The inheritance of the NHS

Of course the health service in this country did not begin in the year 1948. Many of us have associations with the between-the-wars health service; a great patchwork, a good deal of good intentions, a great deal of inadequacies. The Rt Hon Jennie Lee MP, Minister of State, Department of Education and Science (Aneurin Bevan’s widow)¹

The designers of the NHS did not start with a clean sheet of paper. The service was a rationalisation of what existed, conditioned by a need to cajole rather than coerce somewhat reactionary interest groups. Some countries, such as New Zealand and Sweden, had forms of health service but they were not used as models; insularity of outlook prevented that. On the basis of wartime experience it was the hospital service that was most in need of reorganisation. Hospitals were in a muddle and financially at the end of their tether. There were prestigious voluntary hospitals, municipal hospitals displaying the entire spectrum of standards and entrepreneurial cottage hospitals in which local doctors could resurrect dormant surgical skills. In 1948 it had been little more than a decade since the first sulphonamide gave doctors a powerful weapon against streptococcal, meningococcal and gonococcal infections. The next ten years saw dramatic improvements in treatment greatly accelerated by research and development carried out by the medical equipment and pharmaceutical industries.

General practice covered workers under Lloyd George’s National Insurance Act of 1911, but not their wives and families, whose proper demands were curtailed by the need to pay fees for service.² When they were sick, it was the GP to whom people wished to turn. The work of the GP had been described in idealistic terms by Lord Dawson in his report of 1920, which laid out the structure a health service might take.³ The GP should be accessible, attend patients at home or in the surgery, carry out treatment within his competence and obtain specialist help when it was needed. He would attend in childbirth and advise on how to prevent disease and improve the conditions of life among the patients. He should play a part in antenatal supervision, child welfare, physical culture, venereal disease and industrial medicine. Nursing should be available, based with the doctor in the primary health centres Dawson envisaged.

This picture was in stark contrast to the day-to-day pattern of the GP’s life. In inner cities overcrowding led to domestic violence, lice infestation and skin diseases such as impetigo. CAH Watts, a GP writing of his experiences in a mining community before the second world war, recalled the waiting room with rows of seats for about 60 patients who sat facing a high bench like a bank counter.⁴ Behind stood the three doctors and behind them the dispenser. The doctor called the next patient to come forward. Having listened to the complaint, he turned to the dispenser to order the appropriate remedy. There was rarely any attempt at examination. Visits usually numbered about 50 and were made on a bicycle. Diphtheria was endemic and every sore throat was viewed with suspicion. Antiserum was one of the few active treatments available to the GP, and if given within 24 hours of onset the results were excellent. Otherwise, the mortality was about 20 per cent. Patients with diphtheria or scarlet fever were taken away in a yellow fever van to the infectious diseases hospital for at least six weeks; no visitors were allowed. Lobar pneumonia was common, and with the more fortunate patients there was a crisis about the seventh day. It struck terror into the patients’ and the doctors’ hearts, for the mortality was popularly thought to be at least 50 per cent and sulphonamides were not invariably curative. Most dreaded was tuberculosis, blood in the handkerchief after a fit of coughing. Some families were especially vulnerable and it tended to strike young people. The course could be lingering or extremely rapid, with death within weeks. Lung cancer was rare. If it occurred, it would probably not be recognised.

Almost half the babies were delivered at home, mainly a matter for midwives. Pain relief in labour, although available in hospital, might not be provided in the home. When things went wrong the GP would be summoned, because procedures such as breech birth or manual removal of the placenta might be required. Most GPs used chloroform as an anaesthetic though some felt it was quicker and safer without. As they might have neither the skills nor the equipment to handle problems, in many places obstetric flying squads, based on the hospitals, had been established. These could deal with haemorrhage, shock and eclampsia (fits during late pregnancy, labour and the period shortly after), transfuse patients, give anaesthetics, and undertake operative obstetrics in the home.⁵ Tales of obstetric disaster, haemorrhage after delivery and problems with forceps were only too common, although remarkably many women survived crises unthinkable today. Serious infections (puerperal sepsis) killed mothers after childbirth, particularly if there were sore throats going round.

Pain and discomfort were accepted as part of life to be endured with stoicism. The family doctor had to be tough to get on with his many interesting and rewarding tasks. If he had access to a hospital, he might set a simple fracture or reduce a dislocation. Working class people did not expect to be comfortable. Most went hungry and their undernourished children showed evidence of rickets until vitamin D supplements, provided by welfare clinics, controlled it. Many were miserably cold in winter unless they were roasting in front of the coal fire in the kitchen. Successful treatment by the family doctor was accepted with gratitude and the many failures were tolerated without rancour or recrimination. Patients’ expectations were not high. The death of children from infectious disease was the way of the world. Mothers of feverish children expected, if the child was not to be admitted to the fever hospital, to be told that bed rest was crucial until the fever had fully subsided. One of the author’s predecessors in practice was described as ‘a right bastard but a bloody fine doctor’; he used to whip the children out of his way as he rode past. GPs’ hours were long, as most practices were single-handed and deputising services were non-existent. Local rota systems operated on a ‘knock-for-knock’ basis to make a half-day practicable. A car and a telephone were desirable -- but not essential. If it mattered enough there was always a way of contacting the doctor sooner or later.

People did not trouble GPs without good cause. Early in recovery patients might dispense with their services. Most had to pay for the doctor and the medicines. The professional attitude to working class patients was frequently robust, and sometimes downright rude, but this was accepted with tolerance. In middle-class practices there were greater courtesies. There was the ritual preparation of a napkin, a spoon and a glass of water for the doctor’s visit. There might be five shillings (25p) on the mantelpiece for the fee; three and sixpence (17½) if the family was not so well off. High up the social scale the doctor might be treated as a rather superior type of servant. Medical diagnosis was often of academic rather than practical importance. Treatment was limited to insulin, thyroid extract, iron, liver extract for pernicious anaemia, digitalis, the new mercurial diuretics, barbiturates, simple analgesics, morphine derivatives and harmless mixtures.⁶

Entry into a practice was generally by purchase of goodwill, the usual price being one and a half times the annual income.⁷ GPs started with a substantial debt. On average about 1,000 national insurance patients generated about £400--£500 per year, an income boosted by the care of the families who were not covered by national insurance.

GPs and specialists

Since the middle of the nineteenth century the voluntary hospitals had been expanding their outpatient departments, for these were their shop windows. The British Medical Association (BMA), representing the GPs’ point of view, opposed expansion because of the effect it had on GPs’ earnings, but they expanded none the less.⁸ By 1939, 6 million attended them every year, in spite of complaints about inadequate waiting facilities and perfunctory and inconsiderate treatment.⁹ In contrast the hospitals run by local authorities had poor or non-existent outpatient departments and less reason to build up large ones. The London County Council (LCC) rigidly enforced conditions of attendance at outpatient departments to people referred by their GPs, although patients might be seen once without a doctor’s letter, then being referred back to their GP.¹⁰

In 1946, like everyone else, Britain’s GPs were tired from six years of war. The younger ones had been called up, and the older ones had stayed behind -- including many women doctors who had qualified at the time of the first world war, when medical schools had opened their doors wider to women. Some saw an atmosphere of demoralisation and disillusion, with poorer relationships within the profession than ever before.¹¹ Those who had stayed behind had done their own work and that of their colleagues as well, and felt that doctors who had been in the services had enjoyed an interesting time. Those who had served were resentful that their practices had disintegrated, and they had returned to a vastly different world.

