Envoi

In 1948 Everest had not been climbed, food was rationed, people rode the city streets in trams and crossed the Atlantic in Cunarders. Since then there have been major changes in society - increased affluence, wider car ownership, a desire for greater individuality and self-development, a loosening of discipline, authority and hierarchy, loss of both certainties and stability and developments in the media and communications beyond imagination in 1948. Britain, once the centre of an empire, was no longer an imperial power.

The pattern of health service in the minds of its founders owed much to Lord Dawson's report of 1920 and was already conceptually 25 years old when the NHS Act (1946) was passed. The NHS was the political creation of a particular epoch when, because of the experience of war, 'we were all neighbours' and used to a life organised with great purposes in mind. The underlying principle was that all were entitled to what they needed in health care and social support, paid for by central taxation. Few other countries, outside the Eastern bloc, followed this route. The Act created a hierarchical structure that could adapt to the growth of specialisation and clinical science. This structure avoided much of the duplication and the unnecessary expenditure characteristic of the competing hospitals, and the gaps that existed before 1948. Unusually, for such a vast organisation, most of the highest talent worked on the "shop floor". The NHS was created to solve problems of inequity, many of which could be remedied by better organisation without great expenditure. It dealt with a largely indigenous population that could still consider itself an island nation. As with many great ventures, things did not turn out as had been predicted.

What could not have been foreseen was the impending rate of change in medical and allied sciences. In medicine more has happened since 1948 than in all the centuries back to Hippocrates. Countries do not stand in isolation; many developments are world-wide in their impact and people rapidly come to accept advances as the normal order of affairs as yesterday's revolution becomes today's routine.

The changes decade by decade are summarised elsewhere on this site.

The achievements

The verdict on the NHS must be positive. It has achieved Bevan's main aims, largely removing the fear that care during illness would be unavailable or unaffordable (and at the same time redistributing income from the rich to the poor). However, some things were done better than others. In a report by Sheila Leatherman and Kim Sutherland sponsored by the NuffieldTrust in 2008 the authors believed that the NHS has more evidence based care;lower death rates for major disease groups (especially cardiovasculardiseases); lower waiting times for hospital, outpatient, andcancer care; more staff and technologies available; in someplaces better community based mental health care; and fallingrates of hospital infection. Other areas show less progress,such as specialty access, cancer outcomes, patient centeredness,and life expectancy and infant mortality for socially deprivedpopulations.

Benefits of organisational unity

The NHS made it possible to systematise care. The health service formalised a rational system based on the GP as gatekeeper, supported by district hospitals and tertiary centres of referral. Almost uniquely, because the NHS was a single organisation it could deal with significant problems on a national basis. Professional advice could be implemented throughout the country. This applied both to clinical problems and to structural issues, for example the development of group practice and district hospitals. Shortly before the NHS began, the surveillance of communicable disease came under the aegis of the Public Health Laboratory Service and the benefits of a single national organisation, capable like micro-organisms of transcending geographical boundaries, were repeatedly demonstrated. The PHLS and its successors became a flagship of excellence, part of a national security system against the dangers of the development of drug resistance and the emergence of new infections. In the second decade the Committee on Safety of Medicines became responsible, after the thalidomide debacle, for licensing new drugs and we remain a centre of excellence in this field.. Although the UK was tardy in the adoption of some vaccines, a national immunisation programme was introduced and progressively refined. By any standard this has been a success. Central organisations such as NICE have also have become important in assessing the effectiveness of medical procedures.

Some opportunities of national organisation were missed. Although the GPs, the district hospitals and the regional centres provided an effective structure for care, there were repeated failures to develop methods to assess health care needs and the effectiveness of treatment, a gap now filled by Nice and the Healthcare Commission. Quality become a key part of NHS management only recently. Innovative schemes such as the national morbidity studies were only slowly developed into useful tools that could satisfy scientific or health care policy requirements. Such studies as the review of maternal deaths or deaths under anaesthesia were long the exceptions.

