Since it was founded in 1948, the issue of how Britons have laughed with – or at – the NHS reveals much about changes in society, argues Jenny Crane.
When we think of the National Health Service (NHS), laughter may not be the first thing that comes to mind; it is perhaps associated more with hard times, losses, austerity and adversity. Yet the NHS has a close, if complex, relationship with humour. It has, at times, used ‘laughter therapy’, for example, which seeks to provide patients and families with comic moments. Public health videos, too, often use humour and slapstick to disseminate their messages: Let’s Play Things to Put Up Your Nose (2014) suggests that the nasal flu vaccine is a better thing to put up one’s nose than a crayon, penny, smartphone, goldfish or pirate ship. And, outside the NHS, campaign groups have used performance satire to challenge those who seek to reform the institution. The National Health Action Party has staged funerals for the NHS and Keep Our NHS Public has invited passers-by to pretend to operate on one another. Both challenge ideas about the ‘big society’ – which, in theory, gives power and responsibility to local communities and people – and question its appropriateness to medicine.
Such forms of humour have been used to understand, criticise and celebrate the NHS since it was ‘born’ on July 5th, 1948. From this ‘Appointed Day’, healthcare was free to all Britons at the point of access, replacing the previously disparate system in which care was provided for many working men through national insurance and, for others, patchily, through voluntary and local authority hospitals. Alongside the introduction of the NHS came several other welfare reforms, such as the raising of the school leaving age, making secondary school education free, providing extended benefits for families, unemployed and sick people and further provisions for children in need of care. The NHS thus built on existing systems of health and care, but was also part of a key and, to an extent, radical postwar shift in British society. Looking at moments of laughter and humour in NHS history can help us to understand the place of this unique institution among Britons and also to think about changes in culture and humour.
From the 1940s until the 1960s, jokes about the NHS, as seen in public information films and cartoons, tended to be gentle and good-humoured, reflecting the deep appreciation most Britons had for this new institution. From the 1960s until the 1990s a darker and more critical form of humour ruled. This broad shift was by no means universal but nonetheless reflected a changing culture and society, in particular the rise of the so-called ‘permissive society’ and the death of ‘Victorian Britain’. Historians debate the extent of change heralded by the permissive society, but certainly there were broad shifts around this period. The liberalisation of laws around obscenity, for example, enabled more controversial and combative forms of humour to flourish publicly, as well as privately, which resulted in the popularisation of satire. This period also saw the emergence of protest politics and political and economic challenges to the postwar settlement. These changed the way in which the NHS operated and the kind of jokes that were made, internally and externally, about the institution. Perhaps ironically, we need to take humour seriously in order properly to understand the development and significance of the NHS.
Medicine and its practitioners have long been the butt of jokes. The Enlightenment is an important period in the history of comedy, thanks to the work of popular caricaturists, such as William Hogarth and James Gillray, who riffed on the futility of medicine against the ravages of death and disease. Hogarth’s The Company of Undertakers (1736) depicts 15 doctors above the slogan Et plurima mortis imago, ‘Everywhere the image of death’.
Other regular targets for caricaturists were the ‘barber surgeons’, ‘quacks’ and other medical practitioners, widely perceived as inadequate. In Hogarth’s Undertakers we see, at the bottom of the image, a self-taught bone-setter from the period, Sarah Mapp, and Joshua Ward, who was best-known for selling pills of antimony, a metallic element, which was swallowed, passed and swallowed once more to ‘refresh the bowels’. Gillray also mocked the practices of bloodletting, tooth extraction and pneumatics. Indeed, on the latter, he once drew a lecture room filled with well-dressed members of the public and profession, avidly watching as physicians pumped air through a patient’s body and out of their bowels. Gillray also parodied the anxious response to Edward Jenner’s smallpox inoculation. In The Cow-Pock, or the Wonderful Effects of the New Inoculation (1802), the recently vaccinated are sprouting various parts of the cow.
As well as challenging medical practice, Enlightenment caricaturists criticised the doctors themselves for greed and laziness. In 1803 the artist Temple West drew lavishly dressed doctors giving a humble ‘Address of Thanks’ to the ‘Right Honourable Mr Influenzy’, who had enabled them to line their pockets at the expense of sick patients.
