Development of Health and Social Services in the UK from the Twentieth Century Onwards John P. Wattis

IMPERIAL BEGINNINGS: THE POOR LAW AND THE ASYLUM

In Britain, the twentieth century dawned in a blaze of imperial glory. By the beginning of the twenty-first century, the world, including health and social services, had changed beyond recognition. In the year 1900, UK public health measures were rudimentary and confined largely to the establishment (in 1848) of sanitary authorities with medical officers of health to oversee sewers and water supplies. The poor law was still in force and poor law institutions were made deliberately unpleasant. This followed the principle of ‘lesser eligibility’, set out in 1834, which stated that those receiving poor law assistance should not be as ‘eligible’ (well provided for) as an ‘independent labourer of the lowest class’¹. For the poor sick this had been ameliorated, to some extent, by the setting up of poor law infirmaries in 1868, but there was still a vast gulf between these institutions and the voluntary hospitals, which were supported by rich philanthropists. Retirement pensions, even retirement itself, were things of the future and there was an association between poverty, ill health and old age which was recognized by an 1895 Royal Commission on the aged poor. Despite over 50 years of the National Health Service (NHS), the association between poverty, ill health and old age is maintained to this day.

Until the middle of the twentieth century, mentally ill people were still incarcerated in large county asylums. In 1808, partly as a response to the appalling conditions in some private ‘madhouses’, local magistrates had been given the power to set up asylums, and in 1845 this provision had been made mandatory. In recent years we have seen a return to the private sector for some aspects of health and social care provision for people with mental health problems.

From 1900 onwards, developments have been influenced by major world events, political philosophy, public opinion and the power of pressure groups. The Boer War, starting in 1899, revealed the poor physical fitness and ill health of many young men. Improvements in midwifery and child care were soon legislated for, with school meals starting in 1906 and the notification of live births, health visiting and the school medical service soon following. In 1908 the first national scheme for old age pensions was set up to try to alleviate poverty among old people. It was non-contributory and means tested. Initially, recipients also had to be ‘of good character’!

The Royal Commission on the Poor Laws and the Relief of Distress in 1909 considered most of the issues of domiciliary and hospital medical care. A minority report condemned the poor law institutions as a public scandal, with the infirmaries understaffed and lacking skilled medical input². Out of hospital, the poor law doctors had no contact with local authority public health services, the voluntary dispensaries were overcrowded and ineffective and the medical clubs, financed by workers’ subscriptions, underpaid their doctors and did not cater for the chronic sick or dependants. The writers of this report dismissed the idea of a medical insurance system.

Yet, in 1911, the establishment of such a system marked an important development in the evolution of general practice in the UK. The medical profession fought for, and won, independence and capitation fees rather than a salaried service, and administration by insurance-based panels rather than local authorities³. Higher income groups, families and hospital care were excluded but the scheme was nevertheless a qualified success.

THE MINISTRY OF HEALTH: BETWEEN THE WARS

In 1918 the Ministry of Health for England and Wales was formed and the minister quickly appointed a consultative council, which in 1920 produced a report described by Pater² as ‘nothing less than the outline of a national health service’ (p. 7). Their scheme might well have avoided some of the split between general practitioners and hospital doctors that has been one of the problems of the NHS as it was eventually implemented.

Control of the workhouses passed to local authorities in 1930, the beginning of the end for the poor law. After a post-war cash crisis, the voluntary hospitals continued, becoming more specialized in acute care and leaving the chronic sick and infectious diseases to the local authorities. A number of reports pressed for a more coordinated hospital system and for universal health insurance. Knowledge was advancing. In 1935, Warren^4,5 began her work in developing geriatric medicine and, a few years later, pioneers began to write of the issues concerning old people with mental illness^6–8.

Before the Second World War, the Emergency Medical Service (EMS) was set up to cope with expected severe civilian casualties from the bombing of cities. On the declaration of war, 140 000 people, many of them elderly, were discharged from hospital over two days⁹. The EMS also coordinated the work of the voluntary and local authority hospitals, providing the framework for the future NHS Regional Hospital Boards. Physicians and surgeons from the elitist voluntary hospitals came face to face with the conditions of the former poor law institutions.

THE POST-WAR NATIONAL HEALTH SERVICE

The last of the series of British Medical Association (BMA) reports pressing for reform in 1942 coincided with the Beveridge report and was followed in 1944 by the NHS White Paper, enacted in 1946 and effective in 1948.

The National Health Service, as then set up, was tripartite. Primary care services – general practitioners, opticians, dentists and pharmacists – were answerable to local executive committees; maternity, child welfare, health visiting, health education, immunization and ambulances remained the responsibility of the local authority; and hospitals were administered by Regional Hospital Boards with teaching hospitals retaining boards of governors directly answerable to the Ministry of Health. One of the assumptions when the NHS was set up was that increasing health in the population would cause health expenditure to level off. It never did, and in 1956 the Guille-baud Committee, appointed to find ways of avoiding a rising charge upon the exchequer, concluded that there was no evidence of inefficiency or extravagance in the NHS. In fact, the committee was concerned about a lack of capital expenditure (a concern again of relevance more recently). In 1962, this problem was addressed in the Hospital Plan.

Meanwhile, in the mental health field, the idea of community care was gaining ground. Tinker¹⁰ attributed this to five factors. First, there was a general dissatisfaction with institutional care and a search for alternatives. Some of the experiments in the ‘therapeutic community’ work of the Second World War¹¹ had challenged the accepted authoritarian culture of the mental hospital. In addition, the advent of electroconvulsive therapy (ECT), antipsychotics and effective antide-pressants facilitated the move away from custodial care to medical treatment at home or in ordinary hospitals. Next, there were beginning to be practical problems in running residential establishments, including staff recruitment. Then there was concern about the cost of institutional care and, finally, a recognition that mentally ill people were entitled to live in as normal a way as permitted by modern treatments. The 1959 Mental Health Act liberalized the treatment of mentally ill people and opened the way for a move away from the old psychiatric hospitals to the new concept of psychiatric units attached to the district general hospitals of the 1962 Hospital Plan.

The large institutions were, in any case, rocked by a series of scandals about the mistreatment of patients. This resulted in the establishment of the Hospital Advisory Service (later the Health Advisory Service), effectively an inspectorate to monitor standards and spread good practice.

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