MIDDLES

Forty years of the NHS

Origins and early development
George Godber
Details of the structure and organisation of the NHS
are on the record, but the reasons underlying the
pattern of its development are less clear. I am concerned
here, therefore, mainly with evolutionary changes in
the service at work, and I shall keep mainly to the
origins and the first 25 years in England and Wales.
The real NHS is the many services rendered daily by
health professionals and their aides to people in their
homes, in health centres, and in hospitals. Three
quarters of the population use the NHS each year, and
it is by their satisfaction that it should be judged.

Origins in pre-existing structures

The idea of a national health service was not
produced by any one political party. Nearly all the
services which were incorporated in 1948 already
existed. What was needed was a system that would
ensure equality of access in accordance with need, not
AneurinBevan became minister ability to pay. That was part of a consensus in British
of health in the new Labour
govemment of 1945 society about its responsibility to its members, first
fully expressed in the Beveridge report in 1942.
A medical advisory committee to the first minister of In hospitals the increasing pace of scientific advance
health produced an outline plan for a national health required sharper differentiation of medicine into
service as far back as 1920, introducing the idea of specialties and improved training in the paramedical
three levels of medical care approximating to region, professions. These were hampered by the fact that
district, and neighbourhood. Nothing was done at the senior medical staff in voluntary hospitals drew their
time, partly because of postwar retrenchment and incomes largely from private practice. Only in larger
partly because of opposition from sectional interests. centres was this sufficient to support all the specialties
The Poor Law had provided last resort support for required. The less remunerative, such as paediatrics
the indigent in Britain for nearly a century, including and anaesthetics, suffered most. Nursing staff were
what was bleakly called "medical outdoor relief." Poor poorly paid, and recruitment fell behind need.
law institutions included infirmary wards with a Municipal hospital medical staff were paid and were
medical officer in charge, and the larger ones gradually either whole time or had sessional contracts. These
took on the functions of general hospitals for the hospitals tended to concentrate on the statutory health
acutely ill. The voluntary hospitals developed specialist responsibilities such as midwifery and tuberculosis and
services first, but between the wars development was on inpatient work. Outpatient services, which were
greater in municipal hospitals. Hospitals for patients needed to take advantage of new diagnostic services,
with communicable diseases, tuberculosis, and mental were developed mainly at voluntary hospitals.
illness and handicap had long been provided by local Hospital and specialist services in the late 1930s were
authorities-originally for public safety. unevenly distributed, inadequately funded, and lacked
From 1911 personal health care for low income coordination. Most of the buildings were old, and the
workers was provided through National Health requirements of modern medicine were met by adapta-
Insurance. This did not cover hospital care. Other tions in inadequate space. Communicable disease
medical care by general practitioners was a matter for hospitals were often the most modern buildings but
the individual, but there was a feature of special were soon to become redundant. Yet these physical
importance to the future of the NHS in the relationship difficulties were less important than those resulting
between specialists and general practitioners, the from competition, if not overt hostility, between the
former seeing only referred patients, save in an various district hospitals.
emergency. Local authorities also provided clinical
preventive services for children and their mothers.
Home nursing was a voluntary service loosely coordi- Legislation and the end of the Poor Law
nated by the Queen's Institute, but home midwifery The Local Government Acts of 1929 and 1933 ended
was supervised and supported by local authorities. the old Poor Law a century after its last reform. The
Nurses and general practitioners worked together counties and boroughs were empowered to transfer the
Cambridge CB1 4NZ reasonably well, in rural areas at least, but relationships hospital component to public health departments,
Sir George Godber, FRCP, between midwives or health visitors and general where they could be developed as a health rather than a
former chief medical officer practitioners could be cool or even hostile. welfare service. The boundaries between cities and

