Edinburgh Roadshow, 8 January 2018

The People’s History of the NHS project joined forces with Edinburgh Central Library and the Lothian Health Archives for our first roadshow in Scotland.  The project brought some of our own objects – historic pamphlets, badges, glasses, stickers, surveys – to jog some memories, and sent out a call for members of the public to bring their own potential contributions to our virtual Museum of the NHS. Despite the unpromising timing (a workday afternoon in January), we had plenty of people through the door and lots of really engaging discussion about the history of the NHS. More evidence of the resonance this history for the wider public across the UK’s four nations.

Particularly noticeable was the high proportion of visitors who had some background working in the National Health Service.  A number of former nurses came and shared memories of the old Edinburgh Royal Infirmary, whose turreted Nightingale Wards remain a distinctive presence in the city centre. The Lothian Health Archives brought with them original 1879 plans for what was Britain’s largest voluntary hospital, as well as reproductions of plans for the various expansions and adaptations that took place throughout the 20th Century. The eagerness of visitors to share experiences of this institution were a firm reminder of the central role that hospitals have in how we remember and imagine our cities. In nationalising older hospitals, the NHS always took on a civic identity as much as a national one.

Other attendees brought historical materials. These included an NHS procurement professional who brought documentation relating to the buying of wigs in the 1980s.

NHS Wig Catalogue, 1980s

Prior to that decade, the Scottish NHS had bought its wigs on an ad-hoc basis. These documents were evidence of how supplying this huge organisation had only been done systematically relatively late in its history, with personal contacts and historic relationships the dominant theme before then. As new methods of organisation came into being, NHS professionals often had to learn new skills fast, as new career tracks were invented by a constantly changing NHS. With the advance of outsourcing and the internal market differences between Scotland and England emerged, with the NHS north of the border retaining more direct control over these sorts of issues.

Other memories we heard were of a more personal nature. Several women came to tell us about their experiences of strict discipline in Edinburgh’s nursing homes back in the 1970s.

Edinburgh Royal Infirmary badge

Nurses in training lived under authoritarian conditions in the early years of the NHS, with curfews, bans on smoking, male company and room inspection common. Although many hospitals loosened this kind of discipline in the 1960s, not all of them did. Our interviewees told us tales of sneaking boyfriends into the nursing homes past the watchful eyes of their matron. Although the all-powerful matron is often remembering nostalgically in Britain, at the time they could be a controlling presence for young women trying to exert their own autonomy.

Roadshow crowds

The Edinburgh Roadshow brought to life just how central place, in terms of the nurses’ home, hospital, the city and the nation, can be in memories of the NHS.

An efficient, productive NHS?

One of the most long-standing public policy discussions about the National Health Service revolves around efficiency: its efficiency as a health system and the efficiency of its employees. As early as 1951 officials at the Ministry of Health began assuming the service was over-staffed, circulating a memorandum that year instructing Regional Health Boards to reduce headcount by five per cent across the board.  That circular, like many later efforts to cut staff costs, demanded health service managers obtain savings by improving the staff productivity without affecting care, effectively asking them to do more with less.

Such exhortations no doubt sound familiar to present day NHS staff, many of whom will have worked through several rounds of cost-cutting, all aimed at increasing productivity and reducing headcount, usually accompanied by soothing words about not harming “frontline” services.

Since the 1950s the NHS has seen various schemes of this type. The premise behind the 1962 Hospital Plan, introduced by Enoch Powell then reinforced by the 1964 Wilson Government, was that spending on new buildings and new equipment to modernise the NHS would be accompanied by better working practices and staffing reductions. Freed from inefficient old hospitals, all categories of NHS staff would be empowered to shed wasteful habits and old-fashioned ways of doing things.

Hoped for improvements were not to be left to chance. The Health Ministry’s Advisory Council for Management Efficiency hired hundreds of efficiency experts to conduct “organisation and method” studies at dozens of hospitals, examining how workers were managed. These ran parallel to “work study” programmes, where hospital workers were watched and timed during their shifts in the hope of uncovering promising areas for improving productivity.

These programmes were not uncontroversial. Acknowledging that absolute efficiency had the clear potential to adversely affect the quality of care, nurses and doctors were largely excluded from their purview. Work study was overwhelmingly targeted at support staff, particularly laundry, catering, cleaning and portering staff, under assumption that their effort could easily be intensified without cutting the clinical attention paid to the sick.

