History of the National Health Service

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The name National Health Service (NHS) is used to refer to the publicly funded health care services of England, Scotland and Wales, individually or collectively. Northern Ireland's services are known as 'Health and Social Care' to promote its dual integration of health and social services. For details of the history of each National Health Service, particularly since 1999, see:

History of the National Health Service (England)
History of NHS Scotland
History of NHS Wales
History of Health and Social Care in Northern Ireland

The NHS was one of the first universal health care systems established anywhere in the world. A leaflet was sent to every household in June 1948 which explained that
It will provide you with all medical, dental and nursing care. Everyone — rich or poor, man, woman or child — can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as tax payers, and it will relieve your money worries in time of illness. The NHS in Scotland was established as a separate entity with its own legislation, the National Health Service (Scotland) Act 1947, from the foundation of the NHS in 1948. Northern Ireland likewise had its own legislation in 1948. Wales, however, was managed from England and treated much like an English region for the first 20 years of the NHS. In 1969, responsibility for the NHS in Wales was passed to the Secretary of State for Wales from the Secretary of State for Health, who was thereafter just responsible for the NHS in England.

Dr Benjamin Moore, a Liverpool physician, in 1910 in The Dawn of the Health Age was probably the first to use the words 'National Health Service'. He established the State Medical Service Association which held its first meeting in 1912 and continued to exist until it was replaced by the Socialist Medical Association in 1930. Before the National Health Service was created in 1948, patients were generally required to pay for their health care. Free treatment was sometimes available from charitable voluntary hospitals. Some local authorities operated hospitals for local ratepayers (under a system originating with the Poor Laws). The London County Council (LCC) on 1 April 1930 took over from the abolished Metropolitan Asylums Board responsibility for 140 hospitals, medical schools and other medical institutions. The Local Government Act 1929 allowed local authorities to run services over and above those authorised by the Poor Laws and in effect to provide medical treatment for everyone. By the outbreak of the Second World War, the LCC was running the largest public health service in Britain. Dr A. J. Cronin's controversial novel The Citadel, published in 1937, had fomented extensive criticism about the severe inadequacies of health care. The author's innovative ideas were not only essential to the conception of the NHS, but his best selling novels are also said to have greatly contributed to the Labour Party's victory in 1945. Systems of health insurance usually consisted of private schemes such as friendly societies or welfare societies. Under the National Insurance Act 1911, introduced by David Lloyd George, a small amount was deducted from weekly wages, to which were added contributions from the employer and the government. In return for the record of contributions, the workman was entitled to medical care (as well as retirement and unemployment benefits) though not necessarily to the drugs prescribed. To obtain medical care, he registered with a doctor. Each doctor in General Practice who participated in the scheme thus had a 'panel' of those who have made an insurance under the system, and was paid a capitation grant out of the fund calculated upon the number. Lloyd George's name survives in the Lloyd George envelope. in which most primary care records in England are stored, although today most working records in primary care are at least partially computerised. This imperfect scheme only covered workers who paid their National Insurance Contributions and was known as 'Lloyd George's Ambulance Wagon'. Most women and children were not covered.

In 1979 across the whole UK there were about 2,750 NHS hospitals with about 480,000 beds, accounting for about 70% of total NHS expenditure. About one third of beds in England were then provided in new or converted accommodation built since 1948 with a higher proportion in Northern Ireland, but lower in Scotland and Wales. Beds for mental illness, geriatric patients and mental handicap were much more likely to be in older buildings than acute or maternity services.

The National Health Service was a major employer from its foundation. After nationalising Britain's voluntary and municipal hospitals, the new NHS took responsibility for 360,000 staff in England and Wales and a further 45,000 in Scotland. These included 9,000 full time doctors (with thousands more consultants working in multiple part time roles), 149,000 nurses and midwives (23,000 of whom were part time), 128,000 ancillary staff (catering, laundry, cleaning and maintenance), 25,000 administrative and clerical staff, and 19,000 professional and technical staff, of whom the 2,800 physiotherapists, 1,600 laboratory technicians and 2,000 radiographers were the largest groups. This workforce would continue to grow throughout the 20th and 21st Centuries, overtaking the National Coal Board to become Britain's largest employer in 1961. By the end of the 1970s, the NHS had passed 1,000,000 staff and in 2015 was the world's fifth largest work organisation with 1.7m. Nurses are the largest single group of professionally qualified staff in the NHS, with 306,000 employed in English hospitals and community health services as at December 2020.

