The Introduction of the NHS

The NHS Act (1946) for England and Wales said, “It shall be the duty of the Minister of Health to promote the establishment of a health service to secure improvement in the physical and mental health of the people and the prevention, diagnosis and treatment of illness”¹ and be “free of charge”. It was designed by professionals with little recourse to the demands of patients.Reference Greengross, Grant and Collini² A small but significant private health care system existed alongside Government provision. Governments have striven to minimise its budget whilst maximising productivity, but this has been hampered by demographic changes and technical advances. The NHS has regularly been reorganised, sometimes creating periods of employee unrest. In 2008, Gorsky summarised the shift in provision, “the overarching narrative is one of transition from paternalistic and technocratic planning to market disciplines and a discourse of choice and of a ceding of professional autonomy by clinicians to managers and to the state”.Reference Gorsky³

Central NHS management, funding and resource allocation 1948–2010

The service was administered by centrally appointing non-elected bodies who delegated power. Funding came from central government tax revenues, national insurance contributions, other sources (medication prescriptions) and charges to patients (from 1951 for dental examinations, sight tests and spectacles). National taxation provided 85 per cent of the funding and after 1980 funding was determined by a three-yearly Comprehensive Spending Review (CSR). Successive Ministers of Health have tried to improve the quality of care, but this has stretched resources. Between 1948 and 2010, there were 28 Ministers responsible for Health averaging a term of office of 2.2 years.Reference Rivett⁴

Key changes

• • A “Hospital Plan for England and Wales” (1962) specified norms for the number of beds per 1,000 population.⁵

• • The 1970s was a period of “Consensus Management” with funding based on population size and an emphasis on services.⁶

• • “Priorities for Health and Personal Social Services in England” (1976)⁷ concentrated on primary care, health promotion, children, the elderly, the mentally ill and handicapped. While expenditure increased, the capital programme halved.

• • Funding was allocated to 14 Regional Health Boards (RHBs) by the Ministry of Health based on the previous year. RHBs became Strategic Planning Authorities with the operational duty delegated to Area Health Authorities (AHA) serving half to one million. Inequalities existed, for example the Sheffield Regional Hospital Board and the Trent Regional Health Authority (Trent RHA) covered Nottingham, Derby, Leicester, Lincoln, Sheffield and Rotherham. Within TRHA Sheffield was 39 per cent above the regional average for funding, with Nottinghamshire 17 per cent below and Rotherham 62 per cent below average.Reference Buxton and Klein⁸

• • The “Resource Allocation Working Party” (RAWP) (1975) devised a formula to rectify inequalities based on health data as a marker of social deprivation.⁹ Mortality rates, the standardised mortality ratios (SMRs), were introduced in the 1977/78 allocations as a proxy for morbidity. After 10 years reallocation, the gap narrowed from 26 per cent to 11 per cent points. The Black Report “Inequalities in Health” (1980), added social weighting to resource allocation.¹⁰

• • The “Griffith’s Report” (NHS Management Enquiry)¹¹ concluded clinicians should be involved in management. The “Resource Management Initiative” (1986)¹² and “Working for Patients” (1989)¹³ introduced Clinical Directorates. A hospital accreditation process introduced voluntarily in 1989 by King’s Fund, becoming compulsory and included a target of 60 per cent for Day Case surgery.

• • A White Paper “Caring for People” (1998)¹⁴ along with “Working for Patients” (1989)¹³ was incorporated into “The National Health Services and Community Care Act” (1990)¹⁵ replacing RAWP and tried to bridge the gap between health boards and local council social services and introduced the concept of “The Internal Market”, establishing Fundholding General Practitioners. Concerns over allocation inequalities between fundholders and non-fundholders was overtaken by the phasing out of fundholding and creating Primary Care Groups (PCGs). PCGs purchased care for their population and could use the private sector.Reference Levitt, Wall and Appleby¹⁶ Hospitals became self-governing Trusts.

