theme 2: creating a welfare state - 2b public health

Healthcare in 1918:

• 1911 National Health insurance for low paid employees - workers and employers paid in - only applied to wage earners

• Private charity’s paid for healthcare of the poor

• Poor law hospitals

• Workhouses - often had infirmaries and some became hospitals

(1918-1939)Widely believed that the govt had a role in encouraging medial advances - consensus that the govt should:

• invest in research

• Invest in medical training

• Organise a nation network of hospitals

• Play a role in rationing healthcare

Disagreements over the nature of the govts role:

• Fabian Society advocate centralised healthcare

• 1919 Labour Party advocated a NHS

• The BMA advocated a regional system co-ordinated by central Govt

• Dawson Report advocated a network of state funded hospitals

Tuberculosis:

• Ministry of Health Act 1919 creates the Medical Research Council to research cause

• Tuberculosis Act 1921 made building TB sanatoria by LA’s compulsory

• The number of TB cases declined yearly 1920-1938

Local Government Act 1929:

• passed responsibility for poor law hospitals to county councils

• Allowed county councils to convert Poor Law infirmaries into public hospitals

• Gave local authorities responsibility for child welfare, dentistry, school meals and medical services etc

The Pioneer Health Center

est 1935 - 5p weekly subscription - join the clinic, annual health checkups and access to leisure facilities - 950 signed up

Finsbury Health Centre

Opened 1938 - most technology advanced and modern of its era. Addressed lice, poor hygiene and TB - solarium and a lecture theatre - Highly influential - inspired the NHS.

Infant mortality dropped from:

14 in every 1k 1906-1910 to 12 per 1k 1936-1938

Maternal mortality rates during 1920s and 30s

50% higher in WC than MC

Life expectancy 1920’s and 1930’s - class divide

MC men lived 12 years longer than WC men, middle class women lived 19 years longer than WC women

The Emergency Medical Service:

Founded 1939 - first aid and casualty clearing stations during air raids - govt dictated hospital activities - pooling resources, skills and expertise

Doctors in favour of NHS:

1941 Medical Planning Research - group of 200 Drs - endorsed provisional plans for a NHS

Negotiations 1942-44:

BMA: managers of local authority, private and voluntary hospitals

Willing to collaborate but concerned about loss of autonomy

1944 white paper recommended:

A new national system paid for from general taxation.

The National Health Service Act 1946 established an NHS on the principles of:

• universal healthcare for all

• Comprehensive healthcare i.e mental, physical, dental, opticians

• Free at the point of delivery

Bevan’s nationalised but regionalised system:

All existing hospitals were nationalised - merged into one system

NHS hospitals run by regional hospital boards managed by regional health boards - LAs providing ambulances, vaccinations and community nursing

Bevan got the cooperation of Drs by agreeing to compromises for the foundation of the NHS 1948:

• consultants can continue working privately - allocated beds in hospitals for private patients

• GPs avoid becoming LA employees and therefore avoid the LA pay controls

• Regional health boards appointed and dominated by consultants = upper MC

The NHS’s tripartite system:

Hospital services - accident and emergency services and in-patient treatment

Primary care - GPs, dentists, opticians, and pharmacists - operated as independent contractors

Community services - health visitors, vaccination services, health ed, midwives and ambulances - managed by LAs

The NHS inherited unequal infrastructure across the nation. In 1948 it was made up of:

3,100 hospitals, with 550,000 beds employing 360,000 staff

Sir Keith Joseph - NHS Reorganisation Act 1973:

Introduced a new management structure = Significant growth in labour costs

Macmillan’s Hospital Plan in 1962 led to:

The creation of 90 new hospitals, the modernisation of 134 hospitals

(A lot of the investment spent in london = regional inequalities)

life expectant increased from —- for men and —- for women in 1948 to 71 for men and 77 for women in —-

66, 70, 1979

What did the Merrison report 1976 argue:

Hospitals received 70% of NHS funding, more spent on surgery and general medicine than mental illness and geriatrics, investment in hospitals led to regional inequalities

