History of the National Health Service

Foundation

Dr A. J. Cronin's controversial novel The Citadel, published in 1937, had fomented extensive concern about the severe inadequacies of health care. The author's innovative ideas were not only essential to the conception of the NHS, but in fact, his best-selling novels are said to have greatly contributed to the Labour Party's victory in 1945.

The Emergency Hospital Service established in 1939 gave a taste of what a National Health Service might look like.

A national health service was one of the fundamental assumptions in the Beveridge Report which Arthur Greenwood, Labour's Deputy Leader and wartime Cabinet Minister with responsibility for post-war reconstruction had successfully pressed the cabinet to commission from economist and social reformer William Beveridge. The coalition government accepted this assumption in February 1943, and after a White Paper in 1944 it fell to Clement Attlee's Labour government to create the NHS as part of the "cradle to grave" welfare-state reforms in the aftermath of the Second World War. Aneurin Bevan, the newly appointed Minister of Health, was given the task of introducing the National Health Service.

Healthcare prior to the war had been an unsatisfactory mix of private, municipal and charity schemes. Bevan decided that the way forward was a national system rather than a system operated by local authorities. He proposed that each resident of the UK would be signed up to a specific General Practice (GP) as the point of entry into the system, building on the foundations laid in 1912 by the introduction of National Insurance and the list system for general practice. Patients would have access to all medical, dental and nursing care they needed without having to pay for it at the time.

Many doctors were initially opposed to Bevan's plan, primarily on the grounds that it reduced their level of independence. Bevan had to get them onside, as, without doctors, there would be no health service. Being a shrewd political operator, Bevan managed to push through the radical health care reform measure by dividing and cajoling the opposition, as well as by offering lucrative payment structures for consultants. On this subject he stated, "I stuffed their mouths with gold".

The Development of the Workforce in the NHS

The National Health Service was a major employer from its foundation. After nationalising Britain's voluntary and municipal hospitals, the new NHS took responsibility for 360,000 staff in England and Wales and a further 45,000 in Scotland. These included 9,000 full-time doctors (with thousands more consultants working in multiple part-time roles), 149,000 nurses and midwives (23,000 of whom were part-time), 128,000 ancillary staff (catering, laundry, cleaning and maintenance), 25,000 administrative and clerical staff, and 19,000 professional and technical staff, of whom the 2,800 physiotherapists, 1,600 laboratory technicians and 2,000 radiographers were the largest groups. This workforce would continue to grow throughout the 20th and 21st Centuries, overtaking the National Coal Board to become Britain's largest employer in 1961. By the end of the 1970s, the NHS had passed 1,000,000 staff and in 2015 was the world's fifth largest work organisation with 1.7m.

The Workforce

The NHS has long had one of Britain's most varied workforces, with employees from a diverse range of backgrounds in terms of class, occupation, gender, race and nationality. In the early NHS doctors were overwhelmingly men from middle and upper class backgrounds, and were often privately educated. Nurses in general hospitals were usually women and generally from a mixture of middle and working class origins. Men constituted a significant minority of nurses but were largely concentrated in mental hospitals, where their role historically had been more associated with manual labour, particularly the physical control of the patients. Professional organisations like the Royal College of Nursing tended to promote the idea that nurses were middle-class professionals, whilst trade unions encouraged nurses to see themselves as workers. Like nursing, ancillary tasks were also heavily gendered with portering and maintenance largely done by men, and laundry and cleaning largely women.

Increasing demand for health services led to a steady expansion in total staff numbers throughout the second half of the 20th Century and into the 21st century. However, NHS wage rates were usually comparatively low and hours often long and anti-social. Consequently, under conditions of full employment in the 1950s and 1960s the NHS experienced regular recruitment crises in virtually all categories of staff, particularly doctors and nurses in some peripheral provincial areas. One solution adopted by health authorities was to encourage married nurses to return to the workforce part-time. In Britain, historically many nurses expected to leave work after getting married and into the 1960s senior nursing posts were disproportionately likely to held by unmarried women. Nurse training also had a very high drop out rate, in part related to students leaving to get married (in addition to rejection by some of the strict discipline imposed on them). Part-time work brought many of these women back into the workforce and the NHS was a key site in the growth of this kind of work in post-war Britain, employing 65,000 part-time ancillary staff (mostly domestics) and 79,000 part-time nurses and midwives by 1967.

