I’ve spent more than a decade answering a question my Nan asked me. When I was a History student and told her I was studying the social and welfare history of her own childhood, she recounted what was asked of her as a small child between the wars when her father was sick – walking from the east of Bristol to the city’s north to go cap in hand to the vicar to get a ticket, then down into the city centre to the dispensary where the ticket could be cashed in for medicines, which then needed to be taken home. In total over six miles up and down some serious hills – a long journey for little legs. Why, she asked me, was this necessary? Why was there not a National Health Service so he could simply see a doctor?
These questions are at the heart of my new book (which you can read as a free e-book here, thanks for funding from the Wellcome Trust), in which I focus on how people accessed hospital care before the NHS. There were many changes in hospitals during the early twentieth century, a time when developments in medical science and technology meant there were real strides in what being treated in hospital could actually do for you. One of the big changes is that in the 1920s it became the norm for patients to pay something to the hospital where they were treated, either directly at the time or in advance through one of the many local hospital contributory schemes. Before that those who were admitted to hospital were usually those who couldn’t afford to see a doctor privately, while those who could in turn also funded the hospitals through local taxes (for public hospitals) and charitable subscriptions (for the more prestigious voluntary hospitals). A ticket from one of those subscribers worked in the same way as the dispensary ticket my Nan remembered.
We might assume that if the changes in the years following the First World War meant everyone, across class lines, was now being treated in the same institutions and everyone paying something, then the hospital had become a democratic space even before the NHS. In fact, the reality was quite different.
Middle-class people may have started going into hospital for new and more successful operations, but they tried not to stay too long and stayed in separate, private rooms. This was partly their choice, expecting a more comfortable setting than the dormitory-style wards the working-class patients experienced. But they didn’t choose to go private in the sense we know today. A system of income limits barred middle-class patients from the ordinary wards, where treatment was provided either free or at a heavily subsidised rate, but where their admission would be regarded as a scandalous abuse of the charity and welfare provision of hospitals intended for the sick poor still often referred to in the 1930s and 1940s as “the hospital class”.
Paying the hospital was in some rare cases an opportunity for working-class patients to buy their way out of the general wards and into a nice, private room, if they could scrape together enough savings. But middle-class patients, including those just over the threshold, had to find the money for hospital charges maybe ten times higher than those for ordinary wards as well as a private doctor’s fee on top. Who should be treated in which kind of ward was decided by the means test of the hospital social worker, known then as the Lady Almoner.
To understand the difference the NHS made to people’s lives, it’s important to understand what it replaced. And we’ve seen this start to trickle through in the memories and reflections submitted by our members here. One anonymous submission from someone who was 17 when the NHS came into being recalled being aware of the difference it made being able to pay the doctor in their childhood:
“I remember as a young teenager visiting our doctor’s surgery and walking straight past a queue of waiting people. We could go straight in as we were able to pay the Doctor. I felt very uncomfortable- and also pleased with myself at the time for being aware of the situation.”
And another submission from Doris Macdonald reflected on the experience of not having to pay in the new NHS:
“I was about 16 or 17 years old and I sat on a chair which had a pair of scissors down the side which went in to my upper thigh. My Mum sent me off to see the GP pronto as it was about 1952 and not many people had tetanus jabs in those days. He prescribed what I now assume was an antibiotic of some kind and he told me very seriously that I should take the whole series as prescribed as they cost 33/- ( that is thirty three shillings in pre metric money and was a lot of money in those days). I can see them now, they were capsule shaped pills in black and red and there were six in the box thaat. When I got back home I told my Mum what the doctor had said and we were in awe that the medicine cost so much but we were able to access it because of the NHS without having to find the money that day.”
Of course, there are times when we pay within the NHS. Dentures and spectacles were provided entirely free for the first few years, until Labour decided to introduce charges, prompting the resignation of the NHS’s founding Health Minister Aneurin Bevan from the government. A year later the Conservatives took this further by bringing in prescription charges. And charges have been a perennial theme in the politics of the NHS. When Harold Wilson, ho had resigned as a junior minister alongside Bevan, became Prime Minister in 1964 his government abolished prescription charges, only to reintroduce them three years later as the economy came to trump all other concerns. New Labour may have sought widespread exemptions rather than abolition of prescription charges, but the devolved administrations they set up have now abolished them in 3 of the UK’s 4 Nations – in Wales (under Labour in 2007), in Northern Ireland (under the power-sharing Executive in 2010) and in Scotland (under the Scottish National Party in 2011).
Meanwhile there have always been private patients within the NHS. This was a compromise (hoped by some to be temporary) when the NHS was founded. When Labour returned to office in 1974 they set about phasing out the 5,000 pay beds in NHS hospitals, yet there were still 3,000 remaining when Margaret Thatcher was elected five years later and the incoming government immediately dropped the idea. And in the early twenty-first century there was an increase in payments, with the British Medical Journal reporting by 2013 that 89% of NHS acute hospital trusts (119 out of 134) were now offering private or ‘self-funded’ services (where you jump the waiting list by paying at a non-profit rate).
So, as much as we think of the NHS as being ‘free at the point of use’, the reality is often more complicated, changing repeatedly down the years. We’d love to hear from you about how you and the people around you have experienced and navigated these complexities around what you pay for and don’t pay for on the NHS. It’s something we need to understand if we are going to move beyond what politicians and experts have said about the health service, and really get to grips with a people’s history of the NHS.