0
MASARYK UNIVERSITY BRNO
Faculty of Education
DEPARTMENT OF ENGLISH LANGUAGE
AND LITERATURE
The Development of Medical Care in Great Britain
since the 17th
Century
Diploma Thesis
Brno 2007
Supervisor: Written by:
Andrew Philip Oakland, M.A. Zuzana Teplíková
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TEPLÍKOVÁ, Zuzana. The Development of Medical Care in Great Britain since the 17th
Century: diplomová práce. Brno : Masarykova univerzita, Fakulta pedagogická, Katedra
anglického jazyka a literatury, 2007. 72 s. Vedoucí diplomové práce Andrew Philip
Oakland.
Declaration:
I hereby declare that this diploma thesis is my own work and that I used only the sources
listed in the bibliography and websites.
Zuzana Teplíková
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Acknowledgements:
I would like to thank my supervisor, Andrew Philip Oakland, M.A. for his kind help,
comments, and valuable advice.
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Content
1. Introduction.................................................................................................................4
2. Medical Care in Britain before 1946............................................................................5
2.1. The Seventeenth and Eighteenth Centuries............................................................5
2.1.1. William Harvey (1578 ­ 1657).......................................................................7
2.1.2. Thomas Sydenham (1624 ­ 1689)..................................................................8
2.1.3. Edward Jenner (1749 - 1823) .......................................................................12
2.1.4. Hospitals......................................................................................................13
2.2. The Nineteenth Century......................................................................................14
2.2.1. Cholera and Precautions against the Disease ................................................14
2.2.1.1. John Snow (1813 ­ 1858)......................................................................16
2.2.2. James Parkinson (1755 - 1824).....................................................................17
2.2.3. Hospitals......................................................................................................18
2.3. The Twentieth Century .......................................................................................20
2.3.1. Alexander Fleming (1881 - 1955) ................................................................21
2.3.2. Sir Ronald Ross (1857 ­ 1932).....................................................................22
Notes 1 ..............................................................................................................23
3. The National Health Service (NHS)...........................................................................25
3.1. History of the National Health Service................................................................25
3.1.1. Aneurin Bevan (1897 ­ 1960) ......................................................................26
3.2. How the NHS Works..........................................................................................28
3.2.1. Primary Care................................................................................................29
3.2.2. Secondary Care............................................................................................31
3.3. Contemporary NHS ............................................................................................33
3.3.1. The Structure of the NHS in England ...........................................................37
3.3.1.1. The Department of Health.....................................................................37
3.3.1.2. Strategic Health Authorities ..................................................................39
3.3.1.3. Primary Care Trusts..............................................................................39
3.3.1.4. GPs.......................................................................................................40
3.3.1.5. Dentists.................................................................................................40
3.3.1.6. Hospitals...............................................................................................41
Notes 2 ..............................................................................................................43
4. The Medical Profession.............................................................................................44
4.1. Doctors and the Past ...........................................................................................44
4.2. Nurses ................................................................................................................45
4.2.1. Nurses in the Past.........................................................................................45
4.2.1.1. Florence Nightingale (1820 - 1910).......................................................48
4.2.1.2. Mary Jane Seacole (1805 - 1881)..........................................................49
4.2.2. Nurses and the Present .................................................................................51
Notes 3 ..............................................................................................................52
5. Conclusion ................................................................................................................53
6. Summary...................................................................................................................54
7. Resumé .....................................................................................................................55
8. Appendices................................................................................................................56
9. Bibliography and Internet Sources.............................................................................66
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1. Introduction
I became interested in healthcare while I was studying nursing at secondary
school, during the course of my studies I started to be more interested in the subject of
healthcare, especially in England. I had heard about certain well-known Britons in the
medical field, such as Nightingale, Harvey and Fleming, so I decided to gain more
information, not only about those people but also about the whole system of medical care
in Britain in the past as well as the present.
My thesis is a theoretical work focused on the overall state of medical care in
Great Britain from the historic point of view until the present. The intent of my work is to
make an outline of the development of British medical care from the seventeenth century
until the present, concerning the dubious remedies used in the seventeenth and eighteenth
centuries. I also cover the creation of the National Health Service, including hospital care
and medical staff. Moreover, my work contains short concise sub-chapters about several
famous Britons who have contributed to medical advances in British history and therefore
even today have benefited many people's lives. It is not my intention to tell their life
stories. I focus only on the areas of their lives which somehow relate to medicine or are
necessary to mention because of their significant influence upon the person and his or her
professional life.
At the end of my work there is an Appendix with additional materials which
extend the thesis and can help with understanding or explaining the matters which are
mentioned only marginally in the body of the work
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2. Medical Care in Britain before 1946
2.1. The Seventeenth and Eighteenth Centuries
The seventeenth and eighteenth centuries were periods of time when the people
lacked knowledge about their bodies and how to treat illnesses effectively. During this
time developments in medicine were made little by little. This work is concerned with
some of the major developments which occurred in Great Britain. Many diseases existed
then which do not exist nowadays, because there has been much progress made, not only
in medicine but also in the way of life of people living in the 21st
century. For instance,
proper drainage allows people nowadays to stay healthy whereas people in the 17th
century could not perhaps imagine such a luxury. Nowadays there are many books about
medicine, and even without being a doctor, one can know quite a lot about medicine and
how to treat a fever or simple diseases such as influenza or tonsillitis, for example. In that
time such minor illnesses might have caused death because of the lack of proper
treatment which is available nowadays.
The terrible disease in the seventeenth century was the plague which was
sometimes called "Black Death." It had already appeared in Britain in the Middle Ages
and there were also many outbreaks in the 17th
century; in 1603, 1625, 1640 and 1665. In
the last mentioned year was the worst outbreak, also known as Great Plague of London.
Plague was a viral disease transmitted to people from rats through plague-carrying
fleas. People did not know its cause and therefore, precautions against plague were not
effective enough. If a member of a family died of plague, the rest of the family was
locked up in the house for forty days, although the corpse was removed from the house
by the "Searchers of the Dead".1
It frequently meant death for the family members too,
especially due to the infected rats which lived in their dwellings. Such houses were
marked with a red cross on the door and the words "Lord have mercy on us". Plague
progressed very rapidly with the following symptoms:
The first the man knew of this was a cold shivering, followed by terrible
vomiting, so severe that it sometimes killed. Then came a high fever, which made the
patient delirious. There followed the growth of the buboes, black swellings under armpits
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and in the groin, which caused great pain. Sometimes these would burst and the fever
might then go down, but more often the unfortunate man would be dead before they
could do so, killed by the poisoning of his whole body by the germs of plague.2
There were many other illogical precautions taken by the authorities as soon as
new cases of plague emerged. They ordered the killing of all dogs; this meant that there
were no predators to kill the rats, therefore the number of these pests greatly increased.
Nobody was allowed to hold public meetings and some houses were torched because
authorities believed that the cause of plague was in the air, so this way the air needed to
be purified. It is estimated that more than 100,000 people died of plague in 1665.3
In the seventeenth and eighteenth centuries English doctors, although they were
not properly qualified and had little or no medical knowledge, had very high social status,
power and influence. They had to obtain a license in order to practice. To obtain the
license at the Royal College of Physicians, which was set up in 1518, applicants needed
only a slight knowledge of ancient Greek theories about medicine. However, this
knowledge was sufficient only for practicing in the provinces. Doctors in London needed
to be better educated. They were expected to have a better knowledge of the nature of
illness. They did know that being ill meant that something had happened to upset the
normal working of a patient's body, but they did not have a clue as to what had caused
this upset, or how to cure it.
If a person became ill, a doctor would come to try to find out what was wrong
with the patient. In that time, doctors did not have any special devices which helped them
to make the diagnosis. There were no thermometers so the doctor simply put his hand on
the patient's forehead to discover if the patient was feverish. Moreover, doctors would
ask questions and possibly squeeze and poke several tender areas of the body in the belief
that they could find something evidently wrong. Doctors learnt from this examination
practically nothing and some of them even prescribed medicine without seeing the patient
at all. They would prescribe some poultices which used to be placed on painful places,
a sip of medicine to drink or a pill to swallow. Another remedy which was widespread at
that time was blood-letting. It could be performed in several ways. The best was probably
by cutting a vein with a lancet but doctors would also use certain blood-sucking parasites
such as leeches, which are black slug-like creatures. There used to be other appalling
methods of treatment, especially in the seventeenth century. For instance, doctors used to
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put pans of hot coal on a patient's body to bring the patient around, they would give
laxatives and medicine which made a patient vomit, burn plaster on a patient's body to
cause the formation of blisters or make minute cuts on various parts of the patient's body.
Only the rich or royalty could afford many of these various treatments.
In that time, there were several people who wanted to and tried to find out more
about the human body rather than to merely rely upon questionable practices. One of
these was William Harvey who is known among doctors and medical staff all over the
world as the man who discovered the circulation of the blood. His discovery was really
vital because it brought a completely different view of the human body and its function,
even though this did not happen immediately after the discovery. Another man, Thomas
Sydenham, was likewise pre-eminent in the medical field at that time. In the seventeenth
century not much information about diseases and their treatments was known, however
these two men made great strides in medicine during that period.
2.1.1. William Harvey (1578 ­ 1657)
William Harvey was quite important person in the British history of medicine. He
was an English physician and a surgeon, who is credited with the discovery of the
circulation of the blood. He worked as the king James's I personal physician and in 1625
to 1647 he was also Charles's I personal doctor.
In the Harvey's time surgeons were not so important. Many of them were merely
barbers who from time to time did blood- letting. Surgeons in England did not have
propitious conditions. The dissection was banned in England. The only exception was
permitted by the king, Henry VIII, who allowed dissecting four criminals every year (the
number of the bodies was increased to six by Charles II, in 16634
). The dissections took
place in the Barber Surgeons Hall5
in London. Henry VIII decreed that the Company of
the Barber-Surgeons (1540-1745) would give the corpses of for criminals to help
surgeons study the anatomy of the human bodies. Till that time, surgeons could only rely
on books and theoretical diagrams. The dissections were accessible only to barbers,
surgeons, physicians and apprentices. They had to follow some rules; the surgeon who
performed the dissection had to wear clothing which was ordered to him and he had to
use special tools designed for dissections.
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Unfortunately, four dead bodies were not enough for the surgeons' purposes.
Therefore, surgeons often left England for other country where they could study and train
because there dissections were legal. The same case was Harvey; he left England for Italy
where he studied at University of Padua. There, in 1616 he announced his great
discovery. The discovery was not his only contribution to medicine. He dealt with the
function of the valves and clarified the purpose of the valves in veins and heart valves
likewise. He proved many other things about human body. Firstly, the blood did not go
through the heart septum. Secondly, in addition to the systematic circulation he proved
there was the pulmonary circulation in human body. Thirdly, the blood was pumped from
the heart (exactly from the atria into the ventricle) into the arteries of the whole body.
Moreover, he explained that the pulse is the reflection of the heart contractions. What,
however, he did not know was how the blood transferred from the arteries to the veins; he
did not distinguish capillary network so he could only speculate about that transfer.
The other finding which Harvey did, however, it is not as well-know as his
discovery of the blood circulation was that the reproduction of mammals and humans
happened when the ovum was fertilized by sperm.
Harvey's advice addressed to doctors was "Don't think, try." He wrote a book
about his discovery and published it in 1628. Regardless these discoveries and
explanations, Harvey was not appreciated by the people when he came back from Italy to
London. They believed that a person became ill because of the excessive amount of blood
in a human body. Therefore, people accepted practice of blood letting. Harvey's
discovery, however, contradicted such an idea. Despite the fact that his ideas about the
blood circulation were finally accepted during his lifetime, it did not stop other doctors to
continue in blood-letting. Nevertheless, his discovery of the circulation of the blood was
an important step to the other, no less important advances in the knowledge of anatomy
and physiology in the seventeenth century.
2.1.2. Thomas Sydenham (1624 ­ 1689)
Sydenham was the Puritan Physician, sometimes called the English Hippocrates
or the father of English medicine. He is considered to be one of the principal founders of
epidemiology but he was not widely appreciated in his time. He was a Puritan and this
9
was unfashionable for many people. Sydenham was even derided by his colleagues.
Nevertheless, his knowledge was recognized later.
He specifically employed two methods, which came from Hippocrates,
observation and experience. Sydenham believed that there was only one way to learn
more about diseases ­ sitting at the patient's bedside, watching him carefully and trying
to notice all the symptoms. Then he compared one case with another. Due to the
comparisons he noted that some illnesses showed exactly the same pattern of events as
they progressed. This discovery helped him greatly. As soon as he observed the same
pattern again, he knew what to do. He had his clinical experience and knew what to
expect and therefore what remedy had worked, which allowed him to help the patient
more effectively.
Although he practised blood letting (which he pursued less frequently than his
colleagues) his treatment was not so fanciful and he appeared to practise mainly medicine
based on observation as was already mentioned. He used cinchona as a treatment of
smallpox6
and he even invented liquid laudanum. What is more, he started using opium in
medical practice and he was the first to administer iron for the treatment of iron-
deficiency anaemia. Moreover, he encouraged the use of quinine for treating malaria,
which even nowadays is the ingredient of some anti-malarial drugs. Sydenham believed
was that Nature would heal most diseases on her own, it was only necessary to give her
a chance. Furthermore, he assumed that fresh air could also help in the treatment of
disease and illness.
He also deserves credit for discovering and naming scarlet fever. Also Sydenham
noticed the tie between fleas and typhus fever. Although he described a number of other
diseases aptly for the first time such as gout, malarial fever, scarlatina, measles, dysentery
or hysteria, the only eponymous use of his name that is commonly known is
"Sydenham's chorea". It is a streptococcal disease of the central nervous system
accompanied by rheumatic fever and characterized by uncontrolled and purposeless
contractions of the trunk and limb muscles. Ironically, the description refers to
approximately two paragraphs remarked on in one of his papers, more or less of an aside.
As he himself, suffered from gout and renal stones, he managed to describe the disease
precisely and in great detail. He also wrote several books about medicine which seem
nowadays more reasonable than many other works written at that time.
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The seventeenth and eighteenth centuries were difficult time periods to live in.
