They were also an important focus for community activity, with members holding social events and engaging in an annual Easter collection of eggs. At the same time state hospitals were changing. In the poor law was abolished and a growing number of workhouse infirmaries became general hospitals. The main beneficiaries of hospital expansion between the wars were women and children. Most infectious disease patients were children, and as the threat of typhus and smallpox declined these hospitals switched to general child medicine.
Maternity wards were the fastest growing specialist service, with the public hospitals converting old poor-law blocks for the needs of expectant mothers.
Voluntary hospitals like the Jessop in Sheffield expanded their services, introducing scientific laboratories to help tackle rising maternal deaths.
The work of doctors and hospitals was underpinned by a vast reservoir of active first aiders. Building on the work of the British Red Cross and Order of St John Voluntary Aid Detachments of the Great War, the interwar period saw the growth of a voluntary first aid network, providing a range of first response services.
At big events like the British Empire Exhibition at Wembley in the summer of , the two organisations collaborated, caring for over 16, people suffering from accidents or illness. In addition to this medical work, by they had trained over , people to deal with gas attacks expected in the event of a war. By well over half the population could access GP and hospital services free at the point of use. Certainly big gaps remained, some filled by voluntary bodies such as the British Red Cross. Women and children had limited access to GP surgeries but growing hospital services provided for them.
The middle class were largely excluded and had to rely on increasingly expensive private doctors and their sub-standard nursing homes. The budget had to be cut in the early s as the government struggled to keep up with demand. It forced ministers to introduce charges for prescriptions, dental work and spectacles. This is just one of the consequences of devolution, which has seen individual administrations given control over health policy.
Not everything has gone up. The most obvious example is the number of beds. There are now four times fewer beds than there were originally. This is because much more can be done in the community. And patients also spend much less time in hospital than they once did. Women who give birth today now tend to leave on the same day or the day after. After the creation of the NHS, as birth became medicalised, women would spend a week in hospital.
It is a similar story for operations. The first hip replacement was carried out in late The patient spent weeks in hospital. Now the operation can be done as a day case.
At the heart of the story of the NHS, is its impact on the nation's health. People now live 13 years longer than they did 70 years ago. Better access to healthcare has played a key role.
But it is also worth noting that in the 70 years before the creation of the NHS, life expectancy actually increased by double what it has since.
Access to clean water and construction of sewers were two of the biggest factors in that. Infant mortality - defined as deaths before the baby's first birthday - has improved dramatically. There are five key influences - congenital anomalies, prematurity, sudden infant death syndrome, maternal complications and birth injuries. The creation of the NHS, meaning births moved from home into a medical environment, and the advancement of medicine have been hugely influential.
Another factor is immunisation. The NHS was set up not simply to treat illness, but also to promote good health. The introduction of the polio vaccine in the s is a perfect example of this.
Before this programme, cases of polio could climb as high as 8, in epidemic years, but once people started getting immunised the numbers dropped quickly.
Expectations were not always fulfilled. Nurses have never suffered from a lack of advice. In the years before the NHS there had been several reports on nursing, its problems and its needs. That achieved, it proceeded to consider education and training, and finally recruitment. The committee became convinced that, given a liberal outlook and a carefully planned curriculum, nurse training could be developed into something of great importance. Training was, however, too closely linked with the provision of nursing care, a handicap greater than an educational system should have to face.
Entering nursing to receive a professional education, and spending three months in the preliminary training school, the nurse then went on the wards and became an indispensable member of the hospital staff. There was a gap between the theory of the classroom and the practice of the ward, where staff were stretched and supervision by experienced staff might be inadequate.
Marriage ended the career of a student nurse. Indeed nursing was seen as an alternative to marriage. Nursing on the wards interfered with social activities, for many did not know when they would be off duty until sister finished the duty roster; in any case, they stayed on duty until work was finished. They won their battle for a training allowance in , although the RCN felt that the conduct of protesters had been undignified. There was always a shortage of nurses. Two categories of nurse had existed from the nineteenth century.
In there were some 20, of these state-enrolled nurses SENs. Their presence not only added to the workforce but also made it possible to improve the training of students for the register. The success of a national health service was going to depend as much on sufficient numbers of adequately trained nurses as doctors.
