The National Health Service
NHS history has been in the public eye of late and as we are approaching its
seventieth anniversary, it will get more airtime. To understand NHS history,
you need to understand the
politics of the time of its birth.
The NHS has now been in existence for nearly 70 years, it came into being officially on July 5th, 1948, it had been put to the test before its launch, from the years 1939 - 1945 during the second world war years.
Bevan has been credited for its formation and rightly so, action is better than talk. But in all honesty, which ever political party came to power, would have likely brought it in at some stage, although not as quickly and not completely free.
To know the National Health Service fully, you have to understand the conditions that brought about its formation.
The peace of mind we have knowing that the NHS will be there if anything was to happen to our loved ones or ourselves is taken for granted. We believe it is our fundamental right to receive free treatment, this has not always the case, so this is a brief outline of the history of the health service.
The first hospital in Britain were given to us by the Romans in the form of Valetudinarians.
In the 14th century St Bartholomew's was founded. St Bart’s as it was known was found by a monk, Rahere who was at one time, court jester to Henry 1, and was one of the two great hospitals.
St Thomas's is the other great London hospital that was founded in the 10th century. Originally it was the sick house that belonged to the church of St Mary Overie and was founded during the reign of William 11 (Rufus), and as he died in 1100, makes it the first. It was renamed St Thomas’ in 1173, after the Archbishop of Canterbury, Thomas a Becket was murdered in 1170.
This hospital is in fact the oldest in London.
Initially these institutions catered for the poor and anyone who was in dire need, as time went on however the rich were the most common residents within these hospitals.
In 1572, an Elizabethan Act made provision for the punishment of beggars and the relief of the impotent poor. 1
The chaos that was wrought by the reformation of the British Church system, which included the Dissolution and in most cases destruction of the Monasteries, brought with it a rapid decline in moral values.
Prior to the Reformation the communities of Britain were in most cases religious, following the example set by Christ in relation to the poor and needy. It was the case that they adhered to the Bible instructions given to all Christians as quoted in the book of Matthew, Chap 25. (see quote below)
There was a vacuum left in Elizabethan society when the monasteries and convents were closed or destroyed, the biggest loser was the poor, having nowhere to turn too. The English had firmly placed the responsibility of these people firmly on the shoulders of the Elizabethan government.
Lord Burghley was particularly concerned that Starving and homeless people were driven to desperate acts endangering society in general and Law and Order in particular. “Then the King will say to those on his right, 'Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. For I was hungry, and you gave me something to eat, I was thirsty, and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick, and you looked after me, I was in prison and you came to visit me. “2
The Poor LawThe 1574 Act in Scotland followed the English 1572 act. In England, the law was superseded in 1598, but the 1574 Act remained in force in Scotland till 1845. 1598/1601 The Elizabethan Poor Law was a national Act for England and Wales. This put in place the following: A compulsory poor rate The creation of "overseers" of relief Provision for "setting the poor on work". The provision for hospital treatment 1839-1840 A Poor Law Commission enquiry identified disease as a major cause of pauperism.
1842 Edwin Chadwick, the secretary of the Poor Law Commission, and one of the main authors of the 1834 report, wrote a Report on the Sanitary Condition of the Labouring Population of Great Britain, identifying sanitation as a principal issue.
1848 Public Health Act. This was permissive - i.e., a law which allowed authorities to do something, rather than compelling them - which made it possible to build sewers.
The Act excluded London altogether which was strange as it was a very densely populated city at that time. The construction of sewers was opposed on the grounds of cost; the General Board of Health was abolished in 1853, and the Act was repealed in 1858.
1866 Sanitation Act. It created "local boards of health". Scotland was added in 1867.
1872 Public Health Act. This defined responsible sanitary authorities, either town councils (in urban areas) or Poor Law Boards of Guardians (in rural areas),
The reason why the Poor Law authorities were used was that there was no other body in rural areas able to take on new responsibilities effectively. "Are there no workhouses? then the poor better die and decrease the surplus population" 3
Philanthropist InvolvementIt is probable that the original model for the NHS came from London’s voluntary hospitals, these hospitals owed their foundation to charitable institutions, the churches and the wealthy. In the middle ages they accommodated all the sick, whether the sickness was a result of disease, trauma or homelessness. It was mainly the church that supported the hospital institutions with staff and finance.
The big Royal hospitals of London were Guys, St Thomas’s, and St Bartholomew’s. Christ’s Hospital took the sick children, Bedlam Hospital the insane. ( Hence the term Bedlam ). Guy’s was founded in 1721, and was named after the very rich bookseller, Thomas Guy.
Thomas Guy was the Bill Gates of the era a philanthropist. He initially made major donations to St Thomas's hospital, but felt the need to fully fund a hospital himself. Guys Hospital is situated on the North side of the river Thames in my family home area of Southwark. (This was also the childhood home of Guy) In 1745, the Middlesex Hospital was founded.
The Royal Free Hospital was founded by Dr William Marsden in 1828, it was different from the other hospitals as it provided treatment without expecting any form of payment from patients. This was the miniature model of the NHS of the future.
