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.
As this book has argued, histories of the welfare state have had little space for the role of culture in representing the way we think and feel about this important but surprisingly elusive post-war institution. Because of this, we also have an under-developed history of the impact of such representation in shaping popular understanding of and support for the institution. Historians, instead, have concentrated on the development of policy and the political interplay of professions, pressure groups, and parties.1 This focus is perfectly understandable. Rarely a day goes by without these questions of welfare-state policy and politics in the news, and history offers the prospect of lessons from the past that can help us think about the ongoing challenges of the present. These histories are also very viable since not only the state but also the non-state actors within this policy-making process have left a huge written and archival trace. The achievement of such history is substantial and important. Yet it is difficult not to feel that something important is missing from these accounts when it comes to colour, feeling, and meaning. There are different routes available if we want to address this. One is to turn to the social history of experience, an approach taken by Saunders, Crane, and Whitecross in this book. Another, and that which forms the focus of this chapter, is to examine how the welfare state, and here in particular the National Health Service (NHS), was represented.
If we look sideways to the story of the ‘warfare state’ we find a strikingly different picture.2 If we turn, for instance, to the history of the First World War, we find extensive analysis of novels, poetry, film, and art.3 As a consequence, culture now sits firmly alongside the story of battles in the way we think about the creation of meaning about the First World War both at the time and subsequently; indeed, in some respects it has transformed the way we understand the effects of that conflict, highlighting in particular the role of such representation in the creation of post-war emphasis on a ‘lost generation’ and ‘the pity of war’.4 The same thing applies for the cultural legacy of the Second World War.5 Such histories help us to understand the construction of a mythology about the war that could be just as important in the long term as the events of 1914–18 or 1939–45 in shaping attitudes and meanings. Nothing comparable exists when it comes to the history of the British welfare state.6 There are different possible explanations for this absence. Perhaps it is because the story of benefit reform, building of schools and hospitals, and bureaucracy provided no comparable drama of horror and heroism to attract the writers and artists who lived through such developments? Or perhaps it reflects our own lack of interest in looking for what may have been a more prosaic literary, film, and bureaucratic representational culture of the welfare state?
The absence is characteristic for the welfare state as a whole. But it is particularly surprising when it comes to the history of the NHS, given that this has so often been seen as the jewel in the crown of Britain’s post-war welfare state. It has become even more striking in the context of recent efforts to proclaim the central cultural status of Britain’s NHS, perhaps most memorably in the opening ceremony of the London 2012 Olympic Games, and more recently in the seventieth anniversary celebrations of 2018. Watching such events, international commentators have been struck by the strange sight of a nation parading its devotion for something that appears to them as little more than an arm of state bureaucracy. In contrast, within Britain itself it has been easy to assume that such a culture of celebration and devotion through representation was an exercise of continuity and of keeping a flame alive. As one recent campaigning slogan puts it, supposedly in the words of the service’s founder Nye Bevan, ‘the NHS will last as long as there’s folk with faith left to fight for it’. In fact, even this phrase came not directly from Bevan but from a play about Bevan which aired on television well into the second half of the life of the service, or just as interestingly from the playwright’s observation of a culture of memory in the South Wales coalfields.7 In other words, we risk misleading ourselves if we close our eyes to the way in which meaning has partly been the product of a history of representation. But we currently lack the sort of historical analysis that can either demonstrate a case for continuity in representation or explain the type of changes that may have taken place and which have led to the current situation of grand staging of public devotion. The task of comprehensively addressing this absent history of representation is well beyond the scope of this chapter. Instead it draws on a selection of significant examples to help us begin to map this type of cultural history of the NHS. It will show that this entails analysis not only of the arts but also popular culture; not only novels but also plays, television, film, and even the choreography of the Olympics ceremony; and finally not only the arts and popular culture, but also a culture of self-representation produced by the NHS itself.8 What the chapter does not attempt in any systematic fashion is to map the way audiences responded to this culture. This is clearly essential, but it is also a much more challenging task and is not possible within the scope of this chapter. The chapter does nevertheless make some contribution through drawing attention to the issue of the scale of audiences, and this is why it pays particular attention to popular culture.
