By expanding the geographical scope of the history of violence and war, this volume challenges both Western and state-centric narratives of the decline of violence and its relationship to modernity. It highlights instead similarities across early modernity in terms of representations, legitimations, applications of, and motivations for violence. It seeks to integrate methodologies of the study of violence into the history of war, thereby extending the historical significance of both fields of research. Thirteen case studies outline the myriad ways in which large-scale violence was understood and used by states and non-state actors throughout the early modern period across Africa, Asia, the Americas, the Atlantic, and Europe, demonstrating that it was far more complex than would be suggested by simple narratives of conquest and resistance. Moreover, key features of imperial violence apply equally to large-scale violence within societies. As the authors argue, violence was a continuum, ranging from small-scale, local actions to full-blown war. The latter was privileged legally and increasingly associated with states during early modernity, but its legitimacy was frequently contested and many of its violent forms, such as raiding and destruction of buildings and crops, could be found in activities not officially classed as war.
Beyond its seventieth year, Britons are repeatedly told in culture, politics, and media that the National Health Service (NHS) is loved and important, yet under threat.1 What does it mean when we say that we ‘love’ the NHS? How do different public groups ascribe meaning to this service? When do feelings about the NHS, such as love or fear, turn to action, such as protest or changing patterns of usage? Understanding these questions helps us to think through a cultural history of the NHS, bound up with feelings, meanings, and belief. Taking these seriously and examining them through multiple methods enables us to see the vast variety of opinions underlying public attachments to, and behaviours around, the NHS. The idea that Britons ‘love the NHS’ is a rallying cry, political justification, and popular cliché. Cultural history is uniquely placed to help us unpick these assertions and to recognise their complexities.
At present, ‘remarkably little empirical’ or qualitative data exists to help us understand public attitudes towards the NHS.2 Oral historians have begun to try and fill this gap. The ‘NHS at 70’ project – discussed by Angela Whitecross in this collection – aims to ‘collect stories from the first generations [of the NHS] as they are now in their 80s and 90s’.3 The historian Graham Smith has interviewed general practitioners, discussing their views of training, diagnostics, and record-keeping and the relationships between primary and community care.4 John Armstrong, Susan Kelly, and Julian Simpson have used oral histories to trace the experiences of migrant doctors from New Zealand and South Asia, and those of former tuberculosis patients. All of these oral history projects have uncovered critical perspectives which are not always recorded within archives, whose collections are shaped by structures of power.5 Clinicians, also, have used interviews to uncover the lived experiences of discriminatory – and now to be banned in England and Wales – historical treatments, such as homosexual conversion ‘therapies’.6 These projects have all demonstrated the value of documenting public and clinical memories, in addition to conducting valuable archival work.
Yet more work could still be done. With this in mind, this chapter makes a close investigation of a group which has not yet been subject to sustained academic consideration: NHS campaigners and activists. This group has a special attachment to the NHS; these individuals have moved from feelings about the NHS towards action. Campaigners and activists reshape their private and public lives in order to promote or defend a specific and collectively made vision of the NHS. They seek to mobilise and rally broader public opinion and political change, and thus reflect, as well as seek to shape, views. The feelings of NHS campaigners and activists are therefore significant. Tracing these feelings in a structured way – which has rarely been done before – helps us to unpick complexities in public attitudes. If even the views of this relatively small and focused group, with strong passions in relation to the NHS, are fractured, divided, and complex, then this highlights clear difficulties with making bold assertions that ‘everyone’ ‘loves’ the NHS. Furthermore, looking at the views of this group helps us to think about the relationships between publics and state institutions. Studying this group, which has some of the strongest attachments to the NHS, begins to demonstrate when, why, and how members of the public develop ‘love’ for institutions; when members of the public will challenge state provision; and, more broadly, how forms of lay expertise thus come into collaboration and conflict with political and media power.
In part, this chapter examines activist and campaigner feeling through archival materials, analysing papers of three groups: London Health Emergency, the Politics of Health Group, and Spare Rib. Primarily, however, the piece focuses on an analysis of the results of a new survey of 175 self-identified NHS campaigners, composed of over 38,000 words of rich and new qualitative data. The chapter first explains the shape of this survey. Second, it considers findings, demonstrating mixed views about what an ‘NHS campaigner’ and ‘the NHS’ actually are, and how ‘love’ for the service should be defined. Finally, the chapter argues that such analysis enriches a cultural history of the NHS, increasing our understanding of everyday cultures of meaning and exploring networked and collective ‘cultures’ formed between specific groups.