Clinical progress

Clinical improvements fall into two groups. Some are based on scientific advance, for example better imaging, new surgical techniques, the prevention of haemolytic disease of the newborn or phenylketonuria. If such developments provide obvious advantages to patients, are comparatively simple and there is no vast cost, they are often introduced rapidly once the science is firm. The application of scientific knowledge is slower, however, if it is costly, the benefits are less clear cut, or if a professional group believes it will be adversely affected by the change. Secondly, there are changes in working practice, for example the acceptance of group general practice and the improvement in geriatric care. These take longer to implement. It was 30 years before day surgery became commonplace.

The control of the infectious diseases was the first advance had an early effect on the work of the health care system. Within the first 20 years the incidence of tuberculosis and its death rate were greatly diminished. Sanatoria and fever hospitals closed and are forgotten. Immunisation controlled other infections, such as diphtheria, poliomyelitis and measles. Antibiotics altered the pattern of chest infections out of all recognition, affecting the acute episodes and the long-term pattern of disease. The almost complete disappearance of rheumatic fever brought to an end one of the common causes of chronic heart failure. The control of syphilis largely eliminated diseases such as tabes dorsalis and general paralysis of the insane, conditions unknown to the medical students of today but featured regularly in examinations in 1948.

The hospital phase of serious illness was shortened by more effective drugs, less traumatic operations and, on the social side, improvements in housing that allowed discharge to a reasonable environment. Asher led the trend to get people out of bed. Orthopaedic patients, who had often stayed in hospital a long time, could be discharged earlier once the principles of internal fixation and joint replacement were understood. Cataract extraction used to involve a week of total immobility with the head supported by sandbags; now patients are discharged the same day. The existence of midwifery services in the community and a change in obstetric practice allowed early discharge of maternity patients. Pharmaceutical research gave doctors an immensely improved armamentarium, making care in the community possible for many who had previously required hospital admission. It all added up to a wider range of preventable and treatable disease, therapy that was less traumatic to young and old alike, more rapid hospital throughput and different demands on primary care.

Diagnostic accuracy increased, treatment more specific and recovery rapid. New tests, automation in haematology and biochemistry and improvements in diagnostic imaging made it possible to rewrite much of clinical medicine. Sophisticated systems of measurement allowed the application of scientific and physiological principles to medicine and surgery. Surgical instruments, for example endoscopes and robotic surgery, have been refined beyond the dreams of 1948.

Improving performance and increasing clinical activity

Because of changes in the way hospital activity is measured, it is difficult to produce a consistent time-line of clinical activity. Over the 60 years of the health service the age structure of the population has become more elderly, increasing demand. The population has become healthier, which in theory should reduce clinical activity, but patients and their doctors have increasingly high expectations and a well-founded belief that medical care is often beneficial.Every patient cured succumbs later to another condition. People have become increasingly aware of what is possible and clinicians define clinical need more broadly. Clinical progress, as in joint replacement for arthritis, generates new demands for care. Changes in people's tolerance of distress lead to demands not previously experienced, as in psychological counselling. Sometimes demand may fall, with the reduction in incidence or the disappearance of conditions such as the infectious diseases, or with the recognition that some procedures are obsolescent. However, treatment that is largely outdated can continue to generate activity, as in tonsillectomy, although the recognition of the importance of 'evidence-based medicine' is a pressure in the right direction.

GPs and primary health care

In general primary health care has been and remains a success story. In 1948 the distribution of GPs was uneven and their standards were variable. Good primary care was essential if the function of the hospital service, woefully deficient in many places, was to function. The ease of access to and continuity of care by GPs, often over many years, was almost unique to the UK and underpinned the NHS. Community care, family practice and referral by the GP to hospital for specialist care formed an ordered sequence from self-assessed minor illness to disease needing the most complex forms of treatment. The GP and a strong community nursing service has proved to be economical and to make for equity. Over 60 years GPs have become less involved in acute and potentially fatal illness, childhood infections, tuberculosis and home delivery, and developed greater responsibilities for health promotion, chronic conditions and the care of elderly people.

