Observations on the NHS at 75
By David Dandy
Retired Consultant Orthopaedic Surgeon
The NHS celebrates its 75th year as I celebrate my 83rd, allowing me to comment on healthcare before the NHS, being a patient in 1940s, surgical training 50 years ago, as well as the NHS.
Healthcare before the NHS
Going back to the days before the NHS means returning to post-war Britain, a very different country from today. Few people owned cars, there was no television and Bakelite was the only plastic in common use. Also, antibiotics were unknown, rationing was still in force and life was slowly returning to normal after the war.
We lived in Lytham St. Annes and people worked together, as they do in Lancashire. We didn’t lock our doors because if we did, how could neighbours borrow a cup of sugar when you were out?
Healthcare was largely uncontrolled. Infirmaries and large hospitals were generally funded by charities or local authorities, but much elective surgery was carried out in small private nursing homes with a single theatre. Medical staff were firmly in control of their hospitals and authoritarian consultants held sway, many of them unafraid of being rigidly inflexible or acting in self-interest. Orthopaedics had broken free from general surgery in 1918, but gynaecology, eye surgery, radiology and anaesthetics remained within the Royal College of Surgeons.
General practice was usually conducted from the doctor’s home, behind a brass plate bearing their qualifications and often describing the doctor as ‘Physician and Surgeon’. Their premises were called surgeries and many divided their time between hospital and family practice. Health centres were unknown.
Being a patient in the 1940s
The absence of antibiotics changed many lives. My father became very unwell with otitis media and was left with a facial palsy that never recovered. I had a severe chest infection that did not respond to the standard regime of kaolin poultices and Friars’ Balsam inhalations, so I was given M&B 693, a newly developed sulphonamide and not an antibiotic. However, it had to be discontinued because my face and neck swelled, making breathing difficult for a day or two. The GP managed this without referral to hospital. Impetigo was quite common in children and was the condition my contemporaries feared most because it was treated with topical Gentian Violet dye, which left the victims with purple patches on their face and merciless teasing at school.
Recurring tonsillitis led to the removal of my tonsils and adenoids at the age of nine, in an old Blackpool mansion converted into a nursing home. There was one operating theatre and the ward was a large room with two beds – the other occupied by a girl of roughly my age who continually complained that her hottie was cold. The pre-med was a tangerine and white capsule, later identified as Oblivon, a sedative alleged to induce tranquillity. As the Blackpool FC colours were tangerine and white, I assumed this was a tribute to Stanley Matthews and Blackpool FC after winning the FA cup. Barely able to stand, they walked me into the theatre, held me down on the table as I struggled and knocked me out with open ether. It was not a pleasant experience and an explanation beforehand might have been more effective. The smell of ether stayed with me until I met it again at medical school. The following month we moved to London and started to lock our doors.
Surgical training 50 years ago
When the time came to choose a specialty, orthopaedics was the obvious choice. As a student it was uninspiring, but suddenly we had joint replacements and exciting new techniques for the internal fixation of fractures. The whole specialty seemed to be on the move.
General surgery, on the other hand, was imploding. A surgical career was already a daunting prospect, because there were more registrars than senior registrar vacancies, and more senior registrars than consultant vacancies – imposing a cull at each rung of the ladder. Abdominal surgeons were already differentiating into hepatobiliary, colorectal, oncological and other subgroups, but it was a combined operation by an ENT surgeon and a proctologist without an intervening general or thoracic surgeon that confirmed my doubts about its future.
The mismatch between the number of junior trainees and consultant vacancies was not a concern in orthopaedics. However, it was recognised elsewhere as a serious waste of talent, quite apart from the distress caused to those involved and their families. No mechanism was available to the NHS or Royal Colleges to make the radical changes needed to correct this problem, but it proved possible to create a coherent training programme covering a single specialty by combining existing posts.
To the best of my knowledge the first such programme was the Bart’s ‘Percivall Pott’ orthopaedic rotation. Completed in the early 1970s, this programme allowed two trainees to complete specialist training every year and became the model for other specialties. The development of nationwide selection procedures for entry, recognition of training posts and exit examinations was a huge task, only made possible because the NHS and Royal Colleges shared common goals and worked together, and was an example of what cooperation can achieve.
The NHS
What follows is a gross oversimplification, but life is short.
By the time I qualified in 1964, the NHS was up and running. The countless small independent units had largely been brought into some semblance of order, together with regional and district groupings for administration, and there were nationally agreed pay scales. Single-handed GPs were becoming rarer, group practices became commonplace and it was simple to transfer patients between hospitals.
Critics now attacked the massive bureaucracy and some considered guidelines an infringement of personal liberty. The power of consultants in hospital management was diminished and their attempts to make changes were likened to banging one’s head against a brick wall. When structural changes were made to avoid confrontation, it was said to be much the same, but without the wall. The NHS was in danger of becoming a monolith.
It was eventually recognised that local circumstances varied widely and that problems may have more than one solution. The introduction of NHS Trusts was a bold move and allowed greater flexibility without threatening the integrity of the NHS.
As well as managing a multifaceted health service, the NHS must cope with emergencies such as COVID-19 and hugely expensive innovations such as MRI, radiotherapy, organ transplantation, surgical robots and monoclonal antibodies. The story of the NHS is the creation of order out of chaos, unforeseen changes requiring colossal expenditure and intense public scrutiny. It is unlikely that any of this will change.
On the subject of public scrutiny, recent television programmes showing surgeons at work have included operations lasting more than 12 hours and others needing two or more consultants from different specialties –procedures that place heavy demands on resources. While it is amazing that we can now operate on unborn babies in the womb and change a patient’s DNA by bone marrow transplantation, it is regrettable that the NHS still has insufficient resources for patients to benefit from the advances that drew me to orthopaedics 50 years ago.