Working for the NHS

As an institution the National Health Service has had a profound social and cultural impact. For everyone living in Britain the establishment of the NHS has helped shape both our experiences of health and our ideas about society. But for some groups, the importance of their relationship with the NHS seems to be more profound. People with disabilities often note its importance in determining their quality of life. Others who’ve suffered from potentially terminal diseases frequently credit the NHS with having saved their lives. Meanwhile, politicians from Bevan to Blair have used the NHS as a central part of their attempts to persuade the electorate of their merits.

As important as the NHS has been for all these groups however, arguably the section of society whose lives have been most profoundly affected by the foundation and development of the NHS has been its employees. For millions of people the NHS has occupied most of their working life, providing not just a livelihood, but for many an occupation, a vocation and a sense of purpose and identity. In its first full year the NHS employed over 400,000 people in England, Scotland, Wales and Northern Ireland, making it Britain’s third largest employer behind the National Coal Board and the British Transport Commission.

By 1961 it had become the largest organisation in the country, employing more than half a million staff in a dizzying array of roles. Many worked in the health care occupations with which we are most familiar, with doctors, dentists, nurses and midwives accounting for 46 per cent of the total. Meanwhile the rest were employed in supplying and maintaining NHS facilities, or in positions related to administration, scientific or technical work.

Alongside managers, secretaries, cleaners, porters and cooks, the NHS employed social workers, biochemists, chiropodists, darkroom technicians, audiologists, laboratory technicians, medical photographers, occupational therapists, opticians, orthoptists, pharmacists, physicists, physiotherapists, psychologists, radiographers, remedial gymnasts, speech therapists, dietitians, chaplains and more. Amongst the maintenance and domestic staff, you could find engineers, builders, boiler stokers, bricklayers, carpenters, gardeners, laundry workers, farmers, butchers, bakers, ward orderlies, hostel wardens, housekeepers, tailors, shoemakers, hairdressers, barbers, drivers, telephonists and storekeepers. And that’s not counting those like ambulance drivers, district nurses and G.Ps, who contributed to the service but who were not directly employed by the NHS.

Each of these different categories of worker made a vital contribution to the services that the NHS provided, and each had a very different experience of work. Uncovering those different experiences is a huge part of what People’s History of the NHS (with your help) hopes to achieve during our project and with that in mind, today we’re launching a new survey directed at NHS staff past and present.

CLICK HERE FOR THE SURVEY

The survey, which doesn’t take long to complete, encourages people who’ve worked for the NHS (or work for it now) to record their life histories and reflect on what they did (or do) at work and how they feel about it. We are asking people, no matter their job, what it means to work for the NHS. Does it mean something different to a porter, a speech therapist or a nurse? What kind of employer was the NHS if you were a doctor, or a canteen cook? Was the NHS a special employer or just another large, anonymous organisation? And how are people’s feelings about working for the NHS shaped by their background? Does it mean something different to middle class or working class people? Or to women and men? Or to people born outside Britain?

Our survey offers NHS staff past and present the opportunity to anonymously record their experiences, and to offer their own thoughts and feelings about working for the NHS. Once completed, your survey responses will not only feed into our own research and writing, but will form part of our new archive collection, contributing to future understanding of the NHS and its place in British life.

The more voices we can get, the richer our archive will be, so we encourage everyone to complete the survey and to spread the word and share the survey with any NHS staff past and present that they know. Once completed you can simply save the survey on your computer and send it to us either by email (NHSengage@warwick.ac.uk) or by post (People’s History of the NHS project, Centre for the History of Medicine, Warwick University, CV4 7AL).

Vaccination in the NHS Era

This week we have a guest blog post contributed by Dr Gareth Millward.

If you’d like to share your memories of vaccination please comment below or join up as a MyNHS Member. You can read more about the history of  vaccination in our encyclopaedia entry

Vaccination is a rite of passage for most of us. In 2014/15, 92.3 per cent of children under the age of two received at least one dose of MMR. Since the birth of the NHS in 1948, mass immunisation of children has targeted diseases as diverse as smallpox, diphtheria, whooping cough, tetanus, poliomyelitis, measles, mumps, rubella and HiB. And that’s not an exhaustive list.

