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The history of the NHS is that of an organisation, noble in conception, which 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. Below you will find a quick and simplified over-view. It derives from material written by the author on commission for the 50th anniversary of the NHS, and subsequently used in official publications. It has been subjected to a final brief edit by the author. 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, 1978-1987 and 1988-1997 provide the text of several chapters 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, available here. The start of the NHS The genesis of the NHS was slow - stretching over perhaps fifty years or more. Increasingly from the middle of the 19th Century people came to believe that access to health care was part of the structure of civilized society. Municipalities such as the London County Council came to believe this from an early stage. The benevolent had subscribed to charities, such as the King's Fund, or left money for the support of their local hospital. Some 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. The experience of the second world war, when the country came under command and control with great ends in mind, stimulated action. We take the National Health Service for granted now, but it is only a little over 50 years ago that health care was a luxury not everyone could afford. It is difficult today for us to imagine what life must have been like without free health care and the difference that the arrival of the NHS made to people's lives. Just before the creation of the NHS, the services available were the same as after; no new hospitals were built nor hundreds of new doctors employed. What was different was that poor people who previously often went without medical treatment, relying instead on dubious and sometimes dangerous home remedies or on the charity of doctors who gave their services free to their poorest patients, now had access to services. Hospitals charged Access to a doctor was free to workers who were on low pay, but this didn't necessarily cover their wives or children, nor did it cover workers with a better standard of living. Hospitals charged for services, though sometimes poorer people would be reimbursed. Even so, it often meant paying for the service in the first place - which not everyone could afford. The need for free health care was widely recognised, but it was impossible to achieve without the support or resources of the state. Philanthropists and social reformers Throughout the 19th century, philanthropists and social reformers working alone had tried to provide free medical care for the poor. One such man was William Marsden, a young surgeon, who in 1828 opened a dispensary for advice and medicines. His grandly named London General Institution for the Gratuitous Cure of Malignant Diseases - a simple four-storey house in one of the poorest parts of the city - was conceived as a hospital to which the only passport should be poverty and disease and where treatment was provided free of charge to any destitute or sick person who asked for it. The demand for Marsden's free services was overwhelming. By 1844 his dispensary, now called the Royal Free Hospital, was treating 30,000 patients a year. With consultant medical staff giving their services free of charge and money from legacies, donations, subscriptions and fund-raising events, the Royal Free - now re-housed in larger premises - struggled to fulfill Marsden's vision until 1920 when, on the brink of bankruptcy, it was forced to ask patients to pay whatever they could towards their treatment - just like every other voluntary hospital in the country. Municipal hospitals As well as the charitable and voluntary hospitals, which tended to be selective and to deal mainly with serious illnesses, the local authorities of counties large towns provided municipal hospitals - maternity hospitals, hospitals for infectious diseases like smallpox and tuberculosis, as well as hospitals for the elderly, mentally ill and mentally handicapped. The standard varied widely, depending upon the attitude of the Council. Some, such as Middlesex and the London County Council, did a fine job. Others did not. Mentally ill people Mentally ill and mentally handicapped people were generally locked away in large forbidding institutions, not always for their own benefit but to save other people from embarrassment. Conditions might be so bad that many patients became worse, 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 also fared 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 became reality on 5 July 1948. Plans for a health service had been made during the years of the second world war, 1939-1945. Both the major political parties had schemes, but the one adopted was that of a new Labour administration. The principals of the NHS The NHS was based on principles unlike anything that had gone before in the UK, and few other countries followed these.
It was a momentous achievement and 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, and the designation of overspill areas, the New Towns Act (1946) created major new centres of population and all needed health services. The distribution of services was poor, with major hospitals in large cities but poor services in rural areas. In some large counties there were virtually no consultant services at all. The NHS was founded just at the time when massive innovation was occurring in the availability of 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. These advances, as well as better radiology systems, raised the cost of the NHS while improving the lot of the patient. Administrative difficulties The NHS brought hospital services, family practitioner services (doctors, pharmacists, opticians and dentists) and community-based services into one organisation for the first time. However the service was divided into three parts
Financial problems were substantial. It had been hard to cost in advance the day-to-day costs of the new service and public expectations rose. Medical science was rapidly gathering pace, but while hospital beds for tuberculosis and infectious diseases were closed, allowing cash to be released for other services, new developments outpaced savings. More mothers were wanting their babies delivered in hospital, cardiac surgery was being applied to rheumatic heart disease, and the first hip replacements were being performed. Initial estimates of the cost of the NHS were soon exceeded as newer, more expensive and more frequently used drugs were developed. Within three years of its creation the NHS, which had been conceived as free of direct charges for everyone, was forced to introduce some modest fees. Prescription charges of one shilling (5p), which had been legislated for as early as 1949 but not implemented, were introduced in 1952. A flat rate of £1 for ordinary dental treatment was brought in at the same time. Balancing demands Many of the tensions that emerged in the early days of the NHS have challenged its senior management and successive Governments ever since. Today the NHS has a workforce of roughly one million people and a huge budget, and is a sophisticated and modern organisation with many of the advantages of state-of-the-art technology. Yet 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 challenge the system. 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. An immediate problem was the improvement of consultant services, and their introduction in areas where they were deficient. An early planning concept was that of the District Hospital, a local hospital serving a natural geographic area and providing all the more usual services a population should expect. Such hospitals were coupled with university hospitals where more complex facilities were available. 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. 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 nursing support to the family doctors. A major innovation were health centres in the community, planned from the outset but seldom built until the second and third decades of the service. These were 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 specialist ear clinics at which patients could get an expert opinion and, if needed, a new 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. 