The Rise of State Medicine Lecture 6 Cradle to Grave

New ethos The NHS marks a full turn about from idea of a ‘medical marketplace’ – shift from medical consumption based on choice and ability to pay to a system where the state provides medical care. ‘Health for All’ seen as a right and entitlement of citizens. During 20th century domestic and welfare issues – employment, housing, education and health – became stuff of high politics with a great deal of government input and funding. Involved major institutions and health service became a major employer. This was coupled with a belief in progressive power of scientific medicine shared by medical profession, policy makers and consumers. E.g. new vaccines, penicillin

1919-1939. Developments in the interwar period. Lecture Outline 1870-1918. Precursors to the NHS. 1919-1939. Developments in the interwar period. 1939-1948. The emergence of the NHS. John Pickstone’s model of the British health care system/provision of care and role of medicine in the state.

Medical charity Medical charity continued to play a vital role in health care up until setting up of NHS – especially voluntary hospitals. By early 20th century many patients paid directly for care or paid for by insurance scheme, often run by a Friendly Society or charitable organisation. From the 1870s voluntary hospitals were under growing financial pressure – concerns about losing subscriptions. After introduction of NHI increasingly took seriously ill patients referred by GP and became more specialised. Still treated large number of poor as out- patients.

Poor Law Poor Law was only provider of state medicine, funded by local poor rates but with national oversight through Poor Law Commission and Board. Increasingly Poor Law provided better standard of care, especially infirmary provision in major towns and cities/more intervention in public health. 1929 Local Government Act abolished the Boards of Guardians – responsibilities transferred to local authorities. MOHs power increased as they assumed control over general hospitals. Workhouse also abolished in 1929. Haslingden Workhouse and its board of guardians – later became Rossendale General Hospital

Public health Precursors 19th century – Edwin Chadwick’s faith in central government and big engineering projects, linking poverty to disease. By early 20th century public health began to emerge as a national concern. Problems identified in reports by Rowntree, Booth and Snow. State increasingly called upon to legislate to protect people’s health – town planning and sanitation, housing and working conditions e.g. slum clearance. Enforced compliance in terms of housing, factory legislation, occupational health. New focus on prevention as well as cure – believed it depended on medicine and state working hand-in-hand. Medical focus shifted from filth diseases (cholera & typhoid) to infectious diseases (TB). Increasingly close working relationship between state and medicine through rise of public health. Public health became ever more important as concerns about national efficiency grew in the years before World War 1.

‘The Dawn of Hope’, The National Insurance Act of 1911

National Health Insurance introduced in 1911

National Insurance Act 1911 Lloyd George prime mover – aspect of liberal reforms Provided access to GP services via a panel doctor. Three types of benefit: sickness, accident and disability, and pension (cash payment for men during sickness 10s) Financed by contributions from employer, employee & state Administered through ‘approved mutual societies’ Benefits limited to the contributor (worker) - mainly men. Maternity pay provided for working men’s wives. Free hospital treatment provided for patients with TB. Proved extremely popular with the public. However: Only 10% of women worked in occupations that were eligible. Women and children were not covered outside maternity services. Cost of hospital care not included. The act was met with concern from medical practitioners who feared the impact on their private practices and loss of control. Given a high capitation fee – 9s for each panel patient, solid steady income.

Interwar period 1919 Ministry of Health created – took responsibility for care of mothers and children and infant life protection, supervised local authority health services. The Dawson Report of 1920 put forward ambitious plan for integration of preventive and curative services - recommended a two tier system of GP and specialist health centers. 1920s and 1930s local authorities ran large range of services – infant and maternal welfare clinics, VD clinics, TB clinics and sanatoria. Local authorities also became responsible for environmental health, clean food and milk, refuse removal, clean air, river and water pollution.

The Peckham Experiment

Finsbury Health Centre

Medical facilities available at a modern health centre contrasted with ill health in slum housing. Colour lithograph after A. Games, 1942.