Overall, then, the survey demonstrates the ways in which there are no single ‘public feelings’ for the NHS. The cultural meanings of this service are deeply fractured, complex, and divided. At the same time, however, cultural meanings of the service are often formed collectively, through immediate and more distant (often online) networks. Looking at these collective organisations is very important, particularly for understanding how collective action emerges, from NHS marches and rallies to the mobilisation of voting blocs. This chapter thus helps us to think about the appropriate methods of cultural histories, and the ways in which different methods of enquiry trace different types of ‘culture’.
This chapter also contributes to the sense, emergent throughout this collection, that the mid-1940s and the 1980s were distinctive turning points in cultural histories of the NHS. In particular, the chapter argues that contemporary popular ideas about these moments strongly shape present values and beliefs about the service. This archival materials studied show how, increasingly since the 1980s, campaigners have identified a distinctive ‘NHS’ as an object to defend, albeit also one to critique. The chapter’s survey material also emphasises the connections which activists today draw between the foundation of the NHS and their own life histories. While political historians question whether the foundation of the NHS represented a ‘revolution’ or ‘evolution’ in policy terms, certainly the 1948 moment has come to assume cultural significance – as we see throughout this book, notably also in the oral histories of Whitecross’s chapter and in the films, television programmes, and festivals explored by Thomson.7
The original research conducted for this chapter was a ten-item online survey hosted on the website Survey Monkey. The questions in this survey (reproduced in Figure 3.1) were designed to elicit respondents’ own distinctive memories and forms of expression. The first survey question asked for demographic information. The main questions then asked about the perceived nature of NHS campaigning, and respondents’ feelings about the NHS and its reforms over time. In the process of developing these questions, a small pilot was organised, generating feedback from one self-identified NHS campaigner, a sociologist, and two historians. This shifted the questions used. For example, question 8 initially asked about conflict and disagreement between campaigners. Following the pilot study and feedback that this question seemed overly aggressive, it was reframed to ask about what campaigners had ‘in common’. The construction of this survey, therefore, encountered well-documented challenges in qualitative research about how best to work with activist groups while evaluating and documenting them.8
The survey was disseminated via convenience sampling, benefiting from snowballing effects which targeted self-defined ‘NHS campaigners’ by circulating across the online mailing lists of specific campaign groups, notably Keep Our NHS Public, and also via Twitter. This distribution method was in part reliant on speaking to gatekeepers who ran collective mailing lists. The survey thus accessed a specific network of individuals: people who recommended the survey to one another, and those linked to relevant personal and institutional Twitter accounts. Two campaigners made contact before completing the survey, to discuss why the survey had been created and its motivations. Survey research, like oral history, must address participants’ interest in how and why responses will be used.
Between April 2016 and April 2017, the survey received 175 responses. Forty-three of the respondents provided their demographic information but did not answer any further questions. This is in keeping with research about relatively high rates of non-compliance with online surveys, and perhaps suggestive that the open structure of these questions was, to some, offputting.9 For others, however, the broad questions provoked detailed responses. Across the entire survey, participants wrote 38,745 words. On average, the participants wrote 282 words in answer to the survey’s main questions, with response lengths varying from five to 1,367 words. The responses therefore were akin to short interviews. Survey responses are unlikely to record the same details as oral interviews; however, they may gain responses from a larger group, who may have been asked precisely the same types of questions, and in a unified format.
A key challenge for this methodology is the potential risk of declining response rates, given the emergence of an ‘interview society’ in which surveys are used for marketing research, academic work, and statutory consultation.10 Indeed, as noted, 25 per cent of respondents provided only their personal information and then stopped responding to the survey: either they were uninterested or their attention was drawn elsewhere. The barriers to exiting an online survey are low, which may decrease responses. Conversely, however, this has benefits in ensuring that those surveyed have actively consented to participate. Respondents can remove themselves with ease from the virtual encounter at any point. Indeed, and concomitantly, the barriers to entering an online survey are also low. To an extent, with larger surveys this may raise the challenge of controlling the quantities of responses. Historians conducting surveys can potentially find themselves collecting data rather than reflecting on it, or generating unmanageable amounts of data about well-documented subjects without gaining new information.11
Nonetheless, with the proliferation of internet use, contemporary historians or those wishing to reflect on how history is perceived today can potentially use a survey to reach a broader audience, and more quickly, than is possible with interviews. Internet use has grown immensely since the mid-1990s. In 2016, 98 per cent of British households had internet access, and the internet was used daily or almost daily by 82 per cent of British adults. This marked a dramatic increase from ten years earlier, in 2006, when only 35 per cent of adults used the internet near-daily.12 The distribution method of this survey was inexpensive, easy, and available to all academic historians, regardless of their ability to travel or to access funding for interviews and equipment. As Andrea Fontana and Anastacia Prokos have argued, the internet also enables ‘amateur and student researchers to conduct their own surveys for free’.13
The question of whether online surveys will enable us to document minority viewpoints is difficult to answer. Certainly, 12.6 million adults in Britain do not have the digital skills to ‘benefit from the online world’.14 The Good Things Foundation, which studies digital inequality, argues that it is those ‘already at a disadvantage – through age, education, income, disability, or unemployment – who are most likely to be missing out’.15 The challenges of accessing the views of marginalised populations, faced by all historians, are replicated online. At the same time, limited evidence suggests that virtual platforms can sometimes improve researchers’ access to ‘hard-to-reach’ populations, by expanding geographical scope and lowering physical barriers to access.16 Some populations may respond well to the ease, speed, and anonymity of the online survey and may wish to avoid a face-to-face encounter. For research specifically about activism, online surveys may be appropriate as online campaigning becomes prevalent. By enabling contributions from online activists, surveys acknowledge the broad range of types of political participation which coexist in modern Britain.