Alongside this rise in part-time work, hospitals increasingly looked overseas for staff, recruiting particularly heavily in Britain's colonies from the 1950s. By 1955, the Ministry of Health had official recruitment campaigns in 16 British colonies and former colonies. By 1965, there were more than 3,000 Jamaican nurses working in British hospitals and in 1977, 12% of student nurses and midwives came from overseas, 66% of them from the Caribbean, with substantial numbers also coming from the Philippines and South Asia. Large numbers of ancillary staff also migrated to fill NHS vacancies. Doctors were also recruited from across Britain's colonies and former colonies, particularly from India, Pakistan, Bangladesh and Sri Lanka. Doctors born and qualified overseas constituted 31% of all doctors in 1971. Nurses and doctors recruited by the NHS were often marginalised in job allocation. Early nurse migrants were often forced to re-validate their qualifications on arrival in Britain and instructed to take the less academic State Enrolled Nurse (SEN) training, rather than the more prestigious State Registered Nurse (SRN) qualification. SENs had worse pay and fewer promotion prospects. Similarly, employment discrimination often meant South Asian doctors were forced into less desirable posts in run-down provincial hospitals.

The NHS was also a site of expansion in new categories of scientific and technical workers. In 1967, the service employed 31,000 professional and technical staff connected with diagnosis and treatment, including audiologists, biochemists, dietitians, more than 9000 laboratory technicians, occupational therapists, physicists, physiotherapists, psychologists and radiographers. This category of staff had more than doubled in size ten years later, rising to 64,700 people or 6.5% of the total workforce. Although at the start of the period many of these roles had relatively informal career paths, with individuals sometimes recruited as assistants before training as technicians, from the 1970s onwards it became increasingly common for roles to have more formal training schemes and associated degree courses. Professional associations like the College of Occupational Therapists and the Association for Clinical Biochemistry and Laboratory Medicine became better organised and took a greater role both in regulating their professions and in collective bargaining with the Ministry of Health.

The 1980s saw further changes in the NHS' workforce. The Thatcher Government encouraged (and eventually forced) health authorities to put most ancillary services out for competitive tender, effectively outsourcing the jobs of those workers. This led to a substantial reduction in numbers, with 1/3 of ancillary posts disappearing between 1980 and 1987. Those that remained were largely employed by private agencies and no longer subject to national agreements or trade union collective bargaining. For nurses, the introduction of Project 2000 meant that their profession now centred around degree courses run by universities rather than nurse training courses run by teaching hospitals. This effectively removed student nurses from hospital workforces and helped raise the status of the profession. Much of the physical labour done by student nurses was now passed to a new category of health worker, the Health Care Assistant, a role than mirrors that of "auxiliary nurses" in the early NHS. The status of General Practitioners as outside contractors was largely confirmed by the market-based reforms introduced by the Thatcher, Major and Blair governments. The working lives of Hospital Doctors changed from the 1970s onwards, as career paths and work patterns became increasingly formalised. Set rules on hours were introduced in the 1970s and refined in the 1980s and 1990s to dramatically reduce the number of hours junior doctors were expected to contribute.

1948-72

Between 1948 and 1972 the NHS largely remained free of strikes, but nevertheless did experience some other industrial disputes. The foundation of the service was opposed by many doctors, particularly general practitioners, who feared that a state medical service would reduce their independence. Doctors expressed this opposition through their largest professional organisation, the British Medical Association, which held a number of ballots canvassing its members' (largely negative) opinions on arrangements for the new service. After a threat to boycott the new service, the BMA secured some concessions from Aneurin Bevan, the Minister of Health responsible for implementing the NHS Act. The BMA's intransigence did not stop the new health service coming into being, but did secure the right to be paid on a "capitation" basis (per patient) rather than on a set salary. More importantly for doctors the government's concessions established the conventional wisdom in the Ministry of Health that changes to the NHS were impossible without the consent of the medical profession, effectively giving doctors a "medical veto". Winning consent from physicians remained a problem for Health Ministers, who faced regular complaints, particularly over pay. In 1962 the government gave up control over doctors' pay to the independent Review Body on Doctors and Dentists Remuneration.

The first dispute involving nurses took place when student nurses opened their first NHS pay packets in July 1948. Despite having received a modest pay rise, an increase in National Insurance contributions meant their take home pay had gone down. Outraged students at St. Mary's Hospital, Plaistow, organised a protest rally and a march, threatening to resign en masse if their demands for better pay, shorter hours and general improvements in conditions weren't met. The march made headlines but won few concessions from the Ministry of Health. Complaints from student nurses about poor conditions, long hours and low pay were common for much of the post-war period. Up to the 1970s student nurses were responsible for as much as 75% of the physical labour on hospital wards and were often subject to intense disciplinary regimes both on the wards and in their private lives, with many student nurses living in strictly-supervised hospital nurses' accommodation.

