NHS England’s decision to order a rapid evacuation of 15,000 beds, driven from the top down, is unprecedented in normal peacetime: the nearest – much more traumatic – equivalent goes back to before the NHS existed. was the mass clearance which aimed to empty 100,000 beds in days as part of the war preparations in 1939, but which overshot the mark – and took huge risks with public health.
The chosen methods then were:
- • Clearance of patients from some existing hospitals.
- • Crowding beds together and by providing additional beds in some existing hospitals.
- • Improving (“up-grading”) many hospitals through the provision of surgical appliances and other equipment.
- • The erection of new accommodation in the form of hutted annexes or hospital hutted units.
It was the first of these that was the biggest problem: according to Richard Titmuss:
“The Government had hoped to find about 100,000 beds for casualties by turning out the sick, but it seems that the hospitals interpreted their instructions so rigorously that about 140,000 sick were, in fact, sent home. … Included in the figure of 140,000 were about 7,000–8,000 tubercular patients ‘cleared’ from local authority sanatoria, representing nearly thirty percent of all those receiving residential treatment at the time.”
“… Patients in an early operable stage of cancer were sent home untreated; expectant mothers were refused admission for what were likely to be difficult and dangerous confinements; children in plaster of paris were deprived of the care they needed; bedridden patients—the arthritic, the diabetic and heart cases—were discharged to the care of relations, heedless of the fact that these relations might now have evacuated, leaving the house empty; highly contagious tuberculosis patients were sent to crowded homes with young children, perhaps to die, perhaps to infect their families.”
No proper records were kept to show what happened to those people discharged in this way. In today’s much more closely scrutinised NHS with wide-ranging data online it’s unlikely that this will happen now, but it is important to keep track of the aftermath of today’s desperate measures.
Once the patients had been sent home in 1939 the beds were kept free for an expected influx of civilian and military casualties from the war, so access for any other medical needs was drastically reduced: “In addition, therefore, to the sick who were sent home, some of whom were ‘wholly unfit people’ and should not have been discharged, there was the problem of existing waiting lists at voluntary hospitals, tuberculosis sanatoria and other institutions.”
The problem was even greater because more beds were made available in voluntary hospitals than the Government had expected, and all of these were to be paid for – whether they were utilised or not. Voluntary hospital bosses in particular were more than happy to take the money for doing nothing, but keeping so many beds empty meant the hidden waiting list for a hospital bed more than doubled to 250,000.
Unlike now, when we know insufficient beds will be available to deal with the spread of the virus, in 1939 the need for beds had been considerably overestimated. Titmuss argued:
“After six years of war, after the blitz of 1940–1, the later bombings, the flying-bombs and the rockets, the total number of civilian air raid casualties treated in hospitals from beginning to end was roughly forty percent less than the number of sick people turned out of hospitals in about two days in September 1939.”
However despite these harsh measures some of the preparations for war and the way services were delivered during the war were crucial in shaping the NHS legislation in 1946. This is not unusual: as Titmuss pointed out, the Crimean War, through the work of Florence Nightingale, led to the creation of the nursing profession; health defects discovered among recruits for the Boer War stimulated public health measures including the provision of school meals and a school medical service; and concern for the care of mothers and young children in World War One led to the establishment of the Ministry of Health.
Despite a Gallup poll showing 71% of the public favoured making hospitals a public service supported by public funds, progress towards a national, tax-funded health service as WW2 approached was held back by the Treasury, which “clung tenaciously to the principle that ratepayers should bear at least a part of the cost of the medical care of their neighbours injured by air attack”.
There was also the problem that “The dominant feature of the pre-war situation was the existence of two distinct and contrasting hospital systems—voluntary and municipal. Both had grown up without a plan. Their origins and histories were dissimilar; they were differently organised and financed and, in some respects, they catered for different sections of the population.”
No hospitals were controlled by the Ministry of Health, which had a purely advisory role and until 1939 little awareness of the poor state of both hospital systems: More than half the hospitals and two thirds of the beds were in municipal hospitals, the rest under ‘voluntary’ management which was furiously opposed to any control over them by government and especially by local government.
One thing they had in common was both voluntary and municipal hospitals were old and lacking in resources. “Two-thirds were built before 1891 and nearly a quarter before 1861. Many lacked diagnostic facilities, pathology, radiology and operating theatres while catering and heating required urgent attention. At one London hospital, the legs of the cots in the maternity department stood in tins of oil to discourage the cockroaches from crawling up!”