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 in management. Hospital Activity Analysis was introduced to give clinicians and managers better patient-based information and in the hospitals 'divisions' were created with the aim of grouping medical staff by specialty to look at clinical/managerial problems. The Salmon report in 1967 made recommendations for developing the senior nursing staff structure and raising the profile of the profession in hospital management. The 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. Porritt Report Increasingly, though, the tripartite structure of the service was criticised. In the 1962 Porritt report, the medical profession criticised the separation of the NHS into three parts - hospitals, general practice and local health authorities - and called for unification. 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. 1968-1977 In 1968, clinical and organisational optimism prevailed in the NHS, but financial stringency after the oil crisis of 1974 and the seven-day war reduced the growth rate of the NHS. Morale progressively receded until, by 1977, various factors had combined to bring the third decade to an unpromising close. Medical progress This said, medical progress continued, with advances including the increasingly wide application of endoscopy and the advent of CAT (Computerised Axial Tomography) scanning as the service's investigative armoury was extended. Transplants 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 example 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. GP's charter In general practice, the GP's charter was encouraging the formation of primary health care teams, new group practice premises and a rapid increase in the number of health centres. New hospitals As the result of the Government's Hospital Plan, new hospitals were providing more 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. Resources planning A planning system to distribute resources more fairly and to improve management was also needed. 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 Regional Health Authorities covering in theory all three parts of the NHSreplaced Regional Hospital Boards. A new tier of Area Health Authorities intervened in most places between the regions and district health authorities that managed the hospitals. Advantages: Health Authorities were to plan all services for first time and cooperate with local authorities, in theory a more effective system. Disadvantages: too complex & managerially driven The new system 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 too were alienated by proposals to reduce private practice within the service. 1978 -1987 The decade was characterised by the growing acknowledgement that clear financial bounds existed within which the NHS operated. It simply could no longer do everything that had become medically possible. The NHS had become a victim of its own success. New technology was being introduced and more people were being treated in more complex ways. This led to both rising expectations of the health service and an increasingly elderly population with all its attendant health needs. Beginning in 1978 with what was dubbed by the newspapers as 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. Labour launched an attempt to equalise the allocation of resources between different parts of the country (RAWP - the Resource Allocation Working Party) and this was continued by the Conservatives when they took office in 1979. 1982 - NHS restructuring was implemented to simplify the
organisation. There were: 1983-1985 - in the belief that consensus management had failed, general management was introduced following the Griffiths' Report & doctors were encouraged to become more involved with budget decisions. Clinical Advances Advances spanned all fields of NHS activity: primary health care was improving, although less so in the inner cities. Genetic engineering was yielding its first drug successes and magnetic resonance imaging was introduced. On the surgical side, the decade saw the advent of 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 common by the day. This was also the decade when the first cases of AIDS appeared, foreshadowing the world-wide epidemic. Performance indicators But as time passed, 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, and 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. Audit Closer examination of what the professionals were doing followed international concern about rising costs. People began to discuss audit of, for example, the results of anaesthesia and surgery. Community health 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 from the nursing angle of primary health care. 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 Internal market The NHS experienced the most significant cultural shift since its inception with the introduction of the so-called internal market, outlined in the 1989 White Paper, Working for Patients, and 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 arisen in the 1980s as a result of NHS resources being constrained while demand rose inexorably. They 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. 1990 NHS & Community Care Act/ 1991 NHS reforms Health Authorities would cease to run hospitals directly and 'purchase' care for their populations from 'providers' (hospitals / other health organisations). GPs offered 'fund holding budgets' to purchase some care. 1991 - 1995 all 'providers' became independent NHS Trusts which encouraged competing & inequalities. Before the 1990 Act a monolithic bureaucracy ran all aspects of the NHS. After the establishment of the internal market, '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 managements, 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 also given their own 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 (but far from all of them). Those who did not have budgets were controlled by health authorities, which bought health care '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 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 election of a new Government in May 1997 brought a new approach to the NHS. Pledging itself to abolition of the internal market, the new Government set out an approach which aimed to build on what had worked previously, but discarding what had failed. A new white paper issued by the Department of Health, "The New NHS. Modern. Dependable.", put forward a "third way" of running the service - based on partnership and driven by performance. The paper set out an approach which promised to "go with the grain" of efforts by NHS staff to overcome obstacles within the internal market, building on the moves which had already taken place in the NHS to move away from outright competition to a more collaborative approach. It presaged further major change. Once more there would be attempts to improve performance by changing structure. 1998 0nwards The current decade has seen a a wide and varying series of initiatives, financial and organizational changes, and alterations in policy. Of the greatest importance was the overdue recognition that the NHS was, and had for many years been, under funded. Following the Wanless Report, substantial new money began to flow into the service. Just as important were
Successive Secretaries of State, Frank Dobson, Alan Milburn and John Reid, brought forward a succession of white papers. Some were concerned with modifying features of the Conservative reforms that they did not like, for example fund holding. Private practice was first discouraged, and then made an important part of the new structure. Other White Papers made radical alterations in structure. Labour's traditional desire to look at health care from a community and public health perspective led it to produce policies on these topics. Alan Milburn and his successor began to encourage patient choice, and to alter financial flows, to try to increase efficiency and flexibility. Many new central bodies and regulatory authorities were established, the rationale for some being the improvement of the quality of care, for example NICE and the Health Commission. From 2004 a review of these "arms length bodies" was undertaken, to stem their proliferation
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