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National Health Service History

Geoffrey Rivett

home inheritance1948-19571958-19671968-1977 1978-1987  1988-19971998-2007 2008-2017envoishort history London's hospitals

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Many people come to this site for a short account of the health service

The history of the NHS is that of an organisation established after a century's discussion on the provision of health services to meet a long recognised need.  It appeared at a time when Britain saw health care as crucial to one of the "five giants" that Beveridge declared should be slain during post-war reconstruction. (want, disease, squalor, ignorance, idleness) The cataclysm of war provided an opportunity that might not have been taken in quieter times. The NHS was noble in conception and has been faced on the one side with ever increasing costs as a result of advances in medical knowledge, medicines and technology, and on the other with the financial restrictions inevitable in a centrally funded service with changing management dogmas and political beliefs.  Whether knowing what we know now Britain would follow the same pathway towards a universal health care system is anyone's guess.

Below you will find a quick and simplified  over-view.  You may find the link to the inheritance of the NHS is useful for this provides the text of the book's introductory chapter.  The links to 1948-1957, 1958-1967, 1968-1977, 1978-1987, 1988-1997, 1998-2007, 2008-2117 provide the text of the book and more recent decades. Two links give financial information over the years, earlier and later periods.

More information on the factors that led to the creation of the NHS is to be found in Geoffrey Rivett's earlier book on the Development of the London Hospital System,

This short account of the chronological time line, for simplicity’s sake, is mainly about England, though more detailed texts are available on this site and in hard copy  [1] 

The Nuffield Trust has produced a historical timeline (to which I contributed).

How we came to have a health service.

Others have written extensively on the reasons for a health service.  These included

The genesis of the NHS stretched back into the 19th Century.  Even then some believed that access to health care was part of the structure of a civilized society.  Some municipalities, such as the London County Council, had the ambition to run hospitals as well as utilities.   Hospital charities had been supported by the benevolent while socialists such as the Webbs argued for a state system or the insurance principle - pay in advance when well to provide for the care needed when sick.

In the First World War the army medical services had shown the benefits of organisation and transport.  At the government's request in 1920 Lord Dawson produced a forward thinking report on how a health service might be organised.[2] Under the Local Government Act (1929)  local authorities had taken over poor law hospitals that now became municipal hospitals serving ratepayers, not paupers.. They needed much upgrading.  In general the services that existed were in a mess.  The quality varied widely from town to town, and country areas were in general poorly served.  The London County Council and Middlesex were doing an excellent job - but many councils did not.  There might be duplication or an almost total absence of specialist services. During the 1930s a series of reports were produced by the BMA[3] (1930), think tanks such as Political and Economic Planning (1937)[4] and the Hospitals Association.  The King's Fund and the Nuffield Provincial Hospitals Trust as protectors of hospitals were also deeply involved for they appreciated that the future of the voluntary movement depended upon its efficiency. Working together and regionalisation were they key to this.

The experience of the Second World War, when in 1939 an emergency medical service was instantly created as the country came under command and control, provided an example of what could be done. In his report on social welfare systems Beveridge had little to say about the precise nature or funding of a health service, though seeing one as essential to a satisfactory system of social security (1942).[5] A major issue that later split the Labour Party was whether a future NHS should be run by local authorities, or quite separately on a regional basis. During the war the Conservatives produced the first White Paper on a future service in which local authorities would lead. (1944)[6].  But after Labour's election victory in 1945 Bevan presented to the Cabinet a radically different plan favouring nationalisation of all hospitals, voluntary or council, and a regional framework.  After much tough negotiation this plan went through, with modest concessions.

The National Health Service started in 1948 in a society weary but disciplined by war, and accustomed to austerity.  There remained resilience, humour and a sense of fun.  People who had become accustomed to little were content with simple things. Cinema, sport and radio, combined with “holidays at home” or the British seaside and Butlin’s camps, were the entertainment, there being little travel abroad.

We take the National Health Service for granted now, but it is only 60 years ago that health care was a luxury not everyone could afford. It is difficult for us to imagine what life was like without ‘free’ health care and the difference that the NHS made to people's lives. The same services were available the day after the creation of the NHS as the day before, no new hospitals were built nor hundreds of new doctors employed. But poor people who often previously went without medical treatment now had access to services, instead of relying instead on dubious and sometimes dangerous home remedies or the charity of doctors who gave their services free to their poorest patients. 