A narrow and traditional understanding of culture might see the material in this chapter as central to a cultural history of the NHS, even its exclusive territory. This is certainly not the position of what follows. Instead, the chapter accepts that a history of representation sits within, and interrelates with, a broader history of meaning-making of the type outlined in other chapters of this collection. Representation in the arts and popular culture may indeed have had an important position, but this is not seen as a given. Indeed, one of the findings of what follows is that such representation was in some respects, and at certain points of time, less prevalent and less searching than one might imagine for such a supposed central feature of national life. This is a negative conclusion, but that makes it no less significant for thinking about the history of the service.
It is a strange but revealing phenomenon that when one asks people to name a list of the great NHS novels or works of art they can come up with books or paintings that deal with the experience of medicine and illness, but they struggle when it comes to works that have actually addressed the NHS, and its meaning, in its own right. One novel that some people can point to is A. J. Cronin’s The Citadel of 1937. Indeed, it is a book that has come to be regarded as having provided inspiration for the foundation of the service.9 Its status as the great novel of the NHS was recently reinforced through BBC radio serialisation in the seventieth anniversary year. It is a book therefore that provides a good starting point for tracing a history of representation over time.
There is an irony in the fact that perhaps the most famous novel about the NHS was written over a decade before the opening of that service. Its status as the great NHS book stems in part from its crusading zeal, a quality that lends itself to association with the drama of the foundation of the health service.10 It also stems from an appreciation of the novel’s remarkable success at the time, which meant that it reached a very considerable section of the population (selling 100,000 copies in just three months and on the road to being one of the best-sellers of the decade, with its reach boosted even further through Hollywood adaptation in 1938).11 Yet this was a book that focused not on the NHS or even the promise of the NHS, but on the type of services that preceded it. Indeed, there is an important point in this for the cultural history of the service and one that has proved to be enduring: the NHS has often been imagined in terms of what it is not, rather than what it is. In this case, The Citadel offered an indictment of two systems: on the one hand, a private medicine that saw doctors faced by the temptation to place financial reward and social advancement ahead of the best interests of patients, and certainly ahead of the best interests of the mass of poorer patients unable to access such care; on the other hand, the panel system of care provided to an increasing proportion of the working class through the National Insurance system, which Cronin depicted as beset with inefficiency. Yet the book offered no clear picture when it came to solutions and certainly no blueprint for the NHS. It may have been critical of the morality of many doctors in private medicine, but in no sense did it call for private medicine to be abandoned, or for a system of medicine to be extended to all for free. Indeed, Cronin’s personal sympathy did not lie in that direction.12 As Ross McKibbin has argued, The Citadel needs to be read for what it tells us about the medical politics of the 1930s, not the politics that saw the foundation of the NHS.13 It did contribute to a public mood inclined to accept the need for reform, and this was important. But here it was far from alone. It was less the kind of outlier that its status as the foundational text for the NHS suggests, and more consistent with a broader genre of writing centred on the romance of the modernising doctor and the moral dilemmas of balancing personal ambition with a medical duty to cure.14 This was a cultural form that went back well before the NHS, but also carried over into the era of the new state service. The latter point is just as significant as the former. It indicates that not only did the NHS have a less clear-cut cultural blueprint than we might expect, but also that in its early days the new service still inhabited a cultural landscape that often deployed a pre-NHS language for representing progress.