By the mid-1960s, NHS work study operatives had generated studies claiming huge reductions in these categories of staff, sometimes as much as 25 per cent, could be obtained, if new working practices were extended across the NHS.

The mechanism through which this was to be achieved was “productivity bargaining”. Trendy in management science circles in the 1960s, “productivity bargaining” expanded across British industry as a solution to low productivity and increasing numbers of strikes. Firms looked to negotiate bonuses with their workers in exchange for the adoption of new, more efficient, working methods. NHS managers and health workers’ trade unions reached a general agreement to implement bonus schemes in 1967, with the unions hoping that cash incentives would improve their members abysmally low pay. The usual caveat applied from the Ministry of Health that bonus schemes were not to be ‘injurious to the well-being of the sick’.

Progress thereafter was impossibly slow, with just 3 per cent of support staff enrolled in any bonus scheme at all by 1971. As it turned out neither managers nor workers felt that “productivity bargaining” offered them much. Desperate to achieve some kind of improvement in this area, the government’s National Board on Prices and Incomes (NBPI) recommended that hospitals implement interim schemes, where workers were offered bonuses simply for agreeing to reductions in staff numbers, echoing the crude memorandums of the 1950s.

Why were these schemes such failures? At the time, ministry officials suggested bureaucratic inertia was largely to blame. Managers were stuck in their ways and resistant to new ideas. Evaluating the failure in 1971, the NBPI Report blamed hospital administrators and heads of departments for not being ‘alive to the need to keep bonus schemes once introduced under control’. They argued ‘any incentive payment scheme decays in time unless constant attention is paid to its working’.

In their frustration, the NBPI’s investigators revealed why the outcomes of these “productivity and efficiency” programme has historically been so poor. The NHS, for all its varied practices and results, was (and is) a cheap health service and much of its workforce went above and beyond their stated work norms precisely because of their moral investment in work. Extra productivity could only be extracted by continuous management effort to win more intense effort from staff who were already stretched by the NHS’ enormous demands. Health care was labour intensive service work, the efficiency of which was difficult to measure and compare, and even more difficult to make more productive. Moreover, the distinction between “frontline staff” and every other kind of health worker was built on the fiction that support staff were somehow less vital to quality care.

“Work study” was by no means the last attempt to extract more effort from the NHS’ workforce; the 1980s saw the introduction of private sector managerialism; and in the 2000s the Blair government developed an obsession with targets and metrics as a motor for modernisation. Since 2012 Strategic Transformation Partnerships mark the latest attempt to extract more work from health workers. Future health planners might do well to acknowledge previous failures to intensify “productivity” and perhaps be a little more sceptical about the likelihood of drastically improving performance.

 

Ideology and work in the early NHS

Conventionally understood, work is an economic activity driven by the necessity to eat, clothe and house ourselves and our families. For most historians of work, it is also social, concerned with the relationships between people and society, between capital and labour. We tend to expand on the popular idea of work as an economic activity and talk also of working conditions, hours, productivity, wages, as well as industrial relations, union militancy and job security. Sometimes, we also think about work in cultural terms, considering how different occupations spawn collective identities, shaping our sense of self and of our place in the world.

However, we tend to conceive of the cultural dimension in terms of how the job we do contributes to who we are outside of work. For instance, we discuss how coal miners’ shared experiences of danger and exploitation might have contributed to the formation of class-conscious enclaves in some 20th-Century pit villages, or how the monotony of the production line sometimes generated a sense of alienation amongst manufacturing workers in post-war Britain. But what about the workplace and the work process itself? Identity is not the only sense in which work is “cultural”. People generate “cultures” at work and develop complex ideas about what their work is and how they should behave when doing it. These ideas shape how they do their jobs, as well as the extent to which their employers can win “consent” for productivity.

The variety of ideas that employers and employees have about the work process constitute “ideologies of work” – values and ideas that describe how people think that they and others should act as workers. These ideologies are present in society generally (think of moralistic concepts like “work ethic” or “scrounging”), as well as being coded into particular workplaces. In our concept of the NHS, value-laden ideas about work abound. It’s common to hear people talk about the “dedication” of the service’s staff, as well as invocations of “innovation”, “loyalty”, “self-sacrifice” and “professionalism”. On the other hand, we also hear regularly about concerns over “inefficiency”, “neglect”, “waste” and “resistance to change”.

