In the second of two articles focusing on the birth of the National Health Service in Scotland, journalist and historian Chris Holme looks at the growing pains of the new service in its first decades, some of the big medical breakthroughs – and the continuing problem of too many patients and too little money.

There was some humour at the start of the National Health Service. The first NHS joke was recorded by Sir James Stirling Ross in 1951:

Two women met in the doctor’s surgery. Said Mary: “Hello, Jeannie. I didna see ye here last week. What was wrong? Were ye no’ weel?”

But early cracks started to appear in 1950 as economies were demanded to meet the cost of the Korean War. Charges were introduced for spectacles and dentures – which prompted Aneurin Bevan’s resignation from the Cabinet.

After his departure, the minister of health no longer had a seat at Cabinet. The NHS share of UK national spending fell from around 25 per cent to 20 per cent by 1963.

The health service disappeared from the headlines and instead took on the appearance of a National Treatment Service based on hospitals. In the public mindset, hospitals became synonymous with the NHS – “disease palaces” as described by doctor novelist Colin Douglas.

Successive reports in the 1920s and 1930s had emphasised turning from treating illness to prevention, by investing resources into making good health and wellbeing the everyday norm.

GPs and health centres

The focus of this was to be new ‘health centres’ in communities with a range of skills and facilities: dentists, pharmacists, and health visitors working alongside GPs.

Scottish officials began planning enthusiastically at the outset of the NHS but the first “experimental” model at Sighthill in Edinburgh did not appear until 1953. A second followed at Stranraer after which the Treasury pulled funding.

Progress was made at Harlow in Essex which later was extended across England.

Much hope had been invested in GPs. In 1939 only half of the population had a GP – virtually all Scots had one by 1949.

Something had to give – and it did.

A survey by Joe Collings, a young Australian GP, looked at general practices across England and found shocking failings. Scotland appeared as an appendix to the report – slightly better but not by much.

GPs had basically been unable to cope before the NHS – never mind with the huge additional burdens the NHS brought. GPs remained as independent contractors. Their hospital colleagues were on salaries and still able to practise privately.

Most general practices in Scotland were run single handedly in 1948. It would take another twenty years before group practice became the norm. Renewed effort was put into recruitment and training led by universities and the Royal College of General Practitioners set up in 1952.

Nevertheless, the 1950s witnessed spectacular successes.

Stopping the big killers

Unlike other European countries, tuberculosis, particularly among young adults, was on the rise in Scotland at the start of the NHS.

Within a decade it had been largely eradicated, thanks partly to mass radiography campaigns with X-ray vans and staff from across the UK, and the BCG vaccine, but mainly due to a cure developed in Edinburgh. The answer turned out to be to use all three available drugs simultaneously from the start, this becoming the gold standard treatment across the world.

The NHS received its biggest ever dividend – tens of thousands of beds for tuberculosis patents were no longer needed.

This was followed by another boost – vaccines for various childhood disease greatly reduced the need for long-stay children’s beds.

Other uses were found for tuberculosis hospitals and sanatoria. Wrightington near Wigan became the base for surgeon John Charnley to carry out his first hip joint replacement in 1961.

Teflon initially proved problematic as a coating for the joint and Charnley was cautious in his outlook: “'Objectives must be reasonable. Neither surgeons nor engineers will ever make an artificial hip-joint which will last 30 years and at some time in this period enable the patient to play football”.

Hip replacement became routine as did many other innovations such as obstetric ultrasound – first demonstrated in Glasgow.

The NHS and money

With successive medical advances in treatment and people living a lot longer, came increased costs. In its first year, NHS spending worked out at around £8 per head of population. Now it is well over £3000.

Concern over rising costs fuelled intense political debate. The Conservative government which privatised steel, coal and railways nationalised forty years earlier, also turned its attention to the NHS.

Compulsory competitive tendering was introduced for support services. Cleaners, already the poorest paid NHS workers, got poorer.

The idea of an internal market – one body commissioning services and another providing them – took hold with the establishment of NHS trusts.

Trusts did not last long in Scotland. They were abolished by the Scottish Parliament in 2004 although the internal market continues in England with commissioning groups and providers.

So, what is left of Bevan’s legacy? A recent joint report by the Nuffield Trust and King’s Fund reported unprecedented public dissatisfaction with the NHS but not with its founding principles – first class care for all, and free at the point of delivery.

He would have been thrilled by a later nationalisation when the NHS bought what became the Golden Jubilee Hospital at Clydebank. Specifications for the private hospital were the best in the world, including a 170 four-star hotel.

It had already received a £30 million public subsidy as Scotland’s largest inward investment project. But it went bust in 2002. and was purchased for £37.5 million and has since treated tens of thousands of NHS patients.

Bevan would have called it a bargain.

 

Listen to Bevan himself describing the first year of NHS in this short (2 minute) BBC Archive clip.

Chris Holme is a former Reuters Foundation fellow in medical journalism.

Read more from Chris Holme: 75 years on: The birth of NHS Scotland; Dr Finlay and the making of the NHS; TB and the Edinburgh physician; The father of evidence-based medicine; The Glasgow mother of the C-section; Long read: The CMO who spoke the unspeakable