A case in point for the persistence rather than transformation of how medicine was portrayed following the arrival of the NHS was the relaunch of King Vidor’s Hollywood adaptation of The Citadel in 1948. This sat alongside a series of popular British films in the 1940s and early 1950s that took medicine as their stage but made little or no direct reference to the new service or its principles.15 Indeed, one has to search surprisingly long and hard for the cultural response to the arrival of the service itself. The most direct engagement with the novelty and the significance of the new service, and a film that stands out for this reason, was the 1951 White Corridors.16 Directed by Pat Jackson, who brought some of the grittier style of his background in the left-leaning documentary movement, the film for once identified the NHS as a state service, and it updated the moral dilemmas of medicine to speak to this setting. There is indeed ‘a clear optimism about the scope and efficiency of the NHS’.17 The important point, however, is that this kind of direct reference to the service remained remarkably rare. Even when it comes to White Corridors, the film was regarded at the time as little more than another rather generic medical melodrama.18 The fact that it was an adaptation of a novel about a pre-NHS provincial hospital is indicative of the continuity of representation.19
In literature and theatre, one again has to search surprisingly hard to find material that engaged directly with the coming of the new service. One of the most interesting examples was a play that was a West End hit in 1946 and 1947 and also toured around the country, but which has subsequently retreated into obscurity. Written by Warren Chetham-Strode, The Gleam homed in on differences of opinion towards the idea of a state health service through the responses of the various members of a middle-class family on the eve of the service in 1947 and then on how Chetham-Strode imagined this might have changed a year into experiencing the service in 1949.20 No doubt, it provided an interesting conversation piece for its middle-class audiences. But unlike Chetham-Strode’s play The Guinea Pig, which focused on the parallel issue of changes to education under the welfare state, specifically the assisted places grant scheme to assist children attend fee-paying schools, The Gleam would not go on to reach a broader audience through a film adaptation.21 It is intriguing that what we might now consider the far more important story was the one that was never taken forward. In literature, we similarly have to turn towards relatively obscure titles to find debate about the meaning of the new service. Again, these works are most revealing about the shock of the middle classes in encountering the state in intimate fashion, often for the first time.22 Two accounts stand as examples of this work. A lightly fictionalised memoir of giving birth in the new service, Sarah Campion’s National Baby (1950), set out the intimate details and feelings of one woman’s experience of that new encounter.23 The second, Philip Auld’s Honour a Physician (1959), provides a clear sense of the ongoing disgruntlement of doctors towards the new arrangements and the way in which the new service could be a seedbed for stereotypes about working-class abuse of anything that came free.24 Neither of these literary accounts fits comfortably with the idea that the NHS was embraced with unadorned enthusiasm, and this makes them rather interesting. But they both have striking limitations in terms of their privileged perspective and their narrow audience.
If the objective of this kind of history of representation is to seek out what a larger section of the population may have been watching and reading, then we need to turn instead to the great popular successes of the first decades of the NHS at the cinema, in the rapidly expanding audience for television, and in the pages of popular medical romance. The popularity of these forms, and of NHS-set comedy and romance, dictates that they merit serious attention. Unfortunately, if one is looking for direct comment and opinion on the NHS within such material, this was remarkably scarce. Some insight can be garnered from reading between the lines and highlighting common assumptions. But first and foremost this was a culture of entertainment, and as such it tended to avoid direct statements about either the value or the flaws of the new service. Instead, the central significance of this representational culture was the way in which it familiarised the setting of the NHS, broke down fear, and did so in strikingly affectionate terms.
Such a culture is epitomised by the hugely popular ‘Carry On’ and ‘Doctor’ franchises that were regularly among the top box-office films of the post-war decades. Perhaps even more influential in terms of reach was the portrayal of the NHS on the small screen in one of Britain’s first soap operas, Emergency – Ward 10. We should also not underestimate the reach and effect of the romantic medical novels of the era, which formed a mainstay for a publisher such as Mills & Boon. Here, the very act of choosing the NHS setting rather than the world of Harley Street helped promote sympathy for the service.25 At the cinema, the ‘Carry On’ films led the way, with four films set in the NHS: the second in the franchise, Carry On Nurse (1959), followed by Carry On Doctor (1967), Carry On Again Doctor (1969), and Carry On Matron (1972). Not only were these films hugely popular at the time, but they have provided lasting images for how we think about the service.26 Again, direct comment on the NHS was almost wholly absent. But the films were able to use the vehicles of satire and slapstick to poke fun at medicine in a way that was significant in defusing any underlying grievance. Just as crucially, their focus on patients and on the cross-class encounter of the hospital ward associated a still hierarchical medical culture with social democratic values.27 Divorced of humour, but with an even greater element of serialisation to foster a sense of familiarity and community, television’s Emergency – Ward 10 cultivated a similar loyalty to the new service. The show would run on ITV from 1957 to 1967, generally on two evenings a week, at its peak reaching an audience of 24 million viewers a week, with an average of 16 million. The series, suggested one critic, had become ‘part of the national consciousness’ like the Grand National and Royal Family.28 The ‘Doctor’ films were based on books by a doctor, Gordon Ostlere, who wrote about student medical life in the London of the 1940s under the pseudonym Richard Gordon. They followed the careers of young medics in the era of the NHS from hospital training to the world of general practice, but also with forays beyond into the world of private medicine. Doctor in the House, the first in the series, based on Gordon’s successful novel of 1952, was a surprise cinema hit in 1954, the top money-maker of the year. Six further films followed in the period up to 1970 before adaptation to an ITV television series. Doctor at Large (1957) and Doctor in Love (1960) also topped the British box office. Like the ‘Carry On’ films, these were in fact far from being sentimental or romanticised pictures of medical life in the era of the NHS. Indeed, the French New Wave director François Truffaut praised Doctor in the House as ‘historical documentary’.29 Such a description chimes with contemporaries who saw the film as an exposé of medical reality.30 Because of their attention to issues of social change, these films are also not quite as reassuringly comforting as they first appear. Sarah Street has suggested that the ‘Doctor’ series exposes some of the challenges for men in adjusting to a post-war settlement where the security of a welfare state and the nuclear family ‘threatened male responsibilities’.31