In the Ministry of Health established a small working party that included two senior nurses, a social scientist and a doctor, chaired by Sir Robert Wood. It was to look at recruitment, the proper task of a nurse, the training required, the annual intake needed and how it was to be obtained, from where nurses were to be recruited, and how wastage could be minimised.
The Wood working party had to work fast and it reported in Once they were established, it would be easier to gain acceptance of an unpalatable remedy. The starting point was the cost of sickness to the community, the value of working time lost, the cost of treating the sick, and the cost of immunisation and clinics for mothers and babies. An estimate of the need for health nursing was needed, and then the requirement for sick nursing. The working party looked at the size of the nursing profession, and its structure in terms of age, educational background, professional qualifications and socio-economic status.
It examined recruitment, wastage and the pattern of training. Mental hospitals had more than their share of those at the lower end of the scale of intelligence.
Wood believed that wastage was unacceptably high, being the result of discontent among the students and frustration with harsh and cramping discipline. Senior staff and matrons were to blame for this.
Responsible as they were for patient care without an adequate supply of trained staff, as well as training students who were carrying much of the workload, it was inevitable that the needs of patients should be placed before the interests of students. It was no use merely appealing to hospital authorities to modify discipline or to adopt more understanding attitudes. The organisation and staffing of training schools needed structural changes.
There should be a broader training for all nurses, a single General Nursing Council GNC with a more substantial educational role, and regional training bodies independent of the NHS, the costs of training coming from outside the health service. This conclusion was threatening to hospital administration and the matrons who ran the schools. The Wood Report was years ahead of its time. Fifty-four per cent failed to complete training and the report was critical of the conditions of training and the training itself.
More careful selection was needed, using intelligence tests as well as other selection techniques. The service was dependent on assistant nurses.
Although some held that all duties concerned with the patient should be carried out by a trained nurse, supported by ward maids, Wood believed that there would always be scope for a subsidiary nursing grade, taking over some of the repetitive domestic work carried out by student nurses, particularly in their first year. Those below the level of ability required for training should be recruited, if otherwise suitable, to jobs ancillary to nursing.
Better food and accommodation, and three-shift working, were desirable. Students should no longer be regarded as junior employees subject to an outworn system of discipline. They must be accorded full student status as far as the intrinsic requirements of nurse training permitted.
There should be a two-year course, with registration after a third year spent in clinical practice. Training should emphasise social and preventive medicine, considering health and sickness nursing side by side. The Ministry of Health invited comments.
The RCN agreed that nurses in training should be students and not primarily employees. It saw no reason why those student nurses who could afford it should not pay for their training as did physiotherapists — provided that the salaries of the qualified nurses were similar to those of other professional workers. It strongly opposed the idea that the Ministry of Health should be involved in nursing education.
The RCN recommended that studies be carried out of the varying nursing loads created by patients with particular problems, and the hours of care required by patients in different stages of illness. The GNC opposed the separation of training schools from hospitals, and the idea that the training schools should be controlled or inspected by anyone other than itself.
Ministry of Health proposals followed the Wood Report. They were sweeping, ambitious and showed much goodwill towards nurses. Each region would have an educational organisation independent of the hospitals.
There would be freedom for nurses to design their own training, to build their own centres, and create nursing colleges. In many ways the proposals paralleled university education, giving professional independence. The RCN council, on which matrons had a powerful voice, and the GNC discussed the proposals, failed to understand what they offered, drew back in alarm and defeated them.
The staffing needs of the health service became dominant. Common to nursing in all hospitals was the need to provide a hour service, near to the patient, and without fail. Once appointed, ward sisters might manage their ward for life, taking its name. In some hospitals, they had accommodation on the ward, where they slept. Staff nurses were also people of authority. Providing accommodation was expensive, and the Ministry thought it was to the advantage of both the community and the nurse to expect her, like other workers, to find her own accommodation.
Little escaped their eyes. The medical staff knew where to turn if there were problems, and the misdeeds of a junior doctor were soon passed on to his chief. The dress colour, stripes on the hat, and the belt colour identified the seniority of the nurse. Hair was neat, caps were worn and make-up forbidden. The result was stunning. Top hospitals had distinctive outdoor uniforms, recognised by the local population. The NHS brigaded nurses into a single workforce.
