Cabinet Memorandum Proposals for a National Health Service 13 December 1945

Cabinet Memorandum by the Minister of Health, 13 December 1945

1. I submit my general proposals for a National Health Service. I should like to be authorised to prepare a Bill on the lines of these proposals now, so as to come back to my colleagues with it as early as possible in the new year. I do not seek detailed decisions until then. But I need a decision now as to whether this is the broad shape which the Bill should take.

2. When my proposals for the hospital part of the service were approved in principle by the Cabinet on the 18th October [C.M. (45) 43rd meeting] some further details were asked for, particularly as to the new regional and local administration. These are included in the present paper. Misgivings among some of my colleagues attached to the effect of my proposals on local government and – more generally – to the risk of losing from the health service the benefits of local interest and local knowledge in day-to-day administration. I am alive to the importance of both points.

3. I have reviewed, not only the hospital service, but the health service as a whole, in the light of the views expressed at the Cabinet meeting. It is only by seeing the new service as a whole that we can judge the right shape for its parts.

4. As I see it, the undertaking to provide all people with all kinds of health care, using virtually the whole of the medical and other health professions to do it, creates an entirely new situation and calls for something bolder than a mere extension and adaptation of existing services. Here is an opportunity which may not recur for years, for a thorough overhaul and reconstruction of the country’s health position. I see in this reconstruction a proper place both for local and for central government, as the complementary instruments of the public who will be paying for this service through insurance contributions and taxes to the exchequer and through local rates. In a fully modernised service there will be some things which the State can do better than local authorities, and some things which local Authorities can do better than the State. There is also, in my view, both room and need for giving a voice, in the guiding and providing of the service, to those professional people who will in future be almost wholly absorbed in it and on whom its success will depend. This will involve in some cases – as in the provision for a family doctor service – new forms of executive machinery, in which the representatives of the potential patients and those of the professional people undertaking their care can combine.

5. 1 set out my proposals in the appended statement, as shortly as the range of the subject allows. 1 believe that they will achieve a sensible – although new – distribution of responsibility between local and central government, that they will preserve proper decentralisation (in functions which central government assumes) so as to keep up a healthy local interest in administration, and that they will give a useful and reasonable share in future to professional people in helping to steer the service along the right lines.

6. To keep the proposals as short as possible, I have omitted argument. There is much general matter in the original White Paper with which I agree – in particular with the scope of the service to be provided, with the conception of the Health Centre as the new feature of general medical practice, with the importance of rationalising the hospital services for the first time, with the need to take the present bits and pieces of the health services as they have historically emerged and to recast them into a coherent single new service, and generally with the objective of a universal and free service. On method, however, I often disagree; hence these amended proposals.

7. AIl of this is concerned only with the general treatment services. It has to be backed by a review, as we go on, of the environmental provision for health – in local government and otherwise – and by a vigorous policy of health education. It leaves untouched, for the present, the question of industrial health and hygiene. It will need to be supplemented, next session, with measures for the general care and welfare (other than health treatment) of young children, the aged, the blind and the permanently crippled – all of which must become the responsibility of some new service (and, I hope, a local government service) when the present system of Public Assistance is superseded.

8. But the immediate need is to settle the shape of a National Health Service, backing National Insurance for a Bill this session. If the appended proposals commend themselves to my colleagues I will prepare the Bill. While I do this, I propose to meet the representative bodies of the local authorities, medical profession and others, for some discussion of the principal points in the Bill. But I do not propose, nor would time allow, to embark upon any long series of negotiations before the Bill is settled. Nor will the Bill itself have to settle all the details; it will provide the general structure, within which many matters will have to be later discussed and negotiated.


1. The Minister as the Central Authority

1. General responsibility for the service will rest on the Minister of Health. This will extend to mental, as well as physical, health services – the administrative functions of the Board of Control in mental health being absorbed by the Minister, and the Board exercising only the quasi-judicial functions relating to the liberty of the subject under the lunacy and mental deficiency Acts.

2. The Minister will discharge his general responsibility through three main channels:

(1) For parts of the service best organised nationally – the hospital and specialist services – he will assume direct responsibility; but he will delegate the bulk of administration to new regional and local bodies, acting on his behalf and designed to give scope to people with local experience and knowledge to serve on them.

(2) For parts of the service best organised locally – a wide variety of domiciliary and clinic services – direct responsibility will rest on local government, acting in its ordinary relationship with the Minister; this responsibility will be unified in the present major authorities, the county county borough councils.

(3) For new family practitioner services – doctor and dentist – new local executive machinery will be set up, composed partly of members drawn from local authorities, partly of people selected by the Minister, partly of representatives of the doctors and others engaged in the service. These new local bodies will act within national regulations made by the Minister; and by the side of the Minister there will be a special, mainly professional, body to regulate the distribution of general medical practitioners over the country as a whole.

New central advisory machinery

3. To provide the Minister with expert advice, in the technical planning and conduct of the service, there will be a new Central Health Services Council.