• • “The Patients Charter” (1991)¹⁷ set minimum targets such as a 30-minute out-patient waiting time, two years for subsequent treatment and 14 minutes for an ambulance.Reference Stocking¹⁸

• • “Hospital Doctors: Training for the Future” (1993)¹⁹ directed acute hospital services to be consultant based not consultant led. The traditional concept of care based on “firms” was eroded. Juniors worked shifts resulting in reduced morale.

• • The “Capital investment Manual” (1994) set out “Private Finance Initiatives” (PFIs), allowing future schemes to explore private finance²⁰ but with long-term repayments at high interest.

• • ‘The Health Authority Act’ (1995)²¹ abolished Regional Health Authorities (RHAs), District Health Authorities (DHAs) and Family Health Authorities (FHSAs). The NHS Executive and eight new regional offices became responsible for planning and administration.

• • Sir Kenneth Calman, the Chief Medical Officer, published an “Expert Advisory Group on Cancer” (1995)²² with cancer “units” in most district hospitals treating common cancers and designated cancer centres treating uncommon cancers.

• • The “New NHS”: modern, dependable (1997), abolished the internal market and encouraged Primary Care Trusts (PCGs) to enter more long-term contracts.²³ Evidence Based Medicine, Clinical Guidelines and Clinical Outcome Groups were a means to improve quality and outcomes of care, as did “A First-Class Service: Quality in the NHS” in 1998.²⁴

• • The “Health Care Act” 1999²⁵ aimed to improve coordination between local authorities and the NHS by abolishing GP fundholding and establishing primary care trusts (PCTs), which would evolve from primary care groups (PCGs).

• • “The NHS Plan” (2000)²⁶ promoted the development of choice and competition. It was said not to have been costed. The government committed to bring spending on the NHS up to the European average with an increase in staffing, day-case surgery, money for cancer care and 100 new hospitals by 2010.

• • “The National Health Services Reform and Health Care Professional Act” (2002)²⁷ delegated much to primary care trusts (PCTs) and outlined the move to 28 new Strategic Health Authorities (SHAs) reducing to 10 in 2006, only to be abolished in the Health and Social Care Act 2012.

• • “Delivering the NHS Plan (2002) – next steps on investment, next steps on reform”²⁸ led to increased funding and “Payment by Results” (PbR) making a tariff system for purchasers (GPs) to providers (Hospitals).

• • “Improving Outcomes Guidance” (IOGs) (2004) produced guidelines under the auspices of NICE for Head and Neck Cancer IOGs.²⁹

• • “The NHS Improvement Plan” (2004)³⁰ said that by 2008 time from a GP referral to starting hospital treatment would be less than 18 weeks. In 2004, the “NHS Cancer Plan’³¹ updated strategies for improvements with funding including a two-week maximum wait for an urgent outpatient appointment^{32, 33} to be monitored by the Commission for Health Improvement.

• • In 2005, NICE was joined by the Health Development Agency (established in 2000) which included public health, changing its name to the National Institute for Health and Clinical Excellence (still abbreviated as NICE).³⁴

• • In June 2007, the website “NHS Choices” helped patients choose where to be treated but the King’s Fund found patients were loyal to their local trusts. In 2008, “High Quality of Care for All: NHS Next Stage Review”³⁵ aimed at preventing ill health with other agencies. The “Care Quality Commission” (CQC) was established under the “Health and Social Care Act” 2008^{36, 37} and its first review noted improving service but “unacceptable variations continue to characterise the NHS, even in an era of strong central government control.”

