National Health Service History
References to preface
Introduction - the inheritance of the NHS
We are a pragmatic race. We make things work even when they seem, by theory, to be unworkable. We shall probably do the same with our health services.
Lord Horder 19391
Having been at the centre since the earliest planning day I am well aware of the many occasions on which mistakes have been made and yet, not withstanding considerable knowledge of comparable services of other countries, in a time of need for myself or my family I would now rather take my chance at random in the British National Health Service than in any other service I know.
The National Health Service began on 5th July 1948. Already the NHS, which Bevan described as a great and novel undertaking, is the stuff of history. Few people now working in it had been born when it began. Those with clear memories of the early days grow fewer and this book is in part a tribute to their work. It is the story of the NHS, how it was set up, what happened next, and why. It aims to give the reader, whether professionally involved in the NHS or not, a chronological framework of the main events, clinical and organisational. The clinical sections describe the vast and wide-ranging the developments that have imposed demands on the organisation, finance and structure of the NHS. Much of the story of the NHS is about the interaction of the three main parties involved: those needing care, those who deliver skilled care and those whose task it is to raise the money and see it properly spent. The peculiarly difficult triangular relationship between these interested parties has to be satisfactory if the health service is to function to the benefit of society.3 Knowledge of the evolution of the service, and the changes brought about by the advance of medical science, should help those planning, managing or working in the NHS to be realistic. Advance in clinical medicine is international and it has often been developments in other countries that have led to new forms of treatment, and sometimes new patterns of organisation. Only rarely do advances stem from the work of a single pioneer; usually they are the work of a team, or several teams. Charles Rosenberg says in his history of hospitals in the USA4
There is no ideal way of dividing this story into sections. The introductory chapter describes the health services in 1948. The next chapters each cover a decade, and begin with a chronology of events both in the NHS and in national life. The structure of the chapters is broadly consistent so that a particular topic can be followed over the years. In each decade medical progress is considered first, then the developments in general practice and primary health care (the patient’s first point of contact with the system) and the hospital service. Lastly, changes at an organisational and managerial level are discussed.
The story of clinical and organisational developments in the NHS can be seen within the wider context of the development of the welfare state, about which Nicholas Timmins has written.5 To keep within reasonable limits boundaries had to be drawn. This book concentrates on England, for organisational changes in Scotland, Wales and Northern Ireland differed, reflecting the different circumstances. It does not duplicate accounts of the creation of the NHS.6,7 It tries to avoid looking at the NHS through the eyes of central government and does not explore the political background as deeply as Rudolf Klein.8 Neither does it deal with the types of care that shade into social services. The temptation to stray into clinical research leading to advances in medicine, or to explore in any depth the relation between income, illness and mortality, had to be resisted. It was not practicable to include the stories of optical, dental and pharmaceutical services; each could be the subject of a book to itself.
The use of English has changed substantially over the last 50 years. It was assumed in 1948 that doctors were men, and could be referred to as masculine. Concepts were expressed with little regard for the possible offence they might cause; terms such as ‘mental defectives’ and ‘the workhouse’ were well understood and few objections were made to their use. They have changed over time: a White Paper in the 1970s referred to the mentally handicapped but we now talk of people with learning difficulties; senile dements became elderly severely mentally infirm (ESMI), a phrase also now consigned to limbo. I have tried to use contemporary terminology and not to change the words people used; increased sensitivity to those with problems is, in itself, part of the history of the NHS.
Online resources have expanded substantially since the book was written. For example the National Archives have a hospital database, and the London School of Hygiene and Tropical Medicine has one of voluntary hospitals. Poor Law hospitals and workhouses are covered by another site, and hospitals in London that have closed and disappeared by Lost Hospitals.
The Socialist Health Association, in conjunction with Hull University, has a substantial archive of documents, some of national importance, and others part of the history of the Labour Party in respect of health care.
1. Lord Horder. Foreword. In: Herbert SM. Britain’s health: based on the PEP report. Pelican Special S27. Harmondsworth: Penguin Books, 1939.
2. Department of Health and Social Security. On the state of the public health. Report of the CMO for 1972. London: HMSO, 1973.
3. Clark-Kennedy AE. Medicine in relation to society. BMJ 1955; 1: 619--23.
4. Rosenberg C. The care of strangers -- the rise of America’s hospital system. New York: Basic Books, 1987, 7.
5. Timmins N. The five giants: a biography of the welfare state. London: HarperCollins, 1995.
6 Pater JE. The making of the National Health Service. London: King’s Fund, 1981.
7 Webster C. The health services since the war. vol 1. To 1957. London: HMSO, 1988.
8 Klein R. The new politics of the NHS, 3rd edn. London and New York: Longman, 1995. (First published 1983).
I owe a great debt to many colleagues who have helped me reconstruct a period which, though near to us, has seen so much change that it is all too easy for one to forget times past. I have not referenced personal communications though there have been many. Sir George Godber, who was at the centre of the developments of the first three decades and played a substantial role in the solution of problems, was of great assistance. He, Professor Walter Holland, Professor John Blandy and Jane Allen provided extensive comments and editorial assistance; the errors are, however, my own. Barbara, my wife, who was a student nurse when the NHS was established, helped me to expunge jargon and understand nursing issues better. The book would not have been possible without her tolerance and the many people who gave me unstinting and often enthusiastic assistance. They include Professor David Allison, Michael Ashley-Miller, Sir Francis Avery Jones, Ian Ayres, Alan Bacon, John Ballantyne, John and Pamela Ball, Christopher Bartlett, Mark de Belder, Virginia Berridge, Rudolf Blach, Sir Douglas Black, John Bootes, Sir Christopher Booth, Lord Briggs, Michael Brudenell, Margaret Buttigieg, Professor Charles Calnan, Professor Geoffrey Chamberlain, Sir Tim Chessells, Lady Julia Cumberlege, Deidre Cunliffe, Pamela Davies, William Dinning, Sir Richard Doll, Sir Colin Dollery, Nigel Edwards, Johanna Finn, Professor Malcolm Forsythe, Hugh Freeman, Michael Freeman, Dame Phyllis Friend, Dr Edward Glucksman, Professor Sir David Goldberg, Sir Anthony Grabham, Henry Grant, Professor Sir John Grimley Evans, Stephen Hadfield, Dame Nancy Hallett, Valerie Harrison, Julian Tudor Hart, Professor Charles Harvey, Professor David Harvey, Denis Hill, Arthur Hollman, Anthony Hopkins, John Horder, Sir Godfrey Hounsfield, Sir Donald Irvine, Professor Ian Isherwood, Rudolf Klein, Professor Donald Longmore, Annabelle Mark, Robert Maxwell, Professor Alan Maynard, Pauline Munro, Anthony Pinching, Simon Pleydell, Irene Roberts, Professor Jane Robinson, Henry Rollin, Sir Brian Salmon, Professor Karol Sikora, John Smith, Professor Patsy Stark, Professor Robert Steiner, Barbara Stilwell, Sir Eric Stroud, Professor P K Thomas, James Thomson, Sir Leslie Turnberg, Professor Owen Wade, Diana Walford, Lord Walton, Professor Michael Warren, John Wickham, David Willetts, Susan Williams, Professor Jenifer Wilson-Barnett, Eve Wiltshaw, Antony Wing, John Yates and colleagues at the King’s Fund, Nuffield Provincial Hospitals Trust and the Department of Health. My thanks are due, in particular, to staff of St George’s and the Royal Postgraduate Medical School, Hammersmith. The librarians at the Royal Society of Medicine, the Department of Health and the West Suffolk Hospital were most helpful.
The columns of the British Medical Journal provided a vast amount of material, and have helped to prevent the omission of significant developments; readers should be aware that the BMJ has editorial freedom and its views are not necessarily those of the British Medical Association.
I am particularly grateful to the Dunhill Medical Trust for its ready support during the writing of this book and to the King’s Fund Grants Committee for a substantial contribution to the costs of publication. The views expressed are, however, mine and do not necessarily reflect the policy of King Edward’s Hospital Fund for London.
Introduction - the inheritance of the NHS
Of course the health service in this country did not begin in the year 1948. Many of us have associations with the between-the-wars health service; a great patchwork, a good deal of good intentions, a great deal of inadequacies. The Rt Hon Jennie Lee MP, Minister of State, Department of Education and Science (Aneurin Bevan’s widow)1
The designers of the NHS did not start with a clean sheet of paper. The service was a rationalisation of what existed, conditioned by a need to cajole rather than coerce somewhat reactionary interest groups. Some countries, such as New Zealand and Sweden, had forms of health service but they were not used as models; insularity of outlook prevented that. On the basis of wartime experience it was the hospital service that was most in need of reorganisation. Hospitals were in a muddle and financially at the end of their tether. There were prestigious voluntary hospitals, municipal hospitals displaying the entire spectrum of standards and entrepreneurial cottage hospitals in which local doctors could resurrect dormant surgical skills. In 1948 it had been little more than a decade since the first sulphonamide gave doctors a powerful weapon against streptococcal, meningococcal and gonococcal infections. The next ten years saw dramatic improvements in treatment greatly accelerated by research and development carried out by the medical equipment and pharmaceutical industries.
General practice covered workers under Lloyd George’s National Insurance Act of 1911, but not their wives and families, whose proper demands were curtailed by the need to pay fees for service.2 When they were sick, it was the GP to whom people wished to turn. The work of the GP had been described in idealistic terms by Lord Dawson in his report of 1920, which laid out the structure a health service might take.3 The GP should be accessible, attend patients at home or in the surgery, carry out treatment within his competence and obtain specialist help when it was needed. He would attend in childbirth and advise on how to prevent disease and improve the conditions of life among the patients. He should play a part in antenatal supervision, child welfare, physical culture, venereal disease and industrial medicine. Nursing should be available, based with the doctor in the primary health centres Dawson envisaged.
This picture was in stark contrast to the day-to-day pattern of the GP’s life. In inner cities overcrowding led to domestic violence, lice infestation and skin diseases such as impetigo. CAH Watts, a GP writing of his experiences in a mining community before the second world war, recalled the waiting room with rows of seats for about 60 patients who sat facing a high bench like a bank counter.4 Behind stood the three doctors and behind them the dispenser. The doctor called the next patient to come forward. Having listened to the complaint, he turned to the dispenser to order the appropriate remedy. There was rarely any attempt at examination. Visits usually numbered about 50 and were made on a bicycle. Diphtheria was endemic and every sore throat was viewed with suspicion. Antiserum was one of the few active treatments available to the GP, and if given within 24 hours of onset the results were excellent. Otherwise, the mortality was about 20 per cent. Patients with diphtheria or scarlet fever were taken away in a yellow fever van to the infectious diseases hospital for at least six weeks; no visitors were allowed. Lobar pneumonia was common, and with the more fortunate patients there was a crisis about the seventh day. It struck terror into the patients’ and the doctors’ hearts, for the mortality was popularly thought to be at least 50 per cent and sulphonamides were not invariably curative. Most dreaded was tuberculosis, blood in the handkerchief after a fit of coughing. Some families were especially vulnerable and it tended to strike young people. The course could be lingering or extremely rapid, with death within weeks. Lung cancer was rare. If it occurred, it would probably not be recognised.
Almost half the babies were delivered at home, mainly a matter for midwives. Pain relief in labour, although available in hospital, might not be provided in the home. When things went wrong the GP would be summoned, because procedures such as breech birth or manual removal of the placenta might be required. Most GPs used chloroform as an anaesthetic though some felt it was quicker and safer without. As they might have neither the skills nor the equipment to handle problems, in many places obstetric flying squads, based on the hospitals, had been established. These could deal with haemorrhage, shock and eclampsia (fits during late pregnancy, labour and the period shortly after), transfuse patients, give anaesthetics, and undertake operative obstetrics in the home.5 Tales of obstetric disaster, haemorrhage after delivery and problems with forceps were only too common, although remarkably many women survived crises unthinkable today. Serious infections (puerperal sepsis) killed mothers after childbirth, particularly if there were sore throats going round.
Pain and discomfort were accepted as part of life to be endured with stoicism. The family doctor had to be tough to get on with his many interesting and rewarding tasks. If he had access to a hospital, he might set a simple fracture or reduce a dislocation. Working class people did not expect to be comfortable. Most went hungry and their undernourished children showed evidence of rickets until vitamin D supplements, provided by welfare clinics, controlled it. Many were miserably cold in winter unless they were roasting in front of the coal fire in the kitchen. Successful treatment by the family doctor was accepted with gratitude and the many failures were tolerated without rancour or recrimination. Patients’ expectations were not high. The death of children from infectious disease was the way of the world. Mothers of feverish children expected, if the child was not to be admitted to the fever hospital, to be told that bed rest was crucial until the fever had fully subsided. One of the author’s predecessors in practice was described as ‘a right bastard but a bloody fine doctor’; he used to whip the children out of his way as he rode past. GPs’ hours were long, as most practices were single-handed and deputising services were non-existent. Local rota systems operated on a ‘knock-for-knock’ basis to make a half-day practicable. A car and a telephone were desirable - but not essential. If it mattered enough there was always a way of contacting the doctor sooner or later.