4. In addition – to free the Council for its general work on the service as a whole – it will have Standing Advisory Committees on special aspects of the service (medical, hospitals, nursing, mental health service, &c.).

II. Hospital and Specialist Services

Taking over the existing hospitals

6. The ownership of the present public hospitals, voluntary and municipal, will be taken over by the Minister (subject to special arrangements in the case of the teaching hospitals, described later).

Regional Hospitals Boards

7. The country will be divided into about twenty natural areas or regions for hospital organisation.

Regional Hospital Board areas proposed 1945

Each area will be based on one of the eleven university medical teaching centres – the natural focal points of specialist medicine and therefore of hospital services. Two or more areas will sometimes base on the same medical teaching centre, to avoid the areas becoming too big for practical organisation.

8. For each area or region there will be set up a Regional Hospitals Board of some 20-30 members, appointed by the Minister and drawn from the major local authorities in the area, from local people selected by the Minister for their general suitability for the work involved (some of whom may be ex-voluntary hospital experts), and from people representing the university teaching centre and specialist and general medicine in the area. Principal officers of the Boards will be appointed by the Boards subject to the approval of the Minister.

9. Each Regional Board will be required to appoint, subject to the Minister’s approval, a number of smaller Local Hospital Management Committees. There will be one of these committees for each local group of hospitals which together form a natural hospital unit in a planned service – i.e., one or more main hospitals, with some outlying smaller “feeder” hospitals, together providing about 1,000 beds under a common specialist staff, and capable of dealing as a group with all the more normal hospital needs of their immediate area. Sometimes a large hospital not needing to be so grouped -e.g., a mental hospital – will have one of those committees to itself. All the committees will be essentially local executive bodies, although their field of operation cannot be restricted to existing local government boundaries. Their members will be drawn from the local authorities of the areas served by the hospitals after consultation with those local authorities, and from other local people selected by the Regional Boards (including, where desirable, people of local voluntary hospital experience), together with some professional members.

10. The Minister will determine with each Regional Board the best reorganisation of all available hospital and specialist resources in their region, and will supplement those resources as and where necessary, as soon as this can be done. Owning the hospitals, he will entrust their administration to the Regional Boards. The Boards will settle with the Minister each year a budget of normal expenditure, and within that budget will be given as much independence as possible; abnormal, or excess, expenditure will be under more detailed control. The Boards will make all consultant and specialist appointments in the hospitals – regional advisory panels of experts being set up to advise on the professional suitability of candidates.

11. The day-to-day work of running the hospitals will then be entrusted by the Boards to the Local Management Committees. These will be the effective managers on the spot, appointing all ordinary staff of the hospitals, dealing with supplies, handling ordinary running and minor capital expenditure, and generally acting as the “governing bodies.” In mental hospitals they will take the place of the present Visiting Committees. The principal officer of each Committee will be appointed by the Committee with the approval of the Regional Board, and will act also as the chief administrative officer of each hospital covered by the Committee.

Special Provision for Teaching Hospitals

12. Special provision will be made in relation to hospitals providing the bases for the clinical teaching of medical students. They will be taken over by the Minister like other hospitals, and play their part in the national service; but they will be given the special status and measure of independence necessary to enable them to take their proper place as academic institutions standing in close association with the universities whose educational needs they must be organised to meet. Universities must be enabled to exercise an effective influence on the policy and activities of teaching hospitals. Essential features of the organisation of a teaching hospital emphasised by the Goodenough Committee are a governing body which is personal to the hospital and has wide discretion as to expenditure within a reasonable budget; representation of the university and of the teaching staff on that governing body; and selection of medical staff (other than holders of university posts) by a special advisory committee, representative of the governing body of the hospital and of the university.

With these objects in mind it is proposed that the hospitals which are from time to time regarded by the universities and the Minister as providing the main facilities for undergraduate or post-graduate clinical teaching and research shall be differentiated from other hospitals in the following manner:

(1) Instead of being entrusted to the ordinary Regional Boards and local management committees described above, the teaching hospital (in some instances the main and associated hospitals which together constitute the teaching centre) will have its own specially constituted Board of Governors.

(2) The Board of Governors will, as recommended by the Goodenough Committee, include reasonable representation of the university and of the teaching staff. In addition, it will have members nominated by the Regional Hospitals Board and by the Minister (some of whom will be drawn from the present governing bodies).

(3) The teaching hospital will have a separate annual budget approved by the Minister, and within that budget the Governors will have the fullest discretion in expenditure (subject always to observance of any nationally agreed terms of service and remuneration). They can also be allowed to retain various endowments in their possession. Further, the Governors will receive additional funds from university sources, and will be at liberty to accept them from private sources for experimental work and innovations in organisation.

(4) The Governors will have full freedom to appoint their own staff, and in making medical staff appointments will be advised by a special selection committee constituted in the light of the Goodenough Committee recommendations .

