Chronology: the first decade
Railways and electricity nationalised
New town designation starts
5 July 1948
Development of specialist
MRC Social Medicine Research Unit (Central
Pound devalued to $2.80
introduce prescription charges
Cortisone and ACTH
Nurses Act creates regional nurse training committees
Korean war (1950-54)
Link between smoking and lung cancer
Ceiling on NHS expenditure
Bradbeer Committee appointed on internal administration of
Collings Report on general practice
Election: Conservative victory
Festival of Britain
Bowlby’s Maternal and child heath care
Helicopters used in casualty evacuation in Korea.
Death of King George VI
Harrow rail disaster
Bar code invented
Danckwerts award for GPs
Watson and Crick establish the double
helical structure of DNA
London fog - thousands of
deaths from polution
College of General Practitioners formed
Confidential Enquiry into Maternal Death
Elizabeth II crowned
Nuffield report on the work of nurses in hospital wards
Gibbon uses a
heart-lung machine in heart surgery
Jerry Morris study of heart disease related to activity
Food rationing ends
First business computer (IBM)
Committee on general practice
First kidney transplant (identical
Daily visiting of children in hospital encouraged
Beaver Committee on air pollution reports.
Election: Conservative victory
Trust papers on NHS
Ultrasound in obstetrics
Group practice loan
Dr John Bodkin Adams arrested
Clean Air Act
Guillebaud: Cost of the NHS
Large-scale trial of birth control pills
Working Party on health
Macmillan Prime Minister
First satellites, Sputnik I and II
Royal Commission on Mental Illness reported
future number of doctors
Royal Commission on doctors’ pay announced
Hospitals to complete hospital inpatient enquiry (HIPE)
Percy Commission on Mental Illness
On 5th July we start together, the new National Health Service. It has
not had an altogether trouble-free gestation! There have been understandable
anxieties, inevitable in so great and novel an undertaking. Nor will there
be overnight any miraculous removal of our more serious shortages of nurses
and others and of modern replanned buildings and equipment. But the sooner
we start, the sooner we can try together to see to these things and to
secure the improvements we all want . . . My job is to give you all the
facilities, resources and help I can, and then to leave you alone as
professional men and women to use your skill and judgement without
hindrance. Let us try to develop that partnership from now on.
Message to the medical profession. Aneurin Bevan1
For almost a century the government’s Chief Medical Officers (CMOs) had often
begun their annual reports with an account of the year’s weather. It was a
tradition going back to the Hippocratic view of its effect on health.
Sir Wilson Jameson described the problems of 1947, the year before the NHS
The eighth year of austerity, 1947, was a testing year. Its first three
months formed a winter of exceptional severity, which had to be endured by a
people who in addition to rationing of food were faced with an unprecedented
scarcity of fuel. These three months of snow and bitter cold were followed
by the heaviest floods for 53 years, which did great damage, killed
thousands of sheep and lambs, delayed spring sowing and threatened the
prospect of a good harvest which was so urgently needed. Immediately after
these four months of disastrous weather there followed a period of economic
crisis with an ever-increasing dollar crisis. So acute was the crisis that
restrictions more rigorous than any in the war years became necessary. Bread
had to be rationed for the first time late in 1946; in September 1947, the
meat ration was reduced; in October the bacon ration was halved; and in
November potatoes were rationed. A steep rise in the prices of foodstuffs
and cattle food followed disappointing harvests in many European countries,
due to the hard winter and hot dry summer, and in certain crops, notably
corn for animal food, in America. Affairs abroad were as depressing as
conditions at home.
The second world war had created a housing crisis. Alongside post-war
rebuilding of existing cities, and the designation of overspill areas, the
New Towns Act 1946 led to major new centres of population. The boundaries
were drawn generously, land reclamation figured prominently and the problems
of high-rise living were avoided. Most were clustered in the southeast. The
planners covered thousands of acres of farmland, but they avoided tower
blocks and the devastating results of the simultaneous redevelopment of the
centres of older towns. |
Designation of new towns
Newton Aycliffe and Peterlee
Welwyn Garden City and Hatfield
||Source: The Times October
The ethos and the pattern of the NHS had much in common with the newly
nationalised state industries, railways, steel and the utilities. Beveridge, in
his report in 1942, had proposed state funding but not how the NHS should work
in practice.3 In 1944, before victory in Europe had been achieved, a
committee within the Ministry had considered how the emergency hospital service
would be "demobilised". Bevan had worked out the details and the NHS had a
command structure, a ‘welfare state’ ideology and was heavily dominated by those
providing the services. On the appointed day 1,143 voluntary hospitals with some
90,000 beds and 1,545 municipal hospitals with about 390,000 beds were taken
over by the NHS in England and Wales. Of the ex-municipal beds, 190,000 were in
mental illness and mental deficiency hospitals. In addition 66,000 beds were
still administered under Public Assistance, mainly occupied by elderly people
who were often not sick in the sense of needing health care. Among the residents
were some with irrecoverable mental illness, with a generous addition of ‘mental
defectives’ and many old people who would now be regarded as having geriatric
Just before the service started, Aneurin
Bevan sent a message to the
medical profession. He spoke of the profession’s worries about
discouragement of profession freedom and worsening of a doctor’s material
livelihood – and said if there were problems they could easily be put right.
He referred to a sense of real professional opportunity. In the same issue of
the British Medical Journal (BMJ) on 3rd July 1948
the editor was not
so sanguine. While seeing the logic of spreading the high cost of illness over
the whole of the community, it saw dangers in a state medical service, dogma,
timidity, lack of incentive, administrative hypertrophy, stereotyped procedure
and lack of intellectual freedom. However much had been gained in
negotiation over the previous months and now the medical profession would
cooperate with the government. There was an opportunity to mould the
service in partnership with the Ministry of Health. The service would have
to evolve and there would be much trial and error. But the opportunity of
building a healthy Britain would be grasped eagerly.
'The pattern of events
was clear,' said the BMJ. 'The medical man, intensely individual, was becoming
more and more aware of his responsibility to the community'.
Additional resources were negligible. The appointed day, 5 July 1948, brought
not one extra doctor or nurse. What it did was change the way in which people
could obtain and pay for care. They ceased to pay for medical attention when
they needed it, and paid instead, as taxpayers, collectively. The NHS improved
accessibility and distributed what there was more fairly. It made rational
development possible, for the hierarchical system of command and control enabled
the examination of issues such as equity.4 The Times pointed out that
the masses had joined the middle classes. Doctors had become social servants in
a much fuller sense. It was now difficult for them to stand aside from their
patients’ social difficulties or to work in isolation from the social services.5
The Ministry, having worked for the establishment of the NHS, now became
In making allocations
to the regional hospital boards (RHBs) the Ministry of Health worked from what
had been spent in the previous year. The boards took major decisions without
fuss. Ahead of them lay the task of ‘regionalisation’, the development and
integration of specialist practice into a coherent whole.6 Many
reports were to hand, including the Hospital Surveys and the Goodenough Report
on medical education.7 Bevan held a small dinner party on the first
anniversary of the service to thank those who had been concerned with the
preparatory stages. He toasted the NHS, and coupled the NHS with the name of
Sir Wilson Jameson.
NHS managing bodies,
hospital boards (RHBs)
36 boards of governors for teaching hospitals (BGs)
388 hospital management committees (HMCs)
138 executive councils (ECs)
147 local health authorities (LHAs)
There was uncertainty about who was in charge at region. In most regions there
was a viable partnership with no single boss. The senior administrative medical
officer (SAMO) was university educated, but this was not necessarily true of the
secretary, who drew a lower salary. Regional organisation varied and could be
complex. In April 1956 Sheffield RHB had seven standing committees, six standing
subcommittees, some chairman’s and many other advisory committees, 23 committees
of consultants and a nursing advisory committee. There were also nine special
committees, five ad hoc building committees, liaison committees with teaching
hospitals and the university, and joint committees with other authorities on
matters such as the treatment of rheumatic disease. The East Anglian region was
simplicity itself: its last remaining committee (finance) had ceased to meet and
the board did everything! The subordinate hospital management committees (HMCs)
ran the hospitals and sometimes started to rationalise their facilities, but
they had little influence on wider issues. Power increasingly lay at the RHB.
The Central Health Services Council
The standing advisory
committees remained in existence for over 50 years. There were four, each
statutory and uni-professional: the Standing Medical Advisory Committee (SMAC)
and its equivalents for nursing and midwifery (SNMAC), pharmaceutical services
(SPAC) and dentistry (SDAC). They advised ministers in England and Wales when
requested but also ‘as they saw fit’. Members were appointed by the Minister
from nominations by the professions and included the presidents of the Royal
Colleges. Their precise role changed over the years; initially they prepared
guidelines on general clinical problems, usually through subcommittees.
The Central Health Services Council (CHSC), constituted by the 1946 NHS Act, was
the normal advisory mechanism for the Ministry of Health. It had a substantial
professional component alongside members representative of local government and
hospital management.8 It was large and after the first few years met only
quarterly although several of its subcommittees remained influential. The Lancet
believed that the Ministry never encouraged the CHSC to be a creative force. In
its first 18 months a host of novel and difficult problems faced the service and
Bevan remitted 30 questions to it. He received advice from the Council on these
and 12 other topics. At its first meeting a committee was established to examine
hospital administration, chaired for most of its existence by Alderman Bradbeer
from Birmingham. Other issues included the pressure on hospitals and emergency
admissions, the care of the elderly chronic sick, the mental health service,
wasteful prescribing in general practice, and co-operation between the three
parts of the NHS. Ten standing committees were established, some exclusively
professional, and others to examine specific services such as child health, and
cancer and radiotherapy..9 Over the first 20 years of the NHS they
produced a series of major reports that altered clinical practice, for example
on cross-infection in hospitals, the welfare of children in hospital and human
relations in obstetrics. The main committees were the Standing Medical Advisory
Committee (SMAC) and the Standing Nursing and Midwifery Committee. Henry Cohen
chaired SMAC for the first 15 years of the NHS. A general physician from
Liverpool, his intellectual gifts made it possible for him to remain a
generalist at a time when specialisation was becoming the order of the day.10
To begin with there was anxiety in the Ministry that SMAC would prove an
embarrassment in its demands, but soon the members had exhausted the issues
about which they felt strongly.
George Godber found it best to provide SMAC with background briefing on an
emerging problem and only then to ask for its advice. The Ministry could not
give doctors clinical advice but SMAC could and did - for example, that when
drugs were in the experimental stage, or scarce, they should be restricted to
use in clinical trials. Later they should be available solely through designated
centres, and only when they were proven and in unlimited supply should control
be no more than that necessary in patients’ interests.
Professional and charitable organisations
The introduction of the NHS affected many organisations that had taken part in
the debates preceding the NHS. The British Hospitals Association, which had
represented the voluntary hospitals, ceased to have a role and was rapidly wound
up. The British Medical Association (BMA) continued at the centre of serious
medical politics. For historic reasons GPs had always been powerful within it;
they were many and they provided much of its money. When in 1911 Lloyd George’s
national health insurance gave working men a doctor, GPs had to become
increasingly active. The GPs’ Insurance Acts Committee was continued after 1948
as the General Medical Services Committee (GMSC), a standing committee of the
BMA with full powers to deal with all matters affecting NHS GPs. The local
medical committees elected it, as panel committees had done previously. It was
not until 1948 that consultants had to enter the medico-political arena, which
was new and unfamiliar to them. The consultants formed the Central Consultants’
and Specialists’ Committee, with powers analogous to the GPs’ committee as far
as terms of service were concerned. The Joint Consultants Committee (JCC)
succeeded the earlier negotiating committee, federating the BMA and the medical
Royal Colleges, and represented hospital doctors and dentists in discussions
with the health departments on policy matters other than terms of service. This
complex system did not make for unity of the medical profession, particularly on
Royal Colleges maintained powerful positions as a source of expert opinion and
also in political matters. Charles Moran, Winston Churchill’s personal
physician, known familiarly as Corkscrew Charlie, was President of the Royal
College of Physicians (RCP) from 1941 to 1950. Alfred Webb Johnson led the Royal
College of Surgeons, and their relationship was a little prickly. William
Gilliatt, the Queen’s obstetrician, was President of the Royal College of
Obstetricians and Gynaecologists. As his college dated only from the twentieth
century it was regarded as the junior partner. The colleges were London
dominated, and their presidents were usually southern; Robert Platt was the
first provincial President of the RCP. The RCS had been damaged in the war and
there was a chance of getting a neighbouring site so that all three Royal
Colleges could be rebuilt together. Alfred Webb Johnson had a vision of a
medical area in Lincoln’s Inn Fields, perhaps grandiose but it could have
created a broad-ranging academy of medicine and a chance to develop methods of
reviewing clinical practice.11 Moran stopped it, fearing that the RCP
would become subsidiary. The RCS continued to encourage its own sub-specialties
to develop and form close links with the parent organisation.
The Royal College of Nursing
(RCN), founded in 1916 as an association to unite trained nurses, emerged as a
powerful body now that all nurses were working for the NHS. A decision was taken
to discourage membership of mental illness nurses, who stayed with the
Confederation of Health Service Employees (COHSE). COHSE hoped to become the
industrial union for the NHS but other unions recruited nurses (the RCN),
ancillary workers (the National Union of Professional Employees and the
Transport and General Workers Union), administrative staff (the National
Association of Local Government Employees), and laboratory and professional
staff (the Association of Scientific Workers, later ASTMS).12
National medical charities generally acted as pressure groups and they continued
their work, now with the NHS in their sights. For example, there was the
National Birthday Foundation that campaigned for the extension and improvement
of maternity services, the National Association for Mental Health (Mind)
promoting the interests of people with mental health problems, and the
Association of Parents of Backward Children (later Mencap).
King Edward VII’s Hospital Fund for London (King’s
Fund) had previously provided about 10 per cent of the income of London
voluntary hospitals, but the state now funded these. It began to look at new
fields, for example the training of ward sisters and catering.13 The
Nuffield Provincial Hospitals Trust had fought for regionalisation, the pattern
of organisation Bevan had adopted. It rapidly developed into a think-tank on
health service matters but neither the Fund nor the Trust could maintain their
direct influence on policy, although they were valuable sources of expertise.
More informal groups had existed before the establishment of the NHS. Wilson
Jameson had his ‘gas-bag’ committee at the London School of Hygiene and Tropical
Medicine where he was Dean. The same institution spawned the Keppel Club, in
which young doctors from many disciplines came together from 1953 to 1974.14
A small society with a tight membership, it was entirely apolitical and met
monthly for free-wheeling and uninhibited discussion. There was an opportunity
to discuss new methods and systems at an intellectual level. Membership was by
invitation, and included Brian Abel-Smith, John Brotherston, John Fry, Walter
Holland, Jerry Morris, Michael Shepherd, Stephen Taylor, Richard Titmuss and
Michael Warren. Until it ended in 1974, when its members were busier and more
senior, the club discussed such issues as child health, the care of the
adolescent and the aged, general practice, hospital services, mental illness and
the collection of information in the NHS.
Medicine and the media
Newspaper and magazine articles on professional issues were uncommon. Medical
authors were suspected of advertising, an offence for which they might be struck
off the register. Doctors and nurses had mixed views about the media. Some
believed that there would be widespread hypochondriasis if it was no longer
possible to keep people in ignorance of hospital care and their treatment.
Television was slowly spreading from London throughout the country, but as late
as 1957 only half the households had a set, and among the professional classes
there were even fewer. Educated people often talked about television without
actually having seen it. Emergency - Ward 10, one of the earliest popular
programmes, was thought to help nurse recruitment but was creating a modern
mythology about nurses and hospital treatment.15 When BBC TV ran a
programme on slimming and diet, the British Medical Journal (BMJ) was alarmed by
‘this somewhat curious experiment that approached the public over the heads of
the practising doctor’.16
Health education had been pursued during
the years of war. The approach remained mass publicity on all fronts. Messages
were didactic and concentrated on the dangers in the home, infectious disease,
accident prevention and, in the 1950s, the diagnosis of cancer of the breast and
cervix.17 There was little evidence that this technique, largely
modelled on the advertising world, worked. Many doctors felt that the less
patients knew about medicine the better, as Charles Fletcher, a physician at the
Hammersmith Hospital, discovered to his cost when he advocated pamphlets for
patients, explaining the causes of their illnesses and what to do about them.18
In 1951 the BMA launched a new popular magazine, Family Doctor. Primarily a
health magazine, its aim was to present simple articles on how the body worked,
the promotion of health and the prevention of disease. The editor believed
passionately that education and persuasion to adopt a different life style could
improve the health of the nation. He felt that the time was past when medicine
could be regarded as a mystery. Some subjects, however, were taboo,
contraception being one of these.19
Jeremy Morris, (1910-2009) a life long socialist and
epidemiologist at the London School of Hygiene and Tropical Medicine, laid
foundations for the promotion of exercise as important for health. In a study
with London Transport which lasted many years, he found that the drivers of London's double-decker
buses were more likely to die suddenly from "coronary thrombosis" than the
conductors, and that Government clerks suffered more often from rapidly fatal
cardiac infarction than postmen. Lancet 1953, 2, 1053, 1111
ischaemic heart disease in bus drivers and bus conductors
rate per 100 men in 5 years
rate per 100 men in 5 years
Source: Morris JN, Kagan A, Pattison DC and Gardner MJ.
Incidence and prediction of ischaemic heart disease in London busmen. Lancet
1966; 2(7463): 553–9
One of the most important clinical developments was simplicity itself. Richard
Asher was a physician at the Central Middlesex Hospital who combined clarity of
thought, deep understanding of the everyday problems of medicine and sparkling
wit. It was he who gave Munchausen’s syndrome its name, after the famous baron
who travelled widely and told tales that were both dramatic and untrue. In 1947
he was among the earliest to identify the dangers of institutionalisation and
going to bed.20
It is always assumed that the first thing in any illness is to put the patient
to bed. Hospital accommodation is always numbered in beds. Illness is measured
by the length of time in bed. Doctors are assessed by their bedside manner. Bed
is not ordered like a pill or a purge, but is assumed as the basis for all
treatment. Yet we should think twice before ordering our patients to bed and
realise that beneath the comfort of the blanket there lurks a host of formidable
to the risks of chest infection, deep vein thrombosis in the legs, bed sores,
stiffening of muscles and joints, osteoporosis and, indeed, mental change and
demoralisation. He ended with a parody of a well-known hymn:
Teach us to live that we may dread
Unnecessary time in bed.
up and we may save
Our patients from an early grave.
The medical profession, although not immediately convinced, recognised that here
was an issue to be explored. Francis Avery Jones, a gastroenterologist at
Asher’s hospital, later said that early ambulation saved the health service tens
of thousands of beds, and many people their health and lives. Doctors had
previously equated close and careful postoperative supervision with keeping
people in bed; once they were out of bed there was a danger of premature
discharge, and fatal pulmonary embolus might occur. For example, the BMJ said
that a surgeon would be in a difficult position if he allowed a patient to be
discharged the fourth day after appendicectomy or the seventh day after
cholecystectomy (as happened in the USA) and developed a fatal embolus in the
second week.21 The probability that the embolus was the result of the
closely supervised bed rest was not appreciated.
Surgeons were concerned that incisions would not heal if patients got up too
soon but Farquharson, at Edinburgh Royal Infirmary, wrote that the cause of
morbidity and mortality after an operation was usually remote from the actual
wound. He believed that there was little evidence that wounds needed bed rest to
heal. He proved his point by operating on 485 patients with hernia under local
anaesthetic and discharging them home before the anaesthetic had worn off. Only
one patient out of 200 needed readmission. The patients liked early discharge,
they waited only a few days for operation, and the financial savings were
The quality and
effectiveness of health care
Doctors seldom looked at their clinical practice and its results. When, around
1952, a paper was put to the JCC that included lengths of stay, one physician
loftily said ‘all that is needed is that a consultant should feel satisfied that
he has done his best for the patient. This arithmetic is irrelevant.’ Death was
the clearest measure of outcome, and infant and maternal mortality were studied
- but comparisons of the results of different types of treatment were rare. On
occasion clinicians might seek Ministry support for medical review projects, but
it had to be covert and not an attempt to impose a central system. The use of
randomised controlled trials now provided a way of validating clinical practice
and the effectiveness of treatments. Matching cases by human judgement was open
to error; randomisation involving large numbers provided an even dispersion of
the personal characteristics likely to affect the outcome. The principles were
established by D’Arcy Hart and Austin Bradford Hill. Austin Bradford Hill
crashed three aircraft without injury while serving in the first world war but
subsequently developed tuberculosis, which barred him from clinical medicine. He
read economics, got a grant from the Medical Research Council (MRC), moved to
the London School of Hygiene and determined to make a life in preventive
medicine. An inspiring writer, many of his ideas passed into common usage; he
understood the ethical and clinical problems that doctors faced, and could
convince senior members of the profession that they should adopt controlled
trials. A friend of Hugh Clegg, Editor of the BMJ from 1947, Hill chose that
journal for his publications because of its wide circulation among doctors of
all specialties. Clegg wanted good scientific papers and accepted long summaries
because many doctors would not be prepared to read the entire papers.23
Hill fed Clegg the MRC’s report on the randomised trial of streptomycin in the
treatment of tuberculosis, the trials of cortisone and aspirin in rheumatoid
arthritis and the trial of whooping cough vaccine. Though a powerful tool,
randomised trials were not always applicable; in surgery, for example,
randomisation was not always practicable.
The MRC worked with the Ministry of Health and began to establish clinical
research units. The provincial universities developed academic units more
rapidly than London; for example, Robert Platt, Professor of Medicine in
Manchester, and Henry Cohen, Professor in Liverpool. The medical press and
contacts between doctors had always helped the dissemination of new clinical
ideas. Now the NHS provided a new mechanism. It was said that those in the
Ministry could achieve anything if they did not insist on claiming credit. Many
doctors would take up a good idea when it was drawn to their attention, if the
approach was tactful. The SMAC could be asked to look at specific clinical
problems. Regions could then be given guidance that would be adopted throughout
the country if it was seen to accord with professional thinking. Once a new idea
was spotted, it could be nurtured. Doors could be opened to let people through.
Organisations such as the Nuffield Provincial Hospitals Trust, the King’s Fund
and the Ministry worked quietly together. Some doctors were natural originators,
others born developers, and both could be supported. Those seeing the way ahead
would try to get others to follow. Postgraduate education, statistical methods,
the use of controlled trials, group general practice and the development of
geriatric and mental illness services were all ideas fostered and given a
The drug treatment of disease
Before the second world war many drugs had no effect, for good or ill. Placebo
prescribing was commonplace, with a reliance on the patient’s faith. The first
decade of the NHS saw the discovery of a staggering array of new and potent
drugs. The drugs that were being developed were expensive and sometimes
difficult to produce. Usually they were not immediately released for general
use. The tetracyclines and cortisone were not available on GP prescription until
1954/5 when industrial-scale production facilities had been created. Inevitably
costs rose. At the end of the 1949 parliamentary session, power was obtained to
levy a prescription charge.24 It was not used immediately but was
invoked by the next government and used almost continuously and increasingly
streptomycin were available when the NHS began but it was not known how they
worked. Biochemistry and cell biology had not developed sufficiently for the
underlying mechanisms to be understood.25 Syphilis and congenital syphilis were
among the diseases conquered. Within the next year aureomycin, the first of the
tetracyclines, was discovered and proved to be active against a far wider range
of organisms. The response of chest infections to antibiotics rapidly revealed a
group of non-bacterial pneumonias, previously unsuspected, caused by viruses and
rickettsial bacteria. Chloramphenicol was isolated from soil samples from
Venezuela and soon synthesised; it worked in typhus and typhoid. In 1950
terramycin, another tetracycline, was isolated in the USA from cultures of
Streptomyces rimosus. In 1956 a variant of penicillin, penicillin V, became
available that could be given by mouth, avoiding the need for painful
clinical exploitation of a new antibiotic usually passed through two phases:
first, over-enthusiastic and indiscriminate use, followed by a more critical and
restrained appraisal. Some strains of an otherwise susceptible organism were, or
became, resistant to the drug. An early example was the reduction in efficacy of
the sulphonamides in gonorrhoea, pneumonia and streptococcal infections.
