MICHELLE BLADE looks at the work of Sally Sheard and Jonathan Ashworth from the University of Liverpool who have used local archives that relate to the current North Lancashire PCT region to discover the background to health care institutions, professionals and, most important of all, the patients.

FROM the early nineteenth century, the state has taken an increasing interest and intervention in the health of its population.

Beginning in 1801, censuses have been held every 10th year to record the growth of the population, and from 1837 it became compulsory to register all births, marriages and deaths.

Although some of this information had previously been recorded in church registers, now the state could see exactly how healthy the population was and, more usefully, had information on causes of death.

Local registrars sent summaries of their population statistics to the Registrar General in London, who published them as annual reports.
The county town of Lancaster has grown considerably: from 29,876 in 1889, to 50,250 in 1948 and 142,300 in 2005.

Using Lancaster as representative of the region, some notable changes in health and survival have occurred since the late nineteenth century.
The figures demonstrate the decline of fatal infectious diseases, and the persistence of heart disease and stroke as a cause of death.

The proportion of deaths due to cancers has significantly increased, which can partly be attributed to the population surviving to older ages.

One of the most fundamental determinants on health is income, as this controls people's housing conditions and diet.

The link between poverty and ill-health was well established in the 19th century, and many reports have subsequently been written on this topic.

Dr Parsons, a visiting public health inspector from London commented in 1900 that 'the prevalent habit of keeping animals also conduces to a foul state of the precincts of houses; the Lancashire working man has commonly little taste for gardening, which indeed the soil and atmosphere do not encourage, but he delights in keeping pigeons, rabbits, and other live stock.'

In 1931 there were still 329 houses in Lancaster that did not have their own internal water supply, and the number of houses condemned as overcrowded was 388.

Dispensaries formed a part of the piecemeal provision of medical care for the poor.

The first Lancaster dispensary began in 1781, and moved to Castle Hill in 1785.

In 1832 it merged with the fever hospital and moved to a new site on Thurnham Street where it was known as the Lancaster General Dispensary and House of Recovery.

During the next few decades new wards were added, but problems with outbreaks of smallpox in the hospital led to the Urban Sanitary Authority establishing a purpose-built isolation hospital outside Lancaster on the Marsh in 1881, and renamed it the Lancaster Infirmary and Dispensary. By the 1880s this had also proved to be too small, and a subscription was started for another building, which opened on March 24,1896, and was allowed by Queen Victoria to carry the 'Royal' title.

This had 50 beds for adults and 10 for children. Some institutions were set up to look after particular types of patients, for example the Royal Albert Hospital in Lancaster. This was founded in 1868 for the mentally ill.

Royal Lancaster Infirmary introduced means-tested charges for its patients in 1920, and formed a workpeople's committee to run a contributory scheme in 1922.

The hospital thrived with this regular financing, and by 1931 it had 138 beds.
By 1943 there was such demand for hospital treatment in North Lancashire that the Royal had a waiting list of 640 patients.

The responsibility for hospitals now passed to Regional Hospital Boards, and all hospital property, with the exception of a few privately-owned hospitals, came under the control of the Minister of Health.

These regional boards appointed hospital management committees to be responsible for the day-to-day running of individual hospitals or groups of hospitals.

A district board was created to cover North Lancashire and South Westmorland, an area with a population of 169,948 (and an additional 150,000 during the tourist season).

By this time, it had a variety of hospitals, from small cottage hospitals like Lytham, Fleetwood and St Anne's War Memorial to 'voluntary' hospitals like the Queen Victoria in Morecambe and the Royal Lancaster Infirmary, as well as the Beaumont Isolation Hospital.

The Ministry of Health's recommended rate of acute beds was between 4 and 6 per 1,000 population.

This meant that Lancaster and its surrounding hospitals should be providing 628, and another 82 maternity beds.

Many hospitals were in poor condition, having suffered from a chronic lack of investment.

One hospital that illustrates this well was the Lancaster Moor Hospital – established in 1816 by Lancashire Country Council as an asylum.

These large institutions were designed to be self-sufficient communities, isolated from the rest of society.

They were managed by boards of governors, who when they arrived for meetings were presented with button holes on a silver tray prepared by the head gardener.

Social events punctuated the year, including huge picnics, sports days and garden parties.

In the review written to prepare for its integration into the NHS in 1948, the inspectors commented that 'this hospital possesses practically no buildings erected in the last 30 years during the very period when the modern scientific methods of treatment of mental illness have been developed and have shown the need for specialised hospital buildings differing widely in planning and equipment from the prison-like structures thought necessary 40 years ago, but proving such a serious handicap today'.

It went on to comment on the huge 'barn-like' dormitories which contained multiple rows of beds, and the fact that new admissions were not segregated from 'the sight and sound of the incurable and often depraved type'.

It was overcrowded, with a registered population of 3,060, despite only having facilities for 2,537.

By the 1950s, the regional hospital boards were using such reports to plan hospital closures, amalgamations and new-builds. Not all of this was welcomed by local communities.

In Morecambe there were angry protests about the plan to change the Queen Victoria Hospital from a GP-run institution into a surgical centre.

At the annual trades council meeting, a Morecambe delegate commented that: "Under state ownership there is less democracy than ever in the management of hospitals. In the old days we did have working class representation…Morecambe and Heysham people built and maintained their own hospital and they like to be treated in their own hospital by their own doctors".

When the decision was taken to gradually close down the large mental hospitals after the Mental Health Act of 1959, Lancaster Moor Hospital was re-developed into a general hospital, with updated facilities for x-rays, catering, etc.