The services on which the NHS was based were

General practitioners

Access to a GP had been free to workers who were on low pay, but this didn't cover their wives or children, workers with a better standard of living or the retired. It worked through a "panel" often operated by Friendly Societies that paid GPs as little as possible.   GPs in affluent areas could rely on income from their patients.  Poorer people, if they could not pay the small fee, had little right to care but sometimes obtained it through the GP's charity.

Hospital care

The tempo was slow by today’s standards, lengths of stay being numbered in weeks.  Bed rest was a major form of treatment for heart attacks, ulcers, tuberculosis and childbirth.  Something like a quarter of hospital beds were provided in voluntary hospitals.  These varied from small hospitals in lesser towns supported by public subscription, to internationally famous teaching hospitals such as St Bartholomew's, Guy's and St Thomas' with substantial investment income.  A handful went back to a mediaeval origin and others were the result of the charity of the wealthy such as Thomas Guy in the 18th Century.  Later some hospitals were developed in conjunction with universities, University College Hospital, King's College Hospital and the provincial teaching hospitals.  Special hospitals concentrated on particular diseases or types of patients, children or women.  But each voluntary hospital was a law unto itself, raising funds and deciding its admission policies.  In London, the King's Fund had, since 1897, attempted to bring some order to the financial accounts, management, the location of voluntary hospitals, and to help with their costs.  Patients were often charged and many hospitals were near bankrupt.

Local authority services

Most beds were provided in municipal hospitals by the local authorities of counties and large towns out of the rates.  They were a service to their ratepayers. Local authorities also provided maternity hospitals, hospitals for infectious diseases like scarlet fever, smallpox and tuberculosis, as well as those for the elderly, mentally ill and mentally handicapped and a variety of community services. The standard varied widely, depending upon the attitude of the Council

Mentally ill people

Mentally ill and mentally handicapped people were generally sent away to large forbidding institutions, not always for their own benefit, but because that was how the system worked.  Admission was often for life.  Under the poor conditions prevailing, many patients became worse rather than better and "institutionalised".  However there was, in a true sense, asylum for people who could be 'strange' in private, and a basic standard of food and accommodation.

Older people

Older people who were no longer able to look after themselves fared particularly badly. Many ended their lives in the Public Assistance Institutions, the old workhouses feared by everyone. Workhouses changed their names in 1929, but their character and the stigma attached to them remained.  One of the early achievements in the NHS was the development of active geriatrics, when a start was made on dealing with the problem of the “back wards”, seldom visited by doctors, where people ended their days.


1948-1957

The National Health Service started on 5 July 1948.  It was a momentous achievement and, in spite of earlier professional opposition to some of the details, everybody wanted the new service to work. However, the weather was frightful, food was still rationed, there was a dollar economic crisis and a shortage of fuel.  Yet the 1951 Festival of Britain, on the South Bank, provided a glimpse of a better future.

The war had created a housing crisis - alongside post-war re-building of cities, the New Towns Act (1946) created major new centres of population which needed health services.  Hospitals had little claim on the few building materials available - housing and schools came first. The distribution of consultant services was poor, for specialists were centred in the major hospitals in large cities where private practice was possible, not rural areas.  In some large counties there were few consultants.  The NHS was founded at the time when massive innovation was occurring, some stimulated by war.  The pharmaceutical industry was creating a flood of new drugs.  Antibiotics, better anaesthetic agents, cortisone, drugs for the treatment of mental illness such as schizophrenia and depression, good diuretics for heart failure and the antihistamines all became available. 

Ultrasound was built upon wartime electronics expertise.  These developments, while improving the lot of the patient, raised the cost of the NHS and Government had little experience of running a health service with an explosive tendency to expand.

