At Home with the NHS: Reprise for Covid Times

Today, as we are staying home, protecting the NHS and saving lives, we at the People’s History of the NHS thought it might be a great time to think about where the NHS can be seen in our homes, and how we experience it during our normal day-to-day lives. This is a topic we have considered before, as in the blog and linked gallery from 23 January 2017 that we are reposting today. Now it’s over to you: looking around your home, can you see traces of our National Health Service? What does it mean to your daily life now, in these Covid times?

These two Ministry of Health Posters -- one advising people to wash their hands and utensils before preparing food, the other to cover any cuts or sores before food handling -- from the 1960s were intended to improve food hygiene in the home and catering trades.
These two Ministry of Health Posters from the 1960s were intended to improve food hygiene in the home and catering trades.

In politics, in popular culture, and in historical writing, the NHS is often discussed and represented principally through the hospital. High-cost hospital care, over-stressed accident and emergency units, limits on access to hospital-based technologies or pharmaceuticals: these are the subjects most likely to hit the headlines and spark contentious debates. In part this is because hospitals have, since the early twentieth century, come to symbolise medical modernity. They are where the ‘medical miracles’ happen — and equally, where medical ‘tragedies’ most often come to their dramatic conclusions. And of course, hospital care and hospital-based treatments also absorb by far the majority of the NHS budget (according to the Nuffield Trust, hospital care absorbed some 76% of the NHS budget in 2010/11, and its costs were then rising by about 5% a year).

But most NHS health care – something like 90% of it – takes place beyond the hospital, in GP surgeries, pharmacies, dentists’ offices, ophthalmic services, physio suites, public health settings, and especially in our own homes. Think about it: where do you take (or forget) your medicines; struggle through your physiotherapy exercises; read your health information leaflets; receive calls to preventive medical screening (and decide whether or not to partake in it); monitor your physical health and well-being; maintain and support other family members; restore your mental health? Chances are, you do all these things in and around the place where you live – in your home.

So can we SEE the NHS in our houses? If it does have a presence, what does that mean to us and about the NHS? To start the new year, I asked the People’s History of the NHS team to look around their own homes for traces of the National Health Service. As a group of young adult to middle aged and reasonably healthy people, we were not entirely sure what to expect: would we just find stacks of history books, or would there be evidence of deeper, broader, and more diverse NHS influences on our lives?

You can see the results of our rummaging in the gallery here, with some of our thoughts about what we found. From anniversary coins to abandoned crutches, prescription packets to a blizzard of paperwork (and yes, plenty of books!), it turns out that the NHS has left its mark all over our houses – even if its presence is often so boringly normal that we never noticed it before.

Some of the items we turned up were explicitly meaningful: I treasure my NHS card; another researcher, her childhood NHS specs. The transfer of vaccination certificates and medical cards from parent to child was a part of the transition to independent adulthood in another family, and the cards themselves have consequently survived house moves and spring cleaning culls ever since. Other NHS items probably fall into the ‘clutter’ category (a charity bookmark; a medical gadget; disused crutches). Still others explicitly represent what the NHS means to us not as researchers, but as individuals and citizens: a Bevan tea towel and ‘Born in the NHS’ mug. And finally, of course, there are the traces left by the NHS in its everyday efforts to save and improve our lives: the medications that keep us ticking over.

So now we are asking you again: is the NHS in your house? If it is, send (or tweet) us your selfies, pictures of your stuff, or stories about the stuff that has gone missing over the years. And do tell us what it means to you to find the NHS in your home! The virtual museum of the NHS is now collecting for the NHS in Covid times…

Roberta Bivins

The Story of My Street, St Oswald’s Church, Tile Hill, Coventry 6 July 2019

by Ed Devane, PhD candidate, University of Warwick

This July marked not only the seventy-first anniversary of the NHS but also one-hundred years of council housing by way of the 1919 Housing, Town Planning Act. Supported by the People’s History of the NHS project, we organised a community history event to pilot the University of Warwick’s ‘The Story of My Street’ project on Saturday 6 July. The purpose of the event and wider project is to explore the overlapping cultures of activism, housing, health, and welfare in the city through the memories and experiences of the city’s people and Coventry’s rich archives. The Basil Spence-designed St Oswald’s Church was an excellent setting. Located on Jardine Crescent, Tile Hill, the event took place on one of the first new municipal estates in Britain to open an NHS Health centre after the Second World War.

Katie and Isabelle discuss their research into Coventry Streets with attendees

At the beginning of the event, two presentations were given by Tara Morten and I on public health in the city before and after the Second World War. We also exhibited a collection of texts and images on the history of hospital care in the city, and a range of student-produced posters on Coventry streets by Isabelle Thibault, Olivia Gallogly-Clements, Katie Gardner and Vlad Marazzi. At the end of the event Professor Roberta Bivins chaired a discussion where respondents asked questions, shared their own family stories, and gave us really valuable feedback and advice!

Attendees especially enjoyed the personal stories within Tara Morton’s presentation which drew on the Mapping Women’s Suffrage database. Tara demonstrated how members of the Coventry Women’s Suffrage Society, such as Averal Constance Wilks, were early critics of the City Council’s lack of nursery and childcare facilities. Suffragists took it upon themselves to establish these services in 1915 when they opened the Tipperary Club in Old Palace Yard. By 1939, and with limited state assistance, similar voluntary welfare centres had spread across fourteen neighborhoods in the city. Amazingly, one of our guests had family connections to Coventry’s suffrage activism, which she kindly shared with us!

I discussed how, post-Appointed Day, such community health services were passed over to Local Health Authorities under the tripartite NHS system. Although this meant health centres could be fully incorporated into postwar plans for areas such as Tile Hill, building restrictions and austerity measures in fact limited their provision exclusively to such new municipal housing estates. Attendees felt strongly about this point, drawing on their own and family experiences. As we have seen at previous ‘NHS History Roadshows’ in other communities, they related it to the present perception of a ‘postcode lottery’ in local services. If recent headlines of a ‘GP Premises Crisis’ are to be believed, it seems this trend has, and will continue to become ever more exaggerated over time as smaller GP Partnership surgeries close around Coventry and across the nation.

Discussions built on the idea that the history of housing and healthcare spoke to the wider equity of space in Coventry. Focusing on Paybody Hospital School in Allesley and Burns Road Occupational Centre in Stoke, Olivia Gallogly-Clements and Isabelle Thibault charted how peripheral health services based physically in the communities they served had been established, repurposed, and wound-down – or replaced with centralized, often less local facilities – since the inception of the NHS.

This trend did not apply solely to healthcare buildings. Vlad Marazzi found that whilst conversion to luxury flats has preserved the 1950s Co-operative and Coventry Evening Telegraph buildings on Corporation Street, non-commercial spaces such as the medieval Church of St John the Baptist remain at risk of disrepair. Attending parishioners confirmed the same was true of Coventry’s three Spence-churches (St Oswald’s, Tile Hill; St John’s, Willenhall; St Chad’s, Wood End) despite their recently listed status.   

An original copy of Coventry City Council’s development plan brought along by a local resident. We love it when you share your objects with us! If you have something that belongs in our virtual museum of the NHS, send us a picture and share its story: NHShistory@warwick.ac.uk

As the City Council’s postwar plans for Bell Green, Tile Hill, and Radford all placed clinics and surgeries at their centre, I was slightly disappointed (considering my own research focus on NHS buildings) to hear our attendees say that they did not consider them focal points of their community. Instead the consensus seemed to be that local healthcare facilities represent only one barometer of cultural change. Presently, few people felt they had stronger relationships with their own GP or Nurse Practitioner who, it was said, tend to commute rather than reside locally. No NHS staff were represented at the event despite invitations to staff at the Tile Hill Health Centre that had drawn us to the area.

To our delight, one life-long resident of Coventry brought an original copy of the City Council’s 1951 Town Plan. This served as a springboard for a conversation on the successive promises of the Council to ensure a more equitable development of communal amenities. Another attendee felt the increasingly asymmetric distribution of services such as health centres further entrenched division commenting “…Coventry is now an apathetic city … it used to be divided between north and south, now it is a city divided between north, east, south, and west…”.

Katie Gardiner’s research on Stoke Heath’s Belgian refugee community during the First World War refreshed discussions and widened their focus. We all agreed that young families moving to the city have long made Coventry’s population dynamic. However, people sharing similar backgrounds have historically tended to concentrate in certain areas or move and re-concentrate in other neighborhoods as they get older. As a result event’s attendees – whilst making an invaluable contribution – themselves  could represent only one small sample of the diversity of active older citizens already engaged in local healthcare and urban planning interest groups. We would love to hear from others who are engaged with the NHS and urban planning from Coventry or elsewhere! Please do get in touch via the comments or at NHShistory@warwick.ac.uk or on twitter @NHS_history!

For me, the Story of the Streets event brought to light issues of division and inequity in the provision of public services. Our guests made it clear that cultures of activism, housing, health, and welfare must not be compartmentalised but considered as a whole. However, I also learned from them that focusing on these themes in one specific neighborhood brought its own limitations. Such a community history event is only ever likely to attract nearby interested parties. If we are to unpick these boundaries further, I would certainly aim to do so in a more open and neutral setting. But without first obtaining their feedback, I would have substantially less understanding of the role of public services in such stories.   

Do YOU have memories of the health service in your city, town, village or county that you would like to share? What is your family’s history with health centres and the NHS? Have you or would you like to get involved in something like hospital, clinic or urban planning, to help to shape the place you live? Tell us all about it: we can’t wait to hear from you!

Windrush and the NHS, by the Numbers 2: Where we are today.

Today, the NHS continues to be one of the most diverse workforces in the world as well as one of the largest. In 2018, General Practices in England employed 44,847 doctors, 23,756 nurses, and a further 118,946 other workers. The percentage of overseas-qualified GPs employed varied from a low of 2.3% in the Vale of York to a high of 66.1% in Thurrock, just east of Greater London. Across the UK, 17.86% of GPs were educated outside of the UK and EEA, and 4.08 were trained elsewhere in Europe. (Look at the NHS Digital, General Practice Dashboard for even more) Meanwhile in the hospital and community health services, of 1.2 million staff, 12.7% (144,000 workers) reported a foreign nationality. Some 63,000 of these came from the EU, while another 49,000 were Asian nationals. Looking at London alone, 11.3% of staff were from the EU.