Henceforth there would be a national pay structure, the Ministry would be concerned with staffing a huge service and professional organisations had a negotiating role. Nurses in the mental institutions had never been accepted by the RCN as on a par with state-registered nurses. Other unions had been established by them to fight for better conditions and, simultaneously, better services.
Strike action, though not common, was part of their tradition. COHSE was formed in when two unions merged, and after that it represented many of the nurses in mental hospitals and the auxiliary SENs. Doctors had the BMA to deal with their terms of service, and the Royal Colleges to consider educational and professional issues.
The RCN had to combine the two functions and was not always successful. Senior officers were frequently more political than professional. Nursing has allowed itself in the past to be taken far too much for granted. We have allowed ourselves to be handmaidens of the medical profession. Nurses have not got the slightest intention of accepting a lower plane than that of an active, loyal and wide-awake partnership with the medical team. Nursing in the community had a long and honourable history.
The first recorded venture was in Liverpool in The institute designed a specific training programme, ran local services, and was the main voluntary organisation doing so. In most areas district nursing associations had been founded to provide a service to the community. Rural areas sometimes could not provide a service to such a level.
Midwifery, a profession separate from nursing, was regulated under the Midwives Act of More than half of the babies born were delivered at home, mainly by midwives provided by local authorities or nursing associations. County councils and county boroughs had to provide a domiciliary service directly or through contracts; how they did so was largely for them.
Domiciliary midwifery was an entirely female profession, giving a door-to-door service, mostly on bicycle, 24 hours a day, days a year, to an entirely female clientele. Often working in partnerships of two or three, each midwife cared for women in her geographic patch, delivering 50 to women annually. It was an industrious and insular life. Midwives had a sense of their own worth, with a duty to the public and an accountability to their supervisor.
Few mothers saw more than three or four professionals during their pregnancy, and there was a guarantee of continuity of care. Health visitors had generally undertaken further education after state nurse registration and had midwifery experience. The roots of health visiting were different from the other two nursing professions: it emerged from community work and the radical tradition.
Formal training developed early, and led to an examination by the Royal Sanitary Institute. The ethos of health visiting was that of public health and its interests lay in the social conditions affecting the health and welfare of communities, and therefore families.
They were early to register as trades unions and were involved in radical politics as the way to bring about change in society. The task of the health visitor began with a notification of birth — it was unsolicited. With the advent of the NHS, the work of health visitors was expanded to the health of the household as a whole, advice on the care of people who were ill and measures to prevent the spread of infection.
Because there was no formal demarcation of duties, there was considerable friction between district nurses, health visitors and midwives. In rural areas where mobility was a problem, one nurse might be a qualified midwife, health visitor and district nurse. She would be well known and well respected by the community. There had been nurses in government employ in the Ministry of Health, since the s. Her career had been varied, involving clinical and educational posts in both the north and south of the country.
She was one of the two nurse members of the Wood working party, which did not add to her popularity with the nursing profession. Her staff included public health and hospital nursing officers with regional responsibilities. They were in close contact with professional organisations and advised the Minister, working with medical and administrative colleagues and concerned with matters of nursing policy.
Nursing administration within the hospitals was much the same in the voluntary and municipal hospitals. This was not the case on the medical side. Senior nurses would be moved among the hospitals in preparation for a key position that was becoming vacant; the teaching hospitals often supplied the matrons for municipal hospitals and smaller voluntary hospitals. In large hospitals, a matron, with deputy and assistant matrons, managed the ward sisters, and they managed the more junior nursing staff.
Where there was a nursing school, matron controlled it and selected the students. She managed catering, linen supplies and domestic services, and might be responsible for physiotherapists and other disciplines ancillary to medicine. In municipal hospitals, matron reported to the medical superintendent.
In the voluntary hospitals she had more autonomy and was usually appointed by, and was responsible to, the board of governors. In his Cavendish lecture of , Bertrand Dawson, a physician at the London Hospital and a military doctor during the war, described how a health service could be co-ordinated.
In he was invited to chair a Consultative Council on the future provision of health services, and he proposed a hierarchical system of primary care centres linked with district hospitals, and regional centres with university teaching hospitals.
