preposterous claims about causality, and of maintaining consistency with well‐established historical facts (p. 438).In a rare study of social policy, Emmenegger (2011) drew on literature from other disciplines to develop (best‐case) criteria for good counterfactuals which does not include the limitation of needing to have been under active consideration by actors of the time, but is largely consistent with their other recommendations. Black (2015: 188) stated that it is not clear how to structure in detail a journey down the American poet Robert Frost. “The Road Not Taken.” However, we will draw on (below) Lebow's (2000) modified list of Tetlock and Belkin (1996).METHODPowell (2011) argued that it is important to examine decisions that were not made, or roads that were not taken. He pointed out that some writers have suggested counterfactuals. Honigsbaum (1989: 217) suggested that there might have been a very different outcome if Horder had become Royal College of Physicians President rather than Moran. The onset of war probably made some kind of health service inevitable. For Campbell (1987), the historian's problem is to identify and try to evaluate Bevan's distinctive contribution to the NHS. In what precise ways might it have been different had the Tories won the 1945 general election? Or if another Labour minister had been responsible for introducing it?We follow the advice of Capoccia and Kelemen (2007: 355) for the analysis of critical junctures: to ‘reconstruct the context of the critical juncture and, through the study of historical sources, establish who were key decision‐makers, what choices were historically available and not simply hypothetically possible, how close actors came to selecting an alternative option, and what likely consequences the choice of an alternative option would have had for the institutional outcome of interest.’The approach taken in this paper draws on Tetlock and Belkin (1996)'s list of criteria as modified by Lebow (2000) (above). First, we present an account of the main events leading up to the election of the Labour government in 1945. This allows us to set the scene, as well as to identify significant moments of change in the period leading up to the creation of the NHS. We then make a choice of which juncture we ‘branch’ out from, justifying that choice in terms of these criteria. We then work forward from that juncture (the Cabinet Debate between Bevan and Morrison) identifying the most likely immediate implication of that debate going differently – an NHS organised through local government. We limit the time period under consideration to avoid the criticisms of ‘long‐range’ counterfactual analysis. Our conclusion than considers the potential benefits of counterfactual analysis for social policy research.THE PATH TO THE NHSIt is challenging to find a starting point for the NHS as we know it today. The beginning of the long road towards the NHS has been located in very different places including the voluntary hospitals, the County Asylums Act 1808, the New Poor Law of 1834, and the first Public Health Act of 1848, and the National Health Insurance (NHI) Act of 1911 (e.g., Webster, 1988).Some of these may relate to critical junctures, but we set out the two clearest rival paths, and then focus on the immediate period before the NHS (for more details, see e.g., Earwicker, 1982; Webster, 1988; Powell, 1997; Fraser, 2003; Klein, 2013). First, the National Insurance Act of 1911 introduced contributory insurance that provided (usually male) ‘breadwinners’ with ‘sick pay’ and access to a ‘panel doctor’ (GP) (e.g., Fraser, 2003). Second, there was a clear trend to place public health services with the major local authorities. Perhaps the clearest indication of this was the Local Government Act 1929 that passed administration of the Poor Laws to the major local authorities, allowing them to ‘appropriate’ facilities so that they would be administered by the local authority's ‘public health’ rather than its ‘public assistance’ committee. Although this might sound like a minor symbolic change, it allowed the local Medical Officer of Health to supervise and improve. The intention was to develop municipal medicine, taking facilities away from the stigma of the Poor Laws (Levene et al., 2011).It can be argued that a major ‘critical juncture’ was the formation of the Ministry of Health in 1919, which briefly offered ‘ambitious plans for the development of a comprehensive and unified health service’ (Webster, 1988: 19). However, the ‘Interim’ Report of the Consultative Council on Medical and Allied Service’ (the ‘Dawson Report, after its Chair Lord Dawson) was never followed by a ‘final’ report, with Dawson's plans ‘consigned to the world of medical utopias' (Webster, 1988: 19).As we focus below on the creation of the NHS by the 1945 Labour government, it is also necessary to briefly discuss evolving Labour party policy on health care. The Labour Party set out its views on health care over a long period of time, although there was no significant legislative action during Labour's brief periods in office in 1924 and 1929–31. The year 1931 saw the creation of the ‘Socialist Medical Association’ which saw itself as intending to shape Labour policy. According to Marwick (1967: 399), the 1943 document ‘National Service for Health’ ‘was the first policy statement to appreciate fully the dependence of social policy upon efficient local government, and instead of basing its proposed health service on existing local authorities, as all previous Labour schemes had suggested, it postulated a scheme based on regional authorities.’ Earwicker (1982) provided a rather different account, arguing that the party's belief in the fundamental principle of a universal, comprehensive and free service was first established in 1919. According to Labour's policy statement on Curative and Preventive Services in 1919, the development of a municipal medical service provided the most suitable vehicle for attaining a national health service that was universal, comprehensive, free and democratically accountable to local citizens. Earwicker (1982) argued that the party's 1934 statement, ‘For Socialism and Peace’ was much the most radical it has ever adopted and was the first time that a clear preference for a municipal medical service had been endorsed by party conference. Earwicker (1982) claimed that the 1943 document (above) repeated the party's demand for a free, comprehensive universal service financed through rates and taxes, democratically controlled by a re‐organised system of local government which would run the health centres and co‐ordinate the dual hospital system.The fear of forthcoming war focused attention on health care, with the Emergency Hospital Service or Emergency Medical Service (Titmuss, 1950), created as a ‘temporary expedient’, marked ‘a secular shift towards a nationally planned and rationalised health service’ (Webster, 1988: 22). Ernest Brown, the Minister of Health in the wartime Coalition government made a statement in Parliament committing the Government to the creation of a comprehensive ‘National hospital service’ (Hansard, 1941). A duty was laid on the major local authorities to secure this in in close co‐operation with the voluntary agencies, but it would be necessary to design such a service by reference to areas substantially larger than those of individual local authorities. Brown reiterated the principle that in general patients should be called on to make a reasonable payment towards the cost whether through contributory schemes or otherwise.The Beveridge Report (1942) is often regarded as being a major step towards the NHS. The Report set out ‘Assumption B’ of ‘Comprehensive health and rehabilitation services’ (p. 158), which would be free and universal, rather than based on insurance contributions (e.g., p, 159). The Ministry of Health slowly developed from a ‘national hospital plan’ (above) towards a ‘National Health Service’. After Henry Willink had replaced Ernest Brown as Minister of Health, the Ministry published a White Paper ‘A National Health Service’ in 1944 that attempted to integrate voluntary and municipal hospitals through Joint Boards. It appears as if the Beveridge Report forced the government's hand in pushing towards a free service, but earlier radicalism on issues such as salaried GPs had been diluted in consultation with the medical profession.The 1945 General Election led to the first ever majority Labour government, with Aneurin Bevan appointed as Minister of Health. As Earwicker (1982: 302–3) noted, it was no simple process to translate Labour's ideas on health policy into legislation. While the ambition of a universal, comprehensive and free National Health Service was generally agreed within the Labour movement, the means to achieve this aim was the subject of controversy.Bevan quickly rejected much of Willink's White Paper, but also departed from Labour's traditional stress on local authorities, with his most important structural decision being to create a national hospital service based on appointed hospital authorities termed ‘Hospital Management Committees’ (below). This led to a debate in Cabinet between Bevan and Herbert Morrison, who argued in favour of local authorities (below).The Health Service Bill, published on 21st March 1946, went further than the 1944 White Paper in providing for a universal, comprehensive and free service. There were to be no limitations to NHS services based on ‘financial means, age, sex, employment or vocation, area of residence or insurance qualification’. The NHS Act established a ‘comprehensive health service to secure the improvement in the physical and mental health of the people and the prevention, diagnosis and treatment of illness’. This was the basis for the creation of the NHS on the ‘Appointed Day’ of 5 July 1948.However, Bevan had to engage in discussion with stakeholders, such as the medical profession (Thomas‐Symonds, 2014). The result of the first BMA in February 1947 saw 40,814 disapproving of the act, with only 4735 approving. Discussions continued, but the two parties still seemed wide apart. A BMA Meeting in January 1948 expressed its complete lack of confidence in, and mistrust of, the Minister of Health. The result of the second plebiscite was announced in May 1948, with the overall vote against the NHS of 25,842 compared to 14,620 in favour.CRITICAL JUNCTURES IN THE CREATION OF THE NHSIt is possible to identify a range of candidate critical junctures in the immediate period leading to the creation of the NHS which have been hypothesized in existing research (Table 1).Table 1 represents a rich source of potential counterfactuals in exploring the NHS, with some brief supporting vignettes of evidence. Lebow (2000: 574) stated that ‘there is no consensus about what constitutes a good counterfactual, but there is a common recognition that it is extraordinarily difficult to construct a robust counterfactual‐one whose antecedent we can assert with confidence could have led to the hypothesized consequent.’ He went on to argue that ‘criteria that tie counterfactuals to established laws and statistical generalisations and attempt to limit second‐order counterfactuals are superficially appealing. In practice, they are generally unworkable or would rule out some of the most important uses of counterfactual experimentation (p. 577).’ He noted that some scholars favour counterfactuals that are derived deductively from good theories. However, while ‘this may be possible in a data‐rich and reductionist field like cognitive psychology … it is hardly a realistic standard for counterfactuals in history and most of the social sciences.’ He summed up that ‘the clarity, completeness, and logical consistency of the arguments linking antecedent to consequents are more important than their external validity (p. 581), and then produced his list (above, and Table 2).We have rejected some possible counterfactuals that seem to be clearly in breach of the ‘minimum rewrite rule’ such as no Second World War and Labour not winning the 1945 Election. Others appear more plausible such as Wilkinson being appointed Minister of Health. However, we have chosen the possibility that in Cabinet Attlee summed up in favour of Morrison rather than Bevan, as this seems to fit the counterfactual criteria (above) reasonably well (Table 2).Some of these criteria appear easier to apply or seem more relevant, with the first four criteria being fairly relevant and applicable. In addition, our chosen counterfactual fits the more demanding criteria of being available, considered, and (arguably) narrowly defeated (e.g., Ferguson, 1998; Mahoney, 2000; Capoccia & Kelemen, 2007).CRITICAL JUNCTURE: CABINET DEBATEThe Cabinet debate between Bevan and Morrison has been examined by a number of accounts (e.g., Pater, 1981, Webster, 1988, 1990; Honigsbaum, 1989, Powell, 1997, 2011, Klein, 2013; Thomas‐Symonds, 2014) in the period after the archival material became available, with Pater (1981) claiming to be the first account based on this material (see Powell, 2011).Webster (1988: 84) discussed ‘internal dissension’. He pointed out that while most aspects of Bevan's scheme were accepted without difficulty, agreement to nationalisation of the hospitals was secured only after much dispute. First, Bevan had to convince the civil service, which pointed out that his plan discarded the White Paper which was ‘practically ready’ and would be harmful to local government. Then, discussion moved into the political realm. The main documents are Bevan's Memorandum of 5 October 1945 (TNA, 1945a), the Cabinet Meeting on 11 October (TNA, 1945b), Morrison's memorandum criticising Bevan's plan of 12 October (TNA, 1945c), Bevan's response on 16 October (TNA, 1945d), and a subsequent Cabinet Meeting on 18 October 1945 (TNA, 1945e). Bevan presented a Memorandum on ‘The Future of the Hospital Services’ on 5 October 1945 (TNA, 1945a), asking for ‘a decision on one big question of principle’. He explained that he wished for ‘the complete taking over—into one national service—of both voluntary and municipal hospitals’ with national responsibility based in the Ministry. He noted that the contracting arrangement in the 1944 White Paper would mean that public funds would certainly amount to 70 per cent or more of the income of voluntary hospitals. Following the principle of public control following public money meant ‘taking over either by some form of local government machinery, or by the central government’, but he would strongly deprecate the former’ (paragraph 7). He admitted that while ‘a few local authorities run a good hospital system. The great majority are not suited to run a hospital service at all under modern conditions' with most areas being too small (paragraph 8). This meant that: ‘The right course, I am sure, is to nationalise the hospital services entirely and to take them out of the field of local government altogether’ (paragraph 12). This would achieve ‘as nearly as possible a uniform standard of service for all’ (paragraph 12).The Cabinet discussed this Memorandum on the 11th October (TNA, 1945b). Bevan admitted that his proposals would ‘undoubtedly excite strong opposition by the voluntary hospitals and the local authorities.’ However, the great majority of the doctors would prefer central to local control. (paragraph 6). Bevan's proposals were broadly supported, and it was agreed to return to resume discussion of the proposals at the Cabinet Meeting on the 16th October. Morrison did not express a view at the Cabinet Meeting, but the following day presented his Memorandum (TNA, 1945c).Morrison wrote that he ‘read with admiration’ what he thought was ‘the brilliant and imaginative paper of the Minister of Health.’ He was ‘attracted by the order and simplicity of the solution which he offered for a complex and difficult administrative problem’ but then ‘began to have doubts about some of its wider implications’ (paragraph 1). He presented the precedent of the police service. Like previous Home Secretaries, he rejected the case for a nationalised police force on the grounds of over‐concentration of power at the centre and weakening local authorities. He warned about weakening local government and considered that local government had done well in hospital administration since the Local Government Act 1929 (paragraph 3). He argued that ‘if we wish local government to thrive—as a school of political and democratic education as well as a method of administration—we must consider the general effect on local government of each particular proposal’ (paragraph 4). He admitted that he disliked joint authorities thoroughly, but considered that ‘they provide the best way out of an admittedly difficult administrative problem’ (paragraph 7).Bevan's response (TNA, 1945d). noted that Morrison did not ‘dispute seriously my contention that the way to make these services efficient is to centralise responsibility for them.’ He was convinced that the broader consequences for local government could be overcome. At the Cabinet Meeting on 18th October, (TNA, 1945e) Morrison replied by stating that while he ‘fully appreciated the attractions of a logical and clean‐cut scheme’ of Bevan, the ‘detrimental effect which the loss of hospital functions would have on local government in general, did not outweigh the arguments based on grounds of administrative convenience and technical efficiency’ (paragraph 1). Bevan responded that he had considered very carefully the points made by Morrison, but still felt that the only way to make the hospital services efficient was to centralise responsibility for them.Prime Minister, Attlee summed up that ‘the differences between the proposals made by the Minister of Health and the alternative scheme suggested by the Lord President of the Council were possibly less fundamental than they seemed to be.’ He continued that ‘while approving this proposal in principle, however, the Cabinet would want to look at the details again when they were more fully worked out.’ However, ‘the Cabinet endorsed the course of action proposed by the Prime Minister’ (paragraph 1). This approval ‘in principle’ appeared to set out the path in favour of Bevan rather than Morrison, with little obvious discussions of the ‘details’ at the Cabinet Meeting of 13 December (TNA, 1945f).As noted above, Capoccia and Kelemen (2007: 355) suggested that it is important to reconstruct the context of the critical juncture, establish who were key decision‐makers, what choices were historically available, how close actors came to selecting an alternative option, and what likely consequences the choice of an alternative option would have had for the institutional outcome of interest.We have set out the context above. The key protagonists were Bevan and Morrison, with Attlee the key decision maker within the Cabinet. The key choice was whether to base the hospitals on central or local government. In the period before 1945 the most likely choice was that the NHS would be based on local government, with the Labour Party and much of the Ministry of Health supporting this option. However, Bevan was able to engineer a major change in policy. As we shall see below, views vary on how close the local government option was to being taken.There is little doubt that the decision to nationalise the hospitals was a major ‘fork in the road’. As Earwicker (1982: 314) pointed out, ‘at a stroke, Bevan intended to deprive the municipalities of the central place they had occupied in successive Labour plans since 1919, contravening the letter and spirit of every Labour party policy document on health.’ Similarly, according to Brooke (1992: 337–8), in nationalising the hospitals, ‘Bevan stood Labour policy on its head’. The importance of localism to the Socialist Medical Association (SMA) and to the Labour Party was stressed by contemporaries. The Labour party conference 1945 stated that no scheme that did not give local authority control was acceptable (all in Powell, 1997: 45). However, perhaps the municipal option was viewed too optimistically as Morrison and many SMA members based their case on London, which had made significant progress by the London County Council and had broadly good voluntary provision, and a number of elite Teaching Hospitals (e.g., Levene et al., 2011; Stewart, 1997), which was not typical of the rest of the country.Interpretations appear to vary as to how close the verdict was. Some scholars seem to regard Bevan's victory as very clear. On the one hand, Earwicker (1982) considered that the gladiatorial tone of this Cabinet debate is misleading for the most striking thing about the encounters between Bevan and Morrison is the weakness of Morrison's opposition. While it is likely that most ministers would have preferred a municipal solution, they also recognised that Bevan's solution was the only viable scheme in the circumstances due to opposition from medical interest groups. Similarly, Thomas‐Symonds (2014) viewed Bevan's victory over Morrison as ‘quick and decisive’. He continued that Morrison's arguments were inconsistent, as while arguing passionately for his proposals he sought to persuade the Cabinet that his alternative scheme was not much different from Bevan's, and that Morrison had taken a scattergun approach (p. 135). Members of the Cabinet lined up behind Bevan. Attlee intervened decisively, seizing on the weaker part of Morrison's argument that, in reality, there was little difference between the two schemes (p. 136).On the other hand, Pater (1981: 109) regarded the Cabinet reception to Bevan's 11 October proposals were ‘mixed’. He continued that in Cabinet on 18 October, opinion was still divided, but seemed generally in Bevan's favour (p. 111). Finally, ‘the welcome given by the Cabinet to these proposals on 20 December was ‘less than enthusiastic’. (p. 115).Rintala (2003) argued that, besides Morrison, Bevan's most serious potential problem in the Cabinet