Local authority services

In 1948 there were over 150 local authorities in England that had wide and major health responsibilities. Each had a Medical Officer of Health (MOH) who was a chief executive, responsible to his council. His department ran midwifery and child welfare services. Then there was the school health service, under the Education Act 1944, which provided ‘all forms of medical and dental treatment, other than domiciliary treatment, to children attending maintained schools’. It was not until 1974 that the school health service became part of the NHS. Environmental pollution, food inspection and food and drugs legislation were also within their province. Some ran district medical services under the Poor Law.

The Local Government Act 1929 had given authorities the power to appropriate poor law institutions and develop them into modern hospitals. MOsH such as Sir Frederick Menzies and Allen Daley in London, Tate and Macaulay in Middlesex, Campbell in Lincolnshire, Parry in Bristol, Ferguson in Surrey and John Charles in Newcastle had developed and extended the local authorities’ general hospitals. The local authorities also ran fever hospitals, sanatoria and mental hospitals under the supervision of the Board of Control. As a result, MOsH had a role not only in the health of the population but also in the cure of the sick. Allen Daley, as Sir Frederick Menzies had been before him, was interested in medical education partly because of the need to staff the LCC’s hospitals; they fought for the establishment of the British Postgraduate Medical School at their Hammersmith Hospital. Indeed the LCC would have liked an undergraduate teaching hospital of its own.

Local authorities ran the tuberculosis sanatoria: 32,600 beds in England and Wales. A suggested norm for tuberculosis was 1.5--2 beds for each death annually; there were 23,000 deaths in 1947 and 52,000 new cases.¹² The local authorities had a responsibility for infectious diseases; in the early 1930s 800 children out of every 100,000 died annually from them. Diphtheria, which had affected 50,000 children a year, was coming under control by immunisation at the start of the NHS. In 1947 a major poliomyelitis epidemic led to 7,000 cases and 500 deaths. There were 1,693 cases in 1948, of which two-thirds were paralytic. In the record time of two weeks the Ministry produced a 15-minute film on its early diagnosis. With the co-operation of the BMA an intensive effort was made to screen it; cinemas and halls were booked on Sundays and local doctors were invited. Within six weeks 17,500 doctors and 16,000 nurses had seen the film. By contrast smallpox was rare, although there was an outbreak in 1948 with 78 cases and 15 deaths. Venereal disease increased with the disturbances of war but some control was kept by better systems of contact tracing.

Health promotion

Health promotion was generally regarded as a good thing. It was stressed both by Lord Dawson in 1920 and by the 1937 report on health services produced by Political and Economic Planning (PEP), a pressure group of businessmen, educationalists, architects, economists, social scientists and sympathetic MPs such as Harold Macmillan. PEP believed that the GPs’ non-essential tasks should be removed, that standards of training and equipment should be raised to create in the GPs a more effective family health adviser, and that efforts should be made to promote healthy living to reduce the number of sick people needing continuous treatment.¹³ There was an active public health movement during the years of war that included GPs, public health departments, health visitors and a few health education officers.¹⁴ Health promotion met clear and obvious needs, and was directed at large scale but simple improvements. Much effort went into sex education, venereal disease, infectious diseases, and maternal and child health. Exhortations on growing your own food, eating well on your rations, and getting fresh air and exercise were plentiful. Many leaflets were targeted at women, to teach them how to care for their families and, in the interests of hygiene, to bring death to bugs and flies. Wilson Jameson, the government’s Chief Medical Officer, broke new ground when he spoke openly on the radio about the prevention of venereal disease.

Hospital services

War had badly damaged hospitals in urban areas; not one hospital in London had escaped the bombs. The buildings were not a rich heritage. At St George’s the flowers in the ward were placed on a glass-topped table so that the reflections could be seen. At Paddington General the legs of the cots in the maternity department stood in tins of oil to discourage the cockroaches from crawling up. Two-thirds of the hospitals had originally been erected before 1891 and 21 per cent before 1861. They were in poor physical state and lacked diagnostic facilities, pathology and radiology, and operating theatres. During the 1920s and 1930s there had been substantial expenditure on hospitals but hospital infrastructure, catering and heating, required urgent attention. Most steam heating systems had been introduced around 1900, and the life of boilers was about 50 years.  Hospitals in 1948 provided far more accommodation for chronic illness in the elderly, both physical and mental. Medical wards were full of patients with pneumococcal pneumonia, lung abscess, acute nephritis (inflammatory disease of the kidneys), rheumatic fever and rheumatic heart disease, tuberculosis, syphilis in all its stages and brucellosis (an infectious fever usually the result of drinking unpasteurised milk). Treatment was often based on good nursing, bed rest, barbiturate sedation at night and attention to pressure areas. Compared with today there were few drugs to offer -- salicylates for rheumatic fever, digoxin for heart disease, sulphonamides and penicillin which were controlling the pneumonias, and soon streptomycin.¹⁵ About 16,000 people were dying annually of rheumatic heart disease. Although the incidence was falling, there were still about 5,000 new cases among children and adolescents each year. Surgical wards had many patients with perforated or bleeding peptic ulcers, bone infections (osteomyelitis) and goitre, as well as urine retention from prostatic enlargement. Tuberculosis of the lungs and of the joints formed a major part of operative surgery.

Patients were often admitted at a late stage in their disease. Diagnosis, prognosis and treatment were often a matter of clinical judgement based on bedside observation over a period of time. Anaesthetics was not yet fully distinct as a specialty and a basic knowledge of its techniques was a useful skill for any young doctor, indeed for medical students. Open ether (dropped onto a mask) was still in use, particularly for children (‘blow the gas away’). Induction with nitrous oxide or an intravenous barbiturate followed by nitrous oxide and oxygen, plus ether or triethylene, was the common technique. At The London Hospital any house surgeon who happened to be having a rest or a cup of tea was likely to be summoned to give an anaesthetic for an emergency forceps delivery in the labour ward, above the common room.

