'The origins of the NHS’'The origins of the NHS’

Virginia BerridgeVirginia BerridgeCentre for History in Public Centre for History in Public

HealthHealthLondon School of Hygiene and London School of Hygiene and

Tropical Medicine Tropical Medicine

The NHS nowThe NHS now

Courtesy G. Rivett

The paradox of the NHSThe paradox of the NHS

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

Plan of the lecturePlan of the lecture

• 1.The paradox of the NHS1.The paradox of the NHS

• 2.The origins of the NHS: more 2.The origins of the NHS: more distant and immediatedistant and immediate

• 3.The successes and deficiencies of 3.The successes and deficiencies of the NHSthe NHS

• 4. Issues for the present. 4. Issues for the present.

Some key datesSome key dates

• 1911 National Health Insurance1911 National Health Insurance

• 1919 Ministry of Health 1919 Ministry of Health

• 1920 Dawson Report plans universal system1920 Dawson Report plans universal system

• 1929 End of the Poor Law1929 End of the Poor Law

• 1937 Political and Economic Planning Report1937 Political and Economic Planning Report

• 1939 Emergency Medical Service1939 Emergency Medical Service

• 1942 Beveridge Report1942 Beveridge Report

• 1944 Coalition White Paper1944 Coalition White Paper

• 1945 Labour Government elected1945 Labour Government elected

• 1946 NHS Act1946 NHS Act

• 5 July 1948 ‘The appointed day’.5 July 1948 ‘The appointed day’.

Early precedents Early precedents

• Precedent – Precedent – friendly friendly societiessocieties

• 1906-11 1906-11 Liberal welfare Liberal welfare reformsreforms– School medical inspection School medical inspection – Old age pensionsOld age pensions– Unemployment insuranceUnemployment insurance

• 1911 1911 Health insuranceHealth insurance– Compulsory for wage earnersCompulsory for wage earners– Costs: employees, Costs: employees,

employers, stateemployers, state– Benefits: wage replacement, Benefits: wage replacement,

practitioner attendance, practitioner attendance, not not hospital care hospital care

Inter war developments 1: Inter war developments 1: health insurancehealth insurance

• Insurance income limit Insurance income limit gradually raised: excludes gradually raised: excludes dependents not in work, dependents not in work, housewives, children under 16 housewives, children under 16 and elderly.and elderly.

• Unequal treatment for private Unequal treatment for private and ‘panel’ patients.and ‘panel’ patients.

• Restrictions on clinical Restrictions on clinical freedom by ‘approved’ freedom by ‘approved’ societies.societies.

• Widespread self medication Widespread self medication and ‘ counter prescribing’.and ‘ counter prescribing’.

Inter war developments 2: Inter war developments 2: hospitalshospitals• Voluntary Voluntary

hospitalshospitals• - charity in decline- charity in decline• - growing demand- growing demand• - uneven provision - uneven provision • Poor Law Poor Law

institutionsinstitutions • - the end of the Poor - the end of the Poor

Law?Law?• - what happened to PL - what happened to PL

hospitalshospitals• - poor quality and stigma - poor quality and stigma

Inter war 3: public health as a Inter war 3: public health as a state system?state system?

• The Medical Officer of The Medical Officer of Health and his ‘ empire’Health and his ‘ empire’

• Did public health fail or Did public health fail or was it a success? Could was it a success? Could public health and the public health and the local authorities have local authorities have formed the basis of the formed the basis of the NHS?NHS?

Problems of the pre war Problems of the pre war system system

• Overall problems pre warOverall problems pre war: : integration; finance, integration; finance, comprehensiveness.comprehensiveness.

• The rising demand for planning e.g. The rising demand for planning e.g. 1937 PEP 1937 PEP The British Health Services The British Health Services

Wartime planningWartime planning

• Emergency Medical Emergency Medical ServiceService

• Beveridge report Beveridge report 19421942

• The 1944 White The 1944 White Paper Paper A National A National Health ServiceHealth Service

• 1945 Labour victory 1945 Labour victory and the 1946-48 and the 1946-48 negotiationsnegotiations

Henry Willink

The National Health ServiceThe National Health Service

• Free comprehensive health Free comprehensive health service at the point of need service at the point of need ‘universalising the best’‘universalising the best’

• Direct taxation, not insurance Direct taxation, not insurance or local taxationor local taxation

• Nationalisation of hospitals Nationalisation of hospitals and regional structuresand regional structures

• GPs paid according to GPs paid according to capitation, not salariedcapitation, not salaried

• Prescriptions, dental care and Prescriptions, dental care and spectacles free (until 1951)spectacles free (until 1951)

• Health centresHealth centres• Local authority limited roleLocal authority limited role

The coming of the NHSThe coming of the NHS

• I well remember our Brian being born. He was I well remember our Brian being born. He was delivered by a doctor up at Oldham, a Scotsman, he delivered by a doctor up at Oldham, a Scotsman, he got called up and killed in the war, so we never paid got called up and killed in the war, so we never paid for Brian. The doctors were very good. You’d go to the for Brian. The doctors were very good. You’d go to the doctor. He had your name and address. And after, doctor. He had your name and address. And after, you’d got a bill, and if you couldn’t pay it, which very you’d got a bill, and if you couldn’t pay it, which very few people could, each doctor had his own collector. few people could, each doctor had his own collector. The collectors used to come round each week and The collectors used to come round each week and you’d pay sixpence. My wife’s father and mother used you’d pay sixpence. My wife’s father and mother used to say they’d never be straight in their lifetime. When to say they’d never be straight in their lifetime. When the National Health came in all those doctors’ bills the National Health came in all those doctors’ bills were written off. The collectors used to be the same were written off. The collectors used to be the same type who were park collectors in them days-they’d be type who were park collectors in them days-they’d be no use today, kids’d throw them in the pond - but they no use today, kids’d throw them in the pond - but they were always little wizened fellers.were always little wizened fellers.

Historical debatesHistorical debates

• Consensus or Consensus or conflict? The role conflict? The role of public of public opinion?opinion?

• Bevan - hero or Bevan - hero or villainvillain??

Successes and problemsSuccesses and problems• Access for all especially women. Popular Access for all especially women. Popular

support. Fear of poor health and inability to support. Fear of poor health and inability to pay removed.pay removed.

• Advances in medicine: hence a sickness Advances in medicine: hence a sickness hospital based servicehospital based service

• Financial profligacy?Financial profligacy?• Top down and centralised?Top down and centralised?• Failure of integrationFailure of integration• Public and patient involvement: the Public and patient involvement: the

democratic deficit.democratic deficit.

• Pre 1948 issuesPre 1948 issues• Interface health and social careInterface health and social care• Doctors and the stateDoctors and the state

Current issues with a historyCurrent issues with a history

• The political nature of The political nature of health because of tax.health because of tax.

• Integration of services Integration of services and boundaries with and boundaries with social caresocial care

• Specialist/general: the Specialist/general: the Darzi proposals.Darzi proposals.

• The ‘new localism’ and The ‘new localism’ and democracy democracy

• Rising expectations and Rising expectations and allocation of resources.allocation of resources.

• Prevention and curePrevention and cure• Other echoes from Other echoes from

history?history?