In 1911 a National Health Insurance Scheme was introduced in the United Kingdom that allowed low-paid workers (but not their families) access to primary health care. This was the first intervention by a British government in the area of general health care delivery. There was interest in taking matters further, and at the end of World War I an election pledge to establish a general health service was made by Lloyd George’s coalition. A Consultative Council on Medical and Allied Services was set up, headed by the King’s physician, Sir Bertrand Dawson (1864–1945, later Viscount Dawson of Penn), which produced an interim report in 1920. This discussion document suggested a framework for a comprehensive service emphasizing primary care and preventive medicine while defining the roles of secondary and tertiary services, in the event no action was taken and there was no further report. However, the philosophy and ideas of the Dawson Report were to influence the development of the National Health Service as World War II drew to a close more than 20 years later.

Shortly after the outbreak of World War II, the national government in Britain, which included representatives of all main political parties, asked Sir William Beveridge (1879–1963), an economist and master of University College Oxford, to chair an interdepartmental committee on the coordination of the Social Services. This was not expected to be completed until after the war, but the report entitled Social Insurance and Allied Services was published in 1942, some 18 months after the work started. It proposed a comprehensive social insurance scheme covering the whole population without income limit. The government response, with other pressing priorities, was initially low key, but the report sold 70,000 copies in 4 days and was popular with the public. An understanding then emerged that with the coming of peace a health care service for the nation would be established, free at the point of entry and financed by national taxation, based on a White Paper of 1944. This policy would be carried out by whichever party won the first postwar general election. In 1945, the Labour Party assumed power between the German and Japanese surrenders. Acts of Parliament in 1946 (covering England and Wales) and in 1947 (Scotland) were passed, and the National Health Service (NHS) was inaugurated on July 5, 1948.

The National Health Service Act (1946) defined ministerial responsibility for establishment in England and Wales of “a comprehensive health service designed to secure improvement in the physical and mental health of the people and the prevention, diagnosis and treatment of illness for that purpose.… Service so provided shall be free of charge.…” Responsibility for ushering in the new age fell on the Labour politician Aneurin Bevan (1897–1960), who was the Minister for Health and Housing. There was initial resistance from the medical profession, but Bevan proved an able negotiator, and in his own words overcame doctors’ objections by “filling their mouths with gold.” Bevan believed that access to free medical care would improve ordinary people’s health to the extent that there would be economic benefits, and in particular that the cost of the new NHS would fall with time as the rate of disease was reduced. This thinking was fortunately not enshrined in statute as history proved him completely wrong. Meanwhile private practice was allowed alongside and within the NHS.

Between 1948 and 1974 the NHS consisted of three main branches: Public health services, which were the responsibility of local government; the hospital-based services; and the primary care service in which family practitioners (general practitioners [GPs]) worked. Difficulties in planning and coordinating services led to considerable consultation and debate between 1968 and 1972, and in 1974 a major reorganization created three administrative tiers—at Regional, Area, and District levels—that sought to overcome these problems. This unfortunately proved bureaucratically inefficient, and in 1982, following a Royal Commission report, the middle tier of Area Health Authorities was abolished.

Up to this point stages in the development of the service were a consequence of consultation and forward planning that took place under governments of both main political parties, and the broad policy was bipartisan. From the mid-1980s onward the Conservative government began to introduce changes that deviated from this consensus. In 1985 the NHS was placed under a management board chaired by its own chief executive, accountable to but with some autonomy from the government Department of Health and Social Security. In the late 1980s the NHS was subjected to a private review by the government, after which a major change in its mode of operating was devised. Against concerted opposition from all those relevant professional bodies who expressed an opinion, as well as from other political parties, an amending act was passed in 1991, and a new, reformed NHS appeared on April 1, 1992.