was Ernest Bevin. The Foreign Secretary had not forgotten Bevan's wartime criticisms (p. 41). (However, Bevin was not present at these crucial Cabinet Meetings). Rintala continued that Bevan was probably without a friend in the Cabinet, but he did have at least two principled supporters, neither among the most powerful of his colleagues, on his NHS plans: Minister of Education Ellen Wilkinson, and Christopher, now Lord, Addison, who had given Lloyd George crucial assistance with the National Insurance Bill of 1911. Rintala described Bevan as ‘pragmatic’. ‘In nationalizing municipal hospitals, Bevan was not acting as a loyal partisan … Fidelity to party meant much to Morrison, and little to Bevan’ (p. 49).COUNTERFACTUAL: MORRISON'S NHSThere are many possible different ‘forks in the road’ in considering counterfactual possibilities for a NHS based on local government as championed by Morrison. On the one hand, one set of optimistic forks leads to a successful NHS, similar to the locally based service in the Nordic nations. For example, Byrkjeflot and Neby (2008) state that the Scandinavian hospital sectors are usually described as variants of the NHS in the UK, but are typically classified as decentralised compared with the centralised UK system. They set out three periods: the making of the decentralised model (before 1970); the heyday of the decentralised model (1970‐early 2000s); and challenging the decentralised model (after 2000). Verdicts vary on the success of the model. For example, Dougherty et al. (2019) examined the relationship between the degree of administrative decentralisation across levels of government in health care decision‐making and health care spending, hospital costs and life expectancy. They found a statistically significant effect of ‘administrative decentralisation’ on health expenditure and life expectancy. A ‘moderate’ degree of decentralisation reduced public health spending and increased life expectancy compared to very low decentralisation, but ‘excessive decentralisation’ was associated with higher public spending on health and lower life expectancy compared to an intermediate degree of decentralisation. Martinussen and Rydland (2021) stated that decentralisation has a positive and significant association with health system satisfaction, but not with self‐rated health. They concluded that their study fails to provide clear support for decentralised health systems.On the other hand, there are some possible pessimistic forks which lead in the worst case scenario of no NHS. First, most accounts point to Bevan's successful negotiations with the medical profession. However, if Bevan had resigned in October 1945 after the defeat of his proposals (he did resign from the Cabinet in 1951 when Minister of Labour), it is possible that the new Minister of Health would have not been able to persuade the doctors to serve in the NHS, with medical interest groups essentially providing a veto. Second, if Bevan had continued to be Minister of Health, it would have been much more difficult to persuade hospital doctors to serve in a NHS based on local government. As Bevan pointed out in Cabinet, hospital doctors feared municipalisation much more than nationalisation. It is possible that even Bevan's negotiating skills may not have been successful. In addition, Bevan's preliminary discussions with the medical elite (e.g., Foot, 1975) would have probably signalled his nationalisation plans, and so later stating that the plan was for municipalization would have added an additional major hurdle.However, our ‘most likely’ counterfactual scenario is that Bevan was able to persuade the doctors to serve in a local government NHS. We assume that the actual ‘Tri‐partite’ system (hospitals, Executive Councils, local government) would have become a ‘Bi‐partite’ system (local government, Executive Councils). General Practitioners voted against Bevan's NHS in the two BMA Plebiscites (above), but as Bevan expected, they were forced to sign up for NHS patients as they feared that they would not be able to survive on any remaining private patients. The elite Teaching Hospitals were given a significant measure of independence outside the main Hospital Management Committee (HMC) structure, and it is likely that this would have been similar in Morrison's NHS. This leaves the doctors at hospitals other than Teaching Hospitals. It is clear that most hospital doctors would have preferred nationalisation to municipalization. It is likely that when voluntary hospitals were municipalized, the traditional ‘firm’ approach (ie teams) to organising doctors would have changed to the traditional ‘hierarchical’ (Medical Superintendent) approach of municipal hospitals. This would have represented an additional major hurdle, but perhaps Bevan may have needed to ‘stuff their mouths’ with even more gold.It is likely that Morrison's NHS would have received a similar large majority in the NHS Debates in Parliament. First, it was closer to Labour party policy. Second, it is even possible that more Conservatives may have voted in favour, as one of the Conservatives' stated objection to Bevan's NHS was its negative impact on local democracy and local government.Morrison's NHS would have probably left hospitals in the hands of their existing owners (voluntary and municipal) under local government and joint boards, with some form of contracting for the services of voluntary hospitals. As many voluntary hospitals had significant financial problems, under the principle of control following public money, this would probably have led to a process of ‘creeping municipalization’ or in the words of Chancellor Hugh Dalton ‘to proceed by stages, spread over years, and not by one bold stroke’ (in Foot, 1975: 133).As Bevan argued in Cabinet, it is likely that any local government system would be more uneven, and would find it difficult to ‘universalise the best’ (see also Bevan, 1978). This would have been clear in three main dimensions. First, without strong equalising central grants, poorer local authorities would find it difficult to match hospital provision in the more wealthy local authorities. Second, even with a system of Joint Boards, there would have been significant problems for smaller local authorities to operate large hospitals with a full range of clinical facilities. Third, it would have been difficult for more rural areas without large centres of population to operate large hospitals (see e.g., Powell, 1997). The latest Labour Party document on health of 1943 had suggested that health care should be provided by reformed (probably more regional) local government (above). As Bevan (1978: 114–115) later wrote ‘election is a better principle than selection’ and that ‘a solution might be found if the reorganization of local government is sufficiently fundamental to allow the administration of the hospitals to be entrusted to the revised units of local government’.The Coalition government had issued a White Paper in 1945 titled ‘Local Government in England and Wales during the Period of Reconstruction’. While it admitted that that certain services need to be planned or administered over wider areas; and that the reconstruction programme would place an impossible burden on local government finance, it did not propose much in the way of fundamental reform (e.g., Robson, 2021). The Local Government Boundary Commission was appointed on 26 October 1945, and reported in 1947. It recommended the creation of 47 two‐tiered ‘new counties’, 21 one‐tiered ‘new counties’ and 63 ‘new county boroughs’, but led to little action. The Local Government Act 1958, established the Local Government Commission for England and the Local Government Commission for Wales to carry out reviews of existing local government structures and recommend reforms. This was replaced by a Royal Commission (known as the Redcliffe‐Maud commission), which in 1969 recommended a system of single‐tier unitary authorities for the whole of England, apart from three metropolitan areas. This was broadly accepted by the Labour Party government of the time, but the Conservative Party manifesto of 1970 committed them to a two‐tier structure. The Local Government Act of 1972 under the Conservatives established a uniform two‐tier system across the country. This detour into the history of local government (see e.g., Robson, 2021) suggests that the counterfactual of Morrison's NHS would probably have made it necessary to reform local government structure and finance earlier and more fundamentally.Perhaps the most important factor is that it is likely that local authorities would always be in a weaker financial position than national government (e.g., social care in recent years). While there was limited capital spending in the early austere years of Bevan's NHS, it is likely that local authorities would have been even more cash strapped (compare the problems of building new social housing in the years after 1945).All this suggests that while a NHS based on local government may have been possible, it is likely that it would be more ‘austere’ due to more limited funding, and more unequal due to the varying financial capacities of local government. On the other hand, it could be argued that the NHS may have been more integrated. Before the NHS, Medical Officers of Health argued that it was important for hospital and community services, and clinical and preventive services to be in the same hands (see e.g., Levine et al, 2011). This may be a valid theoretical argument, but in practice it is likely that the hospital dominance of Bevan's NHS would have also applied to Morrison's NHS.CONCLUSION—COUNTERFACTUAL HISTORY AND THE NHSBlack (2015: 2) claimed that a crucial value of counterfactualism is that it returns us to the particular setting of uncertainty in which decisions are actually confronted, made, and implemented. While Evans (2013) did not regard counterfactual thinking as ‘central’, he considered that ‘based on a minimal rewrite, and confined to the short run, a counterfactual can illuminate the choices that confronted individual politicians and statesmen, and the limitations that the historical context imposed on those choices (p. 150), and ‘it can be useful under certain strictly limited conditions and with strictly limited purposes' (p. 151).Counterfactual history reminds us that things could have turned out differently, pointing to the importance of contingency and to causal relations (compare e.g., Tetlock & Belkin, 1996; Cowan & Foray, 2002; Emmenegger, 2011; Black, 2015, Sunstein, 2016). It can also be a useful tool in revisiting debates, such as the national versus local welfare state debate (see e.g., Powell, 1998). Localist writers such as Robson (2021) criticised the Labour Party and Bevan for their treatment of local government, with localism regarded as an essential part of a welfare state. Throughout the NHS there has been a persistent trend of thought on returning health care to local government (see e.g., Powell, 