Penicillin withstood the test of time more successfully, but Staphylococcus
aureus slowly escaped its influence and became resistant. Resistance of the
tubercle bacillus to streptomycin was quickly acquired, and resistance was also
a problem with the tetracyclines.27 Erythromycin was discovered in
1952, resembled penicillin in its action, and by general agreement was reserved
for infections with penicillin-resistant bacteria.28 It became policy to use
antibiotics carefully and to try to restrict their use.29
Cortisone, demonstrated in 1949 at the Mayo Clinic, did not fulfil all early
expectations. It had a dramatic effect on patients with rheumatoid arthritis and
acute rheumatic fever, but this was often temporary.30 Supplies were
limited because the drug was extracted from ox bile and 40 head of cattle were
required for a single day’s treatment. Adrenocorticotrophic hormone (ACTH) was
even more difficult to obtain, being concentrated from pig pituitaries.
Quantities were therefore minute and costs were high, so more economic methods
of production were sought. By 1956 prednisone and prednisolone, analogous and
more potent drugs, had been synthesised and were in clinical use. Like cortisone
they were found to be life-saving in severe asthma. Few effective forms of
treatment had been available to dermatologists. Now there were two potent forms
of treatments: antibiotics for skin infection and corticosteroids that had a
dramatic effect on several types of dermatitis.
The outcome of patients with high blood pressure was well known because there
was no effective treatment. Four grades of severity were recognised, based on
the changes in the heart, the kidneys and the blood vessels in the eyes. In
severe cases, grades three and four, the five-year mortalities (death within
five years of diagnosis) were 40 per cent and 95 per cent. Surgery (lumbar
sympathectomy) might prolong survival but in 1949 hexamethonium
‘ganglion-blocking’ drugs were introduced, and the era of effective treatment
had begun. At first, drugs had to be given by injection but preparations that
could be taken by mouth were soon available. None of the alternatives approached
the ideal; surgery was not particularly successful, dietary advice and salt
restriction made life miserable, reserpine made patients depressed, and
ganglion-blocking drugs had severe side effects, including constipation,
fainting and impotence. Only people with the most severe hypertension were
therefore considered for treatment.31
Vitamin B12 was synthesised and liver extract was no longer required in the
treatment for pernicious anaemia.32 Insulin had been used in the
treatment of diabetes since the 1920s but a new group of drugs suitable for mild
and stable cases, the oral hypoglycaemic sulphonamide derivatives, were
developed. They simplified treatment, particularly in the elderly, and reduced
the need for hospital attendance.33 The antihistamines were
introduced mainly for the treatment of allergic conditions. They were associated
with drowsiness which, in drivers, caused traffic accidents. Reports from the
USA that they cured colds were examined by the MRC; the drugs were valueless.
The common cold had again come unscathed through a therapeutic attack.34
Chlorpromazine was introduced in 1952 for the treatment of psychiatric illness.
It produced a remarkable state of inactivity or indifference in excited or
agitated psychotics and was increasingly used by psychiatrists and GPs.35
The tranquillisers, for example meprobamate, also represented a substantial
advance. Barbiturates had been used for 50 years, but they were proving to be
true drugs of addiction and were commonly used by suicides.36 The new drugs
undoubtedly had a substantial impact on illnesses severe enough to need hospital
admission but whether they helped in the minor neuroses was less certain.37
William Sargant, a psychiatrist at St Thomas’, referred to the extensive
advertising and the shoals of circulars through the doctor’s letterbox. Big
business was beginning to realise the large profits to be made out of mental
health. All that was necessary was to persuade doctors to prescribe for hundreds
of thousands of patients each week.38
Halothane, a new anaesthetic agent, was carefully tested before its
introduction, although repeated administration in a patient was later shown to
be associated with jaundice.39 It was neither inflammable nor
explosive. Explosions during ether anaesthesia, often associated with sparks
from electrical equipment, occurred and inevitably killed some patients.
For many years there had been concern about adverse reactions to drugs and the
best way to recognise them. As the pharmaceutical industry developed an
ever-increasing number of new products, anxieties increased.40 The
problem came to a head in the USA in 1951, when a few patients were reported in
whom chloramphenicol had produced fatal bone marrow failure (aplasia). The
American Medical Association appointed a study group to examine all cases of
blood disorders suspected of being caused by drugs or other chemicals. The
problem was thought to be rare, because chloramphenicol had been widely used,
yet it was found that there had in fact been scores of cases of aplastic anaemia
and it had taken three years to appreciate the potential toxicity. There was
rapid agreement that its use should be limited to conditions untreatable by
In 1956 Dr John Bodkin
Adams was arrested for murder following the death of many of his patients, often
elderly ladies who had left him substantial sums in their wills. Between
1946-1956 160 died under suspicious circumstances. He was acquitted but later
convicted of false statements on cremation forms and offences under the
Dangerous Drugs Act. Opinion remains divided as to whether he was a mass
murderer or an early proponent of euthanasia. He was restored to the
Medical Register in 1961.
investigations were playing an increasing part in the diagnostic process.
Radiology revealed the structural manifestations of disease but the basic
technology had not changed greatly since 1895 when the first films were taken.
An X-ray beam produced a film for later examination, or the patient was
‘screened’ and the image was examined directly in a darkened room. The radiation
exposure was higher with screening and the radiologist had to become
dark-adapted before he could work. From the 1930s radiology developed rapidly,
but hospital services were handicapped by a shortage of radiologists.
Three developments gave radiology a new impetus. First, in 1954 Marconi
Instruments displayed an image intensifier, which produced a much brighter image
although the field was only five inches (12.7 cm) wide. It was visible in
subdued light and good enough to photograph. The technique was immediately
applied to studies of swallowing. Secondly there were improvements in contrast
media, used to visualise blood vessels. They were often unpleasant and sometimes
risky. From the 1950s new ‘non-ionic’ agents were introduced. Cardiac surgery
was developing fast and catalysed developments in radiology; for example,
angio-cardiography in which contrast medium was injected into the blood vessels
leading to the heart before a series of X-rays.42 The third
development, in 1953, was the introduction of the Seldinger technique. This made
possible percutaneous catheterisation, the introduction of a fine catheter into
a blood vessel, thus avoiding the need for an incision. A tracer guide wire
could be inserted and imaged, and when in position a catheter slid over it.
Contrast medium could be injected selectively into blood vessels, under direct
vision using the image intensifier, just where it was required.43
The availability of radioactive isotopes (radio-isotopes) led to the development
of nuclear medicine and a new method of imaging. Radio-isotopes could be
introduced into the body, sometimes tagged to tissues such as blood cells. As
they were chemically identical to the normal forms, they were handled by the
body in the same way. It was possible to measure the presence and amount of the
radio-isotope, its spatial distribution and its chemical transformation. The new
techniques provided a way of studying, at least crudely, some of the body’s
functions, as opposed to its structure. Isotopes were chosen to minimise the
radiation dose as far as possible. At first radioactive tracer work was the
province of the pathologist, as in studies of blood volume and circulation. The
development of gamma cameras and rectilinear scanners, however, meant that
images could be produced as well as ‘counts’, and radiologists came to the fore.44
Early in 1955 the MRC, at the request of the Prime Minister, established a
committee chaired by Sir Harold Himsworth to report on the medical aspects of
nuclear radiation. Its report, a year later, contained the unexpected finding
that exposure of the gonads to diagnostic X-rays significantly increased the
irradiation received, by some 22 per cent.45 The fall-out from
testing nuclear weapons was less than 1 per cent. Shortly after, Dr Alice
Stewart published a report suggesting that childhood leukaemia was associated
with irradiation of the fetus (and also with virus infection and threatened
abortion.)46 Her findings were not accepted until a second study from
the USA confirmed a connection with irradiation during pregnancy. Although
radiologists were already concerned about the dangers of radiation exposure,
there was some delay in taking greater precautions during pregnancy.
Infectious disease and immunisation
Deaths in England and Wales from infectious disease||
|| || |
Diphtheria || Whooping
25,649 ||1,371 ||
722 ||689 ||
84 ||527 ||
1950 ||15,969 ||
33 ||456 ||
32 ||184 ||
23 ||243 ||
1957 ||4,784 ||
1958 ||4,480 ||
8 ||27 ||
The decade saw the end of smallpox as a regular entry in public health
statistics, the decline of diphtheria and and enteric fever to around 100 cases
per year, the greatest ever epidemic of poliomyelitis, and a substantial rise in
food poisoning and dysentery, possibly related to better diagnosis now available
through the Public Health Laboratory Service (PHLS). It is hard nowadays to
appreciate the misery and deaths caused by infectious diseases, which were
common and potentially lethal. In 1948 there were 3,575 cases of diphtheria with
156 deaths. Tuberculosis remained a major problem although notifications to the
medical officer of health (MOH) and deaths were steadily getting fewer. There
were 400,000 notifications of measles with 327 deaths, and 148,410 of whooping
cough with 748 deaths. The USA had introduced diphtheria immunisation in the
1930s but it was not until 1940/1 that local authorities, spurred by Wilson
Jameson, launched a major campaign in the UK. A long-forgotten clause in a
Public Health Act gave local authorities the power to do so. Whooping cough,
tetanus and polio immunisation followed. As new vaccines were introduced, each
was usually given three times; the schedule for infants became increasingly
complex until ‘triple’ vaccines improved matters.
There had been small sporadic outbreaks of poliomyelitis for many years but the
disease assumed epidemic proportions in 1947. Thereafter the numbers fluctuated,
but remained at a historically high level for several years with 250-750 deaths
annually. It was the custom for cases to be admitted to isolation hospitals, and
then transferred to orthopaedic hospitals for the convalescent and chronic
stages. Oxford established a team including specialists in infectious disease,
neurology and orthopaedics so that patients with severe paralysis could be
assessed jointly from the start. Respiratory support with ‘iron lungs’ was
available and passive movement of the limbs reduced the risks of later
deformity. The tide turned when Jonas Salk developed an inactivated vaccine in
the USA and reported the success of field trials in 1955.47
Manufacture began in Great Britain under the supervision of the MRC and
immunisation of children started in 1956.
Bacterial food poisoning was an increasing problem. Imported egg products from
North and South America and, after the war, from China, sometimes contained
Salmonella. Synthetic cream was associated with many outbreaks of paratyphoid
fever, and spray-dried skim-milk was responsible for outbreaks of toxin-type
smallpox occurred intermittently. In 1950 there was an outbreak in Brighton,
introduced by a fully vaccinated RAF officer recently returned from India. There
were 26 cases, 13 of which were among nursing and medical staff, domestics and
laundry workers at the hospital to which the earliest cases were admitted, and
ten deaths.48 In 1952 an outbreak in Rochdale led to 135 cases with
one death, and there were further importations in succeeding years.
The death rate from tuberculosis had begun to decline after the first world war,
but the incidence was still high and primary infection occurred in nearly half
the children before they were 14. When the NHS began there were 50,000
notifications a year and 23,000 deaths. Before streptomycin, doctors relied on
the natural resistance of the patient, aided by bed rest and the indirect effect
of ‘collapse’ therapy. To reduce the movement of diseased lung tissue, in the
hope that this would assist healing, sections of the rib cage were removed (thoracoplasty),
air was introduced to collapse the lung (artificial pneumothorax) or the phrenic
nerve would be divided to paralyse the diaphragm. Antibiotics attacked the
tubercle bacillus directly. There was insufficient streptomycin to treat
everyone who might benefit, and supplies went to those in whom the best results
could be expected, young adults with early disease. A rigorously controlled
investigation run by D’Arcy Hart and the MRC confirmed the effectiveness of
streptomycin. In a second trial the newly discovered para-aminosalicylic acid
(PAS) was proved to prevent the development of bacterial resistance and a third
trial examined the level of dose required.49 In 1952 isoniazid was
introduced. Given alone it was no better than streptomycin and PAS, and patients
could rapidly develop drug resistance. However MRC trials and the work of
Professor Sir John Crofton (1912-2009) in Edinburgh showed that it was not
which drugs were given that mattered, but in what
combination and for how long. As success could only be assessed by
the absence of a relapse in subsequent years, it took time to establish the best
options. Triple-drug therapy over 18 months to 2 years greatly reduced the
problem of the emergence of resistant strains of tubercle bacilli but some
clinicians were slow to adopt the protocols that gave such excellent results.
The results were so good that collapse therapy and surgical methods of treatment
were used far less frequently.50 An MRC trial in India showed that
even under the worst social conditions patients rapidly ceased to be infectious
if they took their treatment. There was no need to admit patients for long
periods to reduce the risk of infection to families and the community. For the
first time, early treatment of tuberculosis had major benefits, yet there was an
average delay of four months between the first consultation and a diagnostic
X-ray; GPs were urged to refer patients more rapidly.51
In the drive for early treatment,
disused infectious disease wards were used, a good example of the new
opportunities open to the NHS. In 1948 the waiting list figures had convinced
the Manchester Regional Hospital Board that a new sanatorium was urgently
required. By 1953 it had not been built but it was now no longer needed as the
waiting time for admission had fallen from nine months to a few weeks.52
Within a few years beds for tuberculosis and the fevers were being turned over
to newly developing specialist units, for example neurosurgery. After a
successful trial of the tuberculosis vaccine BCG (bacillus Calmette-Guérin) by
the MRC, immunisation at the age of 13 was introduced, reducing further the
number of new infections. Mass mobile radiography (MMR) units were important
tools in ‘case-finding’. The vans would visit centres such as colleges and
hospitals where there were many young people, and 35mm pictures were taken of
images produced by fluorescent screening.
There was a major influenza outbreak in 1951/2. From 5 to 8 December 1952 ‘smog’
(fog filled with smoke) of unusual density and persistence covered the Greater
London area. People piled coal onto their fires to keep warm. To most, smog was
no more than an inconvenience. Those with chronic heart and lung disease were
less lucky. Their illnesses got worse and many died. Dying people, their lips
blue from lack of oxygen were forced to walk to the hospital for ambulances
stopped running.. For some years an ‘emergency bed service’ had operated in
London, finding beds for emergency admissions by phoning round the hospitals. It
came under pressure and immediately restricted non-urgent admissions, but the
media were first to spot the severity of the problem. Florists ran out of
flowers for funerals. Newspaper articles drew attention to the death of prize
cattle at the Smithfield show. Not until the death certificates had been
assembled was the full severity of the episode apparent; there were 3,500-4,000
excess deaths.53 St George’s (Hyde Park Corner), like all London
hospitals, admitted many victims of bronchitis and heart failure; as it was not
possible to see from one end of a ward to the other, they were divided in two so
that patients could be properly observed. A committee chaired by
Sir Hugh Beaver was set up in July 1953, which rapidly identified the importance of pollution
from solid fuels. Its recommendations, which smoke abatement groups had been
suggesting for almost a century formed the basis of a single comprehensive Clean Air Act
on 5th July
1956. Emission control was required; industry had to change and methods of
manufacturing had to alter. It became an offence to emit dark smoke from a
chimney, and local authorities could establish smoke control areas. Following
the legislation the age-specific death rates of men in Greater London fell by
almost half. The opposition to the control of atmospheric pollution, for example
from industry, was slight. This was not the case with smoking, for,
although its hazards were far greater, there were issues of individual choice
and liberty, and much more antagonism from industry.
Rheumatic fever, associated with streptococcal throat infection, was another
common disease of childhood normally requiring admission to hospital. More
frequent among the poor, there would be fever, pain and stiffness in the larger
joints. Although some children might die of the acute illness (700 in 1949,
falling to 174 in 1957), the main problem was that about half developed
rheumatic disease of heart valves, which became incompetent (they leaked) or
stenosed (they obstructed blood flow). The result was progressive heart failure
in adolescence or later in adult life.
Milder infections were not ignored. At Salisbury the Common Cold Research Unit
had been established before the war to examine this difficult problem.
Volunteers turned up every fortnight to help the scientific work. By 1950 they
numbered more than 2,000, including 253 married couples, several being on their
incidence of venereal disease had increased in both world wars. After 1945 the
level began to fall and many venereologists thought seriously of leaving what
seemed to be a dying specialty. Venereal disease responded to antibiotics:
syphilis was rapidly cured, and cases of congenital syphilis fell steadily as
antenatal testing became routine, followed by treatment where necessary. The
reduction in gonorrhoea, however, levelled off and drug-resistant strains became
apparent. By 1955 the levels were rising again, and they continued to do so. Dr
Charles, the CMO, said that sexual promiscuity was as rife as it had ever been
in times of peace, and while this was the case the venereal peril would be ever
Public Health Laboratory Service (PHLS) expanded as ‘associated laboratories’
were incorporated into the main network. Increasingly the laboratories were
located on the site of acute hospitals and came to provide bacteriological
services to the hospital as well as to the local authorities responsible to
assist the control of infectious disease. The PHLS was becoming involved both in
the care of individuals and in the health of ‘the herd’. From the early days the
PHLS wanted to recruit epidemiologists, but this was opposed by the Ministry and
the MOsH. From 1954 its weekly summary of laboratory reports contained hospital
as well as community data, and became a comprehensive account of the prevalence
of infection. The PHLS was also deeply involved in the study of
hospital-acquired staphylococcal infection, for patients in surgical wards were
increasingly infected by resistant strains. First detected in 1954, the problem
spread rapidly and led to the appointment, in most hospitals, of
infection-control nurses. The management of the service was reviewed in 1951 and
the MRC was asked to continue to run it.
Orthopaedics and trauma
War has always produced medical
innovations. The Korean War (1950-54) saw the introduction of helicopter
evacuation, which in turn led to a reappraisal of the early treatment of injury.
Within days of the Air Force choppers' arrival the US Eighth Army's surgeon
general asked for their help in evacuating critically wounded soldiers
from the front. Thereafter, when they were not flying search-and-rescue
missions, they pitched in to get the wounded to hospitals. In the first month
alone, the Air Rescue choppers evacuated 83 critically wounded soldiers, half of
whom, the Eighth Army surgeon general said, would have died without the airlift.
The system was soon formalised and the infantry came to see that if not killed
outright, their chance of survival was now good. During their first 12 months of
operation in 1951, Army helicopters carried 5,040 wounded. By mid-1953 Army
choppers evacuated 1,273 casualties in a single month. "Costly, experimental and
cranky, the helicopter could be justified only on the grounds that those it
carried, almost to a man, would have died without it," an Army historian
concluded. It was many years before the lessons learned were applied to civilian
(Barbara Hepworth painted a series of 60 images of surgeons
and nurses circa 1947)
The1939-1945 war had given orthopaedic
surgery impetus. During the latter part of the war, orthopaedic surgeons began
to encounter, among prisoners of war repatriated from Germany, fractures treated
by inserting a nail throughout the length of the marrow cavity. The method,
originally described by Küntscher, was soon seen to be a success, making
possible a shorter hospital stay.56 British surgeons, for example Sir
Reginald Watson-Jones, were also developing and using internal fixation for
fractures of the femoral neck. In 1949 Robert Danis, of Brussels, described a
system of rigid internal fixation that allowed anatomically accurate reduction,
compressing the fracture surfaces. This made it easier to get patients up and
moving. Because of early rehabilitation, complications of treatment were reduced
and there were far fewer bed sores and deaths from thrombosis and pulmonary
embolism.57 At first the plates and screws used were copied from
those familiar in joinery; later they were redesigned for the specific needs of
fracture surgery. As understanding of fracture healing improved, there was
growing recognition that stable fixation of a fracture had immense benefits in
terms of restoring the soft tissues for which the bone serves as a scaffold. In
addition to the techniques of internal fixation, putting strong inert screws
into the fragments of bone and holding them with a light but rigid external
fixation system made it possible to correct major damage to soft tissue, vessels
The other major pressure on orthopaedic
departments was osteoarthritis. Osteoarthritis of the hip was a common and
painful condition. Several operations had been devised that relieved pain at the
cost of mobility, for example arthrodesis that fused the femur to the pelvis.
Among the more successful was Smith-Petersen’s procedure, involving the
reshaping of the joint surfaces and the insertion of a smooth-surfaced cup of
inert metal between the moving parts. Re-operation was sometimes required.
Arthroplasty, the total replacement of the joint by an artificial socket and
femoral head made to fit each other, gave patients a new and mechanical joint.
The procedure was first carried out by Kenneth McKee in Norwich around 1950,
using cobalt-chrome components.58 No great attention was paid to the
surface finish or fit, and the method of fixation proved inadequate. Friction in
the joint was high and there were both failures and successes. Some of his
patients were seen by John Charnley at a meeting of the British Orthopaedic
Association, who considered that the procedure might be improved. The Manchester
RHB funded him to develop a new unit near Wigan to refine it. The engineering
problems were substantial and the results to begin with were not always
In 1952 112
passengers were killed and 200 were seriously injured in a three-train collision
at Harrow. There was chaos. By modern standards the fire and ambulance services
were hopelessly inadequately equipped, and were untrained to keep trapped people
alive. All that could be done was a little bandaging and to take people to
hospital as fast as possible. Edgware General Hospital learned of the crash when
a commandeered furniture van arrived with walking wounded. Among those
responding to the disaster were US teams from nearby bases, who were trained in
battlefield medicine. They were disciplined, brought plasma and undertook triage
- sorting casualties into those needing urgent attention, those who could wait
and those who were beyond help. It was a new experience for the rescue services;
they were amazed and full of admiration.59 Yet the lessons were not learned for
many years. In December 1957 another train crash occurred in thick fog near
Lewisham. The ambulances moved 223 people, and 88 died in the accident. The
Senior Administrative Medical Officer, James Fairley, called for reports. As at
Harrow, there were failures in communication, difficulty in identifying senior
staff at the site, inadequate supplies of dressings and morphine, a shortage of
ambulance transport and difficulties in creating records and documenting the
trauma was also increasing on the roads as traffic was becoming denser. By 1954
there were more than one million motorcycles on the road, and over 1,000 deaths
among their riders. Crash helmets were seldom worn and the neurosurgical units
picked up the problems.61 Roughly 50,000 people required admission
for head injury annually, and three-quarters of road fatalities were the result
of this. The few neurosurgical units whose primary concern had been with tumours
were increasingly asked to care for patients with head injury. More units were
opened, improving accessibility.