Methodologically, survey work also faces the general issues of data collection concerning how to analyse the social world while ourselves living within it.17 As Carolyn Steedman has demonstrated, however, harnessing our own thinking about the present, and our own personal relationships with institutions like the NHS, may provide an incentive to reflect more deeply.18 Thinking about one’s own experiences can encourage us to recognise and uncover richness in other narrative accounts and the ways in which we ‘rework what has already happened to give current events meaning’.19 In further challenges, survey accounts may also shape public testimony, as well as recording it. Providing one small suggestion of this, one respondent to this survey echoed the language of British Social Attitudes surveys – often prominently reported in the press – when arguing that the care and compassion of the NHS were ‘why the NHS is the thing that makes most people in the UK proud of their country’.
While online surveys may be relatively quick or ‘easy’ to construct, historians must also think carefully about how their analysis may reshape present debate. These methodological challenges are significant, but do not invalidate the potential of online social surveys as a tool for historical research. Rather, they emphasise the need to engage with the survey in a reflexive manner, constantly considering and revisiting target respondents, intended purpose, and key findings, from the inception to the evaluation of one’s research. When historians are defining research questions, the survey may enable them to quickly generate useful data. When we try to understand tensions in large groups, the survey may enable us to access complexity.
What are love, activism, and the NHS?
The first set of findings from this survey related to conflicting definitions: of NHS activism, of the NHS, and of ‘love’ or attachment for the service. In the first area, surveying who the NHS campaigner is, the survey was not representative of all people involved in activism in relation to the NHS. Of those who provided their gender, a majority self-defined as ‘female’ (100 participants compared with sixty-seven who wrote ‘male’). The majority of survey respondents wrote that they were ‘white’, ‘white British’, or ‘white English’ (107 of the 149 respondents who provided an ethnicity used these terms), but further participants also defined themselves as ‘British’, ‘Caucasian’, ‘Irish’, ‘English’, ‘Welsh’, ‘European’, ‘Jewish’, ‘Middle Eastern’, ‘Asian’, and ‘Afrocaribbean’. In terms of occupation, most respondents worked or had worked in the public sector: sixty-six in medicine and forty at universities, research institutions, or teaching institutions. The remaining participants worked in the voluntary sector, local and national governments, television, and media. Additional participants identified themselves as ‘housewives’ and ‘carers’. The survey reached respondents from a broad variety of areas across England and Wales. However, there were no responses from campaigners in Scotland or Northern Ireland. The different health systems operative in these countries, shaped by different histories, structures, and government policies, may also have shaped distinct cultures of activism, an idea that is further explored by Stewart, Dodworth and Ercia’s chapter in this collection in relation to activism in Scotland, England, Wales, and Northern Ireland.
Another key demographic finding was that the average age of respondents was sixty-two, although the ages ranged from twenty to ninety-four. Of the 136 respondents who provided their age, eighty-six (63 per cent) were ‘baby boomers’, and 118 (86 per cent) were five years older or younger than this category (born between 1940 and 1970). Interestingly, then, this result suggests that online research does not necessarily exclude older populations. Notably, what the survey failed to do was to capture the voices of the many younger people involved in NHS campaigning, for example through the junior doctors’ strikes. While some campaign groups effectively mobilise people of different ages, these groups were not prominently represented within this sample set.
