I

The record of Northern Ireland’s devolved administration on health and social welfare was not a good one. The state routinely recorded the worst social and health statistics in the United Kingdom. These figures have been cited as often by historians as they were remarked upon by contemporaries. Historians have pointed out that devolution did not lead to an improvement in the health of the people of Northern Ireland. In 1938, a Northern Ireland woman was more likely to die in childbirth than in 1923.Footnote ⁵ In 1931, life expectancy there was the lowest in the United Kingdom at 57.1 years compared with 57.8 years in Scotland and 60.8 years in England and Wales.Footnote ⁶

There were myriad reasons for this. Northern Ireland was the poorest region in the United Kingdom, the government in office in the 1920s was inexperienced and health was not a high a priority in a state primarily concerned with threats from within and without to its own survival.Footnote ⁷ Whilst Britain had had its own ministry of Health since 1919, the state apparatus in Northern Ireland spread responsibility for health among several ministries. These included the ministries of Home Affairs, Labour, Education, Agriculture, Commerce and Finance as well as local authorities and councils.Footnote ⁸ Healthcare in Northern Ireland was administered under a mixture of pre-devolution Liberal reforms and the poor law.Footnote ⁹ Hospitals relied on voluntary contributions. General practice depended upon fee-paying patients.Footnote ¹⁰ A system of dispensary doctors operated under the auspices of poor law guardians. This was often over-stretched. In 1924 alone, for example, there were 140,338 new cases.Footnote ¹¹ The system, however, was relatively cost effective due to the poor wages paid to dispensary doctors. By 1942, the average annual salary was £200. Dispensary doctors routinely treated a panel of a thousand patients and were responsible for their own travel expenses. Many, however, did have their accommodation provided.Footnote ¹² The government of Northern Ireland pursued a stated policy of proceeding step-by-step with reforms in Britain. In practice, however, this most often proved to be something of an aspiration. Nevertheless, there were some notable successes in health and social care. Northern Ireland had a highly successful mandatory vaccination programme. By 1931, Britain’s system of national insurance had been adopted, providing medical insurance for thousands of people and removing some of the stigma attached to their reliance on the poor law.Footnote ¹³

There were voices critical of the government’s record. In 1943, for example, the Socialist Medical Association published a pamphlet condemning the multiplicity of ministerial oversight in health. However, as this was published by the Northern Ireland Labour Party, such criticism could be easily dismissed by government as Opposition carping.Footnote ¹⁴ The growing discontent among Unionist backbenchers on the issue of health was much less easy to ignore. This was particularly true when concern was articulated by ‘old’ Unionism. In October 1942, the Unionist member for Queen’s University, Dr William Lyle, used his maiden speech in the Commons to criticise the record of the government on health. ‘There has been no Act of major importance dealing with public health in this country’, he told the prime minister, J. M. Andrews, ‘since the Imperial Government passed the Local Government Act in 1898.’Footnote ¹⁵ Lyle’s criticism carried weight. A signatory to the Ulster Solemn League and Covenant in 1912, his Unionist credentials were impeccable. It was this same gravitas which accompanied his Commons motion on the creation of a separate ministry for health in December 1942.Footnote ¹⁶

Infant mortality figured prominently in criticism of the government on the issue of health. In December 1942, James Browne, Unionist M.P. for South Down, tabled a question to the minister of Home Affairs, Richard Dawson Bates, asking how infant mortality in Northern Ireland compared with the rest of the United Kingdom. Quoting from figures obtained for 1941, Bates told the House that the rate for Northern Ireland was 77 deaths per 1,000 live births compared with 58 for England in Wales and 83 for Scotland. ‘It will be seen’, he continued, ‘that the figure in Belfast [91] is much higher than that in comparable cities in Great Britain [61 Leeds, 67 Sheffield], while the figures in provincial areas in Northern Ireland compare favourably with those in similar areas of Great Britain.’Footnote ¹⁷

On 22 December 1942, Sir Wilfrid Spender, permanent secretary to the Treasury and head of the Northern Ireland Civil Service, received an outraged letter from W. A. Carson, the registrar general. He accused Bates of having misrepresented the figures supplied by his office to the ministry of Home Affairs. Seven towns which had the lowest infant mortality rate in the United Kingdom had been omitted from the list cited by the minister. ‘The suppression of the greater part of the truth’, Carson told Spender, ‘is not a thing which I feel I can support and I therefore desire to protest against the manner in which the figures have been used.’Footnote ¹⁸ Spender shared Carson’s concerns and put these to the permanent secretary at Home Affairs, Adrian Robinson. He, however, ‘considered that, as the ministry of Home Affairs was responsible for the reply and only came to you [Carson] for certain statistics they were at full liberty to use those statistics in any way that they deemed advisable’.Footnote ¹⁹

The tendency of Andrews’s administration, and Bates in particular, to prevaricate and deny the severity or even the existence of problems was symptomatic of its beleaguered nature. Health, across which the aspirations of Beveridge were writ large, was just one issue on which the government faced biting criticism from its backbenchers as well as from the Opposition. The administration of J. M. Andrews, however, remained gripped by inertia. The refrain often repeated by the government and its supporters was that whilst the goals of Beveridge were laudable, they could not and should not be implemented immediately. This was the point made by the Unionist M.P. for Armagh, Lieutenant-Colonel William Allen, in the debate on Beveridge at Westminster in February 1943. ‘Our people in Northern Ireland’, he told the House, ‘are prepared to do what they can to adopt the Beveridge Plan so far as the Government here may put it into operation’. It was common sense, however, to wait until the end of the war.Footnote ²⁰ Under pressure from Opposition M. P.s in the Northern Ireland House of Commons in March 1943, Andrews described the report as ‘courageous, exhaustive and an earnest attempt to deal with a great social problem sympathetically and effectively’.Footnote ²¹ It was, however, financially impossible to implement it.Footnote ²²