The voluntary hospitals felt a need to combine to defend themselves against the expanding municipal hospitals. The British Hospitals Association, their representative body, asked Lord Sankey to chair a committee, which recommended the formation of regional councils to co-ordinate the planning and organisation over a wide area. Professional and geographic factors were dominant in proposals to organise on a regional basis. Rarer and more complex medical problems required larger catchment populations.
The local authorities, whose boundaries were historic rather than functional, opposed the idea. Outside London the emergency medical service regions were similar to those of the British Hospitals Association. In the southeast there was one region, but within it there were radial sectors spreading into the countryside, each with one or more teaching hospitals at its apex. There had been a national survey of hospitals in to consider provision for casualties in the event of war.
A year after Dunkirk, on 9 October , the government announced its post-war hospital policy and the decision to survey hospitals in London to provide a firm basis for planning. Shortly after, a second survey was mounted in the northwest, and it was rapidly apparent that the whole country needed review.
In further surveys began and there were ultimately ten, co-sponsored by Nuffield Provincial Hospitals Trust and the Ministry. For each region there were two, or later three, surveyors who visited every institution that might be called a hospital. The reports were published in Sheffield and London first, then the rest.
George Godber was one of the Sheffield surveyors, and the detailed knowledge he gathered was the foundation of much of his subsequent work in the Ministry on the development of hospital and specialist services. All the surveys showed wide variation in quality, and major deficiencies in hospital buildings that could only be overcome by rebuilding, although much inefficiency could be remedied more rapidly.
The surveys advocated district hospital centres, uniting individual hospitals into a functional whole, with a common staff, grouped within regions resembling the survey areas. Their main value rested on factual reporting on existing buildings and services, and their confirmation of the need for regional planning. The detailed proposals were often suspect but one point of great importance emerged from all — the idea of a general hospital providing all the ordinary range of specialties for a natural population, linked with regional specialty centres.
Once planned, the DGH should then be given a suitable base. There were then no accepted indices of need, so estimates of hospital size might be almost fanciful, and the location suggested was sometimes at fault. But, for the first time, the country got away from designing hospitals of some empirically determined size, and was attempting to look at how best to provide services for a community. The three main problems were: shortage of beds as a result of poor buildings and equipment; shortage of consultants; and poor patient accessibility to both beds and consultants.
There was no system. Complicated cases often received treatment in hospitals without the necessary facilities, while simple cases occupied beds in hospitals with high standards of staff and equipment. Shortages of beds and specialists led to long waiting lists, even for simple cases.
Acute hospitals frequently had to discharge patients before they were fully recovered, and the obligation of municipal hospitals to admit patients from within their areas meant overcrowding and under-staffing. Local authority boundaries led to uneconomic development and acted as barriers to admission.
Although voluntary hospitals had often tried to expand, restricted sites meant, as at Charing Cross Hospital in the Strand, that the provision of modern facilities was impossible.
Medical staffing had to change. The distribution of specialists had been haphazard, determined largely by the economics of private practice. In municipal hospitals there had been salaried part-time or whole-time specialist posts but they were relatively few.
The consequence was too few specialists who were unevenly spread. There had to be a tremendous redeployment of specialists and at least double the number. Outside large centres, where there was little private practice, there were limits on the choice of staff, and hospitals had to get along with the GPs living in the immediate neighbourhood.
The West Midlands surveyors said that there had been a tendency for GPs gradually to drift into surgery or whatever branch of medicine was of most interest, and to do this as an offshoot from general practice. They might be entirely self-taught. Specialist services were scarce; there was only one gynaecologist in the whole of Lincolnshire.
In Rotherham, the GPs objected to the appointment of full-time surgeons, but examination of their results showed that four prostatectomies had been carried out the previous year, only two of the patients leaving hospital alive.
Radiological and pathological services were poor. For example, there was no whole-time radiologist in Lincolnshire, and Nottingham specialists visited Boston once a fortnight. In Northampton one of the physicians supervised the radiographers and some physicians took it amiss when it was suggested that a radiologist should be running the X-ray department. Similarly, technicians in isolated departments had no senior staff to turn to.