The majority of this sample, then, were ‘baby boomers’, on average born in the 1950s under the new NHS, to parents who remembered a time before this institution emerged. Suggesting similarities between the respondents, multiple participants commented on the ‘older’ age, ‘old age’, or ‘high average age’ of NHS campaigners. Indeed, one respondent wrote bluntly, in response to the question about what campaigners had in common, that ‘We’re all old’. Another argued that the movement would be more effective if it was further connected to the industrial action of current staff. One younger participant, aged twenty-four, suggested that campaign groups could be ‘a bit informal and chatty’, involving ‘people who know each other’. The survey captured a relatively specific social group, which was representative of the challenges for qualitative research in reaching diverse audiences.20
Nonetheless, even within this focused sample, important disparities emerged. The first was in terms of what, exactly, campaigners believed that being an ‘NHS campaigner’ meant. The vast majority of respondents considered themselves campaigners as a result of having joined pressure groups, attended rallies, organised street stalls, and signed petitions. A minority, however, defined ‘campaigning’ in terms of having worked in the NHS, been involved in trade union or Labour Party action, or conducted online activity only. One respondent suggested that they had been an ‘NHS campaigner’ from birth, but the average participant answered that they had been involved in NHS campaigning for thirteen years. In terms of what participants were campaigning for – a question not directly posed but often addressed – responses also varied significantly. Campaigners suggested that they were campaigning for ‘the NHS’, abstractly; for universal and free healthcare; for a specific, individual hospital; for the erosion of a present government reform; or for principles such as ‘fairness’ and ‘equality’.
Within these discussions, respondents offered significantly different explanations of their attachment to the NHS, for example in terms of ‘pride’, ‘love’, or even ‘ownership’ of the ‘NHS’ or ‘welfare state’. Notably, only eight participants used the concept of ‘pride’. Furthermore, even among that small pool of respondents, the term held a broad variety of meanings. Some stated that they were proud of the NHS, others suggested that the existence of the NHS made them proud to be British, and further respondents still stated that they were proud to work within the NHS. While ‘pride’ was used in a variety of senses, the term ‘satisfaction’ was not explicitly mentioned by respondents at all. The rejection of this term possibly owed to its strong links to individualism and consumerism. Indeed, when participants did describe satisfaction with the NHS as a service, this was more commonly framed in terms of the NHS being ‘world class’, a ‘lifeline’, or a ‘safety net’ for all, emphasising collective, rather than individual, benefits. The idea of ‘love’ for the health service was also broadly absent from survey results, being mentioned explicitly by only ten people.
Participants therefore described their specific relationships with the NHS in a variety of terms, but often, as they were given no word limits, they explained this commitment through thick description rather than by using keywords such as ‘love’. Respondents’ descriptions of the NHS, furthermore, were ingrained with criticism of the service. Several campaigners in this survey sought to defend the NHS as a whole, while highlighting problems with how the service was organised, often those resulting from previous reforms. Survey participants described the inadequate provision of mental healthcare, lack of funding, ‘mismanagement’, ‘political interference’, and poor services provided by contractors. It is this long-standing and historical tension between criticism and defence which has shaped how campaigners and publics conceptualise ‘the NHS’.
What campaigners did collectively recognise, however, was a vision of the NHS as an abstract ideal, rather than as a system of primary, secondary, and community care settings. When asked what the NHS ‘meant’ to them, forty-two participants answered with reference to the principles of universal access. Participants also offered high praise through their descriptions of what the NHS was, as a ‘National Institution’, everything that promotes the ‘Common Good’, ‘sacrosanct’, or, echoing but subverting Nigel Lawson, ‘the nearest thing I have to a religion’. They also expressed ownership of this idealised NHS. Thirty-two used the expression ‘our NHS’, reflecting in part the popularity of this phrase in the names of campaign organisations. No respondents, in defining the NHS, referred to specific services provided in their areas. This meant that although the survey received responses from across England and Wales, surprisingly little sense of geographical difference emerged. This absence was notable, given contemporary and long-standing media and political debate about ‘postcode lotteries’ and the ongoing development of health devolution.21
Activism was shaped by the idea that the NHS was an ideal. Reflecting on this, respondents suggested that the ‘good strong brand’ of the NHS attracted many people to this cause, or that campaigning was ‘easier in some ways because most people want to keep the NHS’. Respondents also emphasised that, while other campaign groups had to define ‘more narrowly what they are “for”’, for NHS campaigners, specifically, ‘its [sic] enough to say you are for “it”’. Thomson’s chapter in this collection demonstrates that this recognition of ‘the NHS’ emerged relatively late in the cultural history of the service, in the 1980s and 1990s, before which time patients and publics discussed local hospitals or simply ‘the National Health’ or ‘health insurance’. This study of activism adds to this finding, demonstrating that the newness and abstract nature of this vision, while bringing campaigners together, could also leave them with ‘little agreement about what comes next’ in terms of which measures specifically to oppose or which areas to seek to improve.
