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Medical care in the nineteenth century was principally private or voluntary. However, sickness was a primary cause of pauperism, and the Poor Law authorities began to develop“infirmaries” for sick people. The number of infirmaries grew very rapidly after the foundation of the Local Government Board, because of the influence centrally of doctors.

The demand for the infirmaries was at first resisted by a deliberate emphasis on the stigma of pauperism, of which the main legal consequence was the loss of the vote. Few people who became paupers had the vote, but after the extension of the franchise in 1867 and 1884, the numbers increased dramatically. In 1885, the law requiring people to be paupers before using the infirmaries was abolished.

Prior to 1948, health services were mainly based on three sources:

1. Charity and the voluntary sector.

2. Private health care. Hospitals were fee paying or voluntary; primary care was mainly fee-paying or insurance-based.

3. The Poor Law and local government. Poor Law hospitals were transferred to local government by the 1930 Poor Law Act.

These were unified when the NHS⁴was formed in 1948.

The right to welfare. The NHS is seen by many people as the core of the “welfare state”. People receive health care as a right. There is no right to health care on demand. The principal rights are a right to be registered with a general practitioner, and the right to be medically examined. This generally means that a G.P. must visit a patient on the list who makes a request, though it has been accepted that examination at a distance may be feasible. There is no formal right to receive any treatment. This is within the discretion, or “clinical judgment”, of the doctor.

Comprehensiveness. The NHS is held to protect all citizens. Access to health services depends on registration with a general practitioner. Homeless people in particular have great difficulty gaining access to primary care, because without an address it is generally impossible to register.

The service itself has never been comprehensive. The NHS does ration resources according to priorities. Not only are there not regular checkups for everyone, but there are long waiting lists, and people with quite serious needs—like those from the 1950s onwards needing renal dialysis—may die, because the cost of treatment is greater than the NHS is ready to bear.

A free service at the point of delivery. The initial idea was that no-one should be deterred from seeking health services by a lack of resources. Charges were first introduced by the Labour government in 1950. They were substantially increased by the Conservative government after 1979. The 1988 Act removed free eye tests.

Throughout its history, the NHS has been dominated by the hospital services, in particular by the high-status university hospitals. The bulk of expenditure on the NHS （over 70%） goes to hospitals. General practice, though it deals with the vast majority of reported illness—probably over 95%—accounts for less than 10% of spending.

The NHS inherited a maldistribution of resources, especially in London where the main hospitals were concentrated in the centre of the city. London’s lack of adequate primary carecoverage and over-reliance on hospitals for treatment have created recurring problems. The Labour government in the 1970s attempted to redress the balance by transferring resources from hospital care to primary care, limiting the growth of better served regions, and favouring the development of some underfunded specialties, like medicine for the elderly. This led to hospital closures. The policy was continued by the Conservatives in the 1980s.

Complaints about the NHS tend to focus on the problems of hospitals: waiting lists, lack of spare capacity, and “shroud-waving” in response to spending controls. The severity of the problems is possibly exaggerated. Enoch Powell, a former Minister for Health, commented on “the continual, deafening chorus of complaint” which characterises the NHS. By contrast with the private sector, where people always pretend that things are better than they are, the system of finance in the NHS “endows everyone providing as well as using it with a vested interest in denigrating it.”

Initially, the NHS had a tripartite （three-part） structure, with three branches—hospitals, primary care and local authority health services. In 1974, a “unified” structure was introduced, with three main levels of management, at Regional, Area and District level. The 1974 reorganisation led to a great deal of disruption, and was heavily criticised. Following political disagreements, Area Health Authorities were abolished in 1982—throwing out of the window ideas like local integration of services and co-ordination with social services authorities.

In the 1980s, Enthoven, an American economist, made an influential criticism of the NHS, arguing that it was inefficient, riddled with perverse incentives and resistance to change. The reforms which followed were based in the belief that the NHS would be more efficient if it was organised on something more like market principles. Enthoven argued for a split between purchaser and provider, so that Health Authorities could exercise more effective control over costs and production. The NHS administration was broken up into quasi-autonomous trusts from which authorities bought services. The role of Regional Health Authorities was taken over by 8 regional offices of the NHS management executive. For the first time, Klein comments, the NHS became truly a nationally administered, centralised service.

In principle, the Labour government has now removed the internal market. In practice, it has retained its main elements—the purchasing role of health authorities, the provider trusts and GP commissioning. The reform of services in 2002 replaced the English Regional Health Authorities and District Health Authorities with 28 new Strategic Health Authorities and 310 Primary Care Trusts; the number of SHAs was reduced to 10 in 2006.