Such popular romance and comedy helped to make the British people feel at home with the new service, breaking down fear of hospitals and suspicion of state provision. It was not without its gentle criticism of the new state service, but humour and romance provided a valve for the release of tensions of class and gender that was important in building affection for the system, despite its shortcomings and its inheritance of a hierarchical culture. This popular culture of the 1950s domesticated and to a degree democratised the NHS. In doing so, it helped to make this part of the welfare state integral to broader feelings of social contentment, and where such contentment was being tested the popular culture provided a vehicle for the dissipation of tension over social change.
By the late 1960s, that situation showed signs of breaking down. This was partly because the social tensions were becoming greater. But it was also because a new generation of books, plays, and films were now bolder in their willingness to critique. This did not, however, necessarily demand a new style of representation. Indeed, in many instances, the new works very deliberately adopted the representational conventions of the culture of social contentment as an ironic vehicle for highlighting the gulf between romance and reality. The continuity also reflected the fact that popular culture had already opened up a representational style which allowed a degree of critique within a dominant framework of affirmation. The new representations did push this further, but they remained in the same ambiguous territory as their predecessors. A language of representation had already been formed, and cemented through popularisation into the fabric of national life and consciousness, that allowed critique of the everyday conditions of healthcare to coexist with a faith in the institution of the NHS as a whole. In fact, although the new representations of the 1960s and 1970s went further in critique, they were also more overt and profound when it came to the articulation of prevailing support for the underlying values of the NHS. In that sense, they took a representational culture that could combine critique and faith to the next level. In the longer term, this possibility of looking both ways was of considerable importance for the durability of affection for the institution.
Three examples serve to demonstrate both the continuity in form and the critical sharpening of message. In all three, the critical perspective emerges in part from a greater frankness over the limitations of the service as well as increased expectations, and in part from a more explicit engagement with the way in which the NHS provided a setting for analysis of broader social and national tensions. Perhaps unsurprisingly, given the challenge of knitting together these themes, the examples all involved writers who have attracted far more critical acclaim than those who had provided entertainment and succour in the first decades of the service. Margaret Drabble’s novel The Millstone (1965), subsequently turned into a film under the title A Touch of Love (1969), centres on a middle-class single mother encountering a new world through the maternity services of the NHS. The novel is a romance, but not a comforting one. The doctors and nurses are far from the medical heroes and angels of the Mills & Boon romances of the period, the subject matter of single motherhood (and homosexuality) also breaks with the conventions of that genre, and the NHS is deeply flawed in practice when it comes to the experience of the patient. Yet because of the support it provides for someone who has nowhere else to turn, this is also the first major literary statement of loving the service. As the novel’s central protagonist Rosamund puts it, ‘I am devoted to the National Health Service.’32 The second example is Peter Nichols’s play The National Health, which ran at the National Theatre and also went on to subsequent film adaptation in 1973.33 The National Health drew on the representational forms of ‘Carry On’ but also on soap-opera medical drama. The action is all centred on a hospital ward and the repartee between bed-bound male patients and their doctors and nurses. The reminder of ‘Carry On’ was further emphasised through use of the actor Jim Dale, who performed in the play as well as film and was a regular in the comedy franchise, appearing in Carry On Doctor (1967) and Carry On Again Doctor (1969). The reminder of ‘Carry On’ was also there in the comedy, though now in much darker form, with the beds disappearing one by one as patients pass away amid a climate of neglect. To emphasise this point, the action was intercut with scenes parodying the romanticised world of a medical soap opera – ‘Nurse Norton’s Affair’ – that plays on the hospital television. The National Health sees no statements of love for the NHS. It is far too bleak for that. But the conversations between patients niggle away at the meaning of the service, and as a result the effect is to raise the question of feelings towards the institution far more directly than had been the case in the earlier popular culture. The third example is Dennis Potter’s 1966 BBC television ‘Thirty Minute Theatre’ play Emergency – Ward 9. As its title pronounces, the soap-opera form served as an ironic vehicle for emphasising a gulf between ideal and reality. Once again, the shorthand of the hospital ward, now well established as the symbolic space of the NHS, provided a way of speaking to the state of the nation. This time, layered on top of the question of the relationship between class and the health service and of healthcare as a reward for sacrifice in war, we also have the introduction of race and racism.34 The representation is deeply uncomfortable, but in raising these difficult questions the play placed the issue of the meaning of the NHS and its centrality to ideas of nation centre stage to a degree that had never been the case in the popular culture of the earlier decades.