People did not trouble GPs without good cause. Early in recovery patients might dispense with their services. Most had to pay for the doctor and the medicines. The professional attitude to working class patients was frequently robust, and sometimes downright rude, but this was accepted with tolerance. In middle-class practices there were greater courtesies. There was the ritual preparation of a napkin, a spoon and a glass of water for the doctor’s visit. There might be five shillings (25p) on the mantelpiece for the fee; three and sixpence (17½) if the family was not so well off. High up the social scale the doctor might be treated as a rather superior type of servant. Medical diagnosis was often of academic rather than practical importance. Treatment was limited to insulin, thyroid extract, iron, liver extract for pernicious anaemia, digitalis, the new mercurial diuretics, barbiturates, simple analgesics, morphine derivatives and harmless mixtures.6
Entry into a practice was generally by purchase of goodwill, the usual price being one and a half times the annual income.7 GPs started with a substantial debt. On average about 1,000 national insurance patients generated about £400-£500 per year, an income boosted by the care of the families who were not covered by national insurance.
GPs and specialists
Since the middle of the nineteenth century the voluntary hospitals had been expanding their outpatient departments, for these were their shop windows. The British Medical Association (BMA), representing the GPs’ point of view, opposed expansion because of the effect it had on GPs’ earnings, but they expanded none the less.8 By 1939, 6 million attended them every year, in spite of complaints about inadequate waiting facilities and perfunctory and inconsiderate treatment.9 In contrast the hospitals run by local authorities had poor or non-existent outpatient departments and less reason to build up large ones. The London County Council (LCC) rigidly enforced conditions of attendance at outpatient departments to people referred by their GPs, although patients might be seen once without a doctor’s letter, then being referred back to their GP.10
In 1946, like everyone else, Britain’s GPs were tired from six years of war. The younger ones had been called up, and the older ones had stayed behind -- including many women doctors who had qualified at the time of the first world war, when medical schools had opened their doors wider to women. Some saw an atmosphere of demoralisation and disillusion, with poorer relationships within the profession than ever before.11 Those who had stayed behind had done their own work and that of their colleagues as well, and felt that doctors who had been in the services had enjoyed an interesting time. Those who had served were resentful that their practices had disintegrated, and they had returned to a vastly different world.
In 1948 there were over 150 local authorities in England that had wide and major health responsibilities. Each had a Medical Officer of Health (MOH) who was a chief executive, responsible to his council. His department ran midwifery and child welfare services. Then there was the school health service, under the Education Act 1944, which provided ‘all forms of medical and dental treatment, other than domiciliary treatment, to children attending maintained schools’. It was not until 1974 that the school health service became part of the NHS. Environmental pollution, food inspection and food and drugs legislation were also within their province. Some ran district medical services under the Poor Law.
The Local Government Act 1929 had given authorities the power to appropriate poor law institutions and develop them into modern hospitals. MOsH such as Sir Frederick Menzies and Allen Daley in London, Tate and Macaulay in Middlesex, Campbell in Lincolnshire, Parry in Bristol, Ferguson in Surrey and John Charles in Newcastle had developed and extended the local authorities’ general hospitals. The local authorities also ran fever hospitals, sanatoria and mental hospitals under the supervision of the Board of Control. As a result, MOsH had a role not only in the health of the population but also in the cure of the sick. Allen Daley, as Sir Frederick Menzies had been before him, was interested in medical education partly because of the need to staff the LCC’s hospitals; they fought for the establishment of the British Postgraduate Medical School at their Hammersmith Hospital. Indeed the LCC would have liked an undergraduate teaching hospital of its own.
Local authorities ran the tuberculosis sanatoria: 32,600 beds in England and Wales. A suggested norm for tuberculosis was 1.5- 2 beds for each death annually; there were 23,000 deaths in 1947 and 52,000 new cases.12 The local authorities had a responsibility for infectious diseases; in the early 1930s 800 children out of every 100,000 died annually from them. Diphtheria, which had affected 50,000 children a year, was coming under control by immunisation at the start of the NHS. In 1947 a major poliomyelitis epidemic led to 7,000 cases and 500 deaths. There were 1,693 cases in 1948, of which two-thirds were paralytic. In the record time of two weeks the Ministry produced a 15-minute film on its early diagnosis. With the co-operation of the BMA an intensive effort was made to screen it; cinemas and halls were booked on Sundays and local doctors were invited. Within six weeks 17,500 doctors and 16,000 nurses had seen the film. By contrast smallpox was rare, although there was an outbreak in 1948 with 78 cases and 15 deaths. Venereal disease increased with the disturbances of war but some control was kept by better systems of contact tracing.
Health promotion was generally regarded as a good thing. It was stressed both by Lord Dawson in 1920 and by the 1937 report on health services produced by Political and Economic Planning (PEP), a pressure group of businessmen, educationalists, architects, economists, social scientists and sympathetic MPs such as Harold Macmillan. PEP believed that the GPs’ non-essential tasks should be removed, that standards of training and equipment should be raised to create in the GPs a more effective family health adviser, and that efforts should be made to promote healthy living to reduce the number of sick people needing continuous treatment.13 There was an active public health movement during the years of war that included GPs, public health departments, health visitors and a few health education officers.14 Health promotion met clear and obvious needs, and was directed at large scale but simple improvements. Much effort went into sex education, venereal disease, infectious diseases, and maternal and child health. Exhortations on growing your own food, eating well on your rations, and getting fresh air and exercise were plentiful. Many leaflets were targeted at women, to teach them how to care for their families and, in the interests of hygiene, to bring death to bugs and flies. Wilson Jameson, the government’s Chief Medical Officer, broke new ground when he spoke openly on the radio about the prevention of venereal disease.
War had badly damaged hospitals in urban areas; not one hospital in London had escaped the bombs. The buildings were not a rich heritage. At St George’s the flowers in the ward were placed on a glass-topped table so that the reflections could be seen. At Paddington General the legs of the cots in the maternity department stood in tins of oil to discourage the cockroaches from crawling up. Two-thirds of the hospitals had originally been erected before 1891 and 21 per cent before 1861. They were in poor physical state and lacked diagnostic facilities, pathology and radiology, and operating theatres. During the 1920s and 1930s there had been substantial expenditure on hospitals but hospital infrastructure, catering and heating, required urgent attention. Most steam heating systems had been introduced around 1900, and the life of boilers was about 50 years. Hospitals in 1948 provided far more accommodation for chronic illness in the elderly, both physical and mental. Medical wards were full of patients with pneumococcal pneumonia, lung abscess, acute nephritis (inflammatory disease of the kidneys), rheumatic fever and rheumatic heart disease, tuberculosis, syphilis in all its stages and brucellosis (an infectious fever usually the result of drinking unpasteurised milk). Treatment was often based on good nursing, bed rest, barbiturate sedation at night and attention to pressure areas. Compared with today there were few drugs to offer - salicylates for rheumatic fever, digoxin for heart disease, sulphonamides and penicillin which were controlling the pneumonias, and soon streptomycin.15 About 16,000 people were dying annually of rheumatic heart disease. Although the incidence was falling, there were still about 5,000 new cases among children and adolescents each year. Surgical wards had many patients with perforated or bleeding peptic ulcers, bone infections (osteomyelitis) and goitre, as well as urine retention from prostatic enlargement. Tuberculosis of the lungs and of the joints formed a major part of operative surgery.
Patients were often admitted at a late stage in their disease. Diagnosis, prognosis and treatment were often a matter of clinical judgement based on bedside observation over a period of time. Anaesthetics was not yet fully distinct as a specialty and a basic knowledge of its techniques was a useful skill for any young doctor, indeed for medical students. Open ether (dropped onto a mask) was still in use, particularly for children (‘blow the gas away’). Induction with nitrous oxide or an intravenous barbiturate followed by nitrous oxide and oxygen, plus ether or triethylene, was the common technique. At The London Hospital any house surgeon who happened to be having a rest or a cup of tea was likely to be summoned to give an anaesthetic for an emergency forceps delivery in the labour ward, above the common room.
Admissions to Kidderminster General Hospital (60 adult
Virtually all hospitals were subdivided in the same way: general medical and general surgical wards. The maternity department, if one existed, would be separate, as would be the gynaecology wards. Children were frequently placed in adult wards, perhaps in a cubicle. In the larger hospitals there might be separate orthopaedic wards, and provision for infectious cases or for sick members of staff. Hospitals had few consultants, specialisation being in its infancy. Generally there would be only two or three on any one ward. The consultants and the ward sisters therefore came to know each other’s ways, and to trust and be loyal to each other. It fell to the sister to help and train newly qualified doctors in the ways of the ‘chief’. In the traditional medical ‘firm’ junior doctors of all grades worked predominantly for one or two consultants, ensuring continuity of care for the patients, a clear chain of command, regular contact that helped the education of the juniors and camaraderie under pressure.16 The junior doctors, virtually always unmarried, lived in a bachelors’ mess and were available night and day.
From the patient’s point of view some hospitals had a name for making patients welcome and took pride in keeping it. Friendly doctors, an enlightened matron, well-chosen sisters and contented nurses all played a part. Such traditions were inherited, but bad traditions of grudging, unwilling service also existed. A correspondent to the Lancet described her contrasting experiences in two London teaching hospitals. Patients might be left in the dark about their condition and their simplest rights disregarded. Outpatient departments could be comfortable, or the consultant might invite three patients into the consulting room at a time and deal with them together. Student teaching at the bedside might be conducted courteously, or the patient might be ignored and treated as ‘teaching material’. Questions about diagnosis and treatment might be answered, or the patients left unseen by a doctor. There might be noise in the wards with carelessly served and uninspiring meals, or well cooked and warm food properly presented in the atmosphere of a good hotel.17
The most prestigious hospitals were ‘voluntaries’, institutions that financed themselves as best they could and were responsible only to themselves. They had grown up in a haphazard fashion. Some were institutions founded centuries previously for the benefit of the sick poor, others by citizens proud of their towns or anxious to perpetuate their names. The best-known were the prestigious teaching hospitals: 12 in London (such as Guy's Hospital), most with centuries of tradition, and 10 in the provinces that had usually been founded in the nineteenth century in association with a civic university. There was a gradation from these teaching hospitals, staffed by consultants not engaged in general practice who gave their services free, to smaller ones such as the voluntary hospitals in places such as Bath and Ipswich.
Next came lesser hospitals staffed by visiting consultants who lived at a distance. The smallest had one or more resident medical officers with a visiting staff of local GPs and perhaps special departments under visiting specialists from distant centres. It was a short step from these to the cottage hospital staffed by GPs, often with consultants on call, in some of which major surgery including gynaecology might be undertaken by GPs. These had often been built in the nineteenth century to provide essential care to otherwise inaccessible country populations, and more opened after the first world war as small memorial hospitals. The matron might combine the functions of ward sister, theatre sister, midwife, radiographer, almoner, resident medical officer and even cook. Then there were convalescent homes, to which people might be transferred when their recovery was assured but they were not yet ready for discharge. Often managed by nursing staff with the support of visiting GPs, they prevented the blockage of beds in the larger hospitals.
The voluntary hospitals aimed to provide quality care to a limited number of patients. They were generally well managed and had the ability to choose their staff and maintain firm discipline. There were extensive outpatient services, the presence of which publicised the hospital and attracted donations. Maternity departments were small. Some categories of patients were unlikely to be admitted - elderly people and those with chronic diseases. Taken as a whole the voluntary system had been in financial straits before the war. Over a thousand in number, they barely made ends meet but a hospital never needed to despair as long as it could proclaim itself to be bankrupt; financial problems could be the basis of an emotional appeal to the public - shroud-waving as it was known. In the unusual event of a surplus, hospitals invariably planned an extension or development. Money came from charity, hospital savings schemes, the fees of those who could pay and, increasingly, from local authority grants. Hospitals were the focus for local charitable effort, run by leaders of local society and doctors’ wives. Teaching hospitals and their schools encouraged a feeling of esprit de corps. Medical students were often the sons of doctors who had trained in the same hospital. Matron, able to select her student nurses, required the ‘school certificate’ and tended to choose a ‘nice type of girl from a good family’. Discipline was strict, going out with a houseman might be frowned upon; pregnancy was certainly a cause for dismissal. In spite of the hazards there were many doctor-nurse marriages.