III. Local Clinic, Domiciliary and Welfare Service

14. This part of the service will be the direct function of local government – of the county and the county borough councils – and will include:-

  • (a) School medical services.
  • (b) Maternity and child welfare (in co-operation with the hospital service on the specialist side).
  • (c) Domiciliary midwifery.
  • (d) Health visiting.
  • (e) Home nursing services.
  • (f)Home help services for households in time of sickness.
  • (g) Vaccination and immunisation services.
  • (h) Various forms of care and after-care for the sick and those recovering from sickness.
  • (i) A general ambulance service.
  • (j)The provision and maintenance of Health Centres, Dental Centres, and similar local premises as bases for the Family Practitioner service (to be described later).
  • (k) Ascertainment of mental cases…

IV. Family Practitioner Services

31. This part of the service will cover general medical care by a personal, or family, doctor – with necessary medicines, drugs and appliances – to be available to the whole population as from an appointed day. General dental care – with necessary dentures – will be developed as fast as the supply of dentists allows. There will be priority dental provision from the outset, however, for mothers and children. (This priority dentistry will be provided by local authorities through their maternity and child welfare services and school medical service – and it is not affected, therefore, by the following proposals for the more general service.)

32. A principal objective from the outset, in the general medical and general dental services, will be the development of the Health Centre system, equipping the practitioner with publicly provided premises, apparatus and ancillary staff. This system will be developed as fast and as widely as possible. The arrangements for the provision of the Centres and the engagement of the doctors and dentists in them are referred to below.

33. While the Health Centre system is developing, it will be supplemented by arrangements with doctors in separate practice – to join in the service from their own surgeries. This will be so arranged that everyone can be assured of a family doctor from the outset – either in a Health Centre or not. For dentistry, this assurance cannot be given until more practitioners are available, but during the development of the Health Centre system arrangements will be made to supplement it as much as possible by enabling individual dentists to treat patients at the cost of the new service wherever this can be arranged.

Local Executive Committees

34. There will be a new system of Local Executive Committees for the family practitioner services. There will be a Committee for each county and county borough area, but with power to the Minister to combine two or more areas under one Committee, wherever desirable.

Local Authorityies and Local Executive Areas proposed 1945

Each Committee will have a chairman, appointed by the Minister and one half of its members will represent the “consumer” interest, the public, while the other half represents the professional people providing the service – doctors, dentists and chemists. Of the public representatives, two-thirds will be nominated by the Local Authority of the area and the other third by the Minister…

Health Centres

36. The provision and maintenance of Health Centre (including Dental Centre) premises and equipment – and of nursing, secretarial and other ancillary staff – will rest with the county and county borough councils. It can thus be correlated with their provision of child welfare clinics, school clinics, and other activities. To arrange for the use of the Centres by doctors and dentists in the family practitioner services, the local authority will in each case deal with the new Local Executive Committee, which will be contracting with the doctors and dentists for these services generally – and on which the local authority will have substantial representation. The doctors’ and dentists’ general terms of service covered by national regulations, will cover the terms and conditions governing their use of Health Centres provided by local authorities. The doctors and dentists will thus remain in contract with the Local Executive Committee and be remunerated by it, whether inside or outside the Centres, to secure unity and mobility throughout the family practitioner services.

Remuneration of Doctors

37. Doctors working in Health Centres, whole-time or part-time, will be paid a basic salary, as part of their public income; the rest of a “sum due” to each of them will be pooled in the Centre and divided among the doctors under something like a partnership agreement. The “sum due” will be calculated on a capitation rate for all patients in the care of the doctors in the Centre, while being distributed among them as above. Doctors working outside the Health Centres (while these are being developed) will similarly be paid a basic part salary, the rest of their remuneration depending on a capitation rate in respect of patients on their lists.

38. All remuneration of doctors, under either system, will be fixed by national regulations and will have regard to any national standards recommended by the present Spens Committee or any subsequent body set up for the purpose. Scales of remuneration will be so arranged as to admit of extra inducement to practise in less attractive areas (probably by increase in the basic part-salary scales in areas recommended for this purpose by the Central Committee on the Distribution of Practices (below)), and of extra rewards for special qualifications.

Remuneration of Dentists

39. Dentists, working – whole-time or part-time – in Health Centres or Dental Centres will be remunerated entirely by salary, in proportion to their attendance at the Centre. Supplementary arrangements will be made, while the Centre system is developing, whereby dentists accepting any patient under the public service in their own surgeries can be paid on a scale of fees for approved work done. This scale can provide for payment for minor or urgent work on claims submitted after the event (to avoid delay for the patient); but for more substantial work, the dentist will submit what he proposes to do for approval by a new small professional body, which will have branch offices about the country.

40. All remuneration of dentists, by salary or under scales of fees, will be fixed by national regulations and will have regard to national standards recommended by a body analogous to the Spens Committee for doctors, or other body set up for the purpose…