Introduction

The story of the tripartite split in the NHS is one of policy makers’ and doctors’ attempts to overcome, or use to their advantage, the organisational separation between health services resulting from the organisational compromises present in the founding of the NHS in 1948. This chapter considers the development of the tripartite split one service at a time, but also in terms of the boundaries of the services in relation to one another.

The NHS in the 1940s and 1950s

The creation of the NHS split health services into three largely separately administered services. First, there were the hospitals. Hospitals were nationalised under Bevan's plan, brought into the public sector because of the often precarious state of voluntary hospitals in many locations, but also because this created the possibility of a service with unified planning and delivery of care within the public sector. Second, there were independent contractors, such as doctors and dentists, who managed in the lead-up to the creation of the NHS to secure sufficient assurances that their services would remain independently contracted. This book deals with GPs for the most part when considering independent contractors because of their significance as gatekeepers for access to care within the NHS. Third, there were local authority health services, consisting of health visitors, home nurses, domiciliary midwives and ambulance services, with Medical Officers of Health (MOHs) responsible for coordinating services and often taking a lead on public health. Local government health services were also supposed to develop health centres in order to establish multidisciplinary teams of those working in local health services. Local government had lost control of its municipal hospitals in the nationalisation of the hospitals in 1948, and so had lost its most significant health asset.

If hospital medicine carried the greatest status, GPs could at least console themselves with their independence, but local government health services were hugely variable from location to location, and ranked a clear third in terms of public profile and funding. These three parts of the NHS are summarised in Table 3.1

Hospitals

In 1948, the NHS took over around 2,600 hospitals, with experienced local authority managers mostly taking over the Regional Hospital Boards (RHBs). Consultants entered hospitals not as independent contractors but as employees, in a clearly defined career structure progressing from house officer eventually through to consultant.