1948

Establishment of the service

Berlin air lift

1949

Aureomycin, cortisone

Pound devalued to $2.80

1950

Link between smoking & cancer

Korean war

1951

 

Festival of Britain

1952

Pay rise for GPs; College of GPs founded

Death of George VI

1953

Heart lung machine

Everest climbed

1954

First kidney transplant

Food rationing ends

1955

Ultrasound in obstetrics

Conservatives in power

1956

Polio immunisation; Guillebaud; the Pill

Hungarian uprising/Suez

1957

Royal Commission on Doctors' Pay

First satellite, Treaty of Rome

The principles of the NHS

The NHS was based on principles unlike anything that had gone before in health care. Few other countries followed this pathway outside the eastern (Soviet) block.  Others tended to rely on insurance based schemes.

Administrative organisation

The new service run by the Minister was "tripartite".

It had been hard to cost the day-to-day expenditure in advance and the taxpayer provided the same sums as previously available to each of the hospitals.  High public expectations were encouraged.  Hospital beds for tuberculosis and infectious diseases were soon closed as new treatment rendered them unnecessary, allowing cash to be released for other services, but new developments outpaced savings.  Hospital delivery was increasing, cardiac surgery was being applied to rheumatic heart disease, and the first hip replacements were performed. Estimates of the cost of the NHS were soon exceeded and within three years some modest fees were introduced, prescription charges of one shilling (5p) and a flat rate of £1 for dental treatment. 
A start was made on introducing consultant services in areas where they were deficient. Paying consultants, whatever their specialty, the same throughout the country helped. The District Hospital, a local hospital serving a natural geographic area, was an early concept and went back many years to the Dawson Report (1920).  Such hospitals were coupled with university hospitals where more complex facilities were available.

Balancing demands 

Many of the tensions of the early days of the NHS have challenged its senior management and successive governments ever since. The fundamental questions that tested Bevan and his colleagues - how best to organise and manage the service, how to fund it adequately, how to balance the often conflicting demands and expectations of patients, staff and taxpayers, how to ensure finite resources are targeted where they are most needed - continue to exist. Bevan foresaw this in speaking on 2nd June to a Royal College of Nursing conference.  'We shall never have all we need,' he said. 'Expectations will always exceed capacity. The service must always be changing, growing and improving - it must always appear inadequate.'   Increasing expenditure led to the appointment in 1953 of the Guillebaud Committee to 'enquire into the cost of the National Health Service'.  The report (1956)[7] said that the committee found no opportunity for new sources of income or to reduce in a substantial degree the annual cost of the service.  Indeed capital expenditure was too low.  Guillebaud's comments and recommendations spread far wider than financial affairs and it was, in effect, the first major review of the NHS and its workings.  The service's record 'was one of real achievement' and both parties now accepted the need for it, previously questioned in some quarters.


1958-1967

By the second decade the NHS was beginning to settle down.  National Service was ending as the last conscripts entered the services.  We had the Beatles and our first package holidays.  Elizabeth David provided cooking inspiration.

Treatment was improving as better drugs were introduced. During this decade polio vaccine became available, dialysis for chronic renal failure and chemotherapy for certain cancers were developed, all adding to costs.  Enoch Powell started the move towards the closure of the old asylums in his Church House speech.  Powell's plan was for 'nothing less than the elimination of by far the greater part of this country's mental hospitals as they stand today' (1961).

While much had already been done to appoint consultants in the major specialties throughout the country, their skills were not matched by the outdated and war-damaged buildings in which they worked. Powell's Hospital Plan, published in 1962, proposed the development of district general hospitals for population areas of about 125,000 and laid out a pattern for the future district by district.[8] The ten year programme was new territory for the NHS and it soon became clear it had underestimated the cost and time it would take to build new hospitals. But a start had been made and with the advent of postgraduate education centres, nurses and doctors could see a better future. 

1958

Better treatment of blood pressure

Boeing 707

1959

Mental Health Act

Morris Mini

1960

Royal Commission on doctors' pay

National Service ends

1961

Thalidomide disaster
Powell’s “Water Tower” speech

First man in space

1962

Hospital Plan.  Tripartite service - Porritt

Cuban missile crisis

1963

First liver transplant

Kennedy assassinated; NHS Commissioning

1964

 

Harold Wilson PM

1965

Family Doctors' Charter

Vietnam war

1966

Measles Vaccine.  GP Charter

Sterling Crisis; England wins World Cup

1967

Heart transplantation
Abortion Act

First ATM

Doctors' pay 

There were, however, problems for both GPs and hospital staff despite the slow development of a measure of trust between the professions and the Government. The Royal Commission on doctors’ pay alleviated some of the arguments which had caused problems during the first decade by setting up a review body. Negotiations between the Government and GPs’ leaders led to the GPs' Charter, a new contract that provided financial incentives for practice development, and a substantial award which greatly raised GPs' morale.  Practices slowly became better housed and better staffed, stimulating doctors to join together and the development of the modern group practice. 