The NHS has long had one of Britain's most varied workforces, with employees from a diverse range of backgrounds in terms of class, occupation, gender, race and nationality. In the early NHS doctors were overwhelmingly men from middle and upper class backgrounds, and were often privately educated. Nurses in general hospitals were usually women and generally from a mixture of middle and working class origins. Men constituted a significant minority of nurses but were largely concentrated in mental hospitals, where their role historically had been more associated with manual labour, particularly the physical control of the patients. Professional organisations like the Royal College of Nursing tended to promote the idea that nurses were middle class professionals, whilst trade unions encouraged nurses to see themselves as workers. Like nursing, ancillary tasks were also heavily gendered with portering and maintenance largely done by men, and laundry and cleaning largely women. Increasing demand for health services led to a steady expansion in total staff numbers throughout the second half of the 20th century and into the 21st century. However, NHS wage rates were usually comparatively low and hours often long and anti social. Part time work brought many of these women back into the workforce and the NHS was a key site in the growth of this kind of work in post war Britain, employing 65,000 part time ancillary staff (mostly domestics) and 79,000 part time nurses and midwives by 1967. Alongside this rise in part time work, hospitals increasingly looked overseas for staff, recruiting particularly heavily in Britain's colonies from the 1950s. By 1955, the Ministry of Health had official recruitment campaigns in 16 British colonies and former colonies. By 1965, there were more than 3,000 Jamaican nurses working in British hospitals and in 1977, 12% of student nurses and midwives came from overseas, 66% of them from the Caribbean, with substantial numbers also coming from the Philippines and South Asia. Large numbers of ancillary staff also migrated to fill NHS vacancies. Doctors were also recruited from across Britain's colonies and former colonies, particularly from India, Pakistan, Bangladesh and Sri Lanka. Doctors born and qualified overseas constituted 31% of all doctors in 1971. Nurses and doctors recruited by the NHS were often marginalised in job allocation. Early nurse migrants were often forced to re validate their qualifications on arrival in Britain and instructed to take the less academic State Enrolled Nurse (SEN) training, rather than the more prestigious State Registered Nurse (SRN) qualification. SENs had worse pay and fewer promotion prospects. Similarly, employment discrimination often meant South Asian doctors were forced into less desirable posts in run down provincial hospitals. The NHS was also a site of expansion in new categories of scientific and technical workers. In 1967, the service employed 31,000 professional and technical staff connected with diagnosis and treatment, including audiologists, biochemists, dietitians, more than 9000 laboratory technicians, occupational therapists, physicists, physiotherapists, psychologists and radiographers. The 1980s saw further changes in the NHS' workforce. The Thatcher Government encouraged (and eventually forced) health authorities to put most ancillary services out for competitive tender, effectively outsourcing the jobs of those workers. This led to a substantial reduction in numbers, with one third of ancillary posts disappearing between 1980 and 1987. Much of the physical labour done by student nurses was now passed to a new category of health worker, the healthcare assistant, a role that mirrors that of "auxiliary nurses" in the early NHS. The status of general practitioners as outside contractors was largely confirmed by the market based reforms introduced by the Thatcher, Major and Blair governments. The working lives of hospital doctors changed from the 1970s onwards, as career paths and work patterns became increasingly formalised. Set rules on hours were introduced in the 1970s and refined in the 1980s and 1990s to dramatically reduce the number of hours junior doctors were expected to contribute.