BMJ VOLUME 297 2 JULY 1988 37

Guy'sHospital, London, 1900 counties set arbitrary limits to the services available in its intentions for health services in a white paper in
developing suburbs. General practice and voluntary 1944. Pater has described the negotiations which
hospital catchment areas took no account of existing followed. '
boundaries, but local authority hospital and preventive One vested interest after another eroded the broader
services had to observe them. concepts, and it seemed possible that we would be left
The Cancer Act of 1939 was intended to encourage with merely an extension of the National Health
joint regional schemes for the treatment of cancer, Insurance system, with services provided by existing
mainly by radiotherapy, but the only scheme formally hospital owners under contract. The election of 1945
established and working before the NHS was in was, therefore, crucial for the NHS because it pro-
Lincolnshire. The largest authorities, Middlesex and duced, in Nye Bevan, a strong and committed minister
London County, began limited regionalisation of of health who, with the support of Buchanan in
services in their hospitals, and there were service links Scotland, could carry through proposals which went
for radiotherapy in the north west and elsewhere beyond the 1944 white paper.
among voluntary hospitals. The only broader based Bevan saw that the hospital problem required a
regional programme was initiated by the Nuffield radical solution-the transfer of all non-profit making
Trust in Oxford. hospitals to the ministries and the establishment of
The concept of regionalisation fitted in with the regional boards to plan and administer hospital services
preparations for civil defence in the event of war. and appoint committees in each district to manage
Although the civil defence regions were not quite the them. The service was to be available to everyone.
same as the later hospital regions, they served well Although private medical practice might continue, it
enough as the units for the coordination of casualty was to do so only under controlled circumstances, and
treatment. Some hospitals outside the main cities were the sale and purchase of. practices must end. The
upgraded and extended to receive staff and patients service would be funded predominantly from national
from city hospitals. That wartime experience showed taxation.
that hospital services could, with advantage, be The NHS Bill was introduced four months after the
reorganised and linked in regions for mutual support election and passed during the first session of the new
and better staffing. parliament. There was contention, but not enough to
endanger a scheme with such widespread popular
support. Most of the crises of the next two years
Plans for a coordinated service concerned details of professional terms of service.
In preparation for the expected change all the Many people have suggested that a unified system of
hospitals, except for those for the mentally ill or administration should have been established from the
retarded, were surveyed between 1942 and 1944 under beginning. This was simply not practicable; indeed,
the joint auspices of the health ministries and the we have not achieved unification yet. There was no
Nuffield Trust. I must be the last survivor of those ready made local administrative body, nor was there
surveying teams. The reports of the 10 teams for any body corresponding to the essential regional
England and Wales and one for Scotland were later component, except in Wales and Northern Ireland.
published and were surprisingly consistent. They The various components of the service could not be
found major deficiencies in hospital buildings which united administratively because of the size ofthe task. I
could be remedied only in the long term, though much am still uncertain whether the gains of any of the
confusion and inefficiency could be resolved in the reorganisations in and since 1974 have outweighed the
short term by functional union of the existing hospitals losses or effected any economies.
at each centre with a common and strengthened
specialist staff. The centres should be linked in regions
so that some regional specialist services could be Need for flexibility
provided for all. Those reports provided the basis After the act was passed less than two years remained
for the early work of the regional hospital boards for preparatory work. Only the Public Health
appointed in 1947. Laboratory Service was immediately in a position to be
The coalition government had set up the Good- made permanent.
enough committee to review medical education and Although counties had experienced health depart-
acted on its report by providing funds for reform. After ments they had many new responsibilities, and some of
accepting Sir William Beveridge's report it published them lost outstanding medical officers of health to the

BMJ VOLUME 297 2 JULY 1988

 regional boards. The councils had to produce schemes
for their functions under the act, consult the regional
health boards about them, and secure the minister's
approval. I read all these schemes and remember how
concerned I was that they should not be so narrowly
drawn as to inhibit later change.
Maternal and child welfare and health visiting were
already established; home midwifery was under partial
control; and ambulance services were derived in part
from wartime services; but home nursing, home help,
and after care were almost wholly new territory.
Immunisation against diphtheria and smallpox were
provided but needed reorganisation. Other immunisa-
tions were already available or might follow, so
programmes had to be capable of prompt expansion
and had to involve general practitioners. Local health
authorities had to rearrange their services for the
support of higher profile clinical care without
diminishing the thrust of prevention. Together with
the welfare services, local health authority services
did more to make the NHS viable than has been
recognised.

