History of the National Health Service (England)
Encyclopedia
The National Health Service
in England
was created by the National Health Service Act 1946
which actually created a national health service for England and Wales
though responsibility for the NHS in Wales was passed to the Secretary of State for Wales
in 1969, leaving the Secretary of State for Social Services
responsible for the NHS in England alone.
. Some local authorities operated local hospitals for local ratepayers (under a system originating with the Poor Law
). The London County Council
on 1 April 1930 took over from the abolished Metropolitan Asylums Board
responsibility for 140 hospitals, medical schools and other medical institutions; the Local Government Act 1929
also allowed the LCC to run services over and above those authorised by the Poor Law and in effect to provide medical treatment for everyone. By the outbreak of the Second World War, the LCC was running the largest public health service in Britain.
Systems of health insurance
usually consisted of private schemes such as Friendly Societies
. Under the National Insurance Act 1911
, introduced by David Lloyd George
, a small amount was deducted from weekly wages, to which was added contributions from the employer and the government. In return for the record of contributions, the workman was entitled to medical care (as well as retirement and unemployment benefits) though not necessarily to the drugs prescribed. To obtain medical care, he registered with a doctor. Each doctor who participated in the scheme thus had a 'panel' of those have made an insurance under the system, and was paid a capitation grant out of the fund calculated upon the number. (Lloyd George's name survives in the "Lloyd George envelopes" in which most primary care records in England are stored, although today most working records in primary care are at least partially computerised). This imperfect scheme only covered certain trades and occupations, and was known as 'Lloyd George's Ambulance Wagon'. Moreover, due to cuts during the 1930s, many were unable to obtain treatment.
pamphlet, "A General Medical Service for the Nation" was issued along these lines in 1938. However, no action was taken due to the international crisis. During the war, a new centralised state-run 'Emergency Medical Service' (EMS) employed doctors and nurses to care for those injured by enemy action and arrange for their treatment in whichever hospital was available. The existence of the EMS made voluntary hospitals dependent on the Government and there was a recognition that many would be in financial trouble once peace arrived. The need to do something to guarantee the voluntary hospitals meant that hospital care drove the impetus for reform.
In February 1941 the Deputy Permanent Secretary at the Ministry of Health recorded privately areas of agreement on post-war health policy which included "a complete health service to be available to every member of the community" and on 9 October 1941, the Minister of Health Ernest Brown
announced that the Government proposed to ensure that there was a comprehensive hospital service available to everyone in need of it, and that local authorities would be responsible for providing it. The Medical Planning Commission set up by the professional bodies went one stage further in May 1942 recommending (in an interim report) a National Health Service with General Practitioners working through health centres and hospitals run by regional administrations. The Beveridge
Report of December 1942 included this same idea.
Developing the idea into firm policy proved difficult. Although the BMA had been part of the Medical Planning Commission, at their conference in September 1943 the association changed policy to oppose local authority control of hospitals and to favour extension of health insurance instead of GPs working for state health centres. When Health Minister Henry Willink
prepared a white paper endorsing a National Health Service, it was attacked by Brendan Bracken
and Lord Beaverbrook
and resignations were threatened on both sides. However the Cabinet endorsed the White Paper which was published in 1944.
Willink then set about trying to assuage the doctors, a job taken over by Aneurin Bevan
in Clement Attlee
's Labour
government after the war ended. Bevan encountered considerable debate and resistance from the BMA who voted in May 1948 not to join the new service. The structure of the NHS in England and Wales
was established by the National Health Service Act 1946
(1946 Act) with the new arrangements launched on 5 July 1948. The founding principles of the NHS called for its funding out of general taxation and not through national insurance
.
Services would henceforth be provided by the same doctors and the same hospitals, but:
By the 1950s
, spending on the NHS was exceeding what had been expected, leading to the introduction of a one-shilling
charge for prescriptions and a £
1 charge for dental treatment, in 1952; an exception to the NHS being free at the point of use. The 1950s also saw the planning of hospital services, dealing in part with some of the gaps and duplications that existed across England and Wales. The period also saw growth in the number of medical staff and a more even distribution of them with the development of hospital outpatient services. By 1956, the NHS was stretched financially and doctors were disaffected resulting in a Royal Commission
on doctors' pay being set up in February 1957. The investigation and trial of alleged serial killer
Dr John Bodkin Adams
exposed some of the tensions in the system. Indeed, if he had been found guilty (for - in the eyes of doctors - accidentally killing a patient while providing treatment) and hanged, the whole NHS might have collapsed. The Mental Health Act
of 1959 also significantly altered legislation in respect of mental illness
and reduced the grounds on which someone could be detained in a mental hospital.