Public hospitals grew up separately during the nineteenth century. From the 1830s locally elected bodies, the boards of guardians, had created institutions that housed a range of people from tramps to bed-fast chronic sick. Typically they had casual wards for able-bodied vagrants, a large ‘house’ for destitute elderly who were not sick, and infirmary wards for the chronic sick. After the scandals of the Poor Law workhouses and hospitals, in the 1860s, many were rebuilt such as Shoreditch, now St Leonard's. By the 1920s some boards of guardians, particularly in the big cities, had growing infirmary sections that were larger than the rest of the institution, with resident medical staff and some facilities for laboratory tests, X-rays and surgery. In smaller country institutions the ‘house’ and the ‘chronic sick’ predominated. Under the Local Government Act 1929 counties and county boroughs took over from the boards of guardians. Institutional funding now came from the rates, but with a block grant from central government covering 40 per cent of the cost. Each authority established a public assistance committee to run the institutions. Most remained as they had been, accommodation largely for the elderly and chronic sick, many of whom would remain there until death, together with occasional maternity patients or children suffering from neglect. Counties and county boroughs could, however, ‘appropriate’ the hospital sections of these huge institutions to their public health committees, and upgrade them to modern acute hospitals under the management of the MOH. Enthusiasm for this varied and it was the larger authorities that were most active; the smaller county institutions were a less attractive proposition. In some places, such as Middlesex, Surrey, Birmingham, Bristol, Newcastle and London, the hospitals appropriated from the old Poor Law Board became the centre of civic pride and substantial investments were made in their improvement. The LCC intended that all those appropriated should become general hospitals, and the equivalent of the voluntaries. ‘Only the best is good enough for the patients in our hospitals,’ wrote one LCC councillor. Most councils, however, were selective about the institutions they took over; for example, Leicester took over the city hospital of 600 beds but not the wholly chronic Hillcrest public assistance institution with 370 beds, where visiting GPs provided cover. The county of Leicestershire took over nothing. Nottingham city took over the central hospital but the county took little.
The voluntaries had been unable to keep pace with the growing needs of the population and the municipal hospitals were catching up. The latter were developing better laboratories and theatres although outpatient departments were rudimentary. Nationally they provided three times the number of beds, though many were for long-term care. Medical staffing differed materially from the voluntaries. The senior officer of the hospital was the medical superintendent who, in addition to general administrative duties, usually had clinical responsibility as a physician or surgeon. In the smaller hospitals his responsibilities might spread over a wide clinical field, although most of the work was in the hands of resident medical staff, often of considerable experience and standing. The extent to which consultants from the nearby voluntary hospitals were used was variable; sometimes they visited regularly but more often they were called to specific cases and had no continuing responsibility. The municipal hospitals stood alone when they could.
The municipal hospitals were as ill-co-ordinated as the voluntary ones. The towns were the natural centres for the surrounding population, but an arbitrary line on the map might determine whether a patient had access to a relatively well-staffed modern city borough hospital or a distant and unsatisfactory institution managed by a county council. The municipal hospitals were the last resort for patients unlikely to improve with treatment. The voluntaries were accustomed to transferring chronic cases to them (e.g. cancer patients) and to have little other relationship. Similarly, local authority hospitals took cases of infectious disease from the voluntaries. The role of dumping ground was hotly resented by municipal hospitals, especially when they had developed into well-equipped acute units. There was infighting as the demand for acute hospital care increased and the local authority hospitals took a larger share, particularly in obstetrics. In a few places, such as Newcastle and Lincolnshire, the various hospitals worked side by side without hostility. In Oxford, Lord Nuffield had supported a ‘Hospital Council’ that had been successful in co-ordinating the two camps. But sometimes there was open war. Most thought of first-class medicine in terms of the London teaching hospitals. Increasingly, however, provincial and non-teaching hospitals were becoming recognised as leaders; for example by 1940 the Birmingham Accident Hospital was pre-eminent in trauma and the first Chair of plastic surgery was held by Thomas Kilner in Oxford. Francis Avery Jones, appointed in 1940 to the Central Middlesex Hospital, established one of the first specialist units in a municipal general hospital. A pioneer gastro-enterologist, his guiding principles were that diagnosis should be early and accurate and that treatment should be scientifically based.
The beds provided for the mentally ill and mentally handicapped exceeded in number the acute beds of the voluntary and municipal hospitals, but there were never enough. Bomb damage and the use of some accommodation by the wartime emergency medical services increased crowding. Before 1946 there had been little expectation of the inclusion of these services in the NHS, and therefore little planning. The mental health sector was subsumed into the NHS with difficulty, as an unwilling and inferior partner. Although isolated and disregarded, its problems were massive, for the hospitals were old, isolated, poorly provided with amenities and mostly too large, some with over 2000 beds. The ethos of the mental hospitals contrasted starkly with acute hospitals, but not always for the worse. They were surrounded by large grounds, immaculately tended by a well-trained squad of patients, usually chronic schizophrenics. The institutions turned inwards upon themselves with inter-hospital sports competitions and social activities. The discipline among patients, doctors and nurses was firm but at least for the staff the food was excellent. For most patients, however, enforced idleness produced inertia, loss of morale and of self-esteem.18
Specialisation and specialist hospitals
Generalism had been paramount, the general physicians and surgeons outranking in status doctors who worked in specialist fields such as ophthalmology and dermatology. The large voluntary hospitals were often slow to provide facilities to those working solely in a minor field. However, Geoffrey Jefferson, Professor of Neurosurgery in Manchester and one of the great men of the time, said that the characteristic clinical theme of the first half of the century had been the rise of specialism. As early as 1900 some had seen the writing on the wall. Jonathan Hutchinson, dissatisfied with the results of his treatment of stone in the bladder, handed cases over to a colleague adept at new techniques. The improvement in results after he ceased to operate gave him the utmost satisfaction and pride.19 The earliest specialties dealt with conditions that were found in considerable numbers in every district. In 1948 some ‘minor’ specialties were behind the times; for example, British dermatology lagged behind the rest of Europe where large research-based units were commonly found. Occasionally a pioneer sought to rectify this; Geoffrey Dowling, at Guy’s and later St Thomas’ Hospitals, formed a journal club for young doctors and organised overseas study weeks.20
‘Special hospitals’, which concentrated on one particular disease or organ system and often led their field, developed in large cities during the nineteenth century. In the provinces where there was only one medical school, the special hospitals and the teaching hospital often came to work with each other. They developed a modus operandi by which diseases of women or diseases of the eye were mostly or exclusively handled by the appropriate special hospital that would teach medical students. In London, however, with its 12 teaching hospitals, special hospitals such as Great Ormond Street and the Brompton undertook little if any undergraduate training and remained entirely separate. While specialists might have beds at both a teaching hospital and a special hospital, considerable antipathy often existed between the two groups. Under the NHS Act 1946 the Minister amalgamated similar special hospitals in London, giving the newly formed groups separate boards of governors. The University of London established an institute for each and the specialist postgraduate hospitals remained distinct both from the general teaching hospitals and from the region’s hospitals.
By 1939 units in new specialties, for example trauma and orthopaedics, were increasingly developing in general hospitals. The process was accelerated by war, and units were planned for a regional catchment to deal with plastic surgery and burns, neurosurgery, facio-maxillary surgery, orthopaedics, spinal injuries and rehabilitation. These included Archibald McIndoe’s unit for burns and plastic surgery at East Grinstead, Ludwig Guttman’s spinal injury centre at Stoke Mandeville and Wylie McKissock’s neurosurgical unit at Atkinson Morley’s hospital in Wimbledon.
Specialisation had advanced considerably in large city hospitals, but less so in rural areas. In all large centres ENT (ear, nose and throat) and ophthalmology were distinct specialties but in smaller hospitals general surgery might encompass traumatic and orthopaedic surgery, ENT and even gynaecology. Neurosurgery and thoracic surgery had emerged before the second world war. Geoffrey Jefferson and Hugh Cairns had neurosurgical units in Manchester and London (later Oxford) but it was not generally available outside the main centres. Thoracic surgery was even scarcer and radiotherapy was just being reorganised after the 1939 Radium Act. A general surgeon in Grimsby owned 80 milligrams of radium with which he would treat cancer of the cervix. General medicine might cover paediatrics, cardiology or even pathology and radiology, but medical specialties such as endocrinology were emerging. Laboratory and radiological support was essential for their development. While an accurate history and examination remained essential for good diagnosis, test results gained in importance and some specialties owed their rapid advances to better systems of measurement; for example, it was not now possible to practise cardiology without a grounding in electrocardiography. Increasingly, physicians and surgeons worked as teams, patient care crossing the medical/surgical divide. ‘It is a regrettable fact,’ said a physician, ‘that when surgeons invade a province hitherto considered to be purely medical, diagnosis almost at once becomes more exact.’21 Clinical medicine was entering an exciting phase. New techniques such as needle biopsy were introduced, allowing the effect of treatment to be followed histologically, by microscopical examination of small specimens.
Two patterns of meeting specialist needs therefore evolved. First were the special hospitals, characteristic of the nineteenth century, a time when most advances were made by careful observation and description. Secondly, special units developed in general hospitals, in the age of laboratory studies and experimental research when it was becoming increasingly important and difficult for clinicians to span several fields, and multi-disciplinary working was becoming essential.22 Superb clinicians, often excellent teachers and authors, were rewriting clinical medicine. The Royal Postgraduate Medical School at the Hammersmith Hospital brought together basic scientific research, physiology and biochemistry, and clinical medicine. The facilities and the approach were attractive to research workers; in medicine the assistants to Professor Francis Fraser included Guy Scadding and Paul Wood, chest and heart specialists. John McMichael, succeeding Fraser, led developments in renal physiology and high blood pressure. Ian Aird, heading the surgical department, worked with Melrose on a pump oxygenator, Melrose developing a method of producing ‘elective’ cardiac arrest. Sheila Sherlock, at the Hammersmith before moving to the Royal Free, made the liver - a somewhat mysterious organ -- understandable, bringing together its pathology and clinical diseases.23 Knowledge of metabolic pathways, of cellular pathology, the nervous system and the workings of the mind, when added to the rapid development of new drugs, encouraged a new vision of medicine in the future. A medical remedy for cancer would surely be found. If not within the next 50 years, at least within an imaginable span of time medicine would replace surgery. Some hazarded a guess that in time medical methods of treatment would be so effective that there would be one only kind of surgery - traumatic surgery.24
The Public Health Laboratory Service
Shortly before the second world war the Medical Research Council (MRC) considered proposals for an emergency bacteriological service, because of the possibility of bacteriological warfare, and the risk that the movement of people in large numbers might lead to outbreaks of infective disease. The Emergency Public Health Laboratory Service (EPHLS) was subsequently established and administered by the MRC. The major epidemics that had been feared did not materialise, and the laboratories came to support the MOsH in their public health work and to provide GPs with access to bacteriology. Benefits flowed from a nationally organised network of laboratories, reporting their findings and exchanging information about new scientific and epidemiological methods. Their work grew rapidly. The EPHLS also undertook research into the accurate identification of strains of bacteria and viruses, developing central reference laboratories. The value of the service ensured its post-war continuation, and it was agreed that the MRC should continue its management. It was formally re-established as the Public Health Laboratory Service (PHLS) in 1946 with the passage of the NHS Act.25
A national transfusion service
In 1939 the MRC agreed to administer blood depots in areas close to concentrations of hospitals yet outside the areas likely to be the target of enemy aircraft. The principles of blood grouping, blood banking and transfusion had been established by that time, and the depots proved their worth at the time of Dunkirk. Towards the end of the war it became clear that, although blood depots had been established to meet the needs of air-raid casualties, the bulk of their work had been with civilians. The rational solution seemed to be a nationwide transfusion service, and plans were made for one to be organised on a regional basis, managed by the regional hospital boards (RHBs).26 Established in 1946, the work of the National Blood Transfusion Service, and its unpaid donors, would underpin many advances in vascular surgery, transplantation, chemotherapy, the treatment of coagulation disorders and shock from massive blood loss.
In the years before the NHS there had been three roots to pharmaceutical development.27 The first involved the slow accumulation of knowledge about folk medicines, many derived from plants such as the poppy and the foxglove, producing opium and digitalis. Production of these had become standardised by the middle of the nineteenth century. The second was related to the increasing importance of pure natural products such as colchicine and emetine (from plants), and heparin, insulin, sex hormones and vitamins (from animals). Penicillin was the first of many antibiotics to be obtained from micro-organisms. Thirdly, starting in the nineteenth century, was the rapid growth of synthetic medicinal chemistry, leading to salvarsan, aspirin and barbitone, the sulphonamides and later the antihistamines and benzodiazepines. In the 1930s Domagk, the research director at Bayer in Germany, saw promise in two approaches to the control of bacterial infections, enhancing the natural defensive powers of the body by vaccines or sera, or damaging the invading bacteria. It was his inspiration to test prontosil (the first sulphonamide used clinically) in mice, even though it was ineffective in the test tube. After its introduction in 1935 many derivatives were synthesised and the idea was born of designing drugs with specific properties, and assessing their benefits and drawbacks. To the great disappointment of clinical pharmacologists, the sulphonamides were totally ineffective against the tubercle bacillus, a disappointment to recur when in 1943 it was found that this was also true of penicillin. Nevertheless, with penicillin, people with chest infections previously admitted to hospital could be managed in general practice. Venereal disease could be treated more effectively and the long-term complications of syphilis became increasingly rare. Streptomycin, isolated in the USA in 1943, was found to be effective in guinea-pigs against the tubercle bacillus and the first trial in humans took place at the Mayo Clinic in 1944. Almost at once bacterial resistance became a problem and, when streptomycin became available in limited quantities in the UK in 1946, the MRC established a rigorously controlled trial in patients between 15 and 25 years of age with acute progressive bilateral tuberculosis. Within six months its effectiveness was proven.
