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 not family’s or the unemployed

• Private charitable and philanthropic groups paid for healthcare of the poor

• Poor law hospitals

• Workhouses - often had infirmaries and some were made into 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 free and comprehensive NHS

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

• Dawson Report advocated a network of state funded/organised hospitals

Tuberculosis

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

• Tuberculosis Act 1921 made the provision of TB sanatoria by LA’s compulsory

• The number of TB cases declined in every year 1920-1238

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 - local residents paid a subscription of 5p a week to join the clinic and receive annual health checkups and access to leisure facilities - 950 signed up for the scheme

Finsbury Health Centre

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

Infant mortality

England and wales dropped from 14.3 in every 1k between 1906 and 1910 to 12 per 1k between 1936 and 1938

Maternal mortality rates during 1920s and 30s

50% higher in low-income groups than the middle class

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

Middle class 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 - 200 Drs - endorsed provisional plans for a national wide health service

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 - NHS would offer: curative and preventative, mental and physical, hospital care, GPs, dental care and specialist services like opticians

• Free at the point of delivery. Direct taxation rather than insurance

Bevan’s nationalised but regionalised system:

All existing hospitals were nationalised - local authority, voluntary and private were merged into one system

NHS hospitals would be run by regional hospital boards managed by regional health boards - local authorities providing ambulances, vaccinations and community nursing

Bevan got the cooperation of doctors by agreeing to a series of compromises for the foundation of the NHS July 1948:

• consultants were allowed to continue working privately and were allocated beds in hospitals for private patients

• GPs were able to avoid becoming local authority employees and therefore subject the LA pay controls

• Regional health boards were appointed and were 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 were managed by LAs

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

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

Sir Keith Joseph introduced the NHS Reorganisation Act 1973

Introduced a new management structure of the NHS. Significant growth in labour costs

Macmillan’s Hospital Plan in 1962 led to:

The creation of 90 new hospitals, the redesign and modernisation of 134 hospitals, the refurbishment of 365 hospitals.

(A lot of the investment was 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 1979 argue

That hospitals received 70% of NHS funding, more money was spent of 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% = these WC areas had less investment and modernisation

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

£4.98, £3.19

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 between 1949&1972 this meant that:

• WC women were twice as likely to die in childbirth

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

Proof that the NHS face women a greater control over their fertility (birth rates)

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 such as increased risk of stroke and some cancers

The availability of the pill meant that men took less responsibility for contraception

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? How many were performed in the 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%

A survey reported that 70-90% of women who gave birth in hospitals were given an episiotomy

This led to pain when sitting in 68% of cases. Procedure was carried out without the consent or knowledge of the woman

Caring profession - in 1948 the government tried recruit —— female nurses

54,000

What group was concerned that the NHS was not treating mental illness effectively

The 1957 Royal Commission On Mental Illness and Mental Deficiency argued that patients with mental illness were routinely stigmatised, that there rights were not respected and that mental health hospitals acted more like prisons

The 1959 Mental Health act

• introduced new technology - ‘mentally ill’ rather than insane

• Removing judges from the process - decisions to force treatment would be made by mental health tribunals - had a responsibility to protect the liberty of the patient

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

1962 Hospital plan proposed:

A 50% reduction in hospital beds do people with mental illnesses by 1975 = more outpatient and drop-in care

The 1959 reforms did not have the hoped impact - by 1975:

• only 15% of day care (voluntary treatment sessions) places needed were available

• Only 33% of the hospital places needed were available

Between 1967 and 1981 there were — separate inquires into — and — at psychiatric hospitals in the UK

25, misconduct and abuse

The NHS was a victim of its own success

• the effectiveness of NHS hospitals led to increasing expectations

• Longer lives led to an ageing population with more complicated health needs

• Medical advances meant that the NHS could perform new procedures

Prescription drugs:

• June 1948 (last month before NHS) 6.8 million prescriptions were dispensed, by September 1948 had risen to 13.6

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

• NHS spent 250% more on drugs in 1964 than 1951 - drugs themselves had become more expensive

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

Public opinion of the NHS 1964:

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

Problems with the NHS by 1964:

1948-1960 there had been little investment in modernising NHS hospitals and little done to tackle inequalities.

the National Institute of Economic and Social Research predicted that NHS spending would increase by 3% each year from 1960-1975

In reality it increased by an average of 4.5%

High tech medical equipment needed specialist stadd - from 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

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

Between 1964 and 1979 there was important advancement in organ surgery - in 1979 the NHS offered:

8k kidney transplants, 5k heart bypass operations