Since we received the majority our vaccines at the GP’s clinic, it’s tempting to think that the NHS must have been responsible for all this. But it was not until the re-organisation of 1974 that vaccination fell under the control of the NHS. And since 2013, NHS facilities have performed vaccination under the direction of Public Health England.

As with all health administration, it’s complicated. Unsurprisingly, the roots of this complication are historical.

Vaccination pre-dates the NHS by over a century. It was seen as a vital public health tool in the Victorian Era. From 1840 onwards, a succession of Vaccination Acts gave local authorities the power to vaccinate people against smallpox.[1]

Although this policy was dictated by central government, the administrative machinery was local. Medical Officers of Health and Poor Law Guardians were made responsible for providing funds, vaccinators and publicity.[2]

When the war-time government decided to introduce diphtheria immunisation in 1940, administration was also made at the local level. Medical Officers of Health were responsible for advertising the availability of the vaccine in their areas, and for ensuring that parents presented their children.

Unlike with smallpox vaccination in the latter half of the nineteenth century, diphtheria immunisation was not compulsory. However, parents welcomed it and presented their children in great numbers.

Diphtheria toxoid had been used in other parts of the world (notably Canada and New York City) with great effect in the 1920s and 1930s. It had fewer obvious side effects than smallpox vaccination. It was a “clean”, modern “drug”. And, more importantly, affected tens of thousands of children every year. Smallpox had ceased to be endemic since the early 1930s.

When the Appointed Day arrived, then, Britain had experience a long history of providing vaccination for its citizens. There was already a machinery in place to deliver it. The National Health Service Act restated local authorities’ obligations to provide vaccines as mandated by the central government, and removed the final vestiges of the compulsory smallpox vaccination legislation of the previous century. But it was the Ministry of Health – not the NHS – that ran the immunisation programme.

But for most of us, our experience of vaccination would be a visit to our NHS doctor to receive something paid for by the state. To all intents and purposes, vaccination was free at the point of delivery, and administered in an NHS clinic.

This pattern would be repeated with the flow of new – and welcomed – vaccines against a host of diseases across the first few decades of the NHS era. Jonas Salk and Albert Sabin’s breakthroughs with polio over the 1950s and 1960s were contemporaneous with the introduction of vaccinations against whooping cough. Measles followed in the late 1960s.

Some immunisations were not provided in this way. BCG, for example, the anti-tuberculosis vaccine, was given to children of school-leaving age (13 or 14 years old). This was done through the school medical services. More recently, the HPV vaccine has been delivered in a similar fashion.

Public health and the NHS effectively merged into the same entity in 1974. After this point, vaccinations were provided to patients, and policy was directed, by the same body. As far as parents were concerned, this meant no real change. It was still free, and still (mostly) provided in an NHS building.

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The NHS is dominant in our minds as British citizens when we think about health. So much so, that it is just generally assumed that vaccination must be part of the NHS too. It makes sense. Both of these “institutions” represent modern medicine and modern medical politics.

But the distinctions being made here between Public Health England, the NHS and local authorities aren’t simply nit-picking. For a start, they show a number of ways in which central governments have been able to co-opt various parts of the medical profession to perform healthcare functions – even before the NHS was founded.

Moreover, the historical shifts tell us something about the relationship between personal and public health care.

Why, for instance, did everyone have access to free smallpox vaccination a hundred years before the right to free treatment for a broken leg? Why did the governments of the 1980s strengthen the vaccination schedule and provide performance-related pay for GPs at a time when the rest of the NHS suffered chronic under-funding? The answers to those questions may seem a little obvious at first. But once you delve into them, we start asking even more questions about preventative medicine, “cost-benefit” relationships and social priorities at different points in time.

The relationship between the NHS and vaccination is messy and continually evolving. And that tells us something intriguing about both.

Notes

[1] The story of the Acts is central to the history of eighteenth- and nineteenth-century medicine and the state. Many historians have done excellent research on the topic, but a good starting point is ‘The Politics of Prevention’ by Dorothy and Roy Porter.