The early years of the NHS were equally suffused with “ideologies of work”. As the politician most associated with the health service Nye Bevan was one loud voice in determining the cultural meaning of NHS work, reflecting on multiple occasions on the nature of its workforce. His most famous remarks were reserved for doctors, whose reticence about the early NHS threatened to impede its initial establishment. Bevan’s claim to have “stuffed their [consultants] mouths with gold” helped establish the idea of senior doctors as largely financially-motivated and self-interested when it came to public service, an attitude that stood uneasily next to the idea of the NHS as the realisation of “socialist principles”.

Bevan’s affirmations regarding doctors helped create, through criticism of non-believers, the idea that work for the NHS was a great exercise in patriotic socialism and of service to the people, something he reaffirmed when talking to other health workers. Alongside his intense negotiations with the British Medical Association, in his addresses to nurses, Bevan employed them as the best example of the new service’s values. Speaking at a conference organised by the Royal College of Nurses one month before the appointed day, Bevan looked to turn on the charm. “Nurses – I can say this as the doctors are not here – are the most important part of the Health Service”.

Whilst Bevan was imagining a workforce of dedicated health workers engaged in making a “socialist NHS” come to life, newspaper commentary echoed senior civil servants in worrying about the cost of the new service. Rather than a “dedicated” workforce, early reports emphasised the dangers of a spendthrift one. For instance one editorial in The Times (despite the paper being generally sympathetic to the NHS) worried in February 1949 that the infant service was overspending at an alarming rate, perceiving an “internal pressure towards lavish expenditure” by Regional Health Boards.

Such concerns set the terms for the first major inquiry into the functioning of the service, the 1956 Guillebaud Report. Largely written by left-leaning economist Brian Abel-Smith, the report defended the service’s cost-effectiveness, noting in particular the “responsible attitude among hospital authorities” towards the “efficient and economical” use of public funds. The report praised the thoroughness of the service in reducing staff numbers from 1950 onwards. Guillebaud thus simultaneously refuted accusations of “waste”, whilst accepting “efficiency” as a the most pertinent framework for understanding the service.

Debates over its efficiency have recurred constantly since the service was founded. For workers in the early NHS, the ideals that were supposed to drive their work were already a matter for fierce public debate. Arguments over their supposed “profligacy” and “inefficiency” came from parliamentarians, civil servants and from journalists, asserting conflicting expectations around their levels of “dedication” and their twin duties of care to the patient and responsibility for public funds. Much of the agency in these processes was, predictably, projected onto the most powerful groups in the service – hospital authorities and doctors, with nurses and ancillary workers largely absent from these debates. Discussions over their role and their “dedication” would only become more urgent as both the NHS and British workplaces saw more industrial conflict in the form of strikes and protests in the 1970s.

Discerning how far this peculiar public discourse on health work penetrated the actual working lives of the NHS’ workforce and the ideals they brought to their work is difficult, but vital if we are to understand how the “cultural meaning” of the NHS may have shaped the values and behaviour of its employees.

Do NHS staff have “ideals”? Tell us what you think in the comment section, or tell us about your own experiences of NHS work in our life history survey.

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).

Helen Bissett Reid: Student nursing in the 1940s

Elsewhere on the site this week we’ve been focusing on student nursing under the NHS, with an encyclopaedia entry charting the history of nursing training and a gallery of 1960s nursing school prospectuses. Building on that, this blog features some extracts from a huge submission we got from the daughter of a former district nurse, Helen Bissett Reid.

Helen began her training as a student nurse in Aberdeen in 1938, eventually becoming a ward sister after the war then finally a District Nurse after her marriage. She gives a vivid personal description of her own experiences as a “probationer” before the NHS, reflecting many of the issues discussed in our encyclopaedia entry and allowing us to make some interesting comparisons on what changed under the NHS.

After leaving school at 14 and spending three years helping out at home, she decided to become a nurse at City Hospital, Aberdeen. Along with 13 other 17-18 year olds, she spent three months in Preliminary Training School studying physiology, sociology and practical nursing with tests every Friday before finally sitting their National Nursing Exam. 

In Helen’s memories, the tension around passing or failing exams is linked with everyday life as a probationer, particularly the quality of the food in the canteen.

Unfortunately we had semolina every day except Friday and Sunday. Friday was steamed pudding day and of course we did not really enjoy due to the impending exam immediately afterwards. Once the big exam was finished, came the long wait for results.