The hospital surveyors reserved their bitterest comments for long-stay provision. Often buildings were antiquated, with bare, overcrowded large wards and cheerless uncomfortable day rooms, and primitive facilities for nursing. In most instances the wards did not provide the physical or the mental amenities to be found in a domestic dwelling. In some institutions the ratio of patients to trained nurses was 60 or more to one. Young children and people with senile dementia were herded together with elderly patients, many of whom might have been able to return to their homes had there been earlier diagnosis and treatment.
The surveyors believed that the first need was for every patient to be thoroughly examined and treated. The Labour Party had put forward proposals for a national hospital service before the first world war, and between the wars there was increasing interest in resolving problems. Several reports — commissioned by the government, produced by independent groups, or the work of professional or hospital organisations — had laid out alternatives.
In the s it became apparent that a health service run by them could be introduced only in the teeth of opposition from the medical profession. The war had increased the sense of social solidarity, and many saw the advantages of a command structure. Most doctors had military experience and knew that service personnel had, from a health point of view, been looked after better than in peacetime. Janet Vaughan found it hard to understand how anyone could be a doctor before the war and not become a socialist.
Julian Tudor Hart, a Welsh GP, believed that people who had experienced the effect of the market on the distribution of services meeting basic human needs, and the revelation that in wartime the market could be overridden for great purposes, were resolved never to return to the old system.
Labour came to power with one of the largest majorities in British history. It was committed to a programme of public ownership and lost no time in carrying it out. The Bills nationalising the Bank of England, coal, and cable and wireless received Royal Assent in In the following year it was the turn of transport, railways, canals, road-haulage and electricity.
The gas industry was nationalised in , and iron and steel in The NHS Act was introduced four months after the election and passed during the first session of the new Parliament. In the words of the Minister of Health, Aneurin Bevan , the Act would create an atmosphere of greater security and serenity up and down the country for families faced by anxiety and the distress of illness.
Rising costs hastened the inevitability of a state medical service. With the advance of science and specialisation, a patient had not one, but many doctors. The cost of illness was beyond the purse of the average person. Until the Labour victory, local authorities looked likely to play a lead role. Bevan came as a man with a mission to change things. He looked at the draft Bill from the previous administration and insisted that the hospitals should be nationalised and that the service must cover everyone.
The key was the realisation that, without executive control of both the voluntary and the municipal hospitals, effective hospital planning was impossible. It was like a breath of fresh air to the officials involved, Sir Wilson Jameson, the CMO, who had an instinct for what was required, George Godber who did the medical drafting and John Horton and John Pater who dealt with administrative issues.
The regional concept brought together service considerations the natural territory within which normal and highly specialised services could best be organised and the university medical schools the natural centres of research, development and education.
With university and medical concurrence, regions could establish an integrated specialist system and rationalise nurse training. Boards had to have the ability to close, amalgamate and expand hospitals. If the boards were too weak, the anarchy of the old voluntary system would begin all over again. The main oddity was the division of the southeast into four metropolitan regions that met in the centre of London. In the war, a radial pattern of organisation had been adopted to make the evacuation of casualties easier.
It worked well as it accommodated the teaching hospitals and medical schools. For Bevan it had another advantage, the pattern was utterly unlike that of the LCC. A single London health authority would have had massive and undesirable political clout and would have been totally insensitive to the periphery.
At local level the unit would not be a group of hospitals, but a complex of hospitals, GPs and health centres. A partnership of general and specialist practice would make general practice viable and relate the hospital to the community it served. Bevan refused to discuss the details of his proposals until, after the first reading, there was a measure of parliamentary approval. In the final round of negotiations Bevan accepted key demands from the doctors.
For the specialists this was a part- or whole-time salary plus merit awards, and the right to treat private patients in NHS hospitals. For GPs it was a system as far removed from a salary as possible; capitation was a defence against the perils of state servitude. Many doctors had received state funds through the Lloyd George national insurance scheme, but now they were even more dependent on government for their incomes and the resources at their command.
The state had become dependent on the medical profession to run the NHS and to cope with the problems of rationing scarce resources in patient care. The decision to take hospitals into national ownership in and the inevitable compromises did not please everyone. Herbert Morrison, in the Cabinet, and the local authorities, some themselves Labour, were upset at the loss of their municipal hospitals. The voluntary hospitals disliked their loss of independence.