Many of the newly synthesised agents were found to have unanticipated properties, sometimes initially regarded as unwanted side effects. For example, the observation at Johns Hopkins Hospital, Baltimore, that animals treated with sulphonamides might develop goitres led to the development of a number of drugs acting on the thyroid. Chance observations played their part but, with notable exceptions such as penicillin, the great majority of new medicines were discovered and developed by scientists working in the laboratories of an industry devoted to profit, where there was no sharp dividing line between pure and applied research. There was criticism of minimal modification of a patented drug in order to produce a ‘new’ one, but sometimes this produced substantial improvements on the original compound.28
Research and development
The second world war stimulated scientific developments that had crucial effects on the pattern of medical care, altering the work of the NHS. An example was research at the Royal Postgraduate Medical School at Hammersmith Hospital on crush injury that led to kidney failure. As a casualty hospital taking patients from central London, it received many who had been dug out of bombed buildings after many hours. As a result the hospital developed expertise in renal disease.29 Ian Aird, a great professor of surgery at the Hammersmith, said on appointment in 1948 that he wanted two things out of life: artificial hearts (he recruited Dennis Melrose) and transplanted kidneys (he recruited Jim Demster).
The health service also inherited technologies developed during the war that were put to medical use. As the Russians moved into East Germany, the Zeiss technicians moved west. With them went the designs for a binocular operating microscope that was soon in production and radically altered ear surgery. Mullard Research Laboratories and Philips developed the principle of the linear accelerator during the war, made possible by Randall and Boot’s development of the magnetron, a special type of valve for wartime radar. Cobalt for radiotherapy replaced radium and was produced in the Chalk River plant of Atomic Energy of Canada during the war. Radioactive isotopes produced at the Atomic Energy Research Establishment, Harwell, gave Britain an early lead in nuclear medicine.
In pathology, the development of the electron microscope in the AEI Research Laboratory and the evolution of phase contrast microscopy aided the development of histopathology (the microscopical study of pathological changes in structures). Continuous flow biochemical analysis developed in Birmingham by Whitehead opened up the prospects for automation in biochemistry. Similarly, Wallace Coulter’s use of the ‘impedance monitoring’ of an orifice through which blood flowed led to the automation of blood cell counting. Scientific developments had a substantial effect on diagnosis and treatment. The health service, in turn, came to provide a large market for science and technology.
Shortage of equipment was a problem. In 1948 many hospitals were without any surgical diathermy machines (used to stop bleeding from small blood vessels), because the more powerful had been requisitioned for use in the nose cones of Blenheim bombers in submarine hunting. It was therefore impossible to cut tissue under water, important in bladder surgery. Endoscopes were primitive. It was the task of the registrar to hold the patient still while attempts were made to force barely flexible gastroscopes down the patient’s throat. The standard optical design had changed little since the days of Galileo, and were lit by a small bulb that often failed at the crucial moment. Medical appliances were also rudimentary. There were no adhesive stoma bags, a bulky rubber cup being strapped over a colostomy. This worked fairly well as long as the stools were solid, but not for urine or the contents of the upper intestine. It was only in 1960 when his daughter underwent colectomy for ulcerative colitis that Mr Salt, an engineer, devised an appliance that would stick to the skin without causing soreness.
British medicine had a worldwide reputation for good bedside care and clinical excellence; in the research field it was lagging. The tradition of research in the clinic was a nineteenth century German development, stemming from well organised academic and laboratory facilities. Medical schools in the USA had adopted the model of research-orientated clinical departments after the Flexner Report of 1910. In Great Britain the Haldane Commission (1907 - 1913) had argued that university departments with full-time staff were urgently needed but the development of clinical research within medical schools developed more slowly in Britain than in the USA.30 There were a number of outstanding individuals but no structure to encourage an academic and research-based approach to medicine. Virtually all specialists made their living from private practice and had little time for teaching and research. Only with the establishment of academic clinical units headed by salaried senior staff, within university hospitals, could research flourish. In 1939 only six of the twelve London medical schools had a clinical professor in any discipline. Even then a professor in Britain was only one among many consultants, while in the USA he was the head of a department that included all sub-specialties of medicine or surgery, and chief of service of the clinical department. When in the 1930s it was suggested that one of the London teaching hospitals should become a centre for postgraduate education, all refused. The British Postgraduate Medical School was established in 1935 in association with the Hammersmith Hospital, managed by the LCC, and alone among the London hospitals had academic professional leadership. Private beneficence such as that of Lord Nuffield in Oxford and the government-funded MRC were responsible for most of the other developments in the period before the establishment of the NHS.
The medical student course consisted of two parts. During the first two years students studied basic clinical sciences such as anatomy, physiology and biochemistry. Then they began their clinical studies moving in turn through the hospital departments medicine, surgery and obstetrics. In parallel there were lectures seldom closely related to the practical work the students were undertaking. London provided over a third of the country's doctors. Here the medical schools operated individually, largely independent of the University of London and as departments of the hospitals. They provided income from student fees to the consultants and a ready source of cheap junior staff. The provincial medical schools were from the outset an intrinsic and valued part of a multi-faculty civic university.
Service and education are interlinked. In 1942 the Ministry of Health, with the Department of Health for Scotland, established a committee to look at medical education, the clinical facilities required and how they should relate to a new health service. It was chaired by William Goodenough, Deputy Chairman of Barclays Bank and Chairman of the Nuffield Provincial Hospitals Trust. The government already held views on medical education and the members were chosen with these in mind. Goodenough himself was committed to regionalisation; there were two members from University College Hospital, which had the most highly developed professorial system of all the London medical schools; and Janet Vaughan, an eminent haematologist and the Principal of Somerville College, Oxford, who had strong views about women in medicine. Sir Wilson Jameson as CMO of the Ministry kept a watching brief.
The report was published in 1944 at the time of the Normandy landings and attracted little immediate attention.31 It was, however, the most important statement on medical education for many years.32 Goodenough made four opening comments:
The pattern outlined was of university medical school, a radical idea in London. This meant phasing out Scottish extramural schools and the West London Hospital’s school, and changing the constitution of most of the many London medical schools that were subsidiaries of the teaching hospitals rather than academic bodies in their own right.
Goodenough dismissed the idea of university-managed teaching hospitals, and sold the idea of ‘university teaching centres’. Such centres would comprise the medical school (integral with a university), a group of teaching hospitals and clinics providing teaching facilities. The facilities should form a geographically compact group, one hospital being the ‘parent’ and providing much of the teaching. The medical schools and teaching hospitals were receptive to the idea of grouped facilities for it would increase the number of beds available. The wartime emergency medical service had made the teaching hospitals familiar with other hospitals nearby. Goodenough thought that every hospital throughout the NHS should be brought, directly or indirectly, into association with a university teaching centre. These should have a zone of influence and take part in the administration and staffing of the health service more generally. Every medical school should have whole-time professors of medicine, surgery, and obstetrics and gynaecology. Teachers must make their educational work their principal or at least one of their main activities.
Goodenough said that, in the management of teaching hospitals, equal emphasis must be placed on the treatment of patients and on research and the training of students -- complementary and reinforcing functions. There was wide agreement about the number of beds required, and the BMA’s evidence was specific. Professor Henry Cohen, from Liverpool, explained how the numbers had been worked out, and they were accepted by the Committee. A school admitting 100 clinical students should have access to 950 -1000 beds, excluding tuberculosis, infectious and mental diseases, and highly specialised functions such as radiotherapy. Few medical schools had anything like this; by the standards set, ten of the London schools were short of medical beds and seven were short of surgical beds as well. Goodenough thought that the geographical distribution of the London schools was untenable, and that Charing Cross and St George’s hospitals should move so that they provided better access to local populations. Expansion of the provincial and Welsh medical schools should be encouraged to meet the growing requirements of the NHS. If new schools were needed, London was not the place for them. Unsuitability for a medical career should be the sole barrier to admission to a medical school -- not gender. Financial grants to students for both fees and maintenance should be available, but exchequer grants to the schools should be conditional upon their being co-educational; many in London were not.
The body of the report dealt with the individual specialties, the effects of specialisation, the curriculum and issues of postgraduate education and research. Postgraduate education in London would be reconstituted as a Federation within the University, with Institutes for selected special hospitals. The teaching of social and preventive medicine and of psychiatry, was seen as important. General practice was mentioned largely because of the problems GPs had as a result of their professional isolation. Lastly there was the question of the bill to be met by government to ensure a solid educational foundation for the new NHS. The government agreed to a contribution of £1 million a year.
Although the NHS Bill that came before Parliament gave each teaching hospital its own board of governors, no reference was made to any duty with regard to teaching or research. The academics were alarmed but Aneurin Bevan, the Labour Minister of Health, was under fire from so many quarters that he was loath to accept any more amendments to his Bill. An approach was made to Lord Addison, a doctor and an ex-Minister of Health, and to Lord Sankey, who had chaired a review of the voluntary hospital system in the 1930s. As a result an explicit duty was laid upon boards of governors to provide the clinical facilities necessary for teaching and research.33 Legislation needed for changes to the medical schools was implemented along with the NHS Act in 1946.
No woman should take up the profession of nursing unless she is prepared for hard work, constant subordination of her will, and for continual self denial . . . She must be trustworthy, conscientious and faithful in the smallest detail of duty. She must be observant and possess a real power of noting all details about her patient. She must be promptly obedient and respect hospital etiquette . . . A nurse’s manner to her patient should be dignified, friendly and gentle, but no terms of endearment should be used. She should surround herself with mystery for her patient and never discuss her own private affairs.
Probationer Hartman’s notes, St George’s Hospital, 1946
‘The greatest satisfaction in life is to be gained from making other people happy,’ said an LCC brochure on nursing as a career. Nursing was essentially women’s work, a woman’s finest qualities were brought out in rendering service to others, and nursing called for all that was best and noblest. Training equipped her, as nothing else could, to cope with all the human emergencies that were encountered in life. The nursing profession had been revolutionised; the nurse was no longer merely useful help in the sick-room. There had been a complete change in status, and the nurse was now regarded by doctors and surgeons as a competent trained assistant. From the outset, the LCC maintained, it was a career of dignity and responsibility.34
Nurse education and staffing
Medical and nurse training differed significantly. There were many nursing students, the training was shorter and there was little penalty for giving up. Nursing experience, and the experience of handling people, could be useful in other occupations. In medicine the numbers were smaller, students were often highly selected and had a long training that would be useless unless they completed the course. The educational patterns also differed. Medical education was university based. Nursing schools were part of the hospital’s organisation, under matron’s control, and the student nurse, unlike the medical student, was a crucial part of the hospital labour force.
Although some hospitals could be choosy and had high entry standards for nurses, most could not afford this luxury. The course lasted three years but, after passing the examinations, the new state registered nurse often had to spend a fourth year as a staff nurse before getting the much-prized hospital badge. That helped to retain nurses. The ‘block’ system of education, in which nurses spent a number of weeks in the school of nursing at particular times in their course, had been introduced in the 1930s. There might be tension between the sister tutors and the ward sisters. The ward sisters expected students to come to them with some knowledge of basic nursing techniques, able to observe and report on patients, and to be well disciplined. The tutorial staff expected the students to return with clinical experience, and be able to associate theory and practice. Expectations were not always fulfilled.
