Britain Before the NHS

Mar 1, 2021 | Healthcare

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It’s hard to imagine life without the National Health Service. Since its launch in Britain on 5th July 1948, it has provided free healthcare for people from all walks of life, putting an end to the practice of medical care being something only the rich could afford.

In the 19th century, healthcare was provided mainly by charities and the unregulated private sector, while local welfare committees put the “poor law” into operation, managing the workhouses where impoverished individuals were sent. The workhouse infirmary was a stark place that people tried to avoid at all costs.

Victorian hospitals

The main developments in the healthcare industry included the building of mental health and fever hospitals. It was an era when potentially fatal diseases, such as smallpox, TB and cholera, were rife and swept through the population at epidemic levels.

There were no antibiotics or penicillin in those days and the best way of dealing with people who had contagious diseases was to send them away to isolation hospitals. Every hospital in Victorian times was an institution and the upper classes tended to procure treatment from a private physician at home instead.

The best hospitals were the elite voluntary hospitals founded by the upper and middle classes to serve the needs of the poor free of charge, but the care varied from place to place and there was no national recognised standard.

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Lady almoners

To ensure the system wasn’t abused and that only the genuinely needy received free treatment, a number of lady almoners were appointed. The first, Miss Mary Stewart, was responsible for assessing the patients arriving at London’s Royal Free Hospital from 1895.

Some were sent away to seek private treatment if they were too well-off, while others were asked for a part-payment to the hospital. The genuine poor received free treatment, but were encouraged to join a community savings scheme to help pay for future treatment.

The system of employing almoners was rolled out from London across the UK at the time of the First World War. The country was poor due to the war effort and new medical treatments were becoming more expensive.

There were no financial clerks or debt collectors – just the almoners, who considered the patient’s family set-up and social background when working out how much they should pay towards treatment.

It was considered a job for women, as nurses cared for the sick, midwives guided young mothers and almoners dealt with the financial side of illness. According to a report of the King’s Fund Committee in 1912, the almoner’s job was “ladies’ work”.

The almoner was usually middle-class, well-educated and unmarried. Early almoners came from a charity background and could be moralistic. A two-year training course comprising practical work with scholarly social and economic studies was set up to improve their skills.

Private treatment

At the more prestigious voluntary hospitals, richer patients began to demand private rooms. They were on a different floor from the general wards and introduced a class system in the hospitals, where the wealthy would never meet the poor.

The payments system began to echo the class distinctions in society, although private medicine remained a relatively small activity in hospitals. However, private GPs’ surgeries became more common and doctors often worked in hospitals to build their reputation in order to open a lucrative private practice.

In the early 20th century, the fee for seeing the doctor was six pence – around £8 in today’s money. Most people couldn’t afford this, let alone the cost of any medicines as well.

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Health insurance

Two schemes were launched to help poor people: health insurance was launched by the government in 1911, to be paid through National Insurance. It was compulsory for workers in some industries, but was for the insured individual only, rather than family members. It would enable access to a GP, but not hospital treatment.

A second scheme invited people to join one of many community-owned medicinal clubs and mutual aid funds. People could pay into it if they had any spare cash. They could access a doctor, medicine and even hospital treatment, without being assessed by the almoner.

There were other health insurance schemes for the middle-classes, enabling them to pay for treatment in their own home, or in a private hospital room or nursing home. These schemes continued after the NHS was launched in 1948, funding treatments that were outside its remit.


Private hospital wards were kept as “paid beds” for patients wishing to go private, although the defining feature of the NHS was to deliver a free health service for all. The Labour party’s plans to phase out private treatment within the NHS in the 1970s were abandoned when the Conservatives came to power in 1979.

The NHS became one of the UK’s biggest employers soon after its launch, with 360,000 employees in England and Wales and 45,000 in Scotland. These included 9,000 full-time doctors, 149,000 midwives and nurses, 128,000 staff in the catering, cleaning, laundry and maintenance departments and 25,000 admin staff.

In addition, there were 19,000 technical and professional staff, such as lab technicians, physiotherapists and radiographers. The workforce has continually grown and has become one of the biggest work organisations in the world.

It is also one of Britain’s most diverse workforces today, with staff coming from many different backgrounds, nationalities and social classes.

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Record demands

The NHS is finding it increasingly difficult to meet record demands, with social care services stretched to their limit today. The number of patients attending accident and emergency departments has steadily increased by between 1.4% and 2.6% a year. Hospital admissions via the A&E department have also risen from 19% in 2004 to 27%.

Some of this stems from new guidelines which state a standard four-hour waiting time in A&E, so more short-stay patients are being admitted.

Britain remains fiercely proud of the NHS – as was proven when US President Donald Trump commented that the NHS could form part of a future trade deal between America and the UK after Brexit. The suggestion, which was made during his visit to Britain in early June, sparked furious outcry on social media.

There was also a backlash from both Conservative and Labour MPs and trade union chiefs, who were united in telling the president that the NHS would never be on the table during any trade talks.

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