Most of the voluntary hospitals were small, not dissimilar in size from today’s private hospitals: only 75 general (all-purpose) voluntary hospitals had more than 200 beds. Over 500 had fewer than 100 beds, and over half of these had fewer than 30. The smaller voluntary hospitals also behaved not unlike today’s private hospitals in limiting themselves to the less complex patients, and passing on any they could not or chose not to handle to the public sector. Titmuss notes a report by what is today’s King’s Fund:
“voluntary hospitals exercised ‘their discretion over the admission of these patients (the chronic sick) and having admitted them transfer them to municipal hospitals’. During 1935–7 some 27,000 patients were transferred by voluntary hospitals to general hospitals provided by the London County Council.”
This is one reason why, while they wanted and needed handouts of public money to keep going, the voluntary hospitals were also desperate to avoid any scrutiny or accountability from local or central government. Despite this, the war preparations forced a massive upgrade:
“The adaptation and improvement of hospital buildings, including the installation of operating theatres, X-ray rooms, laboratories, dispensaries and stretcher lifts, and the improvement of sanitary and kitchen facilities, lighting and heating. By the outbreak of war about 150 hospitals had been selected for this work of upgrading, and much of the essential engineering had been done, but more than half the programme remained to be completed.”
It was a huge effort: “Nearly 1,000 completely new operating theatres were installed by October 1939. By the same date, some 48,000,000 bandages, dressings and fitments had been ordered. Close on a million surgical instruments were said to be wanted. The estimated number of artery forceps required represented, for instance, over thirty years’ demand for the whole country.”
By later 1941 an extra 80,000 beds had been added, funded by central government. The emergency preparations also created an emergency public health laboratory service, and the expansion and improvement of pathological laboratories in many areas of the country, and the first blood transfusion service, to collect and store blood, beginning in London in 1939.
The new Emergency Hospital Service and an Emergency Medical Service was introduced as soon as war broke out, to link the municipal and voluntary hospitals and provide a team of doctors. Central funding of the voluntary hospitals and 60% of the costs in the municipal hospitals gave the government a right of direction over both for the first time.
As Nick Timmins writes in his Five Giants study of the birth of the welfare state, even though the elderly remained excluded: “As the war progressed, free treatment under the emergency scheme had gradually to be extended from direct war casualties to war workers, child evacuees, firemen and so on until a sixty two page booklet was needed to define who was eligible. … Wartime proved that a national health service could be run.”
It had also proved that the old system could not deliver what was needed, and it was clear that the voluntary sector could not continue on its traditional basis after the war. The divisions between the two under-resourced hospital systems had been broken down, and could not realistically be re-erected.
NHS historian Geoffrey Rivett argues that:
“The Emergency Medical Service, more than any other single factor, can be held responsible for the form and pattern of hospital organisation which emerged in London. … Doctors and nurses for the first time moved freely between the voluntary and the municipal hospitals, seeing the problems each faced. The experiences of teaching hospital staff and students who were drafted to municipal hospitals, where standards of clinical care often left much to be desired, helped later in the acceptance of the National Health Service.”
Future prospects
We can expect when the Covid-19 crisis eventually subsides, similar wider questions will be asked to those that helped Bevan shape the NHS after the war.
Why, for example, since it was apparently so simple to do, did it take a global pandemic to get ministers to release proper funding for the NHS, after a decade of unprecedented austerity had slashed bed numbers and restricted services.
NHS England had already called a halt and partial reversal of the continued reduction of front line acute bed capacity, and has also paused any implementation of its deeply flawed Long Term Plan, which was written to comply with financial constraints. But doesn’t it make sense for the plan as a whole to be junked, now the situation has completely changed since it was written?
NHS England has also taken powers to override local CCGs and drive the NHS from the centre: the payment by results system has also been set aside. These are key elements in the market system established by the disastrous Health and Social Care Act in 2012. Since so little of the Act is being enforced, it surely makes sense to scrap it altogether, along with the wasteful division between purchaser and provider that has added bureaucracy since 1990 and fuelled privatisation of clinical care since 2000.
Private contractors remain as providers of non-clinical support services and of clinical care – but their quest for profit from the public purse stands in stark contrast to the collective effort, dedication and sacrifice of front line NHS staff putting their health at risk dealing with the virus. Most blatant of all are the support service contractors ISS whose staff resorted to strike action at Lewisham Hospital when they had not been paid, and who had still not paid up two weeks later as the epidemic has taken hold. When the crisis subsides the fight must be stepped up to eliminate these companies which contribute nothing but impede the work of our most prized public service.
Unions and campaigners are also challenging the wisdom of NHS England forking out a reported £2.4m per day to block book 8,000 private hospital beds to help make up for the 10,000-plus acute beds that have closed in the NHS since 2010, rather than the government requisitioning or nationalising these resources.
From the chaos and confusion, ministerial bungling and lies, the crisis measures and the lessons learned, it’s possible to chart a future way to an improved, fully-funded, publicly owned, provided and accountable NHS.
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