Florence Nightingale, the National Health Service and Universal Health Care

by Lynn McDonald, for the Nightingale Society

Nightingale was a pioneer not only of nurse training but health promotion, disease prevention and hospital safety. The bold ideas she set out in Notes on Nursing, Notes on Hospitals and later writings influenced health care policy in the U.K. and indeed throughout the world. Herewith some examples:

Integrating health promotion and disease prevention with treatment: Nightingale called for this in her 1860 Notes on Nursing. The principle was finally enshrined, years later, in the National Health Service Act of 1946. It called for a comprehensive health service, to “secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness.”

Access to health care for the poor: Nightingale was the first person, in 1866, to call for quality hospital care for all, specifically that workhouse infirmaries, the only recourse for 80% of the population, should provide as good care as the best hospitals in the suburbs (workhouses were not in the suburbs). Governments, with Nightingale prodding, made piecemeal improvements over many years. The National Health Service Act of 1946 set up the comprehensive, single-payer system. Canada’s medicare system was based on the British model.

An independent, centrally administered system. Nightingale saw the importance of removing the stigma of “the workhouse.” In 1866, she called for removing the workhouse infirmaries from the Poor Law, to manage them centrally, under Parliament, paid for by tax money. The legislation adopted in the U.K. in 1867, the Metropolitan Poor Bill, was only permissive: it made it possible for workhouse infirmaries to make improvements, even start a nursing school, but it did not require them to, which Nightingale wanted.

The Nightingale School: Improvements were made gradually in the old workhouse infirmaries, thanks to the School providing teams of rained nurses with a matron. The Metropolitan Asylums Board established state-run hospitals without the name “workhouse.” The Poor Law Board was renamed the Local Government Board.

Abolition of the Poor Law: Nightingale, in 1866, called for the end of the harsh provisions of the Poor Law itself, for the aged, disabled, mentally ill and children, in favour of agencies to provide care instead. The National Assistance Act, 1948, did this in Section I: “The existing Poor Law shall cease to have effect.”

Health as a Human Right: Nightingale never used “rights” language, but rather stressed the obligation to provide quality health care services. Using her knowledge of statistics, she showed that this was doable–statistics to save lives. As countries increasingly made health care accessible to all, the idea of health as a “right” took hold.

The World Health Organization: The WHO Constitution was adopted in 1946. It makes “the highest attainable standard of health as one of the fundamental rights of every human being, without distinction of religion, political belief, economic or social condition.” This came into force in 1948.

Disease prevention and health care-acquired infections. As early as her 1860 Notes on Nursing, Nightingale explained the importance of handwashing: “Every nurse ought to be careful to wash her hands very frequently during the day. If her face, too, so much the better.” Details followed, the specifics becoming more stringent as knowledge increased.

Handwashing is now recognized as the primary means of avoiding cross-infection. Said Dr. A. Gawande, “Proper hand hygiene is the primary method for reducing infections” (“Notes of a Surgeon: On Washing Hands,” New England Journal of Medicine, 2004). So says the WHO: “Health-care associated infection is a major problem for patient safety and its surveillance and prevention must be a first priority” (World Alliance for Patient Safety, WHO Guidelines on hand hygiene in health care, 2009).

Celebrating the 2020 Nightingale Bicentenary: Nightingale’s far-seeing vision and solid understanding of health concerns are among the many reasons to celebrate her Bicentenary, 2020, also designated (not a coincidence!) The Year of the Nurse. The Nightingale Society invites nursing, medical and health care faculties and other organizations to feature Nightingale’s groundbreaking work–not as a nod to the past, but inspiration for the future. We encourage the establishment of annual Nightingale lectures, for example, on evidence-based health care, innovation (and its assessment!) in nursing and health care.