Streets in the larger towns and cities were extremely filthy so it was no wonder that
diseases could spread very quickly and that so many people became ill. In the eighteenth
century there were Commissioners appointed for the larger cities and they arranged for
the clean up of some of the main streets. Unfortunately, they were not able to take care of
the side streets where the majority of people lived. Refuse was thrown into the streets;
there was no water or drainage system. People used communal wells frequently
contaminated by cesspits which were often placed near a well. Unfortunately, many
people, especially paupers, regularly died because of the lack of medical care. They
simply could not afford a doctor. Nonetheless, they could rely on the apothecary if they
had at least a little money. The apothecary has disappeared from our modern society, but
the job might be compared to that of the chemist, who prepares the medicine prescribed
by a doctor, by mixing various ingredients. Unlike the modern chemist, the apothecary
acted as a doctor for poor people. He not only sold all sorts of drugs but he also treated
people much cheaper than would a physician at that time. He had no qualifications for
doing this. His only training was by working as an apprentice so gaining experience at
another apothecary. On account of having almost no qualifications yet earning quite a lot
of money, he was sometimes regarded as an artful seller by more respectable people.
An apothecary even had advertisements for his wares, and the advertised medicine
sold very well regardless of whether it was effective or not. If it appeared to be effective,
people who had tried it recommended the remedy to their friends. Spending money on
such a remedy was still cheaper than the fees charged by any physician. Yet for the
poorest, even a shilling spent on pills was too much so they had no choice but to take
either nothing or rely on the odd traditional remedies which were handed down from their
ancestors. For example, here are some traditional remedies which were present in
Hertfordshire in the eighteenth century:
To cure jaundice, it was recommended to take nine lice in a little ale every morning for
a week. Shingles could be cured by using ointment made up of blood from a black cat's
tail, mixed with juice from a house-leek and cream. Ague was relieved either by taking
strong beer and honey, or by dumping the sufferer into a tub of cold water. Hedgehog
drippings dropped into the ear was a certain cure for deafness, while consumption could
be banished by drinking `the very disagreeable liquor' produced by boiling turnips with
a piece of rusty bacon. Swallowing young frogs was good for asthma and hog's dung
would stop bleeding. Oddest of all, rashes and skins diseases could be put right by
carrying a dried toad in a silk bag around one's neck.7
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Besides apothecaries, there were also surgeons who treated people by operating on
them. It was not easy for surgeons to work in that time period because they were regarded
as somewhat less respectable than physicians and moreover, they had little chance to
learn any useful details about human anatomy. Dissections were banned, so they learnt
anatomy from their own patients. Unfortunately, it was often too late. The other
possibility, although an illegal one, was to purchase bodies from so called `resurrection
men'8
to practise dissections.
Due to the knowledge gained from making dissections, surgeons were able to
perform a number of operations even though the results of these operations were not
always successful. Failure was attributed to many causes. First, the operations were
limited because of shortness of duration. A patient was not able to bear the pain caused
by cutting for long without any anaesthetic. Second, the operation often ended with the
death of a patient which was brought about by dirty instruments which caused successive
blood poisoning. Despite such complications and life threatening situations, surgeons
continued to pursue various kinds of operations; they ordinarily amputated damaged
limbs, let blood or removed stones from the bladder or kidneys. The last mentioned
operation was the only one which included cutting open the patient. The operation was
very risky as were other operations at that time, the pain caused by the bladder or kidney
stone was so great and unbearable that patients were often willing to undergo the dubious
operation.
In the eighteenth century there was quite a lot of progress made concerning
surgery. In 1727 surgeons became a little more respectable after an Englishman, William
Cheseldon, performed a successful operation, extracting a kidney stone. He used a French
method which he modified slightly to make it safer. He usually charged 500 guineas for
an operation, but he proved himself willing to carry out operations on the poor for free
The other surgeon who played an important role in the development of surgery was
a Scottish surgeon, John Hunter. He maintained that not only were speed and accuracy
important in surgery but that precise knowledge of the human body was indeed
indispensable. He was interested in every organ in the human body, in its shape, function
and its specific location in the human body. To gain the knowledge he needed, Hunter
pursued thousands of dissections, not only on human bodies but also on various kinds of
animals as well. John Hunter was not the only doctor in his family, his elder brother,
William Hunter, was a successful anatomist at that time as well. William was, however
12
more interested in obstetrics.
The eighteenth century, moreover, brought some discoveries which resulted in it
being possible to treat people using more scientific methods. In some cases observations
sufficed.
The disease which was most easy observable was scurvy. It was caused by lack of
vitamin C and usually afflicted sailors who did not have enough fresh fruit and vegetables
to eat. Ship's captains did not know the cause of the illness but they did know that if
sailors ate fresh fruit and vegetables the disease would not appear. Therefore they took on
board a fresh supply of fruit and vegetables at every port. After having found the fact that
fruit and vegetables kept them healthy, every ship Of the Royal Navy was obliged to have
limejuice onboard their ships. Actually, scurvy was already known by Hippocrates but
the proof that it could be cured by eating citrus fruit came from a Scottish captain James
Lind who lived in the eighteenth century. Lind wrote a book in 1753 about his
experiments called A Treatise of the Scurvy.
Another great discovery made in the eighteenth century was Dr Jenner's smallpox
vaccine.
2.1.3. Edward Jenner (1749 - 1823)
Edward Jenner was an English physician who is well-known, mainly for his
discovery of a vaccination against smallpox. Jenner studied nature and practised medicine
in Gloucestershire in England. He went to London and studied under, besides others, the
famous surgeon John Hunter at St George's, University of London.
Jenner made a great discovery when he noticed that smallpox never afflicted
milkmaids. He observed that they often had small pocks on their hands. They had been
infected by cowpox, (which was a disease very similar to smallpox, but no so virulent)
which they got from milking the cows. This finding led Jenner to the idea that cowpox
would prevent people from being infected from smallpox. In 1796, he tried to vaccinate
an eight-year-old boy by using the cowpox serum from the cowpox blister on
a milkmaid's hand and injected the boy. The vaccination caused a fever but no serious
disease. Jenner repeated the vaccination of the boy but no disease followed and no signs
of infection were observed. Jenner continued with his research and finally, he wrote
a report about what he had discovered. It took a while but over time, Jenner's effort
13
proved to be very useful and successful. In 1840 the British government accepted
vaccination and it was even provided to people free of charge.
2.1.4. Hospitals
In the eighteenth century there was quite substantial progress made in the
development of hospitals. Hospitals had existed in the previous century also but they used
to serve as a place where people were only taken care of rather than treated. These kinds
of hospitals were established as a part of convents these institutions were simultaneously
being cancelled in the 18th
century and only a small number of them remained.
Nevertheless, other new hospitals were being founded and became centres of training for
physicians, surgeons and nurses.
At the end of the eighteenth century and at the very beginning of the nineteenth
century, in other words, around 1800 it was possible to find two kinds of hospitals. There
were the workhouses and the voluntary ones. The former hospitals were mainly for sick
paupers. There were no nurses until the second half of the nineteenth century. Therefore,
the sick paupers were taken care of by other poor people who could at least walk but
were frequently insane. The latter hospitals were voluntary hospitals that carried over into
the following century. They were founded by charitable people and designated especially
for use by the poor.
In the eighteenth century there were also hospitals for people who were popularly
considered to be 'lunatics'. The most famous one was the hospital of St Mary of
Bethlehem in London founded already in the Middle Ages. It was commonly known as
`Bedlam'. Treatment in this hospital from the perspective of today would be considered
inhuman and the mentally ill were rarely cured.
`...patients [were] kept permanently in chains, and others had their blood let, were given
vomits and laxatives, were kept drugged with opium, or were dumped into baths of cold
water.'9
What is more, Bedlam was also something like a museum. For their amusements, visitors
could go round the hospital for a mere penny. They watched, teased and provoked
patients. Fortunately, in 1770 these undignified visits were stopped. Public could visit
Bedlam but only under an attendant's supervision.
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2.2. The Nineteenth Century
Although medicine had become a more exact science by the nineteenth century,
there remained many deficiencies in medical care and hygiene. Many people died
because of squalid conditions in the towns and cities, which were overcrowded and
unhealthy. There was dangerous filth and squalor everywhere and what was worse, it was
tolerated. There was an effort to introduce some elementary steps of sanitary reform but
unfortunately, the Commons and local authorities refused to accept it. Poor people could
not afford proper drainage systems or clean a water supply. In the tightly packed and
filthy slums where the poor lived there was very little air or light either. Therefore, many
different kinds of diseases flourished.
2.2.1. Cholera and Precautions against the Disease
One of the feared diseases during that time was cholera. It was a disease in which
germs would spread by dirty water or by contact with excrement. It killed about 31,000
people in 1832.10
People started to suffer from violent stomach pains and vomiting, their
bodies became cold and their skin turned blue. It did not last long; they sometimes died
within only two hours. Medical science was almost totally helpless against cholera, which
could spread with terrifying rapidity especially in slums where there was no drainage or
clean water supply.
There was little knowledge about infections and disease in general. The germ
theory had existed previously, but it was supported only by very few scientists.
` The most popular explanation was that infection was carried through the
atmosphere, hanging in the air like an invisible mist, and was therefore most prevalent
amid the filth in the courtyards and back streets of the great cities.'11
This explanation was called "miasma theory of disease" which referred to the mentioned
mist, filled with particles ­ miasmas- which smelt foul and caused illness.
The reformers reacted to this interpretation by sweeping the sewage into nearby
rivers. It was absolutely the wrong remedy; their efforts to clean the towns brought only
faster transmission of disease. Fortunately, in 1832 the Cholera Prevention Act was
passed. On the one hand, the Act gave local authorities the right to require elementary
15
sanitary precautions; on the other hand, it was practically useless because the authorities
did not have any means of enforcing the right.
Other diseases such as typhus, tuberculosis, smallpox, typhoid and scarlet fever
were always present and the situation was rapidly deteriorating. Wood claims that "in
Glasgow a death rate of twenty-eight per thousand in 1821 had risen to thirty-eight per
thousand by 1838, and to forty per thousand in 1843"11
. Living conditions were
improved towards the middle of the century. Health officers started to provide proper
drainage and clean water which led to the reduction of mortal diseases.
In 1842, Edwin Chadwick, an English social reformer, played an important role in
the beneficial improvement of public health. He wrote Report on the Sanitary Condition
of the Laboring Population, in which he required the appointment of local medical
officers. He wanted each house to be supplied with pure water for drinking and for the
operation of a water closet as well; all waste matter was to be drained off through small
egg-shaped sewerage pipes to remote country districts, where it could be utilized as
mature. (See Appendix 1 below.)
Finally in 1848 the Liberal Government, under Prime Minister Lord John Russell,
passed the Public Health Act. It was passed particularly in response to urges by Edwin
Chadwick. The object of the Act was to improve the sanitary conditions (as Chadwick
demanded) in towns and other places in England and Wales where many people lived.
The improvement covered the supply of water, sewage, drainage, cleansing and paving,
all under a single local body. It did not affect the City of London and some other areas in
the Metropolis because they were already under the control of sewer commissioners.
Moreover, the act laid down the first boards of health. The central authority was
the General Board of Health but its life was limited to only five years. However, during
the time of its existence the Board consisted of a chairman and two Commissioners. It
was created to advise Parliament and to support urban authorities to organize their own
Local Boards, sometimes called Local Boards of Health. These Local Boards were
established on the grounds of cholera epidemics and their responsibilities were to control
sewers, clean the streets and ensure the proper supply of water to their districts. They also
undertook many other activities which helped introduce more sanitary conditions. Due to
Chadwick and Ashley's admirable effort, 182 local boards were set up by 1853.12
These
local boards either merged with the corporation of municipal boroughs in 1873 or they
became urban districts in 1894.13
16
The fresh wave of cholera, which was sweeping into Europe from the East,
reached cities in England and Wales in the summer months of 1848 and 1849; more than
72, 00014
people died of cholera. Cholera returned again in 1853 but because of the
success of the General Board of Health, the death rate was much lower. Regardless of
such success, in 1854 the Board was doomed to failure because there were 65 votes for
and 74 against the preservation of the Board in the House of Commons and a Board of
Ministers took the place of the Board of Health.14
In spite of all the above mentioned efforts, a report from 1869 showed that some
towns remained as dirty and unhealthy as they had been in 1830s.15
In the nineteenth century, there lived another man, who helped in the fight against
cholera. His name was John Snow.
2.2.1.1. John Snow (1813 ­ 1858)
Snow was a British physician, who is considered to be one of the founders of
epidemiology. He studied medicine at University of London and graduated in 1844. Six
years later, Snow was admitted to the Royal College of Physicians.
He was a supporter of medical hygiene and usage of anesthesia in practice. In
1854 during a cholera outbreak, he observed that the disease was restricted to a small area
in Soho, London. By visiting the houses where the ill people lived, he deduced that the
source of cholera was in the water which came from the public water pump on Broad
Street, nowadays called Broadwick Street.
Snow applied the germ theory without knowing any other details about it because
it was not fully formulated until 1865. He examined the water under a microscope. Even
though he observed that there was something in the water which could cause the disease,
he was not able to describe it more, he did however make important steps not only
towards getting rid of cholera but also towards the investigation of the micro-organism.
His other contribution to medicine was made in the field of anaesthesiology.
Snow was one of the first physicians who calculated the dosage of anaesthetics such as
ether and chloroform. Obstetric anaesthesia was commonly used as well. Snow was even
present while Queen Victoria was giving birth to one of her children and he personally
administered ether to Her Majesty.
17
In the nineteenth century there appeared on the scene quite a lot of university-
educated physicians, who helped develop medicine as a science. Not only were medical
anatomy and physiology advanced, but considerable strides were made in pharmacology
too. In the first half of the century morphine, atropine, digitalin and others were
beginning to be used. Moreover, there was significant progress made in the identification,
classification and description of various diseases. British doctors who played important
roles in such demanding and outstanding work are; Thomas Addison (1793-1860),
Richard Bright (1789-1858), Thomas Hodgkin (1798-1866), John Hughlings Jackson
(1835-1911), Joseph Lister (1827 ­ 1912), James Parkinson (1755­1824) and others.