The porter who delivered the mail informed us that if you receive a long brown envelope, you have failed and all the passes are in small envelopes. Unfortunately only 8 of us passed and proceeded to the wards. The others could resit but I think all decided not to continue or felt nursing was not for them.“

This sort of turnover was not uncommon, with only around [40%] of nurses actually completing their training in the 1940s (something that would steadily improve under the NHS). This was a product not only of challenging examinations but often of the strict discipline imposed on new recruits:

The first ward two of us were sent to [work] for 3 months was the scarlet fever ward. Sister was Sister A… [whom] we called “Biscuit.” She was very strict but very fair and gave us a lecture at the very beginning that she would not tolerate work being done slovenly. We found the nurses who were 2nd and 3rd years very bossy and also the Staff nurse of whom we were quite afraid, more than the Sister!”

Matron, at the City Hospital, seemed to us 17 year olds as being very old but was a pleasant lady though the rules were so strict. Whatever we were doing, when she entered the ward, we had to stand with our hands behind our backs like stookies till she left. All the counterpanes on the beds had to be straight. All the wheels on the beds straight and facing away from the doors.”

Helen continued her training, first as a fever nurse then later as a general nurse, during World War Two. Moving to Stirling Royal Hospital to complete her education, she encountered more petty discipline:

I was put in a Sister’s room as she was on holiday. As I was unpacking my case I was singing –

In land or sea what matters where

Where Jesus is, tis Heaven there”

Suddenly there was a loud knock on my door and a voice bellowed “Nurse, will you stop singing. I have a terrific headache and it is annoying me!”

I said “Sorry, I don’t feel like singing anyway.””

I thought I had better tread carefully here! During my two weeks in that residence, to my knowledge all I did wrong was have a bath in the Sister’s bathroom and I was not supposed to do that so that was another row.”

Overall though, Helen confessed, a sense of camaraderie amongst the nurses made the regime at Stirling more bearable.

I found Stirling much easier than City especially on night duty when we at least got a seat. We had a great Sister on night duty. Cannot remember her name . She never reported us if she caught us having tea. One nurse usually stood watch at the end of the corridor. If Sister came early and she wasn’t there, Sister would say “Where is your watchdog tonight ?”

Sister always carried a big torch and one night she told us, she was walking up Livilands Lane where there was a battalion billeted. One soldier appeared and asked her “Can I see you home“ She shone the torch in her old wrinkled face and said “take a look at that and come if you like!”

Do you wonder why we all loved her?”

At the end of her third year, Helen sat her exams to qualify as a State Registered Nurse, with one question in particular sticking in her mind years later:

I cannot exactly remember where these were held but I do remember the huge pictures of possibly notable men, old-fashioned with long beards. The cold reception as you entered the building and treaded the long stone stairs lives on. The written was OK. The oral was preceded by a period of nail biting. Nurse W. and I were next in line. She went to the examiner on the right and I went to the one on the left. She had to explain the nervous system and I the urinary system. He also asked me to explain “Herpes Zoster” (shingles ) and unsuccessfully tried to trick me asking what is “Weil’s Disease”.

Answer :- “jaundice carried by germs in urine of healthy rats “

They could not be very healthy carrying germs, would they?”

Yes, healthy rats”
Our Sister Tutor instilled it into us. “Remember HEALTHY rats”

That over, I did not know if I passed, as they never gave you any indication. Time will tell. Quite a nice man though. …”

After qualifying, Helen was appointed as staff nurse in the outpatient department at Stirling Royal, then moved in 1945 to take up a position as ward sister (a supervisory role) at Falkirk Royal Infirmary. Soon after she got married and gave up nursing for 16 years before returning to work as a District Nurse after her children had grown up. Marriage was a common reason to abandon the profession in the 1940s, in part because of the expectation that working nurses would live-in. Mandatory living-in was abandoned in 1948 with the coming of the NHS, reflecting a more general shift towards a less rigid discipline in nurses’ lives and an expansion in work (often part-time) for married nurses. 

Helen’s return to work 16 years later as a district nurse under the NHS is described in her full memory, which you can find in our members’ section (join here), where you could also add your own recollections of life in the NHS.

When do doctors’ strikes end? A perspective from 1975

During the current junior contract dispute the events of 1975 have been a point of comparison for various commentators (including me in a Guardian piece), but there’s been little focus on the details of negotiations and what eventually settled it. In this blog I’ll be looking in detail at how the context around the last junior doctors’ strike, what happened and why eventually came to an end.

