| nhshistory.net nhshistory.com Email author | National Health Service History |
The history of the NHS is that of an organisation established to meet a long recognised need, at a time when Britain saw health care as crucial to one of the "five giants" (want, disease, squalor, ignorance, idleness) that Beveridge declared should be slain during post-war reconstruction. It 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 the financial restrictions inevitable in a centrally funded service and changing management dogmas and political beliefs. Whether knowing what we know now Britain would follow the same pathway 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 and 1988-1997 provide the text of the book
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,
The start of the NHS
The genesis of the NHS was slow - stretching back into the 19th Century From the middle of the 19th Century some came to believe that access to health care was part of the structure of civilized society.
Some influences were home grown, but others came from abroad. Bismark's
social security system in Germany, for example, or Flexner's approach to medical
education in the USA. From early on some municipalities, such as the London County Council, thought this from so and had the ambition to run hospitals. Charities had been supported by the benevolent who had subscribed to Hospital Sunday, or the King's Fund, or left money for the support of their local hospital. The left argued for the insurance principle - pay when well for care needed when sick. In the First World War the army medical services had shown the benefits of organisation and transport. The medical profession in the nineteen thirties had published a major report on a national hospital service. The services that existed were, however, in a mess. The quality varied widely from town to town, and country areas were generally poorly served. There might be duplication, or an almost total absence of specialist services. At the government's request in 1920 Lord Dawson produced a forward thinking report on how a health service might be organised. During the 1930s a series of reports was produced by the BMA (1930), political think tanks such as Political and Economic Planning (1937) and the Hospitals Association. The King's Fund and the Nuffield Provincial Hospitals Trust contributed their views. Beveridge had little to say about the nature or funding of a health service,
though seeing one as essential to a satisfactory system of social security. A major issue became whether a future NHS should be run by local authorities or quite separately on a regional basis. Local authorities varied substantially in their performance. The London County Council and Middlesex doing an excellent job - but many did not. The experience of the second world war, when an emergency medical service was formed as the country came under command and control provided an example of what could be done. During the years of war the Conservatives produced the first White Paper on a future service (1944). 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.
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. While 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 - poor people who previously often 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. Watch the National Archives film.
GPs
Under earlier legislation access to a GP had been free to workers who were on low pay, but this didn't cover their wives or children, nor did it cover workers with a better standard of living or the retired. If covered it was 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 ones if they could not pay the small fee, had little right to care but sometimes obtained it through the GP's charity.
Hospital care
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
The remaining hospital beds were provided in municipal hospitals
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 and "instituitionalise", not better. 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 workhouse - a Victorian institution feared by everyone - where paupers did unpaid work in return for food and shelter. Workhouses changed their names to Public Assistance Institutions in 1929, but their character and the stigma attached to them, remained.
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, food was still rationed, building materials were short, there was a dollar economic crisis and a shortage of fuel. 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 and needed health services. Hospitals had little claim on the 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 virtually no consultant services at all. 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 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 | |
1949 | Aureomycin, cortisone | Pound devalued to $2.80 | |
1950 | Link between smoking & cancer | Korean war | |
1951 |
| Festival of | |
1952 | Pay rise for GPs; | 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 an insurance based scheme..
Administrative difficulties
The new service 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 the hospitals. High public expectations were encouraged. Hospital beds for tuberculosis and infectious diseases were soon closed as 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 (5) 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
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. '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) 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 the service, previously questioned in some quarters.
Family health services
The foundation of the new service was the family doctor or general practitioner (GP). Then, as now, the family doctor acted as gate-keeper to the rest of the NHS, referring patients where appropriate to hospitals or specialist treatment and prescribing medicines and drugs. However the GPs had been stretched by the war, as younger doctors were away, their pay, status and morale was low. In 1955 some money was made available to GPs to develop group practices, a major improvement.
Dental services consisted of check-ups and all necessary fillings and dentures. There was a school dental service and a special priority service for expectant and nursing mothers and young children that was organised by local authorities. Eye tests were provided by ophthalmic opticians on production of a GP referral note.
