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How has nursing changed since the birth of the NHS in 1948?

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Widespread shortages of nursing staff, chronic underfunding and an over-burdened health system struggling to cope – welcome to the new National Health Service in 1948.

It is easy to look back on the early days of the NHS through rose-tinted spectacles but the fledgling institution was teetering on the verge of collapse before it had even really got off the ground – not least because of a desperate shortage of nurses.

“The shortage of nurses at the outset was one of the critical ingredients that almost scuppered the launch of the NHS itself”

Anne-Marie Rafferty

At its inception, there was a severe lack of nurse across all specialties – a situation described in 1945 by health minister Aneurin Bevan as approaching “a national disaster”.

“The shortage of nurses at the outset was one of the critical ingredients that almost scuppered the launch of the NHS itself,” said Anne-Marie Rafferty, professor of nursing policy at King’s College London.

“Looking at what is happening in terms of shortages now – with an ageing workforce, removal of the bursary and reductions in continuous professional development – we have another crisis on our hands today,” she said.

A King’s Fund briefing on the initial NHS workforce noted that, by December 1948, a shortage of nurses affecting “small general hospitals” and “the female wings of mental hospitals” meant more than 53,000 beds were unoccupied through lack of staff.

“We get a lot more entrants to nursing in their 30s than we did in 1948”

Mary Watkins

The Ministry of Health of the time estimated that the NHS lacked nearly 48,000 nurses and midwives – about 30% of the actual numbers employed.

Staffing shortages were particularly acute in mental health, where nurses often worked between 48 and 60 hours a week, said Dr Claire Chatterton, chair of the Royal College of Nursing’s History of Nursing Society.

The work was also physically and mentally gruelling, with around a quarter of nurses’ time spent on domestic chores. One report from 1945 noted that nurses regularly hauled around large bales of laundry and emptied buckets of pigswill. “The male staff are in an even worse case,” said the report. “They do farming, gardening and work of the crudest types.”

Retention was a huge issue with nursing recruits – almost always young women in general nursing – ill-prepared for the demands of the job. Now most universities look for some kind of work experience, highlighted Dr Chatterton.

But for those entering the profession straight from school in the late 1940s and early 1950s, it was often “a massive shock”. “It was such hard work and then there was the fact there was a very strong hierarchy, so young nurses were very much under the thumb of matron,” said Dr Chatterton.

“There was a very strong hierarchy, so young nurses were very much under the thumb of matron”

Claire Chatterton

Unlike today when speaking up is supposed to be actively encouraged and nurses are valued members of multi-disciplinary teams, it would have been practically unheard of for a student nurse to address a doctor directly – certainly in a large teaching hospital.

Huge numbers upped and left and, while the “marriage bar” that prevented married women working began to be lifted from 1944 onwards, there continued to be significant “wastage” due to nurses leaving to embark on married life.

Nurses were often lured away by better terms and conditions elsewhere, said Dr Chatterton, whose PhD research focused on nursing shortages and recruitment in mental health. “When I looked at why people left nursing, it was often because they could go and work in factories where they had better hours, slightly better conditions and better pay,” she said.

Other equivalent professions like teaching were seen as more attractive, added Professor Rafferty. “There was too much domestic work and nurses were not able to operate at the top of their scope of practice and you could say we have the same challenge today,” she said.

Anne-Marie Rafferty

Anne-Marie Rafferty

Anne-Marie Rafferty

While the challenges of recruitment and retention in the early days of the NHS resonate today, so too do some of the proposed solutions. “[State] enrolled nurses were introduced in 1943 as a solution to a shortage and you might argue we’re doing the same thing now with nursing associates,” said Professor Rafferty.

Concern about “dilution” of the workforce was a hot topic back then too. “In mental health nursing, it was about bringing in lots of nursing auxiliaries and them doing some of the jobs that traditionally a registered nurse would have done,” said Dr Chatterton.

Education and training were also much-debated in the 1940s and 50s. “There were huge debates about whether you could raise the status of nurses by making them more educated,” she said, adding that some argued doing do risked “setting the bar too high and excluding people”.

Now nursing is an all-graduate profession in the UK, some of the same arguments rumble on with the development of new entry routes like apprenticeships.

Early strategies designed to get more people into nursing included high profile recruitment campaigns at home and abroad. “They did these massive advertising campaigns,” said Dr Chatterton.

“The nurses look very glamorous and are pictured holding trays with doctors looking longingly – the subtext almost being that if you come into nursing you will meet a doctor,” she said. “But those adverts didn’t work, so they then started to go to Ireland, Europe and further afield – to Mauritius and the West Indies and we’re still doing that.”