The positive noises emanating from Andrews’s administration on reform and post-war reconstruction could not rid it of the taint of stagnation. There was mounting criticism of the performance of Home Affairs minister, Richard Dawson Bates, and a general feeling in the Unionist Party that the cabinet had gone on too long.Footnote ²³ Andrews was determined to face down his critics but was forced to resign following a meeting of M.P.s on 29 April 1943. Wilfrid Spender wrote in his diary that he ‘thought it was a pity the P.M. had allowed his friendship for his colleagues to cause him to hesitate in making changes’.Footnote ²⁴

A new Unionist administration was installed under the premiership of the former minister for Commerce, Sir Basil Brooke. The post of Finance minister went to John Maynard Sinclair, M.P. for Cromac in Belfast, while Bates was replaced at Home Affairs by William Lowry, M.P. for the City of Londonderry. William Grant, M.P. for Duncairn in Belfast, was appointed minister for Labour. It was not the case that, having ejected such bulwarks against change as Richard Dawson Bates, reform of health and social care was guaranteed. There was the no small matter of the Second World War and addressing the morass of problems into which Andrews had allowed the government to sink.Footnote ²⁵ Certainly, there was no hint from the new administration that any reform, let alone a revolution in social and health care, was imminent. In his opening address to the Commons, Brooke retreated from even the vague reconstruction rhetoric of Andrews, preferring, in a dour pronouncement, to concentrate on Northern Ireland’s part in the war effort.Footnote ²⁶

To a certain extent, Andrews had forestalled the issue of health reform by establishing a select committee on health in January 1943. The move had been made to postpone a vote on a motion tabled in the House of Commons by William Lyle the previous December calling for the establishment of a separate ministry of Health. Rather than face the possibility of defeat, Andrews had offered the select committee.Footnote ²⁷ The government was acutely aware of the negative signals emanating from the committee, even in the absence of a report.Footnote ²⁸ The committee was chaired by a medical doctor, Howard Stevenson, Unionist M.P. for Queen’s University. Among the other Unionist members were two more doctors, George Dougan, M.P. for Central Armagh and William Lyle. Northern Ireland Labour was represented by Harry Midgley, M.P. for Dock in Belfast while the Nationalist representative was Thomas Campbell, M.P. for Belfast Central. There were two Unionist M.P.s closely aligned with the government, Hugh Minford, M.P. for Antrim and Samuel Hall-Thompson, M.P. for Belfast Clifton. The other Unionist members were John Bailey, M.P. for West Down, John Johnston, M.P. for North Armagh and Thomas Bailey, M.P. for North Down.

The select committee sat until January 1944 and confirmed that health and social provision in Northern Ireland was woefully inferior to comparable services in the rest of the United Kingdom. It recommended the wholesale reform of health and social care starting with the immediate establishment of a ministry of Health.Footnote ²⁹ Brooke’s government acceded to the pressure from M.P.s and in 1944 a ministry of Health and Local Government was established. The addition of local government functions were added on the recommendation to the cabinet of John Maynard Sinclair, minister of Finance, and Northern Ireland’s attorney general, John MacDermott. Public health, they argued, ‘cannot be detached and treated in isolation. It is bound up in the most positive fashion with the problem of housing and unless public health is to become a centralised service administered directly by the state, it is also bound up with the problem of local government. The higher the general standard of local government is the better the health of the community.’Footnote ³⁰

To fill the post of Health minister, Brooke chose William Grant. An experienced cabinet minister with whom the prime minister enjoyed a good working relationship, Grant was very much cast in the mould of ‘old’ Unionism. He had been a founding member of the Ulster Volunteer Force and the Ulster Unionist Labour Association. Grant was a more palatable choice for the Ulster Unionist Party than Brooke’s first preference, the former Northern Ireland Labour M.P., Harry Midgley.Footnote ³¹ The new ministry set out its reform agenda almost from the outset. In August 1944, Grant proposed that the functions of boards of guardians be transferred to local councils for which his new ministry was responsible.Footnote ³² However, this modest administrative reform was far removed from the prospect of a revolutionary change in health and social care as the aspirations of Beveridge became political reality with the Labour landslide in 1945.

II

The new Labour government was committed to the principles of Beveridge which formed the basis of its health and social care policies. The problem for Brooke’s administration was how much, if any, of this proposed legislation the Northern Ireland government could adopt as part of its own commitment to step-by-step. There already existed within Ulster Unionism a coherent body of opinion in favour of radical reform of health and social care. In 1943, for example, David Lindsay Keir, vice-chancellor of Queen’s University, delivered a positive speech on Beveridge to the Ulster Reform Club.Footnote ³³ Wilfrid Spender looked favourably on the ideals of Beveridge. Following debates on the report in both Belfast and London in 1943 he speculated that reform, along the lines of Beveridge, ‘should bring home to the public the benefits which the people of Northern Ireland get from their association with Great Britain’.Footnote ³⁴

In addition, there was the pressure for reform emanating from the select committee on Health. Not every measure of reform courted controversy. When Grant moved to implement some of the select committee’s recommendations on county health schemes in 1946, Brooke was able to record that the ensuing debate was ‘one of flattery and pleasure’.Footnote ³⁵

However, the relationship between Ulster Unionism and Labour was a difficult one. The government benches in the imperial parliament now contained members who were bitterly critical not only of partition in Ireland but of the Unionist regime in Belfast. The position of Unionist M.P.s at Westminster was also problematic. In 1947 Brooke complained that Unionism had the ‘curious anomaly that Westminster M.P.s owe their allegiance to the Conservative Party [who do not] necessarily have the Ulster point of view. We, on the other hand, have to work with whichever government is in power.’Footnote ³⁶ This had implications for the Northern Ireland government as the Conservatives were closely aligned with those in the medical profession in England and Wales who were bitterly opposing the same health reforms being considered by Brooke and his cabinet.Footnote ³⁷ The suspicions about Labour were compounded by a philosophical rejection of the Left by large sections of Ulster Unionism. As the Belfast Telegraph pointed out in 1947 ‘the spoon of devolution is not long enough for supping with the devil of socialism’.Footnote ³⁸