Through these caricatures we can begin to see how medicine has changed over time. These cartoons assume that medicine must be paid for: well-heeled people spend their funds on a wide variety of medical practitioners. The caricatures accept the limitations of medicine, an acceptance that has perhaps declined as the rapid development in medical technologies and innovations in the 20th century have led us to expect cures for everything that ails us. These images also demonstrate that medical developments, which are retrospectively regarded as impressive, such as vaccinations, were at the time met with suspicion and fear.
In the immediate postwar period, much humour about healthcare was gentle, particularly that produced by the state. In a series of four public health films produced between 1945 and 1949, the actor (and former clinician at the London Fever Hospital) Richard Massingham promoted awareness of personal hygiene by playing a charming buffoon. In Coughs and Sneezes (1945) he sneezes furiously in a cinema, a queue and a workplace. The narrator warns that this type of behaviour is ‘a real danger’, far more dangerous than people who balance buckets perilously atop doorways, trip people over or take people’s chairs away before they can sit down. As punishment, Massingham is sat down firmly and a mysterious hand shakes pepper all over him. The narrator then repeats ‘Handkerchief sneeze, sneeze handkerchief’ until Massingham learns to associate them and to behave appropriately in public.
In Handkerchief Drill (1949) a woman asks the film’s narrator how best to stop her husband – Massingham again – from coughing and sneezing without using a handkerchief. She is first counselled to try being kind and gives her husband a token pat on the head. When this does not work, she tries throwing water over him and then, as in Coughs and Sneezes, attempts sprinkling him with pepper, all of which fails. Furthermore, the wife exasperatedly tells us, when her husband has a cold he puts his handkerchief in the laundry basket, instead of letting her boil it. At this stage, the narrator concedes, in a deadpan tone, that: ‘He’s obviously dangerous. Get him locked up.’ He is driven away in a police van to the sounds of cheering.
Postwar British cartoonists – like their Enlightenment counterparts – remained fascinated by payment, or the novel lack of payment in the NHS. Notably, in Anton Yeoman’s Punch cartoon, the women are prim and proper: a distinctly 1950s reincarnation of the lavishly dressed women of Gillray and Hogarth. But now they are a symbol that free healthcare would not guarantee equality in its uptake nor in its successful treatments. This cartoon may also be poking fun at the mixed reactions to the NHS from those accustomed and able to pay for their own care, or at widespread anxieties that ‘free’ medicine would be abused and would breed dependency and hypochondria. When talking about the free nature of the service, a key point of comparison for British cartoonists was not healthcare in Britain’s past but the contemporary US system. To give just one example, in 1964 the artist Ken Mahood published a cartoon in Punch in which a doctor leans over a patient and charmingly states that: ‘If this were in America you couldn’t afford to be as ill as you are.’
Early cartoonS in the left-wing press revealed much affection for Aneurin Bevan, the Welsh Minister for Health who introduced the NHS. Bevan was represented as a patient, as the NHS itself and, memorably if ahistorically, as a version of Florence Nightingale, the ‘Laddie of the Lamp’. Inevitably, though, not all postwar figures received such kind treatment and even Bevan was represented as a bully, a socialist or communist villain and as a dangerous demagogue in some of the right-wing press. Postwar negotiations between the government and the British Medical Association (BMA), established in 1832 to represent the medical profession, also became the subject of biting satire. The BMA did not want doctors to be employed by the state because it feared a loss of independence and, some argued, a decline in income, if they were no longer paid per patient. The cartoonist David Low was especially ferocious on this matter, portraying Dr Charles Hill, the BMA Secretary, as suffering from an ‘enlargement of the social conscience’. At this time, such aggressive and cutting humour was not commonly directed at medicine but was used to defend the principles and foundation of the NHS itself. The preference for more sympathetic rollicking humour, at least in print, reflected a relatively conservative generation – ‘the last of the Victorians’ – as well as the newness of the NHS and widespread appreciation for the expansion and ease of access to healthcare.