The 1960s
have been characterised as a period of growth. Prescription charges were abolished in 1965 and reintroduced in 1968. New drugs came to the market improving healthcare, including polio vaccine, dialysis for chronic renal failure and chemotherapy for certain cancers were developed, all adding to costs. Health Secretary Enoch Powell
undertook three initiatives:
Concern continued to grow about the structure of the NHS and weaknesses of the tripartite system. Powell agreed the creation of a Royal Commission on doctors’ pay, which resulted in a statutory review body. Further development came in the form of the Charter of General Practise, negotiated between new Health Minster Kenneth Robinson
and the BMA, that provided financial incentives for practice development. This resulted in the concept of the primary health care
in better housed and better staffed practises, stimulating doctors to join together and the development of the modern group practice.
In 1969, responsibility for the NHS in Wales was passed to the Secretary of State for Wales
from the Secretary of State for Health who was thereafter just responsible for the NHS in England.
also saw the end of the economic optimism which had characterised the 1960s and increasing pressures coming to bear to reduce the amount of money spent on public services and to ensure increased efficiency
for the money spent.
Through the 1970s and 1980s
, it became clear that the NHS would never get the resources necessary to provide unlimited access to the latest medical treatments, especially in the context of an ageing population. This led to the beginning of a major process of reform, starting about 1980, which is still continuing in 2009.
This recommended the appointment of general managers in the NHS with whom responsibility should lie. The report also recommended that clinicians be better involved in management. Financial pressures continued to place strain on the NHS. In 1987, an additional £101 million was provided by the government to the NHS. In 1988 the then Prime Minister
, Margaret Thatcher
, announced a review of the NHS. From this review and in 1989, two white paper
s Working for Patients and Caring for People were produced. These outlined the introduction of what was termed the "internal market", which was to shape the structure and organisation of health services for most of the next decade. In spite of intensive opposition from the BMA, who wanted a pilot study or the "reforms" in one region, the untried untested internal market was introduced.
In 1990, the National Health Service & Community Care Act
(in England) defined this "internal market", whereby Health Authorities ceased to run hospitals but "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients. The "providers" became NHS trust
s, which encouraged competition but also increased local differences.
. Opposition to what was claimed to be the Conservative
intention to privatise the NHS became a major feature of Labour's election campaigns.
Labour came to power in 1997 with the promise to remove the "internal market" and abolish fundholding. In a speech given by the new Prime Minister, Tony Blair
, at the Lonsdale Medical Centre on 9th December 1997, he stated that:
However in his second term Blair renounced this direction. He pursued measures to strengthen the internal market as part of his plan to "modernise" the NHS.
Driving these reforms have been a number of factors. They include the rising costs of medical technology and medicines, the desire to increase standards and "patient choice", an ageing population, and a desire to contain government expenditure. Since the National Health Services in Wales, Scotland and Northern Ireland are not controlled by the UK government, these reforms have increased the differences between the National Health Services in different parts of the United Kingdom. (See NHS Wales and NHS Scotland
for descriptions of their developments).
Reforms have included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous clinical
and corporate governance
. In addition medical training
has undergone an unsuccessful restructuring which was so badly managed that the Secretary of State for Health was forced to apologise publicly. MMC is now being revised but its flawed implementation has left the NHS with significant medical staffing problems which are unlikely to be resolved before 2009. Some new services have been developed to help manage demand, including NHS Direct
. A new emphasis has been given to staff reforms, with the Agenda for Change
agreement providing harmonised pay and career progression. These changes have, however, given rise to controversy within the medical professions, the media and the public.
The Blair
Government, whilst leaving services free at point of use, has encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative
, an increasing number of hospitals have been built (or rebuilt) by private sector consortia; hospitals may have both medical services (such as "surgicentres"
), and non-medical services (such as catering) provided under long-term contracts by the private sector. A study by a consultancy company which works for the Department of Health shows that every £200 million spent on privately financed hospitals will result in the loss of 1000 doctors and nurses. The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced.