Emergency – Ward 10 may have been shelved by ITV in 1967, but in its place came a series of new NHS soap operas and dramas.35 The 1980s saw the emergence of Casualty, a series still going strong today and indeed now the longest-running medical drama in the world.36 Story lines that mixed the human drama that inevitably came in a medical setting and the use of serialisation to capture viewer loyalty were in no sense distinctive and were characteristic across the modern world. What distinguished the British, NHS variant was that it continued to cultivate a grittier realism that happily acknowledged problems in service delivery, inadequacy of resources, and staff under often impossible pressures. The narrative focus on the working lives, romances, and crucially self-sacrifice of staff was important. It meant that the system could be portrayed as being at fault, while at the same time cultivating affection through identification with the mission, humanity, and strife of those who ran it. The message of the drama was that the service was beset by problems, but it was to be hugely valued and needed more support, not rejection, and this was embodied in the stoical efforts of the carers at its heart.
When critique was not offset by this kind of balancing act of fostering affection through serialised story lines and sympathetic character development, NHS drama struggled for the same popular purchase. A case in point was the 1982 film Britannia Hospital. Directed by Lindsay Anderson, Britannia Hospital, as its title suggests and like The National Health before it, used an NHS hospital as the setting for state-of-the-nation commentary. The screwball, fast-paced style echoed the ‘Carry On’ films, but their warmth was jettisoned for despair, and the targets of satire were now updated. Gone was the focus on how hospital wards and the lives and class relations of the staff and patients provided a picture of the nation in microcosm, divided by class but ultimately united through the common experience of the service. Instead, Anderson provided a picture of the NHS in disintegration, inspired by the dual upheavals of 1970s industrial discord and fears of a Thatcherite free-market assault on the welfare state. The key difference from earlier representations was that there was now nothing positive to relieve this bleak vision. Gone was an underlying faith in the idea of the institution. Gone too was the sympathy that emerged from a focus on self-sacrifice and care. In their place were the hospital and NHS as a site of economic and medical brutality. Without the warmth, it was far more difficult for those sympathetic towards the NHS to feel comfortable about this critique, even if they shared the anxieties about new threats posed by Thatcherism.37
Britannia Hospital introduced a further challenge. Earlier depictions of the NHS may have been critical of the service’s shortages and discomforts, but they had represented modern medicine as a good. The dystopia of Britannia Hospital now presented its audience with the nightmare spectre of a medicine driven by its own ambitions rather than the welfare of patients. This disillusion was more broadly characteristic of the time. Counter-cultural writing by figures such as Ivan Illich had fuelled suspicion.38 So too in their different ways had feminist critique, anti-psychiatry, and research on ongoing inequalities of health. More generally, this was an era that saw people becoming less deferential, more concerned about their individual rights, and more interested in choice.39 Within this context, there was a moment of opportunity for radical rethinking of healthcare on the left, not just the right. Britannia Hospital awkwardly filled that space with its Frankenstein-vision of a medicine gone mad in its enthusiasm for genetics and the harvesting of body parts. So too did G. F. Newman in his novel The Nation’s Health, which was turned into a four-part television series on the new Channel 4 in 1983, albeit with a different set of targets for why medicine could make people worse rather than better.40