General practice underwent revolutionary change in its organisation, adapting to the new requirements. Few groups of professionals have altered their pattern of work more. A cottage industry of single-handed doctors, working from their own homes and with little support, evolved into a network of organised and sizeable groups, in good accommodation, with a substantial infrastructure and computing facilities. Vocational training and continuous medical education were developed, based on district postgraduate centres. Nurses increasingly took over functions previously carried out by GPs. Improvements were not uniform. Inner city primary health care lagged, and the system of partnership, organisation and finance found elsewhere was not ideal for conurbations. Then, with changes in society, GPs gave up their 24 hour commitment, creating problems of patient access. The health service's remedy, direct access to walk in centres, telephone help lines (NHS Direct) and a range of alternative contracts including some with the private sector, have created some disarray, rising costs, pressure on ambulance and accident services and increasing dissatisfaction with the service.

Hospital services and secondary health care

Hospital services can also be regarded as a success story. Hospital consultants were appointed and distributed more evenly throughout the country. New forms of treatment were steadily introduced. A national and regional system made it possible to improve clinical services, as in obstetrics, by applying improved policies for health care in all localities. In 1948, because patients were in hospital for longer, wards were more leisurely than today, although there were always gravely ill people to be nursed. The development of medical technology and the shortening length of stay led to increased activity and later to a reduction in the physical size of the hospital service.

Progress had been made before 1948 towards the better organisation of hospitals by some local authorities, and the King Edward's Hospital Fund (King's Fund). Once an adequate range of consultant services was available in each locality, it became important to bring them into closer relationship. First hospitals were grouped under a single hospital management committee to form a functional entity. Later came merger, closure and rebuilding, spurred by the 1962 Hospital Plan. Because the NHS was a monopoly service operating within a fixed budget, for many years the pressure was to move towards a unified hospital service for any given area. The idea of a single hospital for a specific population, rather than competitive services, was in tune with the professional wishes of the doctors who generally did not object to closing old hospitals. Sometimes hospitals lost their reason for existence, for example the fever hospitals. Solidly built and on large sites they provided assets of great value to the NHS. Their revenue could be reallocated to other and more modern uses. The closure of the hospitals for tuberculosis and later for mental illness and mental handicap, provided a further financial boost for newly developing services. Later, the back wards of district hospitals, where elderly people had been placed, were upgraded and bed numbers reduced, as modern geriatric care replaced a largely custodial service. The management of an acute hospital became ever more complex. In ways quite undreamt of in 1948 management has to respond to national priorities and political imperatives and to pay more attention to health and social care in the community. During the last 15 years the acceptance of the poor structure of our hospitals, and problems funding a major rebuilding exercise on the public balance sheet, has led to the use of private funds. The Private Finance Initiative has succeeded in getting many new hospitals built at a cost that will haunt the NHS for many years to come.

Specialisation, responsible for great improvements in patient care, is also reshaping the pattern of hospital services. Some activities, such as cardiology, cardiac and and vascular surgery, need to be reconfigured to provide the best possible access to patients while concentrating expertise on units that can provide a service 24/7. There may be a hub and spoke arrangements in which a centre of high expertise is brought into relationship with peripheral supporting centres as in cancer networks. Sometimes hospitals that have had a long tradition as a DGH lose specialties such as paediatrics that cannot be provided effectively in a small unit. A new type of hospital is emerging, the sub-regional centre. Such hospitals, serving a population of a million or more, are not teaching hospitals in the traditional sense, although they have important roles in teaching and often in research. They provide a range of sub-specialty services beyond the range of smaller district hospitals. In the 1960s there was a clear vision of the pattern of a hospital service. This clarity is now lacking.

Residual problems

Remaining problems often are the result, as outlined by Rudolf Klein of the clashes between values.^{BMJ 2008;337:a628}

"The main reason why flux and conflict have characterised the past 60 years and will probably continue to do so is that the tensions within the NHS (and in all healthcare systems) cannot be neatly resolved by heroic policy initiatives. For they involve balancing desirable goals and values that conflict with each other. The values of the NHS do not necessarily point in the same direction, and the weight attached to individual values may vary between different groups.

The subject of whether patients should be able to top up treatment by buying drugs not available in the NHS is a case in point. To permit this would clearly offend against the equity principle—that patients with equal need should receive equal treatment irrespective of their ability to pay. But to prohibit it would offend against the autonomy principle—that the decisions and preferences of patients should be respected. Or consider opposition to reconfiguration proposals. Many factors are involved, but the different weights attached to different policy goals by different groups is prominent among them. Clinical safety and excellence (the professional aspiration), efficient and economic use of resources (the managerial imperative), and local accessibility (the public preference) are all worthy goals, but they are not necessarily and invariably consistent with each other.