Management 

Better management became a priority. The Cogwheel Report[9] in 1967 encouraged the involvement of clinicians.  Hospital Activity Analysis was introduced to provide better patient-based information and in the hospitals 'divisions' were created to group medical staff by specialty to look at clinical/managerial problems. The Salmon Report[10] in 1967 encouraged the development of a senior nursing staff structure and raised the profile of the profession in hospital management.

Porritt Report 

Attempts were made to reduce the disadvantages of the three part structure and there was growing acknowledgement of the complexity of the NHS and the importance of organisational change to meet future needs.  Maude, a former permanent secretary at the Ministry, had entered a note of reservation about it in Guillebaud (1956). In the 1962 Porritt Report, the medical profession also criticised the separation of the NHS into hospitals, general practice and local health authorities, called for unification and fired the debate on the structure of the NHS[11]


1968 - 1977

At the start of the third decade of the service clinical and organisational optimism prevailed in the NHS, but after the oil crisis of 1974 and the seven-day Israeli/Arab war, financial stringency reduced the growth rate of the NHS.  Morale fell as such factors combined to bring the decade to an unpromising close.
In the NHS attention turned to groups of patients who traditionally had a poor deal.  The elderly, the mentally ill and handicapped, children’s services and the disabled were the subjects of reports, sometimes following scandals.

Medical advances included the increasingly wide application of endoscopy and the advent of CAT (Computerised Axial Tomography) scanning. Transplant surgery was becoming increasingly successful and genetic engineering slowly began to influence medicine. Intensive care units were now widely available and new drugs appeared, including non-steroidal anti-inflammatory treatments.  Kidney dialysis became more widely available and surgery established a place in the care of coronary heart disease. On the downside, new infections, such as Lassa Fever emerged.  Changes in abortion law led to new pressures on gynaecological services.

1968

Seebohm/Todd/heart transplants

Czechoslovak uprising

1969

Ely hospital report

Man on the moon

1970

2nd green (reorganisation) paper

Bridge over troubled water

1971

coronary artery bypass

Currency decimalisation

1972

ancillary staff strike

Watergate

1973

Health Service Commissioner

UK joins the EEC

1974

NHS reorganisation

3day working week, industrial unrest

1975

Whole body CT scans

North sea oil

1976

RAWP Report

Concord

1977

Health for all 2000 declaration

 

In general practice, the GPs' charter was encouraging the formation of primary health care teams, new group practice premises and an increase in the number of health centres.  As the result of the Hospital Plan, some new hospitals were appearing and providing people with a better and more local service. The organisation of hospital nursing services was changed by the Salmon Report (not to everyone's satisfaction) and nurse education by Briggs, while the advent of information technology saw the first steps in health service computerisation and clinical budgeting.
From 1968 to 1974 debate continued on the how the NHS should be organised. Key issues included local government reorganisation (Seebohm) and the desire to improve the co-ordination of health and social services by matching the boundaries of health and local authorities.   Two plans for structural reorganisation fell by the wayside; the third was implemented in April 1974, but not until the Conservative Government that devised it had been replaced by Labour in a General Election.  It created problems rather than solving them.

1974 NHS reorganisation

Fourteen Regional Health Authorities, covering all three parts of the NHS and incorporating the teaching hospitals, replaced the previous authorities. Consensus management, a belief that in a multidisciplinary NHS all skill groups should have a voice in decisions, underpinned reorganisation.  A new tier of Area Health Authorities was established, with boundaries largely co-terminous with local authorities, between the regions and the district health authorities that managed the hospitals. The advantages were that the Area Health Authorities could unite the tripartite service and plan all NHS services in cooperation with local authorities. The disadvantages were that the system was complex & managerially driven and it soon earned criticism. Within two years, a Royal Commission on the NHS was appointed to look into the problem areas.  Just as strategic planning, long-range forecasts and reallocation were introduced, inflation reached 26 per cent and wage restraint came in. Industrial action hit the NHS while consultants were alienated by proposals to reduce private practice within the service.