Although 1975 was the first time British doctors had officially gone on strike, it wasn’t the first conflict over pay in healthcare. The British Medical Association (BMA) had been active over doctors’ pay almost since its inception. From 1838 physicians fought over payments under the poor law, then from 1911 over money for free treatment administered by panel doctors. Even as the new national health service was being established in 1947, doctors debated the structure of their pay packets.

Although the 1950s and 1960s were largely conflict-free, dissatisfaction was building amongst many over the value of doctors’ pay. In 1962 the BMA’s complaints forced the government to establish the Review Body for Doctors’ and Dentists’ Remuneration (RBDD) and in 1966, 18,000 doctors threatened to resign en masse if their pay continued to decline. By 1975, both Labour and Conservative governments had spent thirty years barely avoiding direct conflict with doctors over pay, and with almost every other group of employees (including nurses) going on strike in the early 1970s the prospects for keeping industrial peace rapidly diminished.

The motivation for conflict when it finally came was a mixture of hours and pay. Prior to 1975, junior doctors had been paid extra whenever they worked above 80 hours a week, clocking 85.6 on average (43.2 on normal duty, 42.4 on call). Recognising this workload to be excessive, the RBDD proposed to reduce standard hours to 44, offering additional pay for any overtime.

Initially, some in the BMA were in favour of the new contract as it left doctors “better able to plan their lives”. However, with the Labour Government looking to restrain public sector pay, no new money was available and the scheme proposed reducing the bonus level for each additional hour by two thirds. Consequently, Junior doctors claimed the new contract would cut their pay and do little to curb excessive hours. Calling for no wage cuts and a 40-hour standard week, in October thousands of junior doctors organised bans on non-emergency work and various other kinds of collective action in different parts of the country.

Back then, junior doctors felt little need to brand their collective action as a defence of the service by proxy, instead arguing in terms of their living standards. One of their leaders, Dr Wasily Sakalo, an Australian doctor of Ukrainian descent earned particular notoriety as a militant in the 1975 strike, putting the doctors’ case in The Times:

“One of my sisters, Alla, who is 24, is a first-year house officer [in Australia] and she is earning £9,000 for 40 hours, with time and a quarter for overtime. She has been qualified for nine months. I have been qualified for seven years and I am on £4,500. It made me determined to try to obtain the same work conditions for British doctors.”

As historians David Wright, Sasha Mullally and Mary Colleen Cordukes note, by the mid-1970s NHS doctors formed part of an internationalising workforce, featuring migration in and out of Britain. Canada was a favoured destination, and during the 1960s approximately 8,000 British-trained physicians moved there, often being replaced by migrant doctors themselves. Consequently, many junior doctors were highly aware of their value on a global market-place. Then, as now, the prospects for “medical brain drain” were emphasised as the potentially disastrous consequence of their grievances being left unresolved.

However, unlike in the present dispute, the junior doctors’ actions were widely criticised by senior colleagues. One letter to The Times, by four London-based consultants read:

“The present dispute… is concerned with the relative affluence of doctors. It is not a fight to cure their poverty. Can it be right that a doctor be struck from the medical list for having sexual relations with a patient, while it appears to be legitimate to deliberately withhold treatment in the cause of doctors’ own financial gain?”

Despite their lack of external support and dependence largely on their own capacity for disruption, the junior doctors’ dispute dragged on for months of “go-slows”, partial strikes and walkouts, continuing the government found a further £2.3m to fund their overtime and concessions over hours. They finally resumed normal working in January 1976.

This partial victory for the doctors reflected in part the leverage that NHS staff wield when they stop work even in quite partial ways. The service often seems to teeter on the margins of functionality, and fairly small bouts of collective action can often send things rapidly out of kilter. In 1975, the NHS’ precariousness combined with the doctors’ own self-awareness of their value to the service to make it difficult for the government to force them back to work through moral pressure alone, even when that pressure was applied by their senior colleagues. Only when substantial extra money was found and a real improvement in working conditions offered did the BMA feel like it could finally persuade their members both to settle and, ultimately, to stay in Britain.

Securing a similar outcome with no new money and in the teeth of support from the public and other groups of NHS workers represents a huge problem for health minister Jeremy Hunt.

Do you remember the 1975 doctors’ strike? You can share your memories below.