Many examples of complex problems that involve difficult trade offs are available. It is now conventional wisdom that the NHS has become excessively centralised and the time has come to devolve decision making to the periphery. Yet postcode rationing—different health economies making different decisions about their priorities—is also unacceptable. So are uniform national standards to be brought about without central direction?

Again, although everyone agrees that competition is a spur to efficiency, services need to be integrated. So how can these challenges be met? One suggested option is to allow patients to choose between integrated systems rather than between individual providers of one-off treatments.6 In effect, primary care trusts would become redundant and replaced by "health maintenance organisations." But if they were to disappear, so would the NHS’s capacity to plan for geographically defined populations. Once again, competing and desirable policy goals seem to be incompatible. Most importantly, perhaps, there is dissonance between the rhetoric of a consumer driven NHS and the reality of a model for allocating (and rationing) resources that is based on professional need: what would happen if consumer demands were to trump judgments of professional need?

The list of such incompatibilities goes on, but the point has been made. And it has an implication not only for the future but also for the present. As far as the future is concerned, it means—as argued—that flux and conflict are inevitable. For the present, it suggests that flux and conflict can be reduced, but not eradicated, to the degree that the policy making process acknowledges the complexities involved. It underlines the danger of rushes of blood to the head of policy makers—the search for instant fixes."

Politics and the NHS

A question raised repeatedly is whether it would be possible to take the NHS "out of politics". The immediate answer is 'not while the Chancellor pays and the money comes from taxes raised by Parliament'. Enoch Powell, Harold Wilson's government, and Keith Joseph all toyed with the idea. All rejected it. Yet the concept is still re-explored from time to time.

Rationing

There has always been a need to prioritise care to remain with the budget. New technology and pharmaceutical developments have produced an inexorable rise in costs. Advances in operative surgery, by making more diseases amenable to cure, also increases expenditure. The obsolescent forms of treatment were comparatively cheap; the newer ones are vastly more expensive. Yet doctors cannot, or are loath to, ration care, to deny it to people who may not be entitled to it, to those who choose to engage in activities that endanger health, for example smoking and skiing and are costly to the NHS, even to those who wish to push the boundaries of life beyond reasonable limits. Enoch Powell said that even the wealthiest country could not afford to finance in its entirety a health service free to the consumer, open to all and offering every procedure from which anyone might benefit. Something has to give. It cannot be the exclusion of particular individuals or groups. It must be a priority system based on the nature of the clinical problem - including an assessment of problems that are marginal and can be a matter for decision and payment by patients, and the efficacy of available treatment. NICE attempts to fill this role. The notion of an equitable health service implies that somebody makes a judgement, or somehow a judgement is made. Although we distrust experts and challenge professional judgements, as patients we lack the information of cost and benefit that would enable a rational choice. Because professionals treat, and people are treated, at somebody else's expense, the patient cannot take all decisions in the way that is possible with one's own disposable income. Some new forms of treatment such as anti-cancer drugs produce only minimal advantages in survival for a substantial additional cost. It may be that the elimination of less effective forms of treatment would free resources for more effective ones, but the decision is seldom a black and white one. There is always the possibility that the patient under consideration will be one of the few who will gain from a procedure; and who is to make the judgement when there is a finite chance of improvement?

The hospital team

The NHS inherited a 'firm' system, in which each patient was the responsibility of a single consultant, who usually held beds on two wards, male and female. Consultant-led teams were the rule, and each covered its own emergencies. There were close relationships with the nursing staff. Now, the firm system has largely gone and no equally good alternative has emerged. Specialisation and the need to work within European directives on working hours complicate matters. More patients are admitted and they spend less time in hospital. Patients, nurses and doctors have less time to get to know each other. Beds are seldom allocated to specific specialties and each ward may contain a continually changing mixture of cases. Junior doctors find that their patients are distributed widely around the hospital, and receive less support than they did in the past from experienced ward sisters. More junior doctors, ward sisters and staff nurses need to relate to each other. Juniors who, in 1948, had almost no time off for the six months of their job, now cover for each other and see patients previously unknown to each other. Lacking the support of resident seniors, they may be under great stress. Team nursing on the wards has removed some of the responsibility of the ward sisters for patients, and with it the crucial role they played in maintaining contact with doctors, relatives and the widening range of special departments within the hospital. The result may be inefficiency, and sometimes inhumanity.