Between 1948 and 1972 the NHS largely remained free of strikes, but nevertheless did experience some other industrial disputes. The foundation of the service was opposed by many doctors, particularly general practitioners, who feared that a state medical service would reduce their independence. Doctors expressed this opposition through their largest professional organisation, the British Medical Association, which held a number of ballots canvassing its members' (largely negative) opinions on arrangements for the new service. After a threat to boycott the new service, the BMA secured some concessions from Aneurin Bevan, the Minister of Health responsible for implementing the NHS Act. The BMA's intransigence did not stop the new health service coming into being, but did secure the right to be paid on a "capitation" basis (per patient) rather than on a set salary. Although strikes in the NHS remained rare, changes in everyday industrial relations were more profound. The NHS saw a significant expansion in the number of workplace representatives in this period, sometimes forcing managers to consider the views of sections of the workforce, like the ancillary staff, who they had long ignored. This sometimes caused conflict between different groups. The "pay beds" dispute pitched nurses and ancillaries, who opposed private practice, against consultants, the direct beneficiaries of private practice. The NHS has also been an important topic within public health, often forming a central part in public information films about health and wellbeing. This commitment to producing public information films continued after the end of the War in 1945 with the newly formed Central Office of Information taking responsibility for the production of these films. This ensured that the launch of the NHS was accompanied by a number of public information films shown nationwide during Spring and Summer 1948. Three main films were produced – Charley: You're Very Good Health (Halas & Batchelor, 1948), Here's Health (Douglas Alexander, 1948) and Doctor's Dilemma (Unknown, 1948). These films introduced the NHS in three distinct ways with Charley: You're Very Good Health focused on explaining how the NHS would work upon its launch in a light hearted manner with Charley standing in as the 'everyman' within the film's narrative. The film used a series of 'suppose' scenarios to outline how the new NHS system would work in practice in comparison to the pre NHS health care system. The Doctor series, starring firstly Dirk Bogarde and later Leslie Philips, took a comedic look at the antics of a young doctor in an NHS hospital and the Carry On comedies Carry On Nurse (Gerald Thomas, 1959), Carry On Doctor (Gerald Thomas, 1967) and Carry On Matron (Gerald Thomas, 1972) also used comic situations within the NHS hospital to poke fun at both the NHS as an institution and the capers of doctors, nurses and patients alike. From the late 1950s, the NHS also became an important subject within the wider history of British soap operas. Emergency – Ward 10 was first broadcast in 1957 on ITV and ran until 1967 and followed the life and loves of the staff and patients of the fictionalised Oxbridge General. ITV later followed this up with General Hospital which borrowed much from Emergency Ward 10 in terms of its themes and focus. The idea of a medical hospital as a suitable and popular setting for a soap opera continued to take root in the 1980s. Casualty, set in an A&E department, was first broadcast in 1986 and has since become the longest running medical drama in the world. At a time when controversy over the NHS was high on the public agenda, Paul Unwin and Jeremy Brock began their proposal for Casualty by declaring that 'In 1948 a dream was born: a National Health Service. In 1985 the dream is in tatters.'

There have been lots of cartoons about the NHS throughout the institution's history. Even before the NHS was launched, there were cartoons documenting the political debates about its form. In the 1940s, the British Medical Association was opposed to the idea of doctors becoming state employees on fixed salaries. Cartoonists made their opinions about this conflict known. David Low published a cartoon in the Evening Standard on 14 December 1944 showing Charles Hill, the BMA Secretary, being examined by a doctor. The doctor states, 'Don't be alarmed. Whatever's the trouble, you're not going to die from enlargement of the social conscience.' When the NHS was launched, many cartoons showed how people responded to the NHS being free at the point of access. One cartoon, published in 1951 by Antonia Yeoman, portrayed women in a doctor's waiting room, one of whom stated that she had seen eighteen doctors and seven psychiatrists. Eventually, she had been diagnosed with a 'deep seated guilt about getting things free from the National Health Service.' Analysing cartoons about health featured in Punch magazine from 1948, the psychiatrist Bernard Zeitlyn argues that they 'centred on the bonanza of free spectacles, beards and trips abroad' that the NHS would bring. Cartoonists also portrayed public excitement about the availability of free wigs on the NHS. In one such example, from January 1949, cartoonist Joseph Lee showed an irate man chasing a child, asking, 'Who's been practising Home Perms on my free National Health Service wig?' Cartoons were also used to criticise NHS policy. From 1948, Zeitlyn also found cartoons portraying concern about the 'bureaucratic consequences' of the NHS. Other cartoonists suggested that too much was being spent on the NHS. For example, in the Daily Mail in 1968, John Musgrave Wood drew a man to portray the NHS, who was wearing a dunce's cap and being fed 'Defence Cuts'. Many cartoons have been very interested in portraying NHS staff, both their lives and industrial conflict. The cartoonist Carl Giles, who often drew for the Daily Express, was very interested in drawing nurses in particular. Historian Jack Saunders has argued that Giles' presentation shifted from presenting nurses from 'caring and sexualised' to 'bolshie and assertive'. Giles sent a cartoon of nurses stealing peas from patients directly to the East Suffolk Nurses League. On the cartoon, Giles wrote 'with deepest sympathy', referring to the cutting of food allowances.

Patients and staff have made jokes about the NHS to one another, on a daily basis, throughout time. However, it is very hard to locate and to understand these. The People's History of the NHS project at the University of Warwick has collected more such memories on its website, and invites contributions for more. Researchers and clinicians hope that humour and laughter may be able to be used to improve human health. The term 'gelotology', to denote the study of laughter, was created in 1964 by Edith Trager and W. F. Fry. One experiment from 2011, led by researchers at the University of Oxford, suggested that watching comedy videos may raise people's pain thresholds, when watched in a group. This effect did not hold when videos were watched alone, or if research participants watched videos such as scenes of nature. In 2003, the artist Nicola Green and film maker Lara Agnew created a 'laughter booth' at the Royal Brompton Hospital. In this booth, patients and staff could watch videos of people laughing. The idea of laughter as healing has also influenced language, through the phrase 'laughter is the best medicine'.