Outbreak of WWII: demand for change Socialist Medical Association Left wing doctors who called for a free national health service administered by local authorities. 1937 Report by the Political and Economic Planning Group on British health services. Recommended a central role for GPs and a coordinated specialist system backing up primary care. Emergency Medical Services This was founded to deal with civilian bombing casualties – hospital beds, casualty clearing facilities and specialist hospitals. Regional coordination directed by the Ministry of Health. Breakthrough in organization and experience - critical in accelerating plans for a national health service.

Proposed that doctors should be employed directly by the state. The Beveridge Report Recommended a comprehensive social security system and health care service. Health care should be available to all regardless of their ability to pay. Proposed that doctors should be employed directly by the state. More generally, the report recommended that the government should find ways of fighting the five ‘Giant Evils’ of ‘Want, Disease, Ignorance, Squalor and Idleness’. White Paper, A National Health Service 1944 – set out basis for comprehensive national health service for all, free to public at point of use. http://www.bl.uk/onlinegallery/takingliberties/images/712beveridgereportbig.jpg

And here is Beveridge fighting the first of the evils want And here is Beveridge fighting the first of the evils want. These social evils are just as relevant to the C19th as well I think – poor conditions, poverty, lack of education or knowledge on how to be healthy are issues that will come up time and time again in several topics we’re going to look at. Idleness is a very interesting one because it connects with ideas of responsibility and self help which are very current in the modern period.

‘To ensure that everybody in the country – irrespective of means, age, sex, and occupation – shall have equal opportunity to benefit from the most up to date medical and allied services available…to divorce the case of health from questions of personal means and other factors irrelevant to it; to provide the service free of charge…and to encourage a new attitude to health – the easier obtaining of early advice on, the promotion of good health rather than only treatment of the bad’ (MOH, 1944, p.47)

Labour Party election posters (1945) Labour elected 1945 in landslide victory – massive programme of social welfare.

Opposition from medical profession, especially BMA Anuerin Bevan Minister of Health and architect of NHS. Faced much opposition from doctors, especially BMA. Objected to the concept of a salaried service. Objected to Local Authority control. Fear that would threaten clinical freedom. Echoed control of Poor Law and Friendly Societies. Wanted an enhanced role for voluntary hospitals and consultants. Resolved by allowing consultants part-time contracts and won GPs over by making them independent contractors. Members of the BMA dressed up as Gladiators facing Bevan (aka. Nero)

National Health Service Act 1946 - tripartite system Hospitals: Voluntary and local authority hospitals were nationalised – managed by regional boards. Local authorities – health centres, clinics, health visiting, ambulances. GP, dental and optician services – operated on an independent contractor basis; administered by Executive Councils.

The NHS came into being on 5 July 1948. Care was free at the point of delivery. Free dental care, free spectacles, free consultations with a GP, referral to hospital and free treatment.

John Pickstone, ‘Production, community and consumption: The political economy of twentieth-century medicine’ (2000) 20th century : ‘great troika of progress - science, profession, state’ 1900-1948 - Productionist Focus on health of the industrial worker and the armed services – resulted in National Insurance. 1948-1970 - Communitarian NHS - expansion of services, focus on social inclusion, welfare orienatation. Rise of the professional. 1970-2000 - Consumption Renewed emphasis on market and lay management of health services. Medicine is serving consumers who demand more and more. e.g. of infant and maternity care applies well to this model.

Conclusions Turn of the 20th century: transformation in public and official expectation - notion of state intervention in health gained ground. National Insurance Act 1911 marked a significant extension of medical and state involvement in the health of the nation. The NHS greatly extended the reach of organized medicine and encouraged those who had previously been too poor or reticent to come forward for consultation/treatment. Overall shift in perception of medicine as part of free market, governed by ability to pay to becoming a right for all citizens ‘from cradle to grave’.