The name National Health Service (NHS) is used to refer to the publicly funded health care services of England, Scotland and Wales, individually or collectively. Northern Ireland's services are known as 'Health and Social Care' to promote its dual integration of health and social services.
For details of the history of each National Health Service, particularly since 1999, see:
History of the National Health Service (England) History of NHS Scotland History of NHS Wales History of Health and Social Care in Northern Ireland
The NHS was one of the first universal health care systems established anywhere in the world. A leaflet was sent to every household in June 1948 which explained that
The NHS in Scotland was established as a separate entity with its own legislation, the National Health Service (Scotland) Act 1947, from the foundation of the NHS in 1948. Northern Ireland likewise had its own legislation in 1948. Wales was part of a single system with England for the first 20 years of the NHS. In 1969, responsibility for the NHS in Wales was passed to the Secretary of State for Wales from the Secretary of State for Health, who was thereafter just responsible for the NHS in England.
Background
Dr Benjamin Moore, a Liverpool physician, in 1910 in The Dawn of the Health Age was probably the first to use the words 'National Health Service'. He established the State Medical Service Association which held its first meeting in 1912 and continued to exist until it was replaced by the Socialist Medical Association in 1930.
Before the National Health Service was created in 1948, patients were generally required to pay for their health care. Free treatment was sometimes available from charitable voluntary hospitals. Some local authorities operated hospitals for local ratepayers (under a system originating with the Poor Laws). The London County Council (LCC) on 1 April 1930 took over from the abolished Metropolitan Asylums Board responsibility for 140 hospitals, medical schools and other medical institutions. The Local Government Act 1929 allowed local authorities to run services over and above those authorised by the Poor Laws and in effect to provide medical treatment for everyone. By the outbreak of the Second World War, the LCC was running the largest public health service in Britain.W. Eric Jackson, "Achievement: A Short History of the LCC", Longmans, 1965, p. 25.
Dr A. J. Cronin's controversial novel The Citadel, published in 1937, had fomented extensive criticism about the severe inadequacies of health care. The author's innovative ideas were not only essential to the conception of the NHS, but his best-selling novels are also said to have greatly contributed to the Labour Party's victory in 1945.R. Samuel, "North and South," London Review of Books 17.12 (22 June 1995): 3–6.
Systems of health insurance usually consisted of private schemes such as friendly societies or welfare societies. Under the National Insurance Act 1911, introduced by David Lloyd George, a small amount was deducted from weekly wages, to which were added contributions from the employer and the government. In return for the record of contributions, the workman was entitled to medical care (as well as retirement and unemployment benefits) though not necessarily to the drugs prescribed. To obtain medical care, he registered with a doctor. Each doctor in General Practice who participated in the scheme thus had a 'panel' of those who have made an insurance under the system, and was paid a capitation grant out of the fund calculated upon the number. Lloyd George's name survives in the Lloyd George envelope in which most primary care records in England are stored, although today most working records in primary care are at least partially computerised. This imperfect scheme only covered workers who paid their National Insurance Contributions and was known as 'Lloyd George's Ambulance Wagon'. Most women and children were not covered.
Foundation
Bertrand Dawson was commissioned in 1919 by Christopher Addison, the first British Minister of Health to produce a report on "schemes requisite for the systematised provision of such forms of medical and allied services as should, in the opinion of the Council, be available for the inhabitants of a given area". An Interim Report on the Future Provision of Medical and Allied Services was produced in 1920, though no further report ever appeared. The report laid down plans for a network of primary and secondary health centres, and was very influential in subsequent debates about the National Health Service. However, the fall of the Lloyd George government prevented any implementation of those ideas at that time.
The Labour Party in 1932 accepted a resolution moved by Somerville Hastings calling for the establishment of a State Medical Service and in 1934 the Labour Party Conference at Southport unanimously accepted an official document on a National Health Service.
Prior to the Second World War there was already consensus that health insurance should be extended to the dependants of the wage-earner, and that the voluntary and local authority hospitals should be integrated. A British Medical Association (BMA) pamphlet, "A General Medical Service for the Nation" was issued along these lines in 1938. However, no action was taken due to the international crisis. During the war, a new centralised state-run Emergency Hospital Service employed doctors and nurses to care for those injured by enemy action and arrange for their treatment in whichever hospital was available. The existence of the service made voluntary hospitals dependent on the Government and there was a recognition that many would be in financial trouble once peace arrived.Paul Addison, The Road to 1945, Jonathan Cape, 1975, pp. 178–81. The need to do something to guarantee the voluntary hospitals meant that hospital care drove the impetus for reform.