How lucky we are, we don't really understand why, we are lucky because of the NHS! It has now been in existence for 60 years.
If I can take you back 200 years, you would be living in a country where 5% of the population were holding 95% of the wealth of the country.
That means 95% of the population were poor and struggled to feed themselves. If you were unfortunate enough to require Surgery, this generally meant that without it, you would surely die.
For example, if you got injured you were generally put onto a handsome cab (if you could afford it) and be taken to a hospital or doctors surgery. Here is where a doctor or surgeon would assess your wound and say, if it was a limb that was damaged and was bad enough, he would probably amputate the damaged limb.
It is possible that you be one of the lucky ones and the wound was not open, then your limb would be manipulated, splinted and dressed and then sent home after a very short stay. There was not much in the way of pain killers post operation.
If you were one of the lucky few who could afford treatment, the surgeon would even come to your house and do the exact same thing, except you could properly obtain strong pain relief post op. Sadly, a high percentage would die of post-operative infection Guy anyway.
In 1704 Guy became a governor of St Thomas' Hospital.
In 1707 he had built three wards and supported the hospital afterwards.
The Ambulance ServiceThe ambulances of today get to your house or to the place where your injury took place within minutes, in the 17th and 18th century it sometimes took days and by the time the handsome cab got to you, it was probably too late anyway.
There was no such thing as anaesthesia, sure, alcohol, opium, some herbs and other forms of pain relief were used, but in general the injured person that required surgery generally suffered immense and excruciating pain.
It is a myth though that the surgeon would operate without the consent of the patient, it was physiologically traumatic for the surgeon to operate having to listen to the patients screams, this would have been made even worse if the patient had not consented first.
Some surgeons had the patient’s agreement that they should be gagged prior to starting.
The surgeon would work extremely quickly this would lessen the suffering of the patient, reduce the amount of shock they would endure and give some chance of survival as the longer surgery was, the more likely you would bleed to death.
Surgeons therefore undertook anatomical lecturing as their primary role and they were generally known as lecturer first and foremost; then surgeon.
The introduction of Anaesthesia changed everything, the surgeon did not have to work as fast, his primary role became that of surgeon, the respect for the Surgeon increased from within and out of the medical establishment and because of this, there was an enormous increase in the number of medical students wishing to take up surgery.
This was not only because of the respect people now showed for it but simply because there was so much work to be done as they could now perform operations that were deemed impossible prior to the introduction of adequate Anaesthesia.
On top of this the surgeon did not have to endure the screams of the patients any more.
Hospitals now became overwhelmed with patients who not only required surgical procedures to save their lives, (this was the case before Anaesthesia).
Now people were being promised operations to cure deformities and non-life-threatening conditions.
The surgical workload increased a hundredfold. With this more hospitals appeared more surgeons were trained, and the surgeon became respectable, there was not a fear of having to see one. “We simply have to reign in the piggish people and money-hungry lawyers who chase every ambulance they see and expect companies and individuals to pay for everything that goes wrong.” 4
David Lloyd George (1863-1945)In 1911 David Lloyd George introduced National Insurance payments for employees and employers, this would be the basis for funding the NHS, 37 years later.
This is where a very small proportion of your earnings would be deducted from your salary and your employer and the government would also contribute a sum on your behalf.
By paying this, the contributions would cover not just your medical care, but also unemployment benefits and your retirement pension.
To get the medical care, all you needed to do is register with a General Practitioner.
Lloyd George's name survives in the "Lloyd George envelopes” in which most primary care records in England were stored. In today’s modern hospitals the computer has taken over this task.
With the advent of World War 1, mass casualties were returning home from Flanders, the British hospital system under the control of the military became more organized and this was to set the tone for the eventual formation of the National Health Service years later.
The war also forced the government to build more hospitals for the long term wounded with relatively new specialities such as plastic surgery being given prominence within the surgical theatre. Lloyd George said, “You cannot feed the hungry on statistics.”
The Dawson Report 1920Bertram Dawson was a physician at the London Hospital, he was asked in 1919 to report on the health services by the newly established Ministry of Health.
The report in 1920 proposed the linkage of hospitals into a single system.
The report suggested that the organisation of medicine had become insufficient and was failing to bring the advance of medical knowledge adequately within the reach of the people: " The insufficiency of organisation has become more apparent with the growth of knowledge, and with the increasing conviction that the best means of maintaining health and curing disease should be made available to all citizens." 5
Dawson was in part inspired by the revolutionary changes in health care in the Soviet Union, where a system of polyclinics, bringing together specialist and other services, and based in local government, had been established by the new government after the October Revolution. He suggested Britain might look more closely at how the new Soviet Union was organising its medical facilities.
Dawson’s blueprint was a radical one, and envisaged replacement of the uncoordinated provision of the time by a network of primary and secondary health centres, linked to district hospitals and then to regional hospitals.
Lord Dawson's plan lacked political feasibility. All doctors relied on private fees or insurance payments through the panel system and resented the idea of becoming salaried employees of the state.
The idea was seen at the time as costly and never got off the ground. However, in London in the next decades it was tested.