Nurses have never suffered from a lack of advice. In the years before the NHS there had been several reports on nursing, its problems and its needs. The Royal College of Nursing (RCN) had established a Nursing Reconstruction Committee (1942-1950) chaired by Lord Horder. Three fundamentals inspired his committee’s approach: ‘the patient, the human touch and informed treatment’.35 The committee’s first task was to get statutory recognition of the assistant nurse. That achieved, it proceeded to consider education and training, and finally recruitment. The committee became convinced that, given a liberal outlook and a carefully planned curriculum, nurse training could be developed into something of great importance. Training was, however, too closely linked with the provision of nursing care, a handicap greater than an educational system should have to face. Entering nursing to receive a professional education, and spending three months in the preliminary training school, the nurse then went on the wards and became an indispensable member of the hospital staff. There was a gap between the theory of the classroom and the practice of the ward, where staff were stretched and supervision by experienced staff might be inadequate.36 There was the difficulty in recruitment and the wastage caused by marriage. Marriage ended the career of a student nurse. Indeed nursing was seen as an alternative to marriage.37 Many working-class 18-year-olds were interested in boys and an engagement, not education and the classroom. Nursing on the wards interfered with social activities, for many did not know when they would be off duty until sister finished the duty roster; in any case they stayed on duty until work was finished. Student nurses were angered by their pay and, with support from the Confederation of Health Service Employees (COHSE), demonstrated in the streets. They won their battle for a training allowance in 1948 although the RCN felt their conduct had been undignified.38
There was always a shortage of nurses. Two categories of nurse had existed from the nineteenth century. Alongside the trained nurses, who were ‘state registered’, were nursing assistants. In 1943 the Nurses Act granted legal status to assistant nurses, establishing a ‘roll’ (trained nurses were on a ‘register’), and a system of examination, admission and removal of names. In 1948 there were some 20,000 of these state enrolled nurses (SENs). Their presence not only added to the workforce but also made it possible to improve the training of students for the register. Nurses and their professional organisations were always ambivalent about auxiliaries, holding divergent views of their teaching and the length of their training, needing them, sometimes nurturing them -- but sometimes rejecting them as ‘dilution’.39 The prime concerns of the RCN were the position and salaries of qualified nurses, and the social conditions they had to endure.
The Wood Report
The success of a national health service was going to depend as much on sufficient numbers of adequately trained nurses as doctors. In 1945 the Ministry of Health established a small working party that included two senior nurses, a social scientist and a doctor, chaired by Sir Robert Wood. It was to look at recruitment, the proper task of a nurse, the training required, the annual intake needed and how it was to be obtained, from where nurses were to be recruited, and how wastage could be minimised. The Wood working party had to work fast and it reported in 1947.40 Little advantage was seen in synthesising existing ‘literature’ and adding yet another expression of opinion to the large number already available. Wood’s aim was to discover the facts and let the facts speak for themselves. Once they were established, it would be easier to gain acceptance of an unpalatable remedy. The starting point was the cost of sickness to the community, the value of working time lost, the cost of treating the sick and the cost of immunisation and clinics for mothers and babies . An estimate of the need for health nursing was needed, and then the requirement for sick nursing. The working party looked at the size of the nursing profession, and its structure in terms of age, educational background, professional qualifications and socio-economic status. It examined recruitment, wastage and the pattern of training. It looked at ‘the mental calibre of the nursing profession’ and found a striking range of ability. Wood found it ‘inconceivable that persons differing so very widely in their mental capacity should respond to the same training or be fitted to the same functions’. The average was ‘probably somewhat above the population as a whole’. Mental hospitals had more than their share of those at the lower end of the scale of intelligence. The central message of Wood was carefully wrapped. Wood believed that wastage was unacceptably high, being the result of discontent among the students and frustration with harsh and cramping discipline. Senior staff and matrons were to blame for this. Responsible as they were for patient care without an adequate supply of trained staff, as well as training students who were carrying much of the workload, it was inevitable that the needs of patients should be placed before the interests of students. It was no use merely appealing to hospital authorities to modify discipline or to adopt more understanding attitudes. The organisation and staffing of training schools needed structural changes. There should be a broader training for all nurses, a single General Nursing Council (GNC) with a more substantial educational role, and regional training bodies independent of the NHS, the costs of training coming from outside the health service. This conclusion was threatening to hospital administration and the matrons who ran the schools.
The Wood Report was years ahead of its time.41 Nursing was a high recruitment but high wastage profession, massively dependent on new student intakes. Fifty-four per cent failed to complete training and the Report was critical of the conditions of training and the training itself. More careful selection was needed, using intelligence tests as well as other selection techniques. The service was dependent on assistant nurses. Although some held that all duties concerned with the patient should be carried out by a trained nurse, supported by ward maids, Wood believed that there would always be scope for a subsidiary nursing grade, taking over some of the repetitive domestic work carried out by student nurses particularly in their first year. Those below the level of ability required for training should be recruited, if otherwise suitable, to jobs ancillary to nursing. Better food and accommodation, and three-shift working, were desirable. Students should no longer be regarded as junior employees subject to an outworn system of discipline. They must be accorded full student status as far as the intrinsic requirements of nurse training permitted. There should be a two-year course, with registration after a third year spent in clinical practice. Training should emphasise social and preventive medicine, considering health and sickness nursing side by side.42
The Ministry of Health invited comments. Rosemary White, in later years, said there was a difference in approach between the Ministry and hospital management, which saw advantages in a large and low-paid student work force, and nursing’s professional organisations, which placed greater accent on the pay and conditions of trained staff.43 The RCN commented that Wood had not defined the work of the nurse satisfactorily nor the relationship of nursing to domestic staff, also in short supply. It disagreed with Wood’s accent on ‘health’ nursing, and with the shorter two-year course. The RCN agreed that nurses in training should be students and not primarily employees. It saw no reason why those student nurses who could afford it should not pay for their training as did physiotherapists -- provided that the salaries of the qualified nurses were similar to those of other professional workers. It strongly opposed the idea that the Ministry of Health should be involved in nursing education. The RCN recommended that studies be carried out of the varying nursing loads created by patients with particular problems, and the hours of care required by patients in different stages of illness.44 Nor was the Wood Report received well by the Association of Hospital Matrons. The GNC opposed the separation of training schools from hospitals, and the idea that the training schools should be controlled or inspected by anyone other than itself.45 The King’s Fund said that the role of the nurse was to care for the sick and helpless under medical direction, and that ward sisters should be on an incremental scale so that they would not need to transfer to administration for a better salary. The Nuffield Provincial Hospitals Trust pointed to the failure to answer the first question -- ‘What is the proper task of the nurse on the ward?’ The Trust recommended a job analysis and proceeded to mount one, studying nursing work in hospital wards.46
Ministry of Health proposals followed the Wood Report. They were sweeping, ambitious and showed much goodwill towards nurses. Each region would have an educational organisation independent of the hospitals There would be freedom for nurses to design their own training to build their own centres and create nursing colleges. In many ways the proposals paralleled university education, giving professional independence. The RCN council, on which matrons had a powerful voice, and the GNC discussed the proposals, failed to understand what they offered, drew back in alarm and defeated them.47 The recommendations carried forward were those concerned with the creation of the NHS, nurse training budgets for regions and reform of the membership of the GNC. The staffing needs of the health service became dominant.
Common to nursing in all hospitals was the need to provide a 24-hour service, near to the patient and without fail. Ward sisters once appointed might manage their ward for life, taking its name. In some hospitals they had accommodation on the ward, where they slept. Staff nurses were also people of authority. Nurses generally lived in the nurses’ home in a protected environment, although in 1948 the Ministry recommended that those trained should readily be permitted to live out. Providing accommodation was expensive, and the Ministry thought it was to the advantage of both the community and the nurse to expect her, like other workers, to find her own accommodation.48 Hospitals differed in their nursing organisation and tended to suspect innovations developed elsewhere. Nurses from teaching hospitals tended to be the élite of the profession although there was generally fierce pride in one’s hospital, wherever it was. Matron’s office was keenly aware of what was happening in the hospital, for matron toured the wards each day and the night sister each night, talking to staff and patients. Little escaped their eyes. Wards were run with economy in mind; bandages were washed and matron’s office inspected the ward orders to ensure that they were appropriate. The medical staff knew where to turn if there were problems, and the misdeeds of a junior doctor were soon passed on to his chief. Discipline was strict; the uniform was spotless, shoes shone, dress hems had to be level with the apron and hems the same height (14 inches, 35 cm). The dress colour, stripes on the hat and the belt colour identified the seniority of the nurse. Hair was neat, caps were worn and make-up forbidden. The result was stunning. Top hospitals had distinctive outdoor uniforms, recognised by the local population. Those at St George’s were made by Harrods; Westminster nurses were recognised by their long capes and bonnets.
ST GEORGE’S HOSPITAL
Duties of the Staff Nurses
1. Staff nurses should manage their work methodically and keep their Wards neat, clean and in good order. They should pay constant attention to the warmth, freshness and ventilation and study the welfare and comfort of their patients in every respect. Every effort should be made to keep the Wards as quiet as possible.
2. The senior Staff Nurse on duty shall deputise for the Ward Sister in her absence, and at such times shall report to the Sister who is ‘on call’ for her Ward (or in their absence to the Assistant Matron’s Office) the admission of any patient who is seriously ill and on any occasion when there is cause for anxiety.
3. Staff Nurses should give a kindly welcome to new patients immediately on their arrival in the Ward, treating them with gentleness and consideration and making them and their friends feel assured from the first that they will be tenderly cared for.
4. The admission of new patients should be carefully supervised, particular attention being given to observing the condition of the pressure areas. Any abrasion of the skin, however slight, must be reported immediately to the Sister in charge. Staff Nurses shall also see that proper care is taken of the clothing and valuables of patients admitted to their Wards.
5. Staff Nurses shall be responsible for looking after relatives and friends visiting the Wards, and shall see that those waiting for long periods in the Hospital receive food and refreshment.
6. An important part of their duties is to assist the Ward Sisters in the training of Student Nurses, teaching them to be accurate, careful and observant, and thorough in every detail.
7. They shall see that all new Student Nurses coming to the Ward understand the clinical work allocated to them and are carefully instructed in all procedures practised in the Ward.
8. They shall study the rules laid down for the care and checking of Dangerous Drugs, and see that these are properly observed.
9. They shall be responsible to the Sister in charge of the Ward or Department for the care of the following: Linen, Instruments, Surgical equipment including surgical stock, Crockery and cutlery. A weekly inventory should be taken and any losses reported immediately to the Sister in Charge. It is recommended that instruments and cutlery in regular use be checked every day.
10. It is a strict rule of the Hospital that nothing may be borrowed from one Ward or Department for another without a written request signed by the Sister or Staff Nurse in charge. At night the request should be made to the Night Sister. This rules also applies to Dangerous Drugs.
11. Staff Nurses should supervise the work of the Ward Maids and Orderlies, instructing new members of the staff in their duties and helping them to feel that they are essential members of the Ward team. They shall see that the Domestic Staff are punctual in arriving and leaving the Ward, and shall teach them to be quiet and thorough in their work and to avoid waste.
12. Constant attention should be paid to every method by which economy may be effected, particularly with regard to food, surgical dressings, lotions, stationery and cleaning materials. Good management in this respect can save the Hospital considerable expense.
13. Any accident affecting either a patient or a member of the Nursing or Domestic Staff on duty in a Ward or Department shall be reported immediately to the Sister in Charge and a written statement made by the member of the Staff involved or witnessing the accident.
14. Staff Nurses should be thoroughly conversant with all the rules made for the prevention of infection in the Hospital and should see that these are conscientiously and carefully carried out.
15. Nursing Procedures practised in the Hospital shall be those laid down in the Nursing Procedure Book, a copy of which shall be available in every Ward and Department.
Muriel B. Powell, Matron, 13 December 1951
The NHS brigaded nurses into a single workforce. Henceforth there would be a national pay structure, the Ministry would be concerned with staffing a huge service and professional organisations had a negotiating role. Nurses in the mental institutions had never been accepted by the RCN as on a par with state registered nurses. Other unions had been established by them to fight for better conditions and, simultaneously, better services. Strike action, though not common, was part of their tradition. COHSE was formed in 1946 when two unions merged, and after that it represented many of the nurses in mental hospitals and the auxiliary state enrolled nurses.49 The RCN found itself having to act simultaneously as a trades union alongside others and as a professional organisation. Doctors had the BMA to deal with their terms of service, and the Royal Colleges to consider educational and professional issues. The RCN had to combine the two functions and was not always successful. Senior officers were frequently more political than professional. With optimism, Dame Louisa Wilkinson, President of the RCN, said things were going to be quite different.50
Nursing has allowed itself in the past to be taken far too much for granted. We have allowed ourselves to be handmaidens of the medical profession. Nurses have not got the slightest intention of accepting a lower plane than that of an active, loyal and wide-awake partnership with the medical team.
Nursing in the community
Nursing in the community had a long and honourable history. The first recorded venture was in Liverpool in 1863. In 1889 the Queen’s Jubilee Fund endowed the Queen Victoria’s Jubilee Institute for Nurses, later the Queen’s Nursing Institute. The Institute designed a specific training programme, ran local services, and was the main voluntary organisation doing so. In most areas district nursing associations had been founded to provide a service to the community. Such voluntary associations had to raise funds to pay their nurses’ annual salaries. There were village fêtes with stalls and rides on the lake for tuppence and gardens open to the public. District associations had to reach certain standards to affiliate with the Queen's Institute, and Queen's Institute trained nurses were the gold standard of quality. Rural areas sometimes could not provide a service to such a level. Some local authorities looked to voluntary agencies like the Queen’s Nursing Institute; others provided their own nursing services.51 On a national basis, the training of district nurses was not well codified and local authorities could employ those without qualifications in district nursing.52 Local authorities initially looked to the voluntary associations but sooner or later brought these services in house.