The first problem for Brooke’s administration, however, was that if they were to follow the example of Westminster and enact a comprehensive health scheme then the government needed constitutional amendments to enable it to do so. The Government of Ireland Act which had established the state of Northern Ireland in 1920 granted insufficient powers to enable Brooke’s administration to enact all the provisions of its own Health bill. Specifically, it had not mandated the power to enable the Northern Ireland government to nationalise property and services, neither could the government prohibit the sale of medical practices. In March 1946, the cabinet discussed the possibility of having Attlee place an enabling clause in the Health bill for England and Wales which would give Northern Ireland the necessary powers. It was believed that such a clause, buried in the legislation, might give the government of Northern Ireland the powers to implement a scheme without raising expectations among the public that it was about to do so.Footnote ³⁹ The Home Office in London, however, did not want to complicate the Health bill with additional clauses.Footnote ⁴⁰

Instead, Attlee introduced a Northern Ireland bill at Westminster to fill the gaps in legislative authority. This removed restrictions on the powers of property transfer and nationalisation, and granted authority to conduct cross-border initiatives and greater freedom regarding public utilities.Footnote ⁴¹ The measure seemed straightforward enough but the process proved fraught for the Northern Ireland government. Before the Commons debate on the bill, 200 Labour members put their name to a motion opposing the extension of powers to Northern Ireland. Brooke was outraged. ‘There can be little doubt in the minds of the people here’, he said, ‘that this motion has been put down with one supreme object – to embarrass the Northern Ireland government in its ordinary tasks, to expose it to criticism at Westminster and generally to vilify the name of this part of the world.’ The special position of Northern Ireland was something which needed to be constantly stressed across the Irish Sea.Footnote ⁴²

The debate on the Northern Ireland bill proved equally difficult. Labour M.P.s used the opportunity to critique the Northern Ireland government and the nature of the state itself. The bête-noire for Unionists at Westminster was the Labour M.P. for Hornchurch, Geoffrey Bing. In the debate on the bill in June 1947, Bing accused the government in Belfast of exercising dictatorial powers. He wondered if the Special Powers Act in Northern Ireland, with its sweeping powers of arrest and internment, was used as ‘merely a weapon against political opponents’. He accused Brooke’s administration of fostering discrimination for party purposes and questioned whether local and parliamentary elections in Northern Ireland were being fairly conducted.Footnote ⁴³ The debate might have induced some squirming on the part of Northern Ireland’s M.P.s at Westminster and anger on the part of the government in Belfast but the bill passed and the necessary powers were transferred over. Brooke noted in his diary with satisfaction ‘a good deal of dirt thrown but our people appear to have been effective’.Footnote ⁴⁴

The question of welfare reform meant that Brooke had to overcome his own innate suspicions of Labour and construct a viable modus operandi with Attlee’s government. The Northern Ireland government was also committed to other reforms in social provision which the Labour administration was in the process of introducing. The first of these was a comprehensive scheme of national insurance which would radically reform unemployment, sickness, maternity and other benefits. Whilst the measure was only being introduced in England and Wales in January 1946, the Belfast Telegraph assured its readers that the Northern Ireland government would enact similar provision.Footnote ⁴⁵ ‘Our government has promised’, the newspaper told its readership, ‘a policy of step-by-step in all social services.’ But, the editorial went on to state that ‘a good medical service can be provided without slavishly following the English Socialist model’.Footnote ⁴⁶ Disquiet regarding the U.K. government’s socialistic tendencies was voiced frequently by the Ulster Unionist Council (U.U.C). A resolution tabled at the council’s conference in February 1947, for example, viewed ‘with alarm the ever-increasing growth of bureaucratic control and public expenditure in this non-Socialist community’.Footnote ⁴⁷ However, the signals emanating from the U.U.C. were mixed. In February 1948, the annual conference warned against the introduction of more ‘indigested socialist legislation’ whilst another resolution recognised the higher standard in social care in Northern Ireland compared to Éire and endorsed the ‘government’s policy of continuing to maintain our social services on the same level as those in Great Britain’.Footnote ⁴⁸

Brooke was convinced that reform was both necessary and desirable, as was a good working relationship with Westminster. In October 1946, he advised the executive of the Ulster Unionist Party that ‘it would be a mistake to get [Winston] Churchill over to the Unionist Association meeting as he might use this as a platform to attack the Socialist Party. This would make it more difficult to cooperate’. In 1947, as deliberations on the Northern Ireland bill proceeded at Westminster, Brooke was very conscious of ‘alienating the Socialists. Many of whom are our friends’. There was disquiet, too, in the Unionist Parliamentary Party at Stormont. It was not just the adoption of Labour’s reforms that caused anxiety. Unionist M.P.s were also uneasy at the new centralism of the Northern Ireland government. Brooke met his critics head-on at a party meeting in October 1947. He argued that centralised control was necessary in the current economic climate. He also delivered an ultimatum. ‘We must either maintain the general unity of Ulster with the U.K. and by doing so accept some of the legislation’, he told Unionist M.P.s, ‘or we must find other ways of working’. The alternatives included ‘joining Éire, back to Westminster or Dominion Status’. He also told them if they had someone they thought could do a better job they must say so immediately.Footnote ⁴⁹

By November 1947, Brooke was at pains to emphasise to the government’s critics that the upcoming Northern Ireland Health bill had been framed to be ‘more in keeping with Unionist principles’, though the Northern Ireland public would get the same benefits. These Unionist principles included Northern Ireland G.P.s ‘getting very much what they have always asked for – a standard fee for each patient on their lists rather than a basic salary plus fees’. Health professionals in Northern Ireland were ‘fairly well satisfied and on the whole sympathetic’ while English and Scottish ministers had ‘a great struggle with the medical professionals and are still in difficulties’.Footnote ⁵⁰