Immediately below there is mention of the work of James Parkinson only because the
disease named after him is generally known, even to people uninitiated in the field of
medicine. On account of the above mentioned reasons, the nineteenth century is
considered to be a very remarkable time period in the development of medicine.
2.2.2. James Parkinson (1755 - 1824)
Parkinson was an English physician and a palaeontologist. He was born on April
11, 1755 in Hoxton Square, Shoreditch, in London. It is not known where he studied,
nevertheless, his name was written down on the list of surgeons approved by the
Corporation of London. So in 1784 he became a surgeon. Besides medicine and science,
he was involved in various social and revolutionary causes and he was a member of
certain secret political societies. Parkinson was interested in politics very much, but
fortunately since 1799 he started to become interested in medicine more than in politics.
He published several works about medicine concerning gout and the description of
a perforated and gangrenous appendix with peritonitis. Moreover, he was interested in
general public health and the well-being of the population and he was an advocate of
legal protection for the mentally ill, as well as their families and doctors. The work for
which Parkinson deserves the most profound admiration is the excellent clinical
description of the disease (nowadays called Parkinson's disease), which he described in
his work called An Essay on the Shaking Palsy published in 1817. Parkinson's disease is
defined as "A degenerative disorder of the nervous system characterized by masklike
facies, a fine, slowly spreading tremor, cogwheel rigidity, bradykinesia, and postural
18
instability with a peculiar gait."16
The name Parkinson's disease did not come from
Parkinson himself. Approximately 60 years later, French neurologist, Jean Martin
Charcot, named the disease as Parkinson's disease.
Just as Parkinson had changed his interest from politics to medicine, he soon
switched from medicine to nature, so there are no other important descriptions of diseases
from Parkinson. Despite little attention from his English-speaking colleagues in his time,
Parkinson's disease is one of the best known medical eponyms and his description of the
disease was a great asset in the development of medicine.
2.2.3. Hospitals
In the nineteenth century poor people either had to do without medical treatment
or rely on dubious home remedies, which could often be dangerous. Medical care at that
time was mainly private or voluntary. Some poor workers had free access to a doctor but
this was not the case for their wives and children. There were however some doctors who
provided free treatment to the poorest people.
Medical care was pursued in hospitals as well as outside. At the very beginning of
the nineteenth century the worst hospitals were in a very bad state. There was a typically
unpleasant smell in hospital wards which could be found not only in England but also
elsewhere. The wards were stuffy and overcrowded. Patients were not bathed so often
and usually slept two to a bed. Sheeting was rarely washed and windows were not opened
frequently. The people who worked there and were called nurses were ordinarily very
poor women as well. They were often not clean, and were considered by the majority of
the public to be of a lower class. They slept in the wards and took care of patients but
they only brought them food or washed their clothes. Nurses were not supposed to do any
skilled work. It was done by surgeons themselves. People did not want to be placed in
such hospitals but those who did not have any relatives who could look after them had no
other choice. Moreover, there was one condition to be met by the sick to be able to be
admitted to the hospital. They had to have money for their burials in case they died,
which they handed over upon admission to the hospital. Because of the very bad
conditions of such hospitals, it was quite likely for patients to die there. Conditions there
generally contributed to a worsening of the state of health rather than an improvement.
19
In 1828 William Marsden, a young doctor who helped people free of charge,
opened London General Institution for the Gratuitous Cure of Malignant Diseases. It was
a dispensary for advice and medicines which is now called the Royal Free Hospital. It
was built as a hospital for poor, ill people who could not afford to pay for medical care.
Free care lasted until 1920, when the institution was forced to ask patients to pay for their
treatment.
Hospitals were built in urban areas. Two-thirds of the hospitals were originally
built before 1891 and approximately 21 per cent before 186117
. Their physical state was
very poor and besides, they lacked operating theatres, diagnostic facilities, pathology and
radiology.
Treatment in hospitals was very much based on good nursing, bed rest and the
giving of sedatives, especially at night. Patients were often admitted to the hospital at
a very late stage of their disease. Diagnosis, prognosis and treatment were often based
only on bedside observation over a period of time. In that time, there were not as many
drugs available as today. Doctors frequently used salicylates for rheumatic fever, digoxin
for heart disease, sulphonamides, penicillin and streptomycin for controlling pneumonias.
Essentially, all hospitals were subdivided into general medical and general
surgical wards. If any maternity department or gynecology wards existed, they were
separate. Children were commonly placed in adult wards. In some larger hospitals there
might have been orthopedic wards.
During the nineteenth century and at the beginning of the twentieth century there
were two main kinds of hospitals - voluntary hospitals and municipal hospitals.
Voluntary hospitals were the most prestigious hospitals, which were responsible
only to themselves, mainly because they financed themselves. They offered considerable
outpatient services which enabled the hospitals to advertise themselves. This kind of
hospitals would provide care only to a limited number of patients and it tended to deal
especially with serious illnesses. Voluntary hospitals admitted only limited categories of
patients; people with chronic diseases and elderly people were not admitted at all.
Hospitals were well controlled at large and they could afford to choose their staff.
Matrons chose only the student nurses who gained a "school certificate". Among others,
the selected nurses usually came from "good families". Discipline was very firm; if
a nurse became pregnant she was dismissed. Nevertheless, despite hard working
20
conditions and running the risk of being dismissed, there were quite a number of
marriages between doctors and nurses.
Municipal hospitals were provided by the local authorities of large towns. In
contrast to voluntary hospitals which were not able to keep pace with the increasing
needs of the population, the municipal hospitals kept up. They provided more beds even
though many of them were intended for long-term care. Better laboratories and operating
theaters were slowly developing, yet outpatient departments remained elementary.
In some places hospitals co-operated with each other without hostility but there
were other places where hospitals were engaged in what could only be described as open
war.
Mentally ill and mentally handicapped people represented a special group of
patients. Mainly at the beginning of the twentieth century there was a greater number of
hospital beds for such patients than there were for patients suffering from acute
symptoms of physical illness. Crowding was caused by bomb damage in the wartime.
`Before 1946 there had been little expectation of the inclusion of these services in the
NHS, and therefore little planning. The mental health sector was subsumed into the NHS
with difficulty, as an unwilling and inferior partner'17
Institutions and care the mentally
ill is too complex topic and it might be the subject of further investigation. Therefore, it is
mentioned in this chapter only marginally.
2.3. The Twentieth Century
At the beginning of the twentieth century, when the NHS in Britain did not exist,
people had already started to realize more and more that staying healthy and preventing
illnesses is much better than attempting to cure them. They perceived that even if
a person is healthy one might still become ill. Therefore, it was necessary to continue
with observation of various symptoms; searching for the causes of illnesses or rather
trying to prevent them. The Liberal Government, which was in power between 1906 and
1914, in 1907 launched medical inspection for school children. Nevertheless, not until
1912 was free medical treatment made available for children who needed it. Otherwise,
medical care was charged for and therefore, the poor rarely went to a doctor. In 1911
David Lloyd George, British Prime Minister, introduced medical insurance and the
21
National Insurance Act was passed, but only workers, not their wives and children, could
get free treatment. Dental treatment and spectacles did not use to be free of charge. This
was not changed until the NHS was established.
In the following sub-chapters, two significant British men are mentioned who
contributed to the development of medicine at the turn of the twentieth century and in the
twentieth century itself. In addition to Fleming and Ross, Sir Almroth Wright must be
mentioned, at least briefly.
His full name was Sir Almroth Edward Wright (1861-1947) and he is probably
not as well-known as the two others mentioned above. Wright was a British
bacteriologist, an immunologist who is respected for `advancing vaccination through the
use of autogenous vaccines (prepared from the bacteria harboured by the patient) and
also through typhoid vaccination with typhoid bacilli killed by heat.'18
It is very hard to
imagine being ill, suffering from a simple case of tonsillitis and not to have any certainty
that it is going to be healed quickly, because there may not be any efficient drugs. At the
present time, penicillin and other kinds of antibiotics are foregone conclusion for most
people in the developed world but without the hard work of bacteriologists, mainly
Fleming, it would not be so self-evident that people would not have died from lesser
illness, such as for instance, tonsillitis.
2.3.1. Alexander Fleming (1881 - 1955)
Alexander Fleming was a Scottish bacteriologist. He was born in Lochfield,
Scotland but later moved to London. After spending four years in a shipping office, he
entered St. Mary's Medical School at London University. In 1906 he graduated with
distinction. Afterwards, he began research at St. Mary's with Sir Almroth Wright and he
became a lecturer there. He stayed at St Mary's until World War I in 1914, but returned
again after the war in 1918. During the war he served as a captain in the Army Medical
Corps. He gained many distinctions in his life. Firstly, in 1928 he was elected Professor
of the School. Secondly, in 1943 he was elected Fellow of the Royal Society. Thirdly, in
1944 he was knighted and finally, in 1948 he became Emeritus Professor of Bacteriology,
University London.
He was very interested in the natural bacterial action of the blood and in
antiseptics. He searched for antibacterial substances which would not be toxic to animal
22
tissue. Finally, in 1921, he discovered an important bacteriolytic substance which he
named Lysozyme. The main thing which made Fleming famous was his discovery of
penicillin. It happened accidentally in 1928 while he was working with a bacterial culture
of Staphylococcus Aureus. He observed that mould had developed on a staphylococcus
culture plate. The mould had created a bacteria-free circle around itself. It was inspiring
for Fleming so he did further experiments and he found out that a mould culture
prevented growth of staphylococci. The mould was very powerful because it had an
effect even when it was diluted 800 times. The first people who were treated with
penicillin were soldiers in World War II. The usage of penicillin diminished the number
of amputated limbs. In the WWI, 70 per cent of seriously wounded limbs were
amputated, whereas in the WWII it was a mere 20 per cent.19
Although Fleming discovered penicillin, it is believed that without Florey and
Chain's work (two Oxford scientists, who isolated penicillin in its pure form 11 years
after Fleming's initial discovery) penicillin may have remained a substance without any
practical importance. Alexander Fleming together with Ernst Boris Chain (Germany) and
Howard Walter Florey (Australia) received the Nobel Prize for the discovery and the
curative effect of penicillin in various infectious diseases.
Fleming wrote many papers on bacteriology, immunology and chemotherapy, in
which he also described lysozyme and penicillin.
2.3.2. Sir Ronald Ross (1857 ­ 1932)
A Scottish physician, Sir Ronald Ross made a big discovery in 1898 when he
found out that the disease, malaria, was carried by the female of the Anopheles, a species
of mosquito. He investigated the disease in Calcutta in India and ascertained the presence
of malaria parasite in mosquito's salivary glands. The parasite was transmitted from the
bite of a mosquito.
Moreover, he noticed that that the species of mosquito needed water for their
reproduction and therefore, they appeared in marshy areas. Ross suggested precautions
against the reproduction of mosquitoes and consequential spread of malaria. For instance,
he found it effective to create drainage of all marshy areas; pouring a little oil on the
trenches or pools. The layer of oil was supposed to prevent hatched mosquitoes from
breathing in cases where the trenches were filled with water. It was only possible to use
23
this method in quite small areas. For bigger areas it was much more effective to use
a pesticide called D.D.T. (Dichloro-Diphenyl-Trichloroethane) developed at the
beginning of the World War II. Larger areas were sprayed with it and both mosquitoes
and malaria vanished.
For his discovery, in 1902 Ross was awarded the Nobel Prize in Medicine.
Although there has not yet been any vaccine invented, Ross did very sterling
work. Even though there is, for the time being, no vaccination against malaria, it is
greatly beneficial that at least the cause of the disease is known. People who travel to
such tropical places (Africa, Central and South America, etc.), where malaria is known to
exist, should be aware of the risk. There are at least some antimalarial drugs available but
unfortunately they are not 100 percent effective. It is possible for people who live in
malarial areas for longer periods of time to acquire local immunity which might be lost
very quickly if they abandon the malarial area. Provided that they are exposed to repeated
malarial infection approximately from 4 to 10 years, there is a chance of building the
immunity.20
Malarial symptoms are very similar to those of flu at first. Malaria starts with
headache, aching muscles and weakness but later the symptoms are much more serious. It
all depends upon which kind of parasite a patient is attacked by. Malaria is one of many
very severe diseases which are quite frequently fatal. Therefore, there was a strong need
for such influential experts as Wright, Fleming and Ross, whose efforts are nowadays
considered priceless.
________________________________________________________________________
Notes 1
1. Searchers of the Dead ­ usually two old women whose job was to inspect corpses and
determine if the cause of death was plague or not. They were often bribed to tell that
the cause of dead was something else.
2. Patrick, A.J. A History of Britain: The Making of a Nation 1603-1789, Penguin Books
1967 p. 80
3. Patrick, A.J. A History of Britain: The Making of a Nation 1603-1789, Penguin Books
1967, p. 82
4. http://elane.stanford.edu/wilson/Text/6c.html
5. the room still exists; Monkwell Square in London
6. As far as smallpox is concerned, Sydenham's treatment was quite moderate and not
effective enough. Proper and effective treatment of smallpox was not introduced untill the
second half of the eighteenth century by Edward Jenner (see 2.1.3.) He attached the specific
inflammation of the blood to smallpox. Nevertheless, his great contribution was that he
distinctly recognized the difference between smallpox and measles.
http://www.whonamedit.com/doctor.cfm/1989.html
7. Patrick, A.J. A History of Britain: The Making of a Nation 1603-1789, Penguin Books
1967, p. 207-208
8. resurrection men ­ men who would dig up coffins in the churchyard and take the body
24
which they sold. They would usually do this the night after a burial. It was very dangerous
for them. If caught, they ran the risk of being torn to pieces.