Life threatening diseases

In the first two decades of the NHS most of the life
threatening diseases of childhood were brought under
control. In 1930 five diseases caused over 800 deaths
per million children under 15 each year; by 1970 that t~~~~~~~i rnc,
mortality was down to five per million. This was partly
because of social and environmental factors and largely
because of educational work by health visitors, but
immunisation also played a major part. Immunisation
is far from complete even now, mainly because of the not a suitable qualification for the future specialist in
publicity given to wrong assessment of risks, but that community medicine, who should rank with his clinical
should not obscure the gains achieved by medical colleagues and be able to support them in planning and
officers of health and their staff. evaluating their work. The reorganisation of this
The pioneering work on the care of the mentally ill specialty eventually came about with the formation of
and handicapped was done in collaboration with the Faculty of Community Medicine in the 1970s and
medical officers of health. Junior training centres for so the report of the Hunter committee on its functions.
called ineducable children and adult training centres Now that changes in lifestyle and clinical practice are
were started by health departments and only when seen to be so important to health promotion the
successful were they transferred to the education or function of the community physician has changed.
welfare departments. Health education requires communication of the right
Problems of health control reminiscent of the earlier messages to the healthy and modification of factors
years of public health were also handled effectively. inimical to health such as the uncontrolled promotion
The medical officer of health was the key figure in the of unhealthy products. Education needs medical
control of smallpox, and the virologists began to and allied knowledge and the ability to present it
provide help in diagnosis only during the 1950s. The acceptably. Doctors, nurses, and other clinical workers
NHS has good reason to value the supporting work of do not necessarily have those skills. The Health
the Public Health Laboratory Service-happily now to Education Council, set up in 1967, made considerable
continue-and the skill of university laboratories. progress before it was transmuted into the Health
That still leaves a need for local knowledge and better Education Authority last year. The Scottish Health
regional support within the NHS. Collaboration does Education Unit, with more resources, probably had a
occur-for example, in the Medical Research Council's greater local impact, but funds allocated to this work
field trials of BCG and poliomyelitis vaccines, the were always insufficient.
clarification of the cause of retrolental fibroplasia in the
early 1950s, the initiation of the confidential inquiries Preventive health
into maternal deaths since 1951, and local studies of The greatest failing, however, has been the slowness
perinatal deaths-but the opportunity to use the of government to recognise the need for firm regulation
epidemiological skills of those trained in community of the commercial promotion of tobacco, alcohol, and
medicine was too seldom used, despite the pioneering unsuitable foods, or to enforce that simplest and
work of J N Morris, John Brotherston, Matthew Fyfe, safest of preventive measures-fluoridation of drinking
Michael Warren, and Archie Cochrane. water. The first clear demonstration that smoking is a
John Ryle chose to move from clinical medicine to major cause of premature death was 37 years ago, but
Oxford and the first chair of social medicine. Hiatt at about 100 000 people still die prematurely every year as
Harvard and Hetzel in Melbourne made similar moves a result of the habit or because they have been exposed
nearly 30 years later. In the interval, largely because to other people's smoking. The health cost of alcohol
of the work of Breslow, Morris, and others, the overuse may be less in terms of premature deaths, but
epidemiology of much chronic and degenerative disease the social costs in other ways are probably greater. The
was clarified and the possibility of prevention became NHS could not undo the harm that this failure of
an important new concern. government brings.
The teaching of public health had remained centred Screening for inapparent disease is a relatively new
on the academic diploma in public health, which the preventive activity involving clinical and community
medical officer ofhealth was required to hold. This was services. It was introduced as miniature chest radio-

