Our NHS is an engaging, inclusive history of the NHS, exploring its surprising survival and the people who have kept it running. Andrew Seaton’s book was first published in the summer of 2023, coinciding with the 75th anniversary of the founding of the NHS.
In this blogpost, part of the 50 Years in 50 Books series for our 50th Anniversary, Andrew Seaton gives us an insight into how he went about writing a history of one of Britain’s best-loved institutions.
Article by Andrew Seaton
Our NHS began in the form of a doctoral dissertation, which I completed as part of my Ph.D. in history at New York University (NYU). When I returned to the U.K. in these years to undertake archival research, my choice to work on such a topic on the other side of the Atlantic sometimes seemed strange to my British colleagues and friends. Why go all the way to the U.S. to study the NHS? Apart from the intellectual benefits of training in the Department of History at NYU, living away from a health service that had treated me for years, employed my mother as a cleaner, and which appeared daily in the news offered a productive basis to approach the institution historically. I could gain some critical distance from the two predominant narratives about the service that circulated in the media and in everyday conversation: that it was a natural part of what made Britain special and/or that it stood on the precipice of collapse. Although these interpretations still carried some weight in my thinking, I tried to not let them determine my analysis. Instead, I sought to remain attentive to the alternative roads that the service might have gone down.
My initial aspiration with the project was to illuminate the wider significance of the NHS in British life. As the popular celebration of the service’s ‘birthday’ in recent years shows, it is far more than just a health system. One of the things that kept me motivated to finish writing the book lay in how the service’s history allowed me to talk about lots of different things, from shifting meanings of class and gender, to Britain’s experience of Commonwealth immigration, to architectural aesthetics or debates in medical economics. I enjoyed visiting as many archives as I could in order to collect source materials that would enable to me pursue such an approach. The book stitches together government reports with, for instance, photographs of patients in health centres, documentary films about U.S. health care, or the personal papers of activists. The sheer scale of the NHS as Europe’s largest employer could be somewhat intimidating but, overall, researching its past proved an exciting challenge. I make no claims to have written a fully ‘complete’ history of every single administrative reform or type of patient, even if I do think it is possible to write a book that speaks to the general development of the NHS and its cultural and political meaning. It is my hope that Our NHS can complement work currently being undertaken by other scholars that also illuminates the past of this world-famous institution, whether through smaller case studies or in macro terms.
The wide lens and varied material that underpins the book allowed me to answer two central questions. First, why did the NHS take on such popular acclaim? After all, it was not inevitable at the service’s inception in 1948 that it would one day regularly top opinion polls of what made people ‘most proud to be British’. Second, why did the institution survive to achieve such significance, given that many other parts of the welfare state or public industries also founded in the mid-twentieth century became residualised or privatised? Our NHS insists that neither the institution’s acclaim nor its survival were automatic or pre-ordained. Instead, the book shows the active work that was required to embed and adapt the service to social change, outmanoeuvre free-market critics, and associated the institution with Britishness itself. By highlighting these dynamics, I build on insights from prior historical scholarship (often informed by social science) that explained the resilience of welfare states through structural factors like the advantages of pooling risks or the power of ‘path dependence’ in social policy. I show that attitudes, culture, ideas, and activism also matter to the fate of welfare services, alongside administration or finances.
I also wanted to write a book that was both academically rigorous and would possess cross-over appeal to a general audience. Yale University Press seemed the perfect fit in this regard, allowing for ample space for both the things that academics tend to care about (references and scholarly debates) and the things that the general public prioritise (accessible prose and human stories). Among Yale’s titles in British history, Deborah Cohen’s Household Gods: The British and Their Possessions (2006), Edmond Smith’s Merchants: The Community That Shaped England’s Trade and Empire (2021), and Sasha Handley’s, Sleep in Early Modern England (2016) all provided examples of how to achieve such a balance. With the help of my editor, Jo Godfrey, and the encouragement of colleagues at St Anne’s College, University of Oxford, where I completed the book as a postdoctoral researcher, I rewrote the manuscript and added two new chapters that more concretely brought the book up to the present.
As part of the book’s conclusion, I also offered some reflections on what the history of the NHS might mean in the wake of the Covid-19 pandemic. Though the full ramifications are still being uncovered, I argued that the pandemic revealed both the strengths and the limitations of the NHS. On one hand, the service had survived and it was able to perform functions such as distributing vaccines with a high degree of public trust. On the other hand, as many public health experts observed, the disproportionate mortality rates from Covid-19 among working-class communities and people from ethnic and racial minority backgrounds underlined the longer-term health inequalities in Britain. The NHS could only do so much and, in order to tackle these longer-term inequities in medical outcomes, it needed the support of a robust ecosystem of welfare services, some of which had been undermined after the 1980s, including under the austerity of the 2010s. If social democratic politics endured through the health service (which remained free-at-the-point-of-use, universal, mainly funded by taxation, and government-coordinated) then it lay fractured elsewhere.
Our NHS was published in the summer of 2023, during a period of serious concern for the health service. The waiting list figures for treatment stood at their worst levels on record, strikes among health professionals unfolded across the service, and unknown numbers of NHS staff seemed to be emigrating for better conditions and pay overseas. Nonetheless, the NHS also received an enormous amount of celebration – including, a service in Westminster Abbey, an NHS ‘Big Tea’ occurring in different parts of the U.K., and a new commemorative fifty pence piece from the Royal Mint. Though I learned first-hand about the serious challenges facing the service from doctors and patients in my audiences as I spoke about the book after its publication, I also encountered public attachment to the NHS that reminded me why it had lasted through other periods of crisis. I hope that my small contribution to telling the service’s history might provide us with another perspective when we think about its future.
About the Author:
Andrew Seaton is a Leverhulme Early Career Fellow in History at UCL. Before joining UCL in October 2023, Andrew was the Plumer Junior Research Fellow in History at St Anne’s College, University of Oxford. An expert in the history of modern Britain and the NHS, he received his PhD in history from New York University in 2021.
About the book:
A History of Britain’s Best Loved Institution
In this wide-ranging history, Andrew Seaton examines the full story of the NHS. He traces how the service has changed and adapted, bringing together the experiences of patients, staff from Britain and abroad, and the service’s wider supporters and opponents. He explains not only why it survived the neoliberalism of the late twentieth century but also how it became a key marker of national identity. Seaton emphasizes the resilience of the NHS—perpetually “in crisis” and yet perennially enduring—as well as the political values it embodies and the work of those who have tirelessly kept it afloat.
Yale University Press is celebrating 50 years of publishing in London. To celebrate, we have selected 50 important Yale London books from our past, present and future to tell the story of our publishing through a series of articles and extracts.