Annex A > Chapter 2 - A Historical Background to the NHS > The National Health Service from 1948 to 1974

The National Health Service from 1948 to 1974

15 During the 1950s policy-makers, administrators and healthcare professionals were given an opportunity for consolidation. Many aspects of the operation of the freshly established service required detailed attention and technical rule-making. Little information was available, for instance, about many features of the institutions that were brought under the new regional boards. Partly as a result of the paucity of data, considerable local autonomy was given to the regional boards and hospital management committees. Within the limits of a fixed budget set by national government, local diversity was considerable, and national policy-making frequently proceeded by exhortation. Administrative staff were recruited by the local boards and committees; there was no national cadre of National Health Service administrators. Medical staff made up a significant proportion of the membership of these administrative bodies.

16 At the level at which doctors treated patients, or that of clinical decision-making, the autonomy of the medical professional was unchallenged. Thus: `While central government controlled the budget, doctors controlled what happened within that budget'. [8] When, in 1974, the office of the Health Service Commissioner was established to investigate patients' complaints, its jurisdiction did not extend to investigating issues of clinical judgment. These were to be dealt with by means of the professional self-regulatory machinery (see Chapter 4 - National Accountabilities and Roles), or by the courts.

17 Contrary to the early expectations of steady or reducing costs, the cost of the NHS soon became an issue, as expenditure began to outstrip estimates. Despite the commitment to a free service, charges for spectacles and dentures, for some people, were first introduced in 1951. Prescription charges were first introduced in 1952. Concern over rising costs led to the appointment of the Guillebaud Committee of Enquiry in 1953, with a remit to see how health expenditure could be contained. But it found no evidence of extravagance or inefficiency. On the contrary, although the service had inherited old buildings in poor condition, little money had been spent improving such stock during the 1950s. It was not until the 1960s that the 1962 Hospital Plan led to an expansion of the hospital sector, with proposals for the creation of large district general hospitals serving a population of 100, 000-150, 000. [9]

18 The Plan demonstrated a growing emphasis upon the need to plan services within the NHS, as well as a faith in the ability of such planning to achieve greater efficiency and rationality in the use of NHS resources. Such an emphasis reflected the pressures on resources exerted by the rising costs of care. The reasons for such rises were debated. They included developments in medical technology and medical pressure to keep pace with such developments; rising expectations on the part of the population; pressures for higher wages and salaries within the service; and the demographic changes caused by an ageing population.

19 The Plan also sought to build on the advantages that the creation of hospital management committees had been able to bring to the organisation and planning of local hospital services. The creation of a national health service, with national pay scales and conditions of service for hospital consultants, had helped to even out the distribution of hospital staff around the country. At the same time, however, professional gulfs between the hospital consultant and the general practitioner began to widen. One of the members of the Guillebaud Committee recorded a concern that the tripartite organisation of the NHS (see Table 1 at para 9) unduly emphasised the importance of the hospitals at the expense of the other two branches of the service. Suggestions that the divisions ought to be reduced by the creation of a more unified management structure followed. [10]

20 In 1967 the Joint Working Party on the Organisation of Medical Work in Hospitals issued its first report. [11] The `Cogwheel' Report [12] saw a need for a more corporate approach to medical administration. It recommended the creation within hospitals of clinical divisions of broadly linked specialties, to ensure efficient deployment of resources and to cope with the management issues that arose within clinical fields. Divisions would be represented on a medical executive committee that would consider major medical policy and planning issues, co-ordinate hospital clinical activities and provide links to nursing and administration. It was hoped that the sharing of information produced by such links would improve the use of resources. In the same vein, hospital activity analyses would provide consultants with better data on the patterns of activity within their hospitals. The Salmon Report, in 1967, set up a new structure for nursing, when it recommended a new hospital nursing structure under the direction of a chief nursing officer. [13]

21 During the 1960s, securing co-ordination and integration between the three wings of the NHS (see Table 1 at para 9) came to be perceived as an increasing problem. Hospital authorities, local authorities and executive councils did not work together to achieve integrated solutions to problems of patient care, such as long-term care for the elderly, that spanned all three sectors. Furthermore, certain services came to be recognised as neglected or `Cinderella' services, where low standards of care for patients were common. The care of the elderly, the mentally ill and those with learning disabilities were examples. But it proved difficult to shift priorities and spending towards these disadvantaged groups. Medical advocates of such groups, such as consultant psychiatrists and geriatricians, were less influential than doctors in the acute specialties. In general, the provision of community-based services lagged behind hospital services.