BMJ VOLUME 297 2 JULY 1988 39

 for the profession. Suddenly, four years after the NHS
began, there was a large sum to distribute in general
practice and an opportunity to encourage group prac-
tice and new entrants through collaboration not com-
petition.
Dissatisfaction with the state of general practice was
not simply because of injustice over pay or maldistri-
bution. Several reports had been critical of the poor
quality of some practices and morale was generally low.
Two things slowly changed this-the improvement
after Danckwerts's arbitration and a spontaneous
movement among the doctors, which led to the founda-
tion of the Royal College of General Practitioners. An
initiative from the profession contributed £100000 a
year from their own remuneration to provide interest
free loans for the improvement or construction of
group practice premises. The anomaly that no rent
allowance was paid to doctors remained until the
Pilkington royal commission in 1960. Conditions for
practice development, and particularly for the health
centres, were only finally made favourable in the mid
1960s when the general practitioner charter was
negotiated with Kenneth Robinson.
"The doctor was so tired, dear" graphy before the value of screening as part of ordinary
clinical practice was accepted. -Other routines, such as Cooperation with other staff
neonatal screening for phenylketonuria and hypo- In 1954, quite independently, two groups in Win-
thyroidism, fitted easily into NHS practice. Cervical chester and one in Oxford arranged for health visitors
cytology screening was first introduced in the early from the local health authority to work in attachment
1960s, and screening for breast cancer is now also with to their practices. The result was so successful that
us, at greater cost. The greatest gains, however, are the arrangegnent became general in Oxford and Hamp-
likely to come from simpler procedures, such as checks shire within a few years and by the early 1960s was
for hypertension or glycosuria, incorporated into the copied widely elsewhere. Credit should be given to
routines of general practice. The foundation provided the pioneers, of whom I remember particularly Drs
by the local health authorities in public health and Gibson, Swift, and Lawrie among the general prac-
community medicine has been one of the major titioners, Drs Warin and Macdougall, the medical
strengths of the NHS. officers of health, and Miss Hayes, the health visitor.
The act also gave local health authorities power to The Cumberlege report shows there is still much to be
provide health centres to accommodate the various done, but the old format of singlehanded medical
components of the service. The original financial practice no longer meets requirements, and in its place
arrangements were unfavourable for doctors and local multidisciplinary primary care must be developed with
health authorities and even worse for dentists. Doctors the patients having a greater say.
were especially suspicious of council control. Fortu- I have deliberately left hospital and specialist services
nately, some experimental development began under to the last because, despite their cost and potential for
other auspices-for example, Oxford regional hospital saving life, their true function is to support the caring
board at Faringdon-but real expansion only began in services provided outside. A hospital should be part of
the mid 1960s when the general practitioner charter the community it serves, and specialists, whether
introduced sensible financial arrangements. doctors or nurses, neither supplant nor control
but supplement the work of their colleagues in the
Remuneration of general practitioners community.
Changes in general practice were necessary before The minister in England and Wales had completed
care in the community could be greatly improved, and
consultations and appointed boards for 13 regions and
they could be effective only if they began from within. the principality by the early summer of 1947, and the
At the outset general practitioners were probably the first meeting of a board took place in Sheffield in July.
least content with the new service. Over 95% of the The independent boards of governors of teaching
population registered with their chosen doctors, and hospitals were appointed in the following spring.
very few of these declined to take part. Since, however,
Scotland and Northern Ireland took similar action but
did not have the complication of boards of governors.
payment was to be almost wholly by capitation fee the
distribution of medical incomes changed abruptly. In Regions had less than a year to collect staff, learn
prosperous areas, where formerly there had been most
their jobs, plan their districts, and secure ministerial
opportunities for private practice, there were more approval before consulting and appointing manage-
ment committees. The emphasis was on sound repre-
doctors but the NHS lists were small. Areas with sentation of local people and of skill in the existing
fewer doctors became those providing the largest services, and we have lost too much of that emphasis in
incomes from capitation fees. General practitioners recent years. The centre recognised that local people
were aggrieved by what they, with good reason,
regarded as an unfair dictate on their remuneration. might prefer sometimes to make their own mistakes
The Spens committee had recommended earnings and live with them. The development of a district
above those estimated for 1939 but left this to be service was crucial for the provision of full health care
adjusted to 1948 values, and doctors believed that the and led to a gradual lessening of old hostilities between
formula used undervalued this betterment by about a hospitals.
quarter. There was discontent, a much needed increase
in the number of doctors was impeded, and many Development of specialist services
young doctors who had been in the forces could The greatest early gains were made by rationalising
not establish themselves. Eventually the dispute was and improving professional staff and the use of beds.
referred to arbitration and Judge Danckwerts found Nursing schools could be broader based when they