Walpole Lewin, in Oxford, argued for regional planning in close association with
a major accident service.62 Research work at the Birmingham Accident
Hospital improved the treatment of injury immeasurably. It was widely recognised
that severe collapse after major injury was associated with a vast fall in blood
volume, far greater than could be accounted for by external loss. Where had the
blood gone, and what should the treatment be? Blood volume studies after
accidents made it clear that huge amounts of blood were lost from the
circulation into the swelling around fractures. Major burns led to a similar
depletion of circulating blood volume. Rapid and large blood transfusion saved
lives. Lecturing to the St John’s Ambulance Brigade, Ruscoe Clarke appealed for
the re-writing of first-aid textbooks. The hot cup of tea and a delay while
patients got over the shock of injury had to go; time was not on the patient’s
side and recovery would only begin after transfusion and surgery.63
He provided the Association with new text for its handbooks.
Cardiology and cardiac surgery
In the 1940s the only methods available for the diagnosis of heart disease,
other than bedside examination, were simple chest X-rays and the three-lead
electrocardiograph. The effective drugs were morphia, digitalis and quinidine.64
The management of heart disease was about to change out of all recognition. It
was a subject that attracted the cream of the profession; Paul Wood at the
National Heart Hospital was only one among a number of clinicians who educated a
new generation of doctors about valvular, ischaemic and congenital heart
disease, taught new ways of listening to the heart and interpreting what was
heard, and opened new pathways in treatment.65 Were he to have a
heart attack, Wood did not wish to be resuscitated. When he did, some years
later, he was not.
disease of the heart had been a major problem but the effectiveness of
antibiotics in streptococcal infections, which might otherwise have been
followed by acute rheumatism, began to change its incidence. Syphilitic heart
disease with aortic incompetence (valve leakage) was yielding to arsenicals,
heart damage as a result of diphtheria to immunisation and infection of heart
valves following rheumatic fever to antibiotics.66
There was little effective treatment for coronary artery disease, an increasing
problem. Coronary arteries might slowly become narrowed, and a heart attack
(myocardial infarct) would occur if arteries suddenly became blocked. Losing its
blood supply, heart muscle would be damaged, abnormal rhythms might develop, the
patient might suffer great pain and death often occurred rapidly. In 1954
Richard Doll and Bradford Hill reported that there was a high incidence of
coronary disease among doctors who smoked, a finding supported a few months
later by the American Cancer Society. Its vice-president said that the problems
raised by the effects of smoking on the heart and arteries were even more
pressing than the more publicised linkage of smoking and lung cancer.67 An
association with high fat consumption was also suggested, for populations with
the highest consumption also seemed to have the highest death rate from coronary
heart disease. The greater incidence in the better-off countries could, however,
be due to other factors such as a low level of physical exercise and other
features of high standards of living.68
It being an axiom in medicine to rest damaged structures, prolonged immobility
was traditional for people with heart attacks. A few specialists, however,
suggested that the abrupt and grave nature of the disease, when coupled with
long-continued bed rest, devastated the morale of people who had previously been
active and healthy. ‘Armchair’ treatment was introduced without any apparent
problems.69 Anticoagulation by heparin had been used for deep vein
thrombosis since the 1930s, and their value in treating life-threatening
pulmonary embolus was beyond dispute. Heparin could be given only by intravenous
injection but a family of coumarin derivatives that could be taken by mouth was
developed in the 1940s. Control was difficult, and regular estimates had to be
made of the ‘clotting time’. In heart attacks the evidence of their value was
weaker, largely based on a trial in New York in which patients were treated or
not according to the day of the week on which they were admitted. Although there
was less evidence of effectiveness, a vogue developed for their use.70
Cardiac arrest, the ultimate danger in a heart attack, was sometimes
treated successfully with a new piece of equipment, the external cardiac
Cardiac surgical development was an example of how progress in clinical medicine
is the result of developments by many workers in many fields. These included
cardiac catheterisation, new methods of measurement, studies on the coagulation
of blood, hypothermia, perfusion techniques (the heart-lung machine),
pace-making, the use of plastics, new design of instruments and studies of
immune reactions.72 It was the development by Magill and Macintosh of endotracheal anaesthesia (in which a mask was replaced by a cuffed tube inserted
into the trachea) that made surgery inside the chest practicable. Cardiac
catheterisation was devised in Germany in the 1930s but was not commonplace
until the 1950s when it became the tool used to explore the right side of the
heart, to measure atrial, ventricular and pulmonary artery blood pressures and
to take blood samples. Combined with arterial blood sampling it became possible
to determine the nature of heart valve damage, for example after rheumatic
fever. This permitted good case selection and carefully planned heart surgery.
Twenty-four hour electrocardiography was introduced in the USA by Norman Holter,
improving the diagnosis of abnormality of heart rhythm.
Progress in England centred on Guy’s, the National Heart Hospital, Leeds and the
Hammersmith, and was led by people such as Russell Brock at Guy’s, Cleland at
the Hammersmith and Thomas Holmes Sellors at the Middlesex. The heart operations
undertaken before 1948 had included surgery to repair congenital defects that
could be undertaken rapidly without stopping the heart or opening it, for
example operation for patent ductus arteriosus (in which a connection between
the aorta and the pulmonary artery remains open after birth). ‘Blue babies’ with
congenital heart disease would seldom outlive their teens without surgery.73
Brock operated on some, but several of his earliest cases died. The coroner was
alarmed and Brock had to explain the risks of surgery and the way the children
selected for operation were already near the point of death. Unless surgeons
could develop the necessary operative techniques, all such patients were doomed.
Wartime experience with the treatment of bullet wounds of the heart had given
surgeons courage to challenge the long-held belief that operating on the heart
was dangerous. It was commonly believed that rheumatic heart disease was a
disorder of heart muscle and not primarily due to valve damage. Some surgeons,
however, believed that valve damage was the crucial lesion; in 1948 three
surgeons, Dwight Harken and Charles Bailey in the USA and Brock at Guy’s,
independently performed successful mitral valvotomy for mitral stenosis,
widening the opening of valves that had become partially fused and were
restricting blood flow. Brock attempted three operations within a fortnight. The
surgeons were entering unknown territory and their work proved that the problem
of chronic rheumatic heart disease was primarily mechanical. Brock’s work was
followed by Thomas Holmes Sellors at the Middlesex in 1951.74 There
was a backlog of seriously sick people in or approaching heart failure. The
first operations had a high mortality, seven in the first 20 of Brock’s series.
This rapidly improved to about 5 per cent for mitral valvotomy, and more
difficult lesions such as pulmonary stenosis were tackled.75 Many of
the patients were young men and women doomed to an early death without surgery.
Sometimes the type of repair needed was beyond the techniques available. Yet
risky though the attempts were, particularly on pulmonary and aortic valves,
there was often no alternative.
The introduction of hypothermia in the early 1950s was the next advance. It was
found that at a body temperature of 30°C the heart could be stopped for ten
minutes. The commonest method was immersion in a bath of cold water. It proved
possible to repair some atrial septal defects (openings in the division between
the two atria) and make an open direct-vision approach to the pulmonary and
aortic valves. Hypothermia could also be used in the resection of aortic
aneurysms (absence of the aortic valve opening).76 Perfusion came next. The
technique of producing temporary cardiac arrest using potassium was worked out
by Melrose, a physiologist at the Hammersmith Hospital. Heart-lung machines were
developed by the Kirklin unit at the Mayo Clinic and in England by Melrose and
Cleland at the Hammersmith. There was much to be learned; Kirklin reported six
deaths in his first ten cases, and a further six in the next 27. But by the time
he had reached 200 cases, deaths from the procedure were rare.77
British cardiac surgeons deliberately held back and waited to see what the
outcome of Kirklin’s work would be. When he had developed reliable procedures
three British units at the Hammersmith, Guy’s and Leeds began work. All were
well equipped, well staffed and expertly run departments. A pattern was set;
cardiac surgery became established in regional centres, usually in association
with a university teaching hospital. Only near such surgical facilities could
advanced cardiology develop effectively.
Cardiac arrest was not necessary for operations on large blood vessels such as
the aorta. Coarctation of the aorta, in which the vessel became narrowed, and
aortic aneurysms also became manageable surgically.78 After the introduction of
angiography, in which solutions that were opaque to X-rays were injected into
blood vessels, the frequency of atheromatous obstruction of the internal carotid
artery was realised. Angiography was an uncomfortable and sometimes hazardous
investigation. Urged on by George Pickering, Rob and Eastcott performed the
first carotid endarterectomy at St Mary’s Hospital in 1954 on a woman with
transient episodes of hemiplegia and difficulty with speech. Although an
increasing number of patients were treated, it remained a risky operation.79
Renal replacement therapy
Life-threatening kidney disease might be either acute or chronic. Acute renal
failure, from the crush injuries of the blitz, a mismatched blood transfusion or
a prolonged low blood pressure from blood loss, might get better if the patient
could be kept alive long enough. If great care was taken with fluid intake and
diet, some survived. In 1943 it was shown by Kolff in Holland that patients with
terminal renal failure could be kept alive by artificial haemodialysis. Few were
thought to be suitable for this, and it was mainly used for those in acute renal
failure from which spontaneous recovery was to be expected. It was not offered
to patients who had an irreversible condition from nephritis associated with
streptococcal infection, diabetes or high blood pressure.80 Indeed it was
thought unethical to offer dialysis to those with chronic disease, as it would
only delay an inevitable and unpleasant death. However, in 1954 a successful
renal transplant was undertaken in the USA. The patient, who had chronic renal
failure and would otherwise have died, received a kidney from an identical twin.
While only one in 100 would have the chance of a sibling’s kidney that the
body’s immune system would not reject, asking everyone with chronic renal
disease whether he or she was a twin was now important.
Neurology and neurosurgery
The great developments in descriptive neurology and neurosurgery largely
preceded the NHS, under the influence of North American surgeons such as Harvey
Cushing and Wilder Penfield, and British neurologists such as Francis Walshe.
The central nervous system once damaged did not regenerate, neither could it be
repaired surgically. The specialty centred on the accuracy of diagnosis. Seldom
was there any treatment available; only three out of 100 papers published in
Brain held out any hope for the patient. Shortly before the NHS started, the RCP
committee on neurology, seeing a need to develop the specialty outside London,
recommended the development of active neurological centres in all medical
teaching centres, in which neurology, neurosurgery and psychiatry should work
together.81 At least one such a centre, in Newcastle, equalled anything in the
south. There, Henry Miller was followed by John Walton and David Shaw. Miller,
who was interested in immunological disease, pointed out the advantages of the
neurologist working in a hospital providing district services, who would see
local epidemics, deal with people who were at an early stage of their disease
and were often acutely ill, and be in close contact with other physicians.82
Miller, and Ritchie Russell in Oxford who was interested in poliomyelitis, began
to re-orientate neurology and link it more closely to general medicine.
Attitudes began to change, with concentration on the prevention of damage in the
first place, altering the biochemistry of the nervous system, and on
rehabilitation. Developments elsewhere in medicine, in clinical pharmacology,
imaging and later genetics, drove neurology and neurosurgery, which advanced
steadily as specialties rather than experiencing sudden and major developments.
In the 1950s neurosurgery dealt with head injuries, brain tumours, pre-frontal
leucotomy for mental illness, destruction of the pituitary for advanced cancer
of the breast and precise surgery deep in the brain for Parkinson’s disease
(stereotaxic surgery). New diagnostic investigations, in particular cerebral
arteriography, helped it. Seeing the circulation of the brain was possible by
taking a series of radiographs in rapid succession after the injection of
contrast medium. Cerebral tumours and intracranial haemorrhage, cerebral
aneurysms and cerebral thrombosis were all revealed, making diagnosis more
accurate and operation more successful.83
nose and throat (ENT) surgery
Three main developments - antibiotics, better anaesthesia and the introduction
of the operating microscope - underpinned advances. Until the introduction of
antibiotics the main function of the ENT surgeon was to save life by treating
infection, acute or acute-on-chronic, affecting the middle and inner ear, the
mastoids and the sinuses. Untreated infection could spread inside the skull,
leading to meningitis and brain abscesses. By 1950 such catastrophic diseases
were rare. The work of ENT surgeons altered substantially and those mastoid
operations still being carried out were usually for long-standing disease.84
Zeiss produced the first operating microscope specifically for otology in 1953,
revolutionising ENT surgery. Surgeons began to turn their attention to the
preservation of hearing, the loss of which they had previously accepted as
inevitable. Chronic infection of the middle ear prevented the movement of three
minute bones that transmitted sound. Some operations that were now popularised
had been attempted 50 years previously, but without magnified vision and modern
instruments and drills they had been abandoned. Though simple in conception, the
operations demanded scrupulously careful technique and great patience.85 Among
the first to become widespread was an operation for otosclerosis, to free-up
certain small bones in the middle ear (mobilisation of the stapes), or to remove
them (stapedectomy). Tympanoplasty (repairing damage to the middle ear) was
described in Germany in 1953. Under the influence of surgeons such as Gordon
Smyth of Belfast the procedure was rapidly introduced into the UK.
The commonest ENT operation, indeed the commonest operation, was ‘tonsils and
adenoids’ (Ts and As). Surgeons seemed most convinced of the benefits whereas
the MRC regarded the procedure as a prophylactic ritual carried out for no
particular reason and with no particular result. John Fry, a Beckenham GP, in a
careful analysis of his patients, concluded that although nearly 200,000
operations were carried out annually, the number could be reduced by at least
two-thirds without serious consequences. Operation was usually carried out for
recurrent respiratory infections, problems that tended to natural cure at around
the age of seven or eight. The operative rates seemed to depend entirely on
local medical opinion. A child in Enfield was 20 times as likely to have an
operation as one in nearby Hornsey; the children of the well-to-do were most at
risk of operation.86 From the mid-1940s there was dramatic growth in the
incidence, or recognition, of ‘glue ear’ in children, a condition that made them
deaf. Thick gluey mucus remained in the middle ear, usually after upper
respiratory tract infections. It was uncertain whether this was related to the
widespread use of antibiotics, but an operation for inserting a grommet through
the eardrum after removing the mucus by suction succeeded Ts and As as the
commonest operation world-wide.
In the non-surgical field, the MRC had designed a hearing aid shortly before the
NHS began, the Medresco aid. It was developed by the Post Office Engineering
Research Station at Dollis Hill, assembled by a number of radio manufacturers
instead of the hearing aid industry, and issued free of charge on the
recommendation of a consultant otologist. The market was a large one, but the
Medresco aid though cheap was behind the times. It consisted of a body-worn
receiver connected to an ear-piece. Transistors, incorporated into commercial
aids from 1953, were not used in the aids issued free by the NHS until several
The availability of free spectacles under the NHS revealed a huge and pent-up
demand from the public, largely satisfied by opticians under the supplementary
ophthalmic services. Ophthalmologists seldom saved lives but their ability to
maintain function by preserving sight ensured the specialty’s place in every
district hospital. The specialty was a pioneering one, lending itself to
technical innovation, but it had a low priority in many undergraduate courses
although postgraduate education at hospitals such as Moorfields was world
renowned. Many diseases, for example high blood pressure, diabetes and some
genetic conditions, involved the eye. Ophthalmology collaborated effectively
with many specialties in sharing diagnostic advances such as ultrasound and,
later, scanning. Operating microscopes were becoming available. Transplant
surgery was being pioneered by ophthalmologists as corneal grafting. The
treatment of cataract involved the removal of the now opaque lens, an early
example of microsurgery, and the supply of powerful glasses. Operation was
postponed until a late stage of visual loss. In 1949 Harold Ridley, working at
St Thomas’, treated a Spitfire pilot with a piece of Perspex from the cockpit
canopy embedded in his eye. The plastic seemed well tolerated and it was
suggested that a plastic lens might also be accepted. A surgeon of great skill,
he pioneered the implantation of a lens into the eye, and had many successes,
although others were not able to achieve his results for some years. His
achievement was celebrated by the issue of a Medical Breakthrough stamp in 2010. Detachment of the retina,
a largely untreatable disease, was managed by prolonged bed rest until the photocoagulator was introduced around 1950.
The treatment of
cancer involved surgery if a cure was thought possible, and if the disease was
past the point at which surgery could help radiotherapy was used as palliation.
Although surgery was the foundation of treatment in common cancers such as that
of the lung, many patients were inoperable when they first presented, and the
five-year survival was low.87 Surgeons became increasingly radical in an attempt
to eliminate tumours. Few people were told their diagnosis; only the relatives
were informed. The phrase ‘cancer chemotherapy’ was largely incomprehensible and
the claim that malignant disease could be controlled or even cured by drugs was
more appropriate to the charlatan than the physician. The physician’s place was
to administer the medical equivalent of extreme unction - opiates and
kilovolt irradiation could in fact produce worthwhile remissions and some
long-lasting cures but radiotherapy was seldom seen as curative. Radium was
replaced as post-war developments in atomic energy made artificial isotopes
available. Gamma-emitting sources such as cobalt-60 provided a vastly more
powerful source and were first used to treat patients in 1951. This made it
possible to deliver a high dose internally without massive skin damage. By 1955
there were 150 telecobalt machines world wide; six years later there were over
1000. Linear accelerators, a by-product of wartime research on radar, were also
introduced. The NHS ordered four to be installed in major units, the Hammersmith
getting the first in 1953. ‘Super-voltage’ machines became an intrinsic part of
the equipment of radiotherapy departments, and radiotherapy was progressively
organised as an integrated regional service, with just one such department in a
given region.88 The introduction of radio-isotopes was the great hope for the
future, because of the possibility that they would be concentrated selectively
in tumours. Only rarely did they prove an advance.
The modern era of leukaemia therapy began in the 1940s with the work of Sidney
Farber, then pathologist at the Children’s Hospital, Boston. Farber had the idea
of disrupting the growth of malignant cells with antimetabolites. The years of
1940-1950 saw the discovery of several drugs later useful in curing cancer.
Nitrogen mustard had been used since 1942 and produced striking although
temporary regression of the tumours. The next useful drug to be discovered came
from the knowledge that folic acid deficiency was associated with bone marrow
inhibition. Metabolic antagonists to folic acid, such as aminopterin, were shown
to produce temporary remissions in childhood leukaemia.89 Corticosteroids were
also shown to have anti-tumour properties both in experimental animals and in
humans. Mercaptopurine was the result of biochemical reasoning that nucleic acid
metabolism might be altered. By the 1950s many drug development programmes were
under way in the USA, industry was becoming interested and clinical trials were
starting. Although medicine remained largely impotent in the face of
disseminated cancer, the BMJ optimistically but correctly said that the
foundation of a logical approach to the problem had been laid and an efficient
machinery for the selection and testing of remedies devised.90
A new diagnostic tool for cancer was emerging: exfoliative cytology, looking for
malignant cells on mucous surfaces and in body secretions. Before the war,
Professor Dudgeon at St Thomas’ routinely used cytology in the diagnosis of
cancer of the lung and cervical cancer. King George VI’s cancer of the lung was
diagnosed there by sputum cytology. Papanicolaou’s work in 1943 placed this
development on an increasingly firm basis and it was developed progressively
during the first ten years of the NHS, placing an extra burden on pathology
Smoking and cancer
As the impact of infectious diseases lessened, the importance of cancer
increased. Mass radiography, introduced in the years of war to detect
tuberculosis, increasingly revealed carcinoma of the bronchus, although it was
ineffective as a screening measure. In the first ten years 10 million
examinations were carried out and 2,000 cases of intrathoracic cancer were
found, 90 per cent of them in men.
Unlike malignancy as a whole, cancer of the respiratory system had shown a
steady rise since the early 1920s. Many thought this was due to better
diagnosis, or that a fall in the number of cases of tuberculosis had thrown
cancer of the lung into greater prominence, or that sulphonamides had allowed
people to survive pneumonia long enough to develop the signs of cancer. Studies,
some in Germany during the second world war, had associated heavy smoking with
lung cancer.91 Percy Stocks, at the General Register Office, thought that
atmospheric pollution might be involved and wrote to the MRC in 1947 to say that
further investigation was warranted. With typical common sense Bradford Hill
brushed aside the suggestion of air pollution; husbands and wives experienced
similar exposures but smoking men got cancer while their non-smoking wives did
An MRC conference
concluded that it would be unwise to assume that all the rise was an artefact
and Bradford Hill was asked to carry out a study, which he did with the help of
Richard Doll. The two research workers asked hospitals to notify the admission
of patients with possible cancer of the lung, stomach and large bowel; they took
their smoking histories and followed them up after discharge. Practically none
of those with cancer of the lung were lifelong non-smokers; the rise was a real
one and not merely due to better diagnosis. The findings, the result of
interviewing 649 men and 60 women with carcinoma of the lung, were presented to
Harold Himsworth at the MRC in 1949. Himsworth thought it crucial to ensure,
before publication, that the results were right and asked for further hospitals
outside London to be included in the study, which was extended to Leeds,
Newcastle, Bristol and Cambridge. Published in 1950, shortly after an American
case-control study by Wynder and Graham, Doll and Bradford Hill claimed a causal
connection between smoking and lung cancer. At ages 45-74 years the risk was 50
times greater among those smoking 25 cigarettes a day or more than among
non-smokers.92 The iconic paper was probably that of Doll
and Bradford Hill on the mortality of doctors in relation to their smoking
habits. he BMJ said that the practical question which doctors in practice had to
answer was whether any patients, for instance those with a smoker’s cough,
should be advised to give up smoking.93
Many doctors, unaccustomed to controlled studies, remained unconvinced so Doll
and Bradford Hill launched one of the earliest prospective studies. It involved
40,000 doctors, a group that was studied for the next 40 years.94
They published an extension to their case-control enquiry in 1952. The BMJ said
that the probability of a causative connection was now so great that one was
bound to take what preventive action one could. The younger generation would
have to decide, each for himself or herself, whether the additional risk of
smoking was worth taking.95 The Standing Advisory Committee on Cancer and
Radiotherapy, chaired by Sir Ernest Rock Carling, himself a lifelong heavy
smoker, gave no advice on which the Ministry could act. Meeting twice in the
first half of 1952, it advised the Minister that the statistical evidence
strongly suggested that there was an association between smoking and cancer of
the lung, but this evidence was insufficient to justify propaganda. The
Committee thought, in any case, that it would be undesirable for central
government to be involved in cancer education, but that it should be left to
local authorities and voluntary bodies.96 The government got no help on which to
act, even if it had been minded to. Richard Doll published further material in
1953, and the following year Bradford Hill and Doll published the preliminary
results of the prospective study that succeeded in changing attitudes.97 Largely
for financial reasons the government was not keen to give publicity to the
increasingly certain connection between smoking and cancer.98 A panel
subsequently established advised the Minister that it must be regarded as
established that there was a relationship between smoking and cancer of the
lung, and that it was desirable that young people should be warned of the risks
apparently attendant on excessive smoking. On 12 February 1954 the Minister made
a statement in the House.99
No urgent action was felt necessary. In 1956 the Cabinet considered the issue.
In response to the Health Minister, Robert Turton, who suggested warning the
public, Macmillan said that this was a "very serious issue. Revenue was
equivalent to 3/6d
on income tax: - not easy to see how to replace it." He added: "Expectation of
life is 73 for smoker and 74 for non-smoker. Treasury think revenue interest
outweighs this. Negligible compared with risk of crossing a street." The
government resolved to wait until later in the year, when another medical report
The death of George
VI, a heavy smoker who suffered from arterial disease in the legs, coronary
artery disease and cancer of the lung, was not associated in the public mind
with tobacco.100 Its addictive properties were hardly recognised, and it was
thought that if the risk was made clear people would respond. The tobacco
industry spent enormous sums on promotion and the Ministry sat back, baffled.