Nursing

One of the saddest features is a common belief that nursing is not as good as it ought to be. Changes in the nature of society, which have provided wider employment opportunities, and the pressures of family and social activities have played their part. Within the profession there has been a view that nursing, an honourable and worthy job, needed academic status to give it respectability. This was partly the result of an uncritical acceptance of ideas developed within the different cultural context of North America, for which they might have been appropriate. A fight for higher status and university affiliation was accompanied by disparagement of traditional values and systems of management, such as the hospital matron. Instead there was a myriad of new initiatives, patient-focussed care, nursing audit, shared care, named-nurses and nursing development units. At the same time many of the best and most experienced nurses moved into new roles in hospital and the community.

The increased tempo of hospital life alters many assumptions traditional to a hospital nursing service, just as the development of primary health care has affected community nursing services. In 1948 trained nurses could expect to care for very sick patients for many days or weeks. Student nurses gained much practical experience and were supervised by competent ward sisters. Explicit standards of care were stressed in the school of nursing. There was time to get to know patients as individuals, and the nurses' role was careful observation, the maintenance of the physical and if possible the mental comfort of their patients, and to work co-operatively with others. Many patients came from poor social circumstances, some were malnourished and few knew much about their ailments. Now people are fitter, more knowledgeable and can face major illness or surgery with more resilience. Patients are discharged so fast that there is often little chance for nurses to establish a relationship. Medicine has a confidence that makes the provision of skilled nursing over days or weeks less important to physical recovery. Clinical observation is replaced by tests and monitoring equipment. Specialisation in medicine demands increased specialisation in nursing if the two professions are to work side by side. Many basic and technical nursing duties are now performed by others - health care assistants, relatives or technicians.

Long-term care

Better management of acute illness and of diseases in the neonatal period, childhood and the young adult exposed more clearly the problems of chronic illness, mental and physical. The inheritance of the NHS was not good either in terms of staff or of building stock. From the early 1960s the priorities changed to improve the care of those who need protection.

The results have been mixed. In the field of those with learning difficulties, few people would wish to see the return of the large institutions that have now all but disappeared. Local units have enormously increased the quality of life. For the mentally ill the picture is not so good. The NHS inherited a service based on the asylums. Stimulated by media interest and public pressure, a move towards community care was partly a response to the scandalous conditions behind the walls of the institutions. In the 1950s and 1960s policy changed and psychiatric units within the curtilage of the DGH, supported by services in the community, was seen as the way forward. In the event, though it was a good policy, better community support should have matched the impetus as Enoch Powell would have wished. It did not. The mechanics went wrong, and health and welfare services that should have been bonded together remained in opposing camps. The DGH policy has also proved to have drawbacks. Small local acute units, dispersed throughout the community, are the current solution, supported by community teams to intervene in a crisis and also maintain regular contact. There remain regular reports of assaults or murders committed by the mentally ill following what is, in retrospect, premature discharge.

Organisational upheavals

Management philosophy has repeatedly changed and redefined its goals and techniques. Strategic planning, centralised decisions, devolution, large organisations, small and closely focused ones, democratic representation of the community or management by technocrats have followed in swift succession. The tempo of structural reorganisation has quickened to a point that few could now describe accurately what has occurred in the past decade. For the staff delivering care at the 'grass roots', where the majority of the expertise lies, the cumulative effect on morale has been detrimental.