The conflicts of 1947-48 were not very representative of the prevailing industrial relations culture in the NHS. Despite recurrent complaints about low pay and long hours, NHS staff were not prone to outbreaks of collective protest in the 1950s and 1960s. With the exception of an overtime ban and work-to-rule by administrative staff in 1957, organised by NALGO, and a go-slow by laundry workers in Carshalton in 1950, the NHS had little formal workplace conflict. Groups of miners, printers, dockers and car workers did stage a one-hour strike in solidarity with nurses' claims for pay increase in 1962, but the nurses' professional organisation the Royal College of Nursing repudiated their actions and generally preferred to trade on respectability rather than militancy. At that time the Rcn was reluctant to refer to itself as a trade union and nurses looking for more conventional workplace representation looked to the Confederation of Health Service Employees (COHSE) and the National Union of Public Employees (NUPE). The latter was generally strongest amongst ancillary staff and former amongst psychiatric nurses. Recognising the sensitive nature of hospital work both remained cautious regarding industrial action in the NHS until the 1970s, fearing that advocating action that might affect patients would drive away potential members. A combination of cautious organisations, staff who often saw their work as a vocation, and the domineering influence of doctors over the rest of the workforce, led to an "old colonial" system of industrial relations, structured largely by personal patronage and paternalism.

1972-1979

This largely broke down in the 1970s with unions like NUPE, COHSE and ASTMS recruiting large numbers of all categories of staff, and professional organisations like the RCN and BMA becoming more aggressive in collective bargaining. In December 1972, ancillary staff, the worst paid and most marginalised section of the workforce, organised mass demonstrations across the country with around 150,000 workers and supporters protesting poverty level wages. Action continued in March 1973 with ancillaries organising the NHS' first national strike. In the years to come other groups took action over similar issues, with nurses mounting a sustained campaign over pay in 1974 and radiographers following suit in 1975 under the slogan "no raise, no rays". Doctors also took strike action in 1975, with junior doctors walking out over long hours and inadequate pay for extra time and consultants taking action in defence of their right to place their private patients in NHS beds.

Although strikes in the NHS remained rare, changes in everyday industrial relations were more profound. The NHS saw a significant expansion in the number of workplace representatives in this period, sometimes forcing managers to consider the views of sections of the workforce, like the ancillary staff, who they had long ignored. This sometimes caused conflict between different groups. The "pay beds" dispute pitched nurses and ancillaries, who opposed private practice, against consultants, the direct beneficiaries of private practice. Other aspects of the upsurge in workplace activism were less controversial and all categories of staff were active in lobbying central government for better funding. The second half of the 1970s also saw a series of campaigns aimed at saving local hospitals, some of which involved "work-ins" where staff took over hospitals and continued to provide services after health authorities had shut them down. In November 1976, health workers took over Elizabeth Garrett Anderson Women's Hospital saving it from closure. The occupation of Hounslow Hospital in 1977 was less successful with the local authority forcibly removing the patients after 2 months.

By the end of the 1970s, industrial relations in the NHS were widely considered to be in crisis, with poor management and inadequate personnel procedures causing wikt:endemic conflict in a substantial minority of hospitals. The participation of large numbers of health workers in the events of 1978-79 Winter of Discontent was one reflection of this. Ambulance drivers and ancillary staff were both involved in strikes over pay in January 1979, reducing 1,100 hospitals to emergency services only and causing widespread disruption to ambulance services.

1980-2010

As in other sectors, industrial relations under the Thatcher Government continued to be conflictual. Successive Health Ministers looked to hold down pay in the public sector and to outsource ancillary staff where possible. Following the 1983 Griffiths Report, the NHS also tried to import a business model more similar to the private sector with professional managers taking over cost control, reducing the power of the medical profession. There were disputes over all of these policies. In 1982 there was another conflict over pay restraint involving ancillaries and nurses. Campaigning by NUPE, COHSE and RCN won an interim pay rise for nurses who were also granted their own independent pay review body, as the doctors had been 20 years earlier. The status and pay for registered nurses subsequently tended to improve, particularly when nurse education was shifted to university degree courses under Project 2000 in 1986.