1998). Taking health care from local authorities has been termed Labour's ‘great mistake’ by Blunkett and Jackson (1987: 64). As one of Bevan's biographers, Campbell (1987: l77) put it: ‘All the fundamental criticisms of the NHS can be traced back to the decision not to base services on local authorities … In retrospect the case for the local authorities can be made to look formidable, the decision to dispossess them a fateful mistake by a Minister ideologically disposed to centralisation and seduced by the claims of professional expertise.’Klein (2010) analysed ‘60 years of the eternal triangle’ of the conflict between the values of efficiency, equity and democracy. In his view, ‘the contrast between the reality of centralization and the rhetoric of devolution reflects tensions built into the very design of the NHS: tensions that derive from the fact that the design incorporated competing, possibly irreconcilable, goals' (p. 286). His starting point is the Cabinet debate in October 1945 ‘between the political midwives preparing for the birth of the NHS' with Bevan favouring equity and Morrison arguing for democracy. He then discussed another concept of democracy which did not feature explicitly in the Bevan–Morrison debate but which proved crucial in defining the centre–periphery relationship over subsequent decades. This was democracy defined as accountability to Parliament: hence Bevan's much quoted formulation: ‘when a bedpan is dropped on a hospital floor, its noise should resound in the corridors of the Palace of Westminster’ (see also Foot, 1975: 192–193). He argued that ‘the tension between the local and national concepts of democracy was to characterize the NHS throughout its existence.’ In short, for Bevan, territorial justice was deemed more important than local autonomy. The counterfactual of ‘the road not taken’ to ‘Morrison's National Health Service’ or perhaps ‘Local Health Service’ provides important insights into the debates surrounding national versus local welfare states.DATA AVAILABILITY STATEMENTThe data that support the findings of this study are available in TNA (various files).REFERENCESAddison, P. (1975). The road to 1945. Jonathan Cape.Bevan, A. (1978). In place of fear, first published 1952. Quartet Books.Beveridge, S. W. (1942). Social insurance and allied service, Cmnd 6404. HSMO.Black, J. (2015). Other pasts, different presents, alternative futures. Indiana University Press.Blunkett, D., & Jackson, K. (1987). Democracy in crisis. Hogarth Press.Brooke, S. (1992). Labour's war. Oxford University Press.Byrkjeflot, H., & Neby, S. (2008). The end of the decentralised model of healthcare governance? Comparing developments in the Scandinavian hospital sectors. Journal of Health Organization and Management, 22(4), 331–349.Campbell, J. (1987). Nye Bevan and the mirage of British socialism. Weidenfeld & Nicolson.Capoccia, G., & Kelemen, R. (2007). The study of critical junctures: Theory, narrative, and counterfactuals in historical institutionalism. World Politics, 59(3), 341–369.Cowan, R., & Foray, D. (2002). Evolutionary economics and the counterfactual threat: On the nature and role of counterfactual history as an empirical tool in economic. Journal of Evolutionary Economics, 12, 539–562.Dougherty, S., Lorenzoni, L., Marino, A., & Murtin, F. (2019). The impact of decentralisation on the performance of health care systems: A non‐linear relationship. In OECD Working Papers on Fiscal Federalism 27. OECD.Earwicker, R. (1982). 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(45) 43rd Conclusions.18th October 1945.TNA. (1945f). C P. (45) 339. Proposals for a National Health Service. Memorandum by the Minister of Health. 13th December, 1945.Webster, C. (1988). Problems of health care. In The National Health Service before 1957. Peacetime history. The health services since the war. Volume 1. HSMO.Webster, C. (1990). Conflict and consensus: Explaining the British health service. Twentieth Century British History, 1(2), 115–151. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Social Policy & Administration Wiley

It's a wonderful NHS? A counterfactual perspective on the creation of the British National Health Service

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Abstract

INTRODUCTIONThis paper explores a major critical juncture and counterfactual in the creation of the NHS. Counterfactuals have featured in many books and film (e.g., the title is drawn from the 1946 Frank Capra film ‘It's a Wonderful Life’). Counterfactual history has a long history (e.g., Ferguson, 1998; Evans, 2013; Black, 2015). Tetlock and Belkin (1996: 3) opened their book by stating that ‘there is nothing new about counterfactual inference. Historians have been doing it for over two thousand years’. Historians who have made forays into counterfactual history include Edward Gibbon, and G.M. Trevelyan (in 1907) (in Ferguson, 1998). However, a number of eminent historians over the years have dismissed it. For example, A. J. P. Taylor stated that ‘a historian should never deal in speculations about what did not happen’, while according to M. M. Postan, ‘The might‐have‐beens of history are not a profitable subject of discussion’ (in Fearon, 1991). Michael Oakeshott argued that counterfactual history ‘is not merely bad or doubtful history, but the complete rejection of history … a monstrous incursion of science into the world of history’ (in Levy, 2015). More bluntly, opponents have regarded it as a ‘parlour game’ or ‘red herring’ (Raymond Carr) or ‘mere … unhistorical shit’ (E. P. Thompson) (in Ferguson, 1998; see also Evans, 2013; Black, 2015). The most recent major critique is from Evans (2013) who like Antony in Shakespeare's Julius Caesar, came not to praise counterfactual history but to bury it (Rosenfeld, 2014). However, Evans (2013) has himself been critiqued (e.g., Rosenfeld, 2014; Sunstein, 2016, below). Counterfactual analysis has appeared in many academic disciplines (e.g., Black, 2015; Fearon, 1991; Sunstein, 2016). While counterfactual analysis has been argued to be a vital element in many academic disciplines, it appears to be little explored in social policy and health policy (but see Emmenegger, 2011).This article examines the debate on counterfactual history, and discusses criteria for ‘good counterfactuals’, before focusing on the highly cited criteria of Tetlock and Belkin (1996). We then discuss the development of health services in the road to the NHS before considering a range of candidate critical junctures in the creation of the NHS in the period in the years immediately preceding the NHS (Table 1). Our chosen critical juncture is the decision in the Labour Cabinet between the local and national path, as it seems both decisive and the closest to the Tetlock and Belkin (1996) criteria of good counterfactuals (Table 2). This is followed by exploring our chosen counterfactual of ‘Morrison's NHS’, with a number of possible ‘forks in the road’ for a NHS based on local government, which illustrates some of the arguments for a national or local health service (cf Powell, 1998).1TABLECritical junctures in the creation of the NHS.SourcePathCritical juncture?Second world warSpeeded up planningHitler and the Ministry of Health between them had accomplished in a few months what might have taken the British Hospitals Association twenty years to bring about (Webster, 1988: 22);Political and Economic Planning (PEP) (1941, p 3) ‘the bombing plane … has forced on us a transformation of our medical services’ (in Powell, 2011).Emergency hospital service/Emergency medical serviceNational planningEMS was ‘crucial’ for providing a model and for making the voluntary hospitals dependent on government funding (Addison, 1975);EMS marked ‘a secular shift towards a nationally planned and rationalised health service’ (Webster, 1988: 22).Hansard (1941)National hospital serviceCommitment to comprehensive National Hospital ServiceBeveridge report (1942)Comprehensive NHSBeveridge report as ‘the Steamroller Effect’ (Earwicker, 1982)Assumption B was a commitment that it would be very difficult for any administration not to honour (Webster, 1988: 35)Willink Ministry of Health (1944)PrinciplesTwo principles of a comprehensive and free NHS were to remain the foundation of Labour's 1946 Act (Klein, 2013: 7–8)Labour victory in 1945 general electionLabour policy on NHSLabour party had most radical proposals on health care (Webster, 1988: 24).Bevan appointed as minister of healthNationalisation of hospitalsAttlee pencilled in Bevan at education with Ellen Wilkinson at health, before changing his mind and swapping them (Thomas‐Symonds, 2014); ‘Founder of the NHS’; the ‘architect’; his creation’ with NHS ‘synonymous with Bevan’ (Rintala, 2003)Bevan versus Morrison cabinet debateNationalisation of hospitals‘the key clash’ (Thomas‐Symonds, 2014); ‘a classical confrontation’ (Harold Wilson, in Rintala, 2003: 30)Bevan's ‘biggest battle – the most crucial in the whole fight for the Health Service, even though it was fought behind closed doors‐ occurred in the Cabinet’. (Foot, 1975: 132)Nationalisation of all hospitals may have been the most decisive governmental action regarding hospitals ever taken in a Western nation (Rintala, 2003: 49)Bevan NHS Act (1946)Comprehensive NHSTwo critical junctures in British Health policy: NHI and the creation of the NHS Hacker (1998: 87)Bevan versus the doctorsMedical veto?Doctors disliked nationalisation less than municipalisation (e.g., Pater, 1981: 109; Klein, 2013: 5–6)Appointed day (1948)Comprehensive NHSTwo critical junctures in British Health policy: NHI and the creation of the NHS (Hacker, 1998: 87)2TABLECounterfactual criteria for cabinet decision.CriteriaClarityClear condition is that Attlee sums up in favour of MorrisonLogical consistencyCabinet decision leads to Minister of Health developing plans, which are then passed by ParliamentEnabling counterfactuals should not undercut the antecedentThere is no obvious enabling counterfactualHistorical consistency (Minimum rewrite)Minimum‐ rewrite summing up in favour of Morrison, which was more in line with party policy, and more expected in period before 1945Theoretical consistencyWhile there are no relevant theories, the counterfactual is plausible, and in line with Labour party policy and Ministry of Health expectationsAvoid the conjunction fallacyThere do not seem to be any compound counterfactuals or multiple counterfactual stepsRecognise the interconnectedness of causes and outcomesWhile surgical counterfactuals may be unrealistic as causes are interdependent and have important interaction effects, this seems to be reasonably ‘surgical’ in that there appear to be few interaction effectsConsider second‐order counterfactualsThere is a possibility that subsequent developments will return history to the course from which it was initially diverted by the antecedent. It is possible that under our pessimistic scenario (below) a local government service would fail, and nationalisation