Resources planning

Resources had been distributed unevenly across the NHS since 1948 but now successive Ministers, Richard Crossman and Barbara Castle, set up a Resource Allocation Working Party reporting in 1976.[12]  It produced a new system of allocation targets based on population, mortality and other factors.  Subsequently differential allocations helped regions towards their targets.  The gainers were in the north.  The losers were Oxford and the London regions that entered a period of distress lasting many years.


1978 - 1987

The fourth decade was characterised by the growing acknowledgement of the clear financial bounds within which the NHS operated. The NHS had become a victim of its own success. It could no longer even pretend to do everything medically possible.   Genetic engineering was yielding its first drug successes and magnetic resonance imaging was introduced.  Minimal access surgical techniques were introduced, while the number of operations for fractured neck of the femur and osteoarthritis of the hip was reaching almost epidemic proportions.  Increasing numbers of heart and liver transplants were being performed and surgical treatment for coronary heart disease was becoming common. This was the decade when the first cases of AIDS appeared, foreshadowing the world-wide epidemic. Developing countries could not even start to emulate the patterns of health care practicable in the West. Increasingly they looked to primary health care, the use of semiskilled workers based in the community, and collaboration between different sectors, agriculture, water, sanitation and education. In September 1978 the World Health Organization (WHO) and UNICEF called a conference at Alma-Ata in the USSR. Its declaration stressed that primary care was the route to Health For All; this was thought achievable by the year 2000 and at affordable cost.

More people were being treated in more complex ways. This led to rising expectations of the health service in an increasingly elderly population with all its attendant health needs. Beginning in 1978, the winter of discontent, the service's financial problems were worsened by the oil crisis.  NHS management tried to improve efficiency and there were continued attempts to set priorities between the sectors of the NHS, the elderly, the mentally ill and the acute services.
NHS restructuring in 1982 tried to simplify the organisation.  The area tier was abolished so that there were now 192 District Health Authorities responsible to the RHAs.  7 Special Health Authorities continued to manage London postgraduate teaching hospitals and the 90 Family Practitioner Committees that had matched the earlier Areas persisted unchanged.

1978

First test-tube baby.  Alma Ata

Winter of discontent

1979

Royal Commission on NHS

Margaret Thatcher

1980

Black Report.  MRI

SAS storm Iranian embassy

1981

Acheson on GPs in London

Charles & Diana marry

1982

First reported case of AIDS; NHS restructuring

Falklands war

1983

Mental Health Act.  Griffiths Report

Compact discs

1984

Warnock Report

Miners' strike

1985

FPCs gain independence

Word processors

1986

BSE in Cattle

Chernobyl

1987

GP Contract White Paper

Black Wednesday on stock market

Consensus management had been criticised for its managerial slowness but the Royal Commission (1979)[13] had explicitly rejected general (as opposed to consensus) management in the NHS.  This was contradicted only two years later in an influential government-sponsored report (1983)[14] by a leading businessman, Sir Roy Griffiths of Sainsbury's. General management was introduced in 1984, encouraging:

Doctors were encouraged to become more involved with budget decisions.

Audit and Performance indicators

Closer examination of professional activity followed international concern about rising costs. Audit of the results of anaesthesia and surgery was introduced. The tension between increasing demand and finite resources prompted new experiments in clinical budgeting and a desire for better health service information. Performance indicators were introduced. The level of acute hospital services likely to be available in London in the future was examined by the London Health Planning Consortium.  If money was to be moved to the north, into the Shire counties, and into services that had been under-resourced such as mental illness and the elderly, acute services would have to be cut in central London.  A process of merger of hospitals and medical schools in London began.

