History of the NHS
10 September 2019
At the September meeting of the Wargrave Local History Society, local GP Dr Mark Puddy took a look back at the 70 years history of the National Health Service, and in particular how it the influenced the provision of medical services in the village. Mark considered the situation at three specific times - July 5th 1948, when the NHS was founded, September 1st 1989, when he joined the Wargrave GP practice, and the present day. In 1948 there was one village GP, Dr John McCrea. The surgery was at his house, in School Lane - Mark observed that to get up the slope to the house, patients must have been fit! There had also been a district nurse, Olive Cameron, who lived in Blakes Lane. She had just retired after 20 years, and in earlier times had also provided general nursing and midwifery services. Within the village, Woodclyffe House had been a convalescent home, the Evelyn Home, which provided for convalescing London mothers and their children, had moved to Wargrave in 1913, and into East View Road in 1926, whilst the Eleanor Wemyss home, attached to the Evelina Hospital (now part of St Thomas's) in London, opened in Crazies Hill in 1931 (and continued into the 1950s). As well as the Royal Berkshire in Reading, there were voluntary hospitals in Henley, and Battle Hospital in Reading - a municipal hospital that occupied the former workhouse buildings. Specialist hospitals were Smith's at Henley, for mental health concerns, and Prospect Park, for those with infectious diseases. In general, all of these provided for patients who paid when they had treatment, although a scheme had been introduced by David Lloyd George, whereby low paid working men could receive care. It did not cover their families, or any hospital treatment, the intention being to help the men remain in active work, and thus support themselves and their family. The style of patient record cards introduced at that time remained in use for many years, with just a change in colour from brown to white in the 1980s. Most hospitals had been in a poor state of repair before World War 2, and many had also suffered from bomb damage. Under the NHS, all those hospitals would be nationalised. Teaching hospitals were created as centres of excellence, district general hospitals were provided for the general care of people in their district, and GPs became the 'gatekeepers' to the system - patients needed a doctor's referral to get hospital treatment unless they were an accident or emergency case. These new hospital arrangements also gave a chance to reform the training of doctors and nurses. All the medical schools, for example, were opened up to women who wished to train as a doctor, as well as men. One of the visions of the new NHS was to build 'health centres', but funding was not available to buy the existing premises. As a result, GPs became self-employed sub-contractors to the NHS. They were paid on a per capita basis - the doctor was paid the same for a patient they never saw as for one they saw every week. Before the NHS was introduced, few GPs made an excellent living, and some had to employ debt collectors to obtain their payments. However, under the NHS, patients were much happier to visit the GP now that it was free to do so. There was, however, an imbalance of provision, with affluent areas having far fewer patients per GP than was the case in less well-off areas. In an effort to redress this, under the NHS, restrictions were placed on where a GP could set up a practice. Areas where there were more than 2,500 patients per doctor were declared 'free areas', where GPs were free to establish a practice. However, as payment was on a 'per patient' basis, there was no incentive to provide a good service. In Wargrave in 1939 there were 2,200 residents, and by the time Dr Godfrey Black took over from Dr McCrea, he was able to recruit an extra doctor - Dr Joe Paton. Most GPs worked 'single-handed' at that time, and so could only take a holiday if they paid for a locum to provide cover. In those days, patients expected to be able to have night calls - but at the same time appreciated that the same doctor would be working during the following day, and so were only likely to call the doctor if really necessary. The intention of the NHS was to provide a service 'free at the point of delivery' and 'fit for heroes' (it being the immediate post-war era). The idea was that as people were treated for their illnesses, the need for care - and hence cost - would drop, as they would become much more fit. The result was somewhat different. The predicted expenditure for the NHS in 1948 was £170 million, but it actually cost �305 million. Of that, for example, �1 million had been allowed for opticians - but in that first year 5� million pairs of spectacles were issued, at a cost of �32 million! One of the unpredicted problems for the NHS was that if a patient was cured of an illness that was cheaper to treat, they would live longer, and so be more likely to suffer from a more expensive one later. The need to