may have been consideredCOUNTERFACTUALS AND CRITICAL JUNCTURESSome scholars have pointed to the necessity of counterfactual analysis. For example, Cowan and Foray (2002: 542) argued that counterfactual conditionals are ubiquitous in science. They can be, and are, used to express causal relations (see also Black, 2015; Capoccia & Kelemen, 2007; Emmenegger, 2011; Rosenfeld, 2014; Sunstein, 2016; Tetlock & Belkin, 1996). Similarly, Sunstein (2016: 440) claimed that ‘historical explanation is inevitably a form of counterfactual history’ (see also Black, 2015).Capoccia and Kelemen (2007) claimed that the role of counterfactual analysis is enhanced in the critical juncture framework. They identified contingency as the key element of critical junctures. During critical junctures change is substantially less constrained than it is during the phases of path dependence that precede and follow them. Only by taking counterfactual analysis seriously can contingency be studied (p. 368). In the context of the study of path‐dependent phenomena, they defined critical junctures as relatively short periods of time during which there is a substantially heightened probability that agents' choices will affect the outcome of interest (p. 348).Evans (2013) pointed out that there are several theoretical and reflective considerations of the problems counterfactual history, ranging from the ‘highly critical to the carefully justificatory’ (p. 12). He noted that counterfactuals come in many guises, with his particular targets appearing to be ‘exuberant’ or ‘long range’ counterfactuals, or those (like Ferguson, in his view, below) who break their own ‘sane and workable rules’ by taking ‘speculations too far up the stream of time, or by descending into a morass of politically motivated wishful thinking (p. 150).Sunstein (2016: 436) agreed with Evans (2013) on the problems of some forms of counterfactual analysis such as those which are hopelessly speculative, because they depend on wildly elaborate causal chains, those that suggest that some apparently trivial change may lead to large consequences (“the butterfly effect,”), especially those that require a large number of contingencies to come to fruition He noted that much of Evans's exasperation is reserved for these narratives. Sunstein continued that it is possible to dismiss counterfactual history when it is based on’ false historical claims, wildly elaborate causal chains, or all‐bets‐are‐off changes. But what if it is vulnerable to none of these objections? Evans does not give a satisfactory answer to this question’ (p. 437). Moreover, Sunstein (2016: 434) set out a ‘fundamental objection to his ultimate conclusion: For those who seek to venture historical explanations, including Evans himself, counterfactual history is inevitable, because any causal claim is an exercise of counterfactual history. Historians are pervasively counterfactualists.’ Rosenfeld (2014: 451) discussed Evans' ‘perceptive but flawed critique’, arguing that his overall critique can be summarised in three words: plausibility, politicisation, and popularity. However, in Rosenfeld's view, this was a partial one that neglects countervailing evidence (p. 453).WHAT MAKES A STRONG COUNTERFACTUAL ANALYSIS?A number of scholars have suggested criteria for counterfactuals. In what is sometimes considered as one of the first and best‐known counterfactual history texts, Ferguson (1998: 86) suggested that ‘we should consider as plausible or probable only those alternatives which we can show on the basis of contemporary evidence that contemporaries actually considered’. He insisted that we consider only those counterfactual scenarios that contemporary actors considered and committed to paper or some other form of record that is accepted by historians as a valid source. He continued that in order to understand how it actually was, we need to understand how it actually wasn't, but how, to contemporaries, it might have been. This is even more true when the actual outcome is one which no one expected – which was not actually thought about until it happened. That narrows down the scope for counterfactual analysis down considerably (p. 97). However, this has been criticised for being too narrow (e.g., Lebow, 2000; Mackay, 2007).The most comprehensive, and most cited, set of criteria are Tetlock and Belkin (1996). They set out six criteria for judging counterfactual arguments: clarity, logical consistency or contenability; historical consistency (‘minimum rewrite rule’); theoretical consistency; statistical consistency; and projectability (see below), but noted that they were subject to some interpretation, with some contributors to their edited book regarded them as ‘impossible’, ‘undesirable’ or ‘irrelevant’ (p. 17). This list was modified by writers such as Lebow (2000) and MacKay (2007). For example, Lebow (2000) modified the list of Tetlock and Belkin (1996) to set out eight criteria for plausible‐world counterfactuals, where numbers 1, 2, 4, and 5 are drawn from or are variants of the Tetlock‐Belkin list, number 6 was recently proposed by Tetlock, and numbers 3, 7 and 8 are his:Clarity. Good counterfactuals should also specify the conditions that would have to be present for the counterfactual to occur;Logical consistency or co‐tenability. Every counterfactual is a shorthand statement of a more complex argument that generally requires a set of connecting conditions or principles;Enabling counterfactuals should not undercut the antecedent. Counterfactuals may require other counterfactuals to make them possible;Historical consistency. Plausible counterfactuals should make as few historical changes as possible on the grounds that the more we disturb the values, goals and contexts in which actors operate, the less predictable their behaviour becomes;Theoretical consistency. It is useful to reference any theories, empirical findings, historical interpretations, or assumptions on which the causal principles or connecting arguments are based, thus allowing the plausibility of the counterfactual to be assessed;Avoid the conjunction fallacy (an error in judgement that occurs when people overestimate the likelihood of two events happening at the same time). The laws of statistics indicate that the probability of any compound counterfactual is exceedingly low.Surgical counterfactuals are unrealistic because causes are interdependent and have important interaction effects;Consider second‐order counterfactuals (subsequent or ‘follow up’ counterfactuals in the causal chain).Capoccia and Kelemen (2007) pointed out that the literature included a wide range of criteria for counterfactuals to be plausible, including clarity and logical consistency, the most important criterion was perhaps theoretical consistency. They cited Mahoney (2000) who explained that analysts should focus on ‘a counterfactual antecedent that was actually available during a critical juncture period, and that, according to theory, should have been adopted’. They continued that historical consistency (or the ‘minimal‐rewrite rule’) was also critical, suggesteding that legitimate counterfactuals include ‘only policy options that were available, considered, and narrowly defeated by relevant actors’ (cf Ferguson, above). This would rule out ‘miracle counterfactuals’ such as the one considered in an ‘alternative history’ by Niemietz (2023) who set out of a Commission set up by the Conservative‐Liberal Democrat government in 2010 which led to the replacement of the NHS by something similar to the Dutch system of ‘an almost completely privatised healthcare system’.Sunstein (2016) pointed out that Evans (2013) seemed to approve of two rules in particular: the “minimal rewrite” rule, which says that a chain of counterfactual consequences should not extend beyond a certain logical point; and the concept of ceteris paribus, which says that a counterfactual must only make one change in the causal chain and leave everything else the same as it was in reality (p. 453). Summing up Tetlock and Belkin (1996), Sunstein (2016) argues that they stressed the importance of well‐specified antecedents and consequents, of logical consistency among connecting principles, of avoiding preposterous claims about causality, and of maintaining consistency with well‐established historical facts (p. 438).In a rare study of social policy, Emmenegger (2011) drew on literature from other disciplines to develop (best‐case) criteria for good counterfactuals which does not include the limitation of needing to have been under active consideration by actors of the time, but is largely consistent with their other recommendations. Black (2015: 188) stated that it is not clear how to structure in detail a journey down the American poet Robert Frost. “The Road Not Taken.” However, we will draw on (below) Lebow's (2000) modified list of Tetlock and Belkin (1996).METHODPowell (2011) argued that it is important to examine decisions that were not made, or roads that were not taken. He pointed out that some writers have suggested counterfactuals. Honigsbaum (1989: 217) suggested that there might have been a very different outcome if Horder had become Royal College of Physicians President rather than Moran. The onset of war probably made some kind of health service inevitable. For Campbell (1987), the historian's problem is to identify and try to evaluate Bevan's distinctive contribution to the NHS. In what precise ways might it have been different had the Tories won the 1945 general election? Or if another Labour minister had been responsible for introducing it?We follow the advice of Capoccia and Kelemen (2007: 355) for the analysis of critical junctures: to ‘reconstruct the context of the critical juncture and, through the study of historical sources, establish who were key decision‐makers, what choices were historically available and not simply hypothetically possible, how close actors came to selecting an alternative option, and what likely consequences the choice of an alternative option would have had for the institutional outcome of interest.’The approach taken in this paper draws on Tetlock and Belkin (1996)'s list of criteria as modified by Lebow (2000) (above). First, we present an account of the main events leading up to the election of the Labour government in 1945. This allows us to set the scene, as well as to identify significant moments of change in the period leading up to the creation of the NHS. We then make a choice of which juncture we ‘branch’ out from, justifying that choice in terms of these criteria. We then work forward from that juncture (the Cabinet Debate between Bevan and Morrison) identifying the most likely immediate implication of that debate going differently – an NHS organised through local government. We limit the time period under consideration to avoid the criticisms of ‘long‐range’ counterfactual analysis. Our conclusion than considers the potential benefits of counterfactual analysis for social policy research.THE