Campaigners also suggested that abstract ideas about the NHS could inhibit debate, particularly in terms of determining ‘an alternative vision’ for healthcare. One participant wrote that NHS campaigning was ‘Harder to get a handle on’, leaving questions such as ‘What are we asking for? Who do we ask it of? Local or national? I could go on.’ Several participants felt that only the ideal of the NHS remained, and that the organisation was now ‘just a logo’, having lost its ‘founding principles’. Differing conceptions of pride, love, satisfaction, and ‘the NHS’ thus shaped different modes of politics, public feeling, and campaigning. Perceiving the NHS as an abstract ideal was of benefit to campaigners, providing a broad symbol to mobilise around, but also a challenge, making it difficult to determine concrete courses of action. Campaigners also expressed deep-held suspicions about the motivations of policy-makers, which added further to the challenges of enacting political change. Several respondents suggested that politicians wished to privatise the NHS, and discussed the importance of spreading ‘the truth’, particularly when working against right-wing tabloids and the ‘mainstream’ press. Many respondents were particularly suspicious of the language used in policy documents, for example concerning ‘rationalisation’. One wrote that seeing the words ‘Open and Transparent’ made them ‘wonder what they [policy-makers] have got to hide’.
Therefore this survey, considering the viewpoints of 132 individuals in detail, was able to probe tensions, contradictions, and complexities in how the NHS was described and in how popular attachment was felt and explored even within a relatively well-defined sample. A smaller sample set might not have been able to achieve this. Before moving to an analysis of these results, this chapter now turns to another finding: the idea of how attachments to the NHS have been formed.
The personal as political, historical, and familial
This online survey had further significant results in terms of defining the relationships between age, generation, and the NHS, a theme further explored by Elizabeth’s chapter in this collection. Again, despite the focused nature of this sample, significant differences emerged in how respondents defined their support for the NHS. The survey results demonstrated that personal attachments to the NHS were defined in terms of personal, historical, political, and familial factors: all were entwined.
Historical explanations of the NHS were framed as deeply personal by survey respondents. Of the 132 survey participants, 124 answered the question ‘What does the NHS mean to you?’ Within these answers, thirty-six mentioned the ways in which the NHS benefited their or their families’ finances and lifespans. Participants wrote, for example, that the NHS ‘enabled the safe birth of my son and later saved his life’, ‘saved my life twice’, or was ‘the reason I can live a full life without fear of bankrupting my family’. While sixteen respondents framed their answers to this question only in these personal terms, twenty emphasised that these benefits were available to everyone. One stated that the organisation was ‘Crucial to my health, survival, wellbeing [...] and that of my family [...] and of the vulnerable/poor’. Three further participants stated that the NHS could provide expert medical care to themselves, their families, and ‘everybody regardless or wealth or privilege’ or to ‘Jo Public’. Another respondent wrote that the NHS meant a ‘huge amount’ to them, ‘esp. as my friends and I have got older and needed it more’. For this respondent, their own increasing reliance on the service had led them to reflect on its broader social significance, and they had since begun to organise street stalls in order to ‘raise consciousness about how much it means to everyone’.
Further respondents described the individual benefits of the NHS as symbolic of broader social changes, for instance by writing that the service was ‘the pride of Britain’ and ‘makes me proud to be British’. One respondent argued, ‘Personally it has done a lot for me, especially, over the past 8 years. Objectively it is the greatest political achievement since WW2 [the Second World War].’ Another wrote that the NHS had saved their life and the lives of many family members, but that ‘most importantly’ it was a ‘model of how a modern caring principled system should work for everybody regardless of wealth or privilege’. These comments demonstrate the ways in which respondents did not only value the NHS because of how it had personally benefited them, but also thought more broadly about its political significance, often in terms of its encoded meaning as a source of British identity. Thus though survey respondents did often discuss their reliance on the NHS, which tended to relate to age, they were also quick to emphasise that the health benefits of the NHS were universal.
Descriptions of feelings about the NHS were not only linked to its perceived social benefits, but also often explained in terms of the historical contexts in which participants were born. Eight participants, aged between sixty-four and seventy-seven, wrote that they had been born close to the time of the NHS’s inception, and suggested that this may have given them a special sense of connection with the institution. One such respondent hoped that the NHS would continue to ‘care for future generations as it has cared for mine since the year I was born – 1948’. Others wrote that ‘I was born in it, and hope my grand-children can be too’ and that ‘I was born in 1948 like the NHS’.