This diversity intensifies when we look into the hospital. Across our project, we have found that hospitals are the sites most strongly associated with the NHS in cultural terms (even though most NHS funded medical care is delivered elsewhere). When we asked people to tell us about ‘their NHS’ the stories we heard were, by and large, hospital stories, and in our ‘Big Draw’ at University Hospitals Coventry and Warwickshire, we found that this association was true even for young children (kids do also like an ambulance and air ambulance!). Since the 1960s, theatrical, cinematic, and televisual representations of the NHS have also focused mainly on hospital medicine, at least until the recent advent of shows like ‘GPs beyond Closed Doors’.  And newspapers tend to illustrate their articles about the NHS with… you guessed it: pictures of NHS hospitals and those who work in them!

So what SHOULD we be seeing in all these pictures of NHS hospitals? Well, in 2018, 37% of hospital doctors gained their primary medical qualification outside the UK, 20% in Asia and 9% in the EU. Approximately 7% of nurses reported an EU nationality, while 6% reported Asian nationalities and 2.4% were of African nationalities. This is equally true for clinical support staff. While a large majority of workers in this group are British, 4.9% are of Asian or African nationality, and 4.1% come from the EU. Today, the numbers tell us that 0.15% of nurses in the NHS are Jamaican nationals – they represent a new generation of Caribbean men and women supporting our health and our NHS. (Have a look at the excellent House of Commons Library Briefing Paper 7783 for more details!)

And alongside these new Jamaican health workers, the effects of the Windrush Generation still endure and still powerfully shape the NHS workforce, as ‘Here to Stay’ demonstrates! Men and women of Jamaican and other Caribbean heritage, and from BAME communities still contribute disproportionately to the nursing workforce of the NHS. When you read their stories (all here in our ‘Here to Stay’ gallery), you can see how many of them come from families with rich and deep NHS connections.

But we don’t see this super-diversity in all the ways that we should. While images of the NHS have become much more inclusive than they were in the past, those ‘powerful portraits’ that I talked about earlier in our Windrush Season are still going to be White for some time to come. At its very top levels, the NHS is still a white man’s world, despite efforts to change. Among non-medical staff (and remember, 9 out of 10 people working for the NHS fit into this broad category, while only 1 in 10 perform medical roles) 93.6% of the top brass are White. The non-medical workforce of the NHS is 82.5% White, but the figures still show us a level of distortion. In the medical workforce, which is almost equally distributed between White and other ethnicities (57.1% White, 38.7% BAME, 4.1% other and 0.1% unknown) the distinction is stark and a bit shocking: White doctors dominate the consultant posts, holding 61.4% of them, while doctors from non-Asian ethnic minority communities are over-represented in the most junior grades and under-represented at senior ones. (You can look into all these figures and many more here!)

Interestingly, there is no equivalent breakdown for nurses and midwives, but the Royal College of Nursing in London did some very revealing research of its own in 2018. In London, the majority of all nursing staff in London NHS Trusts have BAME background ( 27,982 nurses reported a BAME background compared to 24,847 nurses identifying as White). Yet despite being the only UK region with a majority BAME nursing workforce, London performed worst in terms of meeting race equality targets. And its most elite hospitals were also its least diverse, suggesting that the BAME nurses who are the backbone of nursing care across the capital faced barriers to employment in its flagship services. The Workforce Race Equality Standard (WRES) team have also studied the nursing workforce. Across the UK some 1 in every 5 nurses and midwives are from BAME backgrounds — 23.1% of all nurses in the NHS! But they are underrepresented across all the upper pay bands, and only 8 Directors of Nursing in the UK are from BAME backgrounds (only 3.4%), despite this group’s disproportional contribution to the workforce).

Changing the faces on NHS (and gallery!) walls won’t solve the complex structural issues that underpin the slow rise of BAME workers to the most senior leadership roles in the NHS. But celebrating the long and continuing history of BAME contributions to the National Health Service  — before, during, and after the Windrush years –may help us to think more, and more productively about what we should be doing next to ensure that the NHS we see and benefit from is also the NHS we imagine, represent and remember.

The Windrush Generation and the NHS: By the Numbers

The National Health Service is one of the largest employers in the world, and is the largest employer in Britain itself. It relies on a very wide range of professions and occupations to keep its doors open – from the highly visible doctors and nurses to the often-forgotten or undervalued porters, cleaners, cooks, carpenters, electricians, and managers, among many others. As my colleague Jack Saunders discovered, the figures can be surprising: in 1963, for example, the NHS employed more construction and maintenance staff than hospital doctors (19,552 vs 18,095). And as we know, the NHS has long had a voracious appetite for workers from abroad. This has made it, almost since its inception, one of the most diverse workplaces in the UK. These blogs have reiterated what has become a well-known claim: that migrant workers saved the NHS (and that they still keep it afloat today). But how exactly did they do it, and in what numbers?

Let’s start with a ‘numerical snapshot’ of inward migration to Britain in the early years of the NHS. This was the era of ‘Open Door’ Britain, framed by the British Nationality Act of 1948 which made all ‘British subjects’ into ‘Citizens of the United Kingdom and Colonies’. It is worth noting that this comprised, at least in theory, millions of people: virtually every man, and a much-increased majority of women then alive who had been born or naturalised in the British Isles, Britain’s remaining colonies, protectorates, and the former Dominions of Australia, Canada, Ceylon (Sri Lanka), Newfoundland, New Zealand, India, Pakistan, Southern Rhodesia (Zimbabwe), and the Union of South Africa. Under the 1948 Act, all of them (and the subsequent children of fathers covered by the Act) were entitled to come to the United Kingdom freely, and to take up residence there. However, legislators at the time apparently anticipated little change in established migration patterns, in which there was extensive migration from the British Isles out to the Empire; a free inward flow from the Republic of Ireland and of British subjects from the ‘Old Commonwealth’ (mainly Australia, Canada, and New Zealand); and relatively limited, largely elite, temporary migration to the UK of everyone else.

They were wrong: new transport and communications technologies, lower costs, and the global economic and political turmoil that followed World War Two and decolonization, as well as Europe’s enormous demand for labour both during reconstruction, and with the rise of service-intensive welfare states, prompted significant increases in migration, not least to the UK. The newcomers had no difficulties finding work: of the 233 men who disembarked from the Windrush on 22 June 1948 and travelled on to London, 148 were already in jobs by the 1st of July, with 11 more anticipating immediate placements. By 1958, approximately 125,000 West Indians had come to the UK to work. In the same period, 55,000 migrants arrived from India and Pakistan, many displaced by Partition. These unanticipatedly high numbers would, by 1961, prompt ever tighter immigration restrictions – but notably, such legislation always turned a wary eye towards the needs of the NHS.

As Emma Jones and Stephanie Snow have shown, the new National Health Service was especially greedy for workers to take up the low-paid jobs that local populations rejected once better opportunities were available: porters, cooks, cleaners, and ancillary workers were all in short supply. Nursing shortages, already extensive before 1945, became desperate as the NHS struggled to cope with the enormous backlog of unmet health needs. By 1948, there were 54,000 nursing vacancies, and by 1949 the Ministries of Health and Labour were working actively with the Colonial Office, the Royal College of Nursing and the General Nursing Council to actively recruit Caribbean women. They would fill the yawning gaps in the Service’s nursing, auxiliary and domestic workforces. Their numbers climbed steadily – by late 1965, there were as many as 5000 Jamaican women staffing British hospitals, and by 1977, 12% of all student nurses and midwives in Britain were recruited overseas, with 66% of those from the Caribbean.[1] Numbers for auxiliary and domestic workers are harder to come by, but pictures and stories of NHS hospitals in this period show us that they made essential contributions across the Service, as so many of their descendants do today.

Doctors too were imported from Britain’s diminishing empire and former colonies in large numbers. By 1960, almost 40% of junior doctors in the NHS came from India, Pakistan, Bangladesh and Sri Lanka—countries that, because of the ties of empire, already taught their medical students in English, and indeed, had a significant medical presence in Britain even before the NHS opened its doors. These doctors, like their fellow recruits into nursing, were essential to the survival of the NHS in its first decades. By the 1960s, this was routinely recognised in British politics and culture: ‘without them, the Health Service would have collapsed’ became a truism of the immigration restriction debates of the 1960s and early 1970s. Figures from 1971 suggested that 31% of all NHS doctors in England were born and educated abroad.

Britain’s dependence on a global clinical workforce was reflected in British immigration law. Even Enoch Powell, during his tenure as Health Minister from 1960-1963, actively recruited Caribbean nurses, though their automatic right of entry was removed by the 1971 Immigration Act, and work permits for training nurses were abolished in 1983. These restrictive changes proved to be short-sighted. Strategies to end the UK’s dependence on overseas nurses persistently fell short between the 1970s and 1990s, not least because domestic recruitment was crippled by poor pay and often appalling working condition. New Labour renewed international recruitment in 1998. By 2003, over half of all new nurse recruits had trained abroad. Doctors’ freedom of mobility, meanwhile, continued uninterrupted and almost entirely unrestricted – though so too did the limitations formally and informally placed on them in terms of their access to the most desirable or high-status training posts, specialities, and other professional opportunities.

Next week, in our final Windrush Season blog, we will look at the diversity of the NHS workforce today! And don’t forget to have a look at our beautiful and ever-growing Here to Stay gallery. If you are in the area, you can register HERE to join us at the free Opening event on 15 June 2019, at the University of Warwick campus.


[1] Emma L. Jones and Stephanie J. Snow, Against the Odds: Black and Minority Ethnic Clinicians and Manchester 1948-2009 (Manchester: Manchester NHS Primary Care Trust in association with the Centre for the History of Science Technology and Medicine, 2010), pp.6-19. Do read this lovely book if you have a chance — it has great pictures too! And if you would like to record your NHS story for posterity, try the NHS at 70 Oral History project.

A Word from our Commissioner

In 2018, inspired by the 70th anniversary of the arrival in Britain of the Empire Windrush, Donna Mighty, Assistant Primary Care Liaison Manager and Chair of the BME Staff Network at the Sandwell and West Birmingham NHS Trust, commissioned a series of formal portraits of past, present and future NHS nurses with connections to the Windrush Generation. These portraits are at the heart of the paired ‘Here to Stay’ exhibitions that will open here at the University of Warwick on 15th June (you can register to join us at the opening event here!) Donna tells us a little more about this process in her blog below.

In 2018 we celebrated the 70th Anniversary of the HMT Empire Windrush arriving at Tilbury docks on 22 June 1948 carrying passengers from the Caribbean.

Sandwell & West Birmingham NHS Trust and specifically their BME Staff Network, were very keen to celebrate this occasion and as such set about organising a Windrush Tea Party in partnership with the University of Birmingham’s Black, Asian, Minority & Ethnic (BAME) Staff Network and Recognize Black Heritage & Culture to recognise and celebrate the contribution of the Windrush generation in shaping and building our wonderful NHS.

Our tea party took place on Saturday 16th June at University of Birmingham School. We had a wonderful afternoon of learning, entertainment, music and food.

We were keen to create a lasting legacy and capture portraits and stories of nurses (retired and current) who attended our event. We commissioned photographer Inès Elsa Dalal and the first photo shoot for what was to become our “Here to Stay” exhibition took place on 16th June. We held two further photo shoots in July and August.

In 2018 we had the opportunity to take the exhibition to London in August, Medicine Gallery in September, Sandwell & West Birmingham NHS Trust in October and the University of Birmingham’s School of Medicine in November. (You can see pictures of these events here, here, and here, and learn a little more about Donna’s amazing work for the NHS here!)

We are delighted to be working with Professor Roberta Bivins and the Cultural History of the NHS team to bring “Here to Stay” to a new audience. Do join us!

Portraits and Power

Portraits and Power

What do you see, in your mind’s eye, when you hear the word ‘doctor’? And ‘nurse’? Until very recently indeed, the most common answer to these questions would have been ‘An older white man’ and ‘a white woman’. Even today, research suggests that we commonly expect the members of many high status professions — including doctors, surgeons, and scientists, as well as university professors — to be both male and white. In professions like nursing and teaching, which are socially valued and associated with virtues like care and compassion (but often not well paid), Europeans and North Americans still often picture and represent white faces, though this time those faces are female.

If you look at our galleries here on the People’s History of the NHS, you will start to see why these impressions and stereotypes have lingered. Until very recently, despite the efforts of innovative shows like Emergency Ward 10 (which included a Black nurse by 1959, and a Black female surgeon — AND an interracial kiss — as early as 1964), mainstream sources of information have often whitewashed our images of the NHS. Until the 1980s and 1990s, representations of NHS staff (and even patients) produced by NHS and government institutions for public consumption most often showed individuals of European heritage. Whether explaining mass miniature radiography, depicting nurse training, or illustrating ultrasound scanning), the ‘humans of the NHS’ were portrayed unthinkingly as White.

Coverage in British newspapers was no different; a survey of major papers from across the political spectrum (the Times, The Guardian/Observer, and the Daily Mail) showed that photographs of nurses and images of nursing almost always featured only White women, even though BAME nurses were at the heart of NHS hospital care from the 1950s onwards. Only in articles that specifically discussed ‘race relations’ or ‘immigration’ were BAME nurses and doctors routinely visible. This is not because photos of Black, Asian and Mixed heritage nurses were not readily available. These lovely photos (from 1958 and 1967) kindly shared with the People’s History of the NHS by the Friends of Savernake Hospital, celebrate the diversity of their NHS workforce as well as the Christmas holidays. And by the 1970s and 1980s, photos of union meetings too routinely portray an NHS workforce made up of workers from all nations and ethnic backgrounds.

And still today, if you walk down the hallways and through the boardrooms of British hospitals, medical schools, universities, and professional associations, you will be strolling beneath the gaze of a seemingly endless series of old white men in impressive suits and formal postures. The ‘great and the good’ loom large –often literally – in these settings, and prominently if silently tell a story about the institution’s identity and history. Here at Warwick, for example, a quick look at institutional portraits in the wonderful University art collection reveals a sea of white Vice Chancellors, honorees and benefactors. They look down at us, and sometimes even each other. The only portrait that includes a Black man figures him in the background, literally in the shadow of the portrait’s subject, Lord Scarman (author of the Scarman Report on the 1981 Brixton uprising). They represent a matter of fact about the University: like most, if not all British universities, its appointed leaders have thus far come primarily from one demographic group. Only one portrait, that of Sir Shridath Ramphal, a former Commonwealth Secretary General who held the ceremonial role of Chancellor at Warwick from 1989-2002, challenges this monochromatic vision.

But when an institution’s visual history –its own celebrations of its past — only includes one kind of face, what does it say to those who are not shown? Are their contributions, perhaps, not seen? And what does it say in particular about an institution like the NHS that so obviously includes and absolutely relies on people from every background? The staff of the NHS, like its patients, have never been monolithically White. In fact, both in the past and today, the NHS has long been one of Britain’s most diverse organisations. The portraits in the Here to Stay exhibition coming to Warwick’s brand-new Oculus building from June 15th 2019 – large, formal, and beautifully composed by the artist – begin to bridge this gap between NHS image and NHS realities. They also hang permanently at Sandwell Hospital, and remind us that here in the Midlands, as well as across the NHS, leadership, compassion and inspiration come from BAME NHS staff at every level. This is the National Health Service’s rich Windrush heritage. In a linked exhibition at the Modern Records Centre, we have also curated a display of documents showing the heritage that Windrush and Britain’s BAME communities have built for all of us, at home, at work, and in the arts.

Read more: If you want to know more about the visual stereotypes that shape our expectations about doctors, nurses and other professional groups, here are a few places to start:

Roberta Bivins, Picturing Race in the British National Health Service, 1948-1988, Twentieth Century British History, Volume 28, Issue 1, March 2017, Pages 83–109, https://doi.org/10.1093/tcbh/hww059

Marci D. Cottingham, Austin H. Johnson, and Rebecca J. Erickson. “‘I Can Never Be Too Comfortable’: Race, Gender, and Emotion at the Hospital Bedside.” Qualitative Health Research 28, no. 1 (January 2018): 145–58. doi:10.1177/1049732317737980.

Jane Turner, Vivienne Tippett, and Beverley Raphael. “Women in Medicine — Socialization, Stereotypes and Self Perceptions.” Australian & New Zealand Journal of Psychiatry 28, no. 1 (March 1994): 129–35. doi:10.3109/00048679409075854.

https://www.nursingtimes.net/roles/nurse-educators/the-image-of-nursing-how-to-combat-negative-stereotypes/5018581.article

And for an antidote to monochromatic visions of medical professionals, see:

https://www.instagram.com/melaninmedics/?hl=en

Windrush Season, Week One: The Windrush Generation and the NHS

Page from the HMT Empire Windrush, titled 'Names and Descriptions of BRITISH passengers'. The passengers on the list include nurses from Jamaica, scholars from Burma, plumbers from Bermuda and many others. Note that ALL were included in the category of 'British', as subjects of the Empire.
Page from the Empire Windrush passenger lists 1948 (The National Archives, BT 26/237)

Next month, on the 22nd of June, Britain will celebrate Windrush Day. Windrush Day is new:  the British government instituted it only last year, on the 70th anniversary of the arrival of the demobbed troop ship HMT Empire Windrush at Tilbury Docks in 1948 — and only partly coincidentally, in the 70th anniversary year of the NHS.

From that ship disembarked some 1,029 passengers, two of whom had stowed away. You may have seen reports that 492 ‘West Indians’ arrived on the Empire Windrush; in fact, a total of 802 passengers came from somewhere in the Caribbean. Photographs reveal that the great diversity of the Caribbean region was well-represented on Windrush: we see amongst the crowds on deck faces reflecting African, Asian, European, South American, and mixed heritage. 539 passengers reported that they previously resided in Jamaica, 139 had previously lived in Bermuda, while others came from Trinidad, British Guiana and other Caribbean islands. 119 listed England as their last country of residence, and 66 passengers on the Empire Windrush were Poles displaced to Mexico during WWII. Dozens of the Caribbean men had served in the RAF. Other Caribbean passengers listed occupations ranging from ‘household domestic’ (96 – the largest group, including many women) to ‘mechanic’ (85, the second largest group), ‘scholar’ (18), ‘civil servant’ and ‘boxer’ (3); the ship transported a single hatter, judge, and potter, and two piano repairers. 274 fell into other smaller occupational categories. A bare majority of the Caribbean passengers who reported a specific destination knew they were heading for London. As British subjects, all entered the country legally, as they were entitled to do by the British Nationality Act of 1948.

The ‘empire’ in Empire Windrush, is important – though it certainly does not feature very often in the official annual celebratory narrative of events! Britain was still a major imperial power in 1948, with colonies around the world but especially in the Caribbean, Africa, the Pacific region, and Southeast Asia. India and Pakistan had only become independent in 1947, while Sri Lanka and Myanmar gained their independence just months before the Empire Windrush landed its passengers on English soil. Forty-six formal colonies remained, and the sun still never set on the British empire.

And a rebuilding Britain, with its newly expansive Welfare State, had perhaps never in peace-time needed the people it had colonised more. In particular, the new National Health Service that would open its doors on the 5th of July 1948 depended on migrant workers from its very first day. Doctors, nurses, builders, carpenters, cleaners, cooks, clerical staff and porters from the colonies and Commonwealth were absolutely essential if the State was to fulfil the promise made to the British people: that everyone in Britain, regardless of their ability to pay, would have universal access to all necessary medical care free at the point of need.

It is this significant contribution that we here at the People’s History of the NHS will be celebrating between now and the 22nd of June. Every week, we will post five portraits and life-stories shared as part of Inès Elsa Dalal’s ‘Here to Stay’ exhibition, commissioned by the Sandwell and West Birmingham Hospitals NHS Trust. Every week, we will accompany these amazing images and accounts with a blog addressing the history and heritage of Windrush for the National Health Service. And on the 15th of June, we will open to the public two physical exhibitions celebrating Windrush right here on the University of Warwick campus. Put the date in your diaries, and we will tell you more as we go along!

Sources:

You can read a summary of the passengers’ details here: https://www.bbc.co.uk/news/uk-43808007, or view the original passenger lists yourself in person at the National Archives (https://discovery.nationalarchives.gov.uk/details/r/C9152210) or search them on Ancestry.

The National Archives also has a variety of materials on Windrush available digitally: for instance, you can look at Prime Minster Clement Attlee’s response to concerned Parliamentarians  here: https://www.nationalarchives.gov.uk/education/resources/attlees-britain/empire-windrush-2/

If you are interested in learning more about the Polish passengers, you can start here: https://www.britishfuture.org/articles/windrush-poles/ or here

https://www.theguardian.com/uk-news/2018/jun/22/the-other-windrush-generation-poles-reunited-after-fleeing-soviet-camps

(Not) Shopping for Health: The Limited Appeal of the Medical Marketplace in a Rights-Based Universal Healthcare System

Roberta Bivins, Centre for the History of Medicine, University of Warwick

This blog was written by Roberta Bivins in response to presentations by David Herzberg and Nancy Tomes, made at the College of Physicians of Philadelphia, and organised by the Consortium for History of Science, Technology & Medicine.  The presentations surrounded the issue of why (and when) we refer to patients as ‘consumers’ in the United States.  Roberta provided a UK perspective, below, drawing on her work on the cultural history of the NHS. The initial talks which provoked Roberta’s paper, and another response from Alex Mold, are all freely available here, with thanks to the CHSTM!

‘Shopping for health’ looks, in some ways, very different from the perspectives of the United Kingdom,with its universal health provision free at the point of need. The ‘internal market’ notwithstanding, the UK’s National Health Service (or more accurately, its four separate national health services – NHS England, NHS Scotland, Gig Cymru in Wales, and Health and Social Care in Northern Ireland) is rarely perceived or culturally represented as a marketplace. And while the UK has a flourishing medical marketplace for over-the-counter, alternative, complementary and  health-related products and services, these are rarely considered in the same light as medically mediated goods and services, whether they are prescription drugs, professional services or expert consultations. Indeed, other than in dentistry, privately purchased medical services, as opposed to services commissioned by the NHS from private and corporate providers, are and are likely to remain a minority concern for most British citizens. In the most  recent figures available (for the year 2016), 79.4% of all healthcare spending in the UK was paid for directly from government coffers – and thus from general taxation. To date, UK citizens need not carry identification to access these  services, and even with my noticeable US accent, I have never in almost 20years of living in Britain been asked to prove my right to use these services.Implicitly or explicitly, consciously or unconsciously, in this country, access to medical treatment is regarded as a right for all residents.[1]

This staged photograph, taken in 1948-9 for Life Magazine, but never published, showed an imagined British medical ‘consumer’, happily festooned with all the items he might receive for free from his new state medical service — including a ‘free’ baby, born in the NHS. (c) Time, Inc.

This view of healthcare has had profound effects of the British medical marketplace, marginalising many forms of health consumerism that have flourished in the USA. Private  medical insurance offers one such example. Even at its peak in 2008, only 12.4 percent of British citizens (some 4.35 million people) carried any private health insurance for use in the UK. Even with concerns about Brexit prompting  more companies to offer their employees private cover, the most recent figures available suggest that just over 4 million Britons have any private health insurance. Since over 3 million of those receive that insurance as a workplace perk, it is clear that the consumer appetite for pre-paid access to purely commodified medical care is limited. Individual subscribers – that is, people paying for health insurance themselves — make up only 952,000 of the policies in the latest figures available, though some of these will include cover for dependents.

There are a number of reasons for this low uptake. Private policies cost on average some £650 per year for healthy individuals in their thirties, escalating to some £2300 for individuals in their 70s, who are much more likely to claim.[2]This is seen as an unaffordable luxury for many, particularly since the NHS, for all its flaws and waiting lists, is perceived as reliably excellent at providing both emergency and acute care. In fact, while critical attention to failings in the UK’s national health services has been an abiding feature of the British news media since 1948, and has expanded rapidly in the wake of both cost cutting and with the rise of an ever-larger elderly population with complex needs, so too have cultural representations of a heroic, high-tech, and above all compassionate health service. British contemporary culture abounds in such imagery, perhaps most powerfully via wildly popular reality/documentary programmes including ‘24 Hours in A&E’ (14 series and two special broadcasts so far);‘GPs: Behind Closed Doors’(now showing its sixth series); ‘Ambulance’ (in its fourth series); and ‘Helicopter Heroes’ (in its eighth series of covering what are in fact only partially public, NHS-funded air ambulance services). The   health service is also portrayed, largely positively, through historical and dramatic programmes ranging from the very popular and now internationally distributed ‘Call the Midwife’ series to the wealth of historical documentaries recently produced to celebrate its 70th anniversary. It is perhaps worth noting that these historical representations often include unflattering(and not always entire accurate) comparisons between access to care under the NHS and in pre-NHS Britain, while the proliferation of US medical dramas on UK television ensures that UK audiences are acutely aware of the frightening limitations of wholly marketised, for-profit medicine for all but the most affluent.

Practical as well as cultural factors are important in curbing UK consumer demand for medical services on an insurance or fee-for-service basis. Private hospitals notoriously and controversially rely on NHS-trained medical staff, and beyond London patients are likely to see the same specialists whether in an NHS clinic or its private equivalent. No UK insurers cover emergency or primary care, and few offer cover for two of the non-emergency services most likely to be used by their 30-64 year old customer base: maternity and mental health care. Best current data suggest that truly ‘comprehensive medical insurance’ simply is not available to UK consumers, precisely because it is not needed. Private general practice does exist in Britain – indeed the right both to practice medicine and to purchase medical care beyond the NHS was guaranteed in the 1948 Act that established the NHS in England and Wales (and in the separate Acts for Scotland and Northern Ireland). However, uptake is vanishingly small as compared to the use of NHS primary care services: the most recent data suggests its extent to be some 7 million private GP consultations, less than 3% of the total.

The NHS very publicly struggles,and in almost every region, fails to meet public demand for mental health services, so US readers might expect a different picture of ‘shopping for health’ in this sector. But while the private mental health care sector earns its providers over twice as much as private family practice (approximately £1.1 billion as opposed to £500 million per annum), 87% of its consultations are in fact paid for by the NHS, and only 7% were purchased by individual consumers. In fact, children, adolescents and the (retired) elderly are all but invisible in the in any case unimpressive ranks of the privately insured in the UK, making its provision very profitable, but culturally almost irrelevant. In essence,when people talk about healthcare in the UK, they mean the NHS. And in the NHS, equality of access, if not of outcomes, is both assumed and fiercely cherished.

One site in which this  difference becomes very clear relates to local and regional variations in health service provision. This is an increasingly pressing topic for national as well as local policy makers in the current economic and political climate: as austerity drives cuts in health service provision, sharp regional divides –economic, social and political – prompt loud calls for greater local and  regional autonomy. Yet one of the most enduring and pervasive critical discourses pertaining to the NHS, at least since its proto-marketisation in the 1980s, addresses the much decried existence of a ‘postcode lottery’ in access to services and treatments.

As one US observer wrote, evaluating the NHS at its 10th anniversary in 1958:

The logical difficulties of [national health] planning … inevitably lead to psychological tensions which may become quite unbearable in a period of serious scarcity. To decide between the relative weight of an improvement of the mental health versus the tuberculosis service, or between the demands of the Newcastle versus the Manchester region… may try emotional stability as well as the calculating intelligence.’ (Eckstein, 1958, p. 272).

This has certainly remained the case. Far from offering a solution, the loosening of top-down guidelines and homogeneity initially encouraged by the advent of the NHS internal market and the deployment of ‘GP fundholding’ (a policy from 1991-1998 which granted some general practitioners greater control over their practice’s share of the NHS budget, and allowed them to commission services independent from national health objectives) produced greater strains. Neighboring primary care practices, local areas, and regions of the UK funded different packages of services for their patients, based on expert assessments of need, local health priorities and often-vague notions of‘community standards’. This might have been seen as opening a space for local consumers to act on the health service, and to allow demand to drive provision.But instead, when members of the British public found themselves denied a treatment offered to a friend or acquaintance, or described as available by the media, they were infuriated. In a national health system, funded by general taxation, not local or regional hypothecated taxes, local variation was read straightforwardly and consistently as iniquitous – as a ‘lottery of care’undermining the equality that was perceived as a fundamental feature of Britons’ right to medical care. This model has been subsequently recapitulated– with much the same disputatious effects — by the current dispensations of‘Clinical Commissioning Groups’ and regional devolution.

As the levels and range of services available free at the point of delivery in the NHS expanded to include treatments intended to improve as well as to preserve life – for example,fertility treatment, smoking cessation, addiction prevention and treatment, ‘psychologically necessary’ plastic surgery, gender reassignment surgery, gastric band and other weight reduction modalities, even wheelchair provision – and a wide range of expensive new chemotherapeutic and pharmacological interventions, local decision-making became ever more problematic. Alan Milburn, the first Labour Health Secretary for 18 years, argued in 1997 that, instead of opening the door for a more consumer driven and responsive health system, market-driven NHS reforms were perceived as setting ‘hospital … against hospital, doctor against doctor and patient against patient. … In the two-tier health service, access to care depend[ed] on the lottery of patients’ post codes and their GP practices.’(Milburn, Hansards, House of Commons, 25 June 1997). Markets and the variations they produce were and are simply not readily understood or accepted in the area of healthcare. And while Britain’s consumers were more than happy to shop for over-the -counter pills and potions, skin treatments and vitamins (to the tune  of £2.6 billion in 2017-18 alone) and an ever-growing array of health-related products – from ‘slimming aids’ to medical devices  (accounting for an estimated additional £810 million per year) – they were far less enthusiastic about the concept of choice   driving service availability in the NHS.[3] Interms of healthcare, ‘never enough’ in the UK context is balanced by ‘never unequal’, at least in the public imagination.


[1] It is worth adding the  caveat here that non-EEA long-stay visitors, migrants and international students must now pay an annual ‘healthcare surcharge’ (added onto the cost of their entry visas) in addition to their ordinary taxes to fund their access to NHS services. Currently this fee is £150 per year for students and £200 per year for all others; it covers access to all NHS services (though prescription costs and the like remain payable), and is levied even if the entrant holds private medical insurance.

[2] Data for this piece comes from the UK Office of National Statistics (https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/bulletins/ukhealthaccounts/2016, accessed 5 November 2018); https://www.theguardian.com/business/2017/jan/16/private-medical-insurance-sales-surge-health-nhs (accessed 5 November 2018) and  https://www.kingsfund.org.uk/sites/default/files/media/commission-appendix-uk-private-health-market.pdf (accessed 5 November 2018).

[3] According to the industry group PAGB, https://www.pagb.co.uk/.

Capturing the History of NHS at 70: The Royal College of Physicians & ‘The Museum of Modern Medicine’

In this 70th anniversary week of Britain’s National Health Service, we are delighted to share a guest blog from Curator Kristin Hussey of the Royal College of Physicians (which is also celebrating a significant birthday this year: the big 5-0-0!). Happy Birthday, NHS!

The museum of modern medicine

What would a museum of British medicine since the foundation of the NHS look like? What objects would it include? What stories would it tell?

In light of this year’s NHS70 anniversary, the Museum, Archive and Library of the Royal College of Physicians (RCP) has been rethinking how we collect and display the history of modern medicine. As Curator, it’s my responsibility to help shape and grow our collection of art and objects so it reflects the ever-changing history of doctors in England and Wales. 2018 is also a big anniversary for the RCP as we mark 500 years since we were established by King Henry VIII in 1518. Since our foundation, the College has been collecting artefacts and archives which trace the history of the organisation, of its membership and of physicianship. Our collections of the early modern period in the sixteenth and seventeenth centuries are particularly rich – helping us to understand more about the wealth, power and ceremony of the early College as well as the development of anatomy. However, as you approach the end of the Victorian era, the museum collection grinds to a standstill.

This lack of collecting beyond the First World War is something I have noticed in many medical museums. Why is it so hard for us to imagine a history of medicine beyond the guts, gore and pain of the nineteenth century operating theatre?  Personally I think there’s an aura of the past about famous doctors and surgeons like Joseph Lister, Edward Jenner, John Snow or William Osler that somehow makes them seem more important. Maybe it’s because the gruesome, outdated and strange tools and remedies of the era seem stranger to us than the stuff of ‘modern medicine’ – the everyday things you can find in a GP surgery or a hospital.

I believe that it is actually this everyday stuff of medicine in the last 100 years that we should be collecting. Museums may seem to be about the past, but they are really about the future. What are the stories and objects people will want to see in exhibitions in 25 years, 50 years or 100 years? What will people think of medicine in 1948 or indeed 2018 when they enter into the realm of ‘history’?  Anniversaries like NHS70 remind us that the mid-20th century is a crucial point in the history of medicine and now is the time to be capturing those objects and stories. With that in mind, the Royal College of Physicians would like to collect and display objects related to the foundation of the NHS and its early years.

Medicine between about 1940 and 1990 represents a period of monumental change. Antibiotics and organ donation, genetic testing and the emergence of HIV/AIDS – displaying the many innovations of the 20th century presents an enormous challenge. As a curator though you aren’t just looking to capture moments of discovery (although that’s important), you are looking for objects that tell a personal story. Sometime which has inspired me about the People’s History of the NHS project is the emphasis they place on the individual experiences of patients. When a visitor comes to a museum, they want to understand what people thought and felt in the past. Whether it’s a doctor or a patient, understanding what a particular artefact meant to someone – how they used it, what it reminds them of, why they kept it. These details can helps us to interpret these items meaningfully for the visitor.

One of the greatest challenges I have found in collecting objects from the 20th century is that people often think their items aren’t important enough to go in a museum. Yet it is often these everyday objects which have the most fascinating stories. Any object can be history if it captures a person’s thoughts or feelings at a particular moment in history. Part of the interesting thing about the RCP Museum is we are interesting in the experiences of both patients and doctors – but ideally stories which bring both together, which help us to understand how patients and doctors have interacted in the past. Two items from our collection illustrate the kinds of artefacts we’d like to collect and display from the NHS era: an early telegram from a doctor desperately seeking insulin to save the life of  young diabetic patient, and this 1994 oesophageal stent, donated by our president-elect Andrew ‘Bod’ Goddard. Stents like these are used in the treatment of cancer, helping to ensure that tumours don’t block the food pipe. Originally invented in the 1880s, this type of plastic model was introduced in the 1970s. However, the plastic stents were difficult to place – something which Dr Goddard dreaded as a trainee doctor. More recently, much more flexible expanding metal stents have been introduced, making these uncomfortable versions a thing of the past. As Bod says, ‘As they are for my patients, oesophageal stents are close to the heart’.

 

If you are interesting in donating something to the Royal College of Physicians related to the NHS, please email history@rcplondon.ac.uk   But first, let me tell you a bit more about what we can and cannot collect, and how you can contribute your objects to our collections!

Note from the editors: Remember, the People’s History of the NHS ‘Virtual Museum of the NHS’ is also collecting. We would be thrilled to collect images of all your NHS objects, big or small — and to hear, save, and share all your stories about them.

 

And if you can’t wait to see more objects, don’t forget to watch this wonderful series on BBC 4, Monday night at 9:00 and available on iPlayer! Objects and stories contributed by members like you tell the human story of the NHS from 1948 until today.

Donating to the Museum of the Royal College of Physicians

The RCP Museum needs YOU!

As Kristin Hussey has written in her blog, the Museum of the RCP is urgently seeking to develop its collections on medicine in the NHS era. Below, Kristin explains what they especially would like to collect and how to go about donating in a bit more detail:

We are particularly interested in collecting items like:

  • Insulin injectors and pumps
  • Medical education models
  • Hearing aids
  • Boxes and packaging for vaccines, antibiotics and antivirals
  • Testing kits for blood, DNA and urine
  • Items related to blood transfusions and organ donations
  • Items related to respiratory health, including those used by patients suffering from asthma or tuberculosis, or preventative equipment against air pollution.
  • Items related to cancer treatment.
  • Copies of X-rays, MRIs and CT-scans (only where patient’s permission has been obtained)
  • Items related to antiseptic and a-septic protocols
  • Items which show changes in treatments
  • Items which show changes in diagnostic techniques
  • Items or artworks produced by patients (for example during chemotherapy or during hospital stays)

There are some restrictions to what we can collect. Large items, fragile or broken items, hazardous items will likely not be appropriate for a museum collection. In particular, we can’t collect human remains, mercury or anything flammable. We cannot collect controlled drugs and would need to carefully assess the possible dangers of any chemicals. While we would love to collect large medical equipment, due to space restrictions we are only able to accept small items (approx. 40cm2 ).

If you are interesting in donating something to the Royal College of Physicians related to the NHS, please email history@rcplondon.ac.uk with the following information:

  • Your details (Name, contact information)
  • An image of the item
  • A description of the item
  • Details of how you came to own the item
  • Details of any personal stories connected to the item
  • Approximate measurements

All potential donations are then presented to the LAMS Management Committee and assessed against our Collections Development Policy and a significance criteria chart. Successful donors will be contacted and delivery of objects to RCP arranged. Once acquired, the objects will form a part of the permanent collection of our accredited museum. Potential donations should not been sent directly to the RCP. Any items received will be returned to the senders where a return address is supplied. If no return address is given, items will be held for 6 months and if not claimed may be disposed of.

The Royal College of Physicians Museum is an accredited, public museum with permanent displays and a programme of changing temporary displays, tours and events. We are free and open to the public Monday to Friday, 9-5, with late openings the first Thursday of every month. For more information on us and our 500th anniversary – please visit https://history.rcplondon.ac.uk/. You can also follow us on twitter, facebook and Instagram @rcpmuseum.

Five Questions About the NHS, and What We Learn from ‘First Memories’

Since we launched our People’s History of the NHS website, we have been collecting your first memories of the National Health Service. We have written about some of your stories here,  and here. Those of you who have joined us as members can read even more first memories in the Members’ Area. In fact, your memories have been so rich and revealing that when we started working with the BBC and 7Wonder to create a ‘People’s History of the NHS’ series for television, we encouraged them to collect first memories too. It was pretty hard to choose, but we have picked out just THREE of these amazing memories to share with you on our BBC tab, here.  Watching them, we realised that we want even more: we want and need yours! These memories, each one a snapshot of a moment that has stayed with someone, sometimes for decades, help us piece together a a better picture of how the NHS was actually experienced — the good, the bad, and the profoundly unexpected. So once again, we invite you to tell us your first memory of the NHS.

Just to get us started, it seems only fair that I should tell you mine: I came to Britain from the US in my twenties as a work permit holder. A month or two after I arrived, I got a letter from my doctor at home; she told me that I needed to have a particular health check right away. I knew there was a GP in my area, but  I hadn’t registered; indeed, I hadn’t troubled the NHS in any way, mostly because I couldn’t QUITE believe that I, an American, could just walk in and get free healthcare. So I waited until I had saved up roughly the cost of the test I needed (or at least what I knew it would cost in the USA — about £200). Then I went to see the GP, chequebook in hand, but a bit nervous that perhaps I had not saved enough. Before I sat down for the examination, I asked how much it would be — and she just laughed. Of course, it was free.

Lots of Americans living and working in Britain will have a first memory very much like mine; I have laughingly swapped these stories with American friends and co-workers many times before. But every time I do, I think of Nye Bevan (well, I am a historian of the NHS, after all!). In 1952, when the NHS was still in its infancy, and just after he resigned from the Government which had introduced fees to the fledgling Service, he published a book of essays called In Place of Fear. And that is where the NHS stands for me — and maybe for you too: it is a bulwark against fear and uncertainty. I grew up in a country where medical bills cast a long shadow, one that left families in darkness even before the costs had been incurred. That’s why I delayed getting the test my doctor told me I needed urgently. I was afraid of the cost. The NHS can’t save anyone from the fear of ill-health (though Bevan hoped it might), but it does mean none of us must worry about how we will pay for care we need. I remember that doctor and her infectious laughter with every payslip and every ballot paper.  The NHS isn’t free — but it frees us from fears that affect every American I know.

At Home with the NHS

Today, as we are staying home, protecting the NHS and saving lives, we at the People’s History of the NHS thought it might be a great time to think about where the NHS can be seen in our homes, and how we experience it during our normal day-to-day lives. This is a topic we have considered before, as in the blog and linked gallery from 23 January 2017 that we are reposting today. Now it’s over to you: looking around your home, can you see traces of our National Health Service? What does it mean to your daily life now, in these Covid times?

In politics, in popular culture, and in historical writing, the NHS is often discussed and represented principally through the hospital. High-cost hospital care, over-stressed accident and emergency units, limits on access to hospital-based technologies or pharmaceuticals: these are the subjects most likely to hit the headlines and spark contentious debates. In part this is because hospitals have, since the early twentieth century, come to symbolise medical modernity. They are where the ‘medical miracles’ happen — and equally, where medical ‘tragedies’ most often come to their dramatic conclusions. And of course, hospital care and hospital-based treatments also absorb by far the majority of the NHS budget (according to the Nuffield Trust, hospital care absorbed some 76% of the NHS budget in 2010/11, and its costs were then rising by about 5% a year).

But most NHS health care – something like 90% of it – takes place beyond the hospital, in GP surgeries, pharmacies, dentists’ offices, ophthalmic services, physio suites, public health settings, and especially in our own homes. Think about it: where do you take (or forget) your medicines; struggle through your physiotherapy exercises; read your health information leaflets; receive calls to preventive medical screening (and decide whether or not to partake in it); monitor your physical health and well-being; maintain and support other family members; restore your mental health? Chances are, you do all these things in and around the place where you live – in your home.

So can we SEE the NHS in our houses? If it does have a presence, what does that mean to us and about the NHS? To start the new year, I asked the People’s History of the NHS team to look around their own homes for traces of the National Health Service. As a group of young adult to middle aged and reasonably healthy people, we were not entirely sure what to expect: would we just find stacks of history books, or would there be evidence of deeper, broader, and more diverse NHS influences on our lives?

You can see the results of our rummaging in the gallery here, with some of our thoughts about what we found. From anniversary coins to abandoned crutches, prescription packets to a blizzard of paperwork (and yes, plenty of books!), it turns out that the NHS has left its mark all over our houses – even if its presence is often so boringly normal that we never noticed it before.

Some of the items we turned up were explicitly meaningful: I treasure my NHS card; another researcher, her childhood NHS specs. The transfer of vaccination certificates and medical cards from parent to child was a part of the transition to independent adulthood in another family, and the cards themselves have consequently survived house moves and spring cleaning culls ever since. Other NHS items probably fall into the ‘clutter’ category (a charity bookmark; a medical gadget; disused crutches). Still others explicitly represent what the NHS means to us not as researchers, but as individuals and citizens: a Bevan tea towel and ‘Born in the NHS’ mug. And finally, of course, there are the traces left by the NHS in its everyday efforts to save and improve our lives: the medications that keep us ticking over.

So now we are asking you: is the NHS in your house? If it is, send (or tweet) us your selfies, pictures of your stuff, or stories about the stuff that has gone missing over the years. And do tell us what it means to you to find the NHS in your home! The virtual museum of the NHS is now collecting…

Roberta Bivins

Learning to pay for the NHS: Students, Universities and the NHS Surcharge

Across the UK in the next few weeks, universities will welcome thousands of new and returning students, many of them coming from abroad. These students have been actively recruited by Britain’s higher and further education sectors, and almost universally pay higher fees than their UK and European Economic Area [EEA] counterparts. But they pay other fees as well: for instance, unlike tourists, business travellers, EEA students, and non-resident British expats, non-EEA students (like other non-EEA migrants entering the UK for more than six months) have since April 2015 paid what is call the ‘Health Surcharge’: a fee of £150 per year, paid up-front for the entire duration of their student visas. Indeed, according to the National Union of Students, the circa half a million non-EEA students make up 75% of those to whom the surcharge is applied.

When this new fee was introduced by the Conservative/Liberal Coalition government, British ambassadors around the world scurried to explain it to key student-sending nations. Charles Hay, Britain’s ambassador to South Korea, for example, acknowledged the ‘very valuable contribution’ made by Korean students to the UK economy. In recognition of this, he said, Britain had ‘deliberately kept this surcharge at a competitive level – lower than most private health insurance policies’ required by ‘our competitor nations’. Additional dependents accompanying the student would each pay the same charge, and there was no reduction in the charge for students coming from lower-income nations. Mike Harper, Minister for Immigration at the time that the Health Surcharge was added to the 2014 Immigration Bill, took a slightly different line, asserting, ‘We have been clear that the UK has a national health service not an international health service’ (not a novel claim – it has regularly surfaced in various forms since 1948 – though one for which the 1946 Act establishing the NHS offers no support): the charge, he added, merely represented a ‘fair contribution to the costs of the health service’.

Politicians justified the new surcharge on the basis that ‘international students’ cost the NHS £430 million per year, or around £700 per head. Notably, this is less than half of the cost estimated per head for British expats who return to the UK for free NHS treatment despite living abroad, to whom the charge does not apply (not least because it could not be collected alongside visa fees). In fact, it is an intriguing figure for many reasons: first, since the very earliest days of the NHS, auditing the cost of ‘health tourism’ has proven to be an almost impossible challenge – for more on this murky area, see reports from Full Fact and this government-commissioned research from 2013. Second, most overseas students, like their domestic and EEA peers, are young and healthy, and consequently make few demands on NHS services. In fact, even the weighted estimate of their cost per head – that £700 figure – incorporates assumed costs based on the higher birth rates common among women in their early twenties: yet very few overseas students actually give birth while at university. As the report on which the introduction of the surcharge was based admitted, the estimated costs to the NHS of each student reflected ‘a considerable margin of uncertainty’.  The NHS services that young people are more likely to use – emergency services, treatment for certain contagious diseases, family planning services and compulsory mental health treatment – remain free, either because they benefit the general public health and safety, or because access to such care is still deemed to reflect core UK values (and simple human decency). One might therefore wonder: are the students getting any additional services for their money?

Within six months of its implementation, the Health Surcharge brought over £100 million into the Treasury. According to the Home Office at the time, this income ‘contribute[d] to the NHS for the benefit of us all.’ Perhaps this why this charge on international students produced few ripples in public opinion or the media, particularly in today’s atmosphere of constant NHS crisis. The NUS and voices from the education industry certainly deprecated the charge for students, noting that it might harm the sector and make individual students feel unwelcome. Migrants’ rights organisations also criticized the charges, though their emphasis was almost entirely on the potentially negative impacts it could have for international workers and their families, and for the British communities whose own entitlement to NHS services might be questioned in the rush to ensure compliance with the new rules. Not only were most long-stay migrants already likely to be healthy young taxpayers, and thus net contributors to the NHS, but as one such body, the Migrants’ Rights Network noted:

“The Home Office advice does not explain how NHS service providers in the UK are going to be able to identify non-EU national patients whose eligibility for treatment will be dependent on payment of the surcharge…a lack of clarity on this issue will give rise to confusion as to who is entitled to treatment on the NHS and who will stand to be refused.”

But there were no backbench rebellions, no street marches, and few if any attention grabbing public protests, even on university campuses.

This muted response is strikingly different from what happened the last time a Conservative government tried to impose costs on university students and other overseas ‘visitors’ (then defined as anyone neither in work nor resident in the UK for at least 3 years) accessing the NHS. When on 12 March 1981, Margaret Thatcher’s Secretary of State announced plans to introduce NHS charges for overseas patients, including students, it provoked uproar. As in 2015, the Joint Council for the Welfare of Immigrants and other similar bodies were highly critical, as were organizations dedicated to improving what were then called ‘race relations’.  But in 1981, many other voices were also raised in protest. The Trade Unions Council [TUC] rejected on behalf of the combined NHS unions the very idea that NHS staff should operate identity checks before providing necessary care. The Lecturers’ Union (roughly equivalent to UCU) ‘condemned’ the policy outright as it applied to students and ‘deplored’ its probable effects on ‘race relations’. The Government’s proposals, they proclaimed, ‘would be seriously detrimental’ and it was ‘iniquitous’ for any government to push students into the unscrupulous hands of private insurers who already discriminated against the disabled and, by excluding pregnancy from cover, women. The National Union of Students vigorously protested a policy which would generate NHS ‘apartheid’ and many organizations pointed out the bitter irony that the NHS depended heavily on the labour of overseas student nurses and trainee doctors – but might be forced to charge them for the very care that they provided for free to others, at least until they met certain residency requirements. In fact, protest was so widespread and so vigorous – and so much attention was drawn to the uncertainty both of figures about the costs and benefits of the policy, and to the possibility and effects of enforcement – that the Government was forced to back down.

Like today, the years leading up to Thatcher’s 1981 proposals were marked by economic recession and corresponding austerity, civic and labour unrest (including in the NHS), major concerns about a rising tide of xenophobia and racism, and a widespread sense that the NHS was in crisis, and perhaps at the verge of disaster. Public and political concern about ‘medical tourism’ and the unfair exploitation of the NHS was also widespread and sometimes outspoken. So why did the 1981 proposals fail, while 2015’s ‘surcharge’ passed into law without a hitch? In part, the Coalition Government avoided some of the most deadly pitfalls of the earlier policy: in particular, they outsourced the ugly task of extracting payment by building the ‘health charge’ into the already expensive process of gaining legal permission to enter the country as a student. They also exempted students already in the country, reducing the number of campus voices who would be directly affected by the new policy. Finally, unlike Thatcher’s government, they also offered no model for how the policy might be enforced within the UK. Rather than charging individuals as they incurred NHS costs, the ‘Health Surcharge’ relies on the collection of an (admittedly regressive) fixed universal charge abroad. It does not (yet) require UK health staff to perform identity checks or to assume associated administrative and ethical burdens, and thus did not raise hackles in the NHS itself.

But perhaps too the Coalition relied on us, the anxious and austerity-conscious electorate, to passively accept a charge that would affect none of ‘us’. Are we more ready than in the past to  be convinced by even the sketchiest anecdotal evidence of ‘foreigners’ abusing the NHS? Maybe years of erosion in support for free education — years in which we have heard much about the ‘graduate premuim’ and little about its sharp variations across universities, ethnic groups and fields of study — have made us disinclined in any case to trouble ourselves about students. After all, what is an additional £150 pounds per visa year for young people already willing to assume costs of tens of thousands of pounds a year in tuition alone? And maybe too ‘Thatcher’s children’ (and ‘grandchildren’, the students of today) see access to the NHS with different eyes, as a privilege of citizenship, or a taxpayer’s perquisite, not an outward sign of a national commitment to equity or the human right to health. Nye Bevan, challenged in 1949 to justify visitors’ free access to the new NHS, responded that access to medical care should be seen as part of the ‘normal hospitality’ of a civilized nation. Can we still be proud and confident in our own norms of hospitality, or indeed, in our commitment to that egalitarian post-war vision?

The ‘Appointed Day’: Celebrated or Silent?

With all the tumult that continues to surround the recent EU Referendum and its results, it seems likely that yet another anniversary of the National Health Service’s first day of operation will pass with little notice this week. It is now 68 years since the National Health Service officially opened its doors on 5 July 1948, the so-called ‘Appointed Day’, designated by the National Health Act of 1946. The first NHS baby, Aneira Thomas – born at one minute past midnight on the Appointed Day in the Amman Valley cottage hospital (see its now-abandoned and decaying maternity wing here), not far from Bevan’s own birthplace in Tredegar where a workers’ health cooperative inspired the all-encompassing remit of the NHS – is now herself a pensioner, retired from a life serving the NHS as a mental health nurse. Her sisters and daughter too have lived NHS lives, working as nurses and paramedics.

As an adult, Thomas has expressed great pride in her role, her namesake, and the NHS itself. But when did her unique claim to fame become meaningful to Thomas? Interviewed in 2008, as part of the ‘NHS at 60’ celebrations, she observed that as a child, ‘I never understood what the significance of it was… I just kept saying I was the first national health baby and didn’t understand what it meant.’ And indeed, historical evidence suggests that the significance of the NHS, and thus of its annual anniversary emerged rather slowly for many patients, and service users, and for politicians, professionals and ‘media-types’, too.

Of course, in 1948 – even more than today – the residents of Great Britain faced change on an overwhelming scale. Not only the NHS but a whole raft of services, benefits, and charges came into being between 1944 and 1948: in 1944, the Education Act introduced free secondary education; in 1945, the Family Allowances Act offered families financial support while the National Insurance Act extended a benefits safety net beneath the unemployed and the sick; in 1946, the Industrial Injuries Act gave yet further benefits to those injured at work, and in 1948, the Children’s Act mandated council provision of good housing and care to all children ‘deprived of a normal home life’, while the National Assistance Act came into force, providing ‘the last defence against extreme poverty’ (in the words of the Times newspaper) in the form of benefits available to anyone in need. Whole industries were nationalized, New Towns mushroomed, and existing towns and cities saw massive building – albeit newly constrained by a tightened belt of legally-protected green land. As the Daily Mail’s editorial put it on 3 July 1948,

‘On Monday morning, you will wake up in a new Britain – in a State which “takes over” all citizens six months before they are born, provides cash and free services for their birth, for their early years, their schooling, sickness, workless days, widowhood, and retirement. Finally it helps defray the cost of their departure. … You must begin paying next Friday… Everyone, from duke to dustman, earl to errand boy, must pay, even if they decline the free services or scorn the cash allowances.’

With so many new services, and the reshaping of an entire society, it is perhaps unsurprising that the NHS Appointed Day in 1948 prompted little media fanfare; while some national and local papers carried stories announcing the ‘birth’ of the NHS, few made it front page news, or included pictures to grab readers’ attention. This was not due to any shortage of photos: as well as an extraordinary wealth of news photography documenting the day, the Ministry of Works itself generated a substantial visual archive of the new services and their staff. These are the photos with which we have now become so familiar via celebrations of key NHS anniversaries: its 50th, 60th, and 65th birthdays, for example. But almost none were published in the national press on 5th July 1948. Instead, the front pages carried the usual selection of celebrities, crimes, advertisements, ministerial handshakes and the like. In Manchester, for example, chosen as the site for Bevan’s inaugural tour of his new NHS, the city’s main newpaper gave scant coverage to local events on the day, including a large thanksgiving ceremony honouring the advent of the NHS in the city’s cathedral. It did print a picture of Bevan’s July 5th visit on the inside pages a day later — but it titled the photo ‘The Transfer of the Hospitals’, a title which emphasised loss of local control and resources rather than the advent of a new universal health service. Nor was the Manchester Guardian alone in relegating news of the ‘Appointed Day’ to its inside pages, despite praising the NHS as a symbol of ‘the advance of equalitarianism’. After all, as the paper’s editor noted, ‘the new system of social security’ provided by the Ministry of National Insurance also came into effect on the 5th, and ‘unlike … the National Health Service, will make itself felt at once’, not least through higher taxes.

The Guardian (again, like many others, including the Daily Mail at the other end of the political spectrum) marked the first anniversary of the NHS not at all. Service users, at least, certainly had good cause to celebrate: in its first year, the new NHS had provided patients with 27,000 hearing aids; 164,000 surgical and medical appliances; 6,800,000 dental treatments; and 4,500,000 pairs of glasses – and these figures did not even include items supplied through general practice, hospital dental treatments, or the hospital eye services. Ilford, a photographic supply company, even bid for an additional £1,000,000 in new capital on the back of the National Health Service’s voracious appetite for x-ray films.

However, little more than a year after its birth, the NHS was already facing criticism. For example, some complained that it was a ‘National Ill-Health Service’, too focused on ‘the free provision of corsets, free wigs, and false teeth to all and sundry’, and caring for the unhealthy ‘at the expense of the healthy’. The NHS was, according to some, already encouraging ‘social parasitism’ (Manchester Guardian, 9 August 1949). Others grumbled about ‘abuse’ of the health service by ‘foreigners’ — claims that our own on-going debates about access to the NHS echo all too accurately, of course.

Perhaps in a climate of radical social change, environmental reconstruction, anxiety and seemingly permanent austerity (yes, I am still talking about 1949 here – though viewed from the midst of our current moment of change, it may be hard to tell), the chaos was simply too great to focus on celebrating what had been achieved. Or perhaps in ‘interesting times’, the urge to cynicism, scaremongering and sometimes bitter complaint serves as a vent for wider anxieties. As the 5th of July comes around again this week, we at the People’s History of the NHS will scan the papers for clues about the current meanings of NHS anniversaries – but we won’t be surprised if comments are scanty (or negative), and celebrations muted or absent altogether.

Charting the NHS

Ok. So the NHS is complicated. We get that: after all, it is the largest single employer in Britain, and one of the five largest employers in the whole world. Even if it were just an ordinary business, it would be a complex one, with lots of moving parts.

And it’s not just a case of ‘size matters’ – though of course it does. Famously, of course, the NHS provides cradle to grave services to all British citizens, legal UK residents, and others. Unsurprisingly, that adds to the complexity.  By one means or another, through one outlet or another, the NHS cares for us in sickness and in health – from before our first breaths (via antenatal services) to our last moments of life (in ambulances, hospitals or in our own homes).

But what is with all the organizational charts?

Medical Practitioners’ Union chart of the reforms envisaged by the Willink White Paper in 1944

Even before the NHS was born, it was mapped by and for experts, politicians and the general public. The complex patchwork that made up pre-NHS health care provision (see our gallery here) is visible in diagrams like this one, produced by those seeking to educate workers about the services available to them. And the earliest charts of the NHS itself, intended for the eyes of experts and politicians alone, were pretty blunt about where power lay and how the new services would be administered and directed. Once the National Health Service Act committed the nation to the NHS, the Ministry of Health in England and Wales, the Northern Ireland Home and Health Service, and the Scottish Home and Health Department all began to generate their own charts and diagrams. So did local governments and other bodies. These charts were intended as much to advertise the new health services to their potential users as to provide useable information about the relationships between different parts of the NHS itself. Visually, these charts often placed the public at the centre of the visions of the NHS, or represented its complexity in terms they might recognise. One local authority portrayed the NHS as a modern high street, for example.

Since these early days, many other bodies have also produced diagrams mapping the NHS for various reasons. Academics, including historians, have not been backward in this area. Indeed, some of the most famous charts of the NHS were produced by its official historian, Charles Webster, to explain policy-driven shifts in the structure of the NHS across its history.

Most recently, stakeholders of all kinds and descriptions, from local health authorities through to major think-tanks and political parties have produced their own organisational diagrams of the controversial changes prompted by the Health and Social Care Act of 2012.

As in the first years of the NHS, these vary markedly depending on whom they are intended to inform.  Those addressing the public directly once again often place images of service users at the centre, while those intended for professionals or policy makers may offer a rather different vision. Political and ideological commitments, too, play a strong role in shaping depictions of the new NHS, whether pictorial or purely diagrammatic in nature. A chart produced by the Government as controversy raged over changes that faced strong opposition, looks pretty different from the one produced by those who strongly opposed the changes.

Meanwhile, medical professionals responding to and coping with a major re-organisation, often produce their own mental ‘maps’ of the new NHS, like the one illustrating this blog. Unlike the diagrams produced by each side of the debate, these are maps of the new system as it is experienced or expected to function. Like this one, many such maps are really images of how power, authority and decision making are distributed across a very complicated system, and as such are very individual, based on the specific perspective and position of their creators. The Socialist Health Association has created their own (animated!) organisational chart, at the bottom of the page here, which reflects their doubts about the new system. So has the King’s Fund, with a wonderful companion video, here, drawing and explaining the system.

What would your NHS map look like? Why not draw or describe it for us in the comments below (you can send us your own diagrams here)!

And what does all this mean for us, and for the NHS itself? Well, first, it shows us what a slippery and many-tentacled thing this ‘National Health Service’ really is: we all – experts and ordinary users alike – NEED maps, because providing universal services, free at the point of need, requires many different structures, providers, institutions and pathways. Second, these diagrams remind us that the NHS has never been a static, stable entity. These maps, charts and organisational diagrams are needed in part because the NHS has been reorganised and restructured so many times since its birth in 1948. Finally, they tell us that maps of the NHS, like all historical objects and documents, carry a wealth of meanings, and demand careful interpretation. In other words, even apparently simple and neutral charts have politics – and need to be treated as the ideological artefacts that they so often are.

See our ‘Charting the NHS’ virtual museum gallery here

Examining Alternatives to the NHS

Examining Alternatives: What can ‘managed care’ say to the NHS?