40 BMJ VOLUME 297 2 JULY 1988

 could use the resources of more than one hospital,
and nursing care improved concomitantly. Specialist
medical staffing outside the main centres was improved
rapidly after a painful process of consultant selection
had been completed and more junior staff were
recruited.
Boards had been given guidance on the development
of specialist services prepared by a group of consultant
advisers chaired by Sir John Charles. The Spens
committee on remuneration had also laid down a
pyramidal structure for specialist training, but this
was interpreted wrongly as a guide to staffing, with
damaging effects which still remain. Increases in
consultant time and in other staff, including nurses,
provided treatment for more patients, and improve-
ments continued during the 1950s as training arrange-
ments for the professions associated with medicine
improved after a review by a committee chaired by Sir
Zachary Cope. The emergence of these professions and
Mr(laterSir) the addition of non-medical scientists has been one of
Henry Willink QC the major factors in service development.
In some specialties trained but not yet established
staffwere available from the forces, and some part time The reaction of the Todd Royal Commission 10 years
specialists had time formerly used for private practice later went too far the other way.
now that their incomes came mainly from the NHS. When Sir John Charles's group produced Develop-
But in specialties like pathology, psychiatry, radiology,ment of ConsultantServices, the memorandum on which
anaesthetics, and paediatrics there was a severe short- early planning was based, they described only 22
age, and other new specialties were emerging, especially specialties, not even recognising the separation of
geriatrics. Medical staff expansion was allowed to geriatric from general medicine. Sadly, they also failed
become unbalanced by too great an increase in the to emphasise the collective rather than the individual
senior registrar grade, especially in teaching hospitals responsibilities of consultants to a district, and as their
and in the largest specialties of general medicine amanuensis I share in that failure.
and surgery. When this growth was stopped in 1952 Some still maintain that general medicine should
the registrar grade grew even more rapidly and the include the care of the elderly, but that ignores the
numbers of supposed trainees in medicine and surgery large social and community based component that goes
far exceeded the possible vacancies at consultant level. far beyond the ordinary work of the general physician.
The result was only made worse by central attempts to Boards soon found that active development of services
restrain growth of the consultant grade as an economy for the elderly required specialisation, and geriatrics,
measure. A great injustice was thus perpetrated on and later psychogeriatrics, became one of the fastest
generations of young doctors and harm done to the growing specialties. Many other developments in
NHS simply because the responsibilities of the con- medicine and surgery also called for special depart-
sultant grade were too narrowly defined. ments, and the main increase in consultant staff-
trebling in 30 years-has been in the newer specialties
Imbalance of manpower and in diagnostic departments rather than in the older
The situation was made worse by serious misjudg- clinical specialties.
ment of manpower requirements. In response to the Regional units for specialties such as neurosurgery,
profession's own fears the Willink committee reviewed plastic and thoracic surgery, and radiotherapy were
the intake of medical schools and disastrously under- soon established. Nephrology, transplant surgery, and
estimated requirements. Our own production of scanners of various kinds came later. But most patients
doctors was cut back and many overseas doctors came need less dramatic interventions, and the district
in to distort further the imbalance between senior and specialist services were the greater achievement of the
junior grades. Most of us at the time were blind to the early years. The rapid reduction of deaths associated
error until John Squire pointed it out five years later. with anaesthesia, despite the higher risk surgery
undertaken, was more important than the development
of cardiac surgery, but both were achieved within the
system.
Psychiatry was historically the most detached
specialty. In the early stages of the NHS mental
hospitals were managed by their own committees, but
in some places early attempts were made to reduce
their isolation. Rees at Warlingham Park, Carse at
Worthing, Macmillan at Nottingham, and Bierer at the
Marlborough Day Hospital were all trying to restore
the mentally ill, where possible, to life in the com-
munity. Short stay units and day hospitals for early
cases were developed in Manchester region using
converted sections of old city institutions. Improved
psychotropic drugs have helped, but new social and
medical policies and the growing importance of clinical
psychology and psychiatric nursing have had a larger
effect. The parallel change in the management of the
mentally handicapped has further to go. The old
SirJohn Charles (courtesy of the custodial methods are changing, but the investment
librarian, Royal College of in supporting services has been insufficient. "Com-
Physicians, London) munity care" makes a good slogan, but the real burden