9. Patrick, A.J. A History of Britain: The Making of a Nation 1603-1789. Penguin Books 1967, p.212
10. McDowall, David. An Illustrated History of Britain, Longman Group UK Limited 1991,
p.140
11. Wood, Anthony. Nineteenth Century Britain 1815-1914, Longman 1982, p.119
12. Wood, Anthony. Nineteenth Century Britain 1815-1914, Longman 1982, p. 121
13. http://en.wikipedia.org/wiki/Local_board_of_health
14. Wood, Anthony. Nineteenth Century Britain 1815-1914, Longman 1982, p. 121
15. Chalmers, SAS & Larry Cheyne. Scotland and Britain 1830-1980, Hodder &
Stoughton Ltd.1992, p. 20
16. http://www.whonamedit.com/doctor.cfm/392.html
17. Rivett, Geoffrey. From Cradle to Grave: fifty years of the NHS, The King's Fund ,
London 1998, chapter: The Inheritance of the NHS
18. http://en.wikipedia.org/wiki/Almroth_Wright
19. Nash, E. N. & A. M. Newth. Britain in the Modern World: the Twentieth Century, Penguin Books
1968, p.219
20. http://hcd2.bupa.co.uk/fact_sheets/html/malaria_prevention.html
25
3. The National Health Service (NHS)
3.1. History of the National Health Service
The effort to bring forward a plan for a national health service had already been
discussed before the First World War. In the1920s members of the Socialist Medical
Association had the idea of a national health service which should be controlled by
elected local assemblies and which should work through local health centres. What was,
however, different from the later ideas was the method of financing; members of the
association envisaged fully salaried services. Nevertheless, their idea was never realized.
Later, between the wars, there was an increased interest in solving these problems but
there were no satisfying solutions. Finally, in 1947 a Labour government created the
National Health Service (NHS). It was based on the report called Social Insurance and
Allied Services which was published in December 1942. The report is commonly known
as the Beveridge Report recommendations and its implementation would replace the
previously private system of payment for health care and the voluntary system, which had
not provided health facilities for all people.
Instead of being a rather technical report on social insurance, it became `a new
declaration of human rights brought up to date for an industrial society and dealing in
plain and vigorous language with some of the most controversial issues in British
politics.'1
Besides the other social reforms Beveridge recommended the foundation of
a national health service. The Government accepted the Report in principle but the
country could not afford to implement Beveridge's proposals.
In 1946 there was a debate over the establishment of the NHS as well. The Opposition,
the Conservative Party, elected to support the plan in principle but resisted the second
reading of the National Service Bill in February 1946 because of many reasons which
Sked and Cook claim:
`it prejudiced the patient's right to an individual family doctor, retarded the development
of the hospital services by destroying local ownership, menaced all charitable
foundations and weakened the responsibility of local authorities.'2
26
It is clear that it was very difficult for the Conservative Party. On the one hand,
Conservatives knew how popular the idea of the NHS was in Britain generally. However,
on the other hand, they wanted to make use of the hostility of the medical profession to
the Government's proposals.
Finally, on 5 July 1948 the National Health Service was officially established.
The idea of the NHS was to provide free medical treatment both for the rich and the poor
from birth to death. In other words, as is often mentioned in many books, "from the
cradle to the grave" or "from the womb to the tomb". The founding principle of the NHS
was not just providing treatment for those who are ill but it also to improve health and to
prevent disease.
The aims of the NHS are obvious from the extract of the National Health Service Act of
1946:
(1) It shall be the duty of the Minister of health to promote the establishment in
England and Wales of a comprehensive health service designed to secure
improvement in the physical and mental health of the people of England and
Wales and the prevention, diagnosis and treatment of illness and for that
purpose to provide secure the effective provision of services in accordance
with the following provisions of this Act.
(2) The services so provided shall be free of charge except where any provision of
this Act expressly provides for the making and recovery of charges.3
The day of the establishment of the NHS (5 July 1948) brought about big changes.
People started to pay collectively for medical treatment when they needed it, as
taxpayers. However, there were also some contributions made from the national
insurance scheme.
The NHS became an integrated and organized service which brought together
hospitals, medical staff (GPs, dentists, opticians) and other services and which provided
health care for the whole population.
3.1.1. Aneurin Bevan (1897 ­ 1960)
Aneurin Bevan, then Minister of Health must be mentioned in connection with the
history of the NHS because he deserves the major credit for its foundation. He led
an interesting life, full of turnarounds. When Bevan was a young man, he supported the
27
Liberal Party but later, he converted to socialism. In 1919, Bevan started studying
economics, politics and history at the Central Labour College in London. He read the
Communist Manifesto and liked Marx and Engel's ideas. In 1945, after the General
Election, Aneurin Bevan was appointed as the Minister of Health by the new Labour
Prime Minister, Clement Attlee. He came with a mission to change things in medical
care. Firstly, he insisted on the nationalization of hospitals and secondly, he insisted on
the fact that the service must cover everyone. It meant that the state and medical
profession became mutually dependent, specifically that the state was dependent on the
medical profession to manage the NHS. In 1948 Bevan, as Minister of Health was in
charge of 2,6884
hospitals in England and Wales.
As the quotation below shows, Bevan was sure that it was not going to be easy
but he was determined to fight for his plan which was obvious in his `Message to the
medical profession':
On 5th July we start together, the new National Health Service. It has not had an
altogether trouble-free gestation! There have been understandable anxieties, inevitable in
so great and novel an undertaking. Nor will there be overnight any miraculous removal
of our more serious shortages of nurses and others and of modern replanned buildings
and equipment. But the sooner we start, the sooner we can try together to see to these
things and to secure the improvements we all want . . . My job is to give you all the
facilities, resources and help I can, and then to leave you alone as professional men and
women to use your skill and judgement without hindrance. Let us try to develop that
partnership from now on.5
Bevan refused the idea that doctors should be paid a full-time salaried service
because the doctor's right to reject a patient or the patient's right to choose a doctor
would not be able to function properly. Therefore, Bevan proposed, as a way of payment,
the combination of a small salary and capitation fees in accordance with the number of
patients on the doctors' lists.
There were many other difficulties concerning the Conservative Opposition and
its objection to the nationalization of hospitals and to the proposed decentralization of
general practice. Moreover, doctors were not satisfied, and their dissatisfaction let to
a professional protest. Finally, in 1948, Bevan reassured doctors by declaring that there
would be no salaried services and that after three years every doctor would be free to
choose if he wanted to be paid either by salary plus fees or by fee only. Bevan believed
and hoped that his proclamation would `finally free doctors from any fears that they were
28
to be turned in some way into "salaried civil servants" '.6
Fortunately, Bevan
accomplished this with great success. Research showed that the scheme started operating
on 5 July 1948 among more than 20,000 GPs, which was approximately 90 per cent of
total GP's from the very beginning.7
93 per cent of the population registered as patients
and the scheme received enduring national approval. It was beneficial for both doctors
and patients and proved to be cheaper than the critics of the scheme had predicted.
Bevan left the Ministry of Health in 1951 and for a very short time he was the
Minister of Labour. He resigned because Hugh Gaitskell, the Chancellor of the
Exchequer, announced that he was going to force people to pay half the cost of dentures,
spectacles and prescription charges. Bevan explained his resignation in a letter to Prime
Minister, Clement Attlee:
"It is wrong (to impose national health charges) because it is the beginning of the
destruction of those social services in which Labour has taken a special pride and which
were giving to Britain the moral leadership of the world." 8
Bevan, 1951
After that he became the leader of the left-wing branch of the Labour Party and he stayed
as their leader for five years. In 1956, although he was already very ill, he became deputy
leader of the Labour Party, but only four years later, on 6th
July 1960 he died of cancer.
Because of his great contribution to the development of better medical care in Britain,
Bevan is considered by many to be the most brilliant Minister of Health that Great Britain
has ever had.
3.2. How the NHS Works
Each country of the UK has its own NHS. This thesis concerns mainly the NHS in
England, but similar principles of service and management are common to all four sister
organizations (NHS in Wales, Scotland and Northern Ireland).
The NHS consists of three main parts and their interaction. These parts are those in need
of medical care, those practicing skilled care and those who take care of financial matters.
The largest part of the NHS is expense, approximately 80 per cent of which is funded by
the income tax system. The rest is paid by National Insurance contributions and by
charges made for prescribed drugs which are not subsidized. The NHS uses external
companies for cooking and cleaning because it is more cost-efficient.
29
The NHS is organized centrally, by the UK government, and has had very little
interaction with the private sector. It is established especially on General Practitioners
(GPs).
Care under the NHS can be divided in two parts - Primary care and Secondary
care. Within the primary care there are NHS Directs, NHS Walk-in Centres, GP
Practices, Dentists, Opticians, and Pharmacists. Emergency and Urgent care, Ambulance
Trusts, NHS Trusts, Mental Health Trusts and Care Trusts belong to the secondary care.
The chapters Primary Care and Secondary contain very brief information about each item
of the cares. More detailed and up-to-date information is available directly on the NHS
website About the NHS ­ How the NHS works.
<http://www.nhs.uk/england/AboutTheNhs/Default.cmsx>
3.2.1. Primary Care
Fig.1 Primary Care in England
If people in England have minor injuries, or suffer from minor illnesses, the
quickest way to get some treatment is to go to a Walk-in Centre. In England there are
approximately 84 such centres frequently situated near A&E departments (Accident and
Emergency Department) or on high streets and at train stations. People do not need to
make an appointment to go there. Most of the centres are accessible seven days a week
from morning till evening. The centres are managed by experienced NHS nurses and
provide services such as:
ˇ Assessment by an experienced NHS nurse.
30
ˇ Treatment for minor illnesses (including coughs, colds and infections) and for
minor injuries (such as cuts, sprains and strains).
ˇ Advice on how to stay healthy.
ˇ Information on other health services such as out-of-hours care and dental
services.9
If patients only need some medical advice, they can call NHS Direct (0845 46 47).
This service is available non-stop, 24 hours a day, 365 days a year. The staff who man the
lines are experienced nurses and professional advisers who can give information to
people about:
ˇ What to do if you or a family member feels ill
ˇ Self care for particular health conditions such as coughs and scalds
ˇ Local health services, such as doctors, dentists or out-of-hours pharmacies
ˇ Self-help or support organisations.10
The other possibility to obtain quick advice is by NHS Direct Online via the
Internet. There is a Self-help guide available, which contains many questions about
people's current state of health, which patients are required to answer. Afterwards, the
guide advises on possible illnesses and a course of action. Moreover, the guide will help
patients to find GP, dental, pharmacy and optician services close to the patient's home.
The information about GPs and Dentists is in separate subheads 3.3.1.4. and
3.3.1.5.
If people are experiencing eye problems, they can make an appointment with an
optician. In England, ophthalmic care is provided by three kinds of opticians. The general
public may be under the care of ophthalmic medical practitioners, optometrists or
dispensing opticians. The first group, ophthalmic medical practitioners are doctors whose
main speciality is diseases and abnormalities of the eyes. These opticians will prescribe
patients spectacles but they will not dispense them. Moreover, they examine the health of
the eyes and test sight. The other kind of optician is an ophthalmic optician or simply an
optometrist. Optometrists test patient's sight as well and also prescribe spectacles. They
are able to identify diabetes and glaucoma which are diseases manifested and revealed in
eyes. Whereas optometrists and ophthalmic medical practitioners prescribe spectacles,
a dispensing optician fits and supplies patients with them. He can advise patients on
which types of lens or spectacles they can have but he does not perform eyes tests.
Pharmacists are specialists in drugs and their effects. Their main task is to
dispense prescriptions but they are also able to give advice on minor injuries or less
31
serious illnesses. They can assess if the patient should see a doctor, and provide help
without having to make an appointment. According to the NHS information
"pharmacists use their clinical expertise to ensure the safe supply and use of
medicines."11
Moreover, the Government wants to use pharmacists' skills better. They are supposed to
do this:
ˇ Pharmacists can offer a repeat prescription service so patients don't need to keep
visiting their GP.
ˇ More pharmacists are now being trained to prescribe medication.
ˇ Some are offering tests to monitor conditions such as diabetes and high blood
pressure.12
3.2.2. Secondary Care
Fig.2 Secondary Care in England
This subchapter deals with very short descriptions of each item regarding
secondary care in England. Secondary care mostly takes place in NHS hospitals. This
care involves two parts; elective care and emergency care. The first mentioned includes
various kinds of planned medical care such as hip replacement operations, kidney dialysis
and others. Naturally, a referral from a GP or other medical specialist has to be made
first. Secondary care includes so-called Day surgery and Treatment centres. Day surgery
provides relatively quick care to patients. Patients can receive minor surgery which does
not require a hospital stay. Patients are allowed to go home the same day as the operation.
Treatment centres might be private or managed by the NHS. "They offer patients fast,
32
safe and streamlined surgery and diagnostic tests in several specialities, particularly
concentrating on orthopaedics and ophthalmology." 13
Emergency and urgent care exists for members of the public who are in life
threatening situations and therefore, in need of immediate medical help. Situations which
are considered to be critical or life threatening are:
ˇ Loss of consciousness
ˇ Heavy blood loss
ˇ Suspected broken bones
ˇ Persistent chest pain for 15 minutes or more
ˇ Difficulty breathing
ˇ Overdose, ingestion or poisoning14
Ambulance Trusts are the next part of the system of secondary care. If people
need immediate medical help out of the normal working hours of their GPs and the
situation is serious, they can call 999. Well-experienced professionals who answer the
calls will decide how urgent the situation is. There are three categories. A means a life
threatening situation and an ambulance is immediately sent to the place. B represents
a serious situation but not immediately life threatening and C is non urgent and
sometimes might be solved on the phone and an ambulance may not have to be
dispatched. When the ambulance reaches the patient, the highly trained staff assesses the
situation and provides necessary pre-hospital emergency care. They then decide if the
patient needs hospital care. Patients might be treated at the scene if the situation is not
serious and afterwards they may be advised or given a referral to their GPs or a specialist
to receive the necessary care. Ambulance Trusts take care of people who need acute care
outside their GPs regular working hours. Moreover, they enable patients' transportation
to and from hospitals if needed, in cases where the patient does not have anybody to take
them home.
NHS Trusts; also known as acute Trusts, run the NHS hospitals and check
whether the quality of medical care in hospitals is high enough and if hospitals budget
carefully. Most of the medical staff is employed by these NHS Trusts. The services they
provide are both treatments which require admission to hospitals or day surgery without
the necessity for a patient to stay in a hospital overnight; they also provide out-patient
services.
