Rise of State Medicine

& the Birth of the NHS

Lecture 20

Medicine, Disease and Society in Britain, 1750 - 1950

• Links to previous lecture themes: Social medicine in interwar period, medical marketplace

• Was the NHS a radical new model of health care or were there important continuities with the past?

• Was the NHS born out of consensus or conflict?  • What is the relationship of the health care system

to wider political economy (John Pickstone’s model of Productionist, communitarian and consumerist medicine )

Lecture themes

C20: ‘great troika of progress - science, profession, state’

1900-1948- Productionist focus on health of the industrial worker and the armed services

1948- 1970- CommunitarianNHS - expansion of services, focus on social inclusionRise of the professional

1970-2000- ConsumptionRenewed emphasis on market and on lay management to challenge professionals

John Pickstone, ‘Production, community and consumption: The political economy of

twentieth-century medicine’ (2000)

• 1909- Old Age Pensions introduced

• 1911- National Insurance Act– Access to GP services via a panel doctor– Hospital treatment not included– Sickness benefit (replacing lost income)

– Administered through ‘approved mutual societies’.

– Benefits limited to the contributor (worker) - mainly men. Women and children were not covered.

National Insurance and Pensions

‘The Dawn of Hope’ The National Insurance Act of 1911

National Health Insurance introduced in 1911

A ‘patchwork’ of services - Hospital beds

(Webster, Caring for Health (1993)p. 121.

Public Voluntary

1861 50,000 11,000

1891 83,000 29,000

1911 154,000 43,000

1921 172,000 57,000

1938 176,000 87,000

Sources of income of London voluntary hospitals (Webster, Caring for Health (1993)p. 139).

1938 1947

% %

Voluntary gifts 34 16

Investments 16 8

Public authority 8 46

Other (incl. patients fees) 42 30

100 100

• Hospitals vs local authorities• Early c20th - Local authorities

increasingly involved in health provision e.g. Infant centres

• Local Government Act 1929 – local authorities took over workhouse infirmaries and infectious disease hospitals

• However, provision varied• Coincided with economic social,

political change – extension of franchise, boom and depression

Finsbury Health Centre

By the Outbreak of the 2nd World war, there was demand for change from a number of

groups:

• The Socialist Medical Association (SMA) were a group of left wing doctors who called for a free national health service administered by local authorities

• The Labour Party were committed to the idea of a free National Health Service by 1939

• Public

Beveridge Report - Social Insurance and Allied Services (1942) recommended a

comprehensive health service White Paper A National Health Service published in February

1944.

‘To ensure that everybody in the country- irrespective of means, age, sex and occupation- shall have equal opportunity to benefit from the most up to date medical and allied services available…to divorce the case of health from questions of personal means and other factors irrelevant to it; to provide the service free of charge…and to encourage a new attitude to health- the easier obtaining of advice early on, the promotion of good health rather than only treatment of the bad,. (MoH, 1944, p. 47)’

‘Fight for it now’ - poster from World War 2 showing the Finsbury Health Centre

Opposition from Medical Profession

• Objected to the concept of a salaried service

• Objected to Local Authority control

• Fear that would threaten clinical freedom

• Echoed control of Poor Law and Friendly Societies

• Wanted an enhanced role for voluntary hospitals and consultants.

Members of the BMA

dressed as gladiators,

conceding the introduction of National

Health Service to Aneurin

Bevan, dressed as

Nero.

National Health Service Act 1946 - tripartite system

• Hospitals: Voluntary and local authority hospitals were nationalised - managed by regional boards

• Local Authorities - health centres, clinics, health visiting, ambulances

• GP, dental and optician services - provided by independent contractors administered by Executive Councils

NHS introductory leaflet

C20: ‘great troika of progress- science, profession, state’

1900-1948- Productionist focus on health of the industrial worker and the armed services

1948- 1970- CommunitarianNHS- expansion of services, focus on social inclusionRise of the professional

1970-2000- ConsumptionRenewed emphasis on market and on lay management to challenge professionals

John Pickstone, ‘Production, community and consumption: The political economy of

twentieth-century medicine’ (2000)

Conclusion

• Long build up to change in provision of health services – But when? 1911 Act? 1920s? 1930? Historians disagree

• Opposition from the medical profession and other important groups

• Was the NHS a radical new model of health care or were there important continuities with the past?

• Was the NHS born out of consensus or conflict?