The idea for the National Health Service (NHS) was introduced in the Beveridge report (1942) and it was launched by Health Minister Aneurin Bevan (a Labour party politician) on the 5th of July, 1948.1
As declared in the 1944 White Paper, the NHS was based on three main principles that remains its underlying values today:
- The NHS should meet the needs of everyone
- It should be free at the point of delivery (funded by the tax system)
- It should be based on clinical need and not the ability to pay.2
What was healthcare like before the NHS?
Prior to the introduction of the NHS, the standard of healthcare in Britain was quite poor. In 1911, the Prime Minister David Lloyd George formed the National Insurance Act. Working men had to pay 4p per week, which contributed towards their National Insurance. This meant that they were able to see a ‘panel doctor’ when needed. However, this insurance did not cover their wives and children; therefore, many women and children could not afford health care. Free health care was sometimes available from voluntary hospitals. However, the quality of care in these hospitals was worse than in other hospitals, leading to increased mortality rates. Once the NHS was introduced, everyone in the UK, ‘from cradle to grave’, had access to treatment. This was made possible with the payment of a weekly contribution to the government by all working people. 1
Advances in healthcare since 1948
There has been a vast amount of progress in terms of medical care available to patients since the NHS came into existence. Below are some of the main milestones:
Prescription charges of one shilling are brought in. These charges were then abolished in 1965 and then reintroduced in June 1968.
First mass immunisation programme, offering polio and diphtheria vaccines to under 15s, is introduced.
First UK kidney transplant is carried out, which was successful. The patients lived for a further 6 years before dying of unrelated causes.
Contraceptive pill becomes available to women.
Abortion Act is formed, stating that abortion was legal up to 28 weeks if a woman’s health was at risk. The limit was lowered to 24 weeks in 1990.
UK’s first heart transplant is performed (the 45 year old male patient died after 46 days). For the next 10 years, this surgery is not routine procedure due to fear of failure.
CT (computed tomography) imaging is introduced to diagnose patients.
Louise Brown, the world’s first test tube baby, is born. This marks the first successful instance of in-vitro fertilisation.
First successful bone marrow transplant is carried out on a young child.
MRI (magnetic resonance imaging) is introduced.
The first major AIDS health campaigns are launched. This was triggered by extremely high number of deaths of AIDS patients and these campaigns aimed to increase public awareness of HIV and AIDS.
The NHS breast screening programme is introduced. This leads to earlier detection of breast cancer and subsequently, improved treatment outcomes.
The NHS and Community Care Act is created. Health authorities begin to manage their own budgets to buy health care from hospitals for local populations.
The organ donor register is formed.
NHS Direct is launched. It was a service which provided patients with advice for a range of injuries and illnesses over the phone. This service was discontinued in 2014.
NHS walk-in centres are introduced. A four hour target for A&E departments, in which staff were encouraged to see all patients and transfer or discharge them so that no patient spends more than four hours in A&E, is detailed in the NHS Plan.
Patients’ freedom of choice is acknowledged and improved; for example, patients are given a choice of several hospitals for treatment rather than having their GP make the decision for them. The NHS Bowel Cancer screen programme is also introduced.
Patients referred by their GP to see a consultant are able to choose where they would like to be treated i.e. any hospital or clinic that meets NHS standards.
NHS Health Check for patients between 40 and 74 years of age is introduced. This allows conditions to be diagnosed earlier, leading to preventive measures and early curative measures.
The Mid Staffordshire inquiry, which investigated the high mortality rates of patients and claims regarding poor standards of care provided to these patients is initiated. Also, the NHS non-emergency number (111) is launched in some parts of England. The purpose of this service is to provide fast medical help to patients when it is not a 999 emergency, which leads to the knock on effect of having less patients presenting at A&E.
Proposals supporting the introduction of DNA mapping emerge, specifically for patients with cancer or rare conditions. The aim of this project is to provide doctors with an early understanding of patients’ genetic make-up, disease progression and treatment requirements
NHS 111 becomes available across England. 4
A negative side effect of these advancements is increased costs. In 1948, the yearly cost of the NHS per head per lifetime, was £200; however, 60 years later, that value had risen to £1700.5 Furthermore, the number of patients has increased with the challenge additionally compounded by a lack of funding. For example, in 2015/16, the NHS has been allocated a budget of around £115 billion compared to the £437 million (approximately £9 billion at today’s value) which was available to the NHS when it was created, although costs were much lower then. 6
There have been multiple attempts at improving the quality of service by making structural changes to the NHS. One of the most recent changes to the structure of the NHS was the replacement of primary care trusts (PCTs) from April 2013 onwards with GP-led Clinical Commissioning Groups (CCGs). This means that GPs are responsible for making the majority of the decisions about funding for local services. Policymakers believed that GPs are in the best position to make these choices as they are the ‘gatekeepers’ of healthcare and have extensive contact with a majority of the patient population. This allows them to gain a deep understanding of the services that are needed most by their patients. 7
What can be learnt from the history of the NHS?