If people need help concerning psychiatric problems or suffer from serious
anxiety, they can approach a Mental Health Trust. They provide various kinds of
33
treatment "from psychological therapy, through to very specialist care for people with
severe mental health problems." 15
Care Trusts provides twofold care ­ social and health as well. Nowadays, there
are approximately ten Care Trusts but in the future, their number should rise.
The healthcare provided under the NHS is primarily free; the exception to free
medical care is dental treatment and spectacles which is also the case in most other
European countries. The exception does not concern old age pensioners and children
under 16, for them these items are also free because of subsidy.
Patients have the right to choose their GPs and they are treated as equal partners
in their care. They can choose when and where to be treated and they are asked for their
views which are very important for ratings of hospitals and others medical institutions.
Patients can find their rights and other information on www.nhs.uk.
Treatment in hospitals under the NHS is fully free for British people, European
Union citizens and for people from countries which have exchange health agreements
with Great Britain. Unless the country has an agreement, its people have to pay for
hospital treatment and entire health care.
3.3. Contemporary NHS
The NHS has been viewed with a certain amount of ambivalence in the public
mind. It has had many supporters but also many detractors. On the one hand, people
appreciate its free service, achievements and success in terms of patient demand.
Consumers receive help when they need it and they do not have to suffer or even die as
was prevalent years ago. Better diets have been formulated; standards of living and
medicine have risen. Moreover, there is greater awareness in the population than
previously, mainly due to people's use of the Internet to look up required information.
On the other hand, the NHS is criticized very much; especially because of its
alleged inefficiency, inadequate standards, long waiting lists, treatment discrepancies
throughout the country, and excessive bureaucracy. Medical staff complains about things
such as low pay, long hours, cuts in services and management weaknesses. There is
a shortage of doctors and nurses as well. It is believed that many of the mentioned
34
problems could be solved by funnelling more finance into the NHS. It is inevitable that
the NHS will require more finance to fund its free services and increasingly expensive
medical equipment and procedures.
There are many suggestions on how to improve the NHS. One of them is by
increasing NHS taxation. Setting charges for some services could mean better overall
service but there will be objections - paying for service hits at the principle of free health
care. Another suggestion such as the better management of existing funds could cut costs,
but not enough. There has also been speculation about combining private insurance with
a public service but this would not provide any solution for the poorer people who would
still be dependent on a free NHS. There have been endeavours by the Labour
Government to involve the private sector more closely in the running of the NHS through
Public-Private Partnerships. However, this idea was adapted from the previous
Conservative government. Most of the public regard this as privatization of the NHS.
However, the public sector has had difficulties for many years. For instance, waiting lists
have been growing and in hospitals there is consistent lack of extra capacity and lack of
finance for modernization. Therefore, some efforts have been made to involve the private
sector in providing medical care. Until 1997, the Conservative Government supported
cooperation between the private and public sectors on a commercial basis. The private
sector was seen as complementary to the NHS. The Government's aim was to release
pressure on state funds and help patients by giving them a choice. They intended to allow
NHS patients to be treated in the private sector at public expense.
When the Labour party came to power in 1997, they also liked the idea despite
their old Labour ideology. Resulting from this, some NHS hospitals are now co-owners
of certain expensive equipment, which they share with private hospitals. This enables the
NHS to allow its patients be treated in the private sector at public expense. The private
sector within the NHS is not used very extensively; it is limited only to minor medical
cases. Long-term care which tends to be expensive is pursued by the NHS itself. This
topic has been discussed for a long time.
The Labour Government, however, regularly involves the private sector in NHS
matters. Patricia Hewitt, the current Secretary of State Health, has tried to explain the
intention of using the private sector many times. The main reason is that use of the
private sector enables the government to ensure patients proper treatment quicker, and
35
with more choices than under the NHS. In May 2005 she claimed that the fact that the
private sector could carry out some NHS operations would lead to shorter waiting lists
and times. The idea was that the operations would be carried out by the private sector but
paid for by the NHS. At that time it functioned this way and the percentage of such
operations pursued by private sector was 5%.16
In the five years following 2005, the
number should rise to 10 or 15 %. She promised that by 2008 no patients would wait
longer than 18 weeks after their GPs had made referrals for treatment. The Secretary of
State Health declared:
"This is delivering on, not departing from the fundamental founding principle of the
NHS.." 17
Reactions to the Hewitt's opinions were generally the same. Doctors and NHS managers
were afraid of putting the NHS in danger because the private sector would take work
away from the NHS hospitals resulting in their possible closure. Some people considered
this as a complete destruction of the NHS due to assigning work to the private sector.
In September 2005, the privatization of the NHS was discussed again. Patricia
Hewitt pledged that a Labour Government would never allow the NHS to charge for its
services. For the BBC Mrs. Hewitt said:
"We are not turning a public service into a private service, and above all, we are not
abandoning, and we will never abandon, the principle that health care has got to be
available free at the point of need, not based on people's ability to pay."18
Moreover, Hewitt added that "in five years' time it was planned that 1% of the total NHS
budget - and around 10% of the budget for non-urgent operations - would be spent in the
private sector. " 19
She considered the percentage as a very small part of the total NHS
budget. Besides, it was going to deliver real benefits for NHS. A lot of people have been
fighting against the privatization of the NHS. There are various campaigns which exhort
people to be involved in the fight. For instance the website Keep Our NHS Public
<http://www.keepournhspublic.com/index.php>. Their main aims are:
ˇ To inform the public and the media what is happening as a result of the
government's "reform" programme.
ˇ To build a broadly based non-party political campaign to prevent further
fragmentation and privatisation of the NHS.
ˇ To keep our NHS Public. This means funded from taxation, free at the point of
use, and provided as a public service by people employed in the NHS and
accountable to the public and Parliament.
36
ˇ To call for a public debate about the future of the NHS and to halt the further use
of the private sector until such a debate is had.20
To see how the political parties and their leaders for health were changed, see Appendix
2.
Regardless the difficulties it has faced, the NHS is the largest organization in
Europe21
and employs more than 1.3 million people, which makes it the single largest
employer in Great Britain. The World Health Organization (WHO) considers the NHS as
one of the best and most efficient national healthcare systems in the world. What is more,
in August 2001 the NHS was ranked by WHO as 24th
out of 191countries in terms of the
efficiency of national healthcare systems.22
The NHS was even ahead of countries such as
the USA, Germany and Denmark
It is obvious that the NHS needs to make improvements to cope with the demands
of contemporary society. Therefore, it is becoming more modern and up to date, which
means apart from the other things, that it is becoming a more open and patient-centered
service. On the other hand, the NHS has financial problems as do the health services in
other European Countries. It has to cope with shortfall because expenditure is
increasingly higher from year to year. The NHS costs 43.4 billion to run per year, which
is approximately 15 per cent of government spending.23
The cost of funding the NHS has
increased from in the past as the chart24
below shows. The reason is simple. The quality
of medical care has continued to increase and there has also been an increase in life
expectancy.
YEAR COST (in millions pounds)
1949 388
1958 700
1967 1,400
1971 2,270
1976 5,470
1981 11,944
1985 16,304
Fig. 3 The NHS costs in the past (Chalmers & Cheyne, 98)
37
3.3.1. The Structure of the NHS in England
The NHS in England is divided principally into 3 parts; central government,
regional health authorities and district health authorities. The centre of the NHS is the
Department of Health (DH) which controls and supports the NHS. The next part of the
system represents 10 regional organizations, known as Strategic Health Authorities
(SHAs) which direct more than 300 Primary Care Trusts (PCTs). The Primary Care
Trusts, otherwise called local health bodies, control the majority of the budget
(approximately 80 per cent of the total NHS budget), assess local needs and provide and
commission services. GPs, dentists and hospitals are the last part of this structure.
Fig. 4 The structure of the NHS
3.3.1.1. The Department of Health
This is a Government organization which takes political responsibility for the
health service especially in England. In other parts of the UK responsibility for the NHS
falls under the government organization of the respective country; in Northern Ireland
this is the Department of Health, Social Services and Public Safety; The Scottish
Department
of Health
Strategic Health
Authorities
Primary Care Trusts
GPs Dentists Hospitals
38
Executive Health Department is the organization in Scotland and in Wales, The Welsh
Assembly Government secures matters concerning the NHS.
The residence of the DH is in Whitehall but there are also offices in Leeds and
London. The Department of Health has approximately 2,245 staff25
. There are several
ministers at the DH who are appointed by the Prime Minister but led by the Secretary of
State for Health, who is a cabinet minister. The current Secretary of State for Health is
Rt Hon Patricia Hewitt. Other posts at the DH are: Minister of State for Reform
(at present Lord Warner of Brockley), Minister of State for Health Services (at present Rt
Hon Rosie Winterton MP), Minister of State for Public Health (at present Caroline Flint
MP), Minister of State for Delivery and Quality (at present Andy Burnham MP),
Parliamentary Under Secretary of State for Care Services (at present Ivan Lewis MP).
The DH has many responsibilities but its main purpose is to lead and support the
NHS and social care organizations so that they are able to provide the best medical
services to the people of England while at the same time being financially feasible for
taxpayers. In other words, they try to ensure the highest quality health and social care at
the lowest possible cost for taxpayers. The main task of the DH is to set and
communicate the overall strategic direction of organizations such as the NHS and social
care. Moreover, the DH helps health and social care organizations keep pace with
important and major improvements. They monitor standards, safety of services and
effectiveness in the NHS and social care organizations, and they collaborate with
patients, medical and social staff and other Government departments on issues relating to
public health.
The Department of Health was formally established in 1988. From a historical
point of view, the Department of Health underwent many changes both in name and
function. At first it was called the Ministry of Health (created in 1919), and in 1928 the
Ministry published a White Paper that represented the first steps towards a better
organised healthcare system. In 1968 the Ministry of Health merged with the Ministry of
Social Security to form the Department of Health and Social Security. In 1974 the
Department was reorganised again to be able to operate more effectively with the NHS.
Finally, in 1988 the Department of Health and Social Security split and became separate
departments again - The Department of Health and the Department of Social Security.
39
3.3.1.2. Strategic Health Authorities
Strategic Health Authorities (SHAs) are organizations which manage the NHS
locally. They function as a key link between the Department of Health and the NHS. The
have many responsibilities. Firstly, they support PCTs, hospitals and other NHS
organizations (e.g. NHS Ambulance Services Trusts, NHS Care Trusts, and NHS Mental
Health Services Trusts) and monitor their performance. To prevent falling standards, they
have to take pains to improve services. Secondly, they develop strategies for improving
health services in the area they are responsible for and support the usage of information
technology. Moreover, they ensure service plans which are national priorities such as
improving services of feared disease - e.g. cancer. Finally, to provide better care to more
patients, they increase the capacity of local services and they recruit more specialists e.g.
dentists, because the growth of the capacity of local health services necessitates
increasing medical staff. Besides this, the Strategic Health Authorities enable medical
staff to train in specialist areas of the health care. Strategic Health Authorities were
established by the Government in 2002. There used to be 28 SHAs but in July 2006 this
number was reduced to 10. (See Appendix 3 below). The reduction of the Authorities
should enable better services for patients especially by means of stronger commissioning
functions.
3.3.1.3. Primary Care Trusts
Primary Care Trusts are local organizations which enable the NHS to help and
understand the needs of their communities better. PCTs have been functioning since
April 2002 and they are subordinate to their local SHA. They are responsible for many
things:
ˇ Assessing the health needs of all the people in their local area and developing an
insight into the needs of their local community.
ˇ Commissioning the right services, for instance from GP practices, hospitals and
dentists, to meet these needs.
ˇ Improving the overall health of their local communities.
ˇ Ensuring these services can be accessed by everyone who needs them.
ˇ Listening to patients' views on services and acting on them.
ˇ Making sure that the organisations providing these services, including social care
organisations, are working together effectively.
ˇ Carrying out an annual assessment of GP practices in their area.26
40
The concluding part of the NHS structure is - General Practitioners (GPs), dentists
and hospitals.
3.3.1.4. GPs
GPs or general practitioners are doctors to whom people come first if they are in
need of medical treatment. GPs look after the health of people in the local community in
which they operate. They provide a wide range of family health services such as advising
on health problems, giving vaccinations, doing examinations and administering treatment
(e.g. pursuing simple surgical operations); they also prescribe medicine and refer patients
to other health or social services. Moreover, GPs provide health education for public;
doctors talk to people about the harmfulness of smoking and taking drugs and arrange for
specialist consultation.
GPs are non- specialist doctors and there are currently about 35,000 of them in
Great Britain.27
In people's minds, specialist doctors have greater prestige than GP's, but
generally doctors have very high social status as they do elsewhere outside Britain. For
instance, a so-called consultant is a type of a doctor who works in a hospital and is
considered to have the highest rank on account of being a specialist in a particular area of
medicine. Nevertheless, GPs are very important; they are a major part of the NHS system
and they keep their panel which is the list of their patients' names. The more names they
have, the more they can earn. They are paid according to the size of their panels.
Naturally, there are limits. On average GPs have about 2,500 patients28
on their lists,
although they usually see only a small percentage of this number. According to the NHS
website, patients (in non urgent cases) can be seen by their GPs `within two working days
or a health professional as a nurse within one working day.' 29
If patients do not need an
appointment within two working days, they can book an appointment in advance if it is
more convenient for them. Nevertheless, patients are expected to notify the surgery if
they have to cancel or change the appointment.
3.3.1.5. Dentists
At present, since April 2006, Primary Care Trusts are responsible for
commissioning dental services, this includes routine care as well as specialized care
services. Routine dental care and treatment is undertaken by dentists and their team in
41
general practice and it includes check-ups, any kind of treatment leading to the
maintenance of good oral health, such as fillings, extractions, fitting of bridges and
dentures and scaling and polishing. Advising patients on how to take care of their teeth
and gums in order to prevent oral health problems in the future is also an important part
of their work.
Dental practices may provide a mixture of NHS and private care - the NHS services your
dentist provides depend on local oral health needs and the contract they have agreed
with your PCT.
For more specialised care such as surgery within the mouth, orthodontics (straightening
teeth), domiciliary care (at home), sedation (easing anxiety) and more complicated root
canal and bridge work, your dentist may refer you to another dentist either at a hospital
or to another general dental practitioner who has an interest in this area.30
If people are looking for a dentist, they can contact their PCT and find out about the
availability of general and specialized services within their local area.