Sir John Charles, the CMO, was not a man to stick his neck out. He talked of the
‘mysterious and inexorable rise in cases’. In his reports he said that the
convinced individual could largely avoid exposure to tobacco smoke if he so
wished. The Ministry asked the MRC if it would undertake further research into
the relationship of smoking and cancer and was told that as the answer was known
it would be a waste of money. Asked for a formal opinion on the relationship in
1957, the MRC published its response in the professional journals: the increase
in lung cancer was attributable to the increase in cigarette smoking.
Obstetrics and gynaecology
Pre-war, the high maternal mortality rate had been of great concern. The chance
of a mother dying from her pregnancy or associated causes in 1928 was 1 in 226.
Janet Campbell, a Ministry doctor, had devised a pattern of regular antenatal
supervision for the poor in London’s East End. However, antenatal care remained
patchy, many mothers did not use the services and GPs had played only a minor
part. By 1948 the maternal mortality rate was falling, although there was no
evidence that this was the result of antenatal supervision.101 The perinatal
mortality rate (stillbirths and the number of infant deaths in the first week of
life per 1,000 births) had also fallen, but appeared to have levelled out at
3.85 per cent in 1948.
the 1930s there had been a gradual increase in babies being delivered in
hospital. Cross-infection in maternity hospitals had been a constant danger, but
antibiotics had reduced this risk. The Royal College of Obstetricians and
Gynaecologists (RCOG) in 1944 had advocated that 70 per cent of deliveries
should be in hospital, and ten years later raised its target to 100 per cent.
During the 1950s the percentage of births taking place in hospital remained
fairly static at around 65 per cent, but then it started to rise.102 Public
opinion was drifting to the view that hospital was best, and mothers
increasingly chose it as safest for themselves and their babies. It was free
under the NHS, home-helps were in short supply and the home might be unsuitable
or overcrowded. The birth rate was rising and the demand for beds outstripped
supply, in spite of which maternity beds were sometimes turned over to acute
cases and tuberculosis. The Ministry thought it difficult to justify the
provision of beds for normal cases ‘simply because the mother prefers to have
her baby in hospital’.103 It was said that to get a bed in hospital you had to
book three months before you were pregnant; hospitals had a monthly quota and it
was first come, first booked.104 District midwives delivered many at home who
could not be fitted into the hospital, even when hospital delivery was
indicated. Lack of pain relief was the main complaint women had of the maternity
services. Midwives were not permitted to give pethidine until 1951. Only 20 per
cent of women delivered at home received any form of pain relief, usually as
gas/air, and only half of those in hospital. Because women had to stay in
hospital for 14 days, antenatal patients who needed admission, perhaps because
they had high blood pressure and toxaemia that posed a hazard to mother and
baby, could not be admitted because the obstetric beds were full of mothers most
of whom were fighting fit and desperate to go home. In the mid-1950s Geoffrey
Theobald, at St Luke’s Hospital in Bradford, realised that they could be
discharged home safely after 48 hours provided the district midwives kept an eye
on them. The ‘Bradford experiment’ meant more antenatal beds.105
The question of home or hospital delivery became contentious, although there was
no sound information on which was safer, nor a clear view on the cases that
should be booked for hospital. To begin with the accent was placed on housing
and social problems. Later it shifted towards obstetric risks, the mother’s age
and the number of children she had already had. In 1954 Professor WCW Nixon, of
University College Hospital, arranged a meeting of experts to discuss the
possibility of obtaining data on the relative risks of hospital and home
confinement. Out of this grew the perinatal mortality survey of the National
Birthday Trust Fund, a charity working to improve the health of mothers and
their babies. Not all GPs were up to date; some were unconvinced about the need
for systematic antenatal care. The RCOG had stressed that GPs undertaking
midwifery should have special experience, and supported the midwives who
undertook regular postgraduate training. GPs saw fewer cases, particularly of
operative obstetrics. The average GP had 30-40 deliveries a year, including
those that went to hospital or were handled by midwives. Was this enough to
maintain skills? Some GPs felt threatened and did not want to co-operate in a
consultant-led service. Sometimes midwives respected the GPs with whom they came
into contact; often they did not.
The maternal mortality was lowest in areas in which there was unified
organisation of maternity services. In pioneer areas midwives, GPs and
consultants organised themselves in partnership, in the interests of the GP and
imperative for the of mother and child.106 In Hertfordshire a system of shared
care was adopted in which, after hospital booking, the GP undertook antenatal
care until the 36th week. In Bristol, a similar system operated based on a
health centre, GPs working alongside midwives and hospital staff in managing
pregnancy.107 In Oxford good relations were established between the RHB, the
obstetric departments and the GPs with their local maternity units. The
confidential enquiry into maternal deaths, the first serious British attempt to
scrutinise the outcome of care, was introduced in 1952 following an
international conference on obstetrics in London and discussion between GR:
name, please?, President of the RCOG, and George Godber at the Ministry. The
first report was published in 1957.108 It followed a smaller pre-war study in
Britain and a classic study of maternal mortality in New York City in 1933. The
enquiry was voluntary and confidential, for only if the reports were treated as
privileged, and never disclosed to anyone other than the professional staff
handling them, could frankness be expected. The registration of a death related
to pregnancy was the starting point. Information was obtained from the GP and
local obstetrician, the report then going to a regional assessor, a senior
obstetrician appointed after consultation with the President of the RCOG.
Consultant advisers to the Ministry of Health in obstetrics, anaesthetics and
pathology made a final assessment. Avoidable factors were found too often to
allow the opportunity to improve matters to pass. Reduction of deaths due to
toxaemia and haemorrhage was important. The survey highlighted a danger
appreciated since the 1930s, when the first obstetric flying squad was
established in Newcastle. Women with a retained placenta after home delivery
were often put into ambulances and sent to hospital without either transfusion
or manual removal of the placenta, only to be found moribund on arrival.
Obstetrics was developing increasingly fast. In 1955 Ian Donald, in Glasgow,
used ultrasound for the first time to examine an unborn baby. It became the
preferred technique for monitoring the progress of pregnancy, replacing
radiology, which had been shown by Alice Stewart in Oxford to put babies at
risk. Theobald introduced a new method of inducing and increasing the strength
of labour, the oxytocin drip, and there were advances in reducing postpartum
haemorrhage and the delivery of the placenta (the third stage of labour). In a
few units (e.g. University College Hospital, London) there was interest in the
mother as a person; husbands were allowed and even encouraged to be with their
wives during labour, a policy viewed in most hospitals as eccentric.
a specialty, was weak in 1948 and there was little systematic training. Unlike
the situation in North America, GPs provided much paediatric care. The problem
of infectious disease seemed likely to be solved by the antibiotics. Specialists
in diseases of the heart, the lungs and the joints cared for many children, and
few of those in a children’s ward were under the care of a paediatrician. If
born in hospital the baby was in the care of the obstetrician and relationships
with paediatricians might be prickly. Many diseases of children were becoming
less common, for example rheumatic fever and tuberculous meningitis.
In the years preceding the second world war, special units for premature babies
had been created in some places; for example, Mary Crosse’s department in the
grounds of the Sorrento Maternity Hospital in Birmingham. Crosse and her nurses
would go out in taxis with hot water bottles to bring in small and premature
babies. Victoria Smallpeace in Oxford was another pioneer. Retinopathy of
prematurity, producing blindness in premature infants in the first few weeks of
life, was described in Boston in 1942. In the late 1940s and early 1950s the
number of cases in the UK surged. For ten years little more was known about the
condition than an association with low birth weight and premature baby units;
the cause remained a mystery. Mary Crosse, in a flash of intuitional brilliance
suggested that it might be due to the use of high concentrations of oxygen in
incubators.109 She found no case in Birmingham before 1946, but, out of the
first 14, 12 had been on continuous oxygen for between two and five weeks. It
was the additional money that came with the NHS, she said, that enabled centres
of expertise to buy incubators and the expensive oxygen required. There had been
a well intentioned but misguided change in care, indeed nurses and doctors might
object to the suggestion that oxygen for sick babies should be restricted. In
1951 the MRC started sifting the records of maternity units and ophthalmic
units. This confirmed the connection and showed that a high concentration over a
period of several days was dangerous. Oxygen levels were reduced and the
incidence of the disease fell greatly.110 Retinopathy of prematurity was not the
only disease caused by medical treatment; increasing interest in the neonate was
accompanied by the rapid use of new drugs such as chloramphenicol and the
sulphonamides, and as immature babies did not metabolise these like adults,
overdosage might occur.
emotional problems of sick children in hospital were not understood in 1948.
Children’s wards might only allow parental visits for an hour on Saturday and
Sunday, and would discourage telephone enquiries. Children admitted to hospital
were usually placed in adult wards and few staff felt it necessary to explain
their treatment to them. Simple things, such as moving them from one bed to
another in the ward or the use of red blankets, could create anxiety. Some
children would react by withdrawing into themselves, others by seeking
friendship and reassurance from everyone. However, paediatricians, such as Sir
James Spence in Newcastle and Alan Moncrieff at Great Ormond Street, drew
attention to the great distress caused by the ‘no visiting’ policy.111
Particularly if in hospital for a considerable period, the infant forgot
the mother and clung to the nurse when the time for discharge came, to the
distress of all three. Nursing staff sometimes became possessive about children.
An experiment in daily visiting was tried; the mothers liked it and the nurses
preferred the closer contact with the family. John Bowlby, Director of the child
and family department at the Tavistock Clinic, published a book on maternal and
child health care in 1951. This drew attention to the devastating effect of
separation from the mother and was followed in 1953 by a film, A two year old
goes to hospital, that showed the traumatic and long-term effects on the young
child suddenly separated from the mother and placed in strange surroundings.
Daily visiting, seldom permitted previously, was progressively introduced. A
second film in 1958, Going to hospital with mother, made it clear that the
presence of the mother should be the norm, not the exception. Nurses should
change their role from mother-substitute to adviser and friend, giving the
mother understanding and the child skilled nursing.112
In 1956 Caffey, a radiologist at the Columbia University and Babies Hospital,
New York, speaking to the British Institute of Radiology, described a group of
children suffering from trauma. Paediatricians, he said, faced with unexplained
pain and swelling in the limbs, usually embarked on an elaborate search for
vitamin deficiencies and metabolic diseases. Simple trauma was given short
shrift by those bent on solving the mysteries of more exotic diseases. Correct
diagnosis of injury might, however, be the only way in which abused youngsters
could be removed from their traumatic environment. Once the ‘battered baby
syndrome’ was recognised many cases came to light, usually in children under the
age of two who had suffered repeated injuries, often ascribed to ‘falling
downstairs’ but in reality caused by their parents. They might have brain
injury, fractures of the limbs and ribs, multiple bruises and injuries. Other
children who ‘failed to thrive’ had been persistently underfed or emotionally
neglected. Often the families in which the cases arose already had many other
problems. There was widespread media interest, and health visitors, GPs and
casualty departments now had something else for which to look.113
A major cause of babies dying during labour or in the week after birth (the
perinatal mortality) was haemolytic disease of the newborn. The condition had
been defined and its cause worked out in the USA by Darrow, Levine and Weiner in
the 1940s. Six out of every 1,000 babies suffered from it, as a result of
incompatibility between a rhesus-positive baby and a rhesus-negative mother who
had developed antibodies during a previous pregnancy. Fifteen per cent of the
babies affected were stillborn, and some of the others were rescued only by
replacing the baby’s blood by an emergency exchange transfusion. By the early
1950s mothers developing antibodies to the rhesus factor were admitted to units
with special facilities. Exchange transfusions and early induction of labour
produced some improvement in the mortality for rhesus-positive fetuses, but
there was no way to reduce the numbers of rhesus-negative mothers who became
sensitised during pregnancy and delivery.114
hospital surveys had shown that the care and accommodation for the ‘chronic
sick’ were often inadequate, but the size of the problem made it hard to solve.
Care had largely been custodial, with little more than minimal attention from
few staff either in the back wards of hospitals or else in units separated from
acute services. During the years of war Marjory Warren, at the West Middlesex
County Hospital, found herself looking after the chronic sick wards. She argued
that geriatrics should be treated as special branch of medicine, staffed by
those specially interested in the subject. With greater effort, more patients
could be discharged. The elderly should be cared for within the curtilage of
district hospitals where special investigations and rehabilitation were
available. A change in the attitude of the profession was called for, and the
care of the chronic sick should be an important part of medical and nursing
education.115 Other pioneers included Lionel Cosin, who established
the first day hospital in Oxford, and Tom Wilson, the first consultant
geriatrician appointed in Cornwall in 1948. They got excellent results and a
more intensive use of their beds by treating acutely ill old people vigorously
in short-stay wards, taking medical, social and psychological problems into
account. The achievement of independence depended on a high standard of
medicine, good teamwork and an atmosphere of optimism and activity, combined
with the patient’s confidence and co-operation.116 Marjory Warren, speaking in
1950, said people could be treated in their own homes if there was co-ordination
of GPs and consultants, domiciliary consultations with the geriatric team, and
home helps and district nurses. ‘Keep them in bed and keep them quiet’ was
replaced by ‘get them up and keep them interested’.117 The Nottingham
City Hospital established a geriatric unit in 1949, fully staffed with
physiotherapy, occupational therapy, chiropody and links with psychiatry and the
local authorities.118 University College Hospital was the first
teaching hospital to establish a unit, under Lord Amulree, at St Pancras
Hospital. Nursing faced a major new demand, preventing patients from joining the
ranks of the bed-fast, stiff, incontinent and dull of mind.119 There
was also a preventive aspect; in Salford a health visiting service was developed
for the elderly. The co-ordination of domiciliary services, physiotherapy,
chiropody, laundry and bathing attendants could prevent admission to hospital.
Health visitors could remedy gaps in the service and deal with the needs of
families as whole.120
The Ministry guidance on specialist services had suggested that general
physicians would give an increasing amount of time to the chronic sick. They did
not. In 1954 the Ministry organised a national survey of the services for the
elderly, collated by Boucher, the senior medical officer concerned.121 Some
waiting lists were so long that GPs had stopped referring patients. An
administrator might determine the priority of admission, sometimes swayed by the
importunity of the family doctor. Waiting lists were seldom reviewed and were
grossly inaccurate. Accommodation could be in long rambling drafty buildings far
from other hospital services. An outside cast-iron staircase served one ward on
the first floor over a boiler-house and a paint store. Bed turnover might be as
low as 1.4 per year in some regions. In one group of 447 beds the physician ‘did
not believe in geriatrics’. A nearby colleague with 417 beds was mainly
interested in paediatrics and, unable to raise enthusiasm for the elderly, had
not visited them for months. In contrast were units that had adopted a more
active approach, assessing patients before admission and campaigning for
physiotherapy and occupational therapy services. Cosin at Oxford and Olbrich at
Sunderland had annual bed turnovers of 3.6 and 5.6. Active treatment,
rehabilitation and discharge were coupled with re-admission if patients were
unable to maintain independence even with domiciliary services. Where the
consultant’s primary interest was in elderly people, the service benefited
incomparably. If he had other interests, the elderly always took second place to
could now press for the development of geriatrics as a specialty. A pool of
doctors who had trained in general medicine were looking for posts, and
geriatrics provided them with opportunities. The Advisory Committee on
Consultant Establishments helped them and more than 60 geriatric units were soon
established with the more modern philosophy, although most of the new
consultants found themselves working in poor accommodation. A new group of
specialists had emerged, physicians interested in treating the elderly and not
merely looking after them. Their first task was to deal with the vast number of
patients they had inherited, introducing active management, cutting the number
of beds they needed and reducing the waiting lists. They introduced domiciliary
assessment and outpatient care for people waiting for a bed, many of whom had
social rather than health problems. If properly used, there was probably no
shortage of beds.
Many developments in psychiatric practice took place in the RHB hospitals, often
in the provinces, and were largely divorced from the growing points in acute
medicine, the teaching hospitals and universities.122
The psychiatric departments of the teaching hospitals, where they existed,
were not part of the mainstream, saw few psychiatric emergencies and undertook a
different type of work. Their interests mostly lay in psychological medicine and
psycho-neuroses. They drew a different group of patients, often of higher social
status, who hoped for greater courtesy and personal attention than was usual in
the general hospitals, and that outpatient care rather than admission would
follow expert and thorough assessment.123 Professorial units existed
only in Leeds, at the Maudsley and later in Manchester. Before the second world
war most psychiatric patients had been ‘certified’ although the Mental Treatment
Act 1930 had enabled the admission of voluntary patients and the establishment
of outpatient clinics. By the early 1950s two-thirds of patients were voluntary
and not under a compulsory order. As people became more willing to be admitted
to a mental hospital, increasing numbers led to overcrowding. Yet services were
far from comprehensive, and were poor or non-existent for the elderly who were
mentally infirm, for mentally ill offenders and for adolescents. Drug addiction
was hardly recognised as a problem, neither was attempted suicide that was
occurring more and more often.
Physical methods of treatment had long been used, virtually always for
schizophrenia. Convulsion therapy used chemicals to induce fits, but was
abandoned as patients could remember the entire episode in frightening detail.
Electroconvulsion treatment (ECT), introduced in 1938, produced amnesia, and was
given without anaesthesia. Six strong nurses held the patient down, but the
strength of the muscle contractions frequently produced injuries, particularly
crush fractures of the vertebrae. The introduction of anaesthesia and muscle
relaxants overcame many of its evils and ECT clinics treated a dozen or more
patients in a session. Deep insulin therapy, also introduced for schizophrenia,
was at times hazardous and occasionally fatal. It was progressively questioned
and ceased to be used in the late 1950s. Pre-frontal leucotomy was at first
regarded as a major advance in therapy but proved to be damaging to the
patient’s personality. Its use for schizophrenia ceased, and more limited
operations came into vogue. Psychiatrists awoke from a wish-fulfilling dream
that they had been unwittingly party to a game of ‘Emperor’s new clothes’.124
Only ECT, for depression rather than schizophrenia, proved of lasting use. Just
as physical methods were being given up, drugs appeared. In 1952 chlorpromazine
(Largactil) was introduced. Psychiatric practice was already undergoing major
change. Henry Rollin, a psychiatrist at Horton Hospital, Epsom, and the
anonymous author of a number of BMJ editorials, wrote that such powerful drugs
heralded the onset of a revolution in the treatment of schizophrenia. If
admission to a hospital was necessary, the stay could now be measured in weeks
rather than months.125 People with a recent onset of illness had a higher
likelihood of early recovery and began to be accommodated separately from
long-term patients, difficult in hospitals of traditional design where the
buildings were arranged for security rather than comfort and resocialisation.126
By 1948 some mental hospitals had opened their doors. Their doctors believed
that most if not all patients could be persuaded to co-operate and that locked
doors, at any rate in day time, should be as obsolete as chains. An attempt was
being made to improve the characteristics of the institutions by the
introduction of occupational therapy, music and art classes. The Lancet
published an account of hospitals where this policy worked well.127
TP Rees at Warlingham Park, Croydon, had kept all but two of the 23 wards open
for 12 years, and Macmillan in Nottingham, with 1,100 patients, had all the
wards open day and night. Patients did not abscond and they were unlikely to
wander off if they had a congenial task. Depressed patients might be at risk of
suicide if not treated with ECT on the day of admission but the system was
better for both staff and patients. Nurses preferred not being warders, and
tensions in the wards were fewer. Overcrowding led to a need to expand
outpatient treatment and to Joshua Carse’s ‘Worthing experiment’, based on
Graylingwell Hospital, Chichester.128
The regional board and the Nuffield Provincial Hospitals Trust sponsored a
two-year trial of intensive outpatient and domiciliary treatment that was
rapidly seen to work, reducing admissions.129 Psychotherapy was
simpler on an outpatient basis, and as the antidepressants were introduced more
people could be treated without admission. With better anaesthesia, outpatient
ECT was also possible. The next years saw a rapid emancipation from the
restricted and isolated world of the old mental hospitals. Sometimes, new ideas,
such as Maxwell Jones’ ‘therapeutic community’, were adopted.
The Ministry of Health saw a
comprehensive service, integrating hospital and community resources, as a way of
reducing overcrowding. The CMO’s report said that
The most successful form of rehabilitation has been a combination of
habit-training and full occupation. A start is usually made in the ward
containing the worst type of patient, the noisy, violent and destructive, and
those with degraded habits. Such patients are split into groups of about ten,
each group having one or more specially selected nurses in charge of it. The
group is drilled into an unvarying routine with special emphasis on personal
hygiene, cleanliness and neatness in dress, which need not imply any harshness
since many of these patients appear to be quite indifferent to what goes on, and
come after a time to respond mechanically. Full and suitable occupation is
provided for the group under the supervision of its ‘permanent’ nurse. It is
most desirable that patients being trained in this way should live in
comfortably furnished rooms and that recreations should be provided. It is
essential that they should have and retain their own personal clothing and
underclothing. Few are the patients who fail to respond to such a regime. It is
found that their wards become quiet and peaceful, the use of sedative drugs
almost or entirely ceases, and locked wards can be opened.130
A committee in 1956 made recommendations about the rehabilitation of the
mentally ill before discharge.131 However, continued support after
discharge was not readily to be found. The Lancet said that aftercare probably
had a more important place in the treatment of the mentally ill than in that of
any other type of problem but psychiatric social workers were scarce and
aftercare had almost ceased to exist.132
The isolation of the mental hospitals and their staffs from the public and the
wider health professions was well known.133 Pioneering work on local services
was undertaken in the northwest, where there were many small towns, such as
Burnley, Blackburn and Oldham, of an independent turn of mind. Their town-centre
municipal hospitals usually incorporated chronic and mental illness wards. From
the outset the Manchester RHB’s first chairman, Sir John Stopford, wanted to
improve services and by 1950 the RHB policy when appointing psychiatrists was to
base them centrally to avoid the divorce of mental illness from the broad stream
of general medicine. A planned and coherent system was developed with outpatient
assessment and early treatment in general hospital units. These were 100-200
beds in size, each with its own catchment and admitting all patients. To
everyone’s surprise they seldom needed to send patients to the few, large and
distant asylums. Perhaps this was because the units were small and the patients
got individual attention, perhaps because they were in the centre of the
community and patients didn’t lose contact with friends and went into town to
local cinemas and football matches. Most psychiatrists felt that co-operation
with an integrated geriatric unit was essential as the work overlapped; and that
with 100 beds they could deal with a population of 250,000.134 Another major
development was the requirement, set out in the Goodenough Report, that medical
schools should have an active department of psychiatry.135 Increasingly, such
departments were developed, and took on catchment areas and often led the way in
developing new treatments for the mentally ill, within general hospitals.