Virtually all hospitals were subdivided in the same way: general medical and general surgical wards. The maternity department, if one existed, would be separate, as would be the gynaecology wards. Children were frequently placed in adult wards, perhaps in a cubicle. In the larger hospitals there might be separate orthopaedic wards, and provision for infectious cases or for sick members of staff. Hospitals had few consultants, specialisation being in its infancy. Generally there would be only two or three on any one ward. The consultants and the ward sisters therefore came to know each other’s ways, and to trust and be loyal to each other. It fell to the sister to help and train newly qualified doctors in the ways of the ‘chief’. In the traditional medical ‘firm’ junior doctors of all grades worked predominantly for one or two consultants, ensuring continuity of care for the patients, a clear chain of command, regular contact that helped the education of the juniors and camaraderie under pressure.¹⁶ The junior doctors, virtually always unmarried, lived in a bachelors’ mess and were available night and day.

From the patient’s point of view some hospitals had a name for making patients welcome and took pride in keeping it. Friendly doctors, an enlightened matron, well-chosen sisters and contented nurses all played a part. Such traditions were inherited, but bad traditions of grudging, unwilling service also existed. A correspondent to the Lancet described her contrasting experiences in two London teaching hospitals. Patients might be left in the dark about their condition and their simplest rights disregarded. Outpatient departments could be comfortable, or the consultant might invite three patients into the consulting room at a time and deal with them together. Student teaching at the bedside might be conducted courteously, or the patient might be ignored and treated as ‘teaching material’. Questions about diagnosis and treatment might be answered, or the patients left unseen by a doctor. There might be noise in the wards with carelessly served and uninspiring meals, or well cooked and warm food properly presented in the atmosphere of a good hotel.¹⁷

Voluntary hospitals

The most prestigious hospitals were ‘voluntaries’, institutions that financed themselves as best they could and were responsible only to themselves. They had grown up in a haphazard fashion. Some were institutions founded centuries previously for the benefit of the sick poor, others by citizens proud of their towns or anxious to perpetuate their names. The best-known were the prestigious teaching hospitals: 12 in London, most with centuries of tradition, and 10 in the provinces that had usually been founded in the nineteenth century in association with a civic university. There was a gradation from these teaching hospitals, staffed by consultants not engaged in general practice who gave their services free, to smaller ones such as the voluntary hospitals in places such as Bath and Ipswich.

Next came lesser hospitals staffed by visiting consultants who lived at a distance. The smallest had one or more resident medical officers with a visiting staff of local GPs and perhaps special departments under visiting specialists from distant centres. It was a short step from these to the cottage hospital staffed by GPs, often with consultants on call, in some of which major surgery including gynaecology might be undertaken by GPs. These had often been built in the nineteenth century to provide essential care to otherwise inaccessible country populations, and more opened after the first world war as small memorial hospitals. The matron might combine the functions of ward sister, theatre sister, midwife, radiographer, almoner, resident medical officer and even cook. Then there were convalescent homes, to which people might be transferred when their recovery was assured but they were not yet ready for discharge. Often managed by nursing staff with the support of visiting GPs, they prevented the blockage of beds in the larger hospitals.

The voluntary hospitals aimed to provide quality care to a limited number of patients. They were generally well managed and had the ability to choose their staff and maintain firm discipline. There were extensive outpatient services, the presence of which publicised the hospital and attracted donations. Maternity departments were small. Some categories of patients were unlikely to be admitted -- elderly people and those with chronic diseases. Taken as a whole the voluntary system had been in financial straits before the war. Over a thousand in number, they barely made ends meet but a hospital never needed to despair as long as it could proclaim itself to be bankrupt; financial problems could be the basis of an emotional appeal to the public -- shroud-waving as it was known. In the unusual event of a surplus, hospitals invariably planned an extension or development. Money came from charity, hospital savings schemes, the fees of those who could pay and, increasingly, from local authority grants. Hospitals were the focus for local charitable effort, run by leaders of local society and doctors’ wives. Teaching hospitals and their schools encouraged a feeling of esprit de corps. Medical students were often the sons of doctors who had trained in the same hospital. Matron, able to select her student nurses, required the ‘school certificate’ and tended to choose a ‘nice type of girl from a good family’. Discipline was strict, going out with a houseman might be frowned upon; pregnancy was certainly a cause for dismissal. In spite of the hazards there were many doctor--nurse marriages.

Municipal hospitals

Public hospitals grew up separately during the nineteenth century. From the 1830s locally elected bodies, the boards of guardians, had created institutions that housed a range of people from tramps to bed-fast chronic sick. Typically they had casual wards for able-bodied vagrants, a large ‘house’ for destitute elderly who were not sick, and infirmary wards for the chronic sick. By the 1920s some boards of guardians, particularly in the big cities, had growing infirmary sections that were larger than the rest of the institution, with resident medical staff and some facilities for laboratory tests, X-rays and surgery. In smaller country institutions the ‘house’ and the ‘chronic sick’ predominated. Under the Local Government Act 1929 counties and county boroughs took over from the boards of guardians. Institutional funding now came from the rates, but with a block grant from central government covering 40 per cent of the cost. Each authority established a public assistance committee to run the institutions. Most remained as they had been, accommodation largely for the elderly and chronic sick, many of whom would remain there until death, together with occasional maternity patients or children suffering from neglect. Counties and county boroughs could, however, ‘appropriate’ the hospital sections of these huge institutions to their public health committees, and upgrade them to modern acute hospitals under the management of the MOH. Enthusiasm for this varied and it was the larger authorities that were most active; the smaller county institutions were a less attractive proposition. In some places, such as Middlesex, Surrey, Birmingham, Bristol, Newcastle and London, the hospitals appropriated from the old Poor Law Board became the centre of civic pride and substantial investments were made in their improvement. The LCC intended that all those appropriated should become general hospitals, and the equivalent of the voluntaries. ‘Only the best is good enough for the patients in our hospitals,’ wrote one LCC councillor. Most councils, however, were selective about the institutions they took over; for example, Leicester took over the city hospital of 600 beds but not the wholly chronic Hillcrest public assistance institution with 370 beds, where visiting GPs provided cover. The county of Leicestershire took over nothing. Nottingham city took over the central hospital but the county took little.

The voluntaries had been unable to keep pace with the growing needs of the population and the municipal hospitals were catching up. The latter were developing better laboratories and theatres although outpatient departments were rudimentary. Nationally they provided three times the number of beds, though many were for long-term care. Medical staffing differed materially from the voluntaries. The senior officer of the hospital was the medical superintendent who, in addition to general administrative duties, usually had clinical responsibility as a physician or surgeon. In the smaller hospitals his responsibilities might spread over a wide clinical field, although most of the work was in the hands of resident medical staff, often of considerable experience and standing. The extent to which consultants from the nearby voluntary hospitals were used was variable; sometimes they visited regularly but more often they were called to specific cases and had no continuing responsibility. The municipal hospitals stood alone when they could.