Community care

Clinical advances placed increasing demands on nursing and medical staff. One option for the NHS was to move care from a hospital to a community setting. Community nursing was examined and the Government established two reviews, of general practice and nursing in primary health care (Cumberlege).
Yet by 1987 health authorities throughout the country were in debt, waiting lists were growing and hospital wards were being closed - despite evidence of higher spending, steady increases in staff numbers and the treatment of more patients.  Neither the public nor the health care professions were satisfied and the service was increasingly subjected to scrutiny in the media.


1988-1997             

The consumer society was taking off.  Long haul holidays, increasing reliance on consumer credit and the advent of Sky satellite TV (1989) reflected our changing expectations.  Yet the fifth decade opened with widespread uneasiness about the NHS.  Younger people were cynical about whether they could rely on the NHS; older ones thought that many things had been better in the past. 

Hospital throughput had risen and new radical treatments demanded great stamina of patients. Evidence-based medicine, clinical effectiveness and medical audit were to the fore, internationally as well as in the UK.

A White Paper in 1987 laid out the Conservatives' goals for a new contract for GPs. Early the following year Mrs Thatcher announced that the NHS as a whole would be reviewed.  During 1991-97, a period of limited growth, an "internal market" was introduced throughout the UK, changing health authorities' responsibilities by separating the roles of purchaser and provider. The NHS experienced the most significant cultural shift since its inception , outlined in the 1989 White Paper, Working for Patients,[15] which passed into law as the NHS and Community Care Act 1990.  The internal market was the Conservative Government's attempt to address problems, such as growing waiting lists, which had risen in the 1980s as a result of shortage of money while demand rose inexorably.  The proposals had been designed to increase the responsiveness of the service to the consumer, to foster innovation and to challenge the monopolistic influence of the hospitals on a health service in which community based services were increasingly important.  Competition was one of the keys.

1988

NHS review announced on Panorama

Cows with BSE

1989

Working for Patients (NHS reforms)

Berlin wall falls.  Satellite TV

1990

GPs’ new contract

Poll tax riots

1991

The Health of the Nation

Gulf war

1992

Tomlinson on London

Charles & Diana separate

1993

Calman on hospital staffing

World wide web

1994

Regions reduced to 8

Mandela president of South Africa

1995

GPs' out of hours dispute

 

1996

Districts & FHSAs united

Privatisation gathers pace

1997

Dolly the sheep

Scots vote for devolution
Labour back in power

Before the 1990 Act a monolithic bureaucracy ran all aspects of the NHS. After the establishment of the internal market and the purchaser-provider split, 'purchasers' (health authorities and some family doctors) were given budgets to buy health care from 'providers' (acute hospitals, organisations providing care for the mentally ill, people with learning disabilities and the elderly, and ambulance services).  To become a 'provider' in the internal market, health organisations became NHS trusts, independent organisations with their own management, competing with each other. The first wave of 57 NHS Trusts came into being in 1991. By 1995 all health care was provided by trusts.  The wider problems of the country’s health were considered in The Health of the Nation[16]  published in 1991 which set out diseases and conditions that might be helped by health promotion in the NHS.

GP fund holders

Many family doctors were given budgets with which to buy health care from NHS trusts (and also from the private sector) in a scheme called GP fund holding. Each year more and more GPs joined.  Those who did not have their own budgets had services purchased for them by health authorities that bought 'in bulk' from NHS trusts. Patients of GP fund holders were often able to obtain treatment more quickly than patients of non-fund holders. This led to accusations of the NHS operating a two tier system, contrary to the founding principles of the NHS of fair and equal access for all to health care. Supporters said fundholding saved money and was more efficient.  

Labour in power again

In May 1997 Labour came back to power.  Observers credited the internal market with improving cost consciousness in the NHS, but at a price: that the competition it encouraged between 'providers' saw unnecessary duplication of services.  The new Labour government began to change things, pledging the abolition of the internal market.  Though it said it would build on what had worked but discard what had failed, in the event it discarded some successes and introduced a period of instability.  A new white paper issued under Frank Dobson by the Department of Health, The New NHS. Modern. Dependable[17], suggested that the service would be based on partnership and driven by performance.  Once more there were attempts to improve matters by changing structure.