BMJ VOLUME 297 2 JULY 1988 41

 is carried by families, who need far more help, and the
process is not cheap.
Obstetrics and paediatrics were in transition in 1948.
James Spence had been in the first chair of child health
at Newcastle only a few years and Dugald Baird in
Aberdeen was showing how an obstetric department
was responsible for all the pregnant and parturient
women of a district. These were the models on which
the NHS needed to build. Domiciliary deliveries
gradually gave way to hospital deliveries for almost all
women, by 1960 in Scotland and by 1970 in England.
There is still debate about the justification for this, but
it would have been less embittered if hospital staff had
learned earlier to be less rigid in their handling of
women going through a normal physiological process.
The safety record is attested to by a maternal mortality
rate among the lowest in the world, but human and
interprofessional relatiohships could still be improved.
The Abortion Act 1967 put a strain on obstetrics at a
SirJ'ames (Calvert) Spence time when contraceptive services were becoming a new
element in general practice, and the development of
antenatal diagnosis complicated the service for both private specialist work, parasitic on every district in the
specialties. Paediatric surgery emerged as a regional NHS. Increased specialisation is necessary, but it
specialty towards the end of the first decade. requires closer integration of the specialties, not extra
Neonatology became an important new element in opportunities for profit in some of them. Moreover,
paediatrics. Mary Sheridan's work on developmental specialist work in hospital and generalist work outside
abnormalities gave a new dimension to hospital and require better organised exchange between them, not
community paediatrics which was to emerge fully in competition. Medicine is not a singlehanded job.
the Court Report. Raymond Hoffenberg's Rock Carling monograph2
It has become fashionable to look for competition as gave us the best analysis of and justification for medical
the spur to progress. Incentives are needed in the NHS audit yet published.
as in any other human endeavour, but the professional To achieve its full potential the NHS depends on the
ethos of service to patients should be more important work of the districts. Two things are important-
than financial gain. Nevertheless, financial disadvant- continuing education in the professions with involve-
age can be a damaging disincentive, as in the ment ofall and the sensible development of community
pre-Danckwerts era and again before the general medicine as a specialty with a supportive and coordi-
practitioner charter. The merit awards system for nating role for all the others. The idea of a general
consultants helped in hospital medicine, but it tended practitioner shopping around for a hospital place for
to be too biased toward scientific rather than service his patient is an anachronism forced on us only by
contribution, and tenure for life can be soporific. inadequate development at district level.
Medical education is collateral to my theme, but one
consequence of medical progress is a greater need for
Reviews of practice
postgraduate training and continuing education for all
The unglamorous specialties are as important to the the professions in the health service. A Green College
NHS as the popular miracles. The Royal College of conference in 1986 was critical of postgraduate medical
General Practitioners' campaign for quality review has education in England, and a meeting last year suggested
made considerable progress, but it does not cover the major reforms. The Nuffield sponsored Christ Church
whole of general practice. Reviews of practice should conference, chaired by George Pickering in 1961, was
become part of the generally accepted professional followed by an eager response from the profession
obligation and will not be ensured by some kind of which gave us postgraduate centres in every district.
price list. The three reports of the cogwheel working That episode was one of the most heartening in the first
parties between 1966 and 1973 were aimed at the 20 years of the NHS. Without it there might have been
development of review of medical work in hospitals nothing to reorganise now.
and the outcome of specialist medical care. Despite Pharmacy, dentistry, and ophthalmic optics have all
much individual effort there is still no general system. been important parts of the service, though recent
Yet such activity is even more necessary now than it economies have reduced NHS dental and ophthalmic
was 20 years ago. provision. There is no space to discuss these, but this
Progress will not be obtained by individual com- does not mean that I undervalue the part they play in a
petition, which may be manifest mainly through comprehensive health service. Indeed the provision of
nine million pairs of spectacles in the first two and a
half years of the NHS may have been one of its larger
benefits to society, and the dental service is one of the
few parts of the NHS of which it can be said
unequivocally that it has promoted health in a way that
would not have occurred otherwise.
The development of the NHS was not planned
wholly by the central health departments. The act set
up a central health services council with standing
professional committees, with the object of ensuring an
informed contribution which would act as a check on
central bureaucracy. To an extent the council and
committee did this, but they were less effective than
some had hoped. Advisory committees need to be
Professor (laterSir) asked the right questions, and their capacity for
DugaldBaird initiation is less than many people think.

