The National Health Service (NHS) began on 5 July 1948. Already the NHS, which Bevan described as “a great and novel undertaking”, is the stuff of history. Few people now working in it had been born when it began. Those with clear memories of the early days grow fewer, and this book is in part a tribute to their work. It is the story of the NHS, how it was set up, what happened next, and why. It aims to give the reader, whether professionally involved in the NHS or not, a chronological framework of the main events, clinical and organisational. The clinical sections describe the vast and wide-ranging developments that have imposed demands on the organisation, finance and structure of the NHS. Much of the story of the NHS is about the interaction of the three main parties involved: those needing care, those who deliver skilled care, and those whose task it is to raise the money and see it properly spent. The peculiarly difficult triangular relationship between these interested parties has to be satisfactory if the health service is to function to the benefit of society.1 Knowledge of the evolution of the service, and the changes brought about by the advance of medical science, should help those planning, managing or working in the NHS to be realistic. Advance in clinical medicine is international and it has often been developments in other countries that have led to new forms of treatment, and sometimes new patterns of organisation. Only rarely do advances stem from the work of a single pioneer; usually they are the work of a team, or several teams. Charles Rosenberg says in his history of hospitals in the USA:2
The decisions that shaped the modern hospital have been consistently guided by the world of medical ideas and values . . . the attitudes and aspirations that gave the profession its peculiar identity . . . One can hardly understand the evolution of the hospital without some understanding of the power of ideas, of the allure of innovation, of the promised amelioration of painful and incapacitating symptoms through an increasingly effective hospital-based technology. Management has a tough task to keep up with clinical progress. The implementation of developments has often been slower in the UK than in other countries. Partly this has been due to innate conservatism, but mainly it has been the result of financial restrictions.
There is no ideal way of dividing this story into sections. The introductory chapter describes the health services in 1948. The next chapters each cover a decade, and begin with a chronology of events both in the NHS and in national life. The structure of the chapters is broadly consistent so that a particular topic can be followed over the years. In each decade medical progress is considered first, then the developments in general practice and primary healthcare (the patient’s first point of contact with the system) and the hospital service. Lastly, changes at an organisational and managerial level are discussed.
The story of clinical and organisational developments in the NHS can be seen within the wider context of the development of the welfare state, about which Nicholas Timmins has written.3 To keep within reasonable limits, boundaries had to be drawn. This book concentrates on England, for organisational changes in Scotland, Wales and Northern Ireland differed, reflecting the different circumstances. It does not duplicate accounts of the creation of the NHS.45 It tries to avoid looking at the NHS through the eyes of central government and does not explore the political background as deeply as Rudolf Klein.6 Neither does it deal with the types of care that shade into social services. The temptation to stray into clinical research leading to advances in medicine, or to explore in any depth the relation between income, illness and mortality, had to be resisted. It was not practicable to include the stories of optical, dental and pharmaceutical services; each could be the subject of a book itself.
The use of English has changed substantially over the last 50 years. It was assumed in 1948 that doctors were men, and could be referred to as masculine. Concepts were expressed with little regard for the possible offence they might cause; terms such as ‘mental defectives’ and ‘the workhouse’ were well understood and few objections were made to their use. They have changed over time: a White Paper in the 1970s referred to the mentally handicapped but we now talk of people with learning difficulties; senile dements became elderly severely mentally infirm (ESMI), a phrase also now consigned to limbo. I have tried to use contemporary terminology and not change the words people used; increased sensitivity to those with problems is, in itself, part of the history of the NHS.
References to preface
Online resources have expanded substantially since the book was written. For example, the National Archives have a hospital database, and the London School of Hygiene & Tropical Medicine has one of voluntary hospitals. Poor Law hospitals and workhouses are covered by another site, and hospitals in London that have closed and disappeared by Lost Hospitals.
The Socialist Health Association, in conjunction with Hull University, has a substantial archive of documents, some of national importance, and others part of the history of the Labour Party in respect of healthcare.