In the beginning...
The majority of the population is too young to know what life was like before the NHS. It has always been there. On its 60th anniversary David Hurst traces the start of Britain’s biggest social experiment
Any discussion of the Good Old Days usually founders when medical matters are raised.
Rudimentary medical knowledge and negligible facilities almost always counter any fond thoughts of bucolic rural idylls. There have always been doctors but they needed to earn a living and that came from the affluent.
As part of a community they may have helped those who could not pay – or they may not. Hospitals were few and far between and usually not very nice.
Even in Victorian times some believed that access to health care was part of the structure of a civilized society.
In the First World War the army medical services had shown the benefits of organisation and transport and in the 1930s local authorities had taken over poor law hospitals that became municipal hospitals. Most required major renovations.
The quality varied widely from town to town, and country areas were usually poorly served
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.
A key was the report written in 1942 by the economist William Beveridge and his committee of civil servants that looked at Britain’s social insurance and allied services and made recommendations.
In a survey taken a fortnight after the publication the British Institute of Public Opinion found that 95 per cent, an amazing figure for a government document, had heard of the report and that ‘there was overwhelming agreement that the plan should be put into effect’.
Although often quoted as a prime source for the setting up of a National Health Service, only five of the Beveridge Report’s 300 pages deal with the health services.
There was much discussion though little was done until the Labour landslide election victory at the end of the war.
The country was exhausted by the war and the infrastructure was falling apart. Austerity ruled and there was rationing for most things. People were used to making do and coping with problems as they arose.
The new government embarked on major social changes by nationalising large swathes of industry and services and, in 1948, it was the turn of the health services.
Aneurin Bevan, the Minister of Health, opted for nationalising all the health services although others wanted the option of local authority control.
Immediately on July 5th 1948 the only thing that changed was that the service was free. It was still the same service and had to fight for its resources with the other parts of the economy that also had huge and vital needs.
The NHS was based on principles unlike anything that had gone before in health care. Few other countries followed this pathway outside the communist block, as others tended to rely on insurance-based schemes.
It was financed almost completely from central taxation. The rich paid more than the poor for comparable benefits and Bevan regarded this as crucial. Everyone was eligible for care.
Care was entirely free at the point of need, although prescription charges and dental charges were subsequently introduced.
The new service run by the Minister was "tripartite" – there were hospital services, then GPs, dentists, opticians and pharmacists were treated separately, and finally there were the local authority health services.
The municipal and the voluntary hospitals were brought together in a single system in which all staff were salaried. Organisation was based upon 14 Regional Hospital Boards that oversaw local hospital management committees. The teaching hospitals were directly responsible to the Ministry of Health 'for they served the nation, not the locality’.
Family doctors, dentists, opticians and pharmacists were self-employed under a contract for services from an Executive Council. The family doctor acted as gatekeeper to the rest of the NHS, referring patients where appropriate to hospitals or specialist treatment and prescribing medicines and drugs.
Local authority health services were managed by a Medical Officer of Health, who ran some clinics, provided community nurses to support the family doctors and oversaw the control of infectious diseases. There was a school dental service and a special priority service for expectant and nursing mothers and young children.
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.
There were savings as better treatments and techniques reduced the time patients were in hospital but technology and new drugs have increased costs more quickly. 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.
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 of the Guillebaud Committee to 'enquire into the cost of the National Health Service'.
The report in 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.
The services record 'was one of real achievement' and both main political parties now accepted the need for it.
This was the first major review of the NHS and its workings and such reviews have continued ever since.
Today the NHS is huge. With 1.5 million staff it is the fourth largest employer in the world after the Chinese Army, Wal-Mart supermarkets and the Indian Railways.
Its annual expenditure of £92 billion is, at nearly 15 per cent, the biggest item in the total UK government budget of £618 billion. With figures like these it is inevitable that the politicians will continually want to review and change. And they do.