22 On 1 November 1968 the Ministries of Health and Social Security were amalgamated to form the Department of Health and Social Security (DHSS). On 1 April 1969 responsibility for the NHS for Wales was transferred from the Welsh Board of Health to the Secretary of State for Wales.

23 By the end of the 1960s a consensus was developing that the tripartite structure of the NHS, established in 1948, was a source of problems. A series of reviews [14] proposed a more integrated system of management. These discussions culminated in the passage of the National Health Service Reorganisation Act 1973 (1973 Act), which introduced changes with effect from 1 April 1974.

24 Under the 1973 Act, 14 regional health authorities (RHAs) were created in England; amongst them was the South Western RHA (SWRHA). Members of the RHAs were appointed by the Secretary of State for Social Services. They were responsible for planning local health services. Under them, 90 area health authorities (in England) were established, with a Chair appointed by the Secretary of State and non-executive members appointed by the RHA and by local authorities. An area team of officers was established, made up of an administrator, a nurse, a public health doctor and a finance officer. Areas were expected to liaise with local authorities. Most areas were further divided into health districts administered by district management teams. The structure is set out in the following table:

Table 2: The Reorganised National Health Service 1974 [15]

25 In Wales, area health authorities were established but no RHA was deemed necessary. Instead, the Welsh Office played the role of both central government, and a regional health authority.

26 The reorganisation aimed to unify health services by bringing under one authority all the services which had previously been administered by regional hospital boards, hospital management committees, executive councils and local health authorities (see Table 1 at para 9). However, in a departure from this principle, general practitioners remained independent contractors. The role of the executive councils was taken over by family practitioner committees (FPCs), responsible for GPs, dentists, pharmacists and opticians. A small number of postgraduate teaching hospitals retained separate boards of governors.

27 It was intended that this reorganisation would bring about better co-ordination between the health authorities and local authorities. To foster this end, the boundaries of the area health authorities were designed to match those of the local authorities providing social services. The two were also required to set up joint consultative committees to assist the process of consultation and collaboration. [16]

28 At a district level, community health councils (CHCs) were introduced to represent the views of the public.

29 In the South West, in addition to the establishment of the South Western Regional Health Authority (SWRHA), the 1973 Act gave rise to other changes. Within the SWRHA, the Avon Area Health Authority (Teaching) was created and, below it, a number of health districts. The Avon Area Health Authority (Teaching) area included some 800, 000 people in Bristol, South Gloucestershire and North Somerset but excluded Bath. One of the health districts, Bristol Health District (Teaching), included the Bristol Royal Infirmary and the Bristol Royal Hospital for Sick Children, and served about 360, 000 people, mostly within the Bristol area. [17]

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Footnotes

[8] Klein, R.`The New Politics of the National Health Service', p. 75 (3rd edition, 1995), Longman

[9] Although a programme of hospital expansion followed, not all the aims of the Plan were fulfilled, either in terms of numbers of hospitals, or their standards. In May 1970 the `Hospital Building Maintenance: Report of the Committee, 1968 -70' (the Woodbine Parish Report), London: HMSO, was published. It criticised hospital maintenance standards and the lack of any overall strategy in the development of health service estates

[10] See for example `A Review of the Medical Services in Great Britain: Report of the Medical Services Review Committee' (the Porritt Report), (1962), London: Social Assay; and `The Administrative Structure of Medical and Related Services in England and Wales' (published by the Minister for Health in 1968)

[11] `First Report of the Joint Working Party on the Organisation of Medical Work in Hospitals' (the Cogwheel Report), (1967), London: HMSO

[12] The report, and its successors, received the name because of the design of wheels on the cover

[13] Ministry of Health and Scottish Home and Health Departments, `Report of the Committee on Senior Nursing Staff Structure' (the Salmon Report), (1966), London: HMSO

[14] The independent `Review of the Medical Services in Great Britain' (the Porritt Report) had suggested redesign in 1962. The Ministry of Health published a Green Paper, `The Administrative Structure of Medical and Related Services in England and Wales' in 1968. A further paper followed in 1970, `The Future Structure of the National Health Service'. In May 1971, the DHSS published a consultative document, `The National Health Service Reorganisation', setting out further proposals on NHS reorganisation

[15] 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

[16] The NHS Reorganisation Act 1973 coincided with the reorganisation of local government under the Local Government Act 1972

[17] WIT 0038 0005 Ms Charlwood