In largely WC areas —% of GP surgeries were built before 1900, whereas in MC areas —% were built after 1900

80%, 50%

1950’s: Hospitals in some MC areas received an annual budget of £—- per head whereas some WC budgets were £——

£5, £3

1972: MC areas tended to have per capita diets that were —% higher than WC areas

25%

The Black Report 1980 indicated that the class gap in healthcare grew 1949-1972 - shown by:

• WC women were twice as likely to die in childbirth

• Unskilled workmen were twice as likely to die before 65 than MC proffessionals

NHS gave women a greater control over their fertility:

Women born in 1920 had on average 2 children, women born in 1966 had on average 1.3

Drawbacks of the availability of the pill:

Early contraceptive pills had side-effects - increased risk of stroke and some cancers

The availability of the pill meant that men took less responsibility

Limitations of the 1967 Abortion Act:

The right to terminate was dependent on the approval of 2, typically male, doctors

Medical staff were given the legal right to refuse to participate in terminations

Between 1968 and 1978 how many terminations were carried out? What % were private sector?

1.5 million 58%

How much did a private abortion cost?

£200 - abortion was more easily available to MC women

Medical supervision of abortion was poorly regulated:

86 people died during a legal abortion 1968-1978 - only 72 died as a result of NHS surgery

In the 1950s —% of women gave birth in hospitals by 1978 this increased to —%

60%, 97%

70-90% of women who gave birth in hospitals were given an episiotomy - led to:

pain when sitting in 68% of cases

Caring profession: in 1948 the government tried to recruit —— female nurses

54,000

1957 Royal Commission On Mental Illness and Mental Deficiency argued that:

patients with mental illness were stigmatised - rights were not respected - mental health hospitals acted more like prisons

The 1959 Mental Health act:

• introduced new terms - ‘mentally ill’ not insane

• Removed judges - decisions to force treatment to be made by mental health tribunals - responsibility to protect the patient

• Open door policy - most patients could attend voluntary treatment sessions rather than long term hospital stay

1962 Hospital plan proposal for mental illness:

50% reduction in hospital beds for mental illnesses by 1975 = more outpatient and drop-in care

Unsuccessful - low funding - good intention

The 1959 Mental Health Act unsuccessful - by 1975:

• only 15% of outpatient places needed were available

• Only 33% of the hospital places needed were available

Between 1967 and 1981 there were — separate inquires into ——- at psychiatric hospitals

25, misconduct and abuse

The NHS was a victim of its own success:

• Effectiveness led to increasing expectations

• ageing population with more complicated health needs

• Medical advances = new procedures = more costs

Prescription drugs:

• pre NHS 6.8 mill prescriptions were dispensed, by September 1948 13.6mill

• 1949-1964 ‘pharmacological revolution’ - more medicines available

• NHS spent 250% more on drugs in 1964 than 1951 - drug cost increased

• Vaccinations increased the scope of NHS provision - 1939 only smallpox had a routine vaccination - 1964 vaccines against diphtheria, TB and polio were all available

Public opinion of the NHS 1964:

Shortages and inequalities were never a major political issue, NHS provision was far better than prewar provision.

Problems with the NHS by 1960:

little investment in modernising NHS hospitals and little done to tackle inequalities.

the National Institute of Economic and Social Research predicted NHS spending would increase by 3% yearly 1960-1975

In reality it increased by an average of 4.5%

High tech medical equipment needed specialist staff - 1960’s the NHS could provide:

• kidney dialysis

• Catheters

• Organ transplants

Numbers of consultants and nursing staff increased by —% from 19– to 1979. Number of technical staff increased by -%

66% 1964 300%

In total NHS staffing increased from 407k in 1951 to just over — in 1979

1 million

Thalidomide scandal:

prevention of morning sickness in pregnant women - thousands took it = 10,000 seriously deformed babies,

In 1951 there were - million people of retirement age, this had risen to - million by 1971

7, 9

In 1979 the NHS performed 24k ——— an operation impossible in 1960

Hip replacements

1964-1979 - important advancement in organ surgery - be end of period the NHS completed:

8k kidney transplants, 5k heart bypass operations