III

When the post-war Labour government’s novice Health minister, Aneurin Bevan, unveiled a bill for a free, centrally administered health service in 1946 the controversy between the government and the medical professions escalated into an increasingly bitter running battle. The British Medical Association’s (B.M.A) council chairman, Hugh Guy Dain, spoke of having to choose between ‘Bevan and Belsen’.Footnote ⁵¹ However, while the B.M.A leadership made the running in opposing reform, the medical profession was by no means monolithic. In 1945, for example, the Socialist Medical Association had issued a pamphlet calling for doctors to reject the position of the B.M.A. leadership and calling for the immediate implementation of the Beveridge recommendations.Footnote ⁵² The Medical Practitioners Union, too, opposed the position taken by the B.M.A. leadership. In January 1948, the Union advised their members to join the new service on the appointed day. The changeover to a state system was ‘inevitable because the people welcomed it, the profession recognised the need for it and no political party dared support its postponement’.Footnote ⁵³

The antagonism between the doctors and Bevan was one cause of anxiety for the Northern Ireland government when the Health bill for England and Wales was unveiled in 1946. In Northern Ireland the existing health services –general practice and voluntary hospitals – were proving insufficient to provide opportunity for the numbers of doctors leaving the armed forces at the end of the Second World War. ‘Ex-service housemen and ex-service registrars’, it was argued, ‘became the order of the day and medicine made its contribution to the growing ranks of angry young men.’Footnote ⁵⁴ The relationship between doctors and the new ministry of Health in Northern Ireland, however, was different to the very acrimonious one playing out between Bevan and the B.M.A. In Northern Ireland, dissatisfaction and the desire for reform among doctors, including the Northern Ireland branch of the B.M.A., converged with a determination to compromise on the part of the government.

Rather than present medical professionals with the fait accompli of state control as Bevan had done in England and Wales, William Grant offered doctors in Northern Ireland a voice in shaping the new service from the outset. The minister of Health and Local Government had no doubt that Northern Ireland should have a health scheme of its own. When he announced his intention to draft legislation similar to Bevan’s Health bill in a memorandum to the cabinet in September 1946, he also sought approval to open discussions ‘with those who will be concerned with the provision of the service, for example, associations representing hospitals and local authorities and professional bodies representing doctors, dentists, pharmacists and others’.Footnote ⁵⁵

In March 1947, Grant outlined the progress of his corporate approach to the cabinet. As well as being ‘most anxious’ to avoid anything like the controversy which the minister of Health in England has aroused over his National Health Service Act, ‘he genuinely felt’ that the health service could not work without the goodwill of the medical profession. Thus, he had ‘refrained from outlining proposals until I have had talks with responsible representatives of the profession to find out what they were thinking and to build up as much confidence as possible’. Grant had met with consultants’ and specialists’ groups, the Northern Ireland branch of the B.M.A. and representatives of the British Hospitals Association (B.H.A). He reported that relations were most cordial and the common ground between them was greater than expected.

Grant was very open in his desire to get the support of medical professionals for his bill and was ‘ready to accept their recommendations as far as they can be reconciled with my own responsibility’. He reported that there were divisions among doctors but after his discussions he was in a position to outline his scheme. There would be a merging of voluntary and rate-aided hospitals to form ‘one unified and flexible service which can be placed at the disposal of everyone regardless of residence (that is, within the United Kingdom)’. Grant proposed that payment for doctors should be on the basis of capitation fees as opposed to a salaried scheme. Medical practices might continue to be bought and sold. Thus there was no need to ‘set up any system of control which is so objectionable to the profession’. Prominent among these was the right of appeal for medical professionals. Doctors in Northern Ireland would have a right of appeal to a tribunal on issues of eligibility and other matters rather than the system of appeal to the ministry of Health under the Health bill for England and Wales. Grant believed that he could secure a workable scheme along these lines and that only ill-will on the part of the medical professions would render it impossible. However, he firmly believed that the B.M.A. in Northern Ireland fully recognised his position and were ready to make concessions towards meeting it.Footnote ⁵⁶

The cabinet approved Grant’s approach and offered congratulations for the success of his negotiations.Footnote ⁵⁷ The medical profession, too, approved of the minister’s tactics. In a letter to the British Medical Journal which appeared in November 1946, Dr Colm McCluskey from Dungannon in County Tyrone said that ‘doctors here could show Mr Bevan how cooperative they could be with a bill which satisfied them’. Health proposals for Northern Ireland retained the capitation fee system of remuneration of which the majority of doctors approved; hospital arrangements were satisfactory as were the proposals on doctors’ right of appeal. McCluskey also praised the retention of buying and selling of practices along with the provision of ‘definite hours of leisure’.Footnote ⁵⁸

State administration of at least some medical services was already an established part of Brooke’s administration. In response to the recommendations of the select committee on Health, Grant had overseen the creation of a central Northern Ireland Tuberculosis Authority.Footnote ⁵⁹ The bill creating this new body was introduced in 1946 and amalgamated eight local authorities under which treatment and prevention of T.B. had previously been undertaken. Twelve hundred people died annually from T.B. in Northern Ireland and the bill recognised that the disease was a social problem as well as a medical one. Allowances were provided for those in treatment and the bill removed much of the stigma of T.B. being perceived as a disease of poverty along with the complaint that patients could not afford to be ill.Footnote ⁶⁰ Nevertheless, there remained unease among Unionists. The Belfast Telegraph expressed doubts over the extent of state control. A national health service might well turn out to be ‘a soulless, standardised system which must result if the government takes complete control of all hospitals and doctors’.Footnote ⁶¹ Throughout the negotiating process and the formulating of the health scheme the newspaper remained as supportive of the government as it was sceptical about the scheme.

There was further scepticism on view in Belfast in January 1947 when the secretary of the British Medical Association, Charles Hill, addressed a meeting of health professionals in the Assembly Rooms. In the course of his speech Hill attacked the national health scheme as undermining the relationship between doctor and patient which he said must not be ‘chilled and administratively controlled’. Doctors objected to becoming salaried officers of the state with ‘nice comfortable lives, regular hours, holidays and no night calls’. Hill argued that medicine could not be organised on the shift system. The independence of voluntary hospitals must be maintained. ‘The profession wanted’, he said, ‘coordinated medical services; preservation of professional freedom; no interference with doctor–patient relationship; the responsibility to remain with the individual patient’.Footnote ⁶² These were all issues upon which the government, and William Grant, were very open to meeting the demands of doctors in Northern Ireland.