Local Authority community health services
These services, managed for the local authority by a Medical Officer of Health, provided community nurses to support to the family doctors. A major innovation, health centres in the community, had been planned from the outset but few were built. These were to be premises with accommodation and equipment supplied from public funds (via local authorities) to enable family doctors, dentists, nurses, chiropodists and others to work together to provide a range of services on the spot. There were also to be specialist ear clinics at which patients could get an expert opinion and, if needed, a hearing aid.
1958-1967
By the second decade, the NHS was beginning to settle down. 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. Hospital plan 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. Enoch Powell's Hospital Plan, published in 1962, approved the development of district general hospitals for population areas of about 125,000 and in doing so, laid out a pattern for the future. The ten year programme put forward was new territory for the NHS and it 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 were given a better future. | 1958 | Better treatment of blood pressure | Boeing 747 |
1959 | Mental Health Act | Morris Mini | |
1960 | Royal Commission on doctors' pay | National Service ends | |
1961 | Thalidomide disaster | First man in space | |
1962 | Hospital Plan. Porritt | Cuban missile crisis | |
1963 | First liver transplant | Kennedy assassinated; Beetles | |
1964 |
| Harold Wilson PM | |
1965 | Family Doctors' Charter | ||
1966 | Measles Vaccine. GP Charter | Sterling Crisis; | |
1967 | Heart transplantation | 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 doctor's pay alleviated some of the arguments which had caused problems during the first decade. 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 review body award greatly raised GPs' morale. Practices slowly became better housed and better staffed, stimulating doctors to join together in partnerships and groups and the development of the modern group practice.
Management
Better management became a priority. The Cogwheel Report 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 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 showed the growing acknowledgement of the complexity of the NHS and the importance of organisational change in order 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
1968-1977
At the start of the third decade of the service clinical and organisational optimism prevailed in the NHS, but financial stringency after the oil crisis of 1974 and the seven-day Israeli/Arab war reduced the growth rate of the NHS. Morale soon receded until, by 1977, various factors had combined to bring the decade to an unpromising close. Medical progress continued, with advances including 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 for 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 | ||
1974 | NHS reorganisation | 3day working week, industrial unrest | |
1975 | Whole body CT scans | ||
1976 | RAWP Report | ||
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 Government's 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 crucial question of how the NHS should best be organised. Key issues included local government reorganisation 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 in a General Election.
1974 NHS reorganisation
Fourteen Regional Health Authorities, covering all three parts of the NHS and taking on board 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 the organisation. A new tier of Area Health Authorities was established, largely co-terminous with local authorities, inserted in most places between the regions and the district health authorities that managed the hospitals. The advantages were that the Area Health Authorities could plan all NHS services for first time and cooperate 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. It produced a new system of allocation targets based on population, mortality and other factors. Over the years differential allocations helped regions towards their targets. The gainers were in the north. The losers were
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 no longer could do everything medically possible. New technology was being introduced and 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 was implemented in 1982 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 | 1978 | First test-tube baby. | Winter of discontent |
1979 | Royal Commission on NHS | Margaret Thatcher | |
1980 | Black Report. MRI | SAS storm Iranian embassy | |
1981 | Acheson on GPs in | Charles & Diana marry | |
1982 | First reported case of AIDS; NHS restructuring | ||
1983 | Mental Health Act. | Compact discs | |
1984 | Warnock Report | Miners' strike | |
1985 | FPCs gain independence | Word processors | |
1986 | BSE in Cattle | ||
1987 | GP Contract White Paper | Black Wednesday on stock market |
Consensus management was criticised for managerial slowness. The Royal Commission only 2 yeas before had explicitly rejected general (as opposed to consensus) management into the NHS. This was contradicted only two years later in an influential government-sponsored report (1983) by a leading businessman, Sir Roy Griffiths of Sainsbury's.. General management was introduced in 1984, encouraging:
· one individual at every level of the organisation being responsible and having authority and accountability for planning and implementing decisions;
· more flexibility in team structures;
Doctors were encouraged to become more involved with budget decisions.
