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The National Health Service in England was created by the National Health Service Act 1946. Responsibility for the NHS in Wales was passed to the Secretary of State for Wales in 1969, leaving the Secretary of State for Social Services responsible for the NHS in England alone.
Contents
Background
Dr Benjamin Moore, a Liverpool physician, in 1910 in The Dawn of the Health Age was probably the first to use the words ‘National Health Service’. He established the State Medical Service Association which held its first meeting in 1912 and continued to exist until it was replaced by the Socialist Medical Association in 1930.
Before the National Health Service was created in 1948, patients were generally required to pay for their health care. Free treatment was sometimes available from Voluntary Hospitals. Some local authorities operated hospitals for local ratepayers (under a system originating with the Poor Law). The London County Council (LCC) on 1 April 1930 took over from the abolished Metropolitan Asylums Board responsibility for 140 hospitals, medical schools and other medical institutions. The Local Government Act 1929 allowed local authorities to run services over and above those authorised by the Poor Law and in effect to provide medical treatment for everyone. By the outbreak of the Second World War, the LCC was running the largest public health service in Britain.
Dr A. J. Cronin's controversial novel The Citadel, published in 1937, had fomented extensive 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.
Systems of health insurance usually consisted of private schemes such as Friendly societies or Welfare societies. Under the National Insurance Act 1911, introduced by David Lloyd George, a small amount was deducted from weekly wages, to which was added contributions from the employer and the government. In return for the record of contributions, the workman was entitled to medical care (as well as retirement and unemployment benefits) though not necessarily to the drugs prescribed. To obtain medical care, he registered with a doctor. Each doctor in General Practice who participated in the scheme thus had a 'panel' of those who have made an insurance under the system, and was paid a capitation grant out of the fund calculated upon the number. Lloyd George's name survives in the "Lloyd George envelopes" in which most primary care records in England are stored, although today most working records in primary care are at least partially computerised. This imperfect scheme only covered workers who paid their National Insurance Contributions and was known as 'Lloyd George's Ambulance Wagon'. Most women and children were not covered.
Foundation
Lord Dawson was commissioned in 1919 by Lord Addison, the first British Minister of Health to produce a report on "schemes requisite for the systematised provision of such forms of medical and allied services as should, in the opinion of the Council, be available for the inhabitants of a given area". An Interim Report on the Future Provision of Medical and Allied Services was produced in 1920, though no further report ever appeared. The report laid down plans for a network of Primary and Secondary Health Centres, and was very influential in subsequent debates about the National Health Service. However the fall of the Lloyd George government prevented any implementation of those ideas at that time.
The Labour Party in 1932 accepted a resolution moved by Somerville Hastings MP calling for the establishment of a State Medical Service and in 1934 the Labour Party Conference at Southport unanimously accepted an official document on a National Health Service.
Prior to the Second World War there was already consensus that health insurance should be extended to the dependants of the wage-earner, and that the voluntary and local authority hospitals should be integrated. A British Medical Association (BMA) pamphlet, "A General Medical Service for the Nation" was issued along these lines in 1938. However, no action was taken due to the international crisis. During the war, a new centralised state-run Emergency Hospital Service employed doctors and nurses to care for those injured by enemy action and arrange for their treatment in whichever hospital was available. The existence of the service made voluntary hospitals dependent on the Government and there was a recognition that many would be in financial trouble once peace arrived. The need to do something to guarantee the voluntary hospitals meant that hospital care drove the impetus for reform.
In February 1941 the Deputy Permanent Secretary at the Ministry of Health recorded privately areas of agreement on post-war health policy which included "a complete health service to be available to every member of the community" and on 9 October 1941, the Minister of Health Ernest Brown announced that the Government proposed to ensure that there was a comprehensive hospital service available to everyone in need of it, and that local authorities would be responsible for providing it. The Medical Planning Commission set up by the professional bodies went one stage further in May 1942 recommending (in an interim report) a National Health Service with General Practitioners working through health centres and hospitals run by regional administrations. The Beveridge Report of December 1942 included this same idea.
Developing the idea into firm policy proved difficult. Although the BMA had been part of the Medical Planning Commission, at their conference in September 1943 the association changed policy to oppose local authority control of hospitals and to favour extension of health insurance instead of GPs working for state health centres. When Health Minister Henry Willink prepared a white paper endorsing a National Health Service, it was attacked by Brendan Bracken and Lord Beaverbrook and resignations were threatened on both sides. However the Cabinet endorsed the White Paper which was published in 1944. This White Paper includes the founding principles of the NHS: it was to be funded out of general taxation and not through national insurance, and services would be provided by the same doctors and the same hospitals, but:
Willink then set about trying to assuage the doctors, a job taken over by Aneurin Bevan in Clement Attlee's Labour Party government after the war ended. Bevan quickly came to the decision that the 1944 white paper's proposal for local authority control of voluntary hospitals was not workable, as the local authorities were too poor and too small to manage hospitals. He decided that "the only thing to do was to create an entirely new hospital service, to take over the voluntary hospitals, and to take over the local government hospitals and to organise them as a single hospital service". This structure of the NHS in England and Wales was established by the National Health Service Act 1946 which received Royal Assent on 6 November 1946. Bevan encountered considerable debate and resistance from the BMA who voted in May 1948 not to join the new service, but brought them on board by the time the new arrangements launched on 5 July 1948.
