Why the south Wales town that forged the NHS now points to its future

Growing up in Tredegar in the 1960s, Jackie Rowlands vividly remembers the long benches in the surgery waiting room. Patients would move along the bench until it was their turn to see the doctor: “They were absolutely shining, so people just slid along because they were polished all the time. When you were a child, they were wonderful. You might be at the surgery at nine o’clock in the morning and not be seen until 11 o’clock, and if the doctor was called out to an emergency nobody complained.” She recalls a spirit of camaraderie: “Women used to knit in the surgery. And you had conversations – you got to know people along the bench.”

Coal mining had brought jobs and relative prosperity to the town: Rowlands remembers Tredegar as a thriving community, with two cinemas, a “massive library”, the Workmen’s Hall, which held weekly dances, and a snooker hall. But the industry took its toll on health: pneumoconiosis, a lung ailment caused by coal dust, was widespread.

Things have changed a good deal. When pharmacist Simon Nelson arrived in Tredegar in 1984, the miners’ strike was in full flow. By the end of the decade, the last local coal mine had closed. It was a close-knit community: the local MP, Michael Foot (“a very nice chap, very quiet”), lived just a few doors away from Nelson’s first pharmacy. As industrial diseases disappeared, diseases of poverty, resulting from inactivity and isolation, took their place. Dr Krishan Syal, who began work in Tredegar’s Glan-yr-Afon practice in 1987, says wryly that he doesn’t see very much of the worried well, but that a lot of his patients have mental illnesses such as depression and anxiety.

The burden on the local NHS is growing. A report last year by the local county council described Tredegar as an “area of high levels of deprivation, unhealthy lifestyles and associated ill health”. It also expressed concern at the area’s difficulty in recruiting GPs. In the 1960s, Tredegar and other south Wales towns benefited from an influx of doctors from South Asia, recruited by health minister Enoch Powell to fill multiple vacancies: as those doctors retire, there are few who want to take their place. Syal has been unable to replace the two partners who left his practice; past retirement age himself, he has had to return to work full-time.

How can the NHS cope with the challenges of rising chronic disease, increasing mental health problems and a GP shortage? As a pharmacist, Nelson is already taking on some of the GPs’ workload. “When I put my first consulting room into a shop in the late 90s, some of my colleagues thought I was absolutely crazy,” he says. Now qualified as an independent prescriber, Nelson offers 10-minute consultations to patients with conditions such as eye infections or thrush, freeing up time for GPs to deal with more serious illnesses.

But other problems are harder to tackle. Chris Ham, chief executive of the health thinktank King’s Fund, notes the NHS’s achievement in reducing premature deaths from heart disease, stroke and cancer, but cautions: “We have been incredibly successful at making healthcare available to everybody with rising standards of care, but with the ageing population, and the changing disease burden, we’re having to tackle a very different set of health problems.”

Innovations such as telehealth (using wearable technology and smartphone apps to monitor and give feedback on chronically ill patients in their own home, for example) and personalised medicine, which involves tailoring treatment to individuals, seem to promise a solution. Harry Quilter-Pinner, a research fellow at IPPR, a centre-left thinktank, says that personalised medicine “could be a game changer in terms of life expectancy and quality of life, but it won’t save money. You defer long-term conditions till later but they’re still there. We know that most of the cost comes at the end of life – and everyone has to die.”

There are no easy answers, but Ham believes that one of the key changes that needs to happen is integration of healthcare and social care: older people, he points out, “often need social care support more than they need medical care support and yet one is free at the point of use and the other is means tested and needs tested. And that seems increasingly anomalous.” To achieve that requires a journey similar to that which led to Bevan’s NHS in 1948, he says: “We need a government that has the vision, the courage, the ambition to want to do that, and so far we haven’t had one.”

The spiritual home of the NHS: ‘We are going to “Tredegarise” you’

Before the formation of the NHS, it wasn’t unusual for groups of workers to form self-help organisations to pay for members’ medical care. The Tredegar Workmen’s Medical Aid Society, however, was one of the most successful and comprehensive. It began life in the late 19th century, and was initially made up of miners and steelworkers, though membership was later extended to include their relatives and other workers.

By the 1920s, the society employed the services of five doctors, one surgeon, two pharmacists, a physiotherapist, a dentist, and a district nurse. For an extra sum each week, members could also benefit from hospital treatment.

During the inter-war depression, the society continued to provide services to unemployed people, even though they could no longer afford to pay a subscription. By the mid-1940s, the society was providing medical care for 22,800 of the town’s 24,000 inhabitants.

Aneurin Bevan, who was born in Tredegar, took the Workmen’s Medical Aid Society as his inspiration for the NHS, saying: “All I am doing is extending to the entire population of Britain the benefits we had in Tredegar for a generation or more. We are going to ‘Tredegarise’ you.”

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