Ancillary staff, in contrast, were increasingly marginalised during the 1980s. The Conservative Government put pressure on health authorities to outsource their catering, cleaning, laundry and maintenance services to private companies. Trade unions fought these policies, in some cases successfully, but many hospital services finally ended up in private hands, sometimes with companies who refused to recognise trade unions. Outsourcing dissipated some of the influence unions had built up during the 1970s and towards the end of decade increasingly occupied many shop stewards in detailed negotiations over grading and contract details rather than recruitment and organising.

Doctors' relationship with the government deteriorated during the 1980s. The advance of managerialism under Griffiths irritated many doctors, previously accustomed to a dominant role in NHS governance. By 1989 doctors were extremely hostile to government reforms and were active in lobbying against the implementation of the 1989 government white paper, Working for Patients, which introduced an internal market to the NHS. Their defence of public ownership and opposition to market-based reforms marked a substantial shift from doctors' original opposition to the NHS, reflecting how far doctors' mindsets had changed in relation to state medicine.

Relations between the NHS and the government were generally much improved under the Blair Government. Substantial investment in staff and new facilities were appreciated by many nurses and doctors, although there were concerns about the introduction of private sector suppliers, the use of public-private partnerships to fund much investment and the development of an intensive culture of achievement targets. There was also no attempt to reverse the outsourcing of ancillary services, something health service unions linked to recurrent crises over hospital cleanliness.

Film and Television

Film and television have played important roles in forming cultural understandings of the National Health Service. Hospitals and GP practices, in particular, have been repeatedly dramatised as locations that lend themselves to displaying wider life stories - love, birth, ageing, dying, friendships and feuds. The NHS has also been an important topic within public health, often forming a central part in public information films about health and wellbeing.

Public Information Films

From the launch of the National Health Service in 1948, film was used as an important cultural tool for spreading governmental health messages. During the Second World War, film grew in popularity as a way for the British government to keep citizens informed, impart advice and help raise morale on the Home Front. This commitment to producing public information films continued after the end of the War in 1945 with the newly formed Central Office of Information taking responsibility for the production of these films. This ensured that the launch of the NHS was accompanied by a number of public information films shown nationwide during Spring and Summer 1948. Three main films were produced - Charley: You're Very Good Health (Halas & Batchelor, 1948), Here's Health (Douglas Alexander, 1948) and Doctor's Dilemma (Unknown, 1948). These films introduced the NHS in three distinct ways with Charley: You're Very Good Health focused on explaining how the NHS would work upon its launch in a light-hearted manner with Charley standing in as the 'everyman' within the film's narrative. The film used a series of 'suppose' scenarios to outline how the new NHS system would work in practice in comparison to the pre-NHS health care system. Here's Health instead employed the narrative techniques of melodrama to dramatise one family's response to a household accident and the sudden need for medical attention during the Christmas of 1947. It uses flash-forwards to show how these type of care and the cost of it will be altered by the introduction of the NHS. The third main film used to advertise the launch of the NHS was a much briefer, information short, centred on the use of voice-over and a combination of still and moving images to encourage members of the public to register with an NHS GP before the National Health Service Act came into force on the 5th of July 1948.

Popular Films and Television

Within a few years of the NHS, popular fictional films were beginning to focus on the NHS as a location for dramatic narratives. Films such as White Corridors (Pat Jackson, 1951) and Mandy (Alexander MacKendrick,1952), shown within the early years of the NHS, showed day-to-day life in an NHS hospital as well as dealing with specific single-issue topics such as deafness within postwar British society. The Doctor series, starring firstly Dirk Bogarde and later Leslie Philips, took a comedic look at the antics of a young doctor in an NHS hospital and the Carry on ... comedies, Carry on Nurse (Gerald Thomas,1959), Carry on Doctor (Gerald Thomas, 1967) and Carry on Matron (Gerald Thomas, 1972) also used comic situations within the NHS hospital to poke fun at both the NHS as an institution and the capers of doctors, nurses and patients alike. From the late 1950s, the NHS also became an important subject within the wider history of British soap operas. Emergency Ward 10 was first broadcast in 1957 on ITV and ran until 1967 and followed the life and loves of the staff and patients of the fictionalised Oxbridge General. ITV later followed this up with General Hospital which borrowed much from Emergency Ward 10 in terms of its themes and focus. The idea of a medical hospital as a suitable and popular setting for a soap opera continued to take root in the 1980s. Casualty, set in an A&E department, was first broadcast in 1986 and has since become the longest running medical drama in the world. At a time when controversy over the NHS was high on the public agenda, Paul Unwin and Jeremy Brock began their proposal for Casualty by declaring that ‘In 1948 a dream was born: a National Health Service. In 1985 the dream is in tatters.’ This politicised agenda remained in evidence during the first three series of the Casualty, with the programme showing how those who fictionally worked for the NHS were also dissatisfied with the new direction of the Service. During the 1990s television began more overtly showing medial practitioners who were critical or cynical of the NHS. In particular, Cardiac Arrest was broadcast on BBC 1 utilised this type of cynicism within its narrative plots. Television has also forged a place for the NHS within reality television programming. In particular 24 Hours in A&E and One Born Every Minute have adopted medical documentary formats to show the inner workings of particular NHS hospital departments. Fly-on-the-wall footage is interweaved with interviews with patients, staff and relatives as they give their perspectives on the medical cases shown in each episode.

