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History of the National Health Service

The National Health Service (NHS) is the collective name given to the four public health services of England, Scotland, Wales and Northern Ireland as well as being the name of England's NHS. It was created in England and Wales by the National Health Service Act 1946, and in Scotland by the National Health Service (Scotland) Act 1947. 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.

Prehistory

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 teaching hospitals and charity hospitals, such as the Royal Free Hospital. Some local authorities operated local hospitals for local ratepayers (under a system originating with the Poor Law). Systems of health insurance usually consisted of private schemes such as Friendly 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 who participated in the scheme thus had a 'panel' of those 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 some working records in primary care are at least partially computerised). This imperfect scheme only covered certain trades and occupations, and was known as 'Lloyd George's Ambulance Wagon'. Moreover, due to cuts during the 1930s, many were unable to obtain treatment.

In Scotland, the Highlands and Islands Medical Service provided state funded healthcare to a population covering half of Scotland's landmass from its launch in 1913 until the creation of NHS Scotland in 1948. Though treatment was not free, fees were set at minimal levels and people could still get treated even if the were unable to pay.

The publication of Dr. A. J. Cronin's controversial 1937 novel, The Citadel, drew much-needed attention to the inequities of health care, as did the 1938 film version.

Birth of the NHS

In the aftermath of the Second World War, Clement Attlee's Labour government created the NHS, based on the proposals of the Beveridge Report

, prepared in 1942. A White Paper was published in 1943 and was followed by considerable debate, and resistance organised by the British Medical Association, though in the final BMA ballot in May 1948, GPs and hospital doctors in Scotland voted in favour while their counterparts in England remained against the new service. The structure of the NHS in England and Wales was established by the National Health Service Act 1946 (1946 Act) and in Scotland by the National Health Service (Scotland) Act 1947, with the new arrangements throughout the UK being launched on 5 July 1948. This was driven by health and housing minister Aneurin Bevan, though he himself had responsibility for England and Wales, with the Secretary of State for Scotland having responsibility for NHS Scotland. The founding principles of the NHS called for its funding out of general taxation and not through national insurance.

Services would henceforth be provided by the same doctors and the same hospitals, but:

services were provided free at the point of use;
services were financed from central taxation;
everyone was eligible for care (even people temporarily resident or visiting the country).

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:

Hospital Services - 14 Regional Hospital Boards were created in England and Wales to administer the majority of hospital services. Beneath these were 400 Hospital Management Committees which administered hospitals. Teaching hospitals had different arrangements and were organised under Boards of Governors.
Primary Care - GPs were independent contractors (that is they were not salaried employees) and would be paid for each person on their list. Dentists, opticians and pharmacists also generally provided services as independent contractors. Executive Councils were formed and administered contracts and payments to the contractor professions as well as maintaining lists of local practitioners and dealing with patient complaints.
Community Services - Maternity and Child Welfare clinics, health visitors, midwives, health education, vaccination & immunisation and ambulance services together with environmental health services were the responsibility of local authorities. This was a continuation of the role local government had held under the Poor Law.

By the 1950s, spending on the NHS was exceeding what had been expected, leading to the introduction of a one-shilling charge for prescriptions and a £1 charge for dental treatment, in 1952; an exception to the NHS being free at the point of use. The 1950s also 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. A more equitable distribution of GPs was emerging as was the concept of the primary health care team. The period also saw a growth in health centres. More mental health patients were discharged back into the community and Enoch Powell, who was Minister of Health in the early 1960s, predicted that many of the large mental health institutions would close within ten years. Prescription charges were abolished in 1965 and reintroduced in 1968.Concern also continued to grow about the structure of the NHS and weaknesses of the tripartite system.

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.

Development of the NHS (England) and NHS Wales since 1970

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.

Through the 1970s and 1980s, it became clear that the NHS would never get the resources necessary to provide unlimited access to the latest medical treatments, especially in the context of an ageing population. This led to the beginning of a major process of reform, starting about 1980, which is still continuing in 2006.

Reforms under the Thatcher government

The 1980s saw the introduction of modern management processes (General Management) 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 oposition from the BMA, who wanted a pilot study or the "reforms" in one region, the untried untested 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 independent trusts, which encouraged competition but also increased local differences.

The Blair government

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 9th 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 renounced this direction. He pursued measures to strengthen the internal market as part of his plan to "modernise" the NHS.

Driving these reforms have been a number of factors. They include 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 have included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous clinical and corporate governance. In addition medical training has undergone an unsuccessful restructuring which was so badly managed that the Secretary of State for Health was forced to apologise publicly. MMC is now being revised but its flawed implementation has left the NHS with significant medical staffing problems which are unlikely to be resolved before 2009. Some new services have been developed to help manage demand, including NHS Direct. A new emphasis has been given to staff reforms, with the Agenda for Change agreement providing harmonised pay and career progression. These changes have, however, given rise to controversy within the medical professions, the media and the public.

The Blair Government, whilst leaving services free at point of use, has encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals have been built (or rebuilt) by private sector consortia; hospitals may have both medical services (such as "surgicentres"), and non-medical services (such as catering) provided under long-term contracts by the private sector. A study by a consultancy company which works for the Department of Health shows that every £200 million spent on privately financed hospitals will result in the loss of 1000 doctors and nurses. The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced.

In 2005, surgicentres (ISTCs) treated around 3% of NHS patients (in England) having routine surgery. By 2008 this is expected to be around 10%. NHS Primary Care Trusts have been given the target of sourcing at least 15% of primary care from the private or voluntary sectors over the medium term.

As a corollary to these intitiatives, the NHS has been required to take on pro-active socially "directive" policies, for example, in respect of smoking and obesity.

The NHS has also encountered significant problems with the 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.