What is the history of the NHS/how was it born?

The concept of the NHS first became established following WWII after war had spurred the government to establish an emergency medical service. 

In 1948, the labour government created the National Health Service amid a number of other welfare reforms. The guiding principle was that it would be available to all and free at the point of delivery – it would be financed from general taxation.   

The NHS was initially made up of of three centrally funded but separately managed industries. These are: Nationalised acute hospitals, a nationalised network of General practitioners and community and public health services. The initial division between these organisations has historically created challenges in providing a co-ordinated and comprehensive healthcare system.

In the 1950’s the challenge was how to manage national health services efficiently. GP’s remained as independent contractors but still had to adhere to government agreed contracts for services. In terms of acute hospitals, instructions were passed down from government through a chain of authority to hospital boards. Hospital boards were usually made up of a doctor, a matron and a layperson. A report in 1956 highlighted concerns that one day demand might outstrip supply and called for re-allocation of funding at a national level, focusing on preventative health measures, however this was rejected. 

The NHS grew rapidly in the 1960’s. District General Hospitals took the place of single speciality hospitals in order to provide comprehensive healthcare to the local population. Some specialised hospitals remained, known as regional hospitals. Patients travelled to these if they required more specialised care. This is the first time that healthcare was provided on a population basis, however hospitals did not receive funding based on their population size, rather funding was allocated based on what they had spent the previous year.

Doctors working in hospitals were encouraged to become specialists. General practitioners up until this point had received very little post-graduate training and were poorly paid. This meant that the quality of general practise was very variable. A new agreement between the government and the BMA meant that General practise was recognised as a speciality in it’s own right. Post graduate training was introduced and a new formula for funding was agreed.

In 1974, the NHS underwent a major reorganisation of management. There was more of an emphasis on the coordination of services by region. Authorities responsible in these regions were led by board members who were primarily lay-people and appointed by the health secretary. They were however advised by representatives from hospitals, general practise and public health which helped to bring these organisations together. 

One major issue with the 1974 reorganisation of the NHS was that there were too many layers of management and most decisions were arrived at by consensus amongst teams. This meant that it was difficult to come to decisions and there was a general lack of leadership. Many parts of the reorganisation were dismantled in the 1980s.

The 1970’s also saw greater priority placed on mental health services following a series of highly publicised scandals. More funding was put into community care to invest in an ageing population and preventative medicine.

General management was introduced in 1984, meaning there was a single manager for every level of the NHS as an organisation. This followed the dismantling of the 1974 management structures and created clearer leadership and decision making. District health authorities were formed to make decisions under the supervision of regional health authorities.

In the department of Health, a new board was created to establish NHS policy without the input of the Health secretary. This board was the responsibility of what became known as the Health Executive. More rigorous clinical budgeting systems were introduced, allowing costs to be calculated and allocated on a speciality level. So for example, a cardiology department will receive funding and manage the allocation of resources based on need.

Managers were expected to take a business like approach to providing healthcare in their area. A proposal in 1989 known as “working for patients” encouraged this business ethos by promoting competition between organisations through rewarding well-run hospitals and by creating an internal market. An internal market meant that the purchasing of NHS services were carried out by organisations independent of those providing NHS services. The reaction was divided as some felt that this was a back-door to privatisation.

“Working for patients” also set out a number of other proposals leading to radical changes in the NHS. These aimed to channel money towards patients needs and included:

• The establishment of ‘Trusts’ to manage the provision of hospital and community services. These directly reported to government. 

• GP Practices could apply for fundholding status to allow them to buy services from hospitals

• The move from historical funding to funding based on population size, age and levels of deprivation.

• Giving responsibility to health authorities for purchasing services in order to meet identified population needs.

Many of these changes are reflected in the NHS we see today. More emphasis was placed on decision making at a local level and regional health authorities were abolished. They were replced by regional health offices who reported to the Health executive.

The next set of major reforms were proposed in 1997 and enacted in 1999 and were named: ‘The New NHS: Modern, Dependable’. 

• The internal market remained but purchasing was rebranded as comissioning.

• Foundation trusts with even more independence from the government

• Trust performance was published, resulting in national NHS targets such as the four hour A&E waiting time target.

• Health authorities focused on improvement. The National Institute for Clinical Excellence (NICE) was formed to create health policy standards. trusts were inspected  by the commission for health improvement (CHI) to ensure they conformed. The CHI became the Crae Quality Commission (CQC) in 2009.

Further reorganisation in 1999 meant GP fundholding was abolished and Primary care Trusts formed instead.

The NHS constitution was published in 2009 and updated in 2013. 

In 2012, the NHS Commissioning board is formed as an independent body from the government, this oversees Clinical Commissioning groups which replace primary care trusts.

The NHS commissioning board is later known as NHS England.