The municipal hospitals were as ill-co-ordinated as the voluntary ones. The towns were the natural centres for the surrounding population, but an arbitrary line on the map might determine whether a patient had access to a relatively well-staffed modern city borough hospital or a distant and unsatisfactory institution managed by a county council. The municipal hospitals were the last resort for patients unlikely to improve with treatment. The voluntaries were accustomed to transferring chronic cases to them (e.g. cancer patients) and to have little other relationship. Similarly, local authority hospitals took cases of infectious disease from the voluntaries. The role of dumping ground was hotly resented by municipal hospitals, especially when they had developed into well-equipped acute units. There was infighting as the demand for acute hospital care increased and the local authority hospitals took a larger share, particularly in obstetrics. In a few places, such as Newcastle and Lincolnshire, the various hospitals worked side by side without hostility. In Oxford, Lord Nuffield had supported a ‘Hospital Council’ that had been successful in co-ordinating the two camps. But sometimes there was open war. Most thought of first-class medicine in terms of the London teaching hospitals. Increasingly, however, provincial and non-teaching hospitals were becoming recognised as leaders; for example by 1940 the Birmingham Accident Hospital was pre-eminent in trauma and the first Chair of plastic surgery was held by Thomas Kilner in Oxford. Francis Avery Jones, appointed in 1940 to the Central Middlesex Hospital, established one of the first specialist units in a municipal general hospital. A pioneer gastro-enterologist, his guiding principles were that diagnosis should be early and accurate and that treatment should be scientifically based.

Mental hospitals

The beds provided for the mentally ill and mentally handicapped exceeded in number the acute beds of the voluntary and municipal hospitals, but there were never enough. Bomb damage and the use of some accommodation by the wartime emergency medical services increased crowding. Before 1946 there had been little expectation of the inclusion of these services in the NHS, and therefore little planning. The mental health sector was subsumed into the NHS with difficulty, as an unwilling and inferior partner. Although isolated and disregarded, its problems were massive, for the hospitals were old, isolated, poorly provided with amenities and mostly too large, some with over 2000 beds. The ethos of the mental hospitals contrasted starkly with acute hospitals, but not always for the worse. They were surrounded by large grounds, immaculately tended by a well-trained squad of patients, usually chronic schizophrenics. The institutions turned inwards upon themselves with inter-hospital sports competitions and social activities. The discipline among patients, doctors and nurses was firm but at least for the staff the food was excellent. For most patients, however, enforced idleness produced inertia, loss of morale and of self-esteem.¹⁸

Specialisation and specialist hospitals

Generalism had been paramount, the general physicians and surgeons outranking in status doctors who worked in specialist fields such as ophthalmology and dermatology. The large voluntary hospitals were often slow to provide facilities to those working solely in a minor field. However, Geoffrey Jefferson, Professor of Neurosurgery in Manchester and one of the great men of the time, said that the characteristic clinical theme of the first half of the century had been the rise of specialism. As early as 1900 some had seen the writing on the wall. Jonathan Hutchinson, dissatisfied with the results of his treatment of stone in the bladder, handed cases over to a colleague adept at new techniques. The improvement in results after he ceased to operate gave him the utmost satisfaction and pride.¹⁹ The earliest specialties dealt with conditions that were found in considerable numbers in every district. In 1948 some ‘minor’ specialties were behind the times; for example, British dermatology lagged behind the rest of Europe where large research-based units were commonly found. Occasionally a pioneer sought to rectify this; Geoffrey Dowling, at Guy’s and later St Thomas’ Hospitals, formed a journal club for young doctors and organised overseas study weeks.²⁰

‘Special hospitals’, which concentrated on one particular disease or organ system and often led their field, developed in large cities during the nineteenth century. In the provinces where there was only one medical school, the special hospitals and the teaching hospital often came to work with each other. They developed a modus operandi by which diseases of women or diseases of the eye were mostly or exclusively handled by the appropriate special hospital that would teach medical students. In London, however, with its 12 teaching hospitals, special hospitals such as Great Ormond Street and the Brompton undertook little if any undergraduate training and remained entirely separate. While specialists might have beds at both a teaching hospital and a special hospital, considerable antipathy often existed between the two groups. Under the NHS Act 1946 the Minister amalgamated similar special hospitals in London, giving the newly formed groups separate boards of governors. The University of London established an institute for each and the specialist postgraduate hospitals remained distinct both from the general teaching hospitals and from the region’s hospitals.

By 1939 units in new specialties, for example trauma and orthopaedics, were increasingly developing in general hospitals. The process was accelerated by war, and units were planned for a regional catchment to deal with plastic surgery and burns, neurosurgery, facio-maxillary surgery, orthopaedics, spinal injuries and rehabilitation. These included Archibald McIndoe’s unit for burns and plastic surgery at East Grinstead, Ludwig Guttman’s spinal injury centre at Stoke Mandeville and Wylie McKissock’s neurosurgical unit at Atkinson Morley’s hospital in Wimbledon.

Specialisation had advanced considerably in large city hospitals, but less so in rural areas. In all large centres ENT (ear, nose and throat) and ophthalmology were distinct specialties but in smaller hospitals general surgery might encompass traumatic and orthopaedic surgery, ENT and even gynaecology. Neurosurgery and thoracic surgery had emerged before the second world war. Geoffrey Jefferson and Hugh Cairns had neurosurgical units in Manchester and London (later Oxford) but it was not generally available outside the main centres. Thoracic surgery was even scarcer and radiotherapy was just being reorganised after the 1939 Radium Act. A general surgeon in Grimsby owned 80 milligrams of radium with which he would treat cancer of the cervix. General medicine might cover paediatrics, cardiology or even pathology and radiology, but medical specialties such as endocrinology were emerging. Laboratory and radiological support was essential for their development. While an accurate history and examination remained essential for good diagnosis, test results gained in importance and some specialties owed their rapid advances to better systems of measurement; for example, it was not now possible to practise cardiology without a grounding in electrocardiography. Increasingly, physicians and surgeons worked as teams, patient care crossing the medical/surgical divide. ‘It is a regrettable fact,’ said a physician, ‘that when surgeons invade a province hitherto considered to be purely medical, diagnosis almost at once becomes more exact.’²¹ Clinical medicine was entering an exciting phase. New techniques such as needle biopsy were introduced, allowing the effect of treatment to be followed histologically, by microscopical examination of small specimens.

