Annex A > Chapter 2 - A Historical Background to the NHS > The creation of the National Health Service

The creation of the National Health Service

3 The structure of the NHS in England and Wales was established by the National Health Service Act 1946 (1946 Act). The new arrangements were launched on 5 July 1948.

4 The delivery of healthcare prior to that date had been achieved through a patchwork of fragmented arrangements. Voluntary hospitals, supported in part by charitable donation, provided care to those covered by insurance or contributory schemes, or who could otherwise afford to pay for care. Other hospitals were owned and managed by local authorities. [1] Hospital surveys carried out during the Second World War revealed not only shortages of beds and buildings in a poor state, but that services were not provided in the areas which most needed them. [2]

5 Family practitioner services were provided then, as now, by general practitioners. The National Insurance Act of 1911 gave, for the first time, entitlement to free access to a general practitioner working on the doctor's panel. Some 21 million workers, but not their families, were covered by this insurance scheme in 1942. The quality of services provided varied widely, as it did in the hospital sector. The distribution of general practitioners did not necessarily correspond to the areas where their services were most needed. General practitioners were independent contractors, not salaried employees of a state-provided medical service. This was a status that they would successfully preserve under the new NHS.

6 The late nineteenth century and early twentieth century saw developments towards establishing the professional status of nurses, opticians, midwives, pharmacists and other providers of medical services. But the provision of community health services was highly fragmented. This was particularly so because the levels of services provided to local inhabitants by local authorities varied greatly.

7 Against this background, Sir William Beveridge's report `Social Insurance and Allied Services' [3] recommended the creation of a comprehensive health service, in which the full range of medical and nursing services would be free to each citizen who needed them. These aims were accepted in the White Paper published in 1944, `A National Health Service', [4] and maintained after the Coalition Government of the Second World War years was replaced by a Labour Government in 1945.

8 Under the 1946 Act, it was to be `the duty of the Minister ... to promote the establishment in England and Wales of a comprehensive Health Service designed to secure the improvement of the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness'. The services to be provided to meet these aims were to be free of charge. For the first time, the Minister of Health was made personally accountable to Parliament for hospital and other specialised services. He was indirectly responsible for family practitioner and local health services.

9 The structure of the NHS from 1948-1974 may be summarised as follows:

Table 1: The National Health Service 1948-74 (England and Wales) [5]

10 Hospitals were nationalised. They were managed either by hospital management committees and regional hospital boards, or, in the case of teaching hospitals, by boards of governors responsible directly to the Minister of Health. Funding for the hospitals came from the Ministry of Health directly to the boards of governors of teaching hospitals, or to regional health boards, which in turn passed it to the hospital management committees.

11 Executive councils administered local family practitioner services: that is, general medical, dental and ophthalmic services, and pharmaceutical services. Local authorities were responsible for community health services, including health visitors and district nurses, vaccinations and immunisations, maternal and child welfare, ambulance services and services for the mentally ill and those with learning disabilities who were not in hospital. [6]

12 Negotiations with interested parties, and in particular representatives of the medical profession, ensured that general practitioners retained their status as independent contractors. They had a contract with the local executive councils, rather than being employed by either central or local government. General practitioners were allowed to do an unlimited amount of private work (although there was very little demand for private general practitioner services from the general public). Furthermore, salaried hospital doctors were allowed to undertake private work in hospital pay beds, in addition to their contractual duties to the NHS. A system of merit or distinction awards was introduced: hospital specialists who were judged to be meritorious by their peers were given special payments over and above their basic salaries.

13 While there were differences between various groups, there were broad areas of agreement. In particular:

`Implicit in the consensus about the general aims of policy was a shared, optimistic faith in progress through the application of diagnostic and curative techniques. In turn, this mirrored the belief that medical science had not only triumphed over disease and illness in the past but would continue to do so in future. On this view, the only problem was how best to create an institutional framework which would bring the benefits of medical science more efficiently and equitably to the people of Britain.' [7]

14 Thus, there was little anticipation that the experience of freely available healthcare would stimulate demand. On the contrary, it was thought that expenditure would gradually decline as the nation became healthier.

<< previous | next >> | back to top

Footnotes

[1] The hospitals run by local authorities had evolved from the workhouses provided under the Poor Laws. They tended to provide lower standards of care. Voluntary hospitals tended to concentrate on the needs of the acutely ill, rather than those with infectious diseases or the chronically ill. See Ham C., `Health Policy in Britain', p. 8 (4th edition, 1999), Macmillan Press Ltd

[2] See the survey of the hospital sector from the Nuffield Provincial Hospitals Trust (1946), `The Hospital Surveys: the Domesday Book of the Hospital Services', OUP

[3] Beveridge, W. `Social Insurance and Allied Services' (1942), London: HMSO (Cmnd 6404)

[4] `A National Health Service' (1944), London: HMSO (Cmnd 6502)

[5] Levitt R, Wall A, Appleby J. `The Reorganised National Health Service' (6th edition, 1999), Stanley Thornes (Publishers) Ltd. Reproduced with the permission of Nelson Thornes Ltd from The Reorganised National Health Service 6e, Levitt, Wall and Appleby, 1999

[6] National Health Service Act 1946, Sections 19-30

[7] Klein, R.`The New Politics of the National Health Service', p. 25 (3rd edition, 1995), Longman