In 2005, surgicentres (ISTCs) treated around 3% of NHS patients (in England) having routine surgery. By 2008 this is expected to be around 10%. NHS Primary Care Trust
s have been given the target of sourcing at least 15% of primary care from the private or voluntary sectors over the medium term.
As a corollary to these intitiatives, the NHS has been required to take on pro-active socially "directive" policies, for example, in respect of smoking
and obesity
.
The NHS has also encountered significant problems with the IT
innovations accompanying the Blair reforms. The NHS's National Programme for IT (NPfIT), believed to be the largest IT project in the world, is running significantly behind schedule and above budget, with friction between the Government and the programme contractors. Originally budgeted at £2.3 billion, present estimates are £20-30 billion and rising. There has also been criticism of a lack of patient information security. The ability to deliver integrated high quality services will require care professionals to use sensitive medical data. This must be controlled and in the NPfIT model it is, sometimes too tightly to allow the best care to be delivered. One concern is that GPs and hospital doctors have given the project a lukewarm reception, citing a lack of consultation and complexity. Key "front-end" parts of the programme include Choose and Book
, intended to assist patient choice of location for treatment, which has missed numerous deadlines for going "live", substantially overrun its original budget, and is still (May 2006) available in only a few locations. The programme to computerise all NHS patient records is also experiencing great difficulties. Furthermore there are unresolved financial and managerial issues on training NHS staff to introduce and maintain these systems once they are operative.
National Health Service (England)
The National Health Service or NHS is the publicly funded healthcare system in England. It is both the largest and oldest single-payer healthcare system in the world. It is able to function in the way that it does because it is primarily funded through the general taxation system, similar to how...
in England
England
England is a country that is part of the United Kingdom. It shares land borders with Scotland to the north and Wales to the west; the Irish Sea is to the north west, the Celtic Sea to the south west, with the North Sea to the east and the English Channel to the south separating it from continental...
was created by the National Health Service Act 1946
National Health Service Act 1946
The National Health Service Act 1946 came into effect on 5 July 1948 and created the National Health Service in England and Wales. Though the title 'National Health Service' implies one health service for the United Kingdom, in reality a separate NHS was created for England and Wales accountable to...
which actually created a national health service for England and Wales
England and Wales
England and Wales is a jurisdiction within the United Kingdom. It consists of England and Wales, two of the four countries of the United Kingdom...
though responsibility for the NHS in Wales was passed to the Secretary of State for Wales
Secretary of State for Wales
The Secretary of State for Wales is the head of the Wales Office within the British cabinet. He or she is responsible for ensuring Welsh interests are taken into account by the government, representing the government within Wales and overseeing the passing of legislation which is only for Wales...
in 1969, leaving the Secretary of State for Social Services
Secretary of State for Social Services
The Secretary of State for Social Services was a position in the UK cabinet, created on 1 November 1968 with responsibility for the Department of Health and Social Security...
responsible for the NHS in England alone.
Background
Before the National Health Service was created in 1948, patients were generally required to pay for their health care. Free treatment was sometimes available from teaching hospitals and charity hospitals, such as the Royal Free HospitalRoyal Free Hospital
The Royal Free Hospital is a major teaching hospital in Hampstead, London, England and part of the Royal Free Hampstead NHS Trust....
. Some local authorities operated local hospitals for local ratepayers (under a system originating with the Poor Law
Poor Law
The English Poor Laws were a system of poor relief which existed in England and Wales that developed out of late-medieval and Tudor-era laws before being codified in 1587–98...
). The London County Council
London County Council
London County Council was the principal local government body for the County of London, throughout its 1889–1965 existence, and the first London-wide general municipal authority to be directly elected. It covered the area today known as Inner London and was replaced by the Greater London Council...
on 1 April 1930 took over from the abolished Metropolitan Asylums Board
Metropolitan Asylums Board
The Metropolitan Asylums Board was established under Poor Law legislation, to deal with London's sick poor. It was established by the Metropolitan Poor Act 1867 and was wound up in 1930, its functions being transferred to the London County Council. Despite its name, the MAB was not involved in...
responsibility for 140 hospitals, medical schools and other medical institutions; the Local Government Act 1929
Local Government Act 1929
The Local Government Act 1929 was an Act of the Parliament of the United Kingdom that made changes to the Poor Law and local government in England and Wales....
also allowed the LCC to run services over and above those authorised by the Poor Law and in effect to provide medical treatment for everyone. By the outbreak of the Second World War, the LCC was running the largest public health service in Britain.