In the longer term, writers moved back from this brink of critiquing not just the conditions under which the NHS operated but its underlying biomedical objectives and approach. Instead, those anxious about the implications of Thatcherism for the welfare state rallied to the cause of defending the service against cuts and the prospect of a more radical challenge through the introduction of markets and privatisation.41 This defensiveness played a role in closing down a space for representation of alternatives. Instead, the dominant portrayals of the period went back to the existing formula of combining criticism over aspects of practice with support for the core principles of the institution. This could still prove controversial. Even the opening series of Casualty in 1986 attracted criticism from the Conservative Party for a portrayal of a service and staff under unbearable pressure.42 Nevertheless, the popularity of the series indicates that the public were open to such a portrayal. It may have been a negative for the government presiding over the ailing service, but in the long term such a series confirmed and helped further to cement the NHS as a national institution.43
The limit for permissible critique was again pushed close to its boundary in the writer Jed Mercurio’s NHS-set Cardiac Arrest, which aired in three series on the BBC from 1994 to 1996. Watching the programme now, one wonders whether it would still be possible to produce such a dark depiction of the service. There were plenty of complaints at the time, with particular objection to the way the series broke the unwritten law on offering a sympathetic portrayal of the NHS nurse.44 But in truth, though pushing dark comedy to its limits, Mercurio was still working within well-established conventions. He admitted this, and spoke of the series as a kind of updated Doctor in the House, even if the high-jinks of the young doctors were now pushed into new, darker territory.45 As in the other dramas of this era, management in particular was portrayed in increasingly excoriating fashion. But behind all of this, there remained an underlying morality of the importance of defending a service that in its true form offered an essential good. Terrible things might happen in a service under impossible strain; so terrible that it now put lives at risk. And those working under such conditions might have travelled very far from the medical angels and saints of the past. Yet, ultimately, blame was directed first and foremost at those who had put the service in this position. The story lines of the doctors’ and nurses’ lives still in the end exposed an underlying humanity beneath the black humour and battle-hardened cynicism. The fact that a series like Cardiac Arrest could be part of a culture that managed to defend and even strengthen support for the NHS is remarkable. The reason it could do so comes down to the way in which it worked with existing conventions that helped to make the portrayal of criticism permissible. In fact, in the political climate of the 1990s this had been taken a step forward. The act of being critical could now ironically function, not as an attack upon the principles behind the institution, but as an act of lament and defence.
Until this point, this chapter has concentrated on the portrayal of the NHS in books, plays, television, and cinema. It has suggested that a particular style of representation set in relatively early. Its characteristics included a predominant focus on the hospital as a space, and the hospital ward in particular; close attention to the lives and relationships of staff and patients, the interplay of the two, and encounters across class and race as the NHS provided a model for thinking about the nation in microcosm; the use of romance, comedy, and forms of serialisation to engage audiences, entertain, and humanise; and the willingness to present a picture of conditions that was to a degree de-romanticised and open to elements of criticism. Initially, these representations tended to say remarkably little, in a direct fashion at least, about the NHS. The absence of direct reflection on the NHS did, however, change over time. It was initiated in the late 1960s by work that was often less popular and instead more personal, more polemical, and more critically valued. By the 1980s, such messages were infiltrating the mainstream of popular culture. At times this message was strikingly critical. But this culture had inherited a style of representation that had always found a space for the gritty over the romantic and which could accommodate criticism of the service through the mitigating balm of an affection and humanity based on comedy, romance, and a focus on care. This mix was probably unique to the NHS. Certainly, representations of the NHS from relatively early on thought so, and contrasted themselves with the glamour of depictions of American medicine; that had been the point of the ‘Nurse Norton’ soap opera of Nichols’s National Health. By the 1980s, overt criticism was certainly being taken to a new level. Yet the culture of representation meant that this was possible because it could be read as a defence rather than an attack upon the institution as a whole.