One participant, who was born in the year in which the NHS was founded, offered a different explanatory framework, arguing that the development of the NHS and the post-war education system were ‘gains made by [my] parents’ generation’. For this respondent, the role of their generation was not to passively inherit but to actively ‘defend’ the NHS. Another campaigner in this survey, born in the late 1950s, a decade after the inception of the NHS, nonetheless wrote that the service still ‘feels like a birthright’. Twenty-four participants, aged between forty-three and eighty-one, mentioned that they vested significance in the post-war moment, and a further ten respondents mentioned their admiration for Aneurin Bevan, the Minister for Health when the NHS came into being. This suggests that popular feelings about the NHS are not determined by date of birth alone. Many born in recent decades felt that the service was their ‘birthright’; some of those born in the immediate post-war moment conceptualised the NHS as instead belonging to their parents. Descriptions of the meaning of the NHS were entwined with ideas of ownership; these entwined accounts were autobiographical, and were best accessed through direct consultation and discussion.
Among the survey responses alone, the most common suggestion from participants was that their feelings about the NHS were transmitted by their families. Fourteen participants, aged from twenty to eighty-five, described their attachment to the NHS as shaped by family beliefs. Older respondents discussed family memories of the pre-NHS system. One wrote that when they were born in 1939, the bill for their delivery was £5, and ‘I don’t know how they [their parents] found the money.’ The youngest respondent who made this point, by contrast, discussed how his parents would be unable to afford care in the American insurance-based system. Another participant, aged fifty-nine, suggested that ‘most’ campaigners ‘have parents or grandparents who remember the old days pre-NHS’.
Respondents’ attachments to the NHS, therefore, were affected by family discussion and family mythology. For a small number of participants, their own memories of the early NHS were also important. Thirteen participants were aged seventy-five or over and had thus been young children when the NHS was founded. Five of these individuals suggested that their personal memories of the new NHS had shaped their feelings about the institution today. One seventy-six-year-old wrote, ‘I am old enough to remember asking my mother […] what was an “Almoner”’.22 Further respondents suggested that some NHS campaigners could ‘remember what it was like before the NHS’, or had ‘longer memories’ which were ‘indispensible [sic]’ for campaigning. Again, therefore, this focused survey revealed significant disparities among the sample group. This finding demonstrated that attachment to the NHS was formed through personal and political roots, and with reference to national and familial histories. Personal feelings about the NHS – and, for campaigners, ones which moved them to political action – were never simple, and were shaped through different types of social collective throughout the life course.
The survey does not provide conclusive evidence of how people felt in the past. However, it does provide information about how people remember the past in the present day, and about which historical narratives have grown to assume cultural and political power – a key area for cultural historians. Surveys, therefore, not only provide methods with which to look for traces of feeling, emotion, and belief in archived documents or surveys of the past. They also provide a forum for unheard voices to contribute to historical debate, and for people to participate in history in their own ways. Using online surveys in this way can, in theory, broaden the range of actors whose perspectives historians are studying and considering. This online survey data, therefore, tells us both about how participants feel about the NHS today and also about how they remember and interpret their own histories, their community histories, and histories of nation-states.
Specifically, the survey revealed the complex and rich meanings which the NHS holds for British publics: as family myth, personal life-saver, community supporter, or source of national identity. Through familial discussion and personal memory, many have today constructed and felt a special connection with the NHS, in part founded on a conception of the immediate post-war moment. Throughout this collection, we see that the foundation of the NHS in 1948 came to be seen as a powerful moment particularly from the 1980s onwards, operating as a cultural and personal construct which has enabled people to ‘make sense of their biographies and connect their lives with history’.23 For respondents to this survey, ‘NHS campaigners’, their feelings about the NHS have not only shaped their biographies, but have also driven many to campaigning and inflected their voting and political lives. It is significant that even the views of campaigners, and, in this sample, a relatively focused group primarily of campaigners of similar age, are deeply fractured. This demonstrates that, more broadly, popular attachments to the NHS are highly complex. A range of demographic and democratic attachments underlie any simple framing such as ‘we all love the NHS’.
Enriching cultural histories
Multiple definitions of cultural history run throughout this book. Online surveys such as this one can particularly enrich two strands of cultural history: cultural histories looking ‘from below’, to mobilise engagement, and those drawing on new, and often unexamined, materials to add nuance and complexity to political or social accounts.