3.3.1.6. Hospitals
For further treatment or examination, patients are referred by GPs to specialists
and consultants; this usually takes place at local NHS hospitals. Appointments and
treatment are free at NHS hospitals and they are usually arranged through a GP.
Exceptions are in cases of emergency, where a referral (the appointment of a patient with
a specialist or consultant in hospital, arranged by a GP) is not required. The wide-ranging
services of hospitals are authorized, on behalf of patients, by Primary Care Trusts (PCTs).
NHS Trusts increasingly are being commissioned by PCTs to offer services in the
community closer to people's homes. These services include treatments in which patients
are admitted to hospital, day surgery (patients are not required to stay in hospital
overnight) and outpatient services (people only attend consultations and undergo special
tests).
Hospitals in the NHS are managed by NHS Trusts (sometimes called acute Trusts)
which make sure that the quality of health care provided by hospitals is sufficiently high.
They also ensure that finances are spent efficiently.
NHS Trusts employ most of the NHS workforce: consultants, doctors, nurses, hospital
dentists, pharmacists, midwives and health visitors, managers and IT specialists, as well
as people doing jobs related to medicine - physiotherapists, radiographers, podiatrists,
42
speech and language therapists, dieticians, counsellors, occupational therapists and
psychologists.
There are many other support staff including receptionists, porters, cleaners, engineers,
caterers and domestic and security staff who all make a key contribution to the overall
experience of patients.31
Great Britain has some of the most up-to-date hospitals in the world. However,
there are a number of hospitals from the nineteenth century which are in urgent need of
modernization. Moreover, there is a shortage of beds in some hospitals in Britain, despite
the fact that more and more health care is needed due to fact that the proportion of older
people in the population has been steadily rising. Nevertheless, wards and hospitals are
being closed, and the blame for this situation is placed on government unwillingness to
spend more money on health and its inability to successfully manage the funds which do
exist. Although the British Government has increased its spending on healthcare each
year, it is still not enough and the shortfall has been increasing because of
mismanagement.
Unfortunately, there is also a shortage of nurses, mainly due to low pay, rigid
working hours and also poor working conditions. Violence by patients might be added to
many nurses reasons for quitting. There are several cases of unprovoked attack on nurses
while they were performing their duties in a hospital ward. The recent case has occurred
at accident and emergency department at Western Isles Hospital in Scotland; a drink-
driver assaulted a nurse who was treating him after he was injured in the car crash he had
caused.32
Similar cases are depicted on these websites:
"Nurse attack sparks safety demand"
<http://news.bbc.co.uk/2/hi/uk_news/scotland/3226096.stm>,
"Medical staff call for help against attacks"
<http://news.bbc.co.uk/2/hi/uk_news/scotland/3197788.stm>
"NHS attacks 'must be stopped'"
<http://news.bbc.co.uk/2/hi/health/3086455.stm>
"Hospital cuts attacks on staff"
<http://news.bbc.co.uk/2/hi/health/3246885.stm>
"Attacks on health workers rise"
<http://news.bbc.co.uk/2/hi/health/1141998.stm>
Naturally, every year many nurses start a family and some retire and the average
age of nurses has been steadily rising. There are almost 400,000 nurses (including
43
midwives) who currently work for the NHS.33
Annually a number of nurses are recruited
from overseas but it does not solve the continuing shortfall.
________________________________________________________________________
Notes 2
1. Sked, Alan and Chris Cook. Post-War Britain: A political history; New Edition 1945-1992. Penguin
Books. 1993. p.19
2. Sked, Alan and Chris Cook. Post-War Britain: A political history; New Edition 1945-1992. Penguin
Books 1993. p.41
3. qtd. in Sked, Alan and Chris Cook. Post-War Britain: A political history; New Edition 1945-1992.
Penguin Books 1993, p. 41-42
4. http://www.spartacus.schoolnet.co.uk/TUbevan.htm
5. qtd. in Rivett, Geoffrey. From Cradle to Grave: fifty years of the NHS, chapter 1
6. qtd. in Sked, Alan and Chris Cook. Post-War Britain: A political history; New Edition 1945-1992.
Penguin Books. 1993. p. 45
7. qtd. in Sked, Alan and Chris Cook. Post-War Britain: A political history; New Edition 1945-1992.
Penguin Books 1993. p. 45
8. qtd. in http://www.spartacus.schoolnet.co.uk/Lhealth48
9. http://www.nhs.uk/england/AboutTheNhs/Default.cmsx#nhswalkin
10. http://www.nhs.uk/england/AboutTheNhs/Default.cmsx#nhsdirect
11. http://www.nhs.uk/England/AboutTheNhs/Default.cmsx#pharmacists
12. http://www.nhs.uk/England/AboutTheNhs/Default.cmsx#pharmacists
13. http://www.nhs.uk/england/AboutTheNhs/Default.cmsx#secondarycare
14. http://www.nhs.uk/England/NoAppointmentNeeded/AccidentEmergencySearch.aspx
15. http://www.nhs.uk/england/AboutTheNhs/Default.cmsx#mentalhealth
16. http://news.bbc.co.uk/2/hi/health/4542009.stm
17. qtd. in http://news.bbc.co.uk/2/hi/health/4542009.stm
18. Hewitt, . Patricia. 23 Sept. 2005. qtd. in http://news.bbc.co.uk/2/hi/health/4274164.stm
19. http://news.bbc.co.uk/2/hi/health/4274164.stm
20. McDowall, David. Britain in Close-up, Longman Group UK Limited 1993, p.194
21. http://www.keepournhspublic.com/index.php
22. Oakland, John. British Civilization: An Introduction. Routledge 2002, p. 176
23. Oakland, John. British Civilization: An Introduction. Routledge 2002, p.173-174
24. Chalmers, SAS & Larry Cheyne Scotland and Britain 1830-1980, Hodder & Stoughton Ltd.1992, p. 98
25. www.dh.gov.uk/AboutUs/HowDHWorks/DHObjectives/fs/en?CONTENT_ID=4105906&chk=v5flCI
26. http://www.nhs.uk/England/AboutTheNhs/Default.cmsx#primarycaretrusts
27. Oakland, John. British Civilization: An Introduction. Routledge 2002, p. 174
28. Oakland, John. British Civilization: An Introduction. Routledge London and New York 1989, p. 140
29. http://www.nhs.uk/England/Doctors/Default.aspx
30. http://www.nhs.uk/England/AboutTheNhs/Default.cmsx#dentists
31. http://news.bbc.co.uk/2/hi/uk_news/scotland/highlands_and_islands/6398313.stm
32. http://www.nhs.uk/England/AboutTheNhs/Default.cmsx#nhstrusts
33. http://en.wikipedia.org/wiki/Nursing_in_the_United_Kingdom
44
4. The Medical Profession
There are also many different and varied medical professions in Britain as there
are in other developed countries in the world. Nevertheless, this chapter deals only with
doctors and nurses because they have long been recognized widely as an indispensable
and major part of medical care.
4.1. Doctors and the Past
Doctors were influential and had quite a high social status, even in the 17th
century, in spite of having almost no special qualifications. They were really not much
more than witch-doctors. Nevertheless, they always required payment for their services
even if only for their visit. Some of them did however treat the poor free of charge.
Certainly, there were many who had time only for the rich and earned a great deal of
money. For instance, the very fashionable London physician, Sir Richard Jebb earned
20,000 guineas between 1779 and 17871
. Calling for a doctor was really very expensive
especially for the poor and therefore poor people scarcely saw a doctor and they usually
had no choice but to rely upon on traditional cures.
Nowadays, it is very easy to visit a doctor if one does not feel well but this was
not the case in the eighteenth or nineteenth centuries. Three kinds of "doctors" existed at
that time - apothecaries, physicians and surgeons. There was quite a difference between
these professions.
Apothecaries were basically sellers of various kinds of drugs and pills, who gave
some advice to people, especially to the poorer ones. Their social status was much lower
than the physicians'. Nevertheless, later, apothecaries were held in higher respect
especially in London. (For more information about apothecaries, see chapter "The
Seventeenth and Eighteenth Centuries")
Physicians were the most honoured type of doctors. In the eighteenth century they
were always attached to the court and some nobleman could even afford to employ
a private physician who was always available when needed.
45
Surgeons were ranked as much lower than physicians. The reason for that was
probably due to the fact that they worked with their hands and their work seemed to be
similar to that of the butcher.
Physicians have trained at colleges and universities for many centuries. Until the
middle of the nineteenth century, women were not considered eligible to study medicine.
Many considered the thought of it indecent. The first British woman who succeeded in
being qualified was Elizabeth Garrett Anderson (1836 - 1917). She was educated mainly
at home and studied anatomy privately at London Hospital. Anderson wanted at least to
take exams at London University but she was refused. Finally, she managed to enrol on
the medical register which enabled her to practise the job. In 1873, she even became
a member of British Medical Association and remained there as the only woman doctor
for the next 19 years. Anderson was one of the pioneers of the first medical school for
women in Britain which was opened to women students in London in 1877. Nowadays,
the hospital is named after her.
History shows us that the problems of the doctor were not only with the treatment
of patients and saving their lives. It was not enough merely to have the desire to become
a doctor. Being a woman seemed to be quite an insurmountable difficulty. Fortunately,
even seemingly insurmountable difficulties can become surmountable over the course of
time.
4.2. Nurses
4.2.1. Nurses in the Past
Nursing too has always been a very demanding profession which is perhaps one
of the many reasons why most nurses give up their jobs after only few years. Since the
nineteenth century when Florence Nightingale had a great influence on the development
of nursing "nurses have an almost saintly image in the minds of the British public,..."
Nevertheless, "this image suggests that they are doing their work out of the goodness of
their hearts rather than to earn a living wage."2
Therefore, nurses often seek other work
which will be better paid because nursing is quite a poorly paid job. Moreover, it is not
easy to work with people and burnout syndrome can quickly become a factor. Besides, if
46
the motivation of salary is not sufficient, there is no incentive to stay in work which is
quite often considered by many to be more of a mission than a paid job. Although nurses
practise their job under the doctor's supervision, they have to be able to work on their
own and carry out numerous procedures. It is very stressful and exhausting to work with
people who are seriously ill and therefore anxious and fearful as well. It demands much
concentration and the ability to use theoretical knowledge in practise.
Nurse training differed from medical training very significantly before the
establishment of the NHS, in other words at the first half of the 20th
century. Whereas
medical education was based on university studies, nurse education was provided by
nursing schools which were hospital organizations controlled by a matron. The student
nurses were an indispensable part of the hospital staff. Training for nursing was shorter
and there were many more students studying nursing than those studying to be doctors.
The course for nurses took three years, and then nurses had to pass an examination to
become a so called state registered nurse (SRN). Nevertheless, if a nurse wanted to excel,
she had no choice but to spend another year as a staff nurse to gain a hospital badge. It
was the way how to keep nurses. In the 1930s a new system was established. It was "the
block system of education" which meant that nurses did not gain knowledge only in
a ward but they had to spend several weeks at nursing school. Nurses were expected,
apart from other things, to learn some basic techniques at school and then be able to use
them in practice and be well disciplined. Moreover, it was believed that the learning at
school would be easier for them because they could easily associate theory and practice
since they had already had clinical experience. Unfortunately, the intention was not
always realised.
As mentioned earlier in this text (2.2 Hospitals), the life of a nurse was not easy.
At the beginning of the 20th
century, if a nurse became pregnant, she was dismissed or if
she was still a student nurse, her career was ended. Such problems resulted in a regular
lack of nurses because pregnancy and marriage were often reckoned as an alternative to
nursing.
Nurses' salaries have been discussed for many years. Even before the NHS was
established representatives of nursing were dissatisfied. In 1948, student nurses even
demonstrated in the streets to gain a higher training allowance. They were successful.
Regrettably, the fight for higher salaries has not always been so successful. Some people,
47
and not only British, think that nursing is something like a mission which is done simply
out of the goodness of the women's hearts rather than a means of making a living.
Britain has always struggled with a shortage of nurses. Therefore, from the
nineteenth century onwards there were two classes of nurses; state registered nurses and
nursing assistants. The Nurses Act of 1943, among other things, instituted a system of
examination and gave nursing assistants legal status, which enabled them to assist
registered nurses. Later, they were called state enrolled nurses (SENs). In 1948 there
were approximately 20,000 SENs.3
It was very useful for all concerned to create this kind
of nurse. Hospitals desperately needed a workforce and the state enrolled nurses could
learn very much from training for the register.
Sufficient numbers of trained nurses and doctors was one of the prerequisites in
order for the NHS to be successful. Therefore, in 1945 a small working party was
founded by the Ministry of Health. The chair was Sir Robert Wood; the members of the
party were two senior sisters, a doctor and a social scientist. The main task of the party
was to "to look at recruitment, the proper task of a nurse, the training required, the
annual intake needed and how it was to be obtained, from where nurses were to be
recruited, and how wastage could be minimized."4
"The working party looked at the size of the nursing profession, and its structure in terms
of age, educational background, professional qualifications and socio-economic status. It
examined recruitment, wastage and the pattern of training. "5
Unfortunately, the problem was not solved. There was high recruitment of nurses
but also high turnover. Hospitals were predominantly dependant upon employing new
students. The problems were caused especially by The Wood Report in 1947 which
criticised the training of nurses. It was found out that `the mental calibre of the nursing
profession' was not as high as it had been assumed `it was only somewhat above the
population as a whole' 6
It was shown through research that 54%7
of students failed to
finish training. Changes were necessary to realise the aim of selecting students more
carefully. Besides other techniques, the use of intelligence tests was contemplated. This
did not necessarily mean that an applicant, who desired to be a nurse and yet had a lower
level of intelligence than required for the job, could not fulfil her dreams. That student
could still be recruited, if she was otherwise suitable, but only as an auxiliary to a nurse.
The work of nurses has not been easy. Nurses were required to work shifts
because of the necessity of 24-hour service to care for patients. Some hospitals were
48
adapted so that nurses could sleep on the wards or they used to live in nurses' homes
which were situated nearby in a protected environment. It seemed to the Ministry that it
had proven to be quite expensive to provide accommodation to nurses, so in 1948 the
Ministry recommended that nurses should find their own accommodation.