Comedy

Comedy films, books, and cartoons have been produced about the NHS. These have shaped as well as reflected how people think about this institution.

Cartoons

There have been lots of cartoons about the NHS throughout the institution's history. Even before the NHS was launched, there were cartoons documenting the political debates about its form. In the 1940s, the British Medical Association was opposed to the idea of doctors becoming state employees on fixed salaries. Cartoonists made their opinions about this conflict known. David Low published a cartoon in the Evening Standard on the 14 December 1944 showing Charles Hill, the BMA Secretary, being examined by a doctor. The doctor states, 'Don't be alarmed. Whatever's the trouble, you're not going to die from enlargement of the social conscience.'

When the NHS was launched, many cartoons showed how people responded to the NHS being free at the point of access. One cartoon, published in 1951 by Antonia Yeoman, portrayed women in a doctor's waiting room, one of whom stated that she had seen eighteen doctors and seven psychiatrists. Eventually, she had been diagnosed with a 'deep-seated guilt about getting things free from the National Health Service.' Analysing cartoons about health featured in Punch magazine from 1948, the historian Bernard Zeitlyn argues that they 'centred on the bonanza of free spectacles, beards and trips abroad' that the NHS would bring. Cartoonists also portrayed public excitement about the availability of free wigs on the NHS. In one such example, from January 1949, cartoonist Joseph Lee showed an irate man chasing a child, asking, 'Who's been practising Home Perms on my free National Health Service wig?'

Cartoons were also used to criticise NHS policy. From 1948, Zeitlyn also found cartoons portraying concern about the 'bureaucratic consequences' of the NHS. The number of critical cartoons about NHS policy increased from the 1960s, as the NHS faced cuts, and the satire movement emerged in Britain. In December 1960, cartoonist Victor Weisz drew an image for the Evening Standard showing Minister for Health Enoch Powell as a surgeon covered in blood, accusing him of making too many cuts. Other cartoonists suggested that too much was being spent on the NHS. For example, in the Daily Mail in 1968, John Musgrave-Wood drew a man to portray the NHS, who was wearing a dunce's cap and being fed 'Defence Cuts'. Many cartoons have been very interested in portraying NHS staff, both their lives and industrial conflict. The cartoonist Carl Giles, who often drew for the Daily Express, was very interested in drawing nurses in particular. Historian Jack Saunders has argued that Giles' presentation shifted from presenting nurses from 'caring and sexualised' to 'bolshie and assertive'. Giles sent a cartoon of nurses stealing peas from patients directly to the East Suffolk Nurses League. On the cartoon, Giles wrote 'with deepest sympathy', referring to the cutting of food allowances.

Everyday humour

Patients and staff have made jokes about the NHS to one another, on a daily basis, throughout time. However, it is very hard to locate and to understand these. Sometimes 'everyday' jokes about the NHS are mentioned in passing in newspaper coverage. For example, one letter published by the Daily Mail in October 1988 described the experiences of an NHS secretary who 'seethed with anger' when hearing a consultant joke about spending his days on a golf course. The People's History of the NHS project at the University of Warwick has collected more such memories on its website, and invites contributions for more.

Researchers and clinicians hope that humour and laughter may be able to be used to improve human health. The term 'gelotology', to denote the study of laughter, was created in 1964 by Edith Trager and W. F. Fry. One experiment from 2011, led by researchers at the University of Oxford, suggested that watching comedy videos may raise people's pain thresholds, when watched in a group. This effect did not hold when videos were watched alone, or if research participants watched videos such as scenes of nature. In 2003, the artist Nicola Green and film-maker Lara Agnew created a 'laughter booth' at the Royal Brompton Hospital. In this booth, patients and staff could watch videos of people laughing. The idea of laughter as healing has also influenced language, through the phrase 'laughter is the best medicine'.