If cultural history is used to access ‘ordinary’ or ‘everyday’ life, or to learn more about popular meaning, feelings, and beliefs, then surveys are a significant source. Members of the public may answer survey questions in their own terms, and in their own time. Potentially, surveys can provide an anonymous and private space in which a range of members of the public can reflect – at length – on how they wish to answer questions and on the narratives which they wish to share. Survey responses may provoke external challenges and bring dissonant narratives into historical writing. Engaging with audiences who can still respond to us and challenge our interpretations reminds us to think carefully about the multiple meanings ingrained in all sources which we read. If this is an aim of cultural histories, then such surveys could be well combined with engaged academic efforts towards collecting material culture from members of the public, or towards equipping and empowering community groups to write their own histories and curate their own archives.24 The research project discussed in this chapter also encouraged London Health Emergency, a significant national campaign group that started in the 1980s, to deposit its archives in the Modern Records Centre, Coventry, a deposit which will reshape the work of future historians, putting activist cultures at the centre of historical and political accounts.
Indeed, if the target of our cultural histories concerns bringing further richness, complexity, and questions into social and political accounts, then likewise surveys may be able to serve as useful sources in combination with archival and oral history works. For example, one key finding of the survey was that love for the NHS was embedded with criticism, with campaigners discussing problems of and praise for the NHS concurrently. Using archival research demonstrates that this tension is not new: it has historical precedent, notably in the 1980s – another moment dominated politically by a Conservative administration. In that decade, the Politics of Health group, a pressure group focused on broad social, economic, and cultural determinants of health, argued that ‘many people’ campaigning against hospital closures lived ‘in two minds’ about defending the NHS. Since hospitals had been ‘gradually run down’ before closure, they were ‘defending hospitals where there is declining morale of staff, poor nursing standards, lack of maintenance work and inadequate safety standards’. The group noted in particular that this context made it ‘difficult to obtain popular support’ for a campaign to save a specific hospital.25
In the same decade, contributors to Spare Rib, the feminist magazine, suggested that they could not ask people to ‘rally to a defence of the NHS’ without simultaneously criticising the organisation’s shortcomings. Contributors demonstrated that the power relations of gender, race, and class shaped the experiences of NHS staff and patients.26 For one contributor to this magazine, however, reflecting on and critiquing structural issues in the NHS could perhaps lead to ‘the most fertile ways of struggle’.27 Significantly, therefore, critique and praise for the NHS have long been entwined, and particularly from the 1980s. This survey finding, while important in further exploring this tension, is not only a recent phenomenon, and indeed is echoed in the archival analyses of film, television, magazines, newspapers, and trade union records throughout this collection.
By contrast, contemporary archival research suggests that another finding of this survey is relatively new: the idea that the NHS may be particularly significant for its ‘first generation’ of children. While this idea was expressed by many respondents, archival research demonstrates that it gained cultural traction in the 1980s and particularly from the late 1990s, amid growing rhetoric about ‘generational warfare’ and the costs of the ageing population. The journalist Polly Toynbee, writing for the Guardian in 1998, expressed this idea:
The NHS was created as the cradle for our monster generation. The Butler Education Act nurtured us. Our childhood blossomed in a full-employment boom. A swathe of plate glass new universities greeted us as we left school. When we were young, the whole world was forced to be young with us.28
Contemporary historians would find much to complicate here, and have argued that the inception of the NHS represented the continuation of previous local and national reforms rather than a significant ‘break’, and that publics and media did not greet the new service with great excitement initially.29 Nonetheless, and significantly, culturally in this 1990s moment Toynbee felt, and argued that, the state had produced the NHS specifically for baby boomers, rather than for their parents or grandparents. From the late 1990s, likewise, Members of Parliament would often defend reform by asserting, ‘I love the NHS. I grew up in it.’30 The ‘Born in the NHS’ movement flourished as recently as 2013, and a range of mugs, clothing, and badges bear its slogan.31 This cultural vision was prominent in the social survey, and recurs in archival findings since the 1980s and 1990s. However, it was not prominent in the earlier decades of the NHS, and is rare in earlier archival materials. Therefore using survey and archival work in conjunction with each other suggests that public feelings about the NHS have become more significant over time, and particularly since the 1980s and 1990s, when popular understandings of history have become embedded within discussions of the NHS. This is a significant finding and, when further examined, may help us to explore the bases of public attachment to institutions. This example also certainly demonstrates the significance of ‘time slip’, an oral history phenomenon in which publics describe experiences in a different period from that in which they encountered them.32 More broadly in the survey, recollections of the post-war moment were, for example, generated by respondents who were not alive at that time and who were instead recalling popular and community responses.33
An exploration of two key themes of this survey – NHS critique and generational attachment – has therefore illustrated how surveys may be useful when supplemented by analysis from oral history and archival data. Only by making this contrast between different types of sources can we understand when, how, and why cultural and everyday meanings, beliefs, and attitudes towards the NHS emerge. Looking at surveys in particular helps us to see the complexity and challenges of terms within our archives, which we may otherwise take for granted, and also helps us to think through how cultural meanings are constructed individually and in different collectives. Survey material, finally, enables us to think about how popular beliefs operate today, and about popular visions of history; these are significant elements in the historical formation of meaning and the legacies of recent social change.