Yet those visiting the old asylums, such as Members of Parliament, might be
dismayed at what they found. The chairman of the mental hospitals’ committee of
the Birmingham RHB agreed with the complaints of MPs. Beds were so close that
they had to be moved to enable nurses to deal with troublesome patients. Ward
temperatures might fall to 20°C in the winter. The weekly cost of care was £4 6s
7d against £13 10s 10d in a general hospital and £22 9s 3d in a teaching
hospital. ‘Give us an extra 5 shillings per patient’, said the chairman, ‘and we
will achieve miracles.’ Lack of staff meant that the patient/staff ratio
nationally was 6.6 to 1 in mental illness and 7.0 to 1 in mental handicap
hospitals. In Lancashire some nurses banned overtime above the normal 48 hour
week to call attention to the problem. As action spread, voluntary admissions
had to be restricted.136
The Percy Commission 138
In 1954 the then Conservative government established the
Royal Commission on the Law relating to Mental Illness and Mental Deficiency
(the Percy Commission) to assess the extent to which people
with mental disorders could be treated as voluntary patients. In
summary, it concluded:
"... that the law should be altered so that whenever possible suitable care
may be provided for mentally disordered patients with no more
restriction of liberty or legal formality than is applied to
people who need care because of other types of illness,
disability or social difficulty" ( para. 7).
Its membership included the President of the RCP and Dr TP
Rees. Joint evidence from the Ministry of Health and the Board of Control
provided a set of clear-cut proposals.137 The Commission reported in
May 1957, recommending the repeal of all existing legislation and a single new
law covering all forms of mental disorder.138 Running through the
report were two simple ideas: first, that all distinction - legal,
administrative and social - between mental illness and physical illness should
as far as possible be eliminated; and, secondly, that patients who did not need
inpatient care should, wherever possible and desirable, receive treatment while
remaining in the community.139
Compulsory powers of admission should be used less frequently. The
assumption should be that mental patients, like others, were content to enter
hospital unless they or their relatives positively objected. Its
recommendations formed the basis of the Mental Health Act (1959), and was the
foundation of a move towards community care.
The mental hospitals had shared the
medical superintendent system of the municipal hospitals and the superintendent
was often autocratic. Even consultants might be ‘on parade’ in his office.
Psychiatry, as a discipline, had problems. Its changing world was unfamiliar.
Psychiatrists were few and although there were leaders, the quality as a whole
was questionable. The Ministry wanted to introduce state enrolled assistant
nurses, but the nursing unions and the Mental Health Standing Advisory Committee
argued that fully trained staff or student nurses should exclusively undertake
mental health nursing. In the event most nursing fell to untrained personnel.
The competition of other employers made poor recruitment worse; conditions in
the army were better than in the mental hospitals. The wastage among students,
who had a different pattern of training from those in the general hospitals, was
high, 80 per cent compared with 40 per cent in general nursing.
The NHS Act 1946 provided a family doctor to the entire population. The Bill
emphasised health centres that were to be a main feature.140 At public cost,
premises would be equipped and staffed for medical and dental services, health
promotion, local health authority clinics and sometimes for specialist
outpatient sessions. The programme was aborted before it even started.
Whereas Bevan had persuaded consultants into the service in part by merit
awards, the GPs had been unwilling to join until virtually the last moment. The
public, however, were encouraged to sign on with those doctors willing to enter
the scheme, leaving others with the choice of joining as well or losing their
practices. Within a month 90 per cent of the population had signed up with a GP.
Twenty thousand GPs joined the scheme as they saw private practice disappear
before their eyes.141 The NHS Act made it illegal to sell ‘goodwill’; instead a
fund was established that compensated GPs when they retired, but it was not
inflation-linked. The GPs’ contract for a 24-hour service, the nature of the
complaints procedures and even the patients’ NHS cards were virtually unchanged
(and still are). GPs, fearing that they might be no more than officials in a
state service, argued successfully for a contract for services rather than a
contract of service. As a result they remained independent practitioners,
self-employed and organising their own professional lives. The Spens reports
determined pay, which was entirely by capitation.142 GPs’ income depended on the
number of their patients; even their expenses were averaged and included in the
payment-per-patient. Their independence thus assured, GPs were taxed as though
they were self-employed, yet, unlike most people in small businesses, they could
not set their fees. With a few exceptions, such as payment for a medical
certificate for private purposes, no money could pass between patient and
doctor. This system, combined with a shortage of doctors, provided no financial
incentive to improve services, but neither was there any incentive to over-treat
Variations in list
sizes between 1948 and 1989
England and Wales
Source: John Ball145|| || || || ||
Single handed practitioners|| ||
practitioners in partnership||
As members of partnerships of 2 doctors||
of 3 doctors||2,577||
|of 4 doctors||
of 5 doctors||315||
6 or more||161|
Committee (1954) ||Figures 1st July
GPs, almost entirely male and half of them single-handed, practised mainly from
their own homes. Their distribution was uneven, although not so bad as that of
the specialists because there was less dependence on private practice. Before
the NHS began a few GPs had made an excellent living but many were poorly paid
and some had to employ debt collectors. The NHS gave them security and a higher
average income. Because they were paid by a flat capitation fee, those in the
industrial areas who had large lists of 4,000 suddenly became affluent but had
difficulty serving their patients properly. Proud and wealthy GPs in rural or
rich suburban residential areas with many private patients, but with small
lists, became far worse off.143 The Medical Practices Committee established a
system that defined areas as over-doctored, under-doctored or intermediate, and
barred over-doctored areas to new entrants.144 Half the population lived in
under-doctored areas where the average list size exceeded 2,500, designated as
in need of more GPs. Here it was possible for any doctor to set up practice,
putting up a plate and waiting for patients to come. Eckstein wrote that places
such as Harrogate were gorged with GPs while working-class areas nearby in
cities such as Wakefield, Leeds and Bradford were comparatively starved.145
Swindon had average lists of 4,219 in 1948, while the list sizes in Bournemouth
averaged 1,334. In 1989 the figures were 2,079 and 1,831. John Ball, later
Chairman of the Medical Practices Committee (and of the GMSC), said that there
was always a pressure for distribution to revert to under- and over-provision,
and control was needed to ensure equality of access in the long term.146
The NHS brought fewer changes than the GPs had feared. Patients, uncertain of
their rights, came with questions. Many older people, lacking spectacles for
years, rushed to have their eyes tested and for some months the service was
over-stretched. Much untreated illness was brought to light, particularly in
women who had suffered for years from chronic conditions such as prolapse. There
appeared to be a rise in the workload. The consultation rates of women and
children, who had previously been uninsured, were higher.147 No longer would
people, to the cost of the doctor and the medicine, say that they would be all
right once the worst of an illness was over. Perhaps some work now coming to GPs
was trivial; there was a belief born of years of rationing that ‘a line from the
doctor’ would work wonders with the housing department. Paperwork changed; bills
were no longer necessary but there were forms for eye tests, sickness, milk and
coal. Under the Lloyd George national health insurance scheme, GPs had received
medical record envelopes in which they had to keep a note of consultations ‘in
such a form as the Minister determined’. Wisely, ministers never defined how
this should be. Now the entire registered population had an NHS envelope,
transferred from one GP to another when they moved. It came to contain not only
the GP’s notes but also hospital letters, so potentially everyone now had a
single medical record from birth to death.
A patients’ guide, produced by the Ministry in 1948, said that as everyone could
now have a GP it was the GP who would
arrange for the patient every kind of specialist care he is himself unable to
give. Except in emergency, hospitals and specialists would not normally accept a
patient for advice or treatment unless he has been sent by his family
system had previously been an ideal to which doctors aspired, but were not bound
if it were against their financial interest. Now the NHS established GP referral
as almost invariable practice, imposing at least a partial barrier for patients
seeking hospital care. The decision to go to hospital was transferred from
patient to GP, reducing patient freedom and increasing the cost-effectiveness of
the system. The ‘gatekeeper system’ institutionalised the separation of primary
and secondary care. Family doctors defended it because they had continuing
responsibility for individual patients, consultants because it protected them
from cases that might be trivial or outside their field of interest, and
government because it saved money to have a filter system.149 Relationships
between GP and specialist had been altered. Previously specialists had made
their money from private practice and many patients came on referral. Once the
NHS was established there was no shortage of NHS patients and few consultants
made a substantial income from private practice. All were at least partly
salaried and most ceased to have any financial reason to be grateful to GPs.
One of the first quantitative accounts of the work of a GP was presented by a
young doctor who had recently entered general practice in Beckenham, John
Fry.150 He analysed attendances in 1951 by age and sex, noting the reasons for
the consultation. Respiratory infections, digestive diseases, neuroses, skin
disorders and cardiovascular problems headed the list. The GP dealt with minor
ill-health and those major diseases that did not require admission to hospital.
Three-quarters of his patients came to see him during the year. Philip Hopkins,
in 1951-53, studied the impact of general practice on the hospital service. He
presented data for a practice of roughly 1500 patients with a consultation rate
of 3.3 per year. In three years the practice had referred 860 patients on a
total of 1,225 occasions. Of the referrals, 54 per cent were for treatment,
often of a nature already clear to the GP. Because direct access to laboratories
and X-rays was denied by the local hospital, many were referred solely for a
test. Often referrals were to exclude serious illness before a label of
psychoneurosis was attached. Only in 183 cases was it for a consultant’s opinion
on diagnosis or further management.151 GPs were increasingly interested in
practice organisation. Keith Hodgkin reported on the introduction of a
radio-telephone into his practice. It enabled him to obtain an ambulance without
delay, to continue his rounds while waiting for a delivery and to get hold of a
partner if an anaesthetic was required. The problems were cost and the
inadvertent reception of his messages on TV sets, so Hodgkin had to watch what
In 1948 there was
little information about general practice; by 1952 more was available. There
were 17,204 GPs in England and Wales providing unrestricted services, plus 1,689
permanent assistants and another 309 trainees. The number was increasing only
slowly. A little over half were in partnership. In rural or semi-urban areas a
third of GPs were single-handed, a third in partnerships of two, and a third in
larger partnerships. The main surgery would be in a small town or other
convenient focal point. In urban areas most of the doctors were single-handed
and there were few large groups. The largest lists were found in the industrial
Midlands, the northeast coast, south Yorkshire and Lancashire. Even in
partnerships the GPs might see little of each other. The arrangement was largely
financial, though it was easier to cover the doctors’ time off. More rarely, as
in Skipton, effective group practices were developing in which the partners
aimed to work together from the same premises, supporting each other, using a
common medical record system and sharing supporting staff.
New entrants to general practice were supplicants; they would be expected to
work long hours, reach equality of pay with their seniors in possibly seven
years, accept the hierarchical system of the practice, generally behave
themselves and probably do most of the practice obstetrics.153
The Spens Report on GPs’ remuneration suggested that 10 per cent of GPs
should be selected, because of their success in practice and suitability, to
take on a trainee. The senior GP would be able to manage considerably more
patients, make his services more widely available and increase his income. The
scheme was later developed to provide vocational training, but that was not its
original purpose.154 In 1950 a committee, chaired by Sir Henry Cohen,
reported that the status and prestige of the GP should be the equal of
colleagues in any and every specialty, and that no higher ability, industry or
zeal was required for the adequate pursuit of any of them. Cohen considered
that, as general practice was a special branch of medicine requiring supervised
training, there should be three years’ preparation, one in practice (any
principal having the right to train a new entrant) and two in supervised
hospital posts. GPs should continue their education and reading throughout their
professional life.155 In 1957 the General Medical Services Committee
of the BMA circulated guidance to achieve greater uniformity in trainer
selection and to eliminate abuses.
The cost of prescribing by GPs often exceeded substantially their own pay. The
introduction of a free and comprehensive health service had coincided with the
discovery and large-scale production of valuable expensive drugs. But why should
the number of prescriptions rise when more effective drugs should have returned
people to health and work in a shorter time? In 1955 the prescription pricing
offices began to send GPs analyses of their prescribing costs compared with the
average for the area in which they practised, the beginning of a continuous
attempt to constrain the growth in cost of pharmaceuticals. In 1957 the Minister
established a committee under Sir Henry Hinchcliffe to investigate the cost of
prescriptions. Its interim report said that no evidence of widespread and
irresponsible extravagance was found.
The morale of GPs was low. GPs grumbled and there was little constructive
discussion about how matters could be improved.
Something has gone wrong in general practice today. We treat the same people and
similar complaints, and many of us have been doing the job for many a long year,
and it is puzzling to say what has happened to bring about the change, for
change there is. The doctor is irritable with the patients and they are noticing
it and commenting on it. The patients are more aggravating and the doctor is
noticing it. GPs had been promised more help, an easier life and no bad debts.
He had got much more work, in some cases less income as private practice
slumped, no bad debts, no help at all, a lot of personal frustration, had lost
his soul when he lost the right to sell his practice, and felt that he no longer
ran his practice - it was run for him. The patients had a hospital service
which, save in an emergency, they could only use by appointment after a wait of
several weeks; and a free GP service rushed to the point of indecency. His
haemorrhoids had to bleed for six months before he could be treated; her heavy
periods for nine months before she could get a hysterectomy. And having been in
hospital the patient could be home two weeks before the GP got a report.156
As consultant services improved, GPs were losing access to hospital beds and
some felt that this made it difficult to improve standards and status.157
Teaching hospitals gave little priority either to undergraduate or
postgraduate teaching for general practice. Both GPs and consultants saw the
hospital as the fount of knowledge and GPs felt isolated. They felt embittered
and frustrated, had lost their old enthusiasm and succumbed to the line of least
Theodore Fox, Editor of the Lancet published a leader saying
Admittedly general practice in this country was deteriorating long before the
NHS was introduced, and its further deterioration is due rather to a heavier
load than to any legislative alterations in the Act. But on balance the effects
of the Act on such practice have so far been for the worse and there is little
evidence that its problems are being squarely faced. Of the two possible
policies, the first is to say general practice is so often unsatisfactory that
the correct course is to compensate for its defects - to develop hospital and
specialist services in such a way that the short-comings of GPs become
relatively unimportant. This, we cannot help thinking, is the policy that is,
consciously or unconsciously, being followed. The alternative is to make a big
positive effort to raise the level and prestige of general practice. This can
still be done.159
In 1944 the Nuffield
Provincial Hospital Trust’s ‘Domesday Books’ had examined the hospital service
and found it wanting. In 1948 the Trust funded Dr Joseph Collings, who had
trained in New Zealand as a GP, to look at general practice.160
Nuffield records are silent on why he was selected. Collings surveyed 55 English
practices, all outside London. His report, published in the Lancet on 25th March
1950, raised an issue that was to dog general practice over the years - the wide
and unacceptable variation in standards.
Collings spent between one and four days with each GP, seeing industrial (16),
urban-residential (17) and rural practices (22).161 He was probably looking for
the things he wanted to find. He went on to an academic post in the USA at the
Harvard School of Public Health, and his critique was saleable journalism, just
what the USA then wanted to hear. The Nuffield trustees invited Theodore Fox, of
the Lancet, to edit the report and left the question of publication to the
discretion of their chairman. The chairman of the trustees decided that it
should be published by the Lancet and not the Trust. Fox was non-partisan, an
instrument neither of government nor of the medical profession, but a detached
critic of excess on either side. He did not want to promote Collings’ view of
general practice, but he was fair and would not suppress it.
Collings had expected variations in quality but not how great they were. In city
practices the conditions were so bad that he neither saw effective practice nor
believed it was possible. He described surgeries without examination couches,
where such records as there were lay loose round the room or in boxes,
consulting rooms with a chair for the doctor but not for the patient, and
couches where boxes and bottles had rested so long that they had stuck to the
surface. Symptoms clearly demanding examination or referral were often passed
over. Snap diagnosis and outdated medical knowledge were commonplace. Anything
approaching a general or complete examination was out of the question under the
prevailing conditions. In rural practice the surgeries were more pleasant,
although often lacking basic equipment. The country doctor not only spent more
time with his patients but also knew them better. Many GPs were good clinicians,
good technicians and fine humanists; certainly not all. Urban-residential
practice fell between the two; conditions for the patients were better than the
industrial surgeries for ‘the patient with more cultivated taste expects
attention to the niceties’. Taken as a whole, the detailed 30 page report was a
damning indictment. Collings wrote that there were no objective standards for
practice and no recognised criteria by which standards might be established. ‘We
can all make mistakes’ was certainly true in general practice, but the
individual mistake paled into insignificance beside the predisposing factors
which made serious mistakes not only possible, but in some circumstances highly
probable. The reputation of general practice, Collings said, had been maintained
through identification with an ideal picture that would no longer stand up to
examination. General practice was poorest in proximity to large hospital centres
and improved in scope and quality as one moved away. The worst practice was
found where the need was greatest, in areas of dense population. Some premises
required condemnation in the public interest. Yet Collings remained an
enthusiast for general practice. Instead of building up hospital services he
felt the aim should be to see how they could be dispensed with. That meant
teamworking of doctors, nurses, social workers and technicians in good premises,
which might be based on group practice units perhaps serving 15,000-25,000
people. The widening schism between hospital and practice, the lack of local
authority interest and the failure of administrative co-ordination in his view
did nothing to help.
provided with a pre-publication draft, disputed Collings’ findings. The journal
rightly thought that his 55 practices did not truly reflect the whole of general
practice and certainly Collings had been selective. The BMJ thought that the
report would at least do one good thing - focus the spotlight on general
practice, which should be the most attractive career in medicine. The NHS was
weighted heavily in favour of the hospital and the specialist. Most of the
letters to the BMJ disputed Collings’ findings or excused the shortcomings. A
minority saw that the report might be the turning point in the NHS and it was up
to GPs to take a lead in establishing an integrated service based on general
practice.162 Collings entered the demonology of general practice, but
stirred others into activity. His three further articles in 1953 were largely
ignored.163 In them he argued for group practice, rather than health
centres. Group practice was evolutionary and was the only way to breathe life
back into the finest, dying, elements of traditional general practice. Collings
laid out a detailed and costed plan both at practice and at national level. He
discussed the staffing, the architectural design of premises and the management
and personality issues that arose in groups. He considered the financial
inducements required and the financial advantage to government - the better
general practice became, the less the work falling on hospitals where care was
The BMA survey
Charles Hill, Secretary of the BMA, advised the Council that Collings, having
been published, had to be ‘answered’. He suggested that a general practice
review committee should be set up to obtain an authoritative and statistical
report on general practice. Stephen Hadfield, an assistant secretary at the BMA,
was given the job mainly because he was the member of staff most recently in
general practice. Throughout the next year Hadfield visited four or five
practices chosen at random each week.164 His report was fuller, more
balanced and statistically based. Analysing his findings, he made judgements of
quality of care: 92 per cent of GPs were adequate or something better; 69 per
cent left no doubt that patients received what examination was necessary. Three
out of four paid reasonable attention to record keeping. Seven per cent of both
young and old GPs needed to revise the methods of diagnosis they used. Hadfield
was surprised how often the abdomen was examined with the patient standing and
clothed. In 10 per cent of surgeries the accommodation was dismal, bare,
inhospitable and dirty. Some GPs were clearly discouraged when they saw the
lines round the walls where greasy heads had rested or the marks of nailed boots
on the floor. Relations with the hospitals were good and probably better than
before the NHS, when voluntary hospitals kept outpatients to maintain high
attendance records. With public health medicine the position was worse. GPs saw
district nurses as the salt of the earth, but reported little co-operation from
health visitors and complained bitterly about them as a waste of nursing
manpower. Hadfield believed that GPs, hospital consultants and public health
doctors had to get to know each other better. They were treading different paths
while the NHS was crying out for unified administration. General practice could
follow one of two paths: either adjust to the situation and stimulate new
clinical interests or move towards an impersonal health service taking general
practice into a glorified hospital outpatient department.
There was a delay of a year before Hadfield’s report was published in September
1953. It was passed round the BMA committees for it contained comments about all
branches of medicine. The chairman of the review committee wanted to publish, so
that the profession might see the evidence and the public would know that the
BMA was making a serious effort to raise the status of the GP and the standard
of practice. If nothing else, it would make people think and start things
moving. Others in the BMA thought that the report should be edited before
publication, or should remain private as it showed that not all GPs were quite
angelic. The press would make capital out of shortcomings and some GPs would be
angry. Yet published it was. Every profession, said the BMJ, has its quota of
unsatisfactory practitioners; that a few should be outstandingly bad was only to
be expected. The remedy was in better selection of students. Unsatisfactory
relations with other parts of the service also impeded the work of the GP and
the tripartite structure was a root cause of this. Finally the stresses created
by the rapid advance in medical science over the previous three decades were
responsible for some difficulties.165
Good general practice
Nuffield Provincial Hospitals Trust, inadvertently responsible for stirring up
the hornet’s nest, tried to remedy the situation. In 1951, Dr Stephen Taylor,
doctor, medical journalist, Labour MP and a figure in the political background
of the NHS at its inception, lost his seat in the election and was commissioned
to examine the acceptable face of general practice. He was as selective as
Collings but visited the best, some of whom had been recommended by Hadfield.
They were the ‘doctors’ doctors’ with lessons to teach. He worked under the
supervision of a steering committee of the great and the good, chaired by Sir
Wilson Jameson, to avoid another cause célèbre. Taylor’s report, Good general
practice, described its structure and organisation.166 Doctors who
organised their practices were less stressed, more effective and happier.
Whatever the perfection of the NHS administrative framework, Taylor concluded,
‘in the final analysis, the quality of the service depends on the men and women
who are actually doing the job . . . good general practice begins with the good
GP. So most of the conclusions are suggestions for self help.’ The BMJ commended
the book to all young practitioners.167 Taylor retained his interest
in general practice, was involved in the establishment of a teaching practice at
St Thomas’ Hospital, and was the moving spirit behind one of the earlier health
centres, opened in 1951 in Harlow New Town.
Collings the Central Health Services Council established a wide-ranging review
in December 1950. Chaired by Sir Henry Cohen, Professor of Medicine in
Liverpool, the committee included leading figures in the hospital and local
authority worlds, several well-known GPs and Stephen Taylor. The conclusions of
Taylor’s book, Good general practice, were submitted to the Cohen Committee. The
Medical Practitioners’ Union (MPU), a national organisation of GPs dating from
1914 with Labour Party links, believed it had some answers. It suggested the
development of group practice, revision of the payment system so that GPs were
encouraged to spend money on improving their practice, the attachment of nurses
and home helps to group practices, and a salaried service for GPs.168
The Cohen Committee reported in 1954 and endorsed Stephen Taylor’s findings but
it was not the brightest of bodies and it produced no new thinking.169
Its value lay in its authoritative nature, seeing general practice as
fundamental to health services. Practice could not be replaced by ‘congeries of
specialisms, nor was it subordinate to them’. Cohen commended group practice, as
it encouraged co-operation, and thought it might develop into the natural focus
of the ‘various domiciliary arms of the health service’, securing the advantages
of better staffing, accommodation and equipment more easily than health centres.
Students should be given the opportunity to study the scope of general practice.
More radical ideas were discouraged - long service or merit awards, assisting
retirement of elderly GPs, or undergraduate teaching by GP academics.
One problem that faced GPs was the 24-hour commitment. Their contract was to
provide a round-the-clock service. As independent practitioners they had to find
a substitute to cover holidays and leisure time. The first deputising service
made its appearance in 1956 as a private venture of two South African doctors.
