It is perhaps important for everyone working in the National Health Service (NHS) to have some idea of the origins, development and current structure of what is one of the biggest and most complicated organisations in the world. A detailed analysis of the NHS and its history is outside the scope of this chapter; suggestions for further reading are given at the end. Its purpose is instead to outline briefly how the NHS has evolved and to put into perspective the current changes.

Healthcare before the NHS

Until the middle of the 19th century, the state had virtually no control over the medical profession. Doctors had developed their own organisational structure which satisfied the need for self-protection. Members of the Royal College of Physicians mainly worked in the London teaching hospitals and treated those who could afford their fees. Members of the Royal College of Surgeons (which was the Company of Barbers a century before) were more experienced in the practice of medicine and treated patients both in London (in competition with the physicians) and outside. The vast majority of people were treated at the hands of members of the Society of Apothecaries, who basically prescribed medication. For a considerable time churches provided forms of treatment to people with mental illnesses.

The state became more involved in the health of the population and regulation of the medical profession throughout the 19th century and in the early 20th century. The 1834 Poor Law was the first acknowledgement that government had some responsibility for the care of the population. Among its effects was the statutory provision of a parish medical officer to care for the poor. These established that the parish workhouses should have sick wards where the able-bodied inmates could be treated when they became ill (Levitt, 1976). Free services were offered by boards of guardians to those who could pass a means test.

The Public Health Act 1848 established statutory powers that enabled a local medical officer of health (an official of the local authority) to cater for the health of the local population. Following the Poor Law reforms, the medical officers’ responsibilities were extended to some Poor Law hospitals which were considered to be providing healthcare rather than welfare.