Hero of the Hour
The birth and recent challenges of the NHS by Cumbrian-based GP Ellen Welch
ON New Year’s Eve 2019, as an oblivious world welcomed in 2020, local Government authorities in Wuhan, Hubei Province, China, released a health alert, announcing a mysterious pneumonia in their city. Only weeks later, Wuhan went into lockdown to try to control the growing cases of what we now know as coronavirus (COVID-19). It was not long before the rest of the world followed, as the virus rapidly spread across the globe, infecting millions of people, devastating lives and crashing economies.
In the UK, our National Health Service was thrust into the spotlight as staff left the safety of their homes to continue to care for those who needed them most. Tragically, hundreds of them died after contracting COVID-19, with staff from black and ethnic minority backgrounds disproportionately hit, including many migrant workers on whom the service depends. Thursday evenings became
“Clap for our Carers” night, as the British public, their windows adorned with rainbow posters of thanks, came out into the streets to clap, cheer and bang on pots and pans in gratitude.
Healthcare hasn’t always been available to us whenever we’ve needed it. Pre-NHS, a series of Poor Law Acts, culminating in the the Poor Law Amendment Act of 1834 established brutally cruel workhouses which became a sort of prison system; here the sick were treated punitively and subjected to forced labour. During the last major pandemic (the Spanish influenza pandemic of 1918), healthcare was provided mainly by charities and an unregulated private sector. In a time before vaccines and antibiotics, hospitals were overrun and the 1918 pandemic infected an estimated 500 million worldwide, claiming the lives of 250,000 Britons.
RAF Veteran Harry Leslie Smith, who died in 2018, grew up in poverty in 1920s Barnsley. He frequently spoke in support of the NHS, describing how common preventable diseases “snuffed out life like a cold breath on a warm candle flame” prior to the creation of the service. His sister caught TB, which infected her spine and left her bedbound by the age of ten. Unable to care for her, she was sent to the neighbourhood workhouse, which housed a collection of prisoners, sick paupers and the mentally ill. She died there soon afterwards.
“I will never forget, as long as I shall live,” Smith said, “the screams that fell out of dosshouse windows from the dying and mentally ill, who were denied medicine and solace because they didn’t have the money to pay for medical services.”
The NHS has now been part of the identity of the UK for over 70 years. It was several decades in the making but was eventually conceived during World War II, when the “Blitz mentality” of the war-weary public opened us up to the concept of a welfare state. The state had controlled many aspects of life during the war – sometimes for the better. Rationing
improved diets, while the Emergency Medical Service, set up for the mass casualties, gave people access to healthcare that they had never had before. The Beveridge Report of 1942 set out plans for post-war Britain, to address five “giant evils” in society – squalor, ignorance, want, idleness and disease. These plans included the coalition government’s vision for a free, unified health service, funded from general taxation.
After the war, Aneurin Bevan was chosen as the Minister of Health in Clement Atlee’s new Labour Government and his plans to nationalise the country’s hospitals were fiercely opposed by the opposition party and much of the medical profession, who feared loss of income and autonomy. Bevan hailed from a mining community in South Wales and worked down the mines prior to his involvement in politics. He was no stranger to poverty and disease – three of his nine siblings died during childhood.
“Society becomes more wholesome and spiritually healthier,” he wrote, “if it knows that its citizens have the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide.” This ethos became part of the founding principles of the NHS: that it meet the needs of everyone, that it is free at the point of delivery and that it is based on clinical need, not ability to pay.
On 5 July, 1948, Bevan launched his new National Health Service at Park Hospital in Manchester (now called Trafford General Hospital), removing the fear of how to pay for healthcare for the entire nation. People who had delayed seeking help, sometimes for decades, were eventually able to be treated. The NHS was the first health system in the world to offer free care for all, and its founding principles were revolutionary.
These values still hold true today, despite the world we now live in being a very different place.