Against the initial opposition of the BMA, and with no support from government,
Solomons and Bane launched an emergency call service, providing duty doctors in
cars with two-way radio contact to a central base. GPs, at least in London, now
had a new way of covering their practices to give themselves time off duty.170
Improving general practice
Three factors helped the restructuring of general practice. First there was a
change in the way family doctors were paid, which provided a financial incentive
to improvement in ways both the profession and government desired. Secondly,
innovative GPs began to paint a vision of practice as it might be, and sell the
vision successfully to their colleagues. Articles began to appear describing
better systems of practice organisation, record keeping, appointment systems and
the work of nurses.171 Thirdly, professional organisations began to
work behind the scenes to improve facilities, such as GP access to diagnostic
services. The BMA was already involved. A quiet partnership between government,
the BMA and the Royal College of General Practitioners (RCGP) moulded the most
important ideas into a new policy. Donald Irvine, an Ashington GP later Chairman
of Council of the RCGP, later listed its six elements:172
Rehouse GPs in properly equipped, purpose-built premises.
Help individual GPs develop a viable organisation.
Give GPs access to hospital-based diagnostic services.
Introduce nurses and other health professionals to form primary health care
Provide better postgraduate education.
Money, status and recruitment go hand in hand. GP pay was based on the
recommendation of the Spens Committee, appointed in 1945 and reporting the
following year.173 The starting point was a workload survey conducted
between July 1938 and June 1939.174 Austin Bradford Hill, the
statistician, said that, out of 6,000 doctors selected, less than 1 per cent
refused to co-operate. Those who refused were too busy, or had unprintable views
about the BMA, the Ministry of Health, statisticians or all three.175
According to the way the returns were interpreted, the annual consultation rate
was somewhere between 4.81 and 5.39 per year. The baseline for earnings was the
average pre-war income as declared to HM Inspector of Taxes. As GPs might not
always declare their full earnings this was an underestimate. Spens believed
that the GPs’ average income was too low, in the light of the length of
training, the arduousness of life compared with other professions, the greater
danger to health, and the skill and other qualities required. Spens thought that
before the war many doctors had been deterred from becoming specialists by the
certainty of many lean years. The NHS would remove this deterrent, and if GPs
were not well paid, recruitment would suffer and only the less able young
doctors would enter this branch of medicine, to the detriment of the profession
and the public. Spens recommended a level above the pre-war average, and wished
to see a system enabling good and energetic doctors to achieve substantial
earnings. It left the adjustment to post-war values to others. GPs therefore
entered the service paid on a provisional basis with the promise of a review.
They rapidly and reasonably became dissatisfied with their earnings and a
grossly inadequate betterment factor to bring GP pay up to 1948 levels.176
The review that had been promised did not materialise and two years after the
NHS began the Local Medical Committee Conference instructed the General Medical
Services Committee to make preparations for the ending of contracts.177
GPs had seen the Minister cut the remuneration of dentists and felt at his
mercy. The dispute continued until 1951 when it was agreed to go to
The Danckwerts award
The report by Mr Justice Danckwerts in
March 1952 was a turning point. Taking account of inflation since 1939 and
increases in the incomes of other professions, he recommended that the central
pool divided among the country’s GPs should be increased to £51 million, a rise
of roughly 25 per cent. The government had never expected an award of this size
but was unable to avoid paying. The figures were related to the number of GPs
rather than the size of the population, so if recruitment improved and list
sizes fell, the average GP’s pay would not be affected even though the workload
might fall. Danckwerts said that ‘if the number of doctors in the service became
unreasonably large this point would require reconsideration’.178
It was clear to the Ministry that the size of the award made it possible
to improve general practice. The government accepted it subject to agreement on
a system of distribution that would provide incentives and which could be done
without obviously penalising the ‘back-woodsmen’. Within three months there was
Changing the flat capitation rate to give a higher return
to doctors with intermediate sized lists (500-1500), so that new partners
would be taken on more readily.
An initial practice allowance to make it easier for new
doctors to enter practice.
Financial encouragement to form partnerships and group
The maximum number of patients a
single-handed doctor could have was reduced from 4,000 to 3,500, which also
became the maximum average for a partnership.179 The profession was
broadly satisfied with the outcome and the award rapidly had the desired effect.
GPs received a considerable sum in back-pay; some spent it on modernising their
premises. The following year there was a net increase of 806 doctors and 1,118
new doctors joined partnerships. Long-standing assistants often became partners.
The number who were single-handed fell by 312.180 It was an early
demonstration of the effect of financial incentives on general practice. The
profession agreed that £100,000 each year should be top-sliced to provide
interest-free loans to group practices wishing to provide new or substantially
better premises. This loan scheme was so popular that some applications could
not be approved. In 1954, 36 applications were accepted totalling £159,000.
Continuing disputes about doctors' pay,
and a threat by GPs to withdraw from the NHS, led in March 1957 to the
establishment of a Royal Commission on Doctors' Pay in March 1957. Following the Royal Commission's
recommendations the scheme was funded
directly by the Exchequer and not from top-sliced money. Because it was
impossible to identify precisely to whom money should be reimbursed, it was
agreed to hold it in trust as a medical charity, the Cameron Fund.
Appointments systems, tried experimentally in a few places, had been shown to
reduce the number of visits requested. A more even distribution of doctors was
emerging as a result of the work of the Medical Practices Committee. There was a
steady decrease in the number of patients living in under-doctored areas, from
21 million in 1952 to 9 million in 1956. Although the arrangements went some way
to encourage group practice, it remained difficult for a small practice to find
the funds to pay an additional doctor. There were comparatively few vacancies
and two-fifths of them attracted over 40 applicants each. The easiest place to
enter practice was the north of England, where list sizes were biggest.181
Health centre development, which might have provided new posts, was
minimal. The concept was unpopular with GPs, rents were high and it took a long
time to design and build health centres partly because of the need for many
parties to agree.
The College of General
that proposed a college of general practitioners were presented at a meeting of
the BMA General Practice Review Committee in October 1951. Stephen Hadfield, the
Secretary, knew that Fraser Rose of Preston was interested in founding a
college. At the same time he discovered that a friend of his in private general
practice, John Hunt, had a similar desire. John Hunt was invited to a meeting of
the Committee and introduced to Fraser Rose. The two wrote a letter to the BMJ
and the Lancet, published on 27 October 1951, proposing a college. It was like a
breath of fresh air to many GPs.182 The idea was discussed for about a year and
the strong opposition of the Royal Colleges of Physicians, of Surgeons and of
Obstetricians and Gynaecologists was clear, as was often the case subsequently
when new colleges were in prospect. They would have supported a joint faculty of
general practice within their own structures, but not a separate institution.
Additions to their numbers risked weakening their influence; with few colleges,
people listened when a leader such as Lord Moran spoke. In November 1952 the
College of General Practitioners was formed in secret when the memorandum of
articles of association was signed by the 16 members of the steering committee.
The creation of a college, according to George Godber, provided ‘the banner with
a strange device’ that people could follow. The College ethos was, from the
start, to lead from the front. It encouraged high standards of service, teaching
and research, attracting theorists, for theorists cannot usually work alone.
After six months there were 2,000 members.183 Within four years it had developed
22 regional faculties. Although membership increased steadily, only a minority
joined; in 1957 the membership was a little over 4,000. College influence was
largely restricted to its membership and no responsibility was taken for the
weaker brethren Unlike the older colleges, membership played little part in
professional advancement. The GMSC had wider responsibilities and was in a
position to influence all GPs, as it did in 1954 when local medical committees
were asked to inspect practice premises.184
The crux of the College vision was that family medicine had its own skills and
knowledge base that were as important as anything the hospital services might
bestow upon it. The work of men such as Keith Hodgkin, a GP, and Michael Balint,
a psychoanalyst, was central to this. Balint, at case conferences at the
Tavistock Clinic, cast new light on the nature of the consultation and was an
important figure in the establishment of general practice as a discipline in its
own right.185 He argued for a different type of education and
research, and pointed to the relationship of the GP and the consultant as a
perpetuation of the pupil-teacher relationship.186
One of the College’s first initiatives was to see what, if anything,
medical students were taught about general practice. A survey published in 1953
showed that, although medical students from a number of schools visited GPs, and
many schools were ‘planning’ some opportunity for the teaching of students by
GPs, only Manchester and Edinburgh had such a teaching unit in the medical
school.187 It was the beginning of a struggle to attain recognition
of general practice as a subject entitled to a place in the overcrowded student
College epidemic observation unit in Surrey began to plot infectious disease in
the community. The Birmingham research unit, led by Crombie and Pinsent, was
interested in mathematical modelling of general practice and took the lead in
national morbidity surveys. Crombie, in a remarkable research project, ran
surveys under the auspices of the College and the General Register Office.
Between May 1955 and April 1956 careful records of a year’s consultations were
kept by 106 practices, involving 400,000 patients and 1.5 million contacts.189
These practices provided a clear description of their clinical work. The study
showed who was consulting GPs for what, and what was being referred to hospital.
Consultation rates for cancer, neurosis, circulatory and respiratory disease,
and arthritis and rheumatism were provided for the first time and the surveys
improved knowledge of the incidence and prevalence of most forms of disease. The
CMO at the Ministry, Sir John Charles, thought it an important source of data
that should affect decisions on medical student training.190
Towards a vision for general practice
Iain Macleod, the Minister, addressed the Executive Councils’ Association in
October 1952 about the future.191 The BMJ thought it a refreshing and forthright
speech in line with BMA policy. Macleod stressed the desirability of treating
patients in the community and sending them to hospital only when medical or
social conditions made it essential. This would increase the interest of general
practice, be of benefit to patients, cut waiting lists and save money. Reduction
of list sizes and the development of group practice would help. Co-operation
between hospitals and GPs needed improvement, for example by expanding direct
access to X-rays and pathology departments that GPs were increasingly using.
Without encroaching on the responsibilities of the local health authorities, Ian
Macleod thought that the GP should be the clinical leader of a team within which
the midwife, the district nurse and the health visitor should all work. The GP
should also work more closely with dentists, pharmacists and opticians. There
should be the same spirit of teamwork devoted to the patient in general practice
as in hospital.192 A renaissance of general practice began, on a new model laid
out by the profession and the Ministry.193
The Danckwerts award opened the path ahead but it did not solve all problems.
Variation of practice standards remained a consequence of independent
practitioner status, for while the energetic could improve their practices
substantially and rapidly, not all GPs did and their patients suffered. Enoch
Powell wrote in 1966 that whether the practitioner was good, bad (up to the
point of incurring a disciplinary stoppage) or indifferent, he got the same
payment for the same list. Inside general practice he could increase his
earnings only by increasing the size of his list. The doctor was not primarily
dependent on ability or reputation to increase his list, and in such competition
as there might be, the doctor’s willingness to prescribe a placebo or the drug
recommended by the patient, or to complete the desired certificate, might be as
effective as skilled and conscientious care. The GP’s situation combined private
enterprise and state service without the characteristic advantages of either. He
could not reap the rewards of building up a practice, and the better he did his
work the worse off he was. Money spent on premises, equipment and staff did not
increase his income, for the cost came from an income that would be undiminished
if he did nothing. If he restricted his list to the number that could be treated
properly, he merely ended with a smaller income than less able or less
scrupulous fellows. Powell believed that the essence of the private enterprise
system, competition for gain, had been gouged out of family doctoring, leaving
the empty shell.194
The 1946 Act required local authorities to consult hospital authorities and the
executive councils about their health service plans.195 The transfer
of the general, long-stay, tuberculosis, infectious disease, mental illness and
mental handicap hospitals to the RHBs substantially reduced their role in the
direct provision of care, as did the proposed integration of preventive clinical
services with general practice. Environmental sanitation was passing to
engineering specialists, sanitary inspectors were becoming more expert and
independent, and infectious disease seemed to be diminishing and to require
collaboration with the PHLS, national and even international authorities. The
role of the MOH changed from the development of services to helping services
provided by others, co-ordinating them and reviewing their effectiveness. Those
believing that public health should be managerial and deliver services saw the
passing of a golden age.
However, local health authorities retained broad and important health functions
and a few additions, enabling the MOH to maintain a role as guardian of the
community’s health. Many, for example George Townsend, the MOH for
Buckinghamshire, accepted that there had been gains as well as losses, and
quietly took the opportunities offered. Several components of health care had
been put together for the first time and there was work to be done. Some
services had been in difficulties, the voluntary nursing associations were
inadequate and failing, and health visiting required reorientation. The NHS Act
contained a provision enabling local health authorities to provide ‘care and
aftercare’ that enabled them to develop facilities for the mentally ill and
handicapped. Immunisation needed reorganisation, and the programmes had to
involve GPs and be capable of prompt expansion. Maternal and child welfare and
health visiting were already established; home midwifery had been under partial
local authority control; and ambulance services were derived in part from
local authorities had full responsibilities for nursing in the community and the
development of preventive and social support services, for example the home help
services. Some large authorities had appointed superintendent nursing officers
before the NHS began and all now began to do so, developing leaders of the
public health nursing team just as matrons in hospitals were looked on as
leaders of hospital nursing teams. At first many used voluntary nursing
organisations, such as the Queen’s Institute, as their agent. Rapidly, however,
local authorities brought the nursing services in-house. Everyone now had access
to care, and hospitals discharged patients increasingly rapidly which meant that
more acutely sick patients had to be cared for at home, altering the work of the
district nurses substantially and revealing shortages of staff. Health visitors
had once dealt with a host of minor problems. Now that everyone had a GP, these
were taken to the family doctor. GPs were taking an increasing interest in
mothers and babies, and it was possible that health visitors might be squeezed
out of a viable role.196 In 1953 a working party was established, chaired by the
then recently retired CMO Sir Wilson Jameson, to advise on the work, recruitment
and training of health visitors. The health visitor’s role was defined as
primarily health education and social advice. She should become a general family
visitor, making a contribution in fields such as mental health, hospital
aftercare and the care of the aged. The Jameson working party saw a need for
co-operation with GPs, but dismissed the idea of attaching health visitors to
particular practices, thinking that health visitors would work on an area basis.197
In 1954 MacDougall, MOH for Hampshire, provided health visitor support for
groups of GPs in Winchester by attachment; a little later Warin developed a
similar scheme in Oxford, as did Chalke in Camberwell, an inner city area.
Community nurses were coming into contact with a wider range of professionals
and were now full professional partners and members of the general practice
centres, first proposed in the Dawson report
of 1920, were a local health
authority responsibility.199 Part of the dream of the founders of the NHS, there
was no practical experience of their pros and cons. Six months before the start
of the NHS the Ministry stated that, because of building difficulties and
uncertainty about the best pattern to adopt, no general development of health
centres was appropriate. This and GPs’ suspicions of a state service, an idea
hopelessly entangled with health centres, slowed development to a virtual
standstill. Two opened in 1952, a large and costly one (planned before the NHS
began) by the London County Council to serve a new housing estate at Woodberry
Down200 and a smaller one, the William Budd health centre in
Bristol.201 In the first 15 years of the health service only 17 were opened. The
health centres provided doctors, patients and ancillary staff with many
advantages and few disadvantages were apparent. Many GPs, however, used the
centres only as branch surgeries.
Health promotion and disease prevention made a measure of progress in the first
decade. One pioneer was John Burn, the Salford MOH, who established the first
anti-smoking clinic. He helped the development of mental health services, and
the use of nursing staff in immunisation and screening clinics. After the London
smog of 1952 he was a member of the committee that engendered the Clean Air Act
1956, a massive advance in creating a healthy environment.202 But
there was failure to grasp the nettle, centrally, of the growing consumption of
alcohol, or fluoridation or, most of all, smoking-related disease.
On the appointed day in England and Wales the NHS took over 1,143 voluntary
hospitals with some 90,000 beds, and 1,545 municipal hospitals with about
390,000 beds (including 190,000 in mental illness and mental handicap
hospitals). Experienced and influential SAMOs, who, in their local authority
days, had experience of hospital management, headed most RHBs. They understood
the need to develop good specialist services accessible to the entire
population. The demand for hospital care was rising. New surgical procedures for
common conditions such as varicose veins increased the demand for beds, making
it important to discharge people more rapidly. There was great pressure on both
acute and long-stay beds, and continuous attempts to increase turnover and
occupancy. As a result of the appointment of young well-trained consultants, the
quality of provincial district general hospitals improved. Such was Kenneth
McKeown, from Hammersmith and King’s, who was appointed to Darlington in 1950 as
its first consultant surgeon.203 No longer did major surgical cases
have to go to Newcastle, Leeds or London, and McKeown established the hospital
as a centre for oesophageal surgery. For the first time, major developments
emerged from district hospital specialists. They included Norman Tanner, who
worked on the surgery of peptic ulcers at St James’ Balham, Harold Burge, who
explored the results of vagotomy at the West Middlesex Hospital, and John
Paulley at Ipswich, who showed the mucosal abnormalities in coeliac disease.
Supporting them were better investigation and diagnostic services with good
pathology and radiology departments. Intervention was prompter, and improved
anaesthesia, no longer a part-time activity for some GPs, meant safer operations
for older people. The very success of the NHS created a problem. Even patients
with emergency problems such as retention of urine or with curable diseases
might be difficult to admit. The BMJ drew attention to the shortfalls in the
service; the dangers of going to bed, described by Asher, could be contrasted
with the dangers of not going to bed.204
St George’s female medical ward, June 1951
Tuberculous meningitis ||
acid, aludrox, thyroid, gastric diet|
Right hemiplegia ||
rheumatism ||27 ||
Pernicious anaemia ||
71|| || |
Fractured femur ||
70|| || |
Mitral stenosis ||
33 || ||For
Investigation of headaches
Costophrenic pleurisy ||
40|| || |
65 || ||Nepenthe,
Coronary infarction ||
55|| || |
Ulcerative colitis ||
44|| ||Low residue
diet, chiniofon infusion|
Acute rheumatism ||
24 || ||
24|| ||Bed rest,
methyl thiouracil, phenobarbitone|
30 || ||Aspirin|
Coronary infarction ||
Investigation of right kidney
60|| || |
Sonne dysentery ||
Macrocytic anaemia ||
peritonitis || || ||
Congestive heart failure ||56 ||
||Digitalis folia, cardophyllin|
Duodenal ulcer ||34||
||Pethidine, gastric diet|
Subacute bacterial endocarditis
Investigation of lung ||
Almost all had daily blanket baths and night sedation
The Portsmouth hospitals took the bold step of issuing a patient questionnaire.
Half were returned and two-thirds of those were wholly laudatory. There were,
however, suggestions. Perhaps the food might be warmer, and lavatories more
available. The hair mattresses were lumpy and the wireless service could be
better. Lack of privacy, of chairs for visitors and adequate visiting times
featured among the criticisms. Could not mothers be allowed to handle their
newborn babies more often before discharge?205
limited materials and a strained economy the government’s post-war priorities
were housing and education. However, as money and materials permitted, thoughts
turned to hospital building. Hospital surveys, such as the one for Sheffield
with which George Godber was associated, had outlined a development policy.
Sites should be large enough to allow for expansion and the first new buildings
on a site must be placed in a way that did not prevent this. Plans should be
examined and approved by a central authority, informed by clinicians, matrons
and administrators experienced in hospital work.206 In 1949 the
Nuffield Provincial Hospitals Trust, with the co-operation of the University of
Bristol, sponsored an investigation into the design of acute hospitals and
established a team, led by Richard Llewelyn Davies, that included architects,
statisticians, doctors and nurses. Its report, published in 1955 as Studies in
the functions and design of hospitals, laid the foundation of future hospital
design in the UK.207 An attempt was made to combine experience and
new thinking, and to take advantage of good practice and new designs world-wide.
The study examined the requirement for hospital accommodation, using information
from surveys in the Northampton and Norwich hospital groups to estimate the
demand from the surrounding area. It looked at the physical environment,
heating, lighting, ventilation, the control of noise and fire precautions and it
also covered the detailed design of individual departments. Throughout the
study, architectural proposals were put firmly in the context of clinical
policies and how staff worked.
Little new hospital construction was possible until 1955. Even then there was
not enough money for whole new hospitals, only for individual departments, for
example outpatients, and the replacement of antiquated plant in laundries and
boiler rooms. The Ministry issued a bulletin on the most urgent problem,
operating theatre suites, of which 700 were built in the first decade. Other
building guidance followed. Teaching hospitals were now a national
responsibility and perhaps a disproportionate amount of money was spent on them,
particularly in London. It was necessary to decide how costs should be divided
between the NHS and the universities. Most of the cost inevitably fell on the
board of governors, but the areas used for teaching (e.g. seminar rooms) were a
university responsibility. As to research, the NHS provided facilities for
research on patients being investigated or treated, but other facilities such as
animal houses and research laboratories were a matter for the university.
the teaching hospitals had retained their boards of governors and their
traditional organisation, other hospitals had been grouped functionally under
HMCs. The smaller voluntary hospitals, and municipal hospitals whose system of
management owed little to the voluntary tradition, now had to work together. For
example, Salford Royal Hospital, small but proud of its past, was now coupled
with Hope, the municipal hospital, three times its size, part Victorian
buildings and part pre-war modernisation, and an excellent hospital in its own
right. In the voluntary hospitals it had been traditional for there to be a
partnership between the governing body, the house governor, the matron and the
chairman of the medical committee representing the visiting staff. The municipal
hospitals, however, had enjoyed little local autonomy. The medical
superintendent was in charge, the matron and lay staff reported to him, and he
to the MOH. The two types of hospital had to adjust to the new situation.
Committee was appointed to examine the situation for the Central Health Services
Council in 1950.208 Bradbeer reported in 1954 that each hospital was
a corporate body with a morale of its own that made for efficiency. The report
commended the locally based partnership of medicine, nursing and administration
that had characterised the voluntaries. Each hospital should have a medical
staff committee with a consultant working part-time on administrative matters.
At HMC or ‘group’ level there should be a single administrative officer to whom
the governing body could look for the co-ordination of all activities; he (or
she) would not be a doctor and there should be a move away from medical
superintendent posts. As chief executive officer most business should be
submitted through him to the management committee. After Bradbeer, the group
secretary became more powerful and more distant from the clinicians and the
Hospital information systems
Changes in hospital staffing and activity
Inpatient cases 2.9
million 3.1 million
3.3 million 3.4 million
6.1 million 6.2 million
6.3 million 6.4 million
dental staff (a) 8,954
midwives (a) 125,752
Waiting lists (b) 492,000
Bed turnover (c) 9.5/year
a Whole-time; part-time excluded.
b Includes mental illness and mental handicap.
c All specialties except mental illness and mental deficiency.