Two patterns of meeting specialist needs therefore evolved. First were the special hospitals, characteristic of the nineteenth century, a time when most advances were made by careful observation and description. Secondly, special units developed in general hospitals, in the age of laboratory studies and experimental research when it was becoming increasingly important and difficult for clinicians to span several fields, and multi-disciplinary working was becoming essential.²² Superb clinicians, often excellent teachers and authors, were rewriting clinical medicine. The Royal Postgraduate Medical School at the Hammersmith Hospital brought together basic scientific research, physiology and biochemistry, and clinical medicine. The facilities and the approach were attractive to research workers; in medicine the assistants to Professor Francis Fraser included Guy Scadding and Paul Wood, chest and heart specialists. John McMichael, succeeding Fraser, led developments in renal physiology and high blood pressure. Ian Aird, heading the surgical department, worked with Melrose on a pump oxygenator, Melrose developing a method of producing ‘elective’ cardiac arrest. Sheila Sherlock, at the Hammersmith before moving to the Royal Free, made the liver -- a somewhat mysterious organ -- understandable, bringing together its pathology and clinical diseases.²³ Knowledge of metabolic pathways, of cellular pathology, the nervous system and the workings of the mind, when added to the rapid development of new drugs, encouraged a new vision of medicine in the future. A medical remedy for cancer would surely be found. If not within the next 50 years, at least within an imaginable span of time medicine would replace surgery. Some hazarded a guess that in time medical methods of treatment would be so effective that there would be one only kind of surgery -- traumatic surgery.²⁴

The Public Health Laboratory Service

Shortly before the second world war the Medical Research Council (MRC) considered proposals for an emergency bacteriological service, because of the possibility of bacteriological warfare, and the risk that the movement of people in large numbers might lead to outbreaks of infective disease. The Emergency Public Health Laboratory Service (EPHLS) was subsequently established and administered by the MRC. The major epidemics that had been feared did not materialise, and the laboratories came to support the MOsH in their public health work and to provide GPs with access to bacteriology. Benefits flowed from a nationally organised network of laboratories, reporting their findings and exchanging information about new scientific and epidemiological methods. Their work grew rapidly. The EPHLS also undertook research into the accurate identification of strains of bacteria and viruses, developing central reference laboratories. The value of the service ensured its post-war continuation, and it was agreed that the MRC should continue its management. It was formally re-established as the Public Health Laboratory Service (PHLS) in 1946 with the passage of the NHS Act.²⁵

A national transfusion service

In 1939 the MRC agreed to administer blood depots in areas close to concentrations of hospitals yet outside the areas likely to be the target of enemy aircraft. The principles of blood grouping, blood banking and transfusion had been established by that time, and the depots proved their worth at the time of Dunkirk. Towards the end of the war it became clear that, although blood depots had been established to meet the needs of air-raid casualties, the bulk of their work had been with civilians. The rational solution seemed to be a nationwide transfusion service, and plans were made for one to be organised on a regional basis, managed by the regional hospital boards (RHBs).²⁶ Established in 1946, the work of the National Blood Transfusion Service, and its unpaid donors, would underpin many advances in vascular surgery, transplantation, chemotherapy, the treatment of coagulation disorders and shock from massive blood loss.

Pharmaceuticals

Many of the newly synthesised agents were found to have unanticipated properties, sometimes initially regarded as unwanted side effects. For example, the observation at Johns Hopkins Hospital, Baltimore, that animals treated with sulphonamides might develop goitres led to the development of a number of drugs acting on the thyroid. Chance observations played their part but, with notable exceptions such as penicillin, the great majority of new medicines were discovered and developed by scientists working in the laboratories of an industry devoted to profit, where there was no sharp dividing line between pure and applied research. There was criticism of minimal modification of a patented drug in order to produce a ‘new’ one, but sometimes this produced substantial improvements on the original compound.²⁸

Research and development

The second world war stimulated scientific developments that had crucial effects on the pattern of medical care, altering the work of the NHS. An example was research at the Royal Postgraduate Medical School at Hammersmith Hospital on crush injury that led to kidney failure. As a casualty hospital taking patients from central London, it received many who had been dug out of bombed buildings after many hours. As a result the hospital developed expertise in renal disease.²⁹ Ian Aird, a great professor of surgery at the Hammersmith, said on appointment in 1948 that he wanted two things out of life: artificial hearts (he recruited Dennis Melrose) and transplanted kidneys (he recruited Jim Demster).

The health service also inherited technologies developed during the war that were put to medical use. As the Russians moved into East Germany, the Zeiss technicians moved west. With them went the designs for a binocular operating microscope that was soon in production and radically altered ear surgery. Mullard Research Laboratories and Philips developed the principle of the linear accelerator during the war, made possible by Randall and Boot’s development of the magnetron, a special type of  valve for wartime radar. Cobalt for radiotherapy replaced radium and was produced in the Chalk River plant of Atomic Energy of Canada during the war. Radioactive isotopes produced at the Atomic Energy Research Establishment, Harwell, gave Britain an early lead in nuclear medicine.

In pathology, the development of the electron microscope in the AEI Research Laboratory and the evolution of phase contrast microscopy aided the development of histopathology (the microscopical study of pathological changes in structures). Continuous flow biochemical analysis developed in Birmingham by Whitehead opened up the prospects for automation in biochemistry. Similarly, Wallace Coulter’s use of the ‘impedance monitoring’ of an orifice through which blood flowed led to the automation of blood cell counting. Scientific developments had a substantial effect on diagnosis and treatment. The health service, in turn, came to provide a large market for science and technology.

Shortage of equipment was a problem. In 1948 many hospitals were without any surgical diathermy machines (used to stop bleeding from small blood vessels), because the more powerful had been requisitioned for use in the nose cones of Blenheim bombers in submarine hunting. It was therefore impossible to cut tissue under water, important in bladder surgery. Endoscopes were primitive. It was the task of the registrar to hold the patient still while attempts were made to force barely flexible gastroscopes down the patient’s throat. The standard optical design had changed little since the days of Galileo, and were lit by a small bulb that often failed at the crucial moment. Medical appliances were also rudimentary. There were no adhesive stoma bags, a bulky rubber cup being strapped over a colostomy. This worked fairly well as long as the stools were solid, but not for urine or the contents of the upper intestine. It was only in 1960 when his daughter underwent colectomy for ulcerative colitis that Mr Salt, an engineer, devised an appliance that would stick to the skin without causing soreness.

British medicine had a worldwide reputation for good bedside care and clinical excellence; in the research field it was lagging. The tradition of research in the clinic was a nineteenth century German development, stemming from well organised academic and laboratory facilities. Medical schools in the USA had adopted the model of research-orientated clinical departments after the Flexner Report of 1910. In Great Britain the Haldane Commission (1907--1913) had argued that university departments with full-time staff were urgently needed but the development of clinical research within medical schools developed more slowly in Britain than in the USA.³⁰ There were a number of outstanding individuals but no structure to encourage an academic and research-based approach to medicine. Virtually all specialists made their living from private practice and had little time for teaching and research. Only with the establishment of academic clinical units headed by salaried senior staff, within university hospitals, could research flourish. In 1939 only six of the twelve London medical schools had a clinical professor in any discipline. Even then a professor in Britain was only one among many consultants, while in the USA he was the head of a department that included all sub-specialties of medicine or surgery, and chief of service of the clinical department. When in the 1930s it was suggested that one of the London teaching hospitals should become a centre for postgraduate education, all refused. The British Postgraduate Medical School was established in 1935 in association with the Hammersmith Hospital, managed by the LCC, and alone among the London hospitals had academic professional leadership. Private beneficence such as that of Lord Nuffield in Oxford and the government-funded MRC were responsible for most of the other developments in the period before the establishment of the NHS.