Lord Dawson in his report, advised that Primary Health Centres had one or two 16 bed wards (including maternity), clinics, operating room, radiography, laboratory, dispensary, baths (including hydrotherapy), equipment for physical culture (physiotherapy) massage and electricity and public mortuary and common room for training and clinical records. The report also recommends that the hospital has ambulances to convey the sick, and also to provide travelling clinics.
The Primary Care Centre was also to have communal services, such as child welfare, pre-natal care, medical inspection and treatment of school children and a service for occupational diseases. In addition to these services, the Centre would provide dental clinics and pharmacy.
Lord Dawson died in 1945 and will be remembered more for overdosing King George V with morphine to suit publication deadlines of the newspapers, than his vision of the NHS, cynical I know, but he did.
Margot Asquith said: “My dear old friend King George V told me he would never have died but for that vile doctor, Lord Dawson of Penn.”
William Beverage 1869-1963William Beverage was born in India in 1869, his father was in the Indian Civil service.
In his early years, he trained as a Solicitor, and then advised the government between 1906-1914 and was prominent in the introduction of the National Insurance Bill.
In 1941, the government commissioned William Beveridge to report into the ways that Britain should be rebuilt after World War Two; Beveridge was an obvious choice to take charge.
He published his report in 1942 and recommended that the government should find ways of fighting the five giant evils of: "Want, Disease, Ignorance, Squalor and Idleness".
Sounds like a Dickensian phrase copied from a Christmas Carol, but the war which raged at the time brought plenty of it. A welfare state was needed to combat this.
After the defeat of Germany, the country held elections with the Labour party defeating the wartime Prime Minister Winston Churchill.
The newly elected Prime Minister, Clement Atlee, proposed the introduction of the welfare state which Beveridge outlined in his Report. This included the establishment of a National Health Service in 1948 with free medical treatment for all from cradle to grave.
This came into being on the 5th July 1948, when Bevin opened Park Hospital in Manchester, and is still in place today.
Beverage stated,“Ignorance is an evil weed, which dictators may cultivate among their dupes, but which no democracy can afford among its citizens.”
Aneurin Bevan 1897-1960Aneurin Bevan was born on 15 November 1897 in Tredegar in Wales. His father was a miner and the poor working-class family in which Bevan grew up gave him first-hand experience of the problems of poverty and disease. "Nye" Bevan will go down to history as the greatest Minister of Health we have ever had. His National Health Service Act 1946 was a triumph of achievement in spite of prejudice and misrepresentation.
In 1951, Bevan was moved to become minister of labour. Shortly afterwards he resigned from the government in protest at the introduction of prescription charges for dental care and spectacles.
Bevan led the left wing of the Labour Party, known as the 'Bevanites', for the next five years. In 1955, he stood as one of the candidates for party leader but was defeated by Hugh Gaitskell. He agreed to serve as shadow foreign secretary under Gaitskell. 6
Like some left wingers, Nye Bevan had a sympathetic and lovable personality. Because he always stood up manfully for the bottom dog, and castigated his opponents mercilessly, he made many enemies. Like the invention of anaesthesia, the credit goes to one person, William Morton. The same is with the NHS the credit goes to Nye Bevan but several contributors like Lord Dawson and Beveridge must not be forgotten.
Bevan said: “ This island is made mainly of coal and surrounded by fish. Only an organizing genius could produce a shortage of coal and fish at the same time.”
The NHS TodayIn modern day Hospitals, the development of anaesthesia and surgery is ongoing, with the introduction of highly technical monitoring equipment, and anaesthetic delivery systems, precise multi-function ventilators and a wide range of induction, and maintenance drugs. The surgeon can now call upon Complex Manufactured Instrumentation tailored for specific operative procedures. This can be seen in re-constructive surgery, especially in orthopaedics, plastics or Max facial.
Initially this instrumentation is extremely expensive, and the cost of each individual operation and procedure is high, but as more surgeons use the implants and instrumentation, the cost comes down.
He now works in an ultra-clean environment, with access to a wide variety of antibiotics and other drugs to help ensure the success of the operation. Yes, it is true we still have problems with highly resistant organisms, and I am sure there will always be some organism that will challenge the biochemists, you find a cure for one and another seems to take its place.
The fact is the patient of the 21st century will survive conditions and injuries that would have killed most, 50 years ago.
The development of nursing techniques has radically improved over the years.
The patient’s welfare and rights are now being discussed at every level, audited and the results acted upon. Nursing itself has branched off into different specialities, allowing nurses to develop their roles so that they can tackle the patient’s needs with more professionalism.
This is also seen in the operating theatres, with specialised scrub nurses and ODP for orthopaedics, anaesthetics, general surgery, plastics, neurology and cardiothoracic etc.
Eventually we will see specialised nurses and ODPs as formal scrub assistants and surgical assistants within every speciality of surgery.
1 Http//www.elizabethan-era-.org.uk/the poor Law
2 Matthew, Chap 25
3 Charles Dickens A Christmas Carol
4 Mike Gallagher
5 https://www.sochealth.co.uk/national-health-service/healthcare-generally/history-of-healthcare/interim-report-on-the-future-provision-of-medical-and-allied-services-1920-lord-dawson-of-pen /