Midwifery, a profession separate from nursing, was regulated under the Midwives Act of 1936. More than half of the babies born were delivered at home, mainly by midwives provided by local authorities or nursing associations. County councils and county boroughs had to provide a domiciliary service directly or through contracts; how they did so was largely for them. Domiciliary midwifery was an entirely female profession, giving a door-to-door service, mostly on bicycle, 24 hours a day, 365 days a year, to an entirely female clientele. Often working in partnerships of two or three, each midwife cared for women in her geographic patch, delivering 50--100 women annually. It was an industrious and insular life. Midwives had a sense of their own worth, with a duty to the public and an accountability to their supervisor. Few mothers saw more than three or four professionals during their pregnancy, and there was a guarantee of continuity of care.53
Health visitors had generally undertaken further education after state nurse registration and had midwifery experience. The roots of health visiting were different from the other two nursing professions: it emerged from community work and the radical tradition. It had grown, not out of nursing, but from ‘sanitary’ visiting in the nineteenth century, particularly in areas with poverty and poor living conditions. Formal training developed early, and led to an examination by the Royal Sanitary Institute. The ethos of health visiting was that of public health and its interests lay in the social conditions affecting the health and welfare of communities, and therefore families. The predecessors of the Health Visitors’ Association were involved in most public and social issues -- poverty, ill-health, infant mortality, slums and working conditions for women and children. They were early to register as trades unions and were involved in radical politics as the way to bring about change in society. Most of the health visitors’ work was with pregnant women, nursing mothers and children under school age.54 As the idea of maternal education as a weapon in the fight against infant mortality gained ground, there was an increasing demand for their services. The task of the health visitor began with a notification of birth - it was unsolicited.55 When the NHS began, health visiting was already part of the local authority services, under the control of the medical officer of health. With the advent of the NHS the work of health visitors was expanded to the health of the household as a whole, advice on the care of people who were ill and measures to prevent the spread of infection.56 Maternity and child welfare remained the centre of their work, which was usually based in a local authority clinic.
Because there was no formal demarcation of duties, there was considerable friction between district nurses, health visitors and midwives. In rural areas where mobility was a problem, one nurse might be a qualified midwife, health visitor and district nurse. She would be well known and well respected by the community.
There had been nurses in government employ, in the Ministry of Health, since the 1920s. In 1948 Elizabeth Cockayne was appointed Chief Nursing Officer following Catherine Watt, the first CNO. Her career had been varied, involving clinical and educational posts in both the north and south of the country. She was one of the two nurse members of the Wood working party, which did not add to her popularity with the nursing profession. Her staff included public health and hospital nursing officers with regional responsibilities. They were in close contact with professional organisations and advised the Minister, working with medical and administrative colleagues and concerned with matters of nursing policy.57
Nursing administration within the hospitals was much the same in the voluntary and the municipal hospitals, not the case on the medical side. The matrons had an informal network and when one was to retire a successor might be agreed on the grapevine. Senior nurses would be moved among the hospitals in preparation for a key position that was becoming vacant; the teaching hospitals often supplied the matrons for municipal hospitals and smaller voluntary hospitals. In large hospitals a matron, with deputy and assistant matrons, managed the ward sisters, and they the more junior nursing staff. Where there was a nursing school, matron controlled it and selected the students. She managed catering, linen supplies and domestic services, and might be responsible for physiotherapists and other disciplines ancillary to medicine. Matron’s role was similarly wide ranging in the smaller hospitals. However, the matrons’ accountability might differ. In municipal hospitals matron reported to the medical superintendent. In the voluntary hospitals she had more autonomy and was usually appointed by, and was responsible to, the board of governors.
Towards a health system
Districts and regions
The idea of a ‘district’ general hospital (DGH), providing all the most common hospital services, can be traced back to the nineteenth century.58 It was adopted after the first world war in Labour Party policies. In his Cavendish lecture of 1918, Bertrand Dawson, a physician at The London Hospital and a military doctor during the war, described how a health service could be co-ordinated. In 1920 he was invited to chair a Consultative Council on the future provision of health services, and he proposed a hierarchical system of primary care centres linked with district hospitals, and regional centres with university teaching hospitals.59
The idea of a ‘region’, an organisational unit larger than the district, emerged in the 1930s. The voluntary hospitals felt a need to combine to defend themselves against the expanding municipal hospitals. The British Hospitals Association, their representative body, asked Lord Sankey to chair a committee, which recommended the formation of regional councils to co-ordinate the planning and organisation over a wide area.60 Following the Sankey Report the Association began to delineate regional boundaries. Regional organisation, but taking in the municipal hospitals as well, was commended by Political and Economic Planning, and it became the raison d’être of the Nuffield Provincial Hospitals Trust, founded in 1939. A regional scheme in London was also supported by the King’s Fund, founded in 1897 in celebration of Queen Victoria’s diamond jubilee by Edward VII when Prince of Wales.
Professional and geographic factors were dominant in proposals to organise on a regional basis. Rarer and more complex medical problems required larger catchment populations. The local authorities, whose boundaries were historic rather than functional, opposed the idea.61 With the advent of war an emergency medical service (EMS) organised on regional lines was established under the control of the Ministry. Outside London the EMS regions were similar to those of the British Hospitals Association. In the southeast there was one region, but within it there were radial sectors spreading into the countryside, each with one or more teaching hospitals at its apex.
The Hospital Surveys
All the surveys showed wide variation in quality, and major deficiencies in hospital buildings that could only be overcome by rebuilding, although much inefficiency could be remedied more rapidly. The surveys advocated district hospital centres, uniting individual hospitals into a functional whole, with a common staff, grouped within regions resembling the survey areas. Their main value rested on factual reporting on existing buildings and services, and their confirmation of the need for regional planning. The detailed proposals were often suspect but one point of great importance emerged from all - the idea of a general hospital providing all the ordinary range of specialties for a natural population, linked with regional specialty centres. Once planned, the DGH should then be given a suitable base. There were then no accepted indices of need, so estimates of hospital size might be almost fanciful, and the location suggested was sometimes at fault. But for the first time the country got away from designing hospitals of some empirically determined size, and was attempting to look how best to provide services for a community.63
Together the surveys were known as the Domesday Book.64 ‘Since hospitals are an essential public service,’ said the South Wales surveyors, ‘it is curious but characteristic that in Britain this, Topsy-like, "just grow’d".’ The surveyors did not mince their words, but their harsh statements were written on the assumption that the surveys would pave the way for better things. The three main problems were shortage of beds as a result of poor buildings and equipment, shortage of consultants, and poor patient accessibility to both beds and consultants.
There was no system. Complicated cases often received treatment in hospitals without the necessary facilities while simple cases occupied beds in hospitals with high standards of staff and equipment. Shortages of beds and specialists led to long waiting lists even for simple cases. Acute hospitals frequently had to discharge patients before they were fully recovered and the obligation of municipal hospitals to admit patients from within their areas meant over-crowding and under-staffing. Local authority boundaries led to uneconomic development and acted as barriers to admission. Although voluntary hospitals had often tried to expand, restricted sites meant, as at Charing Cross Hospital in the Strand, that the provision of modern facilities was impossible.
Medical staffing had to change. The distribution of specialists had been haphazard, determined largely by the economics of private practice. In municipal hospitals there had been salaried part-time or whole-time specialist posts but they were relatively few. The consequence was too few specialists who were unevenly spread. There had to be a tremendous redeployment of specialists and at least double the number. Outside large centres, where there was little private practice, there were limits on the choice of staff, and hospitals had to get along with the GPs living in the immediate neighbourhood. The West Midlands surveyors said that there had been a tendency for GPs gradually to drift into surgery or whatever branch of medicine was of most interest, and to do this as an off-shoot from general practice. They might be entirely self-taught. Specialist services were scarce; there was only one gynaecologist in the whole of Lincolnshire. In Rotherham the GPs objected to the appointment of full-time surgeons but examination of their results showed that four prostatectomies had been carried out the previous year, only two of the patients leaving hospital alive. Radiological and pathological services were poor. For example, there was no whole-time radiologist in Lincolnshire and Nottingham specialists visited Boston once a fortnight. In Northampton one of the physicians supervised the radiographers and some physicians took it amiss when it was suggested that a radiologist should be running the X-ray department. Similarly, technicians in isolated departments had no senior staff to whom to turn.
The hospital surveyors reserved their bitterest comments for long-stay provision. Often buildings were antiquated, with bare, over-crowded large wards and cheerless uncomfortable day rooms, and primitive facilities for nursing. In most instances the wards did not provide the physical or the mental amenities to be found in a domestic dwelling. In some institutions the ratio of patients to trained nurses was 60 or more to 1. Young children and people with senile dementia were herded together with elderly patients, many of whom might have been able to return to their homes had there been earlier diagnosis and treatment. The surveyors believed that the first need was for every patient to be thoroughly examined and treated.
Labour and the NHS
The Labour Party had put forward proposals for a national hospital service before the first world war, and between the wars there was increasing interest in resolving problems. Several reports -- commissioned by the government, produced by independent groups or the work of professional or hospital organisations -- had laid out alternatives.65 In the 1930s whenever a new public service was envisaged, such as civil defence, it was considered as a potential function for local authorities. In the 1940s it became apparent that a health service run by them could be introduced only in the teeth of opposition from the medical profession.66 A PEP broadsheet, published in July 1942, anticipated Beveridge and called for a national health service. The Beveridge Report on future social insurance aimed for universal coverage, and named ‘five giants’ on the road to reconstruction: want, disease, ignorance, squalor and idleness.67 The depression in the 1920s and 1930s, the lack of systematic provision for health care at that time, the experience of communal action in war and the efficiency of the EMS all pointed to the need for a health service. The draft interim report of the BMA’s Medical Planning Commission in 1942, which called for the creation of a comprehensive service covering most people, made it easy for Beveridge to assume that one would be created for the whole nation.68
The war had increased the sense of social solidarity, and many saw the advantages of a command structure. Most doctors had military experience and knew that service personnel had, from a health point of view, been looked after better than in peacetime.69 Many of those involved, or who would be important to the future NHS, had at least a social conscience if not an overt inclination to the left, for example George Godber, Richard Titmuss and Richard Doll. Janet Vaughan found it hard to understand how anyone could be a doctor before the war and not become a socialist. Julian Tudor Hart, a Welsh GP, believed that people who had experienced the effect of the market on the distribution of services meeting basic human needs, and the revelation that in wartime the market could be overridden for great purposes, were resolved never to return to the old system.70 As early as 1943 the Ministry of Health was considering the transition of the wartime EMS into a comprehensive health service, free and available to all.71 On these foundations a blueprint for a service was accepted by the Conservative Cabinet in the interval between the wartime coalition government and the election of Attlee’s Labour government in 1945.