Nurses were strongly in favour, as were the younger doctors. The objectors were the older men who were the controllers of the BMA and its committees. From the rubble of war, it was believed that Labour would create a better society. When Bevan died in , a BMJ editorial described him as the most brilliant Minister of Health the country had ever had, much less doctrinaire in his approach than many of his Labour colleagues, and conceiving the NHS on more liberal lines than his Conservative predecessor.
He towered over a long line of Ministers of Health and attracted in the medical profession profound admiration on one side and the sharpest antagonism on the other.
The editorial proceeded to claim that the medical profession, rather than Bevan, was the principal architect of the NHS. He never rose above being a clever politician and at critical moments failed to become the statesman.
He had done his best to make himself disliked by the medical profession, and, by and large, he succeeded. What it did not do was establish an individual entitlement for treatment of particular illnesses, as an insurance scheme would have done.
As the NHS was paid for out of taxation, for the first time the Treasury had a powerful influence on the health care system. The NHS would be: There should have been another distinctive feature, co-operative general practice from shared purpose-built health centres.
Six months before the NHS began, the Ministry wrote to local authorities to say that no general programme of construction would be implemented. The service was tripartite and had to be developed in sections. Otherwise, Sir George Godber has said, it would never have been got to work in time. Nor, in , would a unified system have been able to look after primary and community services in addition to the hospitals.
Unification could have been a disaster for general practice, which carried much of the burden of the NHS in the early years. There would be the hospital service within a regional framework, the only way to achieve a properly planned service and a reasonable distribution of specialist staff.
There were the local authority services that quietly made progress in developing community nursing, home help and immunisation programmes. Then there was general practice where GPs now would look after whole families, not just the breadwinner. In these divisions were the seeds of future problems. Twenty years later, Richard Crossman said that the Bevan compromise gained the support of the consultants by conceding an entrenched position that could not be broken without jeopardising the whole health service.
GPs were given a special place, with elaborate safeguards that kept them isolated from the hospitals and from the community services, which were left in the hands of the local authorities and their MOsH.
They were strong, semi-autonomous boards whose relations to the Minister were like those of a Persian satrap to a weak emperor: if the emperor tried to enforce his authority too far, he lost his throne, or at least his resources or something broke down.
Health service freedom lay in the fact that the centre was weak, the regions strong and the GPs in their enclave were separated off, safe from attack.
Doctors had been treated with consideration, local administrations enjoyed considerable freedom, and the profile of government itself was low. If many remembered the period as a golden age, that was perhaps because it suited almost everyone very well. Although regional boundaries had been drawn as far as possible to coincide with hospital catchment areas, RHBs were not self-sufficient and their boundaries were not meant to be barriers to the flow of patients.
By the early summer of , Bevan had consulted widely and appointed the RHB members. They were to act as individuals, not delegates of interest groups.
There were few political appointments. Most members were of the old guard to maintain continuity, although a few were dropped as they were entirely out of sympathy with the new regime. There were doctors, there might be a nurse or a dentist, and there were elected members of local authorities. There was usually at least one trades union member, but the rest were people who had shown an interest in running health services.
Regions had less than a year to appoint staff, learn their jobs, determine their hospital management committees HMCs and secure ministerial approval before appointing HMC members. The emphasis was on sound representation of local people and skill in running the existing services.
From the outset they were to feel a lively sense of independent responsibility. It was for Boards to decide their committee structure and working methods, although they would want to appoint professional advisory committees.
Bevan made it clear that, just as he would try not to interfere with regions, regions should not interfere with their HMCs.
Boards would need to work closely with teaching hospitals, universities, the Ministry and local authorities. In England and Wales there were 14 regions Wales was one and Wessex was not formed until many years later.
Illustration source: Ministry of Health. National Health Service. The newly appointed members of the RHBs learned together. They had to get to know each other, work in temporary accommodation and build up their staff.
To begin with these were few, and the same was true of the HMCs; some barely knew the institutions under their control. Board members drove from one hospital to another, having delightful hospital lunches and teas. They were welcomed wherever they went and were shown the best and the scandalous. Teaching hospitals were selected by the Minister, with university advice, because of their special importance to medical education.
They had fought for their independence and won. Their pre-war burden of debt had been lifted and they retained their own — sometimes substantial — endowment funds. Most continued to be selective in their admissions policy, serving some, but not all, of the needs of those living in their locality.
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