PATH TO THE NHSIt is challenging to find a starting point for the NHS as we know it today. The beginning of the long road towards the NHS has been located in very different places including the voluntary hospitals, the County Asylums Act 1808, the New Poor Law of 1834, and the first Public Health Act of 1848, and the National Health Insurance (NHI) Act of 1911 (e.g., Webster, 1988).Some of these may relate to critical junctures, but we set out the two clearest rival paths, and then focus on the immediate period before the NHS (for more details, see e.g., Earwicker, 1982; Webster, 1988; Powell, 1997; Fraser, 2003; Klein, 2013). First, the National Insurance Act of 1911 introduced contributory insurance that provided (usually male) ‘breadwinners’ with ‘sick pay’ and access to a ‘panel doctor’ (GP) (e.g., Fraser, 2003). Second, there was a clear trend to place public health services with the major local authorities. Perhaps the clearest indication of this was the Local Government Act 1929 that passed administration of the Poor Laws to the major local authorities, allowing them to ‘appropriate’ facilities so that they would be administered by the local authority's ‘public health’ rather than its ‘public assistance’ committee. Although this might sound like a minor symbolic change, it allowed the local Medical Officer of Health to supervise and improve. The intention was to develop municipal medicine, taking facilities away from the stigma of the Poor Laws (Levene et al., 2011).It can be argued that a major ‘critical juncture’ was the formation of the Ministry of Health in 1919, which briefly offered ‘ambitious plans for the development of a comprehensive and unified health service’ (Webster, 1988: 19). However, the ‘Interim’ Report of the Consultative Council on Medical and Allied Service’ (the ‘Dawson Report, after its Chair Lord Dawson) was never followed by a ‘final’ report, with Dawson's plans ‘consigned to the world of medical utopias' (Webster, 1988: 19).As we focus below on the creation of the NHS by the 1945 Labour government, it is also necessary to briefly discuss evolving Labour party policy on health care. The Labour Party set out its views on health care over a long period of time, although there was no significant legislative action during Labour's brief periods in office in 1924 and 1929–31. The year 1931 saw the creation of the ‘Socialist Medical Association’ which saw itself as intending to shape Labour policy. According to Marwick (1967: 399), the 1943 document ‘National Service for Health’ ‘was the first policy statement to appreciate fully the dependence of social policy upon efficient local government, and instead of basing its proposed health service on existing local authorities, as all previous Labour schemes had suggested, it postulated a scheme based on regional authorities.’ Earwicker (1982) provided a rather different account, arguing that the party's belief in the fundamental principle of a universal, comprehensive and free service was first established in 1919. According to Labour's policy statement on Curative and Preventive Services in 1919, the development of a municipal medical service provided the most suitable vehicle for attaining a national health service that was universal, comprehensive, free and democratically accountable to local citizens. Earwicker (1982) argued that the party's 1934 statement, ‘For Socialism and Peace’ was much the most radical it has ever adopted and was the first time that a clear preference for a municipal medical service had been endorsed by party conference. Earwicker (1982) claimed that the 1943 document (above) repeated the party's demand for a free, comprehensive universal service financed through rates and taxes, democratically controlled by a re‐organised system of local government which would run the health centres and co‐ordinate the dual hospital system.The fear of forthcoming war focused attention on health care, with the Emergency Hospital Service or Emergency Medical Service (Titmuss, 1950), created as a ‘temporary expedient’, marked ‘a secular shift towards a nationally planned and rationalised health service’ (Webster, 1988: 22). Ernest Brown, the Minister of Health in the wartime Coalition government made a statement in Parliament committing the Government to the creation of a comprehensive ‘National hospital service’ (Hansard, 1941). A duty was laid on the major local authorities to secure this in in close co‐operation with the voluntary agencies, but it would be necessary to design such a service by reference to areas substantially larger than those of individual local authorities. Brown reiterated the principle that in general patients should be called on to make a reasonable payment towards the cost whether through contributory schemes or otherwise.The Beveridge Report (1942) is often regarded as being a major step towards the NHS. The Report set out ‘Assumption B’ of ‘Comprehensive health and rehabilitation services’ (p. 158), which would be free and universal, rather than based on insurance contributions (e.g., p, 159). The Ministry of Health slowly developed from a ‘national hospital plan’ (above) towards a ‘National Health Service’. After Henry Willink had replaced Ernest Brown as Minister of Health, the Ministry published a White Paper ‘A National Health Service’ in 1944 that attempted to integrate voluntary and municipal hospitals through Joint Boards. It appears as if the Beveridge Report forced the government's hand in pushing towards a free service, but earlier radicalism on issues such as salaried GPs had been diluted in consultation with the medical profession.The 1945 General Election led to the first ever majority Labour government, with Aneurin Bevan appointed as Minister of Health. As Earwicker (1982: 302–3) noted, it was no simple process to translate Labour's ideas on health policy into legislation. While the ambition of a universal, comprehensive and free National Health Service was generally agreed within the Labour movement, the means to achieve this aim was the subject of controversy.Bevan quickly rejected much of Willink's White Paper, but also departed from Labour's traditional stress on local authorities, with his most important structural decision being to create a national hospital service based on appointed hospital authorities termed ‘Hospital Management Committees’ (below). This led to a debate in Cabinet between Bevan and Herbert Morrison, who argued in favour of local authorities (below).The Health Service Bill, published on 21st March 1946, went further than the 1944 White Paper in providing for a universal, comprehensive and free service. There were to be no limitations to NHS services based on ‘financial means, age, sex, employment or vocation, area of residence or insurance qualification’. The NHS Act established a ‘comprehensive health service to secure the improvement in the physical and mental health of the people and the prevention, diagnosis and treatment of illness’. This was the basis for the creation of the NHS on the ‘Appointed Day’ of 5 July 1948.However, Bevan had to engage in discussion with stakeholders, such as the medical profession (Thomas‐Symonds, 2014). The result of the first BMA in February 1947 saw 40,814 disapproving of the act, with only 4735 approving. Discussions continued, but the two parties still seemed wide apart. A BMA Meeting in January 1948 expressed its complete lack of confidence in, and mistrust of, the Minister of Health. The result of the second plebiscite was announced in May 1948, with the overall vote against the NHS of 25,842 compared to 14,620 in favour.CRITICAL JUNCTURES IN THE CREATION OF THE NHSIt is possible to identify a range of candidate critical junctures in the immediate period leading to the creation of the NHS which have been hypothesized in existing research (Table 1).Table 1 represents a rich source of potential counterfactuals in exploring the NHS, with some brief supporting vignettes of evidence. Lebow (2000: 574) stated that ‘there is no consensus about what constitutes a good counterfactual, but there is a common recognition that it is extraordinarily difficult to construct a robust counterfactual‐one whose antecedent we can assert with confidence could have led to the hypothesized consequent.’ He went on to argue that ‘criteria that tie counterfactuals to established laws and statistical generalisations and attempt to limit second‐order counterfactuals are superficially appealing. In practice, they are generally unworkable or would rule out some of the most important uses of counterfactual experimentation (p. 577).’ He noted that some scholars favour counterfactuals that are derived deductively from good theories. However, while ‘this may be possible in a data‐rich and reductionist field like cognitive psychology … it is hardly a realistic standard for counterfactuals in history and most of the social sciences.’ He summed up that ‘the clarity, completeness, and logical consistency of the arguments linking antecedent to consequents are more important than their external validity (p. 581), and then produced his list (above, and Table 2).We have rejected some possible counterfactuals that seem to be clearly in breach of the ‘minimum rewrite rule’ such as no Second World War and Labour not winning the 1945 Election. Others appear more plausible such as Wilkinson being appointed Minister of Health. However, we have chosen the possibility that in Cabinet Attlee summed up in favour of Morrison rather than Bevan, as this seems to fit the counterfactual criteria (above) reasonably well (Table 2).Some of these criteria appear easier to apply or seem more relevant, with the first four criteria being fairly relevant and applicable. In addition, our chosen counterfactual fits the more demanding criteria of being available, considered, and (arguably) narrowly defeated (e.g., Ferguson, 1998; Mahoney, 2000; Capoccia & Kelemen, 2007).CRITICAL JUNCTURE: CABINET DEBATEThe Cabinet debate between Bevan and Morrison has been examined by a number of accounts (e.g., Pater, 1981, Webster, 1988, 1990; Honigsbaum, 1989, Powell, 1997, 2011, Klein, 2013; Thomas‐Symonds, 2014) in the period after the archival material became available, with Pater (1981) claiming to be the first account based on this material (see Powell, 2011).Webster (1988: 84) discussed ‘internal dissension’. He pointed out that while most aspects of Bevan's scheme were accepted without difficulty, agreement to nationalisation of the hospitals was secured only after much dispute. First, Bevan had to convince the civil service, which pointed out that his plan discarded the White Paper which was ‘practically ready’ and would be harmful to local government. Then, discussion moved into the political realm. The main documents are Bevan's Memorandum of 5 October 1945 (TNA, 1945a), the Cabinet Meeting on 11 October (TNA, 1945b), Morrison's memorandum criticising Bevan's plan of 12 October (TNA, 1945c), Bevan's response on 16 October (TNA, 1945d), and a subsequent Cabinet Meeting on 18 October 1945 (TNA, 1945e). Bevan presented a Memorandum on ‘The Future of the Hospital Services’ on 5 October 1945 (TNA, 1945a), asking for ‘a decision on one big question of principle’. He explained that he wished for ‘the complete taking over—into one national service—of both voluntary and municipal hospitals’ with national responsibility based in the Ministry. He noted that the contracting arrangement in the 1944 White Paper would mean that public funds would certainly amount to 70 per cent or more of the income of voluntary hospitals. Following the principle of public control following public money meant ‘taking over either by some form of local government machinery, or by the central government’, but he would strongly deprecate the former’ (paragraph 7). He admitted that while ‘a few local authorities run a good hospital system. The great majority are not suited to run a hospital service at all under modern conditions' with most areas being too small (paragraph 8). This meant that: ‘The right course, I am sure, is to nationalise the hospital services entirely and to take them out of the field of local government altogether’ (paragraph 12). This would achieve ‘as nearly as possible a uniform standard of service for all’ (paragraph 12).The Cabinet discussed this Memorandum on the 11th October (TNA, 1945b). Bevan admitted that his proposals would ‘undoubtedly excite strong opposition by the voluntary hospitals and the local authorities.’ However, the great majority of the doctors would prefer central to local control. (paragraph 6). Bevan's proposals were broadly supported, and it was agreed to return to resume discussion of the proposals at the Cabinet Meeting on the 16th October. Morrison did not express a view at the Cabinet Meeting, but the following day presented his Memorandum (TNA, 1945c).Morrison wrote that he ‘read with admiration’ what he thought was ‘the brilliant and imaginative paper of the Minister of Health.’ He was ‘attracted by the order and simplicity of the solution which he offered for a complex and difficult administrative problem’ but then ‘began to have doubts about some of its wider implications’ (paragraph 1). He presented the precedent of the police service. Like previous Home Secretaries, he rejected the case for a nationalised police force on the grounds of over‐concentration of power at the centre and weakening local authorities. He warned about weakening local government and considered that local government had done well in hospital administration since the Local Government Act 1929 (paragraph 3). He argued that ‘if we wish local government to thrive—as a school of political and democratic education as well as a method of administration—we must consider the general effect on local government of each particular proposal’ (paragraph 4). He admitted that he disliked joint authorities thoroughly, but considered that ‘they provide the best way out of an admittedly difficult administrative problem’ (paragraph 7).Bevan's response (TNA, 1945d). noted that Morrison did not ‘dispute seriously my contention that the way to make these services efficient is to centralise responsibility for them.’ He was convinced that the broader consequences for local government could be overcome. At the Cabinet Meeting on 18th October, (TNA, 1945e) Morrison replied by stating that while he ‘fully appreciated the attractions of a logical and clean‐cut scheme’ of Bevan, the ‘detrimental effect which the loss of hospital functions would have on local government in general, did not outweigh the arguments based on grounds of administrative convenience and technical efficiency’ (paragraph 1). Bevan responded that he had considered very carefully the points made by Morrison, but still felt that the only way to make the hospital services efficient was to centralise responsibility for them.Prime Minister, Attlee summed up that ‘the differences between the proposals made by the Minister of Health and the alternative scheme suggested by the Lord President of the Council were possibly less fundamental than they seemed to be.’ He continued that ‘while approving this proposal in principle, however, the Cabinet would want to look at the details again when they were more fully worked out.’ However, ‘the Cabinet endorsed the course of action proposed by the Prime Minister’ (paragraph 1). This approval ‘in principle’ appeared to set out the path in favour of Bevan rather than Morrison, with little obvious discussions of the ‘details’ at the Cabinet Meeting of 13 December (TNA, 1945f).As noted above, Capoccia and Kelemen (2007: 355) suggested that it is important to reconstruct the context of the critical juncture, establish who were key decision‐makers, what choices were historically available, how close actors came to selecting an alternative option, and what likely consequences the choice of an alternative option would have had for the institutional outcome of interest.We have set out the context above. The key protagonists were Bevan and Morrison, with Attlee the key decision maker within the Cabinet. The key choice was whether to base the hospitals on central or local government. In the period before 1945 the most likely choice was that the NHS would be based on local government, with the Labour Party and much of the Ministry of Health supporting this option. However, Bevan was able to engineer a major change in policy. As we shall see below, views vary on how close the local government option was to being taken.There is little doubt that the decision to nationalise the hospitals was a major ‘fork in the road’. As Earwicker (1982: 314) pointed out, ‘at a stroke, Bevan intended to deprive the municipalities of the central place they had occupied in successive Labour plans since 1919, contravening the letter and spirit of every Labour party policy document on health.’ Similarly, according to Brooke (1992: 337–8), in nationalising the hospitals, ‘Bevan stood Labour policy on its head’. The importance of localism to the Socialist Medical Association (SMA) and to the Labour Party was stressed by contemporaries. The Labour party conference 1945 stated that no scheme that did not give local authority control was acceptable (all in Powell, 1997: 45). However, perhaps the municipal option was viewed too optimistically as Morrison and many SMA members based their case on London, which had made significant progress by the London County Council and had broadly good voluntary provision, and a number of elite Teaching Hospitals (e.g., Levene et al., 2011; Stewart, 1997), which was not typical of the rest of the country.Interpretations appear to vary as to how close the verdict was. Some scholars seem to regard Bevan's victory as very clear. On the one hand, Earwicker (1982) considered that the gladiatorial tone of this Cabinet debate is misleading for the most striking thing about the encounters between Bevan and Morrison is the weakness of Morrison's opposition. While it is likely that most ministers would have preferred a municipal solution, they also recognised that Bevan's solution was the only viable scheme in the circumstances due to opposition from medical interest groups. Similarly, Thomas‐Symonds (2014) viewed Bevan's victory over Morrison as ‘quick and decisive’. He continued that Morrison's arguments were inconsistent, as while arguing passionately for his proposals he sought to persuade the Cabinet that his alternative scheme was not much different from Bevan's, and that Morrison had taken a scattergun approach (p. 135). Members of the Cabinet lined up behind Bevan. Attlee intervened decisively, seizing on the weaker part of Morrison's argument that, in reality, there was little difference between the two schemes (p. 136).On the other hand, Pater (1981: 109) regarded the Cabinet reception to Bevan's 11 October proposals were ‘mixed’. He continued that in Cabinet on 18 October, opinion was still divided, but seemed generally in Bevan's favour (p. 111). Finally, ‘the welcome given by the Cabinet to these proposals on 20 December was ‘less than enthusiastic’. (p. 115).Rintala (2003) argued that, besides Morrison, Bevan's most serious potential problem in the Cabinet was Ernest Bevin. The Foreign Secretary had not forgotten Bevan's wartime criticisms (p. 41). (However, Bevin was not present at these crucial Cabinet Meetings). Rintala continued that Bevan was probably without a friend in the Cabinet, but he did have at least two principled supporters, neither among the most powerful of his colleagues, on his NHS plans: Minister of Education Ellen Wilkinson, and Christopher, now Lord, Addison, who had given Lloyd George crucial assistance with the National Insurance Bill of 1911. Rintala described Bevan as ‘pragmatic’. ‘In nationalizing municipal hospitals, Bevan was not acting as a loyal partisan … Fidelity to party meant much to Morrison, and little to Bevan’ (p. 49).COUNTERFACTUAL: MORRISON'S NHSThere are many possible different ‘forks in the road’ in considering counterfactual possibilities for a NHS based on local government as championed by Morrison. On the one hand, one set of optimistic forks leads to a successful NHS, similar to the locally based service in the Nordic nations. For example, Byrkjeflot and Neby (2008) state that the Scandinavian hospital sectors are usually described as variants of the NHS in the UK, but are typically classified as decentralised compared with the centralised UK system. They set out three periods: the making of the decentralised model (before 1970); the heyday of the decentralised model (1970‐early 2000s); and challenging the decentralised model (after 2000). Verdicts vary on the success of the model. For example, Dougherty et al. (2019) examined the relationship between the degree of administrative decentralisation across levels of government in health care decision‐making and health care spending, hospital costs and life expectancy. They found a statistically significant effect of ‘administrative decentralisation’ on health expenditure and life expectancy. A ‘moderate’ degree of decentralisation reduced public health spending and increased life expectancy compared to very low decentralisation, but ‘excessive decentralisation’ was associated with higher public spending on health and lower life expectancy compared to an intermediate degree of decentralisation. Martinussen and Rydland (2021) stated that decentralisation has a positive and significant association with health system satisfaction, but not with self‐rated health. They concluded that their study fails to provide clear support for decentralised health systems.On the other hand, there are some possible pessimistic forks which lead in the worst case scenario of no NHS. First, most accounts point to Bevan's successful negotiations with the medical profession. However, if Bevan had resigned in October 1945 after the defeat of his proposals (he did resign from the Cabinet in 1951 when Minister of Labour), it is possible