The 20th century welcomed innovations in healthcare such as the discovery of DNA, surgical firsts such as organ transplants, new medications and the introduction of CTs and MRI scanners. Milestones in women’s rights and fertility were achieved in the Sixties with the legalisation of abortion, widespread availability of the contraceptive pill and, a decade later, IVF and “test tube” babies. The care of people with mental health problems was transformed with the development of antipsychotic drugs, meaning that care could be provided in the community. In the 1950s, 97 per cent of people with mental health problems were treated in asylums. Then, over a 30-year period these asylums closed and today approximately 3 per cent require inpatient care.
Only months after launching the NHS in 1948, Bevan rather prophetically said: “I have been exhorting the general public to make use of this National Health Service prudently, intelligently and morally, because if too great a strain is placed upon it at the beginning it might break down, and because things are free is no reason why people should abuse their opportunity.”
In the 1950s, due to overwhelming demand, charges were introduced for dental services, prescriptions and spectacles, prompting Bevan to resign from the cabinet in protest.
Since then, demand has only grown. As our ability to treat illness and standards of living have improved, we’re living longer, and in becoming healthcare consumers, accustomed to using technology for instant answers, we consult for problems that would have been considered part of life in 1948 (such as baldness and stress).
Not even the founders could have anticipated the NHS becoming the vast organisation it is today. It is now the fifth-largest employer in the world and deals with 1 million patients every 36 hours. Decades of reorganisations have shaped the service into the system we now rely on, and the era of round-the-clock GP-centric care has faded, where the family doctor delivered you as a child and provided your care from cradle to grave.
By the 1980s, the rising costs of healthcare were outstripping politically acceptable levels of funding and services began to feel the squeeze. Waiting lists grew and delays in treatment became the norm. In
attempts to create efficiency by introducing competition to the system, the Thatcher government created the internal market. They created a “purchaser-provider split” within the NHS in England, which meant that “purchasers” (health authorities and some GPs using the NHS funds allocated to them) could decide which “providers” to purchase care from. Whilst previous providers had been the local hospitals, the internal market allowed care to be purchased from other NHS organisations, charities and private companies, opening the NHS up to privatisation and creating huge amounts of bureaucracy.
Today, the past decade of austerity measures have squeezed even harder on the NHS purse strings. Research from the BMJ, the independent medical journal published by the British Medical Association, found that in 2017 the UK spent the least per capita on healthcare compared with nine other high-income comparator countries such as France and
Even before the pandemic hit, winter pressures on the service started to be felt all year round as A&E and ambulance waiting times reached crisis levels. What will help? In my opinion evidence-based management, investments in reducing waste, valuing staff more and, of course, increased government funding. We, the public, can, of course, use the service responsibly to help reduce the strain.
As a fully qualified GP for seven years, I love the flexibility of my role, and being able to provide holistic care for my patients. When I was a junior doctor I feel we had more sense of camaraderie than there is now, and with free hospital accommodation on site we thought nothing of staying late to help out a colleague. The NHS still functions on kindness, though.
During the crisis I took a call from a patient who had had a rushed discharge home from an overflowing COVID ward. He was struggling and needed help. Social services were overwhelmed and could offer no sort of respite, but a local district nurse volunteered to help this gentleman until assistance could be arranged.
Despite its shortcomings, we remain proud of our NHS. Opinion polls consistently rate it highly and it is such a national treasure that it was the central theme of the opening ceremony of the 2012 London Olympic Games. It also remains a worldwide leader when it comes to equity of access and financial protection from the consequences of ill health. The response to the coronavirus crisis has only strengthened this pride.
Dr Jenny Abthorpe was working in intensive care in London when the pandemic broke. She documented her experiences in a series of diary entries which have been shared in my book. “The pandemic response by the NHS was immense and highly complex,” Dr Abthorpe says. “The NHS did not just cope, it saved thousands of lives and I will always be immensely proud of my profession in the part it played against COVID-19.”
How the NHS Coped with COVID-19 by Dr Ellen Welch will be published later this year with all author royalties donated to Mind (£19.99, Pen & Sword). Ellen is also the author of The NHS: The Story So Far and The NHS at 70, available from pen-andsword.co.uk and all good bookshops.