FROM LAISSEZ-FAIRE TO STATE WELFARE (History of the NHS)

Britain was unique in that it was the first country to experience industrial revolution. This had a profound impact on the British population. As industrialization expanded and as a result of urbanization, the population size within major cities expanded dramatically, sanitation issues and increased cases of deadly disease (mainly within the poor and working class) began to rise.

The general ideology amongst the wealthier members of society including the government at large was one of “Laissez-faire”. The government saw no need to intervene in the affairs of the poor. As such those working class people who could not afford health care quickly became victims of disease, with cholera spreading in the public water supply. At the hands of typhoid fever, tuberculosis, influenza and small pox the poorest members of the society suffered greatly, resulting in increased mortality rates.

It was not until the 1840’s that the Laissez-faire ideology was challenged, and the attitude of the government towards its people began to change. With the formation of “The Health of Towns Association” (1848)6 whose goal was to pressure the government into sanitary reform, along with the likes of Edwin Chadwick and his “Report on the sanitary conditions of the laboring population of Great Britain” (1847)--Which pointed out figures to show that in 1839 for every person who died of old age or violence, eight died of specific diseases. 1849 saw John Snow publish the “Mode of communication of cholera” in which Snow had identified the link between the cholera epidemic and the local water supplies. As a result of these organizations and social, medical reformers such as Snow and Chadwick, the Public Health Act (1848) was brought into existence. This act saw the implementation of a Central Board of Health, as well as giving towns the right to appoint a Medical Officer of Health, this introduced the inspection of living conditions, food and water supplies and sewer systems which were some of the leading contributors to poor health and the spread of disease. Sanitary science and interpersonal hygiene began major developments in much earlier periods. One example, the discovery of vaccination, actually emerged in the eighteenth century but did not gain validity until Jenner (1798)7 publicized the vaccination against smallpox, which then after Jenner’s death became compulsory in the mid nineteenth century (1853)7. As a greater understanding of the effects of the environment as well as the diseases caused by such dramatic changes in living conditions and working life became known more and more medical knowledge was gained and its relevance was being realized, as such the importance of public health was identified.

Poor health and disease were not confined to the poor, working class or homeless. The ongoing Crimean War (1853–1856) saw concerns regarding the poor health and malnutrition of those recruited into the army and navy. It was being recognized that the health of those people drafted to fight for the country was of such poor quality that they were unable to fight a war. This was a wakeup call, soldiers needed to be of sound health and to maintain that, the state would need to play an active role in the well-being of their people. It could also be argued that the good health of the working class improved capitalist production and subsequently profit, for the industrialists, however, the improved social conditions most definitely went some way in improving life expectancy and resistance to disease at this time.

In the years leading to the creation of the NHS the British Medical Association (BMA)-(1936)8 produced a report called “the General Medical Services for the Nation” which suggested that the medical benefits of the national health insurance scheme should be extended to include workers’ dependents. The BMA amended their report in 1938 to contain “four fundamental principles”. 1) “That the system of medical service should be directed to the achievement of positive health and the prevention of disease, no less than to the relief of sickness”. 2) “That every individual should be provided with the services of a general practitioner or family doctor of his/her own choice”. 3) “That consultants and specialists, laboratory services and all necessary auxiliary services together with institutional provision when required, should be available for the individual patient, normally through the agency of the family doctor”. 4) “And that the several parts of the complete medical service should be closely coordinated and developed by the application of a planned National Health Policy” (1938)2. No immediate action was taken on these proposed lines because of international crisis.

During World War 2 (1938-1945), a new centralized state run ‘Emergancy Medical Service’ (EMS) employed doctors and nurses to care for those injured in war. This created a system within which hospitals were dependent on the government for funding, this alongside the reinforcement of lessons learned during World War 1 (1914-1918.) and in the Crimean war served as impetus for massive reform, and in 1942 the Beveridge Report addressed the role of the state in meeting welfare needs of the society. This welfare state attempted to tackle what Beveridge described as the ‘five major ills’ afflicting society.

Using the leading events and the cataclysmic effects of the war it became possible to massively reform the system, and so the coalition government put forward proposals for a comprehensive medical service based on the employment of doctors as salaried officers. This proposal drew opposition from some of the BMA who’s “leaders” claimed, “state medicine” would undermine their professional independence and the sacred ‘Hippocratic oath of care’ between the doctor and the patient. Despite this, the proposals ultimately led to the establishment of a system of ‘social security’ and the National Health Service.