Negotiations on the new health scheme continued throughout 1947 and Grant was able to report to the cabinet that these had been ‘distinctly good’ with only ‘a few points of real difficulty’. One of these was the issue of pay-beds.Footnote ⁶³ Hospital consultants favoured the continuation of the system but Grant was unsure. He found the idea of fee-paying for patients ‘hard to reconcile with the principle of free treatment for all […] Is a person, by paying fees, to get admission to a hospital supported by the state while his neighbour, unable to afford the bed fees and the surgeon’s fees, has to take his place on the waiting list?’ Despite his own misgivings, Grant believed he would have to concede the point to secure the support of consultants but he would insist on a ceiling for the amount of fees paid. The number of pay-beds should have some regard to the waiting lists and there should be no pay-beds in new hospitals. Other aspects of the scheme included the continuation of Northern Ireland’s compulsory vaccination scheme against smallpox. Grant was also considering the widening of the scheme to include diseases like diphtheria.

The B.M.A. in Northern Ireland, meanwhile, had changed their demands on remuneration in the course of the negotiations. Grant told the Cabinet that ‘after giving me the most firm assurances on pay scale, sale of practices and control, the spokesmen of the doctors had to come back to me again, eat their words and ask for the principles they had so vehemently denounced.’ Capitation fees remained the preferred method of payment but doctors raised the possibility of a partial salaried scheme for rural practices which would have fewer patients and hence smaller fees. The B.M.A. in Northern Ireland now favoured the abolition of the sale and purchase of practices which would bring them into line with their counterparts in England and Wales. Compensation would have to be paid in the region of £1.9 million. Grant was surprised by the way in which the issue of salaries had re-emerged. ‘But now it becomes, very amusingly, the doctors’ turn to beg for control; they want some protection in the open competition for fees.’Footnote ⁶⁴ It was decided, however, that there would be no need to include salaries. Capitation fees would remain the method of remuneration and restrictions placed on the number of patients on doctors’ panels would ensure adequate numbers of patients in poorer, rural areas. The cabinet agreed that it was unnecessary and undesirable for the government to control the distribution of practices unless specifically requested to do so.Footnote ⁶⁵

The government published a draft bill on 30 June 1947. It provided for a state-funded, free universal health service for Northern Ireland. Voluntary hospitals would now come under a central body – the Northern Ireland Hospitals Authority – and would be funded by the government who would also appoint local management committees. Doctors would be paid through a system of capitation fees corresponding to the number of patients in each practice. Buying and selling of medical practices would be prohibited. General practice would come under the authority of a General Health Services Board. Grant was still negotiating on the level of compensation for doctors which might now be £2 million. He was reluctant to commit to the idea of multi-doctor health centres, preferring to see how the experiment worked in England.Footnote ⁶⁶

The bill was well received. A leading article in The Lancet published in September 1947 pointed out that it granted many of the concessions doctors had vainly sought in London. The size of Northern Ireland, an area not much bigger than some of the administrative areas in England or Scotland, had allowed for much simplification. The continuation of capitation fees and the right of appeal of doctors to a tribunal was noted with satisfaction along with the preservation of the pay-bed scheme for treating private patients in hospitals. The bill ‘offered a practicable adaptation of the earlier schemes to Northern Ireland’s needs and seems to have also made most of the concessions asked by the doctors there’.Footnote ⁶⁷ The line Grant had managed to steer between state administration and state control was welcomed by Brooke. In June 1947 he noted in his diary that the Health Bill ‘endeavours to give [a] national health service to all without involving the country in nationalisation’. He was satisfied that the new service was equal to that of England, ‘but not so socialistic’.Footnote ⁶⁸

IV

In spite of the ostensibly positive reception of the Northern Ireland Health bill, and for the solicitous approach of William Grant, there were some dissenting voices among doctors. F. M. B. Allen, a noted Belfast paediatrician who was Ireland’s representative at the British Paediatric Association, was far from pleased with events.Footnote ⁶⁹ He used his relationship with the Northern Ireland cabinet secretary, Sir Robert Gransden, to vent his frustration with developments. In a letter to Gransden in October 1947, Allen claimed there was substantial opposition to the broad principles of the bill among his colleagues. These measures of nationalisation were, he said, not in the best interest of the people of Northern Ireland, as hospitals could not cope with the demands which would be placed upon them under the new scheme. He hoped that the minister of Health would withdraw his hostility to pay-beds. In the draft bill, Grant sought to limit pay-beds to existing hospitals only, where fees would be capped. The system would not be allowed to operate in new hospitals. He was also determined that those able to afford to pay would not be treated at the expense of those on waiting lists.Footnote ⁷⁰ Restricting access to fee-paying clinics, such as the specialist services offered by the Clark Children’s Clinic in Belfast, Allen argued, was ‘class legislation of the worst kind’.Footnote ⁷¹ A week later, he told Gransden ‘as regards the Health bill, the more I look at it the more convinced I am that the medical profession should never have been involved in any way in its construction.’ It would have been better to let blame for the inevitable ill-service it offered to fall upon the ministry.Footnote ⁷²

Allen’s was not the only voice of discontent. Even before the publication of the Health bill, Grant faced sustained criticism from Marchioness Londonderry, chair of the Queen’s Institute of District Nursing, on the future of nursing in the new local authority structures being discussed at the ministry. Lady Londonderry warned that if local authorities would be deciding the quality and quantity of nursing services in each borough or county it ‘will spell absolute ruin to any improved nursing system. I do most strongly deprecate such a system.’ She favoured the kind of central administration which the general practitioners would have.Footnote ⁷³ Grant tried to reassure the marchioness that nursing services would be protected under the new scheme. Ministry officials had met with the Queen’s Institute of Nursing which he was sure would play a large part in the shaping of the future health service.Footnote ⁷⁴ But Lady Londonderry was not mollified and continued to press Grant over his plans for nursing to such an extent that in August 1947 he appealed to Brooke for help in dealing with her. ‘I have been considerably annoyed’, he told the prime minister, ‘and not a little surprised at Lady Londonderry’s attitude in this matter.’Footnote ⁷⁵