The main changes reflected the adoption of an internal market strategy. This meant that the old District Health Authorities were allocated a grant based on their individual population needs, to purchase health services from provider units such as hospitals. Provider units were given the opportunity to become self-governing trusts, in competition with each other, obtaining their income from purchasing authorities by selling services to them. Doctors working in primary care were allowed (and encouraged) to take responsibility for managing their own budgets for purchasing secondary services (known as GP Fundholders). This controversial purchaser/provider split appeared to lay the foundation for an increase in the establishment of managerial, accounting, and general administrative staff, with a power shift away from health professionals. Some rationalization was attempted by a drastic reduction in the number of Regional Health Authorities in 1994, together with partial devolving of planning to the periphery. At the time of writing, virtually all provider units have self-governing Trust status, while the commissioning of most services is a function
of locality-based Primary Care Trusts. These came about after the Labour Party won the 1997 election with a policy pledge to abolish the internal market of the NHS and to remove the perceived unfair advantage of the fund-holding primary care sector over the non–fund-holding sector. The years since then have seen a series of rapid changes in structure, characterized by the increasing devolution of service commissioning to the primary care level, and a downscaling of the influence of the old Regional Offices, which were eventually abolished. This also happened against a background of devolution of government to Welsh, Scottish, and Northern Irish Assemblies, producing different NHS structures with subtle differences in four jurisdictions. Total spending on health by the government has substantially increased, but not surprisingly some of this has been required to finance the structural reforms and monitoring apparatus that have had to be introduced. In England and Wales recommended treatment guidelines for NHS use are drawn up by a quasi-autonomous government-funded organization, originally called the National Institute for Clinical Excellence, later expanded to the National Institute for Health and Clinical Excellence, but always known by its acronym, NICE. This describes itself as “the independent organization responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.” NICE also appraises health technologies, including drugs, to make recommendations for use within the NHS based on cost effectiveness, with the economic modeling emphasizing cost to the NHS rather than cost to society as a whole—an approach that has led to considerable criticism; it remains to be seen whether this narrow approach will survive. Nevertheless, NHS organizations in England and Wales are required to audit their practice against NICE guidance, and a degree of performance management is dependent on this. NICE produced comprehensive epilepsy management guidelines in October 2004.¹³ In Scotland, some of the equivalent functions of NICE are performed by the Scottish Intercollegiate Guideline Network (SIGN), which produced updated epilepsy guidelines in June 2004.¹⁶ There are some subtle differences in emphasis, which if followed closely could lead to different care pathways being followed by people with epilepsy in the United Kingdom depending on where they live, though whether this is important only time will tell. Both NICE and SIGN guidelines may be accessed through the Internet at www.nice.org.uk and www.sign.ac.uk, respectively. One consequence of current policy is the setting of various clinical and managerial targets (e.g., waiting times) that contribute to performance management of NHS organizations. An early attempt at this in England by a previous government was the publication in 1992 of The Health of the Nation.⁷ Inclusions and exclusions in this document are somewhat arbitrary. Targets for reduction in HIV and suicide are included, despite the relatively small numbers in England of those affected by HIV and the fact that suicide statistics depend on quality control of coroner’s courts. Epilepsy was not mentioned. Later, epilepsy came to move further up the governmental agenda. One of the key influences in this was the National Sentinel Clinical Audit of Epilepsy-related Death, published in 2002.¹⁰ This came about after intensive lobbying of the government by the voluntary sector, and its influence on service development has been significant. The government was moved to produce an Action Plan for epilepsy service improvement, which, although criticized heavily by the voluntary sector and by epilepsy specialists, nevertheless raised the profile of epilepsy considerably.³ Indeed, much direct representation to government about epilepsy services has been through charitable and voluntary groups, such as the British Epilepsy Association (now called Epilepsy Action), the National Society for Epilepsy, and the Joint Epilepsy Council of Great Britain and Ireland. In the United Kingdom these nonprofit organizations are called charities. In 1994 the government tacitly opposed a Disabled Rights Bill and met with much lobbying and criticism from groups advocating rights for the disabled and from consumer groups. Shortly afterward, the Charity Commission, the government-appointed body that regulates the activities of charities (some of which had been highly critical of the government’s failure to support the bill), issued firm guidelines that seemed at first effectively to stop charities from future involvement in political lobbying, unless they were willing to risk losing their charitable status.⁶ This advice was subsequently revised.⁵ The government then brought forward separate legislation on disability rights, the Disability Discrimination Act, which came into law in 1997.