In February 1941 the Deputy Permanent Secretary at the Ministry of Health recorded privately areas of agreement on post-war health policy which included "a complete health service to be available to every member of the community" and on 9 October 1941, the Minister of Health Ernest Brown announced that the government proposed to ensure that there was a comprehensive hospital service available to everyone in need of it and that local authorities would be responsible for providing it."Post-War Policy For Hospitals", The Times, 10 October 1941, p. 4. The Medical Planning Commission set up by the professional bodies went one stage further in May 1942 recommending (in an interim report) a National Health Service with general practitioners working through health centres and hospitals run by regional administrations. When in 1942 Arthur Greenwood, the Labour Party Deputy Leader and cabinet minister with responsibility for post-war reconstruction, successfully pressed the cabinet to commission a report into social insurance from economist and social reformer William Beveridge,Paul Addison, "The Road to 1945", Jonathan Cape, 1975, p. 167-9. Beveridge attached an assumption to the Beveridge Report that this same idea would be implemented; his report stressed the importance of it.
Developing the idea into firm policy proved difficult. Although the BMA had been part of the Medical Planning Commission, at their conference in September 1943 the association changed policy to oppose local authority control of hospitals and to favour extension of health insurance instead of GPs working for state health centres. When Conservative MP and Health Minister Henry Willink prepared a white paper endorsing a National Health Service, it was attacked by Brendan Bracken and Lord Beaverbrook and resignations were threatened on both sides. However, the Cabinet endorsed the White Paper which was published in 1944.Paul Addison, The Road to 1945, Jonathan Cape, 1975, pp. 239–42. This White Paper includes the founding principles of the NHS: it was to be funded out of general taxation and not through national insurance, and services would be provided by the same doctors and the same hospitals, but: Services were provided free at the point of use; Services were financed from central taxation; Everyone was eligible for care (even people temporarily resident or visiting the country).
Willink then set about trying to assuage the doctors, a job taken over by Aneurin Bevan in Clement Attlee's Labour Party government after the war ended. Bevan decided that the 1944 white paper's proposal for local authority control of voluntary hospitals was not workable, as he felt that local authorities were too small to manage hospitals.Hansard , HC 5ser vol 422 cols 48 et seq. He decided that "the only thing to do was to create an entirely new hospital service, to take over the voluntary hospitals, and to take over the local government hospitals and to organise them as a single hospital service".Hansard , HC 5ser vol 422 cols 49–50. He did so working with the civil servant John Hawton."Obituary: Sir John Hawton", The Times (London), 9 January 1982, p. 8.
This structure of the NHS in England and Wales was established by the National Health Service Act 1946 which received royal assent on 6 November 1946. The Act implemented a system where each person resident would be signed up to a specific general practitioner (GP) as the point of entry into the system, building on the foundations laid in 1912 by the introduction of National Insurance and the list system for general practice. Patients would have access to all medical, dental and nursing care they needed without having to pay for it at the time.
Many doctors were initially opposed to Bevan's plan, primarily on the grounds that it reduced their level of independence. The British Medical Association voted in May 1948 not to join the new service,A Labour delivery www.60yearsofnhsscotland.co.uk. Retrieved 11 August 2008 but Bevan worked hard to bring them on board by the time the new arrangements launched on 5 July 1948 knowing that without doctors, there would be no health service. Being a shrewd political operator, Bevan managed to push through the radical health care reform measure by dividing and cajoling the opposition, as well as by offering lucrative payment structures for consultants. At a dinner in late 1955 or early 1956 to celebrate the publication of the Guillebaud Report into NHS costs Bevan remarked to Julian Tudor Hart "ultimately I had to stuff their mouths with gold" about his handling of the consultants. This is often quoted as "I stuffed their mouths with gold".
Establishment In 1979 across the whole UK there were about 2,750 NHS hospitals with about 480,000 beds, accounting for about 70% of total NHS expenditure. About one-third of beds in England were then provided in new or converted accommodation built since 1948 with a higher proportion in Northern Ireland, but lower in Scotland and Wales. Beds for mental illness, geriatric patients and mental handicap were much more likely to be in older buildings than acute or maternity services.
Access Aneurin Bevan, in considering the provision of NHS services to overseas visitors wrote, in 1952, that it would be "unwise as well as mean to withhold the free service from the visitor to Britain. How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? For if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody."