This week we have a guest blog post contributed by Dr Gareth Millward.
Vaccination is a rite of passage for most of us. In 2014/15, 92.3 per cent of children under the age of two received at least one dose of MMR. Since the birth of the NHS in 1948, mass immunisation of children has targeted diseases as diverse as smallpox, diphtheria, whooping cough, tetanus, poliomyelitis, measles, mumps, rubella and HiB. And that’s not an exhaustive list.
Since we received the majority our vaccines at the GP’s clinic, it’s tempting to think that the NHS must have been responsible for all this. But it was not until the re-organisation of 1974 that vaccination fell under the control of the NHS. And since 2013, NHS facilities have performed vaccination under the direction of Public Health England.
As with all health administration, it’s complicated. Unsurprisingly, the roots of this complication are historical.
Vaccination pre-dates the NHS by over a century. It was seen as a vital public health tool in the Victorian Era. From 1840 onwards, a succession of Vaccination Acts gave local authorities the power to vaccinate people against smallpox.
Although this policy was dictated by central government, the administrative machinery was local. Medical Officers of Health and Poor Law Guardians were made responsible for providing funds, vaccinators and publicity.
When the war-time government decided to introduce diphtheria immunisation in 1940, administration was also made at the local level. Medical Officers of Health were responsible for advertising the availability of the vaccine in their areas, and for ensuring that parents presented their children.
Unlike with smallpox vaccination in the latter half of the nineteenth century, diphtheria immunisation was not compulsory. However, parents welcomed it and presented their children in great numbers.
Diphtheria toxoid had been used in other parts of the world (notably Canada and New York City) with great effect in the 1920s and 1930s. It had fewer obvious side effects than smallpox vaccination. It was a “clean”, modern “drug”. And, more importantly, affected tens of thousands of children every year. Smallpox had ceased to be endemic since the early 1930s.
When the Appointed Day arrived, then, Britain had experience a long history of providing vaccination for its citizens. There was already a machinery in place to deliver it. The National Health Service Act restated local authorities’ obligations to provide vaccines as mandated by the central government, and removed the final vestiges of the compulsory smallpox vaccination legislation of the previous century. But it was the Ministry of Health – not the NHS – that ran the immunisation programme.
But for most of us, our experience of vaccination would be a visit to our NHS doctor to receive something paid for by the state. To all intents and purposes, vaccination was free at the point of delivery, and administered in an NHS clinic.
This pattern would be repeated with the flow of new – and welcomed – vaccines against a host of diseases across the first few decades of the NHS era. Jonas Salk and Albert Sabin’s breakthroughs with polio over the 1950s and 1960s were contemporaneous with the introduction of vaccinations against whooping cough. Measles followed in the late 1960s.
Some immunisations were not provided in this way. BCG, for example, the anti-tuberculosis vaccine, was given to children of school-leaving age (13 or 14 years old). This was done through the school medical services. More recently, the HPV vaccine has been delivered in a similar fashion.
Public health and the NHS effectively merged into the same entity in 1974. After this point, vaccinations were provided to patients, and policy was directed, by the same body. As far as parents were concerned, this meant no real change. It was still free, and still (mostly) provided in an NHS building.
The NHS is dominant in our minds as British citizens when we think about health. So much so, that it is just generally assumed that vaccination must be part of the NHS too. It makes sense. Both of these “institutions” represent modern medicine and modern medical politics.
But the distinctions being made here between Public Health England, the NHS and local authorities aren’t simply nit-picking. For a start, they show a number of ways in which central governments have been able to co-opt various parts of the medical profession to perform healthcare functions – even before the NHS was founded.
Moreover, the historical shifts tell us something about the relationship between personal and public health care.
Why, for instance, did everyone have access to free smallpox vaccination a hundred years before the right to free treatment for a broken leg? Why did the governments of the 1980s strengthen the vaccination schedule and provide performance-related pay for GPs at a time when the rest of the NHS suffered chronic under-funding? The answers to those questions may seem a little obvious at first. But once you delve into them, we start asking even more questions about preventative medicine, “cost-benefit” relationships and social priorities at different points in time.
The relationship between the NHS and vaccination is messy and continually evolving. And that tells us something intriguing about both.
 The story of the Acts is central to the history of eighteenth- and nineteenth-century medicine and the state. Many historians have done excellent research on the topic, but a good starting point is ‘The Politics of Prevention’ by Dorothy and Roy Porter.