The legacy of this mode of representation was that it contributed to a situation whereby the British public, despite a culture of growing expectations, could accept significant flaws in the NHS but maintain, and indeed over time increase, its support for the institution. A problem with the mode of representation was that it rarely opened up a space for deep understanding. Its simplification was a powerful asset in providing the service with a cultural identity and distilling its virtues into a set of symbols such as the cross-class encounter of the hospital ward and the heroic efforts of staff. On the other hand, simplification inevitably left a huge amount out of the picture. The persistent image of the security and social solidarity of the hospital ward, for instance, was at odds with a reality of patients being moved as rapidly as possible out of these beds.46 The focus on hospitals also distorted the fact that this was not the most common way in which people really experienced the service. When general practice did attract attention it was often in the form of a rather romanticised ‘family doctor’ more typical of the era before the NHS. The obvious example was the hugely successful BBC television serialisation Dr Finlay’s Casebook, inspired by A. J. Cronin’s 1935 novella Country Doctor.47 Even John Berger’s critically acclaimed study of an NHS GP and his community in the Forest of Dean, A Fortunate Man, was in truth a deeply nostalgic vision that had little in common with the way most people now experienced general practice.48 But at least general practice was represented.49 Other aspects of the service, such as local authority provision, public health, and community care, were left almost wholly out of the picture. There were similar distortions when it came to who was the focus of representation. The NHS was home to a multitude of workers ranging from cleaners, porters, and cooks to managers. Indeed, part of its uniqueness lay in that scale and range. But unsurprisingly, the dominant representations painted a picture centred almost exclusively on doctors and nurses. Most fundamentally, representations of the NHS gave little or no sense of the growing administrative complexity of the NHS. The direction of travel in popular representation was towards simplification in particular sites, images, and personal relationships, while the reality of the service moved in exactly the opposite direction.
Efforts in the arts to address the scale and complexity of the NHS have been rare across much of the history of the service. There are signs, however, that this is changing. A notable recent exception was Michael Wynne’s 2015 Royal Court play Who Cares. Wynne recognised and took on the challenge of the scale and complexity of the subject of the modern NHS. His response was to turn himself into a researcher, interviewing not only the huge range of NHS workers, but also the network of policy experts, politicians, and bureaucrats who surrounded it. Built on the words of these witnesses and of the mass of paperwork spawned by the system, the play then took visitors on a tour descending into the trials and tribulations of an NHS beset by multiple challenges. This was a form of representation that took on education of its audience, embraced complexity, and steered its audience away from black and white conclusions.50 The same could be said to some extent of some of the documentary television coverage of this period. An example was the BBC’s critically acclaimed Hospital, which since 2016 has used a traditional focus on a single hospital space and its staffing, patients, and life-and-death stories, but in a way that has opened up the complex, systemic challenges facing the service. Documentary has always proved a stronger medium than the arts when it comes to representation of the complexity, scale, range, and challenges of the service. Proper analysis of this documentary tradition would demand much more space than is available here. That analysis would certainly qualify some of the conclusions emerging from this chapter’s analysis of drama and literature. On the other hand, it would also be fair to highlight that, despite this capacity to present a more realistic and complicated picture, documentaries also needed to appeal to their audience and were therefore influenced by broader cultural assumptions and political sympathies. As such, they have tended to draw upon the narrative techniques and reinforce some of the messages of NHS drama.51
There are signs, then, that by the seventieth anniversary of the service, there was a growing appetite for and willingness to provide a more searching type of representation. One can even argue that there had been a slow move in this direction in popular representation over the years, with the inclusion for instance of more characters to represent the face of management in drama, and with the spawning of numerous fly-on-the-wall documentary television series which cast light on the messy complexity of NHS reality. As noted earlier, the possibility of a more nuanced picture had been there from the start in the tradition of wanting drama to present a picture that had a degree of realism. Yet since the 1980s, there has also been a countervailing trend in representation that has been just as powerful and influential.