It expanded its catchment area, opened outpatient clinics, and established a school of nursing.

The Royal Albert Hospital, Lancaster also experienced a fall in patient numbers from 900 in the early 1980s, to just over 400 by 1990, as the emphasis in caring for the mentally ill shifted to community care.
The hospital closed in the mid-1990s.

In 1992 the Lancaster Priority Services NHS Trust was established, bringing together the three previously separate divisions of Mental Health, Learning Disabilities and Community Care under a unified management team.

At the same time, the last of the Community Psychiatric Nursing teams moved out of the hospital setting into community bases in Lancaster, Morecambe, Heysham and Carnforth.

Maternity services have also changed considerably, triggered in part because most women increasingly wished to have their babies in hospitals rather than at home.

The new Maternity Unit at the Royal Lancaster Infirmary opened on November 17, 1976, to include maternity beds from the Queen Victoria Hospital, Morecambe. But although it provided 72 maternity beds, the falling birth rate in the region meant that 48 beds were sufficient to cope with all the confinements.

When a new health centre was opened in Heysham in 1974, community services moved into the health centre before the GPs did, and the first Child Health Clinic was held on November 21, replacing sessions previously held in the St. John Ambulance Hall.

After many years of planning, Morecambe Health Centre opened in 1977.
Eight of the 10 consulting suites were occupied by GPs, and outpatient sessions from Queen Victoria Hospital were accommodated in the other two.

A small health centre was built at Galgate in the late 1970s.
It accommodated both GPs and community services, such as health visiting, district nursing and chiropody.

A similar scheme was adopted for the village of Caton. A small health centre was built in 1987, delivering primary care services not only to the village, but also to the rural surrounding area.

Edward Sergeant was the first medical officer of Health for the county of Lancashire, appointed in 1889.

He was confronted with various problems and challenges affecting the public health, especially epidemics of infectious diseases caused by overcrowding in insanitary conditions.

He emphasised the need to make substantial improvements in sanitation, housing, water and sewerage in order to combat the prevalence of infectious diseases such as measles, scarlet fever, and whooping cough.

He also encouraged those sanitary districts in Lancashire that did not have hospital accommodation for the isolation and treatment of infectious diseases to pool their resources together in order to do so.

As medical officer of health, Sergeant was also responsible for monitoring and maintaining the safety of food supplies.

In 1912, a butcher in Lancaster was successfully prosecuted and fined £4 and costs, for offering for sale meat which was 'extensively affected with tuberculosis'.

Dr Sergeant was instrumental in closing many of the small, insanitary slaughter houses that operated in the overcrowded back streets of Lancaster.

When the NHS was reorganised in 1974, all physiotherapy services in the Lancaster District were based at hospitals. A community physiotherapy service was pioneered in 1978.

An anonymous donor donated a new mini-van to the service, and Morecambe Rotary Club gave a diathermy machine.

The introduction of the service meant that patients who were unable to travel to hospital, such as those with acute orthopaedic conditions, and certain geriatric conditions, could be treated by a physiotherapist in their own homes.

A computerised recall system was introduced for cervical smears in 1972, and an intensive campaign was held in 1975 to persuade women living in rural areas to attend for screening.

A caravan was borrowed from the National Women's Cancer Control Campaign which provided sessions in many of the North Lancashire villages.

The Women's Royal Voluntary Service and Women's Institutes assisted in delivering over 10,000 leaflets and acting as hostesses during the sessions. Dr John Dyer, medical officer for health from 1968 until 1990, also faced new demands and challenges in the field of public health.

He had to contend with an outbreak of Legionella Pneumonia amongst workers at Heysham Power Station in October 1981.

At the time, there had only been one other instance of an outbreak of the disease in the country. After months of investigation, legionella organisms were isolated from a cooling tower.

An epidemiological study of the outbreak was carried out, in which he compared workers from the Number 1 power station affected by the disease, with unaffected workers from Number 2 power station.

This disease was seen again in the region in 2002, when an outbreak in Barrow caused 180 cases and seven deaths – one of the worst outbreaks ever in the UK.

The challenges and opportunities in improving health and well-being in North Lancashire are documented in the most recent report of the current Director of Public Health, Dr Frank Atherton.

Protecting the public from threats to health remains as a high priority for the NHS; communicable diseases still need to be monitored and tackled, but there is now an increased emphasis on newer threats including environmental hazards, major incidents, and the potential for acts of terrorism.

The significant improvements on the health status which have been seen since the early 1900s continue up to the present day but cardiovascular disease and cancer continue to be important health issues requiring both prevention and curative services and the recent focus on lifestyle issues such as smoking, diet and exercise represents a significant development of our approaches to building better health.

Dr Atherton's latest annual public health report focuses attention on the need to promote breastfeeding and infant nutrition as a way of improving child health and continuing the significant reductions in infant mortality which have been seen over the last century.

Dr Atherton said: "In this brief summary of the history of our local NHS, Sally Sheard and Jonathan Ashworth provide us with an excellent historical perspective which we can use to further improve health and wellbeing.

"My thanks go to them and to my predecessors who have led the public health movement over the last 60 years."

Chief executive of North Lancashire Primary Care Trust, Ian Cumming, said: "The role of public health is integral to the achievement of our organisations' first objective; to protect and improve the health of the population and reduce inequalities in health.

"The 60th anniversary provides an opportunity to reflect upon the progress made, the benefits that the introduction of the NHS has provided and the future challenges the NHS must tackle to continue to improve the health of our local population. "

* Thanks to Sally Sheard and Jonathan Ashworth from the University of Liverpool for their contribution towards this article.