Nursing has come a long way since the foundation of the NHS. Adrian O'Dowd takes a look at how it used to be
The NHS is certainly one of the outstanding achievements of the UK’s history in the 20th century. Its simple aim – to provide free healthcare to all, rich or poor – was as ambitious back in 1948 as it is today, 60 years on, but it survives nonetheless.
The need for a national health service for the UK had been building for a long time but the Second World War accelerated the process. It may have been a difficult concept for people to grasp initially but the country was ready.
The first step came with the Beveridge Report of 1942, which recommended a comprehensive state welfare system funded through National Insurance. Two years later, the Ministry of Health fleshed out those ideals in a white paper and, by 1946, then health minister Aneurin Bevan introduced a Bill to the House of Commons. The NHS Act became law in England and Wales with a Scottish equivalent following soon after.
The NHS began for real on 5 July 1948, bringing family practitioner services (doctors, pharmacists, opticians and dentists), hospital services and community-based services into one organisation for the first time.
Its first decade was effectively a bedding-in period as nurses and their fellow NHS staff found their feet in the brave, new world after the massive upheaval of world war. This was a very different time from now and nurses were dealing with problems specific to that period, such as the great smog of London, which caused around 4,000 deaths in December 1951 and led to legislation on smoke pollution.
The NHS was making crucial discoveries that would influence healthcare and policy for years – for example, the first link between smoking and lung cancer was made in 1950 in a report in the British Medical Journal, and antibiotics were really taking off as an effective weapon against disease.
Despite these changes and discoveries, some already very strong traditions held fast, such as the all-powerful role of matron and almost equally strong ward sisters. The 1950s matron was in charge of all aspects of patient care, catering, laundry and cleaning, as well as staff homes and nurse training schools. Even senior doctors would not dare enter a ward without first seeking matron or sister’s approval.
Matron had tight control over nurses as Peter Ardern, nurse historian, says: ‘In the 1950s, nursing was still traditional in terms of training and discipline. You still had Florence Nightingale values then and matron and sister had real authority.
‘Matron then was as powerful as senior doctors. She had a bearing and an authority.’
Nurses living in nurse houses had to obey matron in their private life as well, taking instructions on how late they could stay out, how smartly dressed they were and the suitability of any young man they wished to marry – although getting married meant leaving the job.
Nurse training took place in nurse schools, which were part of the hospitals, under matron’s control, and nursing students were an important part of the workforce. The Nurses Act 1949 strengthened the educational role of then nurse regulator the General Nursing Council (GNC) and a new syllabus for general training was completed and approved in 1952. A depleted labour market after the war meant the government looked overseas to help increase nurse numbers and the UK saw a large influx of nurses from the Caribbean.
So what did patients expect of nurses in the 1950s? Christine Hallett, nurse historian and academic at the University of Manchester, says pretty much what they expect today.
‘Patients’ expectations are that nurses will be involved in hygiene, nutrition and care of the environment, psychological and social care of the patient – quite a broad role.
‘People want nurses to have a more hands-on, bedside, caring role and what they perceive is that nurses are doing a lot of technical work but also a lot of paperwork and they are pulled away from the patient rather more than they should be.
‘There is disquiet that nurses are not able to give their time to fulfil all those roles. But at the same time, nurses are highly respected for their level of knowledge and the scientific competence they have.
‘Mr Ardern agrees that the caring, hands-on side of nursing has been somewhat sacrificed as nursing has become more technical and passed on many of the fundamental caring parts of the job to healthcare assistants.
‘The post that has disappeared that would have been superb now is the SEN [senior enrolled nurse],’ he says. ‘These were trained nurses, not too academic, but who could manage the practice area with the sisters overseeing things.’
It is hard to appreciate just how far nursing has come since the NHS’ first decade, he continues.
‘It has become a very technical role now in certain areas. A nurse of 50 years ago would be like a fish out of water now. A nurse of today taken back to the 1950s would be seen as almost a doctor.’
Despite huge changes and advances in the NHS in its first 60 years, Mr Ardern believes that patients’ expectations of nurses have remained fairly static.
‘Nurses are valued now almost as much as they ever were,’ he says. ‘In casualty departments, there is social change and nurses get attacked more but, in general, the respect and value of nurses has changed very little. The standing of the profession has maintained itself.’
As regards the public’s expectations of the service itself, he says people had contrasting feelings.
‘The general public would have been expecting something wonderful but would have also been quite sceptical of such a grand idea. It was a huge undertaking.’
This notion is reiterated by Christine Hancock, former general secretary of the RCN and now European director for the Oxford Health Alliance: ‘I guess the overwhelming thing from a patient/public point of view at the start of the NHS must have been the relief of the fear of having to pay for care. The issue of not having to pay must have been overwhelming. We can’t really imagine it.’
Perhaps a little too ambitious, the original promise of free healthcare at the point of delivery was broken in 1951 when some charges were introduced for spectacles and dental treatment. A prescription charge of one shilling (5p) was introduced a year later.
In some ways, 1950s nursing seems a world away but some issues are as true today as they have ever been. As Dr G.E. Godber stated in an article published by NT in 1950: ‘One of the main problems in a national service is to maintain a sound balance between central control and a satisfactory devolution of responsibility.’
The nature of nursing at the inception of the nhs
Getting to know the patient as a real person was one of the benefits of being a nurse in the 1950s, says Mary Walker, aged 77.
Ms Walker started training the year the NHS began and qualified as a nurse in 1952, working at Barts Hospital in London, where she was later a ward sister.
‘I couldn’t say our training was perfect,’ she says. ‘You had to learn as you went along and you mostly learnt on the ward from your experienced seniors.
‘Nowadays nursing has changed so much. Our patients stayed in a long time and you really got to know them. Our greatest privilege was to consider the whole patient and their comfort.
‘There’s some excellent nursing now and it’s become very challenging. There are different needs now.’
Clinical skills of nurses then and now are different, she adds, which is appropriate given the different world in which today’s staff work.
Her work was more task-orientated: ‘As a junior student you were responsible for taking the temperatures, cleaning bedpans, boiling patients’ eggs and cleaning the lockers. You really got to talk to the patients.’
Ms Walker believes patients’ expectations of nurses have also changed: ‘There was great respect for nurses and patients were very protective of us, especially if we were in trouble with matron.’
These strong leaders were key to hospital nursing. As well as being impressive, she remembers them as ‘wonderful characters, big statuesque ladies who made their presence felt. They were scary but we could always go to them if we were in trouble.’