Between 1960 and 1990, amid the development of ‘counter culture’ and the permissive society, satire flourished once more, spurred on by Peter Cook, Alan Bennett and Eleanor Bron, and David Frost’s immensely popular television programme That Was The Week That Was. New protest movements emerged and flourished, including gay liberation groups and second-wave feminist collectives. The contexts in which the NHS operated changed, too, amid the growth of an ageing population, a less stable economy and the development of increasingly expensive medical technologies and drugs. In terms of medical developments, the UK’s first kidney transplant, heart transplant and full hip replacement were all carried out in the 1960s. The contraceptive pill was made available on the NHS in 1961, although initially it was reserved for married women.
In response to these changing contexts, the NHS was subjected to round after round of reorganisation by various governments. Margaret Thatcher’s Conservative governments introduced especially controversial and radical changes, creating an ‘internal market’ for health services. This meant that Health Authorities and General Practit-
ioners (GPs) would purchase services from primary and secondary care providers, the latter of which would form corporatist groups called NHS Trusts. More broadly, Thatcher sought to reverse the postwar consensus, which included previous agreement between the Labour and the Conservative parties that the government should provide a welfare state. Instead, Thatcher and other New Right thinkers believed that the primary role of the state was to support the free market in the production and distribution
of resources and to deregulate business and industry, encouraging self-reliance. Many campaign groups and left-wing individuals were concerned that these beliefs, embedded in Thatcher’s reforms, would lead to the erosion of the NHS as universal and free, through the introduction of private provision, market principles and charges for more services. Reflecting this, many jokes about the NHS became more critical and specific groups, such as London Health Emergency, founded in 1983, emerged to challenge reform.
The feminist magazine Spare Rib regularly discussed the NHS: offering women’s experiences of health and care; considering alternatives to the NHS, such as community provision and self-help; and criticising the racist and sexist delivery of services. Some Spare Rib articles deployed humour to disseminate their points. In April 1973, the magazine published a strip by the cartoonist Posy Simmonds in which surgeons chop up a patient while discussing the new structure of the NHS: the government had introduced Regional Health Authorities, who would appoint Area Health Authorities, which would have to work with District Management Teams, Community Health Councils, GPs and teaching hospitals. Chopping and sewing away, one surgeon remarks to another that the government planned to ‘consolidate the worst features of the NHS’. In the final frame of the cartoon, the shrouded patient is dead, ‘NHS’ scrawled on his sheet. The idea of the NHS’ death was popular in satire and protest of this period: one of Spare Rib’s defining ‘Images of 88’ was a photo of two nurses holding an ‘RIP NHS’ sign, taken during a protest of 1,500 people in Gloucester against cuts to healthcare.
Industrial unrest came to the NHS in the 1960s and 70s. In 1975 consultants worked to rule, to insist on their right to continue treating private patients, and junior doctors, later in the same year, joined together in a strike to protest about their pay and conditions. Such events did not go unnoticed by cartoonists, satirists and campaign groups. In April 1969, the cartoonist Ronald ‘Carl’ Giles portrayed a nurse ‘pinching’ three peas from her patient in response to the cutting of nurses’ food allowances. Giles even sent the cartoon directly to the East Suffolk Nurses League, signing it ‘with deepest sympathy’. In the 1980s, cartoons featured overworked doctors fitting in just one more round of the wards in the final ten minutes of their 83-hour weeks. Numerous cartoons made jokes about the privatisation of services such as bed bathing, apparently contracted out to burly window cleaners; or expressed concerns about the result of staff cuts, showing patients on the operating table having to reach for their own scalpels. Some cartoonists observed these changes from a very different perspective. John Musgrave-Wood, drawing for the Daily Mail in 1968, portrayed a doctor with a dunce cap pouring ‘Defence Cuts’ down the mouth of the overweight and decadent NHS.
The campaign group London Health Emergency often used satire to demonstrate how illogical and even ludicrous they felt many of Thatcher’s NHS reforms were. The group’s newsletter, Health Emergency, expressed mock sympathy for the ‘pin-striped paupers’ in NHS management, particularly those in the new and non-elected Regional Health Authorities. Parodying new adverts from BUPA, a private healthcare company founded in 1947, Health Emergency showed advertisements for private healthcare provided by ‘BURPA: It can cost you an arm and a leg!’, as well as from the ‘Medical Excess clinic’ for ‘wealthy hypochondriacs who hang around the West End’.