Labour came to power with one of the largest majorities in British history. It was committed to a programme of public ownership and lost no time in carrying it out. The Bills nationalising the Bank of England, coal, and cable and wireless received Royal Assent in 1946. In the following year it was the turn of transport, railways, canals, road-haulage and electricity. The gas industry was nationalised in 1948, and iron and steel in 1949.72 The NHS was a different type of nationalisation, aiming for a radically new type of service. The NHS Act was introduced four months after the election and passed during the first session of the new Parliament. In the words of the Minister of Health, Aneurin Bevan, the Act would create an atmosphere of greater security and serenity up and down the country for families faced by anxiety and the distress of illness.73 The inability of voluntary hospitals to raise charitable moneys made it necessary. Rising costs hastened the inevitability of a state medical service. With the advance of science and specialisation, a patient had not one but many doctors. The cost of illness was beyond the purse of the average person. A single patient with tuberculosis, for whom an operation (thoracoplasty) was required, might pay more than £1000 from the time of admission to discharge some months later. It would be a travesty of justice, said Lionel Whitby, Regius Professor of Physic at Cambridge, were treatment to be available only to the few rich people whom successive Chancellors of the Exchequer had allowed to survive.74
Until the Labour victory, local authorities looked likely to play a lead role. Bevan came as a man with a mission to change things. He looked at the draft Bill from the previous administration and insisted that the hospitals should be nationalised and that the service must cover everyone. He had seen how previous proposals had been picked to pieces by special interests, the hospitals, local authorities and the medical profession, and what had been a coherent if complicated plan had become an administrative dog’s dinner.75 The Bevan solution, opting for a regional scheme rather than one based on local authority boundaries, was a work of genius. The key was the realisation that, without executive control of both the voluntary and the municipal hospitals, effective hospital planning was impossible. It was like a breath of fresh air to the officials involved, Sir Wilson Jameson, the CMO, who had an instinct for what was required, George Godber who did the medical drafting and John Horton and John Pater who dealt with administrative issues. The regional concept brought together service considerations (the natural territory within which normal and highly specialised services could best be organised) and the university medical schools (the natural centres of research, development and education). These would ‘fertilise’ the services in the surrounding areas.76 Indeed it was difficult to conceive of a region without a medical school, and vice versa. With university and medical concurrence, regions could establish an integrated specialist system and rationalise nurse training. Bevan’s regions were sizeable; large regions were less likely to attempt detailed local control, but any high degree of local autonomy might have prevented the region from organising a coherent service. Boards had to have the ability to close, amalgamate and expand hospitals. If the boards were too weak, the anarchy of the old voluntary system would begin all over again.77 There being ten provincial teaching hospitals, that set the number of regions in England and Wales as ten, plus four for London (Wessex became a region in 1959 and Wales separated in 1974). The main oddity was the division of the southeast into four metropolitan regions that met in the centre of London. In the war a radial pattern of organisation had been adopted to make the evacuation of casualties easier. It worked well as it accommodated the teaching hospitals and medical schools. For Bevan it had another advantage, the pattern was utterly unlike that of the London County Council. A single London health authority would have had massive and undesirable political clout and would have been totally insensitive to the periphery. At local level the unit would be not a group of hospitals but a complex of hospitals, GPs and health centres. A partnership of general and specialist practice would make general practice viable and relate the hospital to the community it served.78
Bevan refused to discuss the details of his proposals until, after the first reading, there was a measure of parliamentary approval. In the final round of negotiations Bevan accepted key demands from the doctors. For the specialists this was a part- or whole-time salary plus merit awards, and the right to treat private patients in NHS hospitals. For GPs it was a system as far removed from a salary as possible; capitation was a defence against the perils of state servitude.79 Like it or not, the state and the medical profession had become mutually dependent. Many doctors had received state funds through the Lloyd George national insurance scheme, but now they were even more dependent on government for their incomes and the resources at their command. The state had become dependent on the medical profession to run the NHS and to cope with the problems of rationing scarce resources in patient care.80 The restrictions imposed by local authority boundaries were removed. The decision to take hospitals into national ownership in 1948 and the inevitable compromises did not please everyone. Herbert Morrison, in the Cabinet, and the local authorities, some themselves Labour, were upset at the loss of their municipal hospitals. The voluntary hospitals disliked their loss of independence. Despite the bickering of 1946/7 nearly everyone was in tune with the broad principles and was prepared to do his or her best to make Bevan’s pattern of NHS work. Nurses were strongly in favour, as were the younger doctors. The objectors were the older men who were the controllers of the BMA and its committees. Behind it all was an attitude epitomised by an elderly Civil Defence worker who told Richard Titmuss, the social scientist, that ‘The war made us realise that we were all neighbours’. From the rubble of war it was believed that Labour would create a better society.
When Bevan died, in 1960, a BMJ editorial described him as the most brilliant Minister of Health the country had ever had, much less doctrinaire in his approach than many of his Labour colleagues, and conceiving the NHS on more liberal lines than his Conservative predecessor. He towered over a long line of Ministers of Health and attracted in the medical profession profound admiration on one side and the sharpest antagonism on the other. The editorial proceeded to claim that the medical profession, rather than Bevan, was the principal architect of the NHS. But when Bevan had left the Ministry of Health in 1951 the BMJ had been less generous:
"his vicious attacks on the profession, his attempts to sow discord, and his rudeness in negotiation would never be forgotten. He never rose above being a clever politician and at critical moments failed to become the statesman. He had done his best to make himself disliked by the medical profession, and, by and large, he succeeded."81
The NHS framework
The NHS Act established a ‘comprehensive health service to secure the improvement in the physical and mental health of the people . . . and the prevention, diagnosis and treatment of illness’. What it did not do was establish an individual entitlement for treatment of particular illnesses, as an insurance scheme would have done. As the NHS was paid for out of taxation, for the first time the Treasury had a powerful influence on the health care system. The NHS would be:82
• A service comprehensive in scope, including medical and allied services of every kind. (Earlier there had been the possibilities of excluding mental illness and dentistry but these were brought within the NHS.)
• A service available to all -- the universal coverage Beveridge had proposed -- in spite of some professional opposition. Internationally the usual basis of public medical schemes was insurance, so a health service funded largely from central taxation was, outside the Eastern Communist block, distinctive.
• A service free at the time of need.
• A pattern of medical remuneration reflecting doctors’ wishes.
• A hospital service administered by centrally appointed, not elected, bodies and the officers those bodies appointed with power freely delegated down the line. (The local authority health services were run by elected members and the executive councils largely by nominees of the local authorities and the professions.)
There should have been another distinctive feature, co-operative general practice from shared purpose-built health centres. This idea, advanced by the BMA’s Medical Planning Commission, fell victim to professional disquiet, naive over-enthusiasm, high costs and a shortage of building materials. Six months before the NHS began, the Ministry wrote to local authorities to say that no general programme of construction would be implemented.
The service was tripartite and had to be developed in sections. Otherwise, Sir George Godber has said, it would never have been got to work in time. Nor, in 1948, would a unified system have been able to look after primary and community services in addition to the hospitals. Unification could have been a disaster for general practice, which carried much of the burden of the NHS in the early years. There would be the hospital service within a regional framework, the only way to achieve a properly planned service and a reasonable distribution of specialist staff. There were the local authority services that quietly made progress in developing community nursing, home help and immunisation programmes. Then there was general practice where GPs now would look after whole families, not just the bread-winner. Executive Councils (ECs), a new, broadened type of ‘insurance committee’ in which local health authority representatives replaced the old friendly societies, administered the contracts of GPs, dentists, pharmacists and opticians. In these divisions were the seeds of future problems.
Twenty years later Richard Crossman said that the Bevan compromise gained the support of the consultants by conceding an entrenched position that could not be broken without jeopardising the whole health service. GPs were given a special place, with elaborate safeguards that kept them isolated from the hospitals and from the community services, which were left in the hands of the local authorities and their medical officers of health. Then in order to preserve ‘freedom’ from despotism still further, all hospitals were nationalised and RHBs were set up. These, in Crossman’s view, were remarkable in their powers. They were strong, semi-autonomous boards whose relations to the Minister were like those of a Persian satrap to a weak emperor. If the emperor tried to enforce his authority too far, he lost his throne or at least his resources or something broke down. Health service freedom lay in the fact that the centre was weak, the regions strong and the GPs in their enclave were separated off safe from attack.83 Although Bevan might have considered the NHS as pure socialism, it was rather closer to impure liberalism. Doctors had been treated with consideration, local administrations enjoyed considerable freedom and the profile of government itself was low. If many remembered the period as a golden age, that was perhaps because it suited almost everyone very well.84
During the war MOsH and medical school deans played leading parts as the Ministry’s agents controlling hospital and casualty arrangements, which might have led them to expect a more substantial role in the NHS than they were given. In 1948 MOsH remained with their local authorities, but six in England became the Senior Administrative Medical Officers (SAMOs) of the new regional hospital boards. Having been chief executives in the past, they often became their new employer’s leading officer, paired with a non-medical secretary.
Regional Hospital Boards (RHBs)
Although regional boundaries had been drawn as far as possible to coincide with hospital catchment areas, RHBs were not self-sufficient and their boundaries were not meant to be barriers to the flow of patients. By the early summer of 1947 Bevan had consulted widely and appointed the RHB members. They were to act as individuals, not delegates of interest groups. There were few political appointments. Most members were of the old guard to maintain continuity, although a few were dropped as they were entirely out of sympathy with the new regime. There were doctors, there might be a nurse or a dentist, and there were elected members of local authorities. There was usually at least one trades union member but the rest were people who had shown an interest in running health services. Regions had less than a year to appoint staff, learn their jobs, determine their hospital management committees (HMCs) and secure ministerial approval before appointing HMC members. The emphasis was on sound representation of local people and skill in running the existing services.85 In 1947 the Minister sent guidance to
the new region on the general scope of their work and relationships to others in circular
RHB(47)1. The RHBs would act as the Minister’s agents, but agents on whom he wished to confer the largest possible measure of discretion. From the outset they were to feel a lively sense of independent responsibility.
'It would be entirely alien to his intention that his powers would be used for
any detailed or meticulous control of the Boards'activities.'86
A main function of the .
.It was for Boards to decide their committee structure and working methods although they would want to appoint professional advisory committees. Bevan made it clear that, just as he would try not to interfere with regions, regions should not interfere with their HMCs. Formal schemes and plans for the region’s services would not be required, for ‘the reviewing and organising the service would be a continuous, fluid and developing process not susceptible of reduction to a final paper plan’. Boards would need to work closely with teaching hospitals, universities, the Ministry and local authorities. In England and Wales there were 14 regions (Wales was one and Wessex was not formed until many years later.)
Illustration Source- Ministry of Health. National Health Service. The development of consultant Services, London, HMSO. 1950 (first as RHB memorandum RHB (48)1 January 1948)
Regional functions included:
• planning, medical staffing and hospital capital works;
• managing financial allocations to HMCs, appointing HMC chairmen and members, and controlling HMC staff establishments;
• running some regional services such as blood transfusion and mass radiography;
• providing general advice and support.
The newly appointed members of the RHBs learnt together. They had to get to know each other, to work in temporary accommodation and to build up their staff. To begin with these were few, and the same was true of the HMCs; some barely knew the institutions under their control. Board members drove from one hospital to another, having delightful hospital lunches and teas, welcomed wherever they went and being shown the best and the scandalous.87
Boards of governors
Teaching hospitals were selected by the Minister, with university advice, because of their special importance to medical education. They had fought for their independence and won. Their pre-war burden of debt had been lifted and they retained their own -- sometimes substantial -- endowment funds. To the teaching hospitals were sometimes added local municipal hospitals if they were essential for medical education, or small special hospitals, perhaps a children’s hospital or one for ophthalmology. Most continued to be selective in their admissions policy, serving some, but not all, of the needs of those living in their locality. Occasionally, as in Oxford and Cambridge, the boards of governors dominated the provision of acute hospital services in the city and surrounding districts.88 Each teaching hospital board of governors was directly accountable to the Minister, not to the regional board. Labour Party policy had long been that teaching hospitals that enjoyed a national and international reputation, drawing cases from all over the country, should be maintained and administered under the general control of the Ministry of Health.89 Their boards of governors were partly appointed by the Minister but also included members nominated by universities, medical staff and RHBs. The relations between the teaching hospitals and the RHBs varied from close co-operation to none whatsoever.
Hospital management committees
Hospitals were managed by HMCs within overall plans of the RHBs. RHBs were instructed to create HMCs by grouping together functionally related hospitals to form the equivalent of a full-scale hospital covering all normal specialties. A group might consist of ten or a dozen units, perhaps a voluntary general hospital, a municipal general hospital, a maternity home, an isolation hospital and three or four GP hospitals in small neighbouring towns. In the North West Metropolitan Board the SAMO arranged their pattern while at home in bed with ’flu. By uniting their governance, it would be easier to rationalise hospital services within them. The guiding principals were decentralisation, encouragement of local interest and the avoidance of large and unwieldy units of management. HMCs might be developed on a functional rather than a locality basis. Mental hospitals had been administered by local authorities and had not been included in wartime hospital surveys. They fiercely defended their independence and were grouped separately under their own HMCs so that the new organisation perpetuated the separation of mental hospitals from the rest of the NHS. Some wondered if it was right for them to be isolated from other branches of medicine and it took ten years to get them meshed in.
The service was planned so that patients could be treated in the hospitals best suited to their needs. Before the NHS, patients were often restricted to one municipal hospital but could wander freely among the voluntaries. Afterwards they would be referred to the hospital ‘thought best to meet their needs’. The Hospitals year book said
There are no boundaries on the map where ‘A’ management committee finishes and ‘B’ management committee starts. For ordinary needs the inhabitants of a town go to an acute general hospital in the town run by ‘A’ group, for treatment of tuberculosis to a hospital run by ‘B’ group, those in need of mental treatment to a mental hospital in group ‘C’ and those requiring the attention of a highly specialised kind might find it necessary to go to a hospital in ‘D’ group, the other side of the region or in another region altogether. This is commonsense; a large number of geographical barriers have been swept away and some of the happenings which in the past have aroused either public resentment or public ridicule should no longer occur.90
Financial data for the years immediately before and immediately after the introduction of the NHS are hard to obtain. The Ministry obtained hospitals’ statements of expenditure in 1946/7 and they were asked to provide the actual expenditure in the first few months of 1948.91 The service had to be kept running, so finance was based on historic spending that depended on the revenue available from local rates and charitable sources. The south was therefore better off than the north.92 From the outset there was a grossly uneven distribution of money, largely concealed as the accounts for the first two decades of the NHS were presented functionally over the NHS as a whole, not geographically. Little attempt was made to correct this skewed distribution and less to publicise it.