Grant also faced criticism when presenting the bill in the Northern Ireland House of Commons. Dr Frederick MacSorley, independent M.P. for Queen’s University, told the minister ‘the only doubt I have in my mind is whether I should label it “dangerous – not to be taken” or merely poisonous’. MacSorley said that if the bill became law, the time would come when ‘doctors would have to be very careful not to incur the displeasure of some new department chief in Stormont because differences with politicians might jeopardise the chances of promotion under the new government scheme’.Footnote ⁷⁶ By and large, however, most of the reaction to Grant’s Health bill was positive. Many health professionals shared the opinion expressed by George Dougan who said in the Commons: ‘we medical men appreciate very much all that the minister has stated and we also appreciate his sympathy up until now with the dispensary medical men and with doctors in general’.Footnote ⁷⁷

The most immediate complaint regarding the Health bill among medical professionals was that more time was needed to scrutinise it and offer suggestions. On 20 October 1947, M.P. Sinclair, honorary secretary of the B.H.A. in Northern Ireland, wrote to Brooke pleading for more time. Sinclair offered an assurance that his only wish was to be ‘cooperative and helpful’ and that the opposition of the B.H.A. was ‘constructive and in no way destructive’ of the bill’s many excellent provisions.Footnote ⁷⁸ The president of the B.M.A. in Northern Ireland, H. I. McClure, also wrote seeking a delay to enable medical professionals ‘to see that in every respect it is as good a bill as can be in the circumstances put on the Statute Book’.Footnote ⁷⁹

Brooke was receptive to delaying the committee stage of the bill. As his secretary, W. N. McWilliam, informed L. G. P. Freer, permanent secretary at the ministry of Health, the prime minister was ‘most anxious that every consideration be shown and at the very least a list of amendments currently being considered should be finalised’.Footnote ⁸⁰ Both associations replied with suggestions. The B.M.A. wanted to increase the total amount of compensation for the prohibition on the sale of practices to £2¼ million. The B.H.A. wanted to maintain and extend existing arrangements for pay-beds in hospitals. They also lodged the more incendiary demand that all hospitals in Northern Ireland with religious associations should receive the same consideration as their counterparts in England and Wales. This association should be taken into account when organising a managing committee.Footnote ⁸¹

By far the most controversial aspect of Grant’s Health bill was the position of the Mater Infirmorum Hospital in Belfast. Northern Ireland was a divided society and these sectarian divisions extended into the provision of medical services and even into the medical profession.Footnote ⁸² Established in the 1880s, the Mater was generally regarded and cherished as a Catholic hospital. As well as possessing wards and operating theatres there was also a Catholic chapel and a convent of the Sisters of Mercy on the hospital grounds. The Mater provided the issue upon which the government and its Heath bill faced its most intense and bitter criticism.

William Grant was well aware of the potential for controversy over the Mater hospital. He warned the cabinet of coming difficulties in a memorandum in June 1947. ‘I have always recognised’, he said, ‘that there would be problems here but my mind is more firmly made up than ever that every effort must be made to bring the Mater hospital into the scheme’. Grant told his colleagues that contact with the Mater’s board of management had yielded no results but that he was seeking face-to-face discussions.Footnote ⁸³ Others in the government shared Grant’s determination for the inclusion of the Mater in the new health scheme. In September 1947, the minister of Home Affairs, John Warnock, told Brooke they ‘should have no hesitation in taking over the Mater Hospital because […] if they are left out in the cold they will work up a grievance in two years and say that only Protestant hospitals have been subsidised at the expense of Roman Catholics’.Footnote ⁸⁴

However, the issue of the role of the state in the provision of health and social care was problematic for Irish Catholicism. The experiences of the European church under Fascism during the war and the encroachment of Communism in the immediate post-war years meant that any notion of an enhanced role for the state was viewed with suspicion. Nevertheless, the impact of the Beveridge Report was felt far beyond the United Kingdom and in its aftermath a coherent debate emerged in the Irish Free State among Catholic churchmen, politicians and medical professionals.Footnote ⁸⁵ Here, however, the emphasis was on reform of the national insurance system, rather than the provision of universal free healthcare. This proved radical nonetheless. The report compiled by John Dignan, bishop of Clonfert, on national insurance in 1944, for example, was hailed as a ‘Beveridge for Ireland’.Footnote ⁸⁶

The health proposals in Northern Ireland threw into stark relief the difficult relationship between Catholics and the state. It was not just the idea of an amorphous socialist threat.Footnote ⁸⁷ The problem essentially was this. The Health bill provided for the state assuming control of not just hospital services but the buildings and facilities in them. For many Catholics in Northern Ireland, the prefix ‘state’ in relation to organisations or institutions meant ‘Protestant’. Catholic suspicions had already been heightened by the introduction of an education bill by Brooke’s administration in 1946.Footnote ⁸⁸ Thus, there was deep anxiety about what would happen to the Catholic character of the Mater once it fell into the hands of a Protestant, Unionist government. Sectarian fears blighted the reception of government reforms among sections of Catholic opinion. In January 1946, for example, an editorial in the Irish News declared that ‘reform usually brings disillusionment to everyone except those it directly benefits. The regime in Northern Ireland has always been a government of the Ascendancy.’Footnote ⁸⁹

For its part, the government refused to treat the Mater as a special case when the Northern Ireland Hospitals Authority took control of the voluntary hospitals and began appointing new management committees. Grant was adamant that there would be no half measures regarding the Mater. ‘Either the hospital comes in and enjoys the full benefits’, he told the cabinet, ‘or it stays outside and enjoys none.’Footnote ⁹⁰ He was determined that should the Mater refuse to take part in the scheme it would not be eligible for any of the benefits in funding and grants. He communicated this in no uncertain terms in a meeting with the Mater’s representatives in July 1947. The hospital’s management told him they agreed in principle with the majority of his proposals ‘except involving the handing over of their institutions to the Hospitals Board’.Footnote ⁹¹