Other features were written on behalf of the ‘Confederation of British Contract Cockroaches’, which defended the Thatcher government’s plans to give cleaning contracts to private companies, arguing that ‘cockroaches have a role to play in cleaning up the morsels of rotting food and debris left behind by private contract cleaners, and at no extra cost to the taxpayer’.
Satire about industrial unrest and NHS cuts also filtered into British cinema during this period. Perhaps some of the best remembered films about the NHS are the Carry On series, which offered light-hearted and slapstick representations of chaos within the hospital, featuring battleaxe matrons, doctors in love with their patients, magical sex-changing serums and leaking laughing gas. Less well-known films, however, were much darker comedies. In The National Health (1973), staff struggle to cope in an under- funded NHS hospital overwhelmed by administrators, set against a fantasy hospital, staffed by the same actors, whose patients are all cured with high-tech equipment. In Britannia Hospital (1982), activists surround the hospital to protest against its treatment of an African dictator, while kitchen staff campaign against the unnecessary demands of the hospital’s private patients.
Light-hearted humour about the NHS continued, but the darker vein of jokes that emerged during the 1960s, burgeoned in the following two decades. Much of this humour was propagated by campaign groups in response to changes in health policy and funding and motivated by love and appreciation for the NHS.
Did people enjoy these cartoons, or not notice them among the other sections of their newspapers? Did protest satire encourage members of the public to reflect on NHS privatisation, or was it ignored? More generally, is there any way through which we can understand how the NHS was discussed, described and joked about in daily life, by the patients, families, friends and staff who worked and lived within its institutions? The numbers of people involved are massive: the NHS deals with over a million patients every 36 hours. The institution also has one of the five largest workforces in the world (alongside the US Department of Defence, McDonald’s, Walmart and the Chinese People’s Liberation Army).
While conducting archival work, we find some traces of cases of everyday laughter and humour. In 1949 the journal Public Employees described ‘loud laughter’ at a conference of the National Union of Public Employees, when an ambulance driver described how a local fire brigade had recently turned up at a maternity case and the ambulance staff at a fire. Capturing a more private and intimate exchange, in 1984, reporting on hospice care, June Southworth’s Daily Mail article, ‘Dying With Dignity’, described how a dying father was conscious that he lived in a ‘cheerful little ward’, surrounded by ‘laughter and joy like any other day’. One of his daughters told the newspaper that the staff liked ‘to hear people laugh’ and another daughter added, wryly: ‘We’ve all put our names down to come here.’
There are also some archival traces of moments in which jokes have flopped, causing offence or awkwardness. In ‘No Such Thing as Pain’, an article from Spare Rib, published in January 1982, Ruth Wheeler described her ‘painful’ and ‘humiliating’ experience of childbirth. She had initially bonded with a ‘jovial young medic’ after giving birth, who had complimented her sense of humour. However, as he sewed up her torn vagina, the new mother joked: ‘Don’t stop, please. Anything which could prevent a repeat performance of this must be good.’ The doctor, she recalled, clearly felt that her ‘blatant irreverence was too much’ and that her jokes about ‘this noble state of childbirth’ had gone too far, crushing the sense of shared values and community between the pair, even acting as an ‘insult to his maleness’. This is a rare but important case in which a moment of awkward humour has been documented, probably because of the radical, emotional and personal nature of this publication.
People have always used humour and laughter to bond with one another and to criticise medical professionals, practice and policy. It is hard to access these daily interactions, but it is likely that they have shifted over time and were shaped by, as well as reflected in the media. Particular styles of humour have faded in and out of fashion, evoked or neglected according to broader social and cultural trends. The subjects of humour have changed, too, responding to medical developments from the smallpox inoculation to nasal flu vaccines, and to various political developments and reforms. Laughter has been used therapeutically in hospitals and in public health videos. Thinking about these different types of laughter and jokes can help us to understand better how the NHS has changed the lives of Britons, and reflected and inflected conceptions of British national identity, as the institution approaches its 70th anniversary.
Jenny Crane is part of the Cultural History of the NHS project at the University of Warwick, which is funded by the Wellcome Trust. The website, peopleshistorynhs.org, invites submissions about any memories of the NHS, including moments of humour and laughter.