Different hospitals used different techniques and were suspicious of the
techniques or innovations which were developed by other hospitals. They frequently ran
out of money so their staff had to be economical e.g. they used to wash bandages.
Discipline in hospitals was very strict. "The uniform was spotless, shoes shone, dress
hems had to be level with the apron and hems the same height (14 inches, 35 cm). The
dress colour, stripes on the hat and the belt colour identified the seniority of the nurse.
Hair was neat, caps were worn and make-up forbidden."8
Nurses had to be very obedient
and respect hospital rules. (See Appendix 4 for a description of staff nurses at St.
George's Hospital from the first half of the twentieth century.)
Regarding the history of British nurses, two important women must be mentioned.
Both of lived in the same century and did the same work but it seems that they were very
different from each other.
4.2.1.1. Florence Nightingale (1820 - 1910)
One of the most important and influential women worldwide in the area of
medical care is Florence Nightingale. She lived and worked during the nineteenth century
through to the turn of the twentieth century. This was when Britain was still a very
powerful and self-confident empire. Queen Victoria reigned and that period named after
her, called the Victorian age, was considered a time of great social advancement.
Florence Nightingale was born in Italy in the city Florence after which she was named.
She was known variously as, "an angel of mercy", `the Lady-in-Chief' or `The Lady with
the Lamp'. Even in her day songs were being written about her.
Florence was taught at home by her father who was educated at Cambridge
University. At the age of twenty-five she decided to become a nurse because she heard
the voice of God calling her to this work. Her parents disapproved of her choice. The
reason they disapproved was that the job was associated with working class women.
Finally, in 1851 Florence's father gave her permission to begin training as a nurse.
49
From 1854 to 1856 the Crimean War was fought. It was a war between Imperial
Russia and the Alliance (The United Kingdom, France, Ottoman Empire and the
Kingdom of Sardinia). In 1854, when the Crimean War began, Florence was appointed
by the Minister at War to supervise the introduction of nurses into military hospitals in
Turkey. It was quite a difficult task because doctors did not want nurses there, but finally
when injured soldiers arrived, nurses had much work to do.
She deserves much credit for her remarkable work predicating the organization of
nursing and hospital facilities during the Crimean War and for laying the foundation of
modern nursing.
In 1860, she set up the first nursing school at St. Thomas' Hospital in London. It
was called the Nightingale Training School for nurses. The probationer nurses studied
there for one year but the learning was mainly practical. They worked in hospital wards
under the ward nurse's supervision.
Florence Nightingale wrote many books about nursing. One of them, considered
her best known work, `Notes on Nursing' includes her principles of nursing, which
focused on sensitivity to the patient's needs. The book was first published in 1860, and
remains in print even today. Furthermore, it has been translated into eleven foreign
languages including Czech. She published around 200 books reports and pamphlets.
Nightingale received many honours in recognition of her hard work. In 1883, she
was awarded the Royal Red Cross by Queen Victoria.
Nowadays, the school is called Florence Nightingale School of Nursing and
Midwifery. They offer courses of study in how to become a nurse or a midwife as well as
others such as flexible education and training for registered health care professionals and
undergraduate and postgraduate courses.
4.2.1.2. Mary Jane Seacole (1805 - 1881)
The second woman considered to have been very important in the history of
British nursing is Mary Seacole. She was of mixed race. Her father was a Scot and her
mother a Jamaican Creole. Mary had no special qualifications neither did she come from
a middle class family as Nightingale did. She acquired her skills in nursing from her
mother who knew and used traditional Caribbean and African herbal remedies.
50
Seacole travelled extensively. She spent a year in London because she had
relatives there. Moreover, she travelled in The Caribbean, where she visited the English
colony of the Bahamas, the Spanish colony of Cuba and also Haiti. She wrote
an autobiography about her travels but she omitted to mention some important events
which happened at that time, such as the abolition of slavery in 1838.
She was present at the outbreak of a cholera epidemic in 1850 and used her
knowledge of cholera contagion theory. She treated the poor who had been infected with
cholera for no charge, in Panama in 1849. She shunned using opium in treatment, she
preferred " mustard rubs and poultices, purgative calomel (mercuric chloride), sugars of
lead (lead(II) acetate), and rehydration with water boiled with cinnamon."9
Although her medication was not efficient enough, it was better than the methods which
were used by the Catholic Church (praying for divine intervention) or the preparations of
an inexperienced doctor who was sent there at the command of the Panama Government
to help those suffering from cholera. Seacole herself was infected with cholera when the
epidemic was almost over. Fortunately, she survived.
As was Florence Nightingale, Mary Seacole was also present at the Crimean War.
However, getting there was much more difficult for Seacole than it was for Nightingale.
The problem was caused by her dark skin. She asked to be sent to the war as a nurse but
she was refused not only by the War Office but by the Quartermaster General and the
Medical Department likewise. Due to the refusals, she decided to travel to Crimea at her
own expense. She was fortunate not to have to arrange everything on her own. Seacole's
Caribbean acquaintance, Thomas Day, unexpectedly came to London and helped her to
accomplish her journey and long-awaited mission. Finally, she arrived in the Crimea and
offered her help to Florence Nightingale but she was refused again. Therefore, Seacole
resolved to build a "British Hotel" where she took care of wounded soldiers.
After the war, she went back to England. She was decorated for her efforts during
the war. She was awarded the British Crimean Medal, the French Legion of Honour and
the Turkish Order medal. In July 1857, she published a 200-page autobiographical book
called, "Wonderful Adventures of Mrs. Seacole in Many Lands', in which Seacole wrote
about her travels and experiences; the book is considered to be the first autobiography
written by a black woman in Britain.
Seacole was commonly known to the British Army as "Mother Seacole". She was
a good woman who deserves much credit for what she did. Despite encountering
51
prejudices (because of her dark skin) which oftentimes prevented her from helping and
treating people, she did what she could and helped as many people as she could. She was
well known by the end of her life, but still she was overshadowed by Florence
Nightingale. Notwithstanding, nowadays, she is held in high honour and she "has
become a symbol of racial attitudes and social injustices in Britain."10
A statue honouring her was erected in London in 2003. She was placed in first
position in an online poll of 100 Great Black Britons taken in February 200411
. An annual
prize for nurses, midwives was named in her honour ­ "Mary Seacole Leadership and
Development Awards"; and many other things have been named after her, e.g. The Mary
Seacole Centre for Nursing Practice at Thames Valley University in Ealing, London;
There is an exhibition celebrating her life which opened at the Florence Nightingale
Museum in London in March 2005 as the bi-centenary of Mary's birth. The exhibition
has been so popular that it was to be continued until March 2007.
4.2.2. Nurses and the Present
Nurses and the present is a very wide-ranging topic and therefore, in this chapter
it will be mentioned very briefly and marginally, since it is written here only to show the
contrast with the past, and for readers to see how much progress has been made in how
we understand the profession of nurse.
Nowadays, there are several categories of nurses in Britain. Firstly, two levels of
nurses are distinguished in the UK: first level nurses and second level nurses. The first-
level nurses study for three or four years. The second group used to study for a mere two
years to become a state enrolled nurse (SEN) as was mentioned earlier. However, it is not
possible to obtain the SEN qualification at the present time. All nurses have to be
registered at the Nursing and Midwifery Council (NMC). Secondly, there are specialist
nurses who are well-experienced in their field and have gained extra education. For
instance, nurse practitioners, special community public health nurse, nurse consultants,
lecturer-practitioners and others. Thirdly, nurses might become managers. This means
that they abandon their clinical nursing work and start to work for the NHS in the field of
management. This possibility used to be very attractive and even for some nurses, the
goal of their professional life. However, today, there are more possibilities available than
to simply continue as "an ordinary nurse". Nurses can become various specialists and
52
focus on the specific fields of nursing they are interested in, such as midwifery or
paediatric nursing.
It can be seen from this short description that the field of nursing has developed
noticeably. There are many more and varied categories of nurse now than there used to be
even a century ago. Nowadays, nurses have to be even more highly educated, which
might help nurses to enter better-paid profession in the future.
_______________________________________________________________________
Notes 3
1. Patrick, A.J. A History of Britain: The Making of a Nation 1603-1789. Penguin Books 1967, p.206
2. O'Driscoll, James. Britain ­ The country and its People: An introduction for learners of English. Oxford
University Press, 1996, p. 172
3. Geoffrey Rivett, From Cradle to Grave: fifty years of the NHS, The King's Fund, London 1998, p. 16
4.-7. Geoffrey Rivett, From Cradle to Grave: fifty years of the NHS, The King's Fund, London 1998, p. 17
8. Geoffrey Rivett, From Cradle to Grave: fifty years of the NHS, The King's Fund, London 1998 p. 18
9. http://en.wikipedia.org/wiki/Mary_Seacole
10. http://en.wikipedia.org/wiki/Mary_Seacole
11. http://www.100greatblackbritons.com/results.htm
53
5. Conclusion
My intention has been to make a tidy outline of the development of medical care
provided in Great Britain, especially in England since the seventeenth century. I have
intended to depict the most important events from history which referred to medicine,
such as the discovery of blood circulation and penicillin; the way people were treated by
doctors; descriptions of hospitals; the establishment of the NHS.
I have mentioned some physicians from Great Britain who are well-known even
in the twenty first century. It is not possible to mention every important person from
history who has partaken in the development of medicine and medical care in Great
Britain. There are so many people who have made various contributions to the
development of medical care in Great Britain, many of whom very little is known about.
My choice of who to depict as the most important medical practitioners in the history of
Great Britain forms an important part of this work.
Since my thesis is an outline of the development of medical care in the Great
Britain, there are many possibilities of further research. It is possible to develop each
chapter or even each subchapter in detail. I find specially the remedies and the
practitioners in the seventeenth and eighteenth centuries very interesting. Naturally, it
would be much better to obtain necessary information right in England; there is
undoubtedly easier availability to the books dealing with the topic and there is the
opportunity to visit museums which are devoted to medicine and its history. Further
research might be based on the comparison of British and Czech medical care in the past
and also in the present including the most significant Czech physicians.
54
6. Summary
The diploma thesis depicts the development of medical care in Britain since the
17th
century until the present.
The first chapter, Medical Care in Britain before 1946 deals with, among other
things, descriptions of various treatments pursued in each century starting with the 17th
century until the beginning of the twentieth. Moreover, significant physicians or
scientists, who contributed discoveries to the development of medicine, have been
mentioned along with the century in which they lived.
The second chapter, The National Health Service, is about the creation of the
NHS, its structure and how it functions nowadays, and also with the problems it has had
to cope with.
The last chapter, The Medical Profession, deals with doctors and nurses. The
subchapter about doctors depicts the profession mainly from a historical point of view
because the present profession of Doctor is described as a part of the chapter The
National Health Service. The remainder of the chapter describes the profession of nurses
from a historical point of view, including two famous British nurses who have influenced
medical care and nursing in Great Britain, as well as elsewhere. The subchapter, Nurses
and the Present outlines very briefly the current nursing profession in Britain only for the
purpose of contrast to the history of the profession.
55
7. Resumé
Diplomová práce zachycuje vývoj zdravotní péče v Británii od sedmnáctého
století až doposud.
První kapitola - Zdravotní péče v Británii před rokem 1946 - se zabývá, kromě
jiného, popisem různých léčebných postupů prováděných v jednotlivých stoletích,
začínající od století sedmnáctého až po začátek století dvacátého. V jednotlivých stoletích
jsou zmíněni i významní lékaři a vědci, kteří svými objevy přispěli k rozvoji medicíny.
Druhá kapitola - The National Health Service - je o stvoření, struktuře a fungování
NHS v současné době a o problémech s kterými se musí potýkat.
Poslední kapitola - Zdravotní profese - pojednává o lékařích a zdravotních
sestrách. Podkapitola o lékařích zachycuje profesi zvláště z historického hlediska, neboť
problematika současného lékařského povolání je popsána jako součást kapitoly
The National Health Service. Další část kapitoly popisuje profesi zdravotních sester
z historického pohledu, včetně dvou slavných britských zdravotních sester, které
ovlivnily zdravotní péči a ošetřovatelství nejen ve Velké Británii. Podkapitola - Zdravotní
sestry a současnost - nastiňuje velmi stručně současnou ošetřovatelskou profesi v Británii
pouze jako kontrast k historii této profese.
56
8. Appendices
Appendix 1
[Report...from the Poor Law Commissioners on an Inquiry into the
Sanitary Conditions of the Labouring Population of Great Britain.
London, 1842, pp. 369-372.]
After as careful an examination of the evidence collected as I have been enabled to make,
I beg leave to recapitulate the chief conclusions which that evidence appears to me to
establish.
First, as to the extent and operation of the evils which are the subject of this
inquiry:--
That the various forms of epidemic, endemic, and other disease caused, or aggravated, or
propagated chiefly amongst the labouring classes by atmospheric impurities produced by
decomposing animal and vegetable substances, by damp and filth, and close and
overcrowded dwellings prevail amongst the population in every part of the kingdom,
whether dwelling in separate houses, in rural villages, in small towns, in the larger towns-
-as they have been found to prevail in the lowest districts of the metropolis.
That such disease, wherever its attacks are frequent, is always found in connexion with
the physical circumstances above specified, and that where those circumstances are
removed by drainage, proper cleansing, better ventilation, and other means of
diminishing atmospheric impurity, the frequency and intensity of such disease is abated;
and where the removal of the noxious agencies appears to be complete, such disease
almost entirely disappears.
Contaminated London drinking water containing various micro-organisms, refuse, and
the like.
The high prosperity in respect to employment and wages, and various and abundant food,
have afforded to the labouring classes no exemptions from attacks of epidemic disease,
which have been as frequent and as fatal in periods of commercial and manufacturing
prosperity as in any others.
That the formation of all habits of cleanliness is obstructed by defective supplies of
water.
That the annual loss of life from filth and bad ventilation are greater than the loss from
death or wounds in any wars in which the country has been engaged in modern times.