Managerial culture to improve efficiency (Griffiths and the Thatcher reforms) emphasised money and sight was lost of the ethos of community-based and regional collaborative services. Member-based management authorities, at region and district, disappeared and with them the work of many people from local government and the local community. The last vestiges of local democratic participation were removed, creating a single managerial hierarchy from hospital to central government. The re-emergence of a community voice - albeit a weak one - in Foundation Trusts may reverse this process. Central government's most recent anxieties have for 25 years become local imperatives. Managers on short-term contracts ignore central guidance at peril to their jobs and long-standing institutional loyalties have become a relic. By introducing the idea of markets and competition, the NHS reforms (1989) risked the development of fragmented pieces of care, sometimes organised on the basis of least cost and with little local involvement of the population. The purchaser/provider division owed as much to dogma as to logic in a service in which key decisions are usually taken near to the patient. Some of the most effective services in the world (for example, Kaiser-Permanente HMO in the USA) do not follow this pattern. The NHS was designed to bring together disparate units, to reduce inappropriate competition and to eliminate gaps in the system. A system was developed that concentrated complex care in a few places, while providing a general level of competence more widely in the district hospitals. Such a systematic approach is being lost. The decision that the key role of the NHS was to determine what should be done in terms of volume and quality, and that it did not need to own or even manage health facilities, has been a dramatic development. While the Conservatives introduced some tenuous private sector activity, Labour's full blooded use of the private finance initiative and the involvement of commercial organisations throughout the NHS has changed the NHS radically.

Attempts to solve one problem may create another. Health systems are sometimes discussed in terms of whether their underlying principle is that of business or service. However, while too great an emphasis on management can divert attention from sound clinical decision making, the most businesslike health system cannot survive unless it produces a service acceptable to its clientele. Similarly, the most charitably inclined service has to pay bills, and bills the size of those generated by health care demand a businesslike approach to their settlement. There is no ideal and trouble-free pattern of provision that can simultaneously provide comprehensive care to all, free of charge to the individual, at a cost society can afford, satisfy patients, avoid queues, meet professional aspirations and provide a basis for teaching and research. Discontents are built into the design of the NHS, arising from the tension of a service aiming to be comprehensive, universally accessible, free and paid for out of limited funds.

The lack of long-range strategies

Many of the problems have been around a long time. It is strange that over 50 years the NHS has not developed more effective mechanisms for long-range reviews. Neither does the NHS have a staff college, as does the military. The approach developed by the Nuffield Provincial Hospitals Trust of focusing sharply on major issues, evaluating current initiatives and then taking action has seldom been used at national level. For example, what is the appropriate pattern for a modern hospital service, if one discounts the idea that it should be determined entirely by market forces? Are there major problems in the relationship between management and the consultant body? What is the proper function of a nurse and how should nurses be recruited and educated? How can community care be made more coherent, both for the frail elderly and for the mentally ill? Long-range policy studies have been out of fashion for some years, neither has health care research been regarded with enthusiasm. Health promotion and reducing variations in morbidity and mortality are among the few strategies extant. Important questions remain to be answered. In 1959 the Acton Society, in its sixth report, said that there was a central responsibility, which could not be abdicated. It was the responsibility to inspire, lead and guide; to interpret the lessons of decentralised experience; and to invoke national resources for dealing with problems that could only be dealt with effectively on a national basis. General staff and operational thinking, using the full range of expertise available in the service to develop and review policies of a comprehensive character, are lacking.

As one looks ahead some things are not going to change. Medical innovation - for example, genetic medicine, diagnostic imaging and ever-increasing expertise - will result in continually growing expectations, both public and professional. The last 60 years have also seen changes in societal values and the NHS operates against the background of these. Not all have been predictable; few would have imagined the widespread doubts in many quarters about the welfare state. We are in an era of uncertainty and a clash between social obligations and personal autonomy. Even within the limited confines of the health service there is conflict between, on the one hand, the older public service ethos and a belief in the need for solidarity in society, and, on the other, a belief in the primacy of the individual and an acceptance that not everyone will receive an excellent service. Valid questions are raised about the proper role of a health service. Some patients with minimal claims on a welfare state appear to receive costly care, while others - for example the elderly - do without. The gaps are too obvious: waiting lists for routine procedures of proven efficacy, intolerable conditions in some emergency rooms, rapid transit through wards with little rest or nursing care, and a hospital environment that may be unsatisfactory. In spite of everything, we support the NHS and look for a solution that is equitable, provides the best care to all, allows us to take charge of our own bodies and does so at a cost to ourselves personally that we believe we can afford.