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Wednesday, July 1, 1998 Published at 11:01 GMT 12:01 UK

The NHS: 'One of the greatest achievements in history'

Photo of Dr Arthur Mitchell, N.Ireland GP, by Barry Lewis. Part of touring NHS exhibition

BBC Social Affairs Editor Niall Dickson considers the state of the NHS in 1998.
The UK's National Health Service (NHS) came into operation at midnight on the fourth of July 1948. It was the first time anywhere in the world that completely free healthcare was made available on the basis of citizenship rather than the payment of fees or insurance premiums. The service has been beset with problems throughout its lifetime, not least a continuing shortage of cash. But having cared for the nation for half a century, most Britons consider the NHS to have been an outstanding success.

Only 50 years ago, health care was a luxury not everyone could afford.

Life in Britain in the 30s and 40s was tough. Every year, thousands died of infectious diseases like pneumonia, meningitis, tuberculosis, diphtheria, and polio.

Infant mortality - deaths of children before their first birthday - was around one in 20, and there was little the piecemeal healthcare system of the day could do to improve matters.

Against such a background, it is difficult to overstate the impact of the introduction of the National Health Service (NHS). Although medical science was still at a basic stage, the NHS for the first time provided decent healthcare for all - and, at a stroke, transformed the lives of millions.

[ image: Mary Dowlding: 'Queues stretched down the street']
Mary Dowlding: 'Queues stretched down the street'
Mary Dowlding joined the Warders Medical Surgery in Tonbridge, Kent, as a receptionist on the day the NHS was launched.

"I arrrived in the morning and the queue was from the door, down the street and disappeared into the High Street," she said.

"I think they came because they wondered what was happening and they wanted to see if they were going to have free medicine. It was such a relief, particularly to women with young children who could not afford to call the doctor out."

Dangerous home remedies

The excitement was understandable. Prior to the reforms, the poor often went without medical treatment, relying instead on dubious - and sometimes dangerous - home remedies or on the charity of doctors who gave their services free to their poorest patients.

Dr Sandy Macara of the doctors' professional body, the British Medical Association, describes the pre-NHS era
Access to a doctor was free to workers, who were on lower pay, but 'national health insurance' often did not extend even to their wives or children.

Hospitals charged for services, and although poor people were reimbursed, they had to pay upfront first to receive treatment.

The need for free healthcare was widely recognised, but it was impossible to achieve without the support or resources of the state.

Social reformers

Throughout the 19th century, philanthropists and social reformers working alone had tried to provide free medical care for the poor, but, without government backing, they were destined merely to scratch the surface of need.

The hospitals established by these pioneers dealt mainly with serious illness.

Other demands, such as care of the elderly and mentally ill, were met - at least partially - by local authorities which often ran local municipal hospitals.

Provision, however, was patchy, and people were often locked away in forbidding institutions, not always for their own benefit, but to save other people from embarrassment.

First big step

The Dawson Report of 1920 was the first big step towards a national health service, recommending a comprehensive system under the auspices of a single authority. It was followed by the Royal Commission on National Health Insurance in 1926 which pioneered the idea of a publicly funded health service.

The creation of the Emergency Medical Service in Second World War further hastened the pace of change. It was the first time healthcare funding had been taken over by central government.

In 1941, a government-commissioned independent inquiry found healthcare varied vastly across the country.

With the voluntary hospitals permanently on the verge of financial collapse and the municipal hospitals almost universally loathed, there was no shortage of pressure for change.

Final catalyst

The final catalyst for the NHS came with the Beveridge report into social care in 1942. Sir William Beveridge, an eminent economist, identified a national health service as one of three essential elements of a viable social security system.

[ image: Pressure built for major social reform]
Pressure built for major social reform
Two seminal White Papers proposing a national health service followed before health minister Aneurin Bevan steered legislation through the Commons in November, 1946.

After much political manoeuvring, the NHS was launched two years later with the promise that "everybody, irrespective of means, age, sex or occupation shall have equal opportunity to benefit from the best and most up-to-date medical and allied services available."

It added that the services should be comprehensive and free of charge and should promote good health as well as treating sickness and disease.

Life expectancy rises

[ image: Dr John Marks: 'Healthcare before the NHS was a disaster']
Dr John Marks: 'Healthcare before the NHS was a disaster'
Has the NHS been a success? In purely medical terms the argument seems overwhelming. Men and women are living about 10 years longer on average than they did in 1948 - men to 74 and women to 79.

And during the last 50 years, medical advances have transformed healthcare, from the invention of a vaccine for polio and the birth control pill in the 1950s to laser and keyhole surgery techniques developed over the last 10 years.

However, nobody could claim that the great experiment has been without its downsides.

Surge in demand

When the NHS was introduced in 1948, it sparked a huge surge of demand for medical care from people who had previously been denied access to free treatment. It is a demand which scarcely seems to have abated since 1948 when hospital waiting lists stood at 500,000. Today the figure is over a million.

On a typical day, 700,000 people visit their GP, but family doctors complain that approximately a quarter of their time is taken up by turgid paperwork, and they do not have the resources to devote proper time to their patients.

BBC Radio 4 debate: Is rationing of healthcare inevitable?
Running costs, too, have soared by fourfold in real terms. Each successive administration has promised to solve the cash shortages that have plagued the NHS, but no politician has been able satisfactorily to match resources to demand.

Despite the drawbacks, however, Dr John Marks, for one, is in no doubt that the NHS has proved its worth.

[ image: Roy Lilley: 'Where are the quality controls?']
Roy Lilley: 'Where are the quality controls?'
Dr Marks is a former chairman of the British Medical Association (BMA) council, who qualified on NHS day itself.

"The NHS is one of the greatest achievements in history," he said. "Before that healthcare in this country was a disaster, particularly if you were poor. The unmet needs were not known until the NHS started, and people who had been ill for years and years came forward for help because they did not have to worry about paying for it."

Very few controls

Former NHS trust chairman Roy Lilley disagrees. "A cancer patient is most unlikely to see a cancer specialist, they will be treated by a generalist, unlike most of the rest of Europe and the USA.

[ image: Liverpool GP by Mike Abrahams, Network Photographers. Part of NHS national exhibition]
Liverpool GP by Mike Abrahams, Network Photographers. Part of NHS national exhibition
"When you drill down beneath the surface, and ask do we have the same zero defect quality that we have in industry, the answer is that it is not there, and there are very few controls."

Perhaps the final say should rest with patients themselves. Whatever the financial problems associated with the NHS, polls regularly rate its preservation as the public's top political priority.

On that basis alone, perhaps the NHS truly is the envy of the rest of the world.

Network Photographers are touring the country this year with a special NHS photo exhibition, NHS Now...Towards the Future. Two of their photos are used in this story. The photos cover all aspects of healthcare, including inner city GPs, accident and emergency departments and maternity units.

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In this section

The NHS: 'One of the greatest achievements in history'

Making Britain better

True to its principles?

'Patients broke down my door'

Handle with care

Five decades into the future

Aneurin Bevan - Labour's lost leader

The cost of being healthy

All in the mind: mental health evolves

The health of the nation

The first NHS patient

A career of caring

Towards 2048