Clinical Advances - Genetic engineering was yielding its first drug successes and magnetic resonance imaging was introduced. The decade saw the advent of surgical minimal access techniques, while the number of operations for fractured neck of 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 heart disease was becoming more frequent. This was the decade when the first cases of AIDS appeared, foreshadowing the world-wide epidemic.
Audit and Performance indicators
Closer examination of professional activity followed international concern about rising costs. Discussion began of audit of the results of anaesthesia and surgery. The tension between increasing demand and finite resources prompted 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
Community care
Clinical advances placed increasing demands on nursing and medical staff and each profession looked at its education and organisation. 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 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 A White Paper in 1987 laid out the Conservatives' goals for a new contract for GPs. Early the following year Mrs Thatcher announced that all of the NHS would be reviewed. As a result the NHS experienced the most significant cultural shift since its inception with the introduction of the so-called internal market. This was outlined in the 1989 White Paper, Working for Patients, 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 services in the community were increasingly important. Competition was one of the keys. | 1988 | NHS review announced on Panorama | Cows with BSE |
1989 | Working for Patients (NHS reforms) | ||
1990 | GP's new contract | Poll tax riots | |
1991 | The Health of the Nation | Gulf war | |
1992 | Tomlinson on | Charles & Diana separate | |
1993 | Calman on hospital staffing | World wide web | |
1994 | Regions reduced to 8 | Mandela president of | |
1995 | GPs' out of hours dispute |
| |
1996 | Districts & FHSAs united | Privatisation gathers pace | |
1997 | Dolly the sheep | Scots vote for devolution |
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 NHS trusts.
GP fund holders
Over the same period, many family doctors were given budgets with which to buy health care from NHS trusts (and also the private sector) in a scheme called GP fund holding. Each year more and more GPs joined this scheme. Those who did not have budgets were had services purchased for them by health authorities, which 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.
Labour in power again
In May 1997 Labour came back to power. Observers credit 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 Government changed the approach to the NHS. Pledging itself to abolition of the internal market, it said it would build on what had worked previously, but discard what had failed. Regrettably 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", suggested that the service would be based on partnership and driven by performance. Once more there would be attempts to improve performance by changing structure.
1998 - 2008
|
The decade, entirely one of Labour control, brought a boom in the property and financial markets and yet the debacle of Northern Rock and a pension crisis and an increasing sense disease. Clinical progress proceeded apace and the first results of genetic medicine were appearing. Better drugs were developed for AIDS and for the control of cancer, and in spite of the creation of NICE to assess cost-effectiveness the pharmaceutical bills soared. Imaging and non-invasive surgery continued to improve. | 1998 | NHS Direct. Heart surgery at Bristol | digital TV |
1999 | NICE; Primary Care Groups | fixed Euro exchange rates | |
2000 | Shipman murders. Commission for Health Improvement | collapse of dot.com shares | |
2001 | Wanless on NHS finance | 9/11 attack on | |
2002 | 'Devolution day' & funding increases | stock market fall | |
2003 | GPs and Consultants' new contract | ||
2004 | First Foundation Trusts | expansion of European Union | |
2005 | Payment by Results | ||
2006 | SHAs cut to 10 | Stern report on climate change | |
2007 | Ara Darzi report; public smoking ban | Bulgaria/Romania join EU | |
2008 |
|
| |
|
| . |
There was a drive to increase capacity and reduce hospital waiting lists. Labour decided that while the NHS was a service provided to all without payment, provision would not necessarily be by a publicly owned infrastructure. Private sector organisations came to build and operate hospitals under PFI, and run clinical services such as Independent Treatment Centres and some NHS Walk-in Centres. "Contestability" - i.e. the introduction of competition between providers, became significant. Private practice was first discouraged and then made an important part a new and more sophisticated market wide open to the private sector. Labour's traditional desire to look at health care from a community and public health perspective led it to policies on these topics rather (with the exception of a ban on smoking in public places) than achievements. The decade ended as it had begun with a review of the NHS, (Lord Darzi) this one unique by virtue of its clinical viewpoint.