Highland Healthcare Before the NHS

On the 110th anniversary of the Highlands and Islands Medical Service, Feargus Murray explores its history and legacy.

The Highlands and Islands Medical Service (HIMS), regarded as a precursor to the NHS, marks its 110th anniversary this year. It is part of the long, exceptional history of the Highlands and Islands of Scotland. Its most basic founding followed the 1912 Dewar Report, but the story of HIMS stretches further back into the 19th century and to the legacy of the clearances and the fight for crofters’ rights in the 1880s. In the process of the clearances, the people of the rural Highlands and Islands had been scattered away from the more arable inner straths into bare subsistence crofting communities and a few increasingly overcrowded townships. The squalor, overcrowding and subsistence living conditions had a disastrous impact on health outcomes. In the aftermath of the Highland Potato Famine of 1846, the new poor laws moved the responsibility of medical care for the poor and paupers onto new Parochial Boards under the Board of Supervision. Finally, in 1850, the first attempt was undertaken to ascertain properly the levels of medical provision available in the Highlands and Islands.

A survey was undertaken by the Royal College of Physicians of Edinburgh (RCPE) and led by Dr John Coldstream. Initially, when Dr Coldstream started his inquiries, the College asked the Board of Supervision “for such information as it happened to be possessed of, regarding the supply of medical men practising in the region”; the Board told them that the information did not exist. The RCPE surveyed the ministers and some other residents of 170 parishes and concluded that the entire Highlands and Islands and its population of over 370,000 people were covered by only 133 medical personnel. Despite this alarming statistic, no recommendations were made. People in the Highlands and Islands were left at the mercy of a disinterested Board of Supervision or at the whims and benevolence of their landlords. Some were generous, such as Kenneth Macleod of Greshornish on Skye, who set up the Gesto Hospital in 1878 as a free hospital for the inhabitants of Skye. Later, in light of the land struggle of the 1870s and 1880s, the Napier Report looked into the conditions of crofters in the Highlands and Islands. The resulting Crofting Act did much to alleviate the conditions of crofters. It represented a significant win over the landed interest, but as it did not include medical care, it did little to alleviate the distinct lack of medical coverage.

The first major attempt to provide medical coverage for the poor of Britain came with the Liberal government’s passing of the National Insurance Act of 1911. The act aimed to provide some relief for the waged working poor and the unemployed in a select number of industries in times of sickness. The act’s provisions covered upwards of 70% of Britain’s workforce at the time. However, this did not extend to the Highlands and Islands crofting communities. As wage labour comprised very little of a crofter’s income – nor could they be counted among the unemployed – the National Insurance Act inadvertently excluded much of the crofting community from the new rights to healthcare coverage and sickness benefits. Surveys in 1904 and 1909 insisted that the need for medical provision in the Highlands and Islands was distinct and different from the rest of Britain. Still, given the failure of the National Insurance Act, the government was keen not to antagonise the Highlanders in case of unrest similar to that of the land struggle of the 1880s. In 1912, to circumvent this, Lloyd George set up the Dewar Committee with Sir John Dewar, MP for Inverness, at its head.

The committee was established to “consider at an early date how far the provision of medical attendance in districts situated in the Highlands and Islands of Scotland is inadequate, and to advise as to the best method of securing a satisfactory medical service therein”. To fulfil this objective, the committee interviewed doctors and other interested parties across the Highlands and Islands. These interviews helped demonstrate healthcare’s dire state in the region. One such voice from the report was that of Mr Graham, a fisherman from Rona; he reported on doctors’ difficulties in travelling to their patients.

It is just the Portree Doctor we have, and he must come in a boat, and in the winter-time he cannot come. We may possibly have to wait a fortnight for him, and the patient will be suffering pain all the time. It is quite possible that the patient may die without seeing a Doctor at all.

Another interviewee, Dr MacDonald from Badenoch, had to travel twenty miles to reach some of his patients, only nine miles of which had any path. These difficulties also came with a cost. Doctors had to pay for their travel expenses, equipment, and medicines. Even with the best will in the world, operating in such conditions would have been prohibitively expensive. If they were to cover their expenses, doctors working in the Highlands would have to charge at extortionate rates, rates that the crofters could not afford.

Indeed, the rents paid by the crofters often went towards dwellings that were health hazards in and of themselves. The condition of housing was a major issue raised in the report, in particular with the threat of tuberculosis. The report found:

houses of practically only one room, with damp walls, damp clay floors, sunless interiors, a vitiated and smoky atmosphere, and the cattle under the same roof with the human inmates, the surrounds usually badly drained, and the site often damp. When a case if [sic] phthisis (tuberculosis) occurs in one of these houses, isolation is impossible.

Conditions were abhorrent and a breeding ground for disease.

In response to these conditions, the Dewar Report recommended a radical solution: creating and completely reorganising medical services in the Highlands and Islands under one service. It would be funded by the state, guaranteeing doctors a minimum salary and additional expenses for travel, with massive subsidies for the healthcare costs of the poor – including free healthcare if they could not afford it – and a major investment in the infrastructure of the Highlands and Islands. This investment would look to build new community hospitals, reorganise existing nursing associations and set up new ones, improve the communication network with telephones and telegrams and provide an ambulance service. This was to be provided by an annual grant of £42,000 (about £4 million today). The result was the creation of the Highlands and Islands Medical Service. HIMS had an unsettled start; its first achievement was establishing a nurse on St Kilda in 1914, but the First World War delayed the expansion of the whole service. The provisions of the service started slowly, and by 1929, 175 nurses and 160 doctors covered 150 practices throughout the Highlands. Even many of the more urban towns of the Highlands saw increased provision, with Stornoway receiving its first resident surgeon in 1924 and Wick receiving the same in 1931. In 1933, HIMS provided the first-ever air ambulance service in the world.

One of the most important legacies of HIMS was to recognise the link between living conditions and infrastructure, and the failures of the medical system. It led to the establishment of nursing associations, the investment in telephones and other communication infrastructure, the building of local hospitals and roads, the creation of an ambulance and the financing of doctors, all effectively free at the point of use, which transformed the health circumstances of the Highlands and Islands.

HIMS was a system tailor-made for the Highlands and Islands of the early 20th century. It transformed the healthcare prospects of some of the poorest people in Britain, and it would go on to help inspire the NHS and similar medical systems worldwide. HIMS deeply influenced the setting up of the Frontier Nursing Service (FNS) in Kentucky after its founder, Mary Breckinridge, was inspired by her experience of HIMS during a visit to Scotland in the early 20s. The FNS mainly focused on midwifery and child healthcare in rural, underprivileged areas and is still operating today.

HIMS has lessons for the provision of modern healthcare. Its ambition and investment in connecting communities across the Highlands shows what can be done when proper state intervention is tried. As Scotland prepares for care service reform, workers and trade unions are warning that instead of an ambitious staterun service, we are sliding towards propping up our existing failed care system and the profits of the companies that run it. Instead of connecting and coordinating our care system through public control of the sector, we will still see a system raked by competition and inundated with low pay and abhorrent working conditions that are merely managed differently. Given the utterly inadequate state of mental healthcare, social care and trans healthcare today maybe each of these areas deserves its own HIMS.

For those interested in HIMS, the 1943 film by Kay Mander called Highland Doctor is informative, engaging, and at points quite funny.