About Us
The National Health Service
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It is now over fifty years since the National Health Service came into being. Before that time,
health care was considered to be a luxury and many were unable to afford treatment, either
relying on home remedies or the charity of doctors who were prepared to give their services free.
Access to a doctor was available to some low paid workers, but this did not necessarily cover their wives or children. Hospitals made a charge for services, and although sometimes those in financial difficulties would be reimbursed, they still had to pay for the service initially, and not everyone could afford to do so. That free health care was necessary was obvious, but this was impossible to achieve without the support of the state. |
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Throughout the 19th century, there were philanthropists and social reformers who tried to provide free medical care for the poor. William Marsden was a young surgeon who, in 1928, opened a dispensary for advice and medicines. His London General Institution for the Gratuitous Cure of Malignant Diseases was a four-storey house in one of the poorest parts of London and was a hospital where treatment was provided free of charge to the poor and destitute who needed medical help. |
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Not surprisingly, the demand for Marsden's free services was overwhelming. By 1844, his dispensary,
which had been re-named The Royal Free Hospital, was treating 30,000 patients a year.
With consultant staff giving their services free and money from legacies, donations, subscriptions
and fund-raising events, the Royal Free, now re-housed in larger premises, tried hard to fulfil
Marsden's dream of providing free medical health to those in need. However, in 1920, nearly bankrupt,
they were finally forced to ask patients to pay whatever they could afford towards their treatment –
exactly the same as any other voluntary hospital in the country.
In addition to the charitable and voluntary hospitals, which dealt in the main with serious complaints, the local authorities of the larger towns provided municipal hospitals, e.g. for maternity cases, for infectious diseases like smallpox and tuberculosis, as well as hospitals for the elderly, mentally ill and mentally handicapped. It is a sad reflection on society that the latter were locked away in large forbidding institutions, not necessarily for the benefit of the patients, but often to save others from embarrassment. Conditions were often so bad that patients became worse rather improving. The elderly, who were unable to look after themselves and had no one to care for them also suffered, many ending their lives in the infamous workhouse. Paupers did unpaid work in return for food and shelter in these Victorian institutions – a fate that was feared by the poor. Eventually, in 1929, workhouses changed their name to Public Assistance Institutions, but the stigma and character attached to them, still remained. The Creation of The National Health Service The establishment of the NHS owed a great deal to the skill and energy of Aneurin (Nye) Bevan (1897-1960), who was appointed Minister for Health in 1946. After the war, with the country still suffering from its effects, it was clear that the old hospital system could not be revived. People had been used to the care that had kept the working population fit and the war had stimulated the changes that were so necessary. The voluntary hospitals continued to raise money, but it was only a very small proportion of what was needed. When Bevan nationalised the hospitals he faced little opposition, the hospital consultants were happy with the new arrangements and the hospitals had highly qualified staff for the first time. To start with, the General Practitioners were against the new service as they disliked the idea of not having paying patients and they did not want to lose the right to buy and sell their practices, believing they would become civil servants. However, by July 5th, 1948, the first day of the new service, most of the doctors had changed their minds. The NHS brought together hospital services, family practitioner services (doctors, pharmacists, opticians and dentists) into one organisation for the first time. This did, of course, create major problems and has continued to create administrative difficulties for years. The financing of the NHS created even more problems, the costs doubled then trebled in the first few years. Beveridge and Bevan had expected that people would become more healthy and not need so much treatment, but they were so wrong, they had not recognised the amount of hidden suffering that had been in existence amongst a large proportion of the population. Women came forward with illnesses that they had suffered from for years. Because in the past they would have been charged for medical attention, they sacrificed their health for the sake of their families, but with a free service this no longer applied and there were queues outside hospitals. More mothers wanted their babies born in hospital and the dentists throughout the country were fully booked for months. The costs continued to rise as newer, more expensive and more frequently used drugs were developed. Within three years of its creation the NHS was forced to introduce some modest fees. Prescription charges of one shilling (5p) were introduced in 1952 and a flat rate of £1 for ordinary dental treatment was brought in at the same time. Many of the stresses that emerged in the early days of the NHS have confronted its senior management and successive Governments ever since. Today the NHS has a workforce of over one million people and a budget of around £42 billion each year. However the questions that tested Bevan and his colleagues – how best to organise and manage the service, how to fund it, how to balance the conflicting demands and expectations of patients, staff and taxpayers and how to ensure that resources are targeted where they are most needed – all these problems still continue to challenge the system. Bevan foresaw this. 