The Mater controversy made the government’s English supporters nervous. Christopher Hollis, a prominent Catholic member of the Conservative Party, editor of The Tablet and M.P. for Devizes, was prompted to write to the Unionist M.P. for South Belfast, Hugh Connolly Gage, following unfavourable press reports on the Mater he read while on holiday in Ireland. Hollis was sure that the Mater had been held up at Westminster as an example of the kind of hospital whose character ought to be preserved during debates on the Health bill for England and Wales. ‘I feel that if the Northern Ireland government is making a mistake, then it is a thousand times better that the protest against it comes from our side and if possible from you, rather than that Captain Bing and his pals make all the running.’Footnote ⁹²

Among Nationalist and some Opposition M.P.s in the Northern Ireland Commons, the government’s attitude towards the Mater caused outrage. During the Health bill’s second reading, Dr Frederick MacSorley condemned the government’s ‘confiscation’ of voluntary hospitals. He said the Mater was ‘a Catholic hospital. It was founded by Catholics and is conducted and controlled by Catholics.’ He said they would never agree to ‘the outrageous proposal neither on justice nor on reason to confiscate our hospital buildings, our plant and our equipment’.Footnote ⁹³ Cahir Healy, Nationalist M.P. for South Fermanagh, said that the trustees of the Mater Hospital would not ‘transfer their institutions whatever be the cost to them in hardship and inconvenience’.Footnote ⁹⁴ Grant replied that the Mater’s trustees had told him they would ‘fight to the last ditch’. Nevertheless, he would meet with the Mater’s representatives but he refused outright ‘to consider any amendment which would offer one hospital an advantage over another’.Footnote ⁹⁵

Grant’s reasoning on the issue of the Mater was explained in a letter from Freer to W. N. McWilliam in the prime minister’s office. He believed that any new public service should be launched without reference to religious connections. It would only open the door ‘to assertions of sectarian connections which would otherwise remain happily unthought of’.Footnote ⁹⁶ This was wishful thinking or delusion on the part of the ministry. The controversy over the Mater was certain to stir up sectarian feeling. In November 1947 Brooke received a letter from Norman Porter, secretary of the National Union of Protestants. He told the prime minister that the Union was in favour of the Mater joining the hospital scheme but they opposed the payment of any grants to the hospital should it stay out. Porter also claimed the right ‘to hold protest meetings in the constituencies of those Protestant M.P.s who vote in favour of the grant being given and we also claim the right as a Union of Protestants to preserve and maintain the interests of Loyal Protestant taxpayers’.Footnote ⁹⁷

The government had already faced considerable pressure from the churches, its grass roots organisations and the Loyal Orders on its Education bill. One of the main objections was the increase in grants to non-transferred or voluntary schools which were mostly Catholic. There was also disquiet within the Unionist Party. In October 1946, Brooke had noted that the new sixty-five per cent grant was being viewed as ‘subsidising the Roman Catholic Church’. A week earlier he had told the cabinet he would warn Protestant churchmen that he would call an election or even resign if they garnered enough support to defeat the government on the bill in the Commons.Footnote ⁹⁸ The pressure on the issue of the Mater was not nearly as vociferous. However, the government was already fighting on a number of fronts on health, and an unwillingness to arouse religious sensibilities within the party or its adjuncts perhaps encouraged a certain intransigence when it came to the Mater. Thus, there was no provision in the bill for voluntary hospitals opting out of the scheme to receive funding.Footnote ⁹⁹

During the committee stage of the Health bill, Grant proved inflexible on this issue. Nationalist members accused him of contemptuously refusing to accept the services of the Mater’s board of management. The board, in turn, remained ‘absolutely adamant in its refusal to allow the hospital or its property to be confiscated’. Nationalist members moved that the Health Services Act should not apply to the Mater Infirmorum Hospital.Footnote ¹⁰⁰ Grant insisted that the Health bill had nothing to do with politics or religion. He was equally insistent that the Mater would get no special treatment. The Health bill, he said, was ‘a human bill for every man woman and child in Northern Ireland and all humanitarian and right-thinking people ought to support it on that ground’. Nationalists accused the government of sectarianism, now they asked him to discriminate in their favour.Footnote ¹⁰¹

The Catholic Church remained bitterly opposed to Grant’s position of ‘100 per cent in or 100 per cent out’ with respect to the Mater. In a Lenten pastoral published in February 1948 which condemned the ‘aggression of the state’, the bishop of Down and Connor, Daniel Mageean, insisted on the right of Catholics to maintain their Catholic hospital and to see that ‘it is conducted in conformity with the discipline of the Ten Commandments of God and the teaching of the Catholic Church’. He argued that for Catholics it was not a matter of ‘transferring merely bricks and mortar. The Mater Infirmorum Hospital is more than that; it is an ecclesiastical institution through which the Catholic Church in this area exercises her Divinity-given mission caring for the sick and afflicted.’Footnote ¹⁰² There was much anger and incredulity that the clauses of the ‘English Health bill’ which provided for the preservation of religious affiliations among hospitals could not be extended to Northern Ireland. Bevan, the Irish News reported, had negotiated ‘quite amicably’ with the English Catholic primate, Cardinal Griffin. Catholic hospitals in England and Wales would operate as before, retaining their religious character but were also able to participate in the heath scheme by putting a large number of their beds at the disposal of the local authority.Footnote ¹⁰³ As the National Health Service came into operation in Northern Ireland in July 1948, the Mater was the only hospital to remain outside the scheme. In spite of the outrage expressed by Catholic churchmen and politicians on the Mater, however, there was no attempt to persuade Catholics not to take advantage of the other provisions of the National Health Act.