Instances from the past can teach us more about what works and doesn’t. For example, Enoch Powell’s Hospital Plan initiated the development of district general hospitals in the hope of improving the lack of communication between hospitals and GPs. However, it was soon discovered that the plan had underestimated the cost and time it would take to build these new hospitals. 8 In 2008, the idea of ‘polyclinics’ was suggested by Lord Darzi as a solution to this issue. These polyclinics would place specialists and GPs under a single roof, complete with investigations, equipment and treatments usually available in hospitals. This proved to be controversial, with concerns such as the threat of closure to smaller GP surgeries and the fact that having multiple services in the same place has not be shown to improve communication or treatment outcomes. 9 Examples such as these should be used to inform today’s discussions regarding structural changes to the healthcare system.
Structural changes should be considered carefully as it costs millions to effect a change in the system. Over the past 30 years, the NHS and Department of Health have been reorganised many times, often ending with a return to structural arrangements from the past. These reorganisations have not been shown to have improved the quality of care provided to patients. A possible reason for this may be the discontinuity and distraction that these overhauls cause. 10
Although the NHS is not perfect, we must not take it for granted. Just under 70 years ago, healthcare was not affordable by many patients; now we are lucky enough to not have to consider costs when seeing the consultant or having life-saving surgery. The NHS saves many lives that may not be otherwise saved as patients may not be able to afford their treatment. Mortality rates have decreased; for example, in 1948, there were 86 deaths per 100,000 total live births; in 2008, there are just 6.2 deaths per 100,000. 5 People are now surviving strokes, heart attacks and cancer. Organ transplants, which were not possible before the 1960s, are now saving more than 3,000 patients a year. The increasing use of IVF treatment is helping couples to conceive whereas hip and knee replacements, which are now commonplace procedures are improving many patients’ quality of life such as those affected by arthritis. However, progress does not come free, with an extra £10 billion a year needed to pay for advances in medical technology. 11
As Aneurin Bevan said: “We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving – it must always appear inadequate.” 12 Although there have been and will be many changes to the NHS, its core principles will invariably remain the same. Appreciating the history of the NHS is crucial to ensure that we do not repeat previous mistakes, instead learning and drawing from past experiences to improve that standard of NHS healthcare provided to patients.
1 News.bbc.co.uk., 2015. Timeline of the history of the NHS [Online]. Available from: http://news.bbc.co.uk/1/hi/health/7462013.stm [Accessed 10 September 2015]
2 Nhs.uk., 2015. The principles and values of the NHS in England – NHS Choices [Online]. Available from: http://www.nhs.uk/nhsengland/thenhs/about/pages/nhscoreprinciples.aspx [Accessed 10 September 2015]
3 Politics.co.uk., 2015. NHS (National Health Service) [Online]. Available from: http://www.politics.co.uk/reference/nhs-national-health-service [Accessed 10 September 2015]
4 News.bbc.co.uk., 2015. Timeline of the history of the NHS [Online]. Available from: http://news.bbc.co.uk/1/hi/health/7462013.stm [Accessed 14 September 2015]
5 The Independent, 2008. The birth of the NHS [Online]. Available from: http://www.independent.co.uk/life-style/health-and-families/features/the-birth-of-the-nhs-856091.html [Accessed 14 September 2015]
6 Nhs.uk., 2015. About the National Health Service (NHS) in England – NHS Choices [Online]. Available from: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx [Accessed 15 September 2015]
7 BBC News, 2015. The changing NHS – BBC News [Online]. Available from: http://www.bbc.co.uk/news/health-19674838 [Accessed 15 September 2015]
8 Nhs.uk., 2015. NHS history 2010s – NHS in England – NHS Choices [Online]. Available from: http://www.nhs.uk/NHSEngland/thenhs/nhshistory/Pages/nhs-history-2010s.aspx [Accessed 14 September 2015]
9 News.bbc.co.uk., 2015. Polyclinics ‘may not boost care’ [Online]. Available from: http://news.bbc.co.uk/1/hi/health/7436021.stm [Accessed 14 September 2015].
10 Walshe K., 2010. Reorganisation of the NHS in England. BMJ.341:c3843-c3843.
11 BBC News, 2015. The changing NHS – BBC News [Online]. Available from: http://www.bbc.co.uk/news/health-19721977 [Accessed 15 September 2015]
12 Hospital Planning and Method. BMJ. 1948;1(4563):1197-1198.