Using surveys can help us to operate beyond the discipline of history alone, and towards the kind of interdisciplinary work that has characterised the cultural studies movement. Notably, survey work helps the qualitative analysis of history and sociology to combine in fruitful ways. Such analysis could be useful, for example, in the case of the British Social Attitudes survey, an annual survey conducted since 1983. In 1985, 1988, and 1992, this survey asked around 3,000 respondents how ‘satisfied or dissatisfied’ they were with ‘the way in which the National Health Service runs nowadays’.34 While the results of this survey are influential and are widely reported by newspapers and think-tanks alike, the qualitative analysis in this chapter suggests that the term ‘satisfaction’ may not be the most apt to capture public beliefs about the NHS, even among its most ardent defenders: the term does not necessarily resonate with campaigners.
Furthermore, while sociologists rarely use the term ‘love’ in their survey design, campaigners who responded to this survey deployed this concept. Archival research furthermore revealed that the idea of ‘love’ for the NHS has been a key feature in public-facing campaigns since the late 1980s.35 More broadly, indeed, politicians have used the idea of ‘love’ to justify controversial NHS reforms.36 Thomson’s chapter in this collection highlights the language of ‘devotion’ in this regard, which may also be significant. Conversations between history, sociology, public policy, critical theory, and visual culture – as generated throughout this collection – enable us to form a rich picture of ‘culture’ and of the formation of belief and meaning.
This chapter demonstrates that, in a history of cultures, we cannot assume common feelings and definitions across even tightly defined samples. As is central to cultural studies, historians of the NHS must recognise the ‘fractures and oppositions’ within the ‘whole’ idea that, culturally, everybody loves the service.37 Indeed, we lack even common agreement about what the NHS is, what its issues are, and how it should best be defended. Cultures surrounding the NHS are not only ‘ordinary’, obvious, and clearly displayed in everyday life, but also evasive, complex, and hard to unpick and understand. Only a range of interdisciplinary forms of qualitative analysis – as in this collection – can begin to make clear the ways in which cultural attachments to the NHS are formed.
Surveys may form a valuable part of such analysis. While the survey in this chapter was relatively contained, with a small self-selecting sample of 175 campaigners, significant richness emerged. Even within this group, campaigners defined ‘activism’, ‘the NHS’, and ‘love’ or attachment in very different ways. The ways in which they formed these definitions were shaped by popular history, family memory, and individual experiences with hospitals, past and present. Such surveys can assist with the cultural history projects of understanding belief, meaning, and everyday life, notably by providing a bridge for community engagement, and also by adding dissonant narratives to archival documents, or to research terms that we may take for granted.
Surveys are not a perfect tool and reveal present visions of historical events, but these are important and culturally powerful. As the effects of the internet are realised and negotiated, historians must explore further issues of representativeness, mediated selfhood, and intrusion in relation to survey research. Nonetheless, this survey challenges us to think about when the NHS became loved by the public, and about how public affection can be mobilised, manipulated, or used to shield ideological reform. Public affection coalesces around the NHS in part because of life-cycle effects; everyone comes into contact with, and indeed relies upon, this institution at some point. Affection for the NHS, however, is also grounded in period effects, reflecting a series of beliefs about the institution’s history and in particular the conviction that the provision of universal healthcare, this abstract ideal which the NHS is perceived to embody, speaks positively to a vision of Britishness, ‘values’, and ‘principles’.
Such cultural forms of history have clear contemporary political resonance, raising challenges for media reporting, political lobbying, and contemporary survey work. Such types of history may also inform political and social histories. Geoffrey Eley has argued that cultural histories, or examinations of culture, enable us to begin ‘defining a ground of politics beyond the space conventionally recognized by most political traditions’.38 Centrally, this survey demonstrated how activists and campaigners mobilise outside NHS-defined spaces of participation, through family life and through collective organisations. Campaigners – a group whose feelings about the NHS move them to action and to reshaping their private, public, and political lives – embody the ways in which cultural representations and meanings have significant social and political power. Examination of this group, therefore, is a central component for analysing a cultural history of the NHS and showing why this matters.