“We don’t have the stress of having to talk to patients about whether or not they can afford it”

Mary Watkins

While some strategies are familiar, one idea mooted in 1945 at a meeting of the former National Advisory Council for the Recruitment and Distribution of Nurses and Midwives is unlikely to see the light of day again.

Concerned about the acute staffing shortages at his own hospital, medical superintendent Dr Boyd suggested “the conscription of untrained persons by ballot” to fill rota gaps but was advised this would be “most unwise”.

Funding for the health service is another issue that was as contentious in 1948 as it is in 2018 although, noted Professor Rafferty. “From the very beginning the national health service was always strapped for cash,” she said. In its first year the NHS cost £248m to run, almost £140m more than had been originally estimated.

While health is at the top of the political agenda now, it was not always that way. Successive health ministers – who for many years were not part of the cabinet – struggled to make the case for more money.

“Arguments about always having to go back and grovel to the Treasury and that kind of argy-bargy horse-trading have been a feature of the NHS since day one,” said Professor Rafferty.

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New nurse peer pledges to champion profession

Mary Watkins

But, while there are parallels between nursing then and now, there have also been huge changes, said Baroness Mary Watkins of Tavistock, professor of nursing and cross bench peer. For example, the image of nursing has changed, with caps and aprons abandoned in favour of more comfortable, practical – and less intimidating – attire.

The demographics have changed too, with more men and more mature students, and more flexibility to juggle career with family and other commitments.

Films aimed at addressing chronic nurse shortages soon after the NHS was founded include the 1951 docu-drama Life in Her Hands about a young widow considering nursing as a career.

“What struck me is they thought a 24-year-old widow was old in that film and I don’t think we’d think that now,” said Baroness Watkins. “We get a lot more entrants to nursing in their 30s than we did in 1948,” she said, though there have been recent concerns that the scrapping of the student bursary will turn back the clock and mean fewer mature entrants.

The scope of nursing practice and the types of treatment on offer have expanded dramatically. In particular, the huge 1,000-bed mental hospitals that existed in 1948 are a thing of the past, with the advent of therapeutic drugs and move to more community-based provision.

Aneurin Bevan

Aneurin Bevan

Aneurin Bevan

“We have nurses who do renal dialysis, chemotherapy, cognitive behavioural therapy, assertive outreach in mental health – there was none of that then,” said Baroness Watkins, who says there is much greater professional recognition of nurses now.

“While people thought extremely highly of nurses in 1948, they saw them as predominantly handmaidens to doctors and felt they would comfort and be kind to patients but did not necessarily understand the value of the nurse in progressing recovery,” she said.

People stayed in hospital much longer, with an average stay of about 17 days to have an appendix removed. “Think of length of stay now – you are barely touching the sheets,” said Professor Rafferty.

Turnover on inpatient units is very high with very little slack in the system and “that has made the pace of work even faster than it was”, said Dr Chatterton. “Nurses have always worked really hard but now the pace and the pressure they work under is higher,” she said, adding that the same was true in community nursing.

But have the fundamental values of nursing really changed that much in 70 years? “The essential of being caring, compassionate, interested in people, having high moral and ethical values are just as vital today as they were then,” said Dr Chatterton, who says she is fed up with the idea that graduate nurses these days are somehow less caring or “too posh to wash”.

Yet in the same way there has been a shift in the relationship between nursing and other disciplines, like medicine, there has been a shift in the relationship with patients. “As a society, we’re more tuned into the information giving and the consenting process – how we communicate with patients and families,” said Professor Rafferty.

Ministry of Health

The new National Health Service leaflet 1948

The new National Health Service leaflet 1948

“We have got to be exquisite communicators, not just with patients but with each other,” she said. “We know 80% of complaints are driven by poor communication so good communication is at a premium in contemporary healthcare in a way it probably wasn’t in the past.”

Nurses were respected in 1948 and while some might say the profession’s reputation has been damaged by high profile examples of poor care such as Mid Staffs, nurses today are consistently identified as the most trusted profession in public opinion polls.

“Society still holds nurses in extremely high regard and with good reason, because 95% of people get fantastic nursing care and can largely tell you a great story about when a nurse has made a difference to them or somebody in their family,” said Baroness Watkins. “The other thing that has remained constant is the majority of people are proud if they have a nurse in the family.”

And, of course, there is the fact NHS services remain free to those that need them, and that is something to celebrate, she highlighted. “We don’t have the stress of having to talk to patients about whether or not they can afford it,” she said.

“Because so many of us have only ever worked in the NHS, we forget that before 1948 there were those kinds of discussions between nurses and their patients,” she added.

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