1998 – 2007

In this decade the NHS was controlled by Labour throughout.  The country saw a boom in the property and financial markets and later the debacle of Northern Rock, worldwide financial crisis and a swing to the right.  The accession of new countries to the European Community was followed by substantial immigration.
The increasing capacity of curative medicine, the availability of more and more expensive drugs for the control of cancer and AIDS, and the developments in psychiatry in the community added to costs.  The spectre of the rationing of care was never far from the surface internationally. Imaging and non-invasive surgery continued to improve and genetic medicine was said to promise a future of personalised treatment. 


10 Downing Street became involved in the NHS as never before. Successive Secretaries of State, Frank Dobson, Alan Milburn, John Reid, Patricia Hewitt and Alan Johnson produced a series of plans, white papers and organisational changes. The NHS Plan of 2000 was the most significant.[18]  The "New Labour" internal market applied only to England and in a period of sustained increase in funds.  PCTs contracted selectively with providers, and practice based commissioning with indicative budgets seemed an extension of the GP fundholding model. 

The turmoil hardly bears recounting, with the formation, dissolution and rearrangement of the structure and responsibilities of NHS authorities and trusts.  NHS Foundation Trusts, a new type of trust with more independence, which encouraged public participation as members, appeared. For a while there were 10 strategic health authorities controlling some 200 primary care trusts that contracted with both public and private providers, trusts, hospitals, community, mental illness and ambulance, as well as managing GPs and primary health care.
In parallel, new systems of financial flow, payment by results and a tariff system brought instability to the finances of the NHS.  Health service computing finally began to deliver results, with transmission of data, reports, radiographs and prescriptions, between hospitals, surgeries and pharmacies.  Patient choice for elective surgery was introduced from 2006.

1998

NHS Direct

digital TV

1999

NICE; Primary Care Groups

fixed Euro exchange rates

2000

NHS Plan, better NHS funding, Commission for Health Improvement

collapse of dot.com shares

2001

Wanless to look at NHS finance

9/11 attack on World Trade Center
iPod launched

2002

'Devolution day' & funding increases

stock market fall

2003

GPs and Consultants' new contract

IraqLondon congestion charge

2004

First Foundation Trusts

expansion of European Union

2005

Payment by Results

London terrorist bombings

2006

SHAs cut to 10

Stern report on climate change

2007

Ara Darzi report; public smoking ban

Bulgaria/Romania join EU

2008

 

Labour losses in local elections

Regulation increased. The National Institute for Clinical Excellence assessed the cost-effectiveness of new drugs and technologies.  The Healthcare Commission looked at the quality, governance and financial management of trusts. Bristol and Shipman were followed by a tightening of professional regulation. There was a drive for ‘modernisation’, changing skill mix and looking at effective ‘clinical pathways’ to increase capacity and reduce hospital waiting lists.

Money increased.  The NHS showed signs of becoming an electoral liability and Tony Blair made a commitment on Frost on Sunday (the most expensive breakfast in British history) increasing the growth rate of the NHS substantially for five years.  A report[19] by Derek Wanless underpinned the recognition that the NHS was, by the standards of the developed world, grossly under resourced.  A major expansion of training for doctors and nurses, and the establishment of new medical schools followed.  However mistakes in the negotiation of contracts, particularly with GPs and consultants, added to the pressure on funds and led to a temporary financial crisis. 

The money helped the implementation of the NHS Plan, four principles of which were

Provision was no longer necessarily by a publicly owned infrastructure. Labour achieved a change that, had it been attempted by the Conservatives, would have faced immense opposition.  Private sector organisations came to build and operate hospitals under the public/private partnerships, and to run clinical services such as Independent Treatment Centres and some NHS Walk-in Centres.  "Contestability" - the introduction of competition between providers - became significant.  Private practice was now an important part of a new and more sophisticated market.  Labour's traditional desire to look at health care from a community and public health perspective led to policies rather than achievements (with the exception of a ban on smoking in public places).  The decade ended as it had begun with reviews, Lord Darzi's of the services in London [20] and related reviews of the other SHAs.  Quality was now being made central to NHS development, amid fears that the world wide economic downturn would have a substantial effect on the NHS.

