'The origins of the NHS

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'The origins of the NHS

• Virginia Berridge
• Centre for History in Public Health
• London School of Hygiene and Tropical Medicine

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The NHS now
Courtesy G. Rivett
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The paradox of the NHS

• Why did Britain, with a strong tradition of
  insurance funded health care, and of health
  services funded in local government, adopt a tax
  funded system for the NHS based on the hospital
  sector and centrally directed?

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Plan of the lecture

• 1.The paradox of the NHS
• 2.The origins of the NHS more distant and
  immediate
• 3.The successes and deficiencies of the NHS
• 4. Issues for the present.

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Some key dates

• 1911 National Health Insurance
• 1919 Ministry of Health
• 1920 Dawson Report plans universal system
• 1929 End of the Poor Law
• 1937 Political and Economic Planning Report
• 1939 Emergency Medical Service
• 1942 Beveridge Report
• 1944 Coalition White Paper
• 1945 Labour Government elected
• 1946 NHS Act
• 5 July 1948 The appointed day.

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Early precedents

• Precedent friendly societies
• 1906-11 Liberal welfare reforms
• School medical inspection
• Old age pensions
• Unemployment insurance
• 1911 Health insurance
• Compulsory for wage earners
• Costs employees, employers, state
• Benefits wage replacement, practitioner
  attendance, not hospital care

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Inter war developments 1 health insurance

• Insurance income limit gradually raised excludes
  dependents not in work, housewives, children
  under 16 and elderly.
• Unequal treatment for private and panel
  patients.
• Restrictions on clinical freedom by approved
  societies.
• Widespread self medication and counter
  prescribing.

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Inter war developments 2 hospitals

• Voluntary hospitals
• - charity in decline
• - growing demand
• - uneven provision
• Poor Law institutions
• - the end of the Poor Law?
• - what happened to PL hospitals
• - poor quality and stigma

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Inter war 3 public health as a state system?

• The Medical Officer of Health and his empire
• Did public health fail or was it a success? Could
  public health and the local authorities have
  formed the basis of the NHS?

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Problems of the pre war system

• Overall problems pre war integration finance,
  comprehensiveness.
• The rising demand for planning e.g. 1937 PEP The
  British Health Services

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Wartime planning

• Emergency Medical Service
• Beveridge report 1942
• The 1944 White Paper A National Health Service
• 1945 Labour victory and the 1946-48 negotiations

Henry Willink
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The National Health Service

• Free comprehensive health service at the point of
  need universalising the best
• Direct taxation, not insurance or local taxation
• Nationalisation of hospitals and regional
  structures
• GPs paid according to capitation, not salaried
• Prescriptions, dental care and spectacles free
  (until 1951)
• Health centres
• Local authority limited role

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The coming of the NHS

• I well remember our Brian being born. He was
  delivered by a doctor up at Oldham, a Scotsman,
  he got called up and killed in the war, so we
  never paid for Brian. The doctors were very good.
  Youd go to the doctor. He had your name and
  address. And after, youd got a bill, and if you
  couldnt pay it, which very few people could,
  each doctor had his own collector. The collectors
  used to come round each week and youd pay
  sixpence. My wifes father and mother used to say
  theyd never be straight in their lifetime. When
  the National Health came in all those doctors
  bills were written off. The collectors used to be
  the same type who were park collectors in them
  days-theyd be no use today, kidsd throw them in
  the pond - but they were always little wizened
  fellers.

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Historical debates

• Consensus or conflict? The role of public
  opinion?
• Bevan - hero or villain?

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Successes and problems

• Access for all especially women. Popular support.
  Fear of poor health and inability to pay removed.
• Advances in medicine hence a sickness hospital
  based service
• Financial profligacy?
• Top down and centralised?
• Failure of integration
• Public and patient involvement the democratic
  deficit.
• Pre 1948 issues
• Interface health and social care
• Doctors and the state

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Current issues with a history

• The political nature of health because of tax.
• Integration of services and boundaries with
  social care
• Specialist/general the Darzi proposals.
• The new localism and democracy
• Rising expectations and allocation of resources.
• Prevention and cure
• Other echoes from history?