Systems of health insurance
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
usually consisted of private schemes such as Friendly Societies
Friendly society
A friendly society is a mutual association for insurance, pensions or savings and loan-like purposes, or cooperative banking. It is a mutual organization or benefit society composed of a body of people who join together for a common financial or social purpose...
. Under the National Insurance Act 1911
National Insurance Act 1911
The National Insurance Act 1911 is an Act of Parliament of the United Kingdom. The Act is often regarded as one of the foundations of modern social welfare in the United Kingdom and forms part of the wider social welfare reforms of the Liberal Government of 1906-1914...
, introduced by David Lloyd George
David Lloyd George
David Lloyd George, 1st Earl Lloyd-George of Dwyfor OM, PC was a British Liberal politician and statesman...
, a small amount was deducted from weekly wages, to which was added contributions from the employer and the government. In return for the record of contributions, the workman was entitled to medical care (as well as retirement and unemployment benefits) though not necessarily to the drugs prescribed. To obtain medical care, he registered with a doctor. Each doctor who participated in the scheme thus had a 'panel' of those have made an insurance under the system, and was paid a capitation grant out of the fund calculated upon the number. (Lloyd George's name survives in the "Lloyd George envelopes" in which most primary care records in England are stored, although today most working records in primary care are at least partially computerised). This imperfect scheme only covered certain trades and occupations, and was known as 'Lloyd George's Ambulance Wagon'. Moreover, due to cuts during the 1930s, many were unable to obtain treatment.
Birth of the National Health Service
Prior to the Second World War there was already consensus that health insurance should be extended to the dependants of the wage-earner, and that the voluntary and local authority hospitals should be integrated. A British Medical AssociationBritish Medical Association
The British Medical Association is the professional association and registered trade union for doctors in the United Kingdom. The association does not regulate or certify doctors, a responsibility which lies with the General Medical Council. The association’s headquarters are located in BMA House,...
pamphlet, "A General Medical Service for the Nation" was issued along these lines in 1938. However, no action was taken due to the international crisis. During the war, a new centralised state-run 'Emergency Medical Service' (EMS) employed doctors and nurses to care for those injured by enemy action and arrange for their treatment in whichever hospital was available. The existence of the EMS made voluntary hospitals dependent on the Government and there was a recognition that many would be in financial trouble once peace arrived. The need to do something to guarantee the voluntary hospitals meant that hospital care drove the impetus for reform.
In February 1941 the Deputy Permanent Secretary at the Ministry of Health recorded privately areas of agreement on post-war health policy which included "a complete health service to be available to every member of the community" and on 9 October 1941, the Minister of Health Ernest Brown
Ernest Brown
Alfred Ernest Brown CH was a British politician who served as leader of the Liberal Nationals from 1940 until 1945.-Biography:...
announced that the Government proposed to ensure that there was a comprehensive hospital service available to everyone in need of it, and that local authorities would be responsible for providing it. The Medical Planning Commission set up by the professional bodies went one stage further in May 1942 recommending (in an interim report) a National Health Service with General Practitioners working through health centres and hospitals run by regional administrations. The Beveridge
William Beveridge
William Henry Beveridge, 1st Baron Beveridge KCB was a British economist and social reformer. He is best known for his 1942 report Social Insurance and Allied Services which served as the basis for the post-World War II welfare state put in place by the Labour government elected in 1945.Lord...
Report of December 1942 included this same idea.
Developing the idea into firm policy proved difficult. Although the BMA had been part of the Medical Planning Commission, at their conference in September 1943 the association changed policy to oppose local authority control of hospitals and to favour extension of health insurance instead of GPs working for state health centres. When Health Minister Henry Willink
Henry Willink
Sir Henry Urmston Willink, 1st Baronet PC, MC, KC , was a British politician and public servant.He is best known for his service in the Conservative Party as Minister of Health from 1943-1945 in the wartime Coalition Government of the United Kingdom...
prepared a white paper endorsing a National Health Service, it was attacked by Brendan Bracken
Brendan Bracken, 1st Viscount Bracken
Brendan Randell Bracken, 1st Viscount Bracken PC was an Irish businessman and a minister in the British Conservative cabinet. Primarily, the 1st Viscount Bracken is remembered for opposing the Bank of England's co-operation with Adolf Hitler, and for subsequently supporting Winston Churchill's...
and Lord Beaverbrook
Max Aitken, 1st Baron Beaverbrook
William Maxwell "Max" Aitken, 1st Baron Beaverbrook, Bt, PC, was a Canadian-British business tycoon, politician, and writer.-Early career in Canada:...
and resignations were threatened on both sides. However the Cabinet endorsed the White Paper which was published in 1944.
Willink then set about trying to assuage the doctors, a job taken over by Aneurin Bevan
Aneurin Bevan
Aneurin "Nye" Bevan was a British Labour Party politician who was the Deputy Leader of the Labour Party from 1959 until his death in 1960. The son of a coal miner, Bevan was a lifelong champion of social justice and the rights of working people...
in Clement Attlee
Clement Attlee
Clement Richard Attlee, 1st Earl Attlee, KG, OM, CH, PC, FRS was a British Labour politician who served as the Prime Minister of the United Kingdom from 1945 to 1951, and as the Leader of the Labour Party from 1935 to 1955...
's Labour
Labour Party (UK)
The Labour Party is a centre-left democratic socialist party in the United Kingdom. It surpassed the Liberal Party in general elections during the early 1920s, forming minority governments under Ramsay MacDonald in 1924 and 1929-1931. The party was in a wartime coalition from 1940 to 1945, after...
government after the war ended. Bevan encountered considerable debate and resistance from the BMA who voted in May 1948 not to join the new service. The structure of the NHS in England and Wales
England and Wales
England and Wales is a jurisdiction within the United Kingdom. It consists of England and Wales, two of the four countries of the United Kingdom...
was established by the National Health Service Act 1946
National Health Service Act 1946
The National Health Service Act 1946 came into effect on 5 July 1948 and created the National Health Service in England and Wales. Though the title 'National Health Service' implies one health service for the United Kingdom, in reality a separate NHS was created for England and Wales accountable to...
(1946 Act) with the new arrangements launched on 5 July 1948. The founding principles of the NHS called for its funding out of general taxation and not through national insurance
National Insurance
National Insurance in the United Kingdom was initially a contributory system of insurance against illness and unemployment, and later also provided retirement pensions and other benefits...
.
Services would henceforth be provided by the same doctors and the same hospitals, but:
- services were provided free at the point of use;
- services were financed from central taxation;
- everyone was eligible for care (even people temporarily resident or visiting the country).
Development of the NHS in England and Wales, 1948-1969
The original structure of the NHS in England and Wales had three aspects, known as the tripartite system:- Hospital Services - 14 Regional Hospital Boards were created in England and Wales to administer the majority of hospital services. Beneath these were 400 Hospital Management Committees which administered hospitals. Teaching hospitals had different arrangements and were organised under Boards of Governors.
- Primary Care - GPGeneral practitionerA general practitioner is a medical practitioner who treats acute and chronic illnesses and provides preventive care and health education for all ages and both sexes. They have particular skills in treating people with multiple health issues and comorbidities...
s were independent contractors (that is they were not salaried employees) and would be paid for each person on their list. Dentists, opticians and pharmacists also generally provided services as independent contractors. Executive Councils were formed and administered contracts and payments to the contractor professions as well as maintaining lists of local practitioners and dealing with patient - Community Services - MaternityMaternityMaternity or motherhood is the social and legal acknowledgment of the parental relationship between a mother and her child.It is specially related with the protection of the baby and the mother within and after the childbirth.-See also:...
and Child Welfare clinics, health visitorsHealth visitorHealth visitors are UK community health nurses who have undertaken further training to work as part of a primary health care team. As their name suggests, their role is to promote mental, physical and social well-being in the community by giving advice and support to families in all age groups...
, midwivesMidwiferyMidwifery is a health care profession in which providers offer care to childbearing women during pregnancy, labour and birth, and during the postpartum period. They also help care for the newborn and assist the mother with breastfeeding....
, health education, vaccinationVaccinationVaccination is the administration of antigenic material to stimulate the immune system of an individual to develop adaptive immunity to a disