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Reform before the NHS

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Britain’s National Health Service did not come out of nowhere. There were many notable developments, schemes and efforts to co-ordinate and unify healthcare over the preceding decades. Yet the road to 1948 can look rather sparse in terms of major government reforms.

The pre-WW1 Liberal social reforms marked a significant progressive shift. These included a school medical service and, most memorably, Lloyd George’s introduction of national insurance in 1911. Originally for those in selected industries, it grew to cover most working people by the 1930s, providing cash benefits in times of sickness and entitlement to be seen by a doctor chosen from a local panel. With the exception of those suffering from tuberculosis, however, this did not include any right to hospital treatment.

Calls were already being heard not only to improve access, but to bring about systemic reform. In 1909 the Royal Commission on the Poor Law, unable to agree on a number of key issues, had produced two reports. The majority report sought “schemes of co-operation between public assistance institutions and voluntary hospitals”. Meanwhile the more radical minority report, written largely by the Fabian Beatrice Webb, wanted a comprehensive, “unified” medical service to be forged.

It was a call reiterated in the aftermath of the First World War. It was at this time Lloyd George charged his close ally, Christopher Addison, with implementing his plans for postwar reconstruction while heading up the new Ministry of Health, set up in 1919. As a GP turned Liberal MP, his understanding of the medical profession had been vital in Lloyd George’s successful negotiations over national insurance. Addison now established a committee under the chairmanship Lord Dawson, formerly the King’s physician, to investigate the “schemes requisite for the systematised provision of such forms of medical and allied services as should… be available for the inhabitants of a given area”. Their report the following year recommended a network of teaching hospitals, primary and secondary health centres, supported by domiciliary services (pictured) across the country. Yet Lloyd George’s waning influence in his own coalition government as the 1920s arrived meant the Dawson Report’s proposals were one of many promises never delivered upon. Indeed, Dawson himself wrote in the British Medical Journal in 1942, saying those early plans “might well form the basis of reconstruction to-day”.

In this, as in many other areas, it is hard not to see the First World War as something of a dress rehearsal for the Second. Both saw the government temporarily directing the myriad medical services operating in each area, with huge efforts put in to planning to build on those arrangements with fundamental health reforms as part of reconstruction in the aftermath. So why was the 1940s the more successful? For historian Geoffrey Rivett the answer lies in the wartime Emergency Medical Service set up in 1939, which demonstrated how much could be achieved by government centrally administering the nation’s health services.

And what of the years between the world wars? Certainly there was a lack of the kind of sweeping reforms we find before the First and after the Second. But it would be wrong to assume nothing happened, simply because of a lack of central government activity.

There were a great many pioneering institutions. Perhaps special mention here should go to the Pioneer Health Centre in Peckham, since it put into practice on a voluntarist ‘social medicine’ approach quite different to that of the NHS. After first opening in 1926, it was relaunched in 1935 in a purpose-built home (which you can see on film here). London’s second-largest swimming pool was at the heart of this new building, where members could also use a two-floor gymnasium, a self-service cafeteria, a theatre and a long gallery designed for dancing, as well as spaces intended for playing billiards, darts and table tennis or listening to the wireless.  From 1938 members could also buy milk, eggs and vegetables grown on an organic farm in Bormley in Kent, which had been leased a few years earlier. Consulting rooms and a medical laboratory were located in the middle of this hub of healthy activity. This was a private community centre, membership of which required a modest weekly family subscription of 6d. (half of what the average working-class family spent on newspapers) and agreeing to a regular ‘health overhaul’ for each family member. Their holistic approach was based on a level of medical intervention we would have trouble tolerating today, earning founders George Williamson and Innes Pearse the nick-name of the ‘Peckham Biologists’. Meanwhile their voluntary ethos set them at odds with the National Health Service and difficulty in raising funds forced the Centre to close in 1950.

Independent and charitable initiatives also worked to develop and rationalise the voluntary hospitals that provided the bulk of acute hospital services. Local hospitals councils brought them together in an effort to provide a coherent service. In Oxford this gave rise to the Nuffield Provincial Hospitals Trust, which worked in parallel to the King’s Fund in London, to encourage similar schemes in every part of the country. In numerous areas, this also provided a platform on which to rally the community to support improving local hospitals. In Sheffield this went as far as a Million Pound Appeal to build a new university hospital, although war interrupted in 1939. Despite their largely unfair reputation as conservative and parochial institutions, by the time of the Second World War the voluntary hospitals were typically at the heart of ambitious efforts to bring about something along the lines of an integrated mixed economy of health services for their local area.

This, of course, involved working closely between public and voluntary hospitals. Collaboration proved easier and more successful in some areas than others. At times the two were more operating in parallel. It was certainly a danger of Health Minister Neville Chamberlain’s 1929 Local Government Act – which empowered local authorities to appropriate poor law infirmaries as general hospitals – that public and voluntary hospitals might end up duplicating and competing against each other. Yet while the public focus on paupers, the chronic sick and infectious disease was breaking down, many local areas managed to find ways to work together. Medical Officers of Health were often pivotal to integrating local health services, such as in the Gloucestershire Extension of Medical Services Scheme that Lord Dawson took as his template before funding difficulties undermined its success. Few schemes, however, were as early or as ambitious as the Highlands and Islands Medical Service, launched in 1913.

Progressive municipal hospital policies were a staple of Labour in local government throughout the interwar years, along with a commitment to maternity and child welfare. Indeed, this was an important building block in growing support for the party as it came to be an occasional party of government. So when Bevan announced his plans they were quite a surprise. Not because some sort of national health service was unexpected; it was supported by all parties and its popular association with the Labour Party was an important factor for many who had voted Labour, propelling Clement Attlee’s party to a shock victory over Winston Churchill’s Conservatives in the 1945 election. But because the organisation of that health service – run by central government through regional boards, rather than at local government level – was a break from his party’s existing policy. Although this broke from Labour’s established municipal power base, it put the levers of policymaking more firmly in the hands of a reforming minister and afforded the opportunity to redistribute resources from richer to poorer areas, making it a truly national system. As such, Labour’s introduction of the NHS was both the ultimate realisation of, and a radical break from, the many previous reforms of the early twentieth century.

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Further Reading

Martin Gorsky, The Gloucestershire Extension of Medical Services Scheme: An Experiment in the Integration of Health Services in Britain before the NHS, Medical History, vol. 50, no. 4 (2006), pp. 491-512.

Alysa Levene, Martin Powell, John Stewart and Becky Taylor, Cradle to Grave: Municipal Medicine in Interwar England and Wales (2011).

Geoffrey Rivett, National Health Service History: Inheritance

Charles Webster, Conflict and Consensus: Explaining the British National Health Service, Twentieth Century British History, vol. 1, no. 2 (1990), pp. 115-151.

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2 thoughts on “Reform before the NHS

  1. While not a part of any government reform, the role of friendly societies was a major funding source for workers to insure their health (providing they followed the moral and behavioral guidelines). The societies also played a part in the establishing of the NHS.

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