And so, on July 5th, 1948 within a society still shaken by war, The National Health Service was launched. The NHS was based on unique principles unlike anything in health care before it. It was financed almost 100% by taxation which was based on income. As such, the rich paid more than the poor for comparable benefits. Everyone was eligible for care, even people temporarily resident or visiting the country. Most importantly, care was entirely free at the point of use, this meant poor people who previously would have gone without medical treatment now had full access to medical services. Today, we all take the National Health Service for granted, but only 60 years ago health care was a luxury few could afford. It is difficult to imagine what life would be like without ‘free’ health care and the difference that the NHS has made and continues to make to the lives of millions.

The NHS has faced Issues since before its creation and has had to adapt in response to demands placed upon it, issues such as funding have been apparent from the beginning, the pattern and effect of disease changes continuously, no sooner is one problem solved than another emerges. As the diseases changed, so too have the demands placed upon the NHS.

Many of the challenges that the NHS faced in its early days, continue to test the system today. One of the main factors which increasingly puts a demand on the NHS is that with humanities ever advancing capabilities to battle disease, to extend life and to reduce infant mortality, the number of people who come under the care of the NHS continues to rise. With an ever increasing population, it seems that the complications faced by the NHS will continue into the future. An article posted by Kings Fund (2012) states; “Major progress has been made in improving the performance of the NHS in the past decade. Notwithstanding this progress, the current health and social care delivery system have failed to keep pace with the needs of an aging population”. In this article, the authors call for “fundamental change” and lay out several of the most important issues currently faced by the NHS. Issues such as the changing demands of an aging population and the care system that is needed to cater for and provide appropriate services to the ‘older’ members of our society. The authors also state that a system needs to be in place to support the prevention of disease, tackling obesity, smoking, and other health risks which if not addressed in a preventive way, can and will result in increased cases of disease within the population and as such require massive funding in the future. It is clear that the NHS is an institution which will need to receive much carefully thought out reform in the years to come in order to maintain the fundamental principles it was created to serve.

***Today the National Health Service faces the threat of privatization, and with a new found awareness of its early days and the constant challenges it has faced throughout its growth into one of the fundamental pillars of our civilization. It would be a shame to see one of its initial ideology’s abolished in favor of capitalism:

The idea that, health care is a human right and not something which should only be available to the wealthy.

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"A civilization’s greatness is measured by how it treats its weakest members." - Mahatma Gandhi

References:1) Crimean War, (October 1853–February 1856)(”The Editors of Encyclopedia Britannica”) (11-2-2014) Available online; [http://www.britannica.com/EBchecked/topic/143040/Crimean-War]2) The BMA. General Medical Services for the Nation: Available online; [http://web.bma.org.uk/pressrel.nsf/wall/5E4F5781D4EC62BD802568F500542D9B?OpenDocument]3) Health and Hygiene in the Nineteenth Century. Laurelyn Douglas (1991) Available online; [http://www.victorianweb.org/science/health/health10.html] 4) Before Beveridge: Welfare Before the Welfare State; Gladstone. D (Editor). Green. D. Harris. J. Lewis. J. Thane. P. Vincent. A.W. Whiteside. N. Pub, January 19995) Ham. C. Dixon. A. Brooke. B. TRANSFORMING THE DELIVERY OF HEALTH AND SOCIAL CARE. The case for fundamental change (The Kings Fund 2012). Available on line; [http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/transforming-the-delivery-of-health-and-social-care-the-kings-fund-sep-2012.pdf]6) The health of towns act. The 1848 Public Health Act available online; [http://www.parliament.uk/about/living-heritage/transformingsociety/towncountry/towns/tyne-and-wear-case-study/about-the-group/public-administration/the-1848-public-health-act/]7) Edward Jenner (1749-1823). Available online; [http://www.sciencemuseum.org.uk/broughttolife/people/edwardjenner.aspx]8) BMA. “The General Medical Services for the Nation” Available online; [http://www.nationalarchives.gov.uk/education/resources/thirties-britain/general-medical-service-nation/]

Appendix:1) An article posted on Kings Fund (2012) states; “Major progress has been made in improving the performance of the NHS in the past decade. Notwithstanding this progress, the current health and social care delivery system has failed to keep pace with the needs of an ageing population, the changing burden of disease, and rising patient and public expectations. Fundamental change to the delivery system is needed, with greater emphasis on: preventing illness and tackling risk factors, such as obesity, to help people remain in good health supporting people to live in their own homes and offering a wider range of housing options in the community providing high standards of primary care in all practices to enable more services to be delivered in primary care, where appropriate making more effective use of community health services and related social care, and ensuring these services are available 24/7 when needed using acute hospitals and care homes only for those people who cannot be treated or cared for more appropriately in other settings integrating care around the needs of people and populations”(Kings Fund 2012). P3