In the decades before the National Health Service (NHS), health care in Britain was guided by very different ideas. Most of the country’s hospitals were grim Victorian centers for the destitute, derived from workhouse infirmaries established under the Poor Law. This 1834 statute saw poverty as a moral failing — and one that should be punished with hard labor. The Royal Commission report which preceded its passage summed up its perspective: “every penny bestowed, that tends to render the condition of the pauper more eligible than that of the independent labourer, is a bounty on indolence and vice.”

The rich avoided the nightmare of the workhouse infirmary by using private doctors, who would often perform surgeries as well as more general practice on house calls. But for a growing proportion of Britain’s workers and poor, the infirmary became the norm for hospital care. When the medical journal the Lancet was given leave to form a commission of examination into their conditions in 1865, they dubbed the infirmaries “a disgrace to our civilization.” The facilities, they said, “sin by their construction, by their want of nursing, by their comfortless fittings, by the supremacy which is accorded to questions of expense, by the imperfect provision made for skilled medical attendance on the sick, by the immense labor imposed on the medical attendants, and the wretched pittances to which they are ground down.”

Though the Lancet report would produce reforms, infirmaries remained houses of terror for workers, the elderly, the poor, and the disabled until the twentieth century, long after many were taken into state care as municipal hospitals in the wake of the 1929 Local Government Act. Even as state and charitable provision grew, the British health care system was guided by a conservative ethos and strictly divided by class. It fell far behind its Western counterparts in almost every metric. Surveying this landscape begs the question: how was it that these inauspicious origins developed into the world’s first free, comprehensive, and universal health care system? As historian Charles Webster notes, “the path to the NHS was by no means inevitable.” Indeed, he adds, “any step towards translation of pious sentiments regarding healthcare into practicable objectives was liable to expose clashes of ideological loyalty and stir up conflict between affected vested interests.”