By October 1948 some one and a quarter million people, ninety-three per cent of the population of Northern Ireland, had placed their names on doctors’ lists under the health scheme.Footnote ¹⁰⁴ The National Health Service was a resounding success. The approach taken by the Northern Ireland government was lauded by sections of the medical profession in England. Dr Alexander Montgomery from Bournemouth, for example, chided the British Medical Journal for its lack of coverage of the Northern Ireland Health Act which was ‘streets ahead of the British Act’. The Ulster doctors, he said, were pleased with it ‘and will show every readiness to cooperate with the Ministry of Health […] who have shown themselves to be reasonable and ready to compromise for the common good’.Footnote ¹⁰⁵

Reaction to the Health Act was more mixed in some quarters. At a meeting of the management committee of the Samaritan’s Hospital in Belfast, for example, the creation of a central hospitals authority was condemned for destroying ‘the voluntary spirit and individualism of the hospital’.Footnote ¹⁰⁶ On the other hand, the new chairman of the Northern Ireland Hospitals Authority, Dr F. P. Montgomery, had nothing but praise for the government and the new health scheme. He declared it ‘a great relief’ that hospital maintenance would become the responsibility of the state.Footnote ¹⁰⁷

Grant proved as open to amendments during the committee stages of the bill as he had been in negotiations with the doctors. However, there were a few issues on which he refused to compromise. He would not embroil the ministry in doctors’ rates of pay, insisting that local authorities set the pay-scales of health professionals outside general practice.Footnote ¹⁰⁸ He gave ground on other issues like pay-beds. Overall, Grant’s willingness to consult with the medical professions and associations created a large reservoir of goodwill, not just towards the Health bill but also towards the government. Speaking at the inauguration of the Northern Ireland General Health Services Board, Grant said the Health Act was ‘the culminating point of many brave, honest and sincere efforts in the interests of the people of Northern Ireland’.Footnote ¹⁰⁹

The comprehensive health scheme was just one aspect of the Northern Ireland government’s radical reforms. There was also the creation of the Northern Ireland Tuberculosis Authority which would transform the treatment and prevention efforts. The government also introduced a new system of national assistance. At the same time, a new national insurance system was introduced to finance the health service. The scheme envisaged that £7.7 million would be paid in stamps while the government would pay a £2 million supplement.Footnote ¹¹⁰ In addition, the government had set aside £500,000 to fund a new Mental Health Act which provided for mental health care under the Northern Ireland Hospitals Authority as well as the establishment of a colony for the mentally disabled.Footnote ¹¹¹ There was, inevitably, a few teething problems with the scheme. Post offices ran out of insurance stamps and the authorities were still receiving contracts from doctors on the day the scheme came into operation. Grant remained positive and said he had received many assurances from medical professionals that they were ‘determined to make the service one of which Ulster can be proud and I have every confidence that we shall all work together to that end’.Footnote ¹¹²

V

On the eve of the general election in 1949, the Ulster Unionist Council on behalf of the government in Northern Ireland produced a pamphlet offering a progress report on seven ministries for the years since 1945. Of these, the ministry of Health and Local Government was singled out for triumphant acclaim. The most recently established government department had ‘made such remarkable progress that its childhood and adolescent stages are now long past and it operates in the full vigour of manhood’. Ulster’s health and welfare services had, it said, been revolutionised. The 1947 Health Act has been ‘the greatest direct influence on the Ulster people of all modern legislation’.Footnote ¹¹³ That the Health Act would form a central plank of government propaganda was never in doubt. As early as 1943, Wilfrid Spender had recognised the value to the Union of health and social reform along the lines of Beveridge.

The Northern Ireland Health Act of 1947 was very much shaped by Ulster Unionism. The impetus for change came from the backbenches of the Ulster Unionist Party. The ousting of Andrew’s moribund administration was not enough to ensure the kind of root and branch reform of health and social care that was ultimately enacted. This was only assured by the continued pressure for reform emanating from ‘old’ Unionists like William Lyle and from the watershed select committee on Health. At the same time, Unionist suspicions and fears set the parameters for state intervention on health and social reform. There could not be the kind of fait accompli nationalisation of health resources that Bevan had forced through in England and Wales.

William Grant had a consistent and unwavering commitment to change. His willingness to negotiate with the medical professions spared Northern Ireland the kind of hyperbole and acrimony that accompanied Bevan’s more confrontational approach. His room for manoeuvre on the issue of the Mater was perhaps more limited. Unionism had already reacted negatively to the Education bill with its increased funding for Catholic schools. Nevertheless, there was never any suggestion that the government would wilfully exclude the hospital from the new scheme. At the same time, there was sustained resistance by the Mater’s management committee, the Catholic Church and Nationalist politicians to the government effectively assuming control of the hospital. None of these interests managed to overcome their suspicions of the state while Grant was unable to offer acceptable assurances on preserving the Catholic character of the hospital. Thus, as these factors converged, the Mater remained conspicuously outside the National Health Service.

Grant, as Ditch has argued, was instrumental in keeping the Unionist government in touch with working class opinion, warning it of the dangers of allowing its conservative sensibilities to distance it from its grass roots.Footnote ¹¹⁴ However, although Sir Basil Brooke might not have had Grant’s history with working class Unionism, he also played an invaluable role in this regard. Overcoming his own distaste for Labour, he bullied and cajoled the Unionist Party in Belfast and in Westminster, as well as the Ulster Unionist Council, into accommodating Attlee’s government and the very popular post-war reform agenda. The National Health Service that was established in 1948 in Northern Ireland reflected the concerns, stresses and tensions of Unionism. These were not only visible in, for example, clauses ensuring that the citizens from Éire could not avail of the new service.Footnote ¹¹⁵ They can be seen in the desire of the government to strike a careful balance between state oversight and state control of medical professionals under the scheme. Pressure from politicians like Lyle to enact change that might reverse the negative impact of years of inertia on health was insufficient to ensure reform. The suspicions and fears of Unionism needed to be addressed. Thus, in the end, the Health Act in Northern Ireland emerged as a triumph of both aspiration and political pragmatism.