First, a declaration: I love the NHS as perhaps only a (once-) foreigner can. I grew up largely uninsured in an under-insured family in the United States. As a child, all my medical and dental care was delivered by earnest students and harried junior doctors in America’s over-stretched urban teaching hospitals. Offering me up as ‘teaching material’ was the only way my student parents could afford such treatment. Most of that care was excellent, delivered with kindness and a clear sense of vocation. But it was not preventive. Indeed, it was not health care, but the emergency picking-up of shattered pieces: a tuberculosis infection spotted only by a vestigial school detection programme that was shuttered only a year later; perpetual chest and throat infections amplified by cold housing and extreme weather; malaria brought home from my parents’ tropical research travel. And my timely access to such care was only really guaranteed by my parents’ high levels of education and determined advocacy – their pointy middle class elbows still worked, despite our poverty-level family income.

By comparison to this precarious, contingent and unequal ‘system’ of medical care, the NHS looks and feels like a health paradise, and one that I certainly don’t take for granted. From the moment I arrived in the UK, I knew that I didn’t have to keep an insurance card visible in my wallet (‘just in case I get hit by a bus’); didn’t have to wait until I needed emergency care to address a lingering illness; didn’t have to worry about friends and colleagues facing medical emergencies. This last was a particularly sharp and delightful change from my experience at one US institution, where we held bake sales to support a colleague with poor insurance and a chronic condition.

So when I talk about examining alternatives to the current NHS model, it is by no means because I seek to change the current NHS ‘offer’: universal care from cradle to grave, free at the point of need. I have seen what a ‘competitive’ free market in health care offers to the poor, the socially disadvantaged, and even the ‘strivers’: insured individuals and families in work and well above the poverty line, who find themselves facing sky-rocketing medical costs that their insurers won’t pay. In this free market, if you are hit by cancer, or any catastrophic medical emergency, or even a long term chronic condition like diabetes, you must prepare to lose your house, your car, your access to credit, because there is no way you can afford the care you’ll need even on a middle class income – unless you are one of the lucky few with really good medical coverage.

And this is one face of any comparative analysis of alternatives to the NHS: in this period of austerity and NHS brinksmanship, comparing a nationalised (or even a regionalised, as in Manchester) health system to a medical free market shows us what we, as patients, stand to lose if ideology replaces evidence in our healthcare debates.

But there is another face as well. In the US, the alternative medical system that I know best both as a consumer and a researcher, there are systems analogous to the NHS, but embedded in the neoliberal marketplace. What can such systems tell us about both barriers and pathways to healthcare excellence? And what can they say about the ‘meanings’ of the NHS, both to our health and to our culture?

Kaiser Permanente, one of the largest managed care groups in the USA, is one such system – and it has some striking historical parallels to the NHS. Established in 1938 to serve the employees of industrialist Henry J. Kaiser’s steelworks, shipyards, and Grand Coulee Dam project and opened to other consumers in 1945, this managed care plan runs hospitals, clinics, general practices, and health education programmes, and hosts both publicly and privately funded healthcare research — just like the NHS. Since it is of roughly the same vintage, it can – and now does – boast of ‘Kaiser babies’, just like we talk about being ‘born in the NHS’. And like the NHS, it is a system rooted in a vision of better health (and thus lower costs) as the natural outcome of promoting preventive care and ‘positive health’ for its users. Of course, unlike the NHS, Kaiser is neither free nor universal, but it does offer health services on the basis of capitation (that is, to individuals based on paid memberships), rather than on a fee-for-service basis.

In April 2016, I spent time as a Visiting Professor at Kaiser Permanente’s Northern California Division of Research, hosted by the Division’s Health Care Delivery and Policy Section (thanks to Drs. Alyce Adams and Julie Schmittdiel for the invitation!). Like me, this team is especially interested in disparities in health and access to care, and social determinants of health behaviour and health outcomes. Thus we had a shared focus on a topic where history is highly relevant, despite the very different systems in and on which we work. Here in the UK, recent research has made one thing very clear. In terms of generating equal health outcomes for all populations, free is not enough. Even with the NHS operating on the basic principle that healthcare should be accessible to all regardless of ability to pay, there are still marked differences in both self-reported and clinically observed measures of health and wellbeing between population groups. Almost identical patterns of health disparities emerge in data from the Kaiser system, even when researchers design interventions specifically intended to lower financial and structural barriers to good health for system members. Over the next few years, members of the Kaiser DoR and of this NHS team will be working together to ask ‘what do these similarities – as well as the obvious differences – mean for each healthcare system and its members’? What can we learn from comparing ‘cultures of health’? We’ll keep you posted!

A last word on ‘First Memories’

Six weeks ago, we asked you to share your first memories of the NHS with us – many stories, tweets and comments later, you have already done so much more. Your stories, and those of your families, have captured the National Health Service’s first moments (thanks especially to the Macbeth family, and retired nurse Helen Gallacher, who have shared striking memories of training and practicing medicine before and during the Second World War and in the the fledgling NHS). You have told us about the Service’s more recent past as well: early hospital visits, vaccinations, check-ups and childhood accidents.

In your memories we can begin to see some interesting patterns developing. Several of you recalling the first decades of the NHS, for example, have explicitly mentioned cost – not what younger users might expect in memories of a Service famously ‘free at the point of need’. But as one member told us, in these early years, doctors sometimes told their patients very directly what their treatment cost the Service, as part of urging them to comply with medical regimens. In this case at least, the technique worked: this storyteller reported being ‘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.’ The message – and the awe – stuck in her mind, and she still remembered it more than six decades later. Cost-saving, but easily recognised ‘NHS specs’ are clearly just as memorable, but perhaps not as attractive an aspect of ‘free’ health care. Another member recalled his family’s decision in 1962 to reject free frames, despite the cost of the alternative: ‘my parents insisted on paying for “better” frames when I could have had NHS frames for free… It was bad enough being teased at school … it would have been much worse if I’d been wearing NHS specs.

Others have told us about the NHS as a space for new encounters, both medical and personal. For some older members, it was first place where they met people from other ethnic groups: ‘unbelievably impressive’ black nurses created strong memories for one young patient in the 1970s. But sometimes your memories of the medical encounter itself are considerably less clear: you have also told us about the ‘blur’ of ‘memories of doctors and hospitals, of consultants and blood tests and clinics’. Some of you have described your interactions with the NHS, tellingly, as ‘a long and never ending relationship’ – a phrase that resonates with claims that the NHS is part of our lives, almost a member of our families. Others, those with ‘NHS in the Family’ for instance, have talked about being ‘surrounded by it’, and have described the NHS as ‘something that really sums up the UK’.

Intimate and enduring as your relationships with the NHS may be, it is not always your favourite ‘relative’ (so to speak)! If you care for an older person or live with a chronic condition like diabetes, you may remember disjointed care and difficult regimes – but also your pride in maintaining those regimes no matter how meticulous and challenging. And sometimes you – and your parents – have had to ‘persuade’ NHS gatekeepers to provide the health services you have needed.

As a whole, your stories and comments have tracked technological and cultural changes in the Service. Through your eyes, and your memories, we have seen the breadth of the NHS, too: you have remembered ‘firsts’ from the GP surgery to the School Medical Service, and from the hospital to public health campaigns. In your photos, and in wonderful artefacts like Dr Macbeth’s casebooks, we are seeing both new and familiar aspects of the NHS. While we are now – inspired in part by your collective fascination with needles! –  asking you about vaccination, all your memories of the NHS (first, last, and in between) are welcome here, so keep on sharing. Thank you!

 

First Memories of the NHS

To launch our new People’s History of the NHS website, we asked you to send us your first memories of the NHS. Since the first of February, you have been responding. Thanks to your memories, and your comments on our objects, galleries and the stories that other members have told us, we now know more about childhood vaccinations, the drama of acute care from a child’s perspective, life as an NHS-using mum, and experiencing the death of a loved one in an NHS hospital. You’ve told us about dodging the stigma of NHS specs, loving cottage hospitals, and complaining (or NOT complaining) in the NHS. And you’ve shared your pictures as well as your recollections: we love Giuseppe Giancola’s cheeky grin in the photo above – pretty impressive, given that he was enduring the long slow process of skin transplantation in the 1950s – and gorgeous, ‘born in the NHS’ baby Stanley.

Already, you are showing us areas we need to understand better and to explore in greater detail, like the school medical service, where two of you received vaccinations against tuberculosis. Your memories of BCG vaccination tell us a lot about how medicine has changed (we certainly wouldn’t vaccinate a class full of children with one rapidly blunting needle any more!), and of ways in which it has remained the same: schools are still a place where children become ‘visible’ to medicine and public health, and where the NHS and other state agencies can intervene, hoping to improve their lives. And there is so much more we need to learn about how it felt and feels to encounter ideas of health and medicine in that setting: what about those ‘healthy plates’, and ‘five a day’ messages? Do you remember these? Have they changed since you were a kid? How about the return of programmes related to preventing TB, at least in some areas of Britain? Did ‘Nitty Nora’ visit your school? What else do you remember about the health service in schools or as a child?

We’ve also been hearing from people who work or worked in the NHS, and about care – compassionate, complacent, or grudging – in NHS hospitals, GP surgeries, and other sites. Your stories have highlighted the fact that good NHS care is not always medical (how about that GP who called campus on behalf of a panic-stricken student missing a crucial final exam?) and that bad care in the NHS ranges from the merely impersonal to the actively dangerous. And you have also told us that the NHS is important to you in very striking ways – in one case, that the universal availability of medical care free at the point of delivery actually empowers you to be who you want to be.

So: tell us more! We look forward to more of your ‘first memories’, and to reading your comments below and your responses to the objects and galleries in our Museum and the entries in our People’s Encyclopaedia of the NHS. Did you (or your granny) have an NHS hearing aid? Do you remember those posters about healthy teeth? How is the hospital food in your bit of the NHS? Do you (and should people) fundraise for the NHS? Should doctors have a ‘union’? Did you take part in the doctors’ and nurses’ strikes in the 1970s and 80s, or where you a patient affected by them? Or did you, like me, first encounter the NHS as an adult, perhaps recently arrived in the the UK? Most of all: what does the NHS mean to you?