History of The National Health Service (England) - Development of The NHS in England and Wales, 1948-1969

Development of The NHS in England and Wales, 1948-1969

The original structure of the NHS in England and Wales had three aspects, known as the tripartite system:

• Hospital Services: 14 Regional Hospital Boards were created in England and Wales to administer the majority of hospital services. Beneath these were 400 Hospital Management Committees which administered hospitals. Teaching hospitals had different arrangements and were organised under Boards of Governors.
• Primary Care: GPs were independent contractors (that is they were not salaried employees) and would be paid for each person on their list. Dentists, opticians and pharmacists also generally provided services as independent contractors. Executive Councils were formed and administered contracts and payments to the contractor professions as well as maintaining lists of local practitioners and dealing with patient
• Community Services: Maternity and Child Welfare clinics, health visitors, midwives, health education, vaccination & immunisation and ambulance services together with environmental health services were the responsibility of local authorities. This was a continuation of the role local government had held under the Poor Law.

After the publication by the British Medical Journal on December 24, 1949 of University of Cambridge consultant paediatrician Douglas Gairdner's landmark paper detailing the lack of medical benefit and the risks attached to non-therapeutic (routine) circumcision, the National Health Service took a decision that circumcision would not be performed unless there was a clear and present medical indication. Both the cost and the non-therapeutic, unnecessary, harmful nature of the surgical operation were taken into account.

By the 1950s, spending on the NHS was exceeding what had been expected, leading to the introduction of a one-shilling charge for prescriptions and a £1 charge for dental treatment, in 1952; this was an exception to the NHS being free at the point of use. The 1950s also saw the planning of hospital services, dealing in part with some of the gaps and duplications that existed across England and Wales. The period also saw growth in the number of medical staff and a more even distribution of them with the development of hospital outpatient services. By 1956, the NHS was stretched financially and doctors were disaffected resulting in a Royal Commission on doctors' pay being set up in February 1957. The investigation and trial of alleged serial killer Dr John Bodkin Adams exposed some of the tensions in the system. Indeed, if he had been found guilty (for, in the eyes of doctors, accidentally killing a patient while providing treatment) and hanged, the whole NHS might have collapsed. The Mental Health Act of 1959 also significantly altered legislation in respect of mental illness and reduced the grounds on which someone could be detained in a mental hospital.

The 1960s have been characterised as a period of growth. Prescription charges were abolished in 1965 and reintroduced in 1968. New drugs came to the market improving healthcare, including polio vaccine, dialysis for chronic renal failure and chemotherapy for certain cancers were developed, all adding to costs. Health Secretary Enoch Powell undertook three initiatives:

• The Hospital Plan published in 1962 proposed the development of district general hospitals for population areas of about 125,000 and laid out a pattern for the future district by district;
• The Church House speech predicted that many of the large mental health institutions would close within ten years.

Concern continued to grow about the structure of the NHS and weaknesses of the tripartite system. Powell agreed the creation of a Royal Commission on doctors’ pay, which resulted in a statutory review body. Further development came in the form of the Charter of General Practise, negotiated between new Health Minster Kenneth Robinson and the BMA, that provided financial incentives for practice development. This resulted in the concept of the primary health care in better housed and better staffed practises, stimulating doctors to join together and the development of the modern group practice.

In 1969, responsibility for the NHS in Wales was passed to the Secretary of State for Wales from the Secretary of State for Health who was thereafter just responsible for the NHS in England.