Development of the NHS in England and Wales, 1948–1969
The original structure of the NHS in England and Wales had three aspects, known as the tripartite system:
The new service instantly became Britain's 3rd largest employer with around 364,000 staff across England and Wales. These included 9,000 full-time doctors, 19,000 professional and technical staff (including 2,800 physiotherapists, 1,600 laboratory technicians and 2,000 radiographers), 25,000 administrative and clerical staff, 149,000 nurses and midwives (23,000 of whom were part-time), and 128,000 ancillary staff (catering, laundry, cleaning and maintenance).
By the beginning of the 1950s, spending on the NHS was exceeding expectations, leading in 1952 to the introduction of a one-shilling charge for prescriptions and a £1 charge for dental treatment; these were exceptions to the NHS being free at the point of use. Political concerns about spiralling NHS costs later receded in the wake of the 1956 Guillebaud Report, which praised the "responsible attitude among hospital authorities” towards the “efficient and economical” use of public funds. The 1950s saw the planning of hospital services, dealing in part with some of the gaps and duplications that existed across England and Wales. The period also saw growth in the number of medical staff and a more even distribution of them with the development of hospital outpatient services. By 1956, the NHS was stretched financially and doctors were disaffected, resulting in a Royal Commission on doctors' pay being set up in February 1957. The investigation and trial of alleged serial killer Dr John Bodkin Adams exposed some of the tensions in the system. Indeed, if he had been found guilty (for, in the eyes of doctors, accidentally killing a patient while providing treatment) and hanged, the whole NHS might have collapsed. The Mental Health Act of 1959 also significantly altered legislation in respect of mental illness and reduced the grounds on which someone could be detained in a mental hospital.
The 1960s have been characterised as a period of growth. Prescription charges were abolished in 1965 and reintroduced in 1968. New drugs came to the market improving healthcare, including polio vaccine, dialysis for chronic renal failure and chemotherapy for certain cancers were developed, all adding to upfront costs. Health Secretary Enoch Powell undertook three initiatives:
Concern continued to grow about the structure of the NHS and weaknesses of the tripartite system. Powell agreed the creation of a Royal Commission on doctors’ pay, which resulted in a statutory review body. Further development came in the form of the Charter of General Practice, negotiated between new Health Minister Kenneth Robinson and the BMA, that provided financial incentives for practice development. This resulted in the concept of the primary health care in better housed and better staffed practices, stimulating doctors to join together and the development of the modern group practice.
In 1969, responsibility for the NHS in Wales was passed to the Secretary of State for Wales from the Secretary of State for Health who was thereafter just responsible for the NHS in England.
After the publication by the British Medical Journal on 24 December 1949 of University of Cambridge consultant paediatrician Douglas Gairdner's landmark paper detailing the lack of medical benefit and the risks attached to non-therapeutic (routine) circumcision, the National Health Service took a decision that circumcision would not be performed unless there was a clear and present medical indication. Both the cost and the non-therapeutic, unnecessary, harmful nature of the surgical operation were taken into account.
1970s and early 1980s
The NHS in England was reorganised in 1974 to bring together services provided by hospitals and services provided by local authorities under the umbrella of Regional Health Authorities, with a further restructuring in 1982. The 1970s also saw the end of the economic optimism which had characterised the 1960s and increasing pressures coming to bear to reduce the amount of money spent on public services and to ensure increased efficiency for the money spent.
Thatcher government reforms
In the 1980s, Thatcherism represented a systematic, decisive rejection and reversal of the Post-war consensus, whereby the major political parties largely agreed on the central themes of Keynesianism, the welfare state, nationalized industry, public housing and close regulation of the economy. There was one major exception: the National Health Service, which was widely popular and had wide support inside the Conservative Party. Prime Minister Margaret Thatcher promised Britons in 1982, the NHS is "safe in our hands."
In the 1980s modern management processes (General Management) were introduced in the NHS to replace the previous system of consensus management. This was outlined in the Griffiths Report of 1983. This recommended the appointment of general managers in the NHS with whom responsibility should lie. The report also recommended that clinicians be better involved in management. Financial pressures continued to place strain on the NHS. In 1987, an additional £101 million was provided by the government to the NHS. In 1988 the then Prime Minister, Margaret Thatcher, announced a review of the NHS. From this review and in 1989, two white papers Working for Patients and Caring for People were produced. These outlined the introduction of what was termed the "internal market", which was to shape the structure and organisation of health services for most of the next decade. In spite of intensive opposition from the BMA, who wanted a pilot study or the reforms in one region, the internal market was introduced.