The 1947 circular RHB(47)1 on the functions of RHBs had promised future guidance on the planning of hospital services and the desirable levels of specialist staff. It appeared as The development of specialist services (RHB(48)1).93 It was the work of a group chaired by John Charles, the deputy CMO at the Ministry, which included specialists mainly from provincial teaching centres -- Newcastle (William Hume), Sheffield (Ernest Finch), Oxford (J Chassar Moir), Manchester (Geoffrey Jefferson), Birmingham, Liverpool and Bristol. The secretary, George Godber, wrote the circular using his experience of the Sheffield hospital survey, and the result was the consensus of thought at consultant level. An attempt was made to relate staffing to population, emphasising the importance of providing an area service.94 Estimates of the beds needed by the various specialties were based largely on the past experience of teaching hospitals and had little factual background. It was a successful essay on general principles but not a reliable guide on details. The Royal College of Physicians (RCP) liked it enough to ask for reprints to send to their membership. It "merely suggested tentative answers" and the proposals "could not be made immediately effective."
Drawing on proposals in the surveys, the regions were seen as an aggregation of ‘hospital centres’, serving areas determined by geography, population density and transport facilities. Centres would consist of a group of hospitals (managed by the HMC) providing all normal specialist services, functionally united and with a common medical staff. These would become the basis of the future DGHs. Linkage should be maintained by recognising all specialists throughout the region as members of one team, with the opportunity to move between regional and hospital centres.
The largest hospital centre would be the ‘regional centre’, providing a wider range of services, including those demanding a larger population base, such as plastic surgery, neurosurgery, thoracic surgery and radiotherapy. This regional centre would include the teaching hospital, even though it was outside the curtilage of the RHB. Because the teaching hospitals would be selective about the patients admitted, for reasons of education and research, contiguous HMC hospitals would take the rest. The teaching hospitals alone would not be able to provide all the necessary clinical material for teaching, particularly in the fields of tuberculosis, infectious disease and mental disease; this work would fall to the regional board. One function of the RHB would be the integration of the specialist services of the regional centre with those of the peripheral hospital areas, and cordial relations between the RHB and the teaching hospital’s board of governors would be needed.
Even the smallest hospital centre would need a locally resident physician, surgeon, obstetrician and anaesthetist. Most would require more. Some services should be provided by consultants who practised their specialty exclusively, for example radiology, ophthalmology and ear, nose and throat (ENT). Others would often be undertaken by consultants with a special interest, for example cardiology and urological surgery. The specialty of geriatrics had not then emerged and it was assumed that general physicians would be the providers of better treatment of the so-called chronic sick. A hospital area with a population of 100,000 -120,000 would probably require
The circular RHB(48)1 was all-encompassing, with sections covering the full range of hospital specialties. It was made clear that the first responsibility of RHBs was to keep the service running, but they were to look to the future and see their immediate responsibilities against the background of the long term. The new service could not be built on the ‘appointed day’, when the Act came into force, and RHBs were not to endanger the future by the appointment of inadequately trained people merely because there were pressing service needs.
There remained the issue of specialist pay. Unlike the GPs, the consultants were content to be employees. It was the income that was significant and the basic principles were settled by the Spens reports.95 By opting for a salary rather than a fee-for-service approach, financial incentives for unnecessary treatment were removed, to the benefit of patients and the exchequer. By paying the same salary in all parts of the country, and in each of the specialities, staffing planning was made easier. However some specialists, particularly surgeons, had earned large sums in private practice, the leaders of the profession among them. The equality of NHS earnings that Spens proposed was unusual and Bevan conceded the right to private practice, making it possible for those who were energetic and highly skilled to earn substantially more than their colleagues. He also agreed to additional payments for merit, which was not too closely defined. An attempt was made to balance the merit awards committee, which had a non-medical vice-chairman and representatives of teaching and research. The awards, allocated privately, might double a consultant’s NHS income although most were smaller in value. Bevan was reported as saying that he had achieved agreement by stuffing the doctors’ mouths with gold.
Doctors and the state
Relationships had long been ambivalent. As far back as the nineteenth century there had been proposals for a state-controlled service that had been regarded by many doctors with a mixture of concern, fear and anger. In 1918 Lauriston Shaw, Dean at Guy’s, had written that there
"was no consensus about the relationships which should exist between the two parties. An extreme right party believes that beyond securing the proper education of doctors, and providing a sanitary service to safeguard the drains and control epidemics, the state should leave the medical profession alone to carry out its beneficent work in absolute independence of all government control. These devoted individualists are prepared to die in the last ditch before they will sacrifice the smallest outpost of professional liberty. An extreme left party sees salvation in the Fabian socialist proposal of state employment for all doctors. Illness could then be treated, as Beatrice Webb suggested, as a public nuisance to be suppressed in the interests of the community, by compulsion if necessary. Some believe that the government should take responsibility for seeing that its medical employees carried out instructions faithfully to offer or force upon each member of the community the medical services the state considers necessary to maintain physical health. Between these two factions is a large central party which recognises the impracticability of the ideals of the extremists, and seeks to bring an honourable partnership between the state and the medical profession to bring the benefits of medical science to individuals and society irrespective of wealth or social position".96
Sir George Newman, the first CMO of the Ministry of Health, speaking to the BMA in 1920 shortly after the Ministry’s creation said
"The state has seen in the profession a body insistent upon the privacy and individuality of its work, the sanctity of its traditions and the freedom of its engagements. The profession has seen in the state an organisation apparently devoted to the infringement of these traditions and incapable of putting anything worthy in their place. It has been suspicious and mistrustful of what it considers to be unnecessary intervention. It has feared the imposition of some cast-iron system which might in practice make the practitioner of medicine servile, dependent and fettered."97
Although the medical profession had, individually and corporately, seen that a state health service could be beneficial, the suspicion never disappeared. Charles Hill, first known to the public during the years of war as the Radio Doctor, became the medical profession’s organiser and mouth-piece in its opposition to some aspects of Labour’s plans for the NHS. ‘Let us make sure,’ he said, ‘that your doctor does not become the state’s doctor.’ The profession in general maintained that its support for a national health service was not in question, but that particular proposals worried them. However, some eminent doctors, such as Lord Horder, never accepted the idea. Horder, a St Bartholomew’s Hospital man and a lifelong opponent of the NHS, which he felt could only lower professional standards in medicine, sought to establish a group of those doctors remaining outside the NHS for their mutual protection.98
The passage of the NHS Bill into law in November 1946 did not end the bitter conflicts in the months before 5 July 1948, which left the profession with enmity for Mr Bevan and all his works.99 At the end of May 1948, the BMA recommended that its members accept the NHS and the will of Parliament, but the ill-will lived on. Many doctors of that generation had been taught to disparage medicine as practised under the NHS, to regard the Ministry of Health as its enemy and to speak of the health service in terms of contempt.
The BMA had not yet cast itself as the defender of the health service, but it had adopted its position of habitual opposition to the government of the day. In years to come both Conservative and Labour ministers experienced the implacable anger of the profession when it felt that it was not getting its way. Enoch Powell, Barbara Castle, Kenneth Robinson, Richard Crossman and Kenneth Clarke faced the profession’s bitter attacks. The profession was often led by its right wing, but there were, at the same time, many clinicians who were constructive in shaping the NHS. Sometimes senior doctors used offensive language about politicians, while resenting any implication that their own motives were open to challenge. Often, however, personal relationships at a senior level were close and generous. Almost invariably money was at the centre of the row. All Ministers of Health were in the unenviable position of being regarded as agents of the government by the health professions and as agents of the professions by their ministerial colleagues.100 Nor would the medical profession be alone in its campaigns. Powell referred to the vested interest in denigrating the NHS common to managers and nurses as well as doctors. Government, as the sole supplier of funds, took the blame for everything. Anyone who professed to be satisfied at what was being spent could not unreasonably be represented as a traitor to his colleagues, the professions and the patients.101 The different perspectives of the professions and the government, each changing its position subtly over time, were sometimes constructive but often negative. The trust in the tried and traditional path was deep, and it might be far too long before general professional consent to change was secured. Doctors and nurses are, in the main, people who want to help patients, not administer an organisation or trade with clients. Closely focused on their patients, their ward or practice, and their specialty, they did not always take a broad view and at times were clearly wrong. But once shown a path to better, more acceptable outcomes, they would take it, and probably find an even better one in the process.
Expert advice to government
Government required expert advice on health issues long before the NHS began. The MRC reported on many issues in the 1920s and 1930s. The NHS Act opened with a resounding statement:
It shall be the duty of the Minister of Health to promote the establishment of a comprehensive health service designed to secure . . . the prevention, diagnosis and treatment of illness and for that purpose to provide or secure the effective provision of services . . . as set out in the Act.
The responsibility of the Minister was subtly limited. He was not responsible for the prevention, diagnosis and treatment of illness; only for the establishment of a service to secure those desirable results. At first sight there was a clear-cut division between the Minister who provided the framework and the doctor who followed his profession within that framework. But there was a fuzzy border. In the treatment of a single patient it was easy enough to keep the Minister at arm’s length. However, if the question concerned the treatment of many similar patients, the Minister might not know the answers but he had to find out. The politician was concerned with the general consequences of individual decisions. He resolved the dilemma by creating a professional advisory system, respectable, august, safe and therefore, in the nature of things, rather elderly. Then if, for example, the General Medical Council (GMC) declined to approve qualifications of doctors trained on astrological principles, the Minister could -- very politely -- decline to employ them in the NHS.102
A major source of expert advice was the MRC, the successor to a committee established under the 1911 National Health Insurance Act to administer funds for research into tuberculosis. It had expanded, diversified and been incorporated by Charter, becoming a nearly autonomous body predominantly of scientists, with great liberty in discharging wide terms of reference. Its contributions to health care were many and valuable. Yet there was often a sense of tension between the MRC and the Ministry of Health. This centred around the question of the slant of research, basic and biomedical or operational and immediately applicable to common health problems. Its Secretary, Harold Himsworth, believed that, in the struggle to transform a parochial service into a national one, insufficient attention was paid to how expert knowledge could guide a science-based service.103 Lord Dawson had maintained that the greatest problem facing modern civilisation was the integration of expert knowledge into the machinery of government. With the advent of the health service a robust system was needed that could handle a wide range of issues and work at all levels of the NHS. The chosen mechanism was a CMO, with an expert supporting staff, and a range of advisory committees of external specialists. Himsworth preferred the solution adopted at the Ministry of Defence, where serving professionals worked side by side with civil servants. When the NHS was established, doctors were to be found in many advisory and managerial capacities throughout the service.
The stage is set
During the run up to the start of the NHS, most of the voices heard had been those of the professional élite, the top doctors, the representatives of the large hospitals and the senior nurses from the voluntaries. The Royal Colleges, then far more the public face of medicine than now, were largely controlled by men from London teaching hospitals. London had a dominant influence on what was now a national service, even though in some clinical fields the provinces were leaders. Less had been heard from the public, from the provinces, from general practice and from the long-stay specialties. The medical and nursing professions were cohorts of different ages, and with different patterns of thought. The older ones, in their 60s in medicine and 50s in nursing, were always over-represented in discussions. As a result true professional views and the importance of new developments did not always emerge. Wisdom sometimes came with age, but sometimes it did not. In medicine the leaders were invariably practising clinicians, although sometimes their working situation was atypical. Nursing, however, was hierarchical. Almost by definition those representing the nurses would long since have ceased to have contact with patients. To find nurses for committees, who were able both to see the broader picture and to bring to a meeting a sense of the world as it was, could be difficult.
On 5 July 1948 some thought they stood on the brink of the abyss, others of the millennium. The problem was to meld a mass of often conflicting institutions, keep them working and then get them to work better. The existing components were to be united into a new system for delivering care to everyone, redistributing staff and facilities. The NHS would also redistribute income and the right wing press saw a socialist attack on the professional classes in many of its features. There was acrimony and anger, hope and enthusiasm, fears and forebodings. There was a wish to make the new system work and a naive belief that all would be well. The lessons of war could be applied to the problems of peace, and a planned solution of many previously insoluble problems was now possible. That was the hope and the inspiration for the future. The urgent need was a planned attack on disease, on the basis of the best available sources of information, on a scale and of an intensity that had not previously been possible. But first, said the BMJ, the scarcity of skilled people and the shortage of equipment and institutions must be made good. After that the opportunity for co-operation between the medical profession, the public and the government in building a healthy Britain would be grasped eagerly.104
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