• • The “NHS Constitution for England” (2009) re-stated the principles of the NHS. The Secretary of State for Health and Social Care is ultimately accountable for the operation of the NHS.³⁸

The treatment of many infectious diseases, along with reductions in poverty, malnutrition and overcrowding were being replaced, “by those of affluence and of longevity (obesity, diabetes, cancer, dementia, arthritis etc) and so-called ‘lifestyle illnesses’ such as impotence, baldness or anxiety becoming medicalised and waiting times and lists grew”.Reference Shapiro³⁹

ENT services in Nottingham before the NHS

In 1886, Dr Donald StewartReference Bradley⁴⁰ was the first ENT surgeon based in his general practice which became the Nottingham and Nottinghamshire Hospital for Diseases of the Throat, Ear and Nose (NNHDTEN) receiving support from a local contributory scheme.Reference Bradley⁴¹ NNHDTEN ran alongside the General Hospital Nottingham (GHN) whose general surgeons performed some ENT surgery.Reference Jacobs⁴² In the early 1910s, two ENT surgeons joined the Nottingham Children’s Hospital (NCH)Reference Crothall⁴³ and the “School Clinic”. Funding came from charities, subscriptions and quasi-insurance schemes. More detail on Nottingham ENT provision before the inception of the NHS can be found elsewhere.Reference Bradley^40, Reference Bradley⁴¹

ENT after the inception of the NHS

In 1942/1944, the Second National (England) Hospital Survey reported NNHDTEN “to be… unsuitable for hospital use” and recommended that it join the already existing ENT Department (established in 1920) at the General Hospital Nottingham⁴⁴ (GHN) and in December 1947 NNHDTEN closed.Reference Bradley⁴⁰ The GHN ENT Department was upgraded with 13 children and 38 adult beds.⁴⁵ In 1949, a new T’s & A’s Ward (26 beds) and an Operating Theatre were built at NCH.Reference Crothall⁴³ During the early 1950s, the number of children undergoing T’s & A’s in Nottingham remained static with 1,000–1,500 and more than 100 mastoid operations performed annually. One child operated on at the School Clinic died from post-tonsillectomy haemorrhage in 1965 which resulted in the closure of their surgical lists, but the out-patient clinic remained open.Reference Bradley⁴¹ During the 1960s, a head and neck cancer clinic was set-up with radiotherapists and oral surgeons.Reference Neil, Bittner and Lowe⁴⁶ Before 1969, children with suspected hearing loss were tested at “The School Clinic”, but in 1972, an Annual Report suggested all children should be referred by a General Practitioner.Reference Bradley⁴¹ Day-case surgery was introduced in February 1972 at NCH. It was proposed that Children’s ENT Services would transfer to Queens Medical Centre, University Hospital (QMC) when it opened with some adult ENT outpatient and all adult ENT inpatient care remaining at GHN. Nottingham ENT served King’s Mill Hospital in Mansfield with six sessions until 1985 and Newark General Hospital with two sessions per week until 2003.

In 1973 whilst plans were underway for QMC, ENT at GHN was upgraded.⁴⁷ ENT Outpatients at QMC was only designed for two consultants and their junior staff comprising three consulting rooms, a treatment room, two audiometry booths, a diagnostic room (ENG and Vestibular), a teaching room, sister’s office and clerical staff rooms that opened in 1979. Adult in-patients remained at GHN but in the early 1980s Trent Region’s cash crisis meant GHN was sold to fund the move of radiotherapy to Nottingham City Hospital.⁴⁸ What had been planned as a split site service became compressed into a single site at QMC and in 1984 space was identified for an adult ENT service which included a ward with 33 beds as well as two surgical theatres, secretarial offices, a paediatric audiology booth, a temporal bone, seminar room and four small offices for consultants and junior staff (Figure 1).

Figure 1.

Queens Medical Centre, University Hospital.