42 BMJ VOLUME 297 2 JULY 1988

 for the future, which was immediately broken. During
the 1950s we were spending less than 4% of the gross
national product on health care, but in that decade
there was an unrepeatable bonus to the NHS as a result
of the control of infections, especially tuberculosis. In
real terms the costs of all the other government services
except defence were growing faster than those of the
NHS. During the 1970s, when the relative decline in
professional earnings was remedied, the rate of increase
was sharply reduced and the period of real shortages
and cuts affecting welfare services began.
Geographical disparities were first tackled seriously
by Dick Crossman, who also set up the Health
Advisory Service, and were far from being remedied
during the years of relative plenty. Total uniformity is
probably an illusion because ofunquantifiable variables
which the RAWP formula cannot adjust for, and
Sir George Pickering (Portrait Scotland and Northern Ireland, funded through
byJohn Ward, Pembroke
College, Oxford) separate budgets, were far more generously treated
than England and Wales.
Special committees, such as the Platt committee on The past decade has been one of worsening shortages
the welfare of children in hospital, have had a lasting despite more efficient use of a budget which has not
effect on practice in this and other countries. Others kept pace with demographic change or technical
include the Gillie committee on group practice, progress. The protest by the three presidents earlier
the committee on the nursing day, the Tunbridge this year was fully justified for this government's
committee on occupational health care in hospitals, parsimony has put the first principle of the NHS-
and the Cohen committee on proprietary medicines. equity of access to health care-in jeopardy for the first
Many people gave much time and effort over many time in 40 years.
years and have had too little recognition for it.
In addition to the formal advisory machinery, there Assessing future priorities
were also regional and local committees and, at the The NHS is one of the greatest social innovations
centre, many ad hoc conferences, committees, and this country has produced. Andrew Jessiman of
working parties contributing on special subjects from Harvard recently called it "the finest bit of social
the Guillebaud committee on the cost of the NHS to legislation since Magna Carta." Richard Titmuss said
the Sainsbury committee on prescribing. They were much the same, and I would add only that, unlike
effective because the health professionals and members Magna Carta, it has been for all the people and not for
always seemed ready to give extra time to promote some latter day baronage. It is imperfect and has often
improvement in the NHS in subjects varying from the achieved less than one hoped it would. It still does not
highly technical fields of haemodialysis and organ have inbuilt review of quality. It is underfunded and
transplantation to human relationships in midwifery too much focused on reducing costs. Yet it has
or housekeeping problems like the use of central achieved more for the resources invested in it than any
laundries. The Medicines Commission would have of the other services that I know. It has one great
been needed whether the NHS existed or not, but its advantage in its firm basis of multidisciplinary primary
predecessor, the Committee on the Safety of Drugs was care. It has been restricted by lack offunds, savagely in
yet another example of a great voluntary effort by the 1980s, but no country can have all the resources
Derrick Dunlop and his colleagues through which that could be used to advantage, and at least in the
controls were put in place voluntarily long before NHS we share in accordance with need and, so far, not
legislation. in accordance with ability to pay.
All countries must face difficult choices as to the best
Service at risk use of available resources, but the nearest approach to a
This is not the occasion for a detailed exposition on market system there is, in the United States, does not
the funding of the NHS, nor am I the person to give it, suggest that we should emulate them if we really
but a brief comment is necessary. The first estimates believe in fair shares. If there is one contribution the
could be based only on incomplete information and medical profession could make which would be of
were too low. The first complete year was 1949-50 and greatest value to the NHS I suggest it might be a
ended with Cripps, as chancellor, setting a fixed ceiling collective assessment of priorities. That might lead to
the conclusion that doing promptly and effectively the
things that will bring relief, if not cure, is more
important than straining after the unattainable for the
B | | '. Sl i.
very few
..S,-9
2 .p .2 .,gew
at great cost ino.............
resources and time. The scope
of medical and allied technology is now so great that it
.. ...|~~~~~~~~~~~~~~~~~~~~~~~
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cannot all be used. Anyone achieving some extra

resource for one small field needs to reflect on who goes
l2VgB:+Z... without. In the famous words of an elderly black
R 1l gD.o+.R§:<.:..
American who spent his life shining shoes, "There is
f tgw,gg3_g.. no such thing as a free lunch." It is our duty as a
profession to present our assessment of the most that
can be done for the greatest number of people, and
then the people must choose.
This article is based on a Green College lecture given in
January 1988.
1 Pater JE. Making of the NHS. London: King's Fund, 1981.
2 Hoffenberg R. Clinical Freedom. London: Nuffield Provincial Hospitals Trust,
SirHarry Platt 1986. (Rock Carling Monograph.)

BMJ VOLUME 297 2 JULY 1988 43