In 1990, the National Health Service & Community Care Act (in England) defined this "internal market", whereby Health Authorities ceased to run hospitals but "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients. The "providers" became NHS trusts, which encouraged competition but also increased local differences.
Blair government reforms
These innovations, especially the "fund holder" option, were condemned at the time by the Labour Party. Opposition to what was claimed to be the Conservative intention to privatise the NHS became a major feature of Labour's election campaigns.
Labour came to power in 1997 with the promise to remove the "internal market" and abolish fundholding. In a speech given by the new Prime Minister, Tony Blair, at the Lonsdale Medical Centre on 9 December 1997, he stated that:
The White Paper we are publishing today marks a turning point for the NHS. It replaces the internal market with "integrated care". We will put doctors and nurses in the driving seat. The result will be that £1 billion of unnecessary red tape will be saved and the money put into frontline patient care. For the first time the need to ensure that high quality care is spread throughout the service will be taken seriously. National standards of care will be guaranteed. There will be easier and swifter access to the NHS when you need it. Our approach combines efficiency and quality with a belief in fairness and partnership. Comparing not competing will drive efficiency.
However, in his second term Blair pursued measures to strengthen the internal market as part of his plan to "modernise" the NHS.
Driving these reforms were a number of factors including the rising costs of medical technology and medicines, the desire to increase standards and "patient choice", an ageing population, and a desire to contain government expenditure. Since the National Health Services in Wales, Scotland and Northern Ireland are not controlled by the UK government, these reforms have increased the differences between the National Health Services in different parts of the United Kingdom. (See NHS Wales and NHS Scotland for descriptions of their developments).
Reforms included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of a modified form of fundholding - "practice-based commissioning", closure of surplus facilities and emphasis on rigorous clinical and corporate governance. In addition Modernising Medical Careers medical training had an unsuccessful restructuring which was so badly managed that the Secretary of State for Health was forced to apologise publicly. It was then revised but its flawed implementation left the NHS with significant medical staffing problems. Some new services were developed to help manage demand, including NHS Direct. A new emphasis was given to staff reforms, with the Agenda for Change agreement providing harmonised pay and career progression. These changes gave rise to controversy within the medical professions, the media and the public.
The Blair Government, whilst leaving services free at point of use, encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals were built (or rebuilt) by private sector consortia; hospitals may have both medical services (such as Independent Sector Treatment Centre (ISTC or "surgicentres"), and non-medical services (such as catering) provided under long-term contracts by the private sector. A study by a consultancy company which worked for the Department of Health showed that every £200 million spent on privately financed hospitals resulted in the loss of 1000 doctors and nurses. The first PFI hospitals contained some 28 per cent fewer beds than the ones they replaced.
In 2005, surgicentres treated around 3 per cent of NHS patients (in England) having routine surgery. By 2008 this was expected to be around 10 per cent. NHS Primary Care Trusts have been given the target of sourcing at least 15 per cent of primary care from the private or voluntary sectors over the medium term.
As a corollary to these initiatives, the NHS was required to take on pro-active socially "directive" policies, for example, in respect of smoking and obesity.
The NHS encountered significant problems with the information technology (IT) innovations accompanying the Blair reforms. The NHS's National Programme for IT (NPfIT), believed to be the largest IT project in the world, is running significantly behind schedule and above budget, with friction between the Government and the programme contractors. Originally budgeted at £2.3 billion, present estimates are £20–30 billion and rising. There has also been criticism of a lack of patient information security. The ability to deliver integrated high quality services will require care professionals to use sensitive medical data. This must be controlled and in the NPfIT model it is, sometimes too tightly to allow the best care to be delivered. One concern is that GPs and hospital doctors have given the project a lukewarm reception, citing a lack of consultation and complexity. Key "front-end" parts of the programme include Choose and Book, intended to assist patient choice of location for treatment, which has missed numerous deadlines for going "live", substantially overrun its original budget, and is still (May 2006) available in only a few locations. The programme to computerise all NHS patient records is also experiencing great difficulties. Furthermore, there are unresolved financial and managerial issues on training NHS staff to introduce and maintain these systems once they are operative.
Between 2004/5 and 2013/4 NHS output increased considerably. Hospital admissions increased by 32%, outpatient attendances by 17%, primary care consultations by 25% and community care activity by 14%. Hospital death rates reduced, especially in stroke. At the same time there was an increase in wages of 24% and an increase of 10% in the number of staff and increases in the use of equipment and supplies. As a whole NHS output increased by 47% and inputs by 31%, an increase in productivity of 12.86% during the period, or 1.37% per year.
Coalition and Cameron government reforms
The return of a Conservative-led government in 2010 coincided with another deterioration in industrial relations. The introduction of further private sector involvement in the Health and Social Care Act 2012 provoked mass demonstrations led by health workers, and some NHS workers also participated in a national strike over pay restraint in 2014. 2016 also saw major industrial action by junior doctors, protesting at the imposition of a new contract aiming to extend weekend working.