'We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving – it must always appear inadequate.' The basis of the new service was the family doctor, as with the practice today, he headed the NHS team, referring patients where appropriate to hospitals or specialist treatment and prescribing medicines and drugs. 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 organised by the local authorities. Ophthalmic opticians provided eye tests as long as the patient was able to produce a GP referral note. A major advance was the community health centre, special premises with accommodation and equipment supplied from public funds enabling family doctors, dentists and others to work together to offer a range of services on the spot. Specialist ear clinics were also available, offering an expert opinion and, if necessary, a new hearing aid. Despite the unexpected costs in the early years, the NHS was, and still is, a fair and efficient system, considerably better than that which was offered in the 1930s and more economical that any other service in the world. Gradually the NHS settled down, treatment improved as better drugs were introduced. During the ten years from 1957, the polio vaccine was introduced, dialysis for chronic renal failure and chemotherapy for certain cancers were developed. Problems still existed for both GPs and hospitals despite the improvement of trust between the professions as the outdated and war-damaged buildings did not match the skills of the consultants. 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 a new area for the NHS and it soon became clear it had underestimated the cost and time it would take to build new hospitals. However, a start had been made and with the advent of postgraduate education centres, nurses and doctors were given a better future. The Salmon Report in 1967, detailed recommendations for developing the senior nursing staff structure and the status of the profession in hospital management. Then, also in 1967, the first report on the organisation of doctors in hospitals (known as the Cogwheel Report) proposed speciality groupings that would arrange clinical and administrative medical work more logically. The variety of efforts being made at this time to reduce the disadvantages of the three-part structure showed the growing acknowledgement of the complexity of the NHS and the importance of change in order to meet future needs. Medical progress continued with advances including the increased use of the endoscope and the introduction of the CAT Scan (Computerised Axial Tomography). Kidney dialysis was introduced and surgery was used in cases of coronary heart disease. Transplant surgery was becoming increasingly successful and genetic engineering slowly began to influence medicine. Intensive care units were available, new drugs appeared, including non-steroidal anti-inflammatory treatments. Still, despite the many improvements, new infections appeared, such as Lassa Fever and the changes in the abortion laws led to new pressures on gynaecological services. In general practice, the GP's Charter encouraged the formation of primary health care teams, new group practice premises and increased numbers of health centres. New hospitals provided more people with a better local service. The Salmon Report changed the organisation of hospital nursing services and the introduction of information technology saw the first steps in health service computerisation. The debate on how the NHS should be organised in the best possible way continued from 1968 to 1974. A Royal Commission was appointed to look into problem areas, but just as new measures were about to be introduced, inflation reached 26 per cent and industrial action hit the NHS. Between 1978 and 1987 it became apparent that the NHS could no longer do everything that had become medically possible, it was a victim of its own success. New technology was being introduced and in all areas of NHS activity advances were being made. During this period the number of operations increased, including heart and liver transplants and surgical treatment for heart disease. As time passed, the pressure between demand and resources resulted in experiments in clinical budgeting and performance indicators were introduced. By 1987 health authorities throughout the country were in debt, with lengthy waiting lists and the closure of hospital wards. In 1990, The NHS and Community Care Act 1990 became law, which was an attempt by the Conservative Government to address the problems. Before this Act, a single bureaucracy ran all aspects of the NHS, but after the establishment of the internal market, 'purchasers' (i.e. health authorities and some family doctors) were given budgets to buy health care from 'providers' (i.e. 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 managements, competing with each other. The first 57 NHS Trusts started in 1991, but by 1995, all health care was provided by NHS Trusts. Many family doctors also had their own budgets to enable them to buy health care from NHS Trusts in the scheme called GP funding holding. The GPs who opted out of this scheme were still controlled by the health authorities. GP fund holders were often able to offer their patients treatment more quickly than patients of non-fund holders, leading to the accusation that the NHS was operating a two-tier system. The election of a new government in May 1997 brought a new approach to the NHS, promising to abolish the 'internal market' and endeavour to build on what had previously worked, by discarding what had failed. A new white paper was issued by the Department of Health, 'The New NHS. Modern. Dependable : running the service based on partnership and driven by performance'. The white paper described the approach as 'a new model for a new century', based on six key principles:
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