reduce the overall costs of the NHS led to the introduction of charges for some dental and optician services in 1950, and a 1/- per item prescription charge in 1952. Little changed until into the 1960s. GPs were still paid on a 'per patient' basis, and were not allowed to 'recruit' patients to increase their income. If they wanted to improve their premises, or employ more staff, the cost of doing that had to come out of their own pockets. GPs also tended to be isolated, and there was little 'continuing education'. In Wargrave, the surgery moved to Dr Black's house in Church Street. Patients would queue outside to get into the waiting room, and apart from a part time typist, there was just one other employee - Lucy Jones who was nurse, dispenser, receptionist and practice manager. Help came in the form of a change to the administration and funding of the system, brought in by Health Minister Kenneth Robinson under the GP's Charter in 1966. Loans would be available to buy or improve surgery premises, whilst those who owned their surgeries would be paid a notional rent for their use. Doctors would receive additional payment for patients over 65, and also if they met certain targets for inoculations and smear tests for example. In the late 1960s Bobby Bramall had suggested that as part of the Elizabeth Court development a new surgery could be built. When this opened, it had 2 consulting rooms, a nurse's treatment room, a waiting room, reception area and office at that time and that was the situation when Mark joined the practice. Other health staff - such as health visitors, and later midwives, also became associated with GP practices, especially in rural areas. Further change came when Kenneth Clarke was Secretary of State for Health, under which non-emergency hospital treatment was charged to a local fund-holding practice. Although some GPs made a surplus on the arrangement, many - including Wargrave's doctors - felt that they had entered the profession in order to treat patients, not to be businessmen managing budgets. A further GP contract in 1990 created more performance targets, and also made retirement at70 compulsory. Mark at that time worked 2 nights a week on call, and one weekend in 4, as well as the regular morning and evening surgeries. A decade later, Wargrave became part of the Reddoc system, whereby night and weekend cover was provided by pooling the resources of practices in the Reading area. This ensured that 24 hour cover was provided, but some GPs (including some of the Wargrave team) did not like the fact that the doctor would be seeing patients they did not know. Increased doctor workloads led to a new contract in 2004, under which they could opt out of overnight and weekend working. Even so, village GPs still work a 60 to 65 hour week - hours that would be considered unsafe for pilots or lorry drivers, so certainly should also apply to doctors! When Mark joined the Wargrave practice, there were no computers, but he was keen to introduce some to handle administrative tasks within the practice. Although the NHS helped towards the costs, there was no common format for data handling -programs being developed at that time by doctors who were 'enthusiastic amateurs'. Some GPs did not like the new technology - one local GP regularly placing a vase of flowers in front of the screen rather than use it! Dr Thurston had started to create a summary of each patient's written notes in 1985, and in due course these were transferred to the surgery database. The task was more time-consuming when the hand-written notes of patients transferring from other practices had no summary sheet, though. More recently, the NHS has tried to link the various systems, but concerns over expense and vulnerability to data safety together with Government budget cuts have resulted in a an incomplete system. It is, however, possible for patients to carry out routine tasks such as booking appointments or arranging repeat prescriptions on-line. In the early years of the NHS, treatments were often based on what generations of consultants had thought might work best. A major development came in 1972, when Professor Archibald Cochrane instigated the idea of trials to test the effectiveness of various treatments. As the benefits of lower blood pressure, lower cholesterol and so on have become apparent, GPs have been encouraged to improve the quality of care by promoting these to patients, and additional payments are made under a Quality Outcome Framework if 'target percentages' are reached - enabling more staff to be employed to run additional clinics. Wargrave surgery now caters for about 7,200 people (1,000 more than 25 years ago). It regularly scores well in 'Patient Satisfaction Surveys, being in the top 1½% in the country. The surgery has expanded with 7 treatment rooms for the doctors and nurses and a physiotherapist. For the future, Mark hopes that the human genome project will become the basis of treating patients in the way best suited to them individually, with the most effective medication.