[2] Even before “vaccination”, local authorities and Poor Law Guardians in some areas provided “variolation” for their paupers.

Gareth Millward is a Research Fellow at the London School of Hygiene and Tropical Medicine. He works on the history of British vaccination programmes and has a new article soon to be published on open access: ‘A Disability Act? The Vaccine Damage Payments Act 1979 and the British Government’s Response to the Pertussis Vaccine Scare’,Social History of Medicine (2016). We will update this page to include a link to article as soon as it is available.

Elections time

We are coming in to election season. This week will see local council elections across much of England. Londoners will be voting for a new Mayor and for the London Assembly. The Scots will be voting the Scottish Parliament in Holyrood. The Welsh will be voting for the Welsh Assembly. The Northern Irish will be voting for their Assembly. Thrown in on top of this, there will be elections for Police and Crime Commissioners. It is a complexity that reflects an increasingly devolved system of government. We are yet to find ourselves voting for local NHS commissioners, but we are now seeing significant moves towards devolution in this area also, pioneered since April of this year in Manchester, and with talk of other areas of England to follow Manchester and the earlier devolution of NHS administration to the governments of Wales, Scotland and Northern Ireland.

In such circumstances, it becomes increasingly difficult to generalise about the National Health Service, and we are aware that our People’s History needs to pay far more attention to the significance of devolution and difference in the four nations of the United Kingdom. The NHS unsurprisingly matters more as an issue in the upcoming elections to the national chambers than it does in the English local elections, where the NHS is still the responsibility of central government. National Health Action (NHA), a party set up in response to the Health and Social Care Act of 2012, argues that the NHS is in fact an issue that should be taken very seriously as we vote for county and city councillors. In particular, the NHA warns in relation to devolution that we are on the cusp of taking the N out of the NHS. Local council campaigns also often emphasise that local action is important in relation to the health of the local population, whether directly through the provision of a healthy environment, or indirectly through providing the housing, transport, and services needed to attract a staff to man local NHS facilities. Meanwhile, the UK Independence Party brings the NHS into its local campaigning by using it as an example for its claims that local services are put under strain by immigration. But in general terms, the issue of the NHS appears to have a low profile in the upcoming English elections. This is in striking contrast to the General Election, just a year ago. It is also in contrast to the high profile of the NHS in the media more generally, where ongoing concerns oabout the adequacy of funding, efforts to introduce a seven-day service, and the Junior Doctors’ strikes have contributed to keeping the issue on the front pages of the newspapers. So it is very possible that those who vote in the local elections will nevertheless be swayed by their feelings about the NHS. And certainly our initial research indicates that feelings about the NHS, often run strongest in relation to local communities and the protection of local services.

For this reason, we thought that this would be a good moment to turn the attention of our People’s History of the NHS to the role of party politics. We have a new Encyclopaedia entry on the subject of Party Political Manifestos. This looks back over the way that the two main political parties have presented their position on the NHS since the election of 1945. It draws 10 conclusions. These range from the shifting importance of the NHS in party politics, to the degree to which the positions of the two parties have differed. Taking the long view provides us with a fresh perspective on today’s party political debate. We also have a new Gallery of party political posters on the NHS. You may have already seen our gallery of posters on the politics of health before the NHS. The second gallery takes the story into the era of NHS itself. This striking visual culture offers further insight on changes over time.

What we now need is your stories, memories, and reflections about this party politics of the NHS. So please do take the opportunity to comment in response to the Encyclopaedia entry and the Galleries. We’d also welcome your comments, in response to this blog, about the local and national politics of the NHS.

Looking forward a little further still, there is of course one other upcoming election, and one that already dominates the media in a way that overshadows the local elections. On June 23rd we will be voting to Remain or Leave in the European Union. It has been fascinating to see over the last few weeks how even this election has turned to the issue of the NHS: both sides claiming that only their position will protect the future of the NHS. For those who recall the earlier 1975 European Referendum, we will be fascinated to hear about whether you saw any connection then between being in or out of Europe and being in or out of an NHS.