Waiting lists increased during the 1990s^49–51 and space was inadequate.⁵² In 1995, Mr. David Edwards, CEO QMC, proposed that Nottingham Health Authority would build a unit for Ophthalmology and ENT⁵³ but the Health Services in Nottingham were underfunded by £9m million.⁵⁴

An academic Department was founded with financial help from the Midland Institute of OtologyReference Pahor and Stansbie⁵⁵ and the appointment of a Professor (1993) and Senior Lecturer (1996), both requiring more space. These appointments and other sessions transferred from Mansfield and Newark added pressure on space. Several detailed plans were made, the first agreed in 1997 by the Trent NHS Executive, but central government rejected it.⁵⁶ Yet more plans were compiled, and Kevin Gibbin contributed a great deal, only for each submission to be rejected.^57–59 The Royal College of Ophthalmology said they would withdraw recognition of QMC as a teaching unit unless facilities were improved which would result in the Ophthalmology department being unviable. As a result, building started in 1999 on the “Eye, Ear, Nose and Throat Department” and in 2000 the four-storey extension of QMC was completed.⁶⁰ Built under the PFI Scheme for £18.5 million, the operator leased it back to the Trust for 35 years ending on 31 January 2036.⁶¹ The building was shared by ENT and Ophthalmology which included out-patients, in-patients and theatre space. ENT had adult and paediatric audiology booths, the MRC Hearing Research Outstation and the ENT Academic Department with teaching/seminar rooms and a library (Fig. 2).

Figure 2.

The Eye, Ear, Nose and Throat Department, Nottingham.

Hearing services and Institute of Hearing Research

The “Hearing Aid Centre” was one of 18 set up in 1948. QMC opened with an audiometric service, whilst the hearing aid and vestibular services remained at the GHN. The Medical Research Council’s Institute of Hearing Research (MRC IHR) set up in Nottingham along with other clinical outstations in Southampton, Cardiff and Glasgow.Reference Haggard⁶² In 1981, a service dedicated for children, The Children’s Hearing Assessment Centre (CHAC),⁶³ under Professor Barry McCormack started with “open access” so any professional or parent could refer their child. The Nottingham Paediatric Cochlear Implant Programme (NPCIP) became integrated with these services with almost 100 staff in audiology, hearing therapists and audiological scientists.

Clinical staff

ENT surgeons in Nottingham were generalists until 1978 when Kevin Gibbin (K.P.G.) was appointed as a “Paediatric Otolaryngologist”. Close cooperation with the Children’s Audiology Clinic and the MRC Institute of Hearing Research (IHR) helped K.P.G. promote the concept of super-specialisation. In 1978, Ross Coles was invited by the Medical Research Council (MRC) to be Deputy Director of its new IHR. In 1982, Patrick Bradley (P.J.B.) was appointed “to develop head and neck surgery”. P.J.B. consolidated the head and neck cancer services and developed a “one-stop clinic”. In 1988, Gerry O’Donoghue (G.M.O.) was appointed as an Otologist and implanted the first paediatric multichannel cochlea implant in the UK and formed The Ear Foundation (1998), a charity, to support patients’ families. G.M.O. and K.P.G. implanted over 2,000 children, supported by a multidisciplinary team. In 1991, Nick Jones (N.S.J.) was appointed as a Rhinologist and developed endoscopic sinus and skull base surgery, nasal reconstruction and an interdisciplinary Facial Pain Clinic. In 1993, John Birchall (J.P.B.) was appointed as Professor of Otolaryngology, and in 1996, Julian McGlashan (J.M.) a Senior Lecturer and Consultant focusing on swallowing problems, thyroid, head and neck surgery and formalised a Voice Clinic. In 2002, Nigel Beasley (N.B.) was appointed increasing activity in thyroid surgery. In 1982, ENT medical and consultant staffing comprised four consultant surgeons and two surgical trainees: one Senior Registrar, one Registrar and one Staff Grade with two Senior House Officers. By 2008, there were nine (8.5 equivalent) consultants, six surgical trainees and four Senior house Officers.

