A BRIEF HISTORY OF THE
NATIONAL HEALTH SERVICE (Part 2)






An Expectant Nation Welcomes The New Arrival 1948-1958

The National Health Service came into operation at midnight on the 4th July 1948. It was the first time anywhere in the world that completely free healthcare was made available on the basis of citizenship rather than the payment of fees or insurance premiums.

In social terms although the war had ended three years earlier 1948 fell squarely in what was an era of economic stagnation: food was still rationed, building materials were short, there was a dollar economic crisis and a shortage of fuel. The war had created a housing crisis - alongside post-war re-building of cities, and the designation of overspill areas, the New Towns Act (1946) created major new centres of population and all needed health services.

The new National Health Service launched as a single organisation based around 14 regional hospital boards and it was split into three parts for the purpose of administration:

- hospital services

- family doctors, dentists, opticians and pharmacists

- local authority health services, including community nursing and health visiting


Sylvia Diggory, a 13 year old from Manchester, is officially recorded as the first NHS patient. Sylvia was in the Park Hospital at Trafford in Manchester suffering from acute nephritis, a potentially fatal liver condition, when she noticed that the hospital was being tidied up for the visit of an important guest, Aneurin Bevan. Below is a photograph of Sylvia with Nye Bevan.












Today, Mrs Diggory says of the NHS: "It's fantastic - it's an incredible structure. When you really think about it there is no one else in the world who has anything to come up to it."

There is a plaque in the hospital officially recognising Sylvia Diggory's place in NHS history.

Funding and Organisation

As we know the NHS is funded by the taxpayer and managed by the Department of Health, which sets overall policy on health issues and whose responsibility it is to provide health services to the general public through the NHS.

The National Health Service Act created a free medical service for all, funded partly from National Insurance contributions but mainly out of general taxation. The notion that your National Insurance contributions pay for your health care and your future pension benefits is something that people do still appear to hang onto, even now I hear clients of a certain age refer to "paying their stamp."

It's actually worth taking time out here to explain the National Insurance Fund

National Insurance is the system through which contributions by working people and employers are paid into a fund - the National Insurance Fund - to finance a range of benefits, including state pensions (but not the means-tested pension credit), incapacity benefit, widows benefits, maternity allowance, guardian's allowance, jobseeker's allowance and the Christmas bonus. In 2004-05 the Fund's total expenditure was £63.2bn, of which £48.6bn was spent on state pensions.

Since 1948, a proportion of NI contributions has been allocated to the National Health Service. Originally, the whole of the contribution income was paid into the National Insurance Fund, from which the appropriate amount was transferred to the NHS. The current legislation, however, provides for the contributions to be paid into the NI Fund after deducting the appropriate NHS allocation - but let's get back to 1948 via a quick stop in 1834.

In 1834, the Poor Law Commission set up by Earl Grey the Prime Minister, had examined the workings of the Poor Law in Britain and, after making several recommendations to Parliament, passed the Poor Law Amendment Act. The act stated that:

(a) no able-bodied person was to receive money or other help from the Poor Law authorities except in a workhouse;
(b) conditions in workhouses were to be made very harsh to discourage people from wanting to receive help;
(c) workhouses were to be built in every parish or, if parishes were too small, in unions of parishes;
(d) ratepayers in each parish or union had to elect a Board of Guardians to supervise the workhouse, to collect the Poor Rate and to send reports to the Central Poor Law Commission; (e) the three man Central Poor Law Commission would be appointed by the government and would be responsible for supervising the Amendment Act throughout the country.

In 1948 the Poor Law was abolished. It might seem strange to mention the Poor Law in connection with the NHS but it is important to consider what a huge social change was about to take place as a result of the launching of a service funded by all for all . Although gone it was not forgotten and part of its aims did continue through the National Assistance Board which provided a means-tested safety net for those not adequately covered by the new legislation.

Administrative Difficulties and The Introduction of Fees

The NHS brought hospital services, family practitioner services (doctors, pharmacists, opticians and dentists) and community-based services into one organisation for the first time. But it was not easy. Holding everything together and keeping everyone on board continued to create administrative difficulties for years.

Financial problems, however, were worse. It was impossible to predict the day-to-day costs of the new service and public expectations rose. Medical science was rapidly gathering pace, hospital beds for tuberculosis were closed, allowing cash to be released for other services.

More mothers were wanting their babies delivered in hospital, cardiac surgery was being applied to rheumatic heart disease, and the first hip replacements were beginning to be performed.

More than fifty years after the NHS came into being, figures from 2006 show that there are approximately 30,000 hip replacement operations performed in the U.K each year at a cost to the NHS (and ultimately you and me) of £140 million.

But initial estimates of the cost of the NHS were soon exceeded as newer, more expensive and more frequently used drugs were developed.

Many of the tensions that emerged in the early days of the NHS have challenged its senior management and successive Governments ever since. Today the NHS has a workforce of over one million people and a budget of around £62 billion year - it is a sophisticated and modern organisation with all the advantages of state-of-the-art technology. Yet, the fundamental questions that tested Bevan and his colleagues - how best to organise and manage the service, how to fund it adequately, how to balance the often conflicting demands and expectations of patients, staff and taxpayers, how to ensure finite resources are targeted where they are most needed - continue to challenge the system.

Bevan foresaw this. "We shall never have all we need," he said, "Expectations will always exceed capacity. The service must always be changing, growing and improving - it must always appear inadequate."

The Labour Party's insistence on universality went further than many Liberals and Conservatives wanted or wished and it took less than three years before a compromise had to be reached, when it did the NHS took on a new complexion.

In 1951 means-tested charges were introduced for spectacles.. Prescription charges of one shilling (5p), which had been legislated for as early as 1949 but had not been implemented, were introduced in 1952. A flat rate of £1 for ordinary dental treatment was brought in at the same time and this caused the resgination, in protest against their introduction, of Aneurin Bevan.

The eternal problem of funding the National Health Service had emerged less than three years after it had begun..

Further problems with funding and the inequalities they would cause would be reintroduced by both Labour and Conservative governments during the 1960's but more of that in part 3.

Family doctors and Community Health

The foundation of the new service was the family doctor or general practitioner (GP). Then, as now, the family doctor acted as gate-keeper to the rest of the NHS, referring patients where appropriate to hospitals or specialist treatment and prescribing medicines and drugs.

Dental services consisted of check-ups and all necessary fillings and dentures. There was a school dental service and a special priority service for expectant and nursing mothers and young children that was organised by local authorities. Eye tests were provided by ophthalmic opticians on production of a GP referral note.

A major innovation was the community health centres - a special premise with accommodation and equipment supplied from public funds to enable family doctors, dentists and others to work together to provide a range of services on the spot. There were also specialist ear clinics at which patients could get an expert opinion and, if needed, a new hearing aid.

The social changes caused by the first ten years of the NHS were greater than any other peacetime event, families no longer had to try weird and wonderful remedies when sick, they could see, hear and eat better thanks to the NHS.

If the first ten years of the NHS had proved both challenging to those at the sharp end, and a relief to its patients the next deacde would see further changes in funding and services available. It would also lead to the abandonment of Labour's 1948 idea of universality via a social change that still resonates with those of us over forty years old who were school children during the late sixties and early seventies.

to be continued.......................