As a result of the National Health Service (NHS) (Scotland) Act 1947, the NHS came into being on 5 July 1948. It aimed to meet all health needs free of direct charge to the citizen.
In the years immediately prior to its creation, Scotland had
pioneered new forms of organised health care, such as the Highlands and Islands
Medical Service (HIMS) (1913), and the Clyde Basin Experiment in Preventative
Medicine (1941) which anticipated some of its provisions. Such factors combined
with other features of Scottish society to create a national health service
which was in many ways as distinctive as the Scottish medical culture which
preceded it.
Before the NHS, Scottish healthcare combined elements of voluntary, municipal, provident, private, and government provision at both hospital and community levels. Subsequently, over four hundred hospitals, accommodating around sixty thousand patients, became Crown property and were formally vested in the Secretary of State for Scotland (SSS), operating through the Department of Health for Scotland (DHS). Five Regional Hospital Boards (RHBS) were established to oversee Scottish hospitals on a regional basis. This was achieved through eighty-five local Hospital Boards of Management (HBM). RHBs coordinated various aspects of hospital services, including specialists and diagnostic laboratories, as well as medical research. They also played a similar role in relation to ambulance services for hospitalised patients and blood transfusions, although both continued to be run on a voluntary basis. Hospitals in the Lothian region were managed by the South Eastern Regional Hospitals Board.
The DHS also assumed overall responsibility for twenty-five Local
Health Authorities (LHA) which co-ordinated a variety of community based
services, including maternity and child welfare, midwifery, immunisation,
vaccination and other aspects of preventative medicine, health visiting, home
nursing and mental deficiency. General practitioners (GP), dentists, chemists
and opticians remained self-employed. However, the DHS set up Executive
Councils (EC) to arrange payment for services for NHS patients. In addition, a
Scottish Medical Practices Committee (SMPC) was set up to help co-ordinate the
distribution of GPs nationally. Locally, doctors' views were also represented
via Medical Committees (MC). The DHS placed great emphasis upon the future
co-ordination of doctors' activities through Health Centres (HC) which would be
concerned with health education as well as direct patient care.
The NHS in England and Wales
The administrative structure of the NHS in Scotland differed from that
in England and Wales with respect to some of its arrangements:
- Teaching
hospitals remained under the control of RHBs via Medical Education
Committees (MEC). In England they were managed by Boards of Governors
directly responsible to the Minister for Health.
- Boards
of Governors of hospitals also controlled pre-NHS endowments, whereas in
Scotland they were vested in RHBs and the Scottish Hospitals Endowments
Research Trust (SHERT).
- As
well as communicating with HBMs via RHBs only, the SSS was also
responsible for the provision of HCs, whereas in England and Wales, this
came under LHAs.
- The
SSS also had equivalent responsibilities for the ambulance service, blood
transfusion, and laboratory services, whereas in England and Wales it was
LHAs, RHBs and the Ministry of Health (MH) respectively.
- HBMs
were called Hospital Management Committees south of the border and had a
different appointment mechanism.
NHS re-organisation in Scotland
Since the inception of the NHS in 1948, a number of organisational
changes in the structure of the service have taken place. The first of these
administrative changes was introduced following the publication of the NHS
(Scotland) Act 1972. It was decided that, in order to provide a more integrated
health service, the 3-tiered system of administration should be abolished. This
led to the Regional Hospital Boards (planning and development of hospitals
services) and the Executive Councils (pharmaceutical and general medical,
dental and ophthalmic services) being disbanded and responsibility for
Community Health Services (welfare, preventative medicine and public health)
removed from Local Authorities. Boards of Management, which had been
responsible for the day-to-day management of hospitals, were also abolished
under the new system. Instead, 15 health boards acting on behalf of the
Secretary of State for Scotland were established. Lothian Health Board (LHB)
was made responsible for Midlothian, East Lothian and West Lothian. Within LHB,
three Health Districts operated from 1975-1984: North Lothian District, South
Lothian District and West Lothian District. The Common Services Agency managed
ancillary services such as the ambulance service, blood transfusion service and
health education programmes.
Further reforms followed the publication of the Griffiths Report in 1983
which recommended a move away from consensus management where responsibility
was shared between doctors, nurses and administrators. This approach was seen
to delay decisions and instead general managers were appointed with overall
responsibility for the service. The district level of management of the NHS was
eliminated in April 1984 in order to devolve responsibility for services to
hospital groups of management. General managers were subsequently employed at
unit level to further speed up the administrative process. Clinicians were more
closely involved in the management process and units were now responsible for
their own budgets.
The publication of the white paper "Working for Patients",
January 1989 led to further changes in the health service. In order to provide
a more efficient service, as much responsibility as possible was devolved to
local level with hospitals now having the opportunity to apply for
self-governing status as NHS Hospital Trusts. The role of the Health Boards was
to set performance criteria, monitor the performance of the Health Service and
evaluate its effectiveness. Lothian Health was responsible for assessing the
needs of the local population and purchasing services from health care
providers. The NHS hospitals were concerned with the day-to-day management of
medical services. From 1992, the units of management were re-structured with
the introduction of service units. Hospitals could now "opt out" and
become self-governing hospital trusts.
Sources of reference
Committee of
Enquiry into the Cost of the National Health Service: the National Health
Service in Scotland: Memorandum by the Department of Health for Scotland DE22532/1/944
100 6/52R. DHS. June 1953
Committee of Enquiry into the Cost of the National Health Service: the
National Health Service in Scotland: The main differences between the Service
in Scotland and the Service in England DE 23172/1/351 35 8/53R. DHS.
August 1953
Leathard, Audrey. Health care provision: past, present & future London:
Chapman & Hall, 1990
Lothian Health Board circular: General Management in Lothian, May
1987
Main differences between the health services in Scotland and in England and
Wales DHS. December 1956
The National Health Service in Scotland: notes for speakers DE
2175/1/284 25 2/53R. DHS. January 1953
Scottish Home & Health Department Circular no. 1983 (Gen)27 (LHB1/81/218:
Reorganisation of NHS Jan 1980-83)
Williamson, Peter J. General management in the Scottish Health Service University
of Aberdeen, 1990
Your National Health Service: how it
will work in Scotland Edinburgh: HMSO, 1948