A new medical school at Nottingham University

In 1964, the Minister of Health announced there would be a Medical School and University Hospital in Nottingham.⁶⁴ The first student intake comprised 48 students who graduated in 1975 increasing to 330 students per year. During the third clinical year, students had a two-month attachment in ENT attending out-patients, theatres, lectures with an exam and structured viva. General Practitioners are the primary contact of patients with ENT conditions, managing risk and controlling referral to secondary care, with few specialists compared to other Western countries.Reference Petrucci, Okerosi, Patterson, Hobday, Salano and Waterworth⁶⁵ However, “most medical graduates are not confident managing common ENT conditions”.Reference Mayer, Smith and Carrie⁶⁶ ENT makes up 7.6 per cent of all referrals to secondary care⁶⁷ but the demand on medical school teaching time restricts ENT experience.

Post-graduate training

In 1948, the career structure for surgeons was loosely based on the pre-war hierarchy of teaching hospitals (consultants, senior registrars, registrars, senior house officers and house officers). Consultant numbers could not meet the level agreed by the Memorandum on the Development of Consultant Services for several years.⁶⁸ The Treasury took fright at staff costs and set up an Advisory Committee under the chairmanship of George Godber, with the Joint Consultants Committee of the BMA and professional advisors,⁶⁹ and the Spens Report (1946) said the recommendations were deemed unrealistic.⁷⁰ A Royal Commission on medical pay was set up in 1957 and, in 1960, advised there should be a permanent impartial Review Body.⁷¹

Initially surgical training relied on apprenticeship. Young surgeons rotated through several units, and their career path was ill-defined.Reference Styles⁷² The first surgical discipline to acquire an FRCS was Ophthalmology in 1943 and Otolaryngologists in 1945 with the first examination in 1947.Reference Weir⁷³ In the 1960s the Royal Colleges of Surgeons of Great Britain and Ireland set up the Joint Committee on Higher Surgical Training (JCHST) which became the Specialist Advisory Committee (SAC).Reference Ludman⁷⁴ In 1992, a Joint Committee on Higher Surgical Examinations (JCIE) followed by the Senate of Surgery in 1993, joined the two existing committees, with the JCIE and the Joint Committee for Higher Surgical Training (JCHST), as subcommittees of the Senate of Surgery (renamed The Surgical Forum).Reference Ribeiro, Chaplin, Peel, Treasure, Leopard and Jackson⁷⁵ In 1997, European Specialty Medical Qualification (Order 1995) meant doctors could only be appointed to a substantive consultant post in the UK if they were on the Specialist Register, GMC Good Medical Practice, after September 1996.⁷⁶ In 2005, the Postgraduate Medical Education and Training Board (PMETB) was established, taking over the responsibilities of the Specialist Training Authority of the Medical Royal Colleges. In 2010, PMETB merged with the General Medical Council to monitor training across the whole career path.⁷⁷ In 1990 a ‘new deal’ had reduced working hours to under 72 hours per week, but this posed a threat to the quality of training.⁷⁸ Chief Medical Officer Sir Kenneth Calman produced recommendations in 1993 resulting in the merger of the registrar and senior registrar grades outlined in “Modernising Medical Careers” (2005) and “Hospital Doctors – Training for the Future”.⁷⁹ By 1996, a single specialist training grade was created.⁸⁰ In 2002, the Chief Medical Officer for England, Dr Liam Donaldson, published “Unfinished Business – Proposals for Reform of the Senior House Officer Grade”Reference Donaldson⁸¹ to address junior training. The European Working Time Directive reduced working to 48 hours by 2009. Donaldson cited inadequate planning for senior house officers and argued for “generalist” consultants with shorter training. By 2005 “Modernising Medical Careers” (MMC) reconfigured specialty training starting in 2007.Reference Calman⁸² The four Royal Colleges of Surgeons in the UK and Ireland developed a new surgical curriculum, the Intercollegiate Surgical Curriculum Project (ISCP)^{83, 84} who supervised Postgraduate Medical Education and the Training Board (PMETB) part of the GMC, was established in 2005, A report, “Time for Training”, reviewed the impact of EWTD on training and concluded that it had resulted in reduced training opportunities.Reference Temple⁸⁵