Source: On the state of the public health; annual reports of the CMO
Information about the hospitals’ clinical services was hard to find and would
clearly be needed. From 1949 an annual return was required of all hospitals,
showing the number of staffed beds, the number in use, their daily occupancy,
the number of patients treated, and the waiting list for admissions on the last
day of each year. However, this return was not available until it was months out
of date and was not a tool for effective management. Shortly before the NHS
began the Ministry’s CMO, Wilson Jameson, asked George Godber to look at the
problem and a team was assembled chaired by Sir Ernest Rock Carling, including
Austin Bradford-Hill, Alan Moncrieff, Francis Avery Jones and Percy Stocks (a
statistician from the General Register Office). A front-sheet was designed,
simple enough for even the least organised hospital. It recorded key
information: name, diagnosis and length of stay. In 1949 the Ministry invited
volunteer hospitals to use this sheet and supply a 10 per cent sample of
patient-based data for analysis, the hospital inpatient enquiry (HIPE). A step
in the right direction, HIPE relied on medical record officers choosing a random
sample of case notes and not, for their convenience, the shortest ones. The
scheme became compulsory in 1957 and was run centrally by the General Register
Office.209 Each year the number of beds available rose slightly and
the number of cases treated increased by about 100,000, largely from more
effective use of beds and shorter lengths of stay. There was little impact on
waiting lists, which remained stuck around half a million and were worst in
general surgery, gynaecology and ENT. For tuberculosis new methods of treatment,
shorter lengths of stay and the use of isolation beds to clear the backlog of
patients all but eliminated waiting lists and made resources available for other
types of work. Better use was made of existing facilities but the effect of
better planning was absorbed in previously unmet needs. Obstetricians were
arguing for hospital delivery and mothers were responding. The performance of
hospitals differed. Non-teaching hospitals generally had shorter lengths of stay
than teaching hospitals. London teaching hospitals on average kept patients
longer than those in the provinces, and in extreme cases there were threefold
During the blitz the teaching hospitals had been forced to leave London. Some in
the Ministry pensively hoped that not all would return, for post-war housing
policy was to rebuild homes on the periphery, often in the new towns, and to
move the population outwards. All, however, returned. The Goodenough Report (in
1944) and the Hospital Survey for London (in 1945) had argued that three
teaching hospitals should move from central London; St George’s, Charing Cross
and the Royal Free. Bevan wanted the war-damaged St Thomas’ to move to Tooting
but he was persuaded to change his mind. In 1949 George Godber took him to St
George’s to persuade that hospital to move to Tooting where general hospital
facilities were needed. To help the selection of building schemes and
discussions with London University, a new survey of the hospitals was launched
in 1955. Four Ministry officials visited all London’s hospitals to see what
changes might be needed because of the substantial movement of population
outwards that was now taking place.210 They found that hospital
development in the new areas had been slow and irregular, that some central
hospitals such as St Mary’s still served large local populations, but others
such as the Middlesex and St Bartholomew’s had falling local catchments. Lacking
local facilities, the growing peripheral populations were increasingly dependent
on central hospitals, so it became policy to develop a ring of district general
hospitals in outer London. Teaching hospitals were at greater risk of losing
their patients. Yet the University of London believed that the London medical
schools, and therefore their matching hospitals, should be as close to the
university precinct as possible and opposed plans for relocation. Charing Cross,
which had hoped to move to the new hospital being built at Northwick Park, had
to remain more centrally, and the Northwick Park site became available to the
An unusual activity for a health service, left over from pre-war days, was
hospital farming. It had developed mainly in conjunction with mental illness and
mental handicap hospitals. The Ministry found that 190 hospitals in England and
Wales were farming 40,000 acres without saying much about it. There were 3,800
acres of market garden and 4,000 acres of woodland. There were 7,000 cows and
heifers, 25,0000 pigs, 5,000 sheep and about 63,600 poultry.212 Farming as a
whole was losing money and there was a tendency to buy extra land to make the
farms more economic. The Ministry felt that farming was being developed for its
own sake, and included the maintenance of pedigree herds. In 1954 it was pointed
out to the NHS that the Minister had no authority to run farms unless they were
an essential part of a hospital; were the activities justified in each case?
Regional boards set up small committees, and Sir George Godber told the story of
rows about the future of a piggery in Kent. When it had reached a conclusion,
the committee adjourned to view the pigs - which had all mysteriously
disappeared as part of the hospital diet.
Medicine was one
of the few degrees with a national control on student intake. From 1945 onwards
between 2,500 and 2,700 students were admitted annually and the medical
profession was concerned that there might be too many doctors.213 In 1950 the
BMJ said it was reasonable to accept the current size of the profession as
satisfactory and not to expand it further. It was foolish to spend six years
training someone who would then be given routine work that could be done better
by a clerk or an auxiliary after six months’ instruction. By 1954 numbers had
risen by more than a third since 1939. The BMJ pointed again to the risk of
overcrowding the medical profession.
It was doubtful if the country ought to be
paying for the training of so many students; perhaps medical schools should
reduce their intakes.214 One problem was medical immigration;
hospital returns did not show the origin of junior staff, and it was not
appreciated how many came from Commonwealth countries. More broadly, ensuring
enough bright young people in the other professions, teaching, science and
engineering was also important. In February 1955 a committee under the
chairmanship of Henry Willink was appointed to estimate the number of doctors
likely to be required in the long term.215 It included the great and
the good, people such as Lord Cohen, Professor Sir Geoffrey Jefferson and Sir
John Charles. Two points of view were put to the committee: first that an
adequately staffed, comprehensive and rapidly expanding service needed more
doctors; second that too many doctors were already being trained for the
positions likely to be available. Even before the recommendations were published
some medical schools cut their entries because they had been swamped with
ex-servicemen taking medicine, as well as the normal intake of 18- to
20-year-olds and sometimes substantial numbers of students from overseas. The
committee, having reviewed each branch of the profession, concluded that there
was indeed a risk of overproduction. Because it took at least five years to
train a doctor, the numbers in the pipeline were already determined but from
1961 to 1975 a reduced student intake would put the numbers back in balance.
After that, some expansion would again be needed. The committee arrived at the wrong
answer, largely because of a lack of appreciation of the numbers emigrating and
immigrating. Willink’s name became a byword for disastrous planning.
Women played a small part in the medical staffing of the health service but
their numbers were rising. Because of the recommendation of the Goodenough
Committee that medical school funding should be dependent on a policy of
co-education, this became the norm. In 1948/9 there were 2,931 women medical
students compared with 10,281 men. In London, at University College Hospital and
King’s College Hospital the ratio was 1 to 5. The nine other schools remained
the stronghold of the male. Three ‘lagging behind in gallantry’ were Guy’s, The
London and the Westminster, where less than 5 per cent were women.
The aim of medical education had been to produce ‘a safe doctor’. On passing
finals a student could in theory practice immediately without further
supervision. The RCP, in evidence to the General Medical Council, said that it
was no longer possible to give a full training in all branches of medicine
before qualification and the attempt to do so should be abandoned.216
From 1 January 1953 full registration for unsupervised practice was not granted
without proof of post-qualification experience. Newly qualified doctors had to
work in a resident medical capacity at an approved hospital, institution or
health centre, for 12 months. Usually this meant six months as house physician
and six as house surgeon. At the end of a year they could in theory do anything,
although junior hospital doctors continued under supervision, and if entering
general practice it would usually be as an assistant.
The specialists of the future were educated in the environment in which they
would be working. That was not so for general practice, because undergraduate
and postgraduate education was hospital-based. Marshall Marinker called it a
colonial epoch with journals carrying good news from the hospital to the GP.217
However, the BMA under the chairmanship of Henry Cohen, reviewing medical
training in 1948, considered that there might be a GP component of undergraduate
training, that GPs might be on the teaching staff and that students might visit
practices.218 In 1950 a second committee recommended that future GPs
should have a year of supervised practice, though nothing was said about the
quality of the trainer.219 The Goodenough Report had stressed
postgraduate education. Sir Francis Fraser, formerly Professor of Medicine at St
Bartholomew’s and during the war Director General of the Emergency Medical
Service, was appointed to develop postgraduate medical education in London.
Failing in his ambition to establish a postgraduate teaching hospital in
Bloomsbury, he welded the postgraduate institutes into a single school of the
university, the British Postgraduate Medical Federation. His experience of
wartime organisation had led him to the idea of regional postgraduate education
long before the introduction of the NHS.220
Hospital medical staffing
From the outset there was a significant difference in the approach to manpower
planning for GPs and for consultants. GPs were independent contractors
appointing their own successors and colleagues. There were few controls other
than a prohibition on entering over-doctored areas. It was largely up to the GPs
to decide whether they wanted, or could afford, to expand their practices by
accepting more patients or taking on a partner. Government wanted an adequate
number of reasonably trained GPs rationally distributed and was not too
concerned about the details.
It was different for consultants, who had chosen to be employees. A career
structure based loosely on the pre-war hierarchy of juniors in the teaching
hospitals was put in place (consultant, senior registrar, registrar, senior
house officer and house officer). Pay of consultants and juniors was based on
the reports from the Spens Committee, of which Lord Moran was a member. Key
recommendations were that there should be equality of remuneration between
different branches of specialty practice, and equality of status between
different hospitals.221 If those in prestigious fields were to earn
more than others, and the pay was to be greatest in teaching hospitals, there
would be no hope of providing a full service throughout the country. Spens
recommended that there should be distinction awards allocated by a predominantly
professional body, to provide an adequate reward for those of more than ordinary
ability. Specialists who undertook teaching responsibilities should also have a
claim to higher pay. The Spens reports established a basic grade, equal in all
specialties and places, but it looked more equal than it was. Merit awards were
slanted towards general medicine and general surgery, the regional specialties
consultant posts were not established immediately; in the first year each region
was required to set up a review committee with two outside assessors from the
Royal Colleges to grade hospital staff. They had to decide how much time should
be spent in each hospital, and which individuals should be regarded as
consultants. Some, though able to make a valuable contribution to the NHS, were
considered below this standard. Many of these were in the tuberculosis service
or psychiatry; 2,000 senior hospital medical officer (SHMO) posts were
established for them, and they were offered the chance of a later review. Some
GPs who had worked extensively in hospital were graded as consultants. Many who
had previously held staff appointments turned wholly to general practice or
found that specialists had been brought in to take over from them. Over two
years the move towards specialism, which had been taking place slowly throughout
the century, was completed. The availability of health service finance for
consultant appointments accelerated the process of professional evolution and
the profession was now divided clearly into consultants and GPs.222
In 1948 there were about 5,000 consultants. Establishments could not be brought
immediately to the level set out in the Memorandum on the Development of
consultant services.223 It took a long time to train specialists and
there were severe shortages in pathology, psychiatry, radiology, anaesthetics
and paediatrics. Some regions, for example Newcastle, North West Metropolitan
and Oxford, moved ahead of others, getting staff while money was still
available.224 Many senior registrar posts were established,
particularly in general medicine and surgery, often when the real need was for
more consultants. Early statistics suggested that there were twice as many
senior registrars as were likely to find consultant posts. In 1950/1 regions
were required to appoint small committees of senior or recently retired
specialists to give their views about specialist staffing. Some of their
estimates were clearly too high and there were such bizarre differences between
regions that making the findings of the review public was quite impossible.225
The Treasury took fright at staff costs and the teams were quietly stood down. A
central Advisory Committee on Consultant Establishments was established, chaired
by George Godber, which included the JCC and professional advisers. It worked
constructively, examining all applications for consultant posts, channelling
them to the regions in greatest need, and trying to reduce senior registrars in
overcrowded specialties such as general medicine and general surgery, and
increase those in anaesthesia, psychiatry and pathology. Consultant numbers
slowly increased by about 200 a year but regions did not always get what they
wanted. In the early 1950s the South West Metropolitan RHB wanted to improve
psychiatric services in the cluster of hospitals near Epsom. It applied for 20
psychiatrists in a single year, equivalent to the entire UK training programme.
Sometimes those in general specialties objected to the appointment of colleagues
who might, as in dermatology, relieve them of an interesting facet of their
The position of young
doctors was given less attention. From 1952 controls were imposed on the senior
registrar grade. There were 2,800 senior registrars in post although the career
structure required only 1,700, and consultants were being appointed at 38-40
years of age, instead of at 32-35. The Ministry helpfully pointed to the
vacancies in His Majesty’s Forces and the Colonial Medical Service.226
When the growth in numbers of senior registrars was stopped the registrar grade
grew unchecked. Registrars had not committed themselves to particular
specialties, and the grade was often used to help staffing problems. This
mistake had far-reaching effects for which the health service is still paying.227
Some registrars were prepared to pursue a slim chance of ultimate appointment as
a consultant rather than enter general practice.228 The position was
only made worse by attempts to restrain growth of the consultant grade as an
and the Royal Commission
Doctors’ pay became a major cause of dispute. Spens had suggested a starting
point based on 1939 money, leaving to others the problem of adjusting this to
‘present day values’. A differential had been established between the
consultants and the GPs; the Danckwerts review had increased the GPs’ pay
substantially, closing the gap. There was also concern about cost-of-living
adjustments. In 1955 the BMA put forward a betterment factor of 24 per cent to
cover the period 1951-1954; the Ministry of Health did not agree. The BMJ said
This one-sided tearing up of a treaty is something which neither the profession
nor we believe the public will in any circumstances tolerate. The recent replies
from Ministry spokesmen are what we might expect from the Artful Dodger but not
from men in a responsible position.230
The Times was similarly attacked by the BMJ. The professional classes as a whole
were being squeezed out of decent existence. It was not only their economic
position that was at stake but also a way of life that, with all its faults, was
a powerful force for good in the country.231 The government’s repeated refusal
to deal with pay claims on the basis of the Spens recommendations was seen as a
breach of faith; possibly a breach of contract which should be tested in the
Courts. Ministers in succession found reasons for inaction; Spens could not be
afforded, it was inflexible or unrealistic. Perhaps something new should be
sought.232 Lord Moran said Spens could not be thrown on the dust heap
merely because it subsequently proved inconvenient. The government, shaken by
the size of the Danckwerts award to GPs, finally repudiated Spens in 1957. It
denied that it formed the basis of a contract, implying that doctors could
challenge this in court if they wished.
In March 1957, Harold Macmillan, the Prime Minister, announced a Royal
Commission on medical pay. It would look at medical earnings in comparison with
the other professions, rather than upgrading pay in line with inflation. Sir
Harry Pilkington, Chairman of Pilkington Ltd and a director of the Bank of
England, was the Chairman. Punch published a David Langdon cartoon showing a
Greek physician expostulating with Hippocrates about his new oath - ‘This is all
very fine, Hippocrates, but there’s nothing here about pay.’233 The doctors
thought that comparisons might be misleading and initially the BMA refused to
co-operate. GPs were 24 per cent worse off than they had been in 1951 and were
threatening resignation. The consultants wished to take whatever action they
could; some were considering emigration. By May, however, there were new
assurances. An exchange of letters between the Prime Minister and the profession
led the RCP (rapidly and somewhat eagerly), the GPs and the doctors more
generally to accept the Commission and to submit evidence. The BMA did so in
Nurse education and staffing
There was no provision in the NHS Act 1946 for the training of nurses, and no
organisation within the service charged
with the responsibility for it. Bevan was well aware of this and the Ministry
made farsighted proposals after the Wood Report (published in 1947). During
lengthy discussions preceding the passage of the Nurses Act 1949 the nursing
organisations whittled away ideas such as student status for recruits to
nursing, and new training bodies separated from hospital management. They turned
down the very reforms which they later struggled for many years to achieve. The
most significant development was probably the growth of experimental forms of
training.235 [Training of nurses had been a major issue since
the time of Florence Nightingale and registration - fought for by Mrs (Bedford)
Fenwick - dated from an act of 1919 coming into force in 1923. This badge,
no 1001, was one of the first issued.]
From the outset there was a grave shortage of nurses, and many hospitals were
critically dependent on students. For 600 beds, Aberdeen Royal Infirmary had 93
trained staff and 330 students.236 The NHS was reckoned to have
48,000 too few nurses, so that on the one hand there was a need to expand the
labour force and on the other an awareness of the risks of diluting a skilled
staff by unskilled and semi-skilled people.237 Nurses were afraid
there would be direction of labour, as in wartime, and that they would be sent
to any hospital where there was a severe staff shortage. Bevan told them there
was no power of direction; at most they would be asked - not ordered.238
State registered nurses were supplemented by state enrolled assistant nurses who
undertook a shorter training and in theory were restricted to more limited
roles. There was also a shortage of midwives as a result of public demand for
more hospital confinements.239 There was grave concern about the
staffing of sanatoria, chronic sick hospitals, mental illness and mental
deficiency hospitals. Better methods of treating tuberculosis solved the first
problem, and only slowly did a new outlook on the care of the elderly chronic
sick together with the grouping of hospitals made their care easier. The
problems of the mental illness and handicap hospitals were approached by
attempts to select students more carefully to reduce wastage, recognition of the
nursing assistant as an essential member of the team, and secondment of student
nurses from general hospitals to gain experience in mental illness nursing as
part of their training.
was recognised that, although many student nurses enjoyed their training, until
conditions improved in the worst of the hospitals, students and trained nurses
would continue to leave. On the other hand,
the country secured more nurses it would be impossible to improve the conditions
of which the nurses complained.240 Nursing absorbed a large and
increasing proportion of young women entering the job market. The Minister of
Labour, Walter Monckton, said that in 1939 there had been 160,000 nurses in the
country, but by 1952 this had risen to 245,000. The number of women reaching the
age of 18 had, over the same period, fallen by 100,000. Twenty-one thousand
entered the nurse training schools annually, a high proportion of those with
appropriate educational qualifications. Although the NHS would have more things
to do, there would be no more people to do them. Policies would have to conform
to that reality.241 Nationally, the ‘wastage’ in the student years
was 55 per cent. Before the second world war the General Nursing Council (GNC)
had insisted on a minimum education level for recruits to nurse training, either
school certificate or the GNC’s own test. This requirement was dropped on the
outbreak of war and not restored afterwards. The educational level of nurses had
fallen, save in large voluntary hospitals that had been able to maintain an
entry requirement and still be selective. The official policy of both the GNC
and the RCN was to re-introduce a minimum educational level but there were
internal divisions and neither the Minister nor the hospital authorities wished
to take the risk of making matters worse.242 St George’s, Hyde Park
Corner, was among many hospitals wishing, as Wood had suggested, to improve
selection and reduce wastage. A wide and varied group of performance tests were
given to a group of 126 nurses who were also assessed by three independent
judges on a rating scale covering 18 traits of personality and ability.243
Intellectual capacity and personal relationships were found to be the key
characteristics of the good nurse, and it was hoped that selection based on
these principles would reduce the number of unsatisfactory candidates accepted
Nursing Reconstruction Committee (1942-1950) issued its third and final report
on economic factors and nurse recruitment.244 Fifteen thousand new
students were needed annually, and, unlike entrants to most professions, nurses
gave their services while learning. Hospitals regarded nurses as cheap labour,
and there was no reason now, in a state service, for students to continue to
subsidise the NHS at the expense of their own training. Students asked for
practical bedside training, and for teaching that related theory to practice.
Horder recommendations (1950)244
Bedside work essential for training
Hospitals not to exploit students
Part-time working to be encouraged
Adequate pay for all nursing posts; equal pay for equal work
Nurses should help shape policy
Something was wrong with nursing; Professor Revans of the Department of
Industrial Administration, at Manchester University, was funded by Nuffield to
study the profession. His work suggested that nursing was a profession in
transition. It had developed at a time when there were more women than jobs.
Nursing and domestic service had been seen as God’s ways of ensuring that the
idle fingers of middle and working class women were not led into wickedness by
the Devil. Obedience was paramount and authority was worshipped. As a result
hospitals, while attracting a large number of recruits, were careless in their
handling and blamed the young women for leaving rather than themselves.
Hospitals had widely varying levels of sickness and wastage; both were functions
of the hospitals’ management. While student nurses had many grouses, the
greatest was the fear of not being up to the job. Only the ward sister could
give her confidence, and ward sisters had many other problems to cope with.
Hospitals must address the problem; the age of authority and abundance of cheap
labour was coming to an end.245
The GNC revised its own training syllabus to include preventive and social
issues as well as curative aspects of nursing. In 1956 the RCN published a
statement of nursing policy. It reviewed established principles of the nursing
profession in the light of social and economic change and developments in
medicine, taking into account the recommendations of Lord Horder’s committee.
The College looked at both ‘horizontal’ and ‘vertical’ issues. Horizontally
there was the need to sustain recruitment while maintaining standards of entry
by careful selection. Nurses in training should be given the tasks important to
learning rather than to the hospital. Nursing teams, under the direction of a
state registered nurse, were in the best interests both of the patient and of
conserving nursing resources. ‘Vertically’ the profession should develop its
leadership and look to the future, bringing into the profession more trained
minds with a broad outlook, perhaps through a university degree course. In
future nurses should be involved in health service management, as in the
tripartite teams of hospital administrator, physician and matron, and make a
nursing contribution to policy, for example on management bodies, the Ministry
and the Central Health Services Council. Training for leadership and to develop
nursing on a factual and research basis was therefore important.246
One opportunity was the University of London diploma in nursing, a two-year
part-time course for nurses both in hospital and in public health. It covered
basic medical sciences, preventive and social medicine, social psychology and
modern nursing developments. Many of the profession’s high-flyers took the
diploma. Was there a place for a higher qualification? If it were to be accorded
a place in a university, nursing must demonstrate its own principles and laws;
it must be neither lesser medicine nor a phase of social work, but valuable in
itself. Academic studies would have to be strictly relevant to the practice of
nursing, as medical education was relevant to clinical practice.247
The influence of North American nursing
For the next 50 years British nursing was continuously under the influence of
developments in North America even though, in the view of Virginia Henderson, an
outstanding American professional leader and educator, the relationship of the
doctor and the nurse in the USA was not the same as in the UK. American doctors
prescribed nursing care, but nevertheless might feel threatened by the
experienced nurse, there being more friction than in the UK.248
Nursing in the USA had a long-standing academic basis, while it was only in 1956
that the first British nursing studies unit was established, in Edinburgh. A
course in hospital economics for nurses at Teachers College, Columbia
University, New York, had been established in 1899. Under the leadership of
Adelade Nutting, a Johns Hopkins graduate and former superintendent of their
nursing school, the course grew into a nursing department offering a certificate
programme, a bachelor’s degree and later a graduate programme. From the
beginning the Teachers College programme was under pressure to provide nursing
with skilled and well-trained educators and administrators, and by the 1930s it
had become a cornerstone of nursing education. Virginia Henderson, and later on
its staff, pointed out that in the early days of nursing research when doctoral
degrees in nursing were not available, nurses obtained degrees in sociology,
anthropology or psychology instead and would naturally emphasise these
disciplines when they began teaching; hence the dominance of social sciences in
the American nurses’ curriculum.
Nurses in the USA struggled to achieve autonomy as individual workers and as a
profession, against hospital management and the existing culture of nursing
itself. The general culture assumed
that the nurse’s enduring authority should come from gender, not science; her
place of work was the bedside or hospital, not the laboratory. Hospitals, in
turn, demanded that nursing provide them with a workforce, not a research team.
Physicians primarily wanted assistants, not colleagues. Working nurses often
wanted reasonable hours, not more education, and nursing educators believed in
science, but could not agree on its meaning.249
American academics tried to redefine and change nursing and nursing education.
British nurses often went to work or to attend conferences in the USA to see
what was happening. Articles appeared in the Nursing Times describing systems in
use there, such as team assignment.250 The Wood Report had proposed a
two-year course, and the separation of nursing schools from the hospital
administration. The Nursing Times reported such an arrangement in Windsor,
Ontario, which ran from 1948 to 1952. The school was a university institution
and controlled the students’ time so that bedside clinical experience could be
integrated with the course syllabus. There was no conflict, as there was in
hospital schools, between the provision of a service and educational
requirements. The students liked the course, liked nursing and continued to
nurse. However, in spite of worldwide interest the system was ended, in part
because of the opposition of hospital management, the doctors and the nursing
profession locally.251 A similar experiment was funded by Nuffield at
the Royal Infirmary, Glasgow. It began in 1956 to test a more educational and
less vocational system of training. Students were resident in the school, not
the hospital, and took a two-year course to their finals, followed by a year as
a member of the hospital staff before registration.252 St George’s
ran a similar course.