That of the 43,000 cases of widowhood, and 112,000 cases of destitute orphanage
relieved from the poor's rates in England and Wales alone, it appears that the greatest
proportion of deaths of the heads of families occurred from the above specified and other
removable causes; that their ages were under 45 years; that is to say, 13 years below the
57
natural probabilities of life as shown by the experience of the whole population of
Sweden.
That the public loss from the premature deaths of the heads of families is greater than can
be represented by any enumeration of the pecuniary burdens consequent upon their
sickness and death.
That, measuring the loss of working ability amongst large classes by the instances of
gain, even from incomplete arrangements for the removal of noxious influences from
places of work or from abodes, that this loss cannot be less than eight or ten years.
That the ravages of epidemics and other diseases do not diminish but tend to increase the
pressure of population.
That in the districts where the mortality is greatest the births are not only sufficient to
replace the numbers removed by death, but to add to the population.
That the younger population, bred up under noxious physical agencies, is inferior in
physical organization and general health to a population preserved from the presence of
such agencies.
That the population so exposed is less susceptible of moral influences, and the effects of
education are more transient than with a healthy population.
That these adverse circumstances tend to produce an adult population short-lived,
improvident, reckless, and intemperate, and with habitual avidity for sensual
gratifications.
That these habits lead to the abandonment of all the conveniences and decencies of life,
and especially lead to the overcrowding of their homes, which is destructive to the
morality as well as the health of large classes of both sexes.
That defective town cleansing fosters habits of the most abject degradation and tends to
the demoralization of large numbers of human beings, who subsist by means of what they
find amidst the noxious filth accumulated in neglected streets and bye-places.
That the expenses of local public works are in general unequally and unfairly assessed,
oppressively and uneconomically collected, by separate collections, wastefully expended
in separate and inefficient operations by unskilled and practically irresponsible officers.
That the existing law for the protection of the public health and the constitutional
machinery for reclaiming its execution, such as the Courts Leet, have fallen into
desuetude, and are in the state indicated by the prevalence of the evils they were intended
to prevent.
Secondly. As to the means by which the present sanitary condition of the labouring
classes may be improved:--
The primary and most important measures, and at the same time the most practicable, and
within the recognized province of public administration, are drainage, the removal of all
refuse of habitations, streets, and roads, and the improvement of the supplies of water.
58
That the chief obstacles to the immediate removal of decomposing refuse of towns and
habitations have been the expense and annoyance of the hand labour and cartage requisite
for the purpose.
That this expense may be reduced to one-twentieth or to one-thirtieth, or rendered
inconsiderable, by the use of water and self-acting means of removal by improved and
cheaper sewers and drains.
That refuse when thus held in suspension in water may be most cheaply and innoxiously
conveyed to any distance out of towns, and also in the best form for productive use, and
that the loss and injury by the pollution of natural streams may be avoided.
That for all these purposes, as well as for domestic use, better supplies of water are
absolutely necessary.
That for successful and economical drainage the adoption of geological areas as the basis
of operations is requisite.
That appropriate scientific arrangements for public drainage would afford important
facilities for private land-drainage, which is important for the health as well as sustenance
of the labouring classes.
That the expense of public drainage, of supplies of water laid on in houses, and of means
of improved cleansing would be a pecuniary gain, by diminishing the existing charges
attendant on sickness and premature mortality.
That for the protection of the labouring classes and of the ratepayers against inefficiency
and waste in all new structural arrangements for the protection of the public health, and to
ensure public confidence that the expenditure will be beneficial, securities should be
taken that all new local public works are devised and conducted by responsible officers
qualified by the possession of the science and skill of civil engineers.
That the oppressiveness and injustice of levies for the whole immediate outlay on such
works upon persons who have only short interests in the benefits may be avoided by care
in spreading the expense over periods coincident with the benefits.
That by appropriate arrangements, 10 or 15 per cent. on the ordinary outlay for drainage
might be saved, which on an estimate of the expense of the necessary structural
alterations of one-third only of the existing tenements would be a saving of one million
and a half sterling, besides the reduction of the future expenses of management.
That for the prevention of the disease occasioned by defective ventilation and other
causes of impurity in places of work and other places where large numbers are
assembled, and for the general promotion of the means necessary to prevent disease, that
it would be good economy to appoint a district medical officer independent of private
practice, and with the securities of special qualifications and responsibilities to initiate
sanitary measures and reclaim the execution of the law.
59
That by the combinations of all these arrangements, it is probable that the full ensurable
period of life indicated by the Swedish tables; that is, an increase of 13 years at least, may
be extended to the whole of the labouring classes.
That the attainment of these and the other collateral advantages of reducing existing
charges and expenditure are within the power of the legislature, and are dependent mainly
on the securities taken for the application of practical science, skill, and economy in the
direction of local public works.
And that the removal of noxious physical circumstances, and the promotion of civic,
household, and personal cleanliness, are necessary to the improvement of the moral
condition of the population; for that sound morality and refinement in manners and health
are not long found co-existent with filthy habits amongst any class of the community.
"Chadwick's Report on Sanitary Conditions." The Victorian Web. 11 October 2002.
12 December 2006 <http://www.victorianweb.org/history/chadwick2.html>
60
Appendix 2
Political leaders in the matters of health since the end of the nineteenth
century
President of the Board of Health
ˇ Sir Benjamin Hall (October 14, 1854 - August 13, 1855)
ˇ Hon. William Cowper (August 13, 1855 - February 9, 1857)
ˇ William Monsell, 1st Baron Emly of Tervoe (February 9, 1857 - September 24, 1857)
ˇ Hon. William Cowper (September 24, 1857 - February 21, 1858)
ˇ Charles Adderley (March 8, 1858 - September 1, 1858)
Minister of Health
ˇ Christopher Addison (June 24, 1919 - April 1, 1921)
ˇ Alfred Mond (April 1, 1921 - October 19, 1922)
ˇ Sir Arthur Griffith-Boscawen (October 24, 1922 - March 7, 1923) (Defeated for election to the
House of Commons)
ˇ Neville Chamberlain (March 7, 1923 - August 27, 1923)
ˇ Sir William Joynson-Hicks (August 27, 1923 - January 22, 1924)
ˇ John Wheatley (January 22, 1924 - November 3, 1924)
ˇ Neville Chamberlain (November 6, 1924 - June 4, 1929)
ˇ Arthur Greenwood (June 7, 1929 - August 24, 1931)
ˇ Neville Chamberlain (August 25, 1931 - November 5, 1931)
ˇ Sir Edward Hilton Young (November 5, 1931 - June 7, 1935)
ˇ Kingsley Wood (June 7, 1935 - May 16, 1938)
ˇ Walter Elliot (May 16, 1938 - May 13, 1940)
ˇ Malcolm MacDonald (May 13, 1940 - February 8, 1941)
ˇ Ernest Brown (February 8, 1941 - November 11, 1943)
ˇ Henry Willink (November 11, 1943 - July 26, 1945)
ˇ Aneurin Bevan (August 3, 1945 - January 17, 1951)
ˇ Hilary Marquand (January 17, 1951 - October 26, 1951)
ˇ Harry Crookshank (October 30, 1951 - May 7, 1952)
ˇ Iain Macleod (May 7, 1952 - December 20, 1955)
ˇ Robin Turton (December 20, 1955 - January 16, 1957)
ˇ Dennis Vosper (January 16, 1957 - September 17, 1957)
ˇ Derek Walker-Smith (September 17, 1957 - July 27, 1960)
ˇ Enoch Powell (July 27, 1960 - October 20, 1963)
ˇ Anthony Barber (October 20, 1963 - October 16, 1964)
ˇ Kenneth Robinson (October 18, 1964 - November 1, 1968)
Secretary of State for Social Services
ˇ Richard Crossman (November 1, 1968 - June 19, 1970)
ˇ Keith Joseph (June 20, 1970 - March 4, 1974)
ˇ Barbara Castle (March 5, 1974 - April 8, 1976)
ˇ David Ennals (April 8, 1976 - May 4, 1979)
ˇ Patrick Jenkin (May 5, 1979 - September 14, 1981)
ˇ Norman Fowler (September 14, 1981 - June 13, 1987)
ˇ John Moore (June 13, 1987 - July 25, 1988)
61
Secretary of State for Health
ˇ Kenneth Clarke (July 25, 1988 - November 2, 1990) ­ Conservative Party
ˇ William Waldegrave (November 2, 1990 - April 10, 1992) Conservative Party
ˇ Virginia Bottomley (April 10, 1992 - July 5, 1995) Conservative Party
ˇ Stephen Dorrell (July 5, 1995 - May 2, 1997) Conservative Party
ˇ Frank Dobson (May 3, 1997 - October 11, 1999) Labour Party
ˇ Alan Milburn (October 11, 1999 - June 13, 2003)- Resigned, Labour Party
ˇ John Reid (June 13, 2003 - May 6, 2005) ­ Labour Party
ˇ Patricia Hewitt (May 6, 2005 - ) Labour Party
"Secretary of State for Health." Wikipedia: The Free Encyclopedia. 6 February
2007. 27 February 2007
<http://en.wikipedia.org/wiki/Secretary_of_State_for_Health>
62
Appendix 3
63
SHAs
Current (population) New (Population)
North East 2,545,073:
01 Northumberland, Tyne and Wear 1,396,374
02 County Durham and Tees Valley 1,148,699
North West 6,827,170:
03 Cumbria and Lancashire 1,929,653
04 Cheshire and Merseyside 2,358,474
05 Greater Manchester 2,539,043
Yorkshire and The Humber 5,038,849:
06 North and East Yorkshire and Northern
Lincolnshire 1,652,387
07 West Yorkshire 2,108,028
08 South Yorkshire 1,278,434
East Midlands 4,279,707:
09 Trent 2,687,496
10 Leicestershire, Northamptonshire and Rutland 1,592,211
West Midlands 5,334,006:
11 Birmingham and the Black Country 2,274,964
12 Shropshire and Staffordshire 1,499,568
13 West Midlands South 1,559,474
East of England 5,491,293:
14 Norfolk, Suffolk and Cambridgeshire 2,238,151
15 Essex 1,635,605
16 Bedfordshire and Hertfordshire 1,617,537
London 7,428,590:
17 North Central London 1,227,957
18 North East London 1,531,427
19 North West London 1,834,066
20 South East London 1,514,122
21 South West London 1,321,018
South East Coast 4,187,941:
22 Surrey and Sussex 2,577,631
23 Kent and Medway 1,610,310
South Central 3,922,301:
24 Thames Valley 2,120,859
25 Hampshire and Isle of Wight 1,801,442
South West 5,038,200:
26 Avon, Gloucestershire and Wiltshire 2,206,246
27 Dorset and Somerset 1,212,892
28 South West Peninsula 1,619,062
"Strategic Health Authorities Configurations." Department of Health.
17 August 2006 <http://www.dh.gov.uk/assetRoot/04/13/37/44/04133744.pdf>
64
Appendix 4
Duties of the Staff Nurses
ST GEORGE'S HOSPITAL
London, SW1
Duties of the Staff Nurses
1. Staff nurses should manage their work methodically and keep their Wards neat,
clean and in good order. They should pay constant attention to the warmth, freshness
and ventilation and study the welfare and comfort of their patients in every respect.
Every effort should be made to keep the Wards as quiet as possible.
2. The senior Staff Nurse on duty shall deputise for the Ward Sister in her absence, and
at such times shall report to the Sister who is `on call' for her Ward (or in their
absence to the Assistant Matron's Office) the admission of any patient who is
seriously ill and on any occasion when there is cause for anxiety.
3. Staff Nurses should give a kindly welcome to new patients immediately on their
arrival in the Ward, treating them with gentleness and consideration and making
them and their friends feel assured from the first that they will be tenderly cared for.
4. The admission of new patients should be carefully supervised, particular attention
being given to observing the condition of the pressure areas. Any abrasion of the skin,
however slight, must be reported immediately to the Sister in charge. Staff Nurses
shall also see that proper care is taken of the clothing and valuables of patients
admitted to their Wards.
5. Staff Nurses shall be responsible for looking after relatives and friends visiting the
Wards, and shall see that those waiting for long periods in the Hospital receive food
and refreshment.
6. An important part of their duties is to assist the Ward Sisters in the training of
Student Nurses, teaching them to be accurate, careful and observant, and thorough in
every detail.
7. They shall see that all new Student Nurses coming to the Ward understand the
clinical work allocated to them and are carefully instructed in all procedures
practised in the Ward.
8. They shall study the rules laid down for the care and checking of Dangerous Drugs,
and see that these are properly observed.
9. They shall be responsible to the Sister in charge of the Ward or Department for the
care of the following: Linen, Instruments, Surgical equipment including surgical
stock, Crockery and cutlery. A weekly inventory should be taken and any losses
65
reported immediately to the Sister in Charge. It is recommended that instruments and
cutlery in regular use be checked every day.
10. It is a strict rule of the Hospital that nothing may be borrowed from one Ward or
Department for another without a written request signed by the Sister or Staff Nurse
in charge. At night the request should be made to the Night Sister. This rules also
applies to Dangerous Drugs.
11. Staff Nurses should supervise the work of the Ward Maids and Orderlies, instructing
new members of the staff in their duties and helping them to feel that they are
essential members of the Ward team. They shall see that the Domestic Staff are
punctual in arriving and leaving the Ward, and shall teach them to be quiet and
thorough in their work and to avoid waste.
12.Constant attention should be paid to every method by which economy may be
effected, particularly with regard to food, surgical dressings, lotions, stationery and
cleaning materials. Good management in this respect can save the Hospital
considerable expense.
13. Any accident affecting either a patient or a member of the Nursing or Domestic Staff
on duty in a Ward or Department shall be reported immediately to the Sister in
Charge and a written statement made by the member of the Staff involved or
witnessing the accident.
14. Staff Nurses should be thoroughly conversant with all the rules made for the
prevention of infection in the Hospital and should see that these are conscientiously
and carefully carried out.
15. Nursing Procedures practised in the Hospital shall be those laid down in the Nursing
Procedure Book, a copy of which shall be available in every Ward and Department.
Muriel B. Powell, Matron, 13 December 1951
(Rivett, 1998)
66
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