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ABSTRACT - The NHS has long held a paradoxical position in the national psyche: a constant, reassuring presence that seems to be in a state of continual flux. This is partly because while the service is based in the public sector (with its reputation for risk aversion and change at a glacial pace), it is also exposed to the ever present currents of political pressure. Equally important is the changing nature of both medical technology and public expectation, each of which exert constant and inexorable pressures on the service. This article will briefly describe the story of the NHS from its inception in 1948 to the present day, with an emphasis on developments over the last 20 years. During this time the notion of organising healthcare has developed and formed the focus of much of the change in systems across the developed world. The narrative will highlight some of the major challenges that the NHS will face over the next few years, and introduce the series about the future of the NHS that will appear in this journal signposting some of the topics that will be followed up in these articles.
KEY WORDS: healthcare, history, NHS
The early days
The NHS was conceived during the dark days of the second world war along with many other aspects of the welfare state, such as the modern schooling system, family allowances and the social security system. These all finally appeared just after the end of the war partly as a result of having a radical Labour government in power, which was itself a reflection of the egalitarian mood that prevailed in the UK (and indeed, across much of Europe) at that time. The British class divide was at its narrowest, millions of battle- and strife-weary soldiers were returning to civilian life, and the mood of corporate altruism that was the obverse of the 'blitz mentality' all meant that the population at large welcomed the principle of social insurance that underpinned the entire concept of the welfare state. Behind it all was an attitude epitomised by an elderly civil defence worker who told Richard Titmuss, the social scientist, that 'The war made us realise that we were all neighbours'.1
The political battles with the medical profession...