2008- 2017


The seventh decade opened amidst international financial crises with rising unemployment, attempts to ease the recession by public spending, and the knowledge that public services would soon suffer at best a reduced growth rate and at worst significant cuts.  Clinical advances in genetic medicine, stem cell research, drugs particularly for cancer, and imaging would clearly increase the pressure on the NHS.
 Labour's period in power ended with the 2010 election when a Lib/Conservative coalition was formed. 

The new Secretary of State, Andrew Lansley, had developed and published his proposals in 2007 while in opposition. They were modified during the course of coalition discussions, and changed again over the coming months. It was not clear how the proposals related to current problems in the service.  A White Paper appeared [21], followed by a Bill, including proposals to alter NHS structure yet again, phasing out Strategic Health Authorities and Primary Care Trusts, establishing NHS England and giving Clinical Commissioning Groups, heavily influenced by GPs, the majority of the NHS budget for hospital services. The Act was passed after violent controversy in 2012 while one of the worst financial crises was hitting the NHS and implemented in April 2013.
Wider issues NHS events
2009Israeli invasion of Gaza
Barack Obama  President of USA
Parliamentary financial scandals
UK Population 61 million
Copenhagen climate conference
Mid-Staffs Report on poor quality health care,
Care Quality Commission
Andy Burnham SOS
Financial stringency
Swine flu
2010Election - Lib/Conservative coalition
BP/Gulf oil spill
White Paper
Andrew Lansley SOS
2011Arab Spring uprisings Health & Social Care Bill
2012   Health and Social Care Act passed
Jeremy Hunt SOS
2013   Implementation of new NHS Structure
2014 Russia annexes the Crimea Nicholson 'challenge' to make savings is extended
2015   
2016   
2017   
2018   

 


[1] Rivett G C.  From Cradle to Grave, the first 50 years of the NHS.  1998, London, King’s Fund and www.nhshistory.net.

[2] Great Britain, Ministry of Health, Consultative Council on Medical and Allied Services, Interim Report. (Chairman Lord Dawson) London HMSO 1920 Cmd 693

[3] A general medical service for the nation. London, British Medical Association, 1930 and 1938.

[4] Report on the British health services. London, Political and Economic Planning, 1937.

[5] Parliament. Social insurance and allied services, para 428. Report by Sir William Beveridge. London: HMSO, 1942.

[6] Great Britain, Ministry of Health and Department of Health for Scotland. A National Health Service. London, HMSO, 1944. Cmnd 6502

[7] Parliament. Report of the committee of enquiry into the cost of the national health service. (Chairman: CW Guillebaud.) Cmd 9663. London: HMSO, 1956.

[8] National Health Service. A hospital plan for England and Wales. Cmnd 1604. London: HMSO, 1962.

[9] Ministry of Health. First report of the joint working party on the organisation of medical work in hospitals. London: HMSO, 1967

[10] Ministry of Health and Scottish Home and Health Department. Report of the committee on senior nursing staff structure. (Chairman: Brian Salmon.) London: HMSO, 1966.

[11] Report of the Medical Services Review Committee. Summary of conclusions and recommendations. BMJ 1962; 2: 1178-86

[12] Great Britain, Department of Health and Social Security. Sharing resources for health in England: report of the resource allocation working party. London, HMSO, 1976

[13] Parliament. Royal Commission on the NHS (Chairman: Sir Alec Merrison.) Cmnd 7615. London: HMSO, 1979

[14] NHS Management Inquiry. Letter dated 6 October 1983 to the Secretary of State, Norman Fowler, from Roy Griffiths, Michael Betts, Jim Blyth and Sir Brian Bailey

[15] Parliament. Working for patients. Cm 555. London: HMSO, 1989.

[16] The Health of the Nation.  A strategy for health in England.  July 1992.  London  HMSO.  Cm1986

[17] The new NHS – Modern, Dependable,  1997, London, HMSO, 1997 Cm 3807

[18] The NHS Plan, A plan for investment, A plan for reform  2000, London HMSO

[19] Securing our Future Health: Taking a Long-Term View, Final Report, Derek Wanless, April 2002, HM Treasury, London.

[20]  A Framework for Action  Health Care for London  2007

[21] Equity and Excellence - Liberating the NHS.  White Paper July 2010 HMSO Cm 7881.

 

 

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