Medical education

The medical student course consisted of two parts. During the first two years students studied basic clinical sciences such as anatomy, physiology and biochemistry. Then they began their clinical studies, moving in turn through the hospital departments: medicine, surgery and midwifery. In parallel there were lectures, seldom closely related to the practical work the students were undertaking. London provided over a third of the country’s doctors. Here the medical schools operated individually, largely independently of the University of London and as departments of the hospitals. They provided income from student fees to the consultants and a ready source of cheap junior staff. The provincial medical schools were from the outset an intrinsic and valued part of a multi-faculty civic university.

The Goodenough Report

Service and education are interlinked. In 1942 the Ministry of Health, with the Department of Health for Scotland, established a committee to look at medical education, the clinical facilities required and how they should relate to a new health service. It was chaired by William Goodenough, Deputy Chairman of Barclays Bank and Chairman of the Nuffield Provincial Hospitals Trust. The government already held views on medical education and the members were chosen with these in mind. Goodenough himself was committed to regionalisation; there were two members from University College Hospital, which had the most highly developed professorial system of all the London medical schools; and Janet Vaughan, an eminent haematologist and the Principal of Somerville College, Oxford, who had strong views about women in medicine. Sir Wilson Jameson as CMO of the Ministry kept a watching brief.  The report was published in 1944 at the time of the Normandy landings and attracted little immediate attention.³¹ It was, however, the most important statement on medical education for many years.³² Goodenough made four opening comments:

•          Properly planned and carefully conducted medical education was the essential foundation of a comprehensive health service. It was not merely incidental to the hospitals; the spirit of education must permeate the whole health service, professionals and public alike.

•          A principal aim of national policy should be the encouragement of the promotion of health.

•          It would take time to develop an educational system to meet the needs of a comprehensive health service; developing the teaching staff and the facilities could not happen overnight.

•          Greatly increased public funding would be needed to provide the research and education that would underpin the NHS. 

The pattern outlined was of university medical school, a radical idea in London. This meant phasing out Scottish extramural schools and the West London Hospital’s school, and changing the constitution of most of the many London medical schools that were subsidiaries of the teaching hospitals rather than academic bodies in their own right.  Goodenough dismissed the idea of university-managed teaching hospitals, and sold the idea of ‘university teaching centres’. Such centres would comprise the medical school (integral with a university), a group of teaching hospitals and clinics providing teaching facilities. The facilities should form a geographically compact group, one hospital being the ‘parent’ and providing much of the teaching. The medical schools and teaching hospitals were receptive to the idea of grouped facilities for it would increase the number of beds available. The wartime emergency medical service had made the teaching hospitals familiar with other hospitals nearby. Goodenough thought that every hospital throughout the NHS should be brought, directly or indirectly, into association with a university teaching centre. These should have a zone of influence and take part in the administration and staffing of the health service more generally. Every medical school should have whole-time professors of medicine, surgery, and obstetrics and gynaecology. Teachers must make their educational work their principal or at least one of their main activities.

Goodenough said that, in the management of teaching hospitals, equal emphasis must be placed on the treatment of patients and on research and the training of students -- complementary and reinforcing functions. There was wide agreement about the number of beds required, and the BMA’s evidence was specific. Professor Henry Cohen, from Liverpool, explained how the numbers had been worked out, and they were accepted by the Committee. A school admitting 100 clinical students should have access to 950--1000 beds, excluding tuberculosis, infectious and mental diseases, and highly specialised functions such as radiotherapy. Few medical schools had anything like this; by the standards set, ten of the London schools were short of medical beds and seven were short of surgical beds as well. Goodenough thought that the geographical distribution of the London schools was untenable, and that Charing Cross and St George’s hospitals should move so that they provided better access to local populations. Expansion of the provincial and Welsh medical schools should be encouraged to meet the growing requirements of the NHS. If new schools were needed, London was not the place for them. Unsuitability for a medical career should be the sole barrier to admission to a medical school -- not gender. Financial grants to students for both fees and maintenance should be available, but exchequer grants to the schools should be conditional upon their being co-educational; many in London were not.

The body of the report dealt with the individual specialties, the effects of specialisation, the curriculum and issues of postgraduate education and research. Postgraduate education in London would be reconstituted as a Federation within the University, with Institutes for selected special hospitals. The teaching of social and preventive medicine and of psychiatry, was seen as important. General practice was mentioned largely because of the problems GPs had as a result of their professional isolation. Lastly there was the question of the bill to be met by government to ensure a solid educational foundation for the new NHS. The government agreed to a contribution of £1 million a year. 

Although the NHS Bill that came before Parliament gave each teaching hospital its own board of governors, no reference was made to any duty with regard to teaching or research. The academics were alarmed but Aneurin Bevan, the Labour Minister of Health, was under fire from so many quarters that he was loath to accept any more amendments to his Bill. An approach was made to Lord Addison, a doctor and an ex-Minister of Health, and to Lord Sankey, who had chaired a review of the voluntary hospital system in the 1930s. As a result an explicit duty was laid upon boards of governors to provide the clinical facilities necessary for teaching and research.³³ Legislation needed for changes to the medical schools was implemented along with the NHS Act in 1946.

Nursing 

No woman should take up the profession of nursing unless she is prepared for hard work, constant subordination of her will, and for continual self denial . . . She must be trustworthy, conscientious and faithful in the smallest detail of duty. She must be observant and possess a real power of noting all details about her patient. She must be promptly obedient and respect hospital etiquette . . . A nurse’s manner to her patient should be dignified, friendly and gentle, but no terms of endearment should be used. She should surround herself with mystery for her patient and never discuss her own private affairs.

            Probationer’s notes, St George’s Hospital, 1946 

‘The greatest satisfaction in life is to be gained from making other people happy,’ said an LCC brochure on nursing as a career. Nursing was essentially women’s work, a woman’s finest qualities were brought out in rendering service to others, and nursing called for all that was best and noblest. Training equipped her, as nothing else could, to cope with all the human emergencies that were encountered in life. The nursing profession had been revolutionised; the nurse was no longer merely useful help in the sick-room. There had been a complete change in status, and the nurse was now regarded by doctors and surgeons as a competent trained assistant. From the outset, the LCC maintained, it was a career of dignity and responsibility.³⁴ 

Nurse education and staffing

Medical and nurse training differed significantly. There were many nursing students, the training was shorter and there was little penalty for giving up. Nursing experience, and the experience of handling people, could be useful in other occupations. In medicine the numbers were smaller, students were often highly selected and had a long training that would be useless unless they completed the course. The educational patterns also differed. Medical education was university based. Nursing schools were part of the hospital’s organisation, under matron’s control, and the student nurse, unlike the medical student, was a crucial part of the hospital labour force. 