Nurses were having to adapt to an ever-changing pattern of patient care. Only a
short time previously almost all patients were at some stage in their illness
completely helpless. Now the aim was to avoid the need for total care or to
diminish its duration as much as possible.253 Nurses needed to go
beyond physical needs and consider the relief of anxiety and pain. Earlier
discharge from hospital to the community also altered the pattern of the
district nurse’s work because continued supervision might be required.254
The Nuffield job analysis
After the Wood Report, the Nuffield Provincial Hospitals Trust explored the
‘proper task of the nurse’ and undertook a job analysis of their work in
hospital wards, directed by Mr HA Goddard. Nuffield selected hospitals with
nurse training schools, so there were no data on hospitals for the chronic sick,
a significant gap because some of nursing’s worst problems were in the chronic
wards where student nurses were seldom seen.255 Minute by minute, day
and night, the activities of nurses of all grades were tracked. Published in
1953, the report demonstrated that what was happening in the wards was not what
people thought. It called for a restatement of nursing theory:256
The special province of the trained nurse was satisfying patients’ human
needs, not just skilled technical nursing.
Nursing should be done by trained nurses, not supervised by them.Trained
nurses should be responsible for the total care of a specific group of
Undisturbed rest for patients was not possible as the day lasted from 5am to
The time spent by sisters teaching student nurses was negligible.
The end-result of nurse training seemed to be not nursing but
The trained nurse might still attempt to cover all the tasks concerned with the
care of the patient, but in practice she could no longer do everything, and many
tasks were undertaken by student nurses and orderlies. Basic nursing took up 60
per cent of the time of a first-year student nurse, but as she became more
senior she did less of this and an increasing proportion of ‘technical nursing’.
The heavy contribution made by student nurses to basic nursing exposed the
problem with the recommendation by Wood for ‘student status’; if education was
to take priority over service demands, who would do the work - more auxiliary
help on the wards? Sisters who thought they did much teaching, spent half their
time on ward organisation and only five minutes a day with student nurses. There
were two possible lines of development: the nurse could become recognised as a
technician, or she could insist that the basic and technical aspects of nursing
were indivisible. In the USA, the head nurse, graduate nurse, practical nurse
and nursing aide were each responsible for a particular aspect of the nursing
care of a group of patients. The danger was, however, that both basic and
technical functions originated in human need and were hard to divide. An
auxiliary making a bed might not notice the worsening condition of a patient
that would be immediately apparent to a trained nurse. Ward sisters had a
particularly difficult role, responsible at the same time for the care of
patients, administration of the ward and training student nurses. The study also
showed the inhumanity of a system that gave sick people little time to rest
during a 17-hour day. Nuffield established an advisory panel to comment on the
results of its enquiry. The panel said that nursing should be done by trained
nurses, not merely supervised by them. Basic nursing should not be delegated
wholly to an auxiliary grade, although a ‘second pair of hands’ was desirable.
Nursing skills should be conserved by the reallocation of many non-bedside
tasks, and wards should be divided into a number of nursing teams, each the
direct responsibility of a trained nurse. Goddard, the director of the enquiry,
was convinced that staff were not used to best advantage, and that there was, in
fact, an adequate number of nurses. When hours were spent moving screens about
the wards, or chaperoning doctors or on tasks not requiring their skills, the
problem was one of maldistribution.257 The Nuffield project suggested that
nurses themselves owed it to their patients to be more active in research, as
were the American nurses.258
Sister delegates to the nurses different duties, which each nurse carries
out for all patients in the ward.
Nursing personnel are divided into two or three teams, where possible a
staff nurse acting as team leader, the teams including an assistant nurse,
student or pupil nurses and perhaps a domestic orderly. The staff nurse
considers the needs of the patients and delegates duties according to the
skills of the individuals.
Each nurse is responsible for the total care of a certain number of
patients, conducive to seeing the patient as a whole person and considering
all his needs, social, mental, spiritual and physical.
Source: Catherine Hall, RCN General Secretary: Nursing Times, May 2, 1958.
An RCN official said that patients were being nursed more and more in bits:
student nurses did all the basic and most of the technical nursing, and the
qualified nurse forsook the bedside for administration.259 The House
of Lords considered the Nuffield Report and Lord Woolton, speaking for the
government, said that what the nurses needed was reorganisation. There could be
administrative support and greater use of orderlies.260 Lord Moran
(ex PRCP) said that while he hoped that administration was not the peak of every
nurse’s ambition, regrettably it represented promotion and was better paid.
Moran argued in favour of ‘dilution’, although this was controversial. There was
already dilution in medicine; nurses did jobs the doctors had done years
previously. The Minister, Ian Macleod, asked the Standing Nursing Advisory
Committee to study the report and patterns of ward organisation. Experiments,
particularly in ‘team nursing’, were set in hand. There was a five-year trial at
St George’s, led by the matron, Muriel Powell. Patients were divided into small
groups of 9-13 patients, each allotted to a separate team of nurses led by a
staff nurse. Team methods were based on the principle that good nursing involved
the total care of patients, and student nurses liked it because they could
practise total nursing within the team. It was a compromise between job
assignment that was cheaper but might be associated with poorer care, and case
(patient) assignment that was too expensive.261 On the whole a team
system produced high quality personal and technical nursing, and staff
satisfaction. There were, however, problems; team nursing was designed to
produce a higher quality but not a greater quantity of nursing care, so it was
less adaptable at times of pressure and crisis than job assignment. It was not
used at St George’s at night. The ward teams sometimes competed with each other,
even for equipment they wished to use simultaneously. The American literature
suggested that team organisation ensured better supervision of auxiliary nursing
staff and was more democratic; British literature stressed the more responsible
job for staff nurses, with wider responsibilities. It seemed important to keep
teams as small as possible, consistent with adequate trained supervision. Muriel
Powell also tried case assignment.262 Junior student nurses were
given two patients and seniors five. Students learned quickly, but the young
nurse might identify too much with the patient if he was very ill. Routine
duties might be ignored; the ward steriliser might boil dry.
In hospital, trained nurses might provide only 25 per cent of patient care; in
the district it was nearer 100 per cent. Local authorities developed training
schools for their staff. For example, in Essex the scheme, opened in 1951,
provided experience for student nurses, a part II midwifery training school and
theoretical training for Queen’s (district) nurses. There was a central nurses’
home, for many of the district nurses were resident; by 8.30 a.m. a fleet of
cars and bicycles were ready to leave the home in all directions, as the
district nurses went to work.263
Dame Elizabeth Cockayne, Chief Nursing Officer at the Ministry from 1948 to
1958, talked on the eve of her retirement about changes in nursing practice.
We find more physicians discussing patients’ problems with the nursing team and
we have seen the nurse-patient relationship change with the progress in
medicine. The patient’s point of view is given more attention today, indeed the
patient is part of the team. We find ourselves doing things with patients, and
not just for them as previously, leading them to self-direction and graduated
degrees of independence. As a profession we need to become increasingly
self-analytical, and to examine what we are doing and why.264
The image of the nurse was beginning to matter. The Nursing Times was displeased
with the BBC for its production of a documentary about student nurse training,
Under her skilled hand. The script did not reflect the dignity and sincerity of
the title. What would have been the impression of parents whose daughters were
considering nursing as a career?265
uniforms could always stimulate debate.266 Some saw them as a proof
of the nurses’ competence and a reassurance to the patient. They viewed any
threat to them as an attack on professional dignity. Others held the nurses’ cap
to be a relic of religious practice and the long starched apron from the base of
her starched collar to her ankles to be a hygienic precaution. Now both had
shrunk in size to become more a badge of office than a part of hygiene. Serving
no practical purpose, some thought they might be banished. The styling and
eminently simple but well-cut dresses of American nurses might be envied. Were
not British uniforms old-fashioned, difficult to launder and hide-bound by
tradition? asked a student nurse in the Nursing Times.267
Nurses Act 1949 implemented some of the less contentious proposals in the Wood
Report. The remit and membership of the GNC was broadened and Area Nurse
Training Committees were established. The function of these committees, placed
between the GNC and the nursing schools, was vague. At a senior management
level, when the RHBs were being established, nursing organisations were asked
for nominations as members. The RHBs appointed their own senior staff including
nursing advisers, the future regional nursing officers (RNOs).
In the hospitals, the role and the pay of the matrons varied according to the
number of beds. Those in the teaching hospitals were secure in their power and
their posts, responsible to their boards, and independent of regions. Their main
concern was to ensure that the board understood that its wider policies might
affect nursing. Matrons ran the schools of nursing as well as being responsible
for the running of an efficient nursing service. At The London Hospital the
matron looked after not only the nursing school but also the schools for
radiographers, physiotherapists, occupational therapists and dieticians. Matrons
were responsible for the linen room, laundries, female domestics, catering and
other departments, controlling many services affecting the patient’s
environment. A member of Matron’s office staff was often the most senior person
resident in the hospital at night and the weekend, taking decisions well outside
her purely professional capacity.
In the smaller hospitals, matrons had less authority, for up to a dozen
hospitals might be grouped within a hospital management committee. The group
secretary could not consult all of them about everything yet each felt herself
autonomous and neglected. Far from attending meetings of the HMC, the matrons
often did not even see the minutes. How did the HMC get nursing advice? Within
the groups, division on functional lines was taking place. Initially the
catering officers, supplies officers and domestic supervisors, although
undertaking duties previously carried out by the nurses, remained under matron’s
authority. Following the Bradbeer Report domestic tasks passed increasingly to
lay administrators. Often the matron’s precise responsibilities were not laid
down in a hospital’s standing orders, and they found themselves appointing and
dismissing staff on the basis of traditional practice, without any written
authority to do so.268
and rising expenditure
initial allocations to the RHBs were not equitable but the way in which the NHS
accounts were presented tended to conceal regional disparities. Expenditure was
presented under ‘functional’ subheads, for example the cost of nursing staff by
grade nationally, not by region. Regional allocations, settled each year, were
composed of two elements: a static or inherited element to keep the service
running at the existing level, and a developmental element to cover new
services. From 1951 to 1954 the Acton Society, an organisation concerned with
the place of large-scale organisations in society, was funded by Nuffield in
1951 to examine the organisation of hospitals under the NHS. The Acton Society
recognised that the Ministry was trying to improve matters, but doubted whether
the attempt to ‘level’ the allocations had gone far enough or had been worked
out on a fair basis.269 The Ministry’s policy was to use its
discretion over the development element to level up the more needy regions. Over
the first decade some slight progress was made. The share of one group of
regions (Newcastle, Sheffield, Birmingham, Manchester, Liverpool and Wales)
increased from 39.11 per cent to 42.22 per cent. The richest regions, the
metropolitan boards, fell from 41.72 per cent to 38.30 per cent, and the
remainder were stable (Leeds, East Anglia, Oxford and South Western). The Acton
Society thought this reasonable, particularly as little evidence was available
on the efficiency and economy of different kinds of hospital, taking adequate
account of the nature and the quality of the services provided.
It was a long-standing socialist belief that a state medical service would save
money. In 1911 Lawson Dodd wrote270
The economy of organisation, the greatly lessened cost of illness due to the
increase in sanitary control, and the immense amount saved in the reduced number
of working days lost through illness, would make the health tax seem light, and
it would be regarded as a profitable form of insurance.
In the Beveridge Report (1942)271 the Government Actuary said that
the fundamental changes envisaged could result in the costs differing materially
from the estimates that had been made. However, the report itself stated that
the development of health and rehabilitation services would lead to a reduction
in the number of cases requiring them. Beveridge, like Lawson Dodd, looked
forward to a service that would diminish disease by prevention and cure, and
believed that future developments would reduce the number of cases requiring
health service care. Enoch Powell, in 1961, referred to this as a miscalculation
of sublime dimensions.272 He thought that, in theory, it would be
possible to put together a package of health services limited to those that
would maximise the gross domestic product, concentrating on people who had a
substantial period of productive life before them. The weakling, the old and the
subnormal would be left to die. Powell considered that such a health service
would be scarcely conceivable even in a nightmare dictator state. It would not
be a health service at all. It seemed virtually certain that the increasing
outlay as medical science progressed would be more and more ‘uneconomic’.
Progress in medicine consisted not of doing things more cheaply and simply, but
in discovering complex and difficult things to do that previously could not be
done at all. Medicine was buying life at an ever-increasing marginal cost.
The government had moved into strange territory. A free and universally
available service on this scale was highly unusual. The provisional estimates of
costs for the first year were based on past hospital accounts, some of which
were sketchy in the extreme. They were rapidly exceeded. In 1946 when the NHS
Bill went to Parliament the estimate of the total net cost annually was £110
million. At the end of 1947 it was £179 million. At the beginning of 1949 a
supplementary estimate of £79 million was added and the figures turned out to be
£248 million. The actual cost in 1949/50 was £305 million. The following year it
was £384 million. The government became alarmed.
Analysing the difficulties
Ffrangcon Roberts, a radiologist at Addenbrooke’s, was an early and perceptive
commentator.273 Early in 1949 he drew attention to the unreliability
of the predictions because of three factors:
They ignored the effect of the ageing population
They ignored the intrinsically expansile nature of hospital practice;
previous government experience had been of chronic care and general
practice, not the activities of the voluntary hospitals where the
application of science resulted in expansion with accelerating velocity in
every branch of medicine.
They were based on a false conception of health and disease. ‘Positive
health’ was neither easily nor permanently achieved. The fight against
disease was a continual struggle which was ever more difficult, promoting
the survival of the unfit. We were cured of simpler and cheaper diseases to
fall victim later on to the more complex and expensive.
Roberts saw medicine, like other commodities, as a core of essentials surrounded
by inessentials extending to luxury and extravagances. The present rate of
expenditure would lead to national ruin.
The alternative is hardly less comforting. It is that a limit will be set by
shortage of personnel and materials. This means that medicine will be rationed
and controlled, and there is no reason for supposing that nationalized medicine
possesses any moral superiority rendering it immune from the vices which
rationing and control invariably bring in their train. Medicine is not above
economic law but strictly subject to it.
The NHS accounted for no mean percentage of the national budget, and money was
also needed for education, transport, industrial equipment and defence.
The Korean had imposed an added burden on national finances. Efficiency and economy were therefore continuing concerns. Whereas in a service
such as education the population was limited to those of school or university
age, and the costs of teaching determined by the syllabus, there were no similar
constraints on the NHS. Within a year Labour was on the defensive about the
rising cost. The Conservatives were ‘shocked and alarmed’, saying that, although
they too had planned a health service, a great bureaucracy was growing up and
there was enormous and wasteful extravagance. The Minister had shown himself
quite irresponsible in financial matters and heedless of the best interests of
patients as well of the medical profession. He should go. Bevan replied that it
was hard to know what the Conservatives were complaining about - was it the
inaccurate estimates or spending the money at all?274
Costs kept rising. The BMJ believed that, ignoring the British capacity for
muddling through, the NHS was heading in the direction of bankruptcy.275
The illusion that they were getting something for nothing led people to seek
free supplies of household remedies for which they had previously paid, such as
aspirin, laxatives, first-aid dressings and cotton wool. Many were going round
with two pairs of spectacles when one would have done. Charges would not offend
against the concept of a comprehensive service without financial barriers.
The policy, based upon the decisions of the (wartime) Coalition Government, had
been put into execution by a Minister who could not resist the temptation of
behaving like a fairy godmother to an impoverished nation. The medical
profession had welcomed the service in spite of doubts about the role of the
state in the care of the sick . . . Now the honeymoon period was over; the
relations between profession and state were strained because of shortage of
money; and the NHS would have to undergo successive modifications in the next
few years if it was not to fail. Perhaps the public saw the main benefit as not
paying for medicine at the time of receiving it - and the public had run riot at
the chemist’s shop.276
In 1950 the Chancellor, Hugh Gaitskell, forced the issue of charges. Labour
passed legislation making it possible to charge for drugs, spectacles and
dentures, but did not impose them. Bevan resigned in 1951, in part because of
his opposition to charges but mainly because he felt that government had failed
to distribute the tax burden properly between different social classes, and
military expenditure had been spared when social services were not.277
The BMA argued for hotel charges on admission to hospital in its evidence to the
Select Committee of Estimates and, in May 1951, charges for dentures and
spectacles were introduced. A ceiling was applied to expenditure on the health
service. The Chancellor stated that in 1952 the cost of the service would be
kept within the same bounds.278
The rising cost of prescribing was soon seen as one of the great problems
confronting the NHS.279 Costs rose about 45 per cent during the first
five years of the service. In 1950 the CMO wrote to GPs to say that, while they
had the right to prescribe whatever was necessary for an individual, unnecessary
expenditure should be avoided, and that there were mechanisms to deal with
excessive prescribing.280 In October 1951 Labour lost the general
election and the Conservatives came to power. The following year a prescription
charge of one shilling (5p) was introduced. The Ministry began to issue
‘Prescribers’ notes’ to GPs as an educative measure. In 1953 the Joint Committee
on Prescribing suggested that preparations that were not in the British
Pharmacopoeia, Pharmaceutical Codex or National Formulary, that had not been
proved of therapeutic value or that had dangerous side effects should not be
prescribable under the NHS. Doctors were asked to check the costs of comparable
drugs and review the frequency and quantities prescribed. Medical school deans
were asked to teach students and young doctors about the cost of prescribing.
The BMJ saw this as an attempt to deprive doctors of the responsibility of
deciding whether, in a particular case, the benefits outweighed the dangers.
These were clinical judgements, which had nothing to do with the economics of
prescribing. The dangers of restriction, said the journal, were far greater than
the dangers of liberty.281 By 1956, 228 million prescriptions cost
In May 1953, the Conservative government appointed a committee, chaired by
Claude Guillebaud, a Cambridge economist, to review the present and prospective
cost of the NHS, to suggest whether modifications in organisation might permit
effective control and efficiency, and how a rising charge could be avoided.282
The Committee’s work proceeded at a leisurely pace, which was to the advantage
of the NHS because in the meantime it was hard for the Treasury to insist on a
major economy programme.
was a review perhaps more fundamental than the Royal Commission on the NHS two decades
later.283 The terms of reference allowed the Committee to go well
beyond financial issues and that it proceeded to do. Richard Titmuss, a social
scientist who had worked at the MRC Social Medicine unit at the Central
Middlesex Hospital before moving to the London School of Economics, and Brian
Abel-Smith, his assistant and an economist, provided the Committee with a
detailed analysis of the costs.284 Starting with definition of ‘cost’
in actual prices and 1948/9 prices, and of ‘adequate service’ (the best service
possible within the limits of resources), Guillebaud collected a wide range of
evidence and considered the past, present and future of general practice,
hospitals, local authority services and population demographics. The report
represented a turning point in political thinking about how much should be spent
on health care and how one should measure the expenditure.
Cost of the NHS (England and Wales), net actual and 1948/9 prices (£ millions)
and as a percentage of gross national product (GNP)
Actual net cost
Proportion of GNP
| || ||
|| || || ||
|Source: Report of
the Guillebaud Committee282|
These figures were updated
in 1961 and published in Hansard
The increased cost, when adjusted for inflation, was less alarming than had been
thought. Indeed, as a proportion of gross national product, costs were actually
falling. Analysis showed the effect of higher levels of wages and prices, and
the significant increase in staff costs, as establishments had been
progressively increased. The figures for 1952/3 had to be adjusted for the
Danckwerts award to GPs, which added £24 million to gross costs and included
back-pay owing. The cost of the service, per head of the expanding population,
had risen from £7.65 to £8.75. The report stated that, contrary to public
opinion, the diversion of funds to the NHS had been relatively insignificant.
Most of the rise in hospital expenditure had been from inflation although there
had been a rise in the volume of goods and services purchased. Most of the rise
in local health authority costs was due to inflation. Net expenditure on
executive council services fell, partly because of charges made to patients.
There had been a rise in the cost of drugs, mainly antibiotics, and more
prescriptions were being issued. The ways in which these costs could be
controlled was considered but a restricted list was rejected. Hospital boarding
charges were rejected.
Committee was concerned at the low level of capital expenditure, roughly £10
million per year compared with pre-war levels nearer £30 million. There could be
no doubt about the inadequacy of hospital structure. The Hospital Surveys had
estimated that 45 per cent of hospitals predated 1891 and 21 per cent 1861.285
A return to the pre-war level of spending was recommended. Guillebaud said that
it was difficult to see how more money could usefully be spent on health
promotion, and the approach to health centres should continue to be
experimental. Noting the division of responsibility for maternity services, the
result of history rather than logic, an early review was recommended, which was
chaired by the Earl of Cranbrook. The care of the elderly also required more
provided no basis for a government attack on NHS expenditure on the ground of
financial probity. However, accounting systems were improved and the Ministry
maintained a year on year record of the changes in the cost of the NHS. Such
figures were published at the end of the Report of the Royal Commission on the
NHS (1979). Guillebaud examined organisational issues such as the integration of
the tripartite health service and the relationships of teaching hospitals to
regional boards. The transfer of local authority health services to regional
boards, or vice versa, was seen not as practical politics and no structural
change in the organisation was recommended. The former permanent secretary of
the Ministry of Health and a member of the committee, Sir John Maude, entered a
note of reservation. He analysed past history and the current concerns that the
medical profession had about the tripartite system, and came to the conclusion
a serious weakness of the present structure lies in the fact that the NHS is in
three parts, is operated by three sets of bodies having no organic connection
with each other and is financed by three methods one of which differs radically
from the other two . . . some regard it as a major flaw in the scheme, others as
no more than a piece of administrative untidiness.
Maude thought it might be expedient at some future date to return to the earlier
conception of a unified health service based on local government, but, to enable
the transfer of the NHS as a whole, reorganisation of local authority
administration and finance would probably be needed.286
The first review of the NHS had given it a clean bill of health. The Acton
Society Trust agreed that the structure was basically sound.287 The
Minister of Health, Mr Turton, hoped everyone would note with satisfaction, but
not with complacency, that the NHS record was one of real achievement, but
additional money could not be committed because of the economic situation. So
long as there had to be a limit on financial resources available, the Minister
would not be able to do at once all the things that needed to be done. The
government accepted the committee’s conclusion that though there were weaknesses
the structure was sound, any fundamental change would be premature, and the need
for stability over a period of years was important.288
From now on it became impossible for governments to attack the NHS.
Disagreements in future would be about means, not ends. However, the medical
profession was not unanimous that all was well. The right-wing Fellowship for
Freedom in Medicine published proposals for the reform of the NHS, advocating
state-subsidised compulsory insurance, covering 90 per cent of the cost for
those in a position to pay for it, and a free health service for all others.289
Free drugs should be limited to life-savers and at least some direct
responsibility should be placed on patients for their health. The introduction
of token charges would make them aware of the great benefits received.
The health service had many achievements to its credit.290 The Lancet
believed that it was one of the biggest improvements in the life of the country
since the war. Much had been done to better the conditions of medical care,
especially in hospital, thanks to the hard and intelligent work of many people,
professional and lay. However, NHS administration might be made more efficient
and appropriate.291 In 1957 the BMA Council established its own
Committee of Inquiry into the NHS, a successor to the BMA Medical Planning
Commission of 1941/2 that had proposed or supported many concepts subsequently
incorporated into the NHS.292 Doctors had accepted the principle of
the service, but not all its features. Increasingly they cast themselves as its
defenders, rather than its attackers.
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