that the new Minister of Health would have not been able to persuade the doctors to serve in the NHS, with medical interest groups essentially providing a veto. Second, if Bevan had continued to be Minister of Health, it would have been much more difficult to persuade hospital doctors to serve in a NHS based on local government. As Bevan pointed out in Cabinet, hospital doctors feared municipalisation much more than nationalisation. It is possible that even Bevan's negotiating skills may not have been successful. In addition, Bevan's preliminary discussions with the medical elite (e.g., Foot, 1975) would have probably signalled his nationalisation plans, and so later stating that the plan was for municipalization would have added an additional major hurdle.However, our ‘most likely’ counterfactual scenario is that Bevan was able to persuade the doctors to serve in a local government NHS. We assume that the actual ‘Tri‐partite’ system (hospitals, Executive Councils, local government) would have become a ‘Bi‐partite’ system (local government, Executive Councils). General Practitioners voted against Bevan's NHS in the two BMA Plebiscites (above), but as Bevan expected, they were forced to sign up for NHS patients as they feared that they would not be able to survive on any remaining private patients. The elite Teaching Hospitals were given a significant measure of independence outside the main Hospital Management Committee (HMC) structure, and it is likely that this would have been similar in Morrison's NHS. This leaves the doctors at hospitals other than Teaching Hospitals. It is clear that most hospital doctors would have preferred nationalisation to municipalization. It is likely that when voluntary hospitals were municipalized, the traditional ‘firm’ approach (ie teams) to organising doctors would have changed to the traditional ‘hierarchical’ (Medical Superintendent) approach of municipal hospitals. This would have represented an additional major hurdle, but perhaps Bevan may have needed to ‘stuff their mouths’ with even more gold.It is likely that Morrison's NHS would have received a similar large majority in the NHS Debates in Parliament. First, it was closer to Labour party policy. Second, it is even possible that more Conservatives may have voted in favour, as one of the Conservatives' stated objection to Bevan's NHS was its negative impact on local democracy and local government.Morrison's NHS would have probably left hospitals in the hands of their existing owners (voluntary and municipal) under local government and joint boards, with some form of contracting for the services of voluntary hospitals. As many voluntary hospitals had significant financial problems, under the principle of control following public money, this would probably have led to a process of ‘creeping municipalization’ or in the words of Chancellor Hugh Dalton ‘to proceed by stages, spread over years, and not by one bold stroke’ (in Foot, 1975: 133).As Bevan argued in Cabinet, it is likely that any local government system would be more uneven, and would find it difficult to ‘universalise the best’ (see also Bevan, 1978). This would have been clear in three main dimensions. First, without strong equalising central grants, poorer local authorities would find it difficult to match hospital provision in the more wealthy local authorities. Second, even with a system of Joint Boards, there would have been significant problems for smaller local authorities to operate large hospitals with a full range of clinical facilities. Third, it would have been difficult for more rural areas without large centres of population to operate large hospitals (see e.g., Powell, 1997). The latest Labour Party document on health of 1943 had suggested that health care should be provided by reformed (probably more regional) local government (above). As Bevan (1978: 114–115) later wrote ‘election is a better principle than selection’ and that ‘a solution might be found if the reorganization of local government is sufficiently fundamental to allow the administration of the hospitals to be entrusted to the revised units of local government’.The Coalition government had issued a White Paper in 1945 titled ‘Local Government in England and Wales during the Period of Reconstruction’. While it admitted that that certain services need to be planned or administered over wider areas; and that the reconstruction programme would place an impossible burden on local government finance, it did not propose much in the way of fundamental reform (e.g., Robson, 2021). The Local Government Boundary Commission was appointed on 26 October 1945, and reported in 1947. It recommended the creation of 47 two‐tiered ‘new counties’, 21 one‐tiered ‘new counties’ and 63 ‘new county boroughs’, but led to little action. The Local Government Act 1958, established the Local Government Commission for England and the Local Government Commission for Wales to carry out reviews of existing local government structures and recommend reforms. This was replaced by a Royal Commission (known as the Redcliffe‐Maud commission), which in 1969 recommended a system of single‐tier unitary authorities for the whole of England, apart from three metropolitan areas. This was broadly accepted by the Labour Party government of the time, but the Conservative Party manifesto of 1970 committed them to a two‐tier structure. The Local Government Act of 1972 under the Conservatives established a uniform two‐tier system across the country. This detour into the history of local government (see e.g., Robson, 2021) suggests that the counterfactual of Morrison's NHS would probably have made it necessary to reform local government structure and finance earlier and more fundamentally.Perhaps the most important factor is that it is likely that local authorities would always be in a weaker financial position than national government (e.g., social care in recent years). While there was limited capital spending in the early austere years of Bevan's NHS, it is likely that local authorities would have been even more cash strapped (compare the problems of building new social housing in the years after 1945).All this suggests that while a NHS based on local government may have been possible, it is likely that it would be more ‘austere’ due to more limited funding, and more unequal due to the varying financial capacities of local government. On the other hand, it could be argued that the NHS may have been more integrated. Before the NHS, Medical Officers of Health argued that it was important for hospital and community services, and clinical and preventive services to be in the same hands (see e.g., Levine et al, 2011). This may be a valid theoretical argument, but in practice it is likely that the hospital dominance of Bevan's NHS would have also applied to Morrison's NHS.CONCLUSION—COUNTERFACTUAL HISTORY AND THE NHSBlack (2015: 2) claimed that a crucial value of counterfactualism is that it returns us to the particular setting of uncertainty in which decisions are actually confronted, made, and implemented. While Evans (2013) did not regard counterfactual thinking as ‘central’, he considered that ‘based on a minimal rewrite, and confined to the short run, a counterfactual can illuminate the choices that confronted individual politicians and statesmen, and the limitations that the historical context imposed on those choices (p. 150), and ‘it can be useful under certain strictly limited conditions and with strictly limited purposes' (p. 151).Counterfactual history reminds us that things could have turned out differently, pointing to the importance of contingency and to causal relations (compare e.g., Tetlock & Belkin, 1996; Cowan & Foray, 2002; Emmenegger, 2011; Black, 2015, Sunstein, 2016). It can also be a useful tool in revisiting debates, such as the national versus local welfare state debate (see e.g., Powell, 1998). Localist writers such as Robson (2021) criticised the Labour Party and Bevan for their treatment of local government, with localism regarded as an essential part of a welfare state. Throughout the NHS there has been a persistent trend of thought on returning health care to local government (see e.g., Powell, 1998). Taking health care from local authorities has been termed Labour's ‘great mistake’ by Blunkett and Jackson (1987: 64). As one of Bevan's biographers, Campbell (1987: l77) put it: ‘All the fundamental criticisms of the NHS can be traced back to the decision not to base services on local authorities … In retrospect the case for the local authorities can be made to look formidable, the decision to dispossess them a fateful mistake by a Minister ideologically disposed to centralisation and seduced by the claims of professional expertise.’Klein (2010) analysed ‘60 years of the eternal triangle’ of the conflict between the values of efficiency, equity and democracy. In his view, ‘the contrast between the reality of centralization and the rhetoric of devolution reflects tensions built into the very design of the NHS: tensions that derive from the fact that the design incorporated competing, possibly irreconcilable, goals' (p. 286). His starting point is the Cabinet debate in October 1945 ‘between the political midwives preparing for the birth of the NHS' with Bevan favouring equity and Morrison arguing for democracy. He then discussed another concept of democracy which did not feature explicitly in the Bevan–Morrison debate but which proved crucial in defining the centre–periphery relationship over subsequent decades. This was democracy defined as accountability to Parliament: hence Bevan's much quoted formulation: ‘when a bedpan is dropped on a hospital floor, its noise should resound in the corridors of the Palace of Westminster’ (see also Foot, 1975: 192–193). He argued that ‘the tension between the local and national concepts of democracy was to characterize the NHS throughout its existence.’ In short, for Bevan, territorial justice was deemed more important than local autonomy. The counterfactual of ‘the road not taken’ to ‘Morrison's National Health Service’ or perhaps ‘Local Health Service’ provides important insights into the debates surrounding national versus local welfare states.DATA AVAILABILITY STATEMENTThe data that support the findings of this study are available in TNA (various files).REFERENCESAddison, P. (1975). The road to 1945. Jonathan Cape.Bevan, A. (1978). In place of fear, first published 1952. Quartet Books.Beveridge, S. W. (1942). Social insurance and allied service, Cmnd 6404. HSMO.Black, J. (2015). Other pasts, different presents, alternative futures. Indiana University Press.Blunkett, D., & Jackson, K. (1987). Democracy in crisis. Hogarth Press.Brooke, S. (1992). Labour's war. 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Journal

Social Policy & Administration – Wiley

Published: Nov 1, 2024

Keywords: counterfactual; health; history; National Health Service; UK

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