When the opening ceremony of the 2012 Olympic Games set out to represent the NHS it turned to the symbol of the hospital bed. As we have seen, this had been central in the history of popular representation. The fact that the hospital beds, children, and nurses of the ceremony in fact looked as though they came from the era before the NHS (in keeping with the parallel efforts to represent J. M. Barrie’s Peter Pan as part of a history of Britain as the land of great children’s literature) can be put to one side. The symbol was so powerfully embedded in the national culture as a representation of the NHS that nobody paid attention to this issue of periodisation, or to the fact that the NHS era saw a move away from children spending long periods in hospital beds. What made this episode in the ‘Island Story’ definitively about the NHS was not beds, the children, or the nurses, but the way in which the action on the floor of the stadium lit up a three-letter giant symbol – ‘NHS’ – that could be seen from above and which was projected to the millions of television viewers across the globe. This might seem a strange thing to say. Most British people would assume that this was an obvious thing to do. But the ceremonial position for the acronym was part of what accentuated the strangeness of celebrating such a state organisation when it came to foreign observers. Moreover, historically, there was nothing obvious about it. Go back to representations of the NHS from the 1950s and the 1960s, even the 1970s and the 1980s, and one thing that will be missing is the now ubiquitous blue-lozenge NHS logo. More than this, it took quite some time for people to talk and write in such shorthand. Initially, there was considerable looseness in how people would describe the new system for providing health: ‘the national health scheme’, ‘the national health’, even – indicative of continuities reaching back to the system introduced in 1911 – ‘National Health Insurance’. It took longer still for the familiarity of the acronym to take hold. One finds it increasingly in press coverage from the 1960s, but in the drama of the period it is nowhere to be seen. The spaces depicted in that drama also belong less obviously than is the case nowadays to something called the National Health Service. Until remarkably recently, the branding that now accompanies these spaces and which marks them out, at every turn of the corridor, as belonging to a single thing called the NHS was nowhere to be seen.
The emergence of this branding has an important place in the cultural history of the NHS. This is a history in which the state in alliance with design expertise acted to ensure a sense of unity against a background of fragmentation and growing complexity.52 Crucially, once the power of this symbol was embedded into the representational culture built up since the 1940s, it helped to overcome several limitations. The earlier culture had always risked being limited in its range, too focused on a particular sort of hospital care. At the same time, it had risked being an image that spoke to medical care as a whole, rather than the special nature of the national service. Once popular representation had incorporated the symbol of the NHS, a much broader range of activities and people could rapidly be identified as part of the service. A relationship between cultural representation and the NHS that had often been implicit now became explicit, and this magnified the effects of that culture. The NHS branding also had the advantage that it was wholly symbolic. As we have seen, by the 1980s it was increasingly difficult to depict care without a significant degree of criticism and cynicism, evident in dramas such as Cardiac Arrest, The Nation’s Health, even Casualty. Indeed, there were signs that this culture of representation was on the point of collapse. The representational culture was also threatened by reforms to the service that left it increasingly fragmented, and which some saw as steps on the road to privatisation. The arrival of NHS branding in the 1990s, and the increasing talk of the NHS that accompanied this, bolstered the culture of representation. Increasingly, it was the fact that something was simply of the NHS that was crucial in determining popular support. Nothing marked this out as effectively as the increasingly ubiquitous presence of the symbol and language of the NHS.
The representation of the service in the Olympics opening ceremony provides a fitting endpoint for this survey. Directed by Danny Boyle and written by Frank Cottrell Boyce, the ceremony of course went far beyond the NHS in setting out Britain’s ‘Island Story’. But the section on the NHS was significant and was perhaps the most remarked-upon episode within the ceremony. It crystallised how two tropes in representation of the service had become so powerfully fused that they could now move from the sphere of literature or drama to act as symbols in what came close to being an act of public communion. The ceremony did not need to stage a drama to convey its message; the symbols already held the meaning and did the work. Indeed it was because these symbols – the NHS hospital bed on the one hand, and the collapse of a vast system into an acronym on the other – had become so embedded in the broader culture that it was now possible to exhibit this new form of representation on such a grand stage. In turn, the new art form of the televised public ceremony would act to reinforce support for the idea of the institution and foster the idea that it was a key part of national identity and unity. Under the challenges of Brexit, the attractions of such representational shorthand – famously on the side of a red bus – showed no signs of dimming. The full lexicon was again put into action in efforts to celebrate the anniversary of the service in 2018. As this chapter has suggested, such symbols had power, but they also had a major shortcoming in that they tended to mask complexity, fragmentation, and flaws. Throughout the history of efforts in the arts and popular culture to represent the NHS, meeting that challenge had proved very difficult. The result was that this culture has proved far more effective in cementing broader loyalties and emotional attachment to the service than in fostering deeper and critical understanding. The fact that the history of NHS representation has acted in this way provides one important explanation for why this institution has developed such a uniquely powerful place in British national consciousness and feeling. Whether that situation is easily sustainable is another question.