Although some hospitals could be choosy and had high entry standards for nurses, most could not afford this luxury. The course lasted three years but, after passing the examinations, the new state registered nurse often had to spend a fourth year as a staff nurse before getting the much-prized hospital badge. That helped to retain nurses. The ‘block’ system of education, in which nurses spent a number of weeks in the school of nursing at particular times in their course, had been introduced in the 1930s. There might be tension between the sister tutors and the ward sisters. The ward sisters expected students to come to them with some knowledge of basic nursing techniques, able to observe and report on patients, and to be well disciplined. The tutorial staff expected the students to return with clinical experience, and be able to associate theory and practice. Expectations were not always fulfilled. 

Nurses have never suffered from a lack of advice. In the years before the NHS there had been several reports on nursing, its problems and its needs. The Royal College of Nursing (RCN) had established a Nursing Reconstruction Committee (1942--1950) chaired by Lord Horder. Three fundamentals inspired his committee’s approach: ‘the patient, the human touch and informed treatment’.³⁵ The committee’s first task was to get statutory recognition of the assistant nurse. That achieved, it proceeded to consider education and training, and finally recruitment. The committee became convinced that, given a liberal outlook and a carefully planned curriculum, nurse training could be developed into something of great importance. Training was, however, too closely linked with the provision of nursing care, a handicap greater than an educational system should have to face. Entering nursing to receive a professional education, and spending three months in the preliminary training school, the nurse then went on the wards and became an indispensable member of the hospital staff. There was a gap between the theory of the classroom and the practice of the ward, where staff were stretched and supervision by experienced staff might be inadequate.³⁶ There was the difficulty in recruitment and the wastage caused by marriage. Marriage ended the career of a student nurse. Indeed nursing was seen as an alternative to marriage.³⁷ Many working-class 18-year-olds were interested in boys and an engagement, not education and the classroom. Nursing on the wards interfered with social activities, for many did not know when they would be off duty until sister finished the duty roster; in any case they stayed on duty until work was finished. Student nurses were angered by their pay and, with support from the Confederation of Health Service Employees (COHSE), demonstrated in the streets. They won their battle for a training allowance in 1948 although the RCN felt their conduct had been undignified.³⁸

There was always a shortage of nurses. Two categories of nurse had existed from the nineteenth century. Alongside the trained nurses, who were ‘state registered’, were nursing assistants. In 1943 the Nurses Act granted legal status to assistant nurses, establishing a ‘roll’ (trained nurses were on a ‘register’), and a system of examination, admission and removal of names. In 1948 there were some 20,000 of these state enrolled nurses (SENs). Their presence not only added to the workforce but also made it possible to improve the training of students for the register. Nurses and their professional organisations were always ambivalent about auxiliaries, holding divergent views of their teaching and the length of their training, needing them, sometimes nurturing them -- but sometimes rejecting them as ‘dilution’.³⁹ The prime concerns of the RCN were the position and salaries of qualified nurses, and the social conditions they had to endure.

The success of a national health service was going to depend as much on sufficient numbers of adequately trained nurses as doctors. In 1945 the Ministry of Health established a small working party that included two senior nurses, a social scientist and a doctor, chaired by Sir Robert Wood. It was to look at recruitment, the proper task of a nurse, the training required, the annual intake needed and how it was to be obtained, from where nurses were to be recruited, and how wastage could be minimised. The Wood working party had to work fast and it reported in 1947.⁴⁰ Little advantage was seen in synthesising existing ‘literature’ and adding yet another expression of opinion to the large number already available. Wood’s aim was to discover the facts and let the facts speak for themselves. Once they were established, it would be easier to gain acceptance of an unpalatable remedy. The starting point was the cost of sickness to the community, the value of working time lost, the cost of treating the sick and the cost of immunisation and clinics for mothers and babies . An estimate of the need for health nursing was needed, and then the requirement for sick nursing. The working party looked at the size of the nursing profession, and its structure in terms of age, educational background, professional qualifications and socio-economic status. It examined recruitment, wastage and the pattern of training. It looked at ‘the mental calibre of the nursing profession’ and found a striking range of ability. Wood found it ‘inconceivable that persons differing so very widely in their mental capacity should respond to the same training or be fitted to the same functions’. The average was ‘probably somewhat above the population as a whole’. Mental hospitals had more than their share of those at the lower end of the scale of intelligence.>The central message of Wood was carefully wrapped. Wood believed that wastage was unacceptably high, being the result of discontent among the students and frustration with harsh and cramping discipline. Senior staff and matrons were to blame for this. Responsible as they were for patient care without an adequate supply of trained staff, as well as training students who were carrying much of the workload, it was inevitable that the needs of patients should be placed before the interests of students. It was no use merely appealing to hospital authorities to modify discipline or to adopt more understanding attitudes. The organisation and staffing of training schools needed structural changes. There should be a broader training for all nurses, a single General Nursing Council (GNC) with a more substantial educational role, and regional training bodies independent of the NHS, the costs of training coming from outside the health service. This conclusion was threatening to hospital administration and the matrons who ran the schools. 

 1.     Staff nurses should manage their work methodically and keep their Wards neat, clean and in good order. They should pay constant attention to the warmth, freshness and ventilation and study the welfare and comfort of their patients in every respect. Every effort should be made to keep the Wards as quiet as possible.

 2.     The senior Staff Nurse on duty shall deputise for the Ward Sister in her absence, and at such times shall report to the Sister who is ‘on call’ for her Ward (or in their absence to the Assistant Matron’s Office) the admission of any patient who is seriously ill and on any occasion when there is cause for anxiety.

 3.     Staff Nurses should give a kindly welcome to new patients immediately on their arrival in the Ward, treating them with gentleness and consideration and making them and their friends feel assured from the first that they will be tenderly cared for.

 4.     The admission of new patients should be carefully supervised, particular attention being given to observing the condition of the pressure areas. Any abrasion of the skin, however slight, must be reported immediately to the Sister in charge. Staff Nurses shall also see that proper care is taken of the clothing and valuables of patients admitted to their Wards.

 5.     Staff Nurses shall be responsible for looking after relatives and friends visiting the Wards, and shall see that those waiting for long periods in the Hospital receive food and refreshment.

 6.     An important part of their duties is to assist the Ward Sisters in the training of Student Nurses, teaching them to be accurate, careful and observant, and thorough in every detail.

 7.     They shall see that all new Student Nurses coming to the Ward understand the clinical work allocated to them and are carefully instructed in all procedures practised in the Ward.

 8.     They shall study the rules laid down for the care and checking of Dangerous Drugs, and see that these are properly observed.

 9.     They shall be responsible to the Sister in charge of the Ward or Department for the care of the following: Linen, Instruments, Surgical equipment including surgical stock, Crockery and cutlery. A weekly inventory should be taken and any losses reported immediately to the Sister in Charge. It is recommended that instruments and cutlery in regular use be checked every day.

 10. It is a strict rule of the Hospital that nothing may be borrowed from one Ward or Department for another without a written request signed by the Sister or Staff Nurse in charge. At night the request should be made to the Night Sister. This rules also applies to Dangerous Drugs.

 11. Staff Nurses should supervise the work of the Ward Maids and Orderlies, instructing new members of the staff in their duties and helping them to feel that they are essential members of the Ward team. They shall see that the Domestic Staff are punctual in arriving and leaving the Ward, and shall teach them to be quiet and thorough in their work and to avoid waste.

 12. Constant attention should be paid to every method by which economy may be effected, particularly with regard to food, surgical dressings, lotions, stationery and cleaning materials. Good management in this respect can save the Hospital considerable expense.

 13. Any accident affecting either a patient or a member of the Nursing or Domestic Staff on duty in a Ward or Department shall be reported immediately to the Sister in Charge and a written statement made by the member of the Staff involved or witnessing the accident.

 14. Staff Nurses should be thoroughly conversant with all the rules made for the prevention of infection in the Hospital and should see that these are conscientiously and carefully carried out.

 15. Nursing Procedures practised in the Hospital shall be those laid down in the Nursing Procedure Book, a copy of which shall be available in every Ward and Department.

Muriel B. Powell, Matron, 13 December 1951

The NHS brigaded nurses into a single workforce. Henceforth there would be a national pay structure, the Ministry would be concerned with staffing a huge service and professional organisations had a negotiating role. Nurses in the mental institutions had never been accepted by the RCN as on a par with state registered nurses. Other unions had been established by them to fight for better conditions and, simultaneously, better services. Strike action, though not common, was part of their tradition. COHSE was formed in 1946 when two unions merged, and after that it represented many of the nurses in mental hospitals and the auxiliary state enrolled nurses.⁴⁹ The RCN found itself having to act simultaneously as a trades union alongside others and as a professional organisation. Doctors had the BMA to deal with their terms of service, and the Royal Colleges to consider educational and professional issues. The RCN had to combine the two functions and was not always successful. Senior officers were frequently more political than professional. With optimism, Dame Louisa Wilkinson, President of the RCN, said things were going to be quite different.⁵⁰  

Nursing has allowed itself in the past to be taken far too much for granted. We have allowed ourselves to be handmaidens of the medical profession. Nurses have not got the slightest intention of accepting a lower plane than that of an active, loyal and wide-awake partnership with the medical team. 

Nursing in the community

Nursing in the community had a long and honourable history. The first recorded venture was in Liverpool in 1863. In 1889 the Queen’s Jubilee Fund endowed the Queen Victoria’s Jubilee Institute for Nurses, later the Queen’s Nursing Institute. The Institute designed a specific training programme, ran local services, and was the main voluntary organisation doing so.  In most areas district nursing associations had been founded to provide a service to the community.  Such voluntary associations had to raise funds to pay their nurses’ annual salaries. There were village fêtes with stalls and rides on the lake for tuppence and gardens open to the public. District associations had to reach certain standards to affiliate with the Queen's Institute, and Queen's Institute trained nurses were the gold standard of quality.  Rural areas sometimes could not provide a service to such a level.  Some local authorities looked to voluntary agencies like the Queen’s Nursing Institute; others provided their own nursing services.⁵¹ On a national basis, the training of district nurses was not well codified and local authorities could employ those without qualifications in district nursing.⁵²   Local authorities initially looked to the voluntary associations but sooner or later brought these services in house.

Midwifery, a profession separate from nursing, was regulated under the Midwives Act  of 1936. More than half of the babies born were delivered at home, mainly by midwives provided by local authorities or nursing associations. County councils and county boroughs had to provide a domiciliary service directly or through contracts; how they did so was largely for them. Domiciliary midwifery was an entirely female profession, giving a door-to-door service, mostly on bicycle, 24 hours a day, 365 days a year, to an entirely female clientele. Often working in partnerships of two or three, each midwife cared for women in her geographic patch, delivering 50--100 women annually. It was an industrious and insular life. Midwives had a sense of their own worth, with a duty to the public and an accountability to their supervisor. Few mothers saw more than three or four professionals during their pregnancy, and there was a guarantee of continuity of care.⁵³

Health visitors had generally undertaken further education after state nurse registration and had midwifery experience. The roots of health visiting were different from the other two nursing professions: it emerged from community work and the radical tradition. It had grown, not out of nursing, but from ‘sanitary’ visiting in the nineteenth century, particularly in areas with poverty and poor living conditions. Formal training developed early, and led to an examination by the Royal Sanitary Institute. The ethos of health visiting was that of public health and its interests lay in the social conditions affecting the health and welfare of communities, and therefore families. The predecessors of the Health Visitors’ Association were involved in most public and social issues -- poverty, ill-health, infant mortality, slums and working conditions for women and children. They were early to register as trades unions and were involved in radical politics as the way to bring about change in society. Most of the health visitors’ work was with pregnant women, nursing mothers and children under school age.⁵⁴ As the idea of maternal education as a weapon in the fight against infant mortality gained ground, there was an increasing demand for their services. The task of the health visitor began with a notification of birth -- it was unsolicited.⁵⁵ When the NHS began, health visiting was already part of the local authority services, under the control of the medical officer of health. With the advent of the NHS the work of health visitors was expanded to the health of the household as a whole, advice on the care of people who were ill and measures to prevent the spread of infection.⁵⁶ Maternity and child welfare remained the centre of their work, which was usually based in a local authority clinic.

Because there was no formal demarcation of duties, there was considerable friction between district nurses, health visitors and midwives. In rural areas where mobility was a problem, one nurse might be a qualified midwife, health visitor and district nurse. She would be well known and well respected by the community.

Nursing administration

There had been nurses in government employ, in the Ministry of Health, since the 1920s. In 1948 Elizabeth Cockayne was appointed Chief Nursing Officer following Catherine Watt, the first CNO. Her career had been varied, involving clinical and educational posts in both the north and south of the country. She was one of the two nurse members of the Wood working party, which did not add to her popularity with the nursing profession. Her staff included public health and hospital nursing officers with regional responsibilities. They were in close contact with professional organisations and advised the Minister, working with medical and administrative colleagues and concerned with matters of nursing policy.⁵⁷

Nursing administration within the hospitals was much the same in the voluntary and the municipal hospitals, not the case on the medical side. The matrons had an informal network and when one was to retire a successor might be agreed on the grapevine. Senior nurses would be moved among the hospitals in preparation for a key position that was becoming vacant; the teaching hospitals often supplied the matrons for municipal hospitals and smaller voluntary hospitals. In large hospitals a matron, with deputy and assistant matrons, managed the ward sisters, and they the more junior nursing staff. Where there was a nursing school, matron controlled it and selected the students. She managed catering, linen supplies and domestic services, and might be responsible for physiotherapists and other disciplines ancillary to medicine. Matron’s role was similarly wide ranging in the smaller hospitals. However, the matrons’ accountability might differ. In municipal hospitals matron reported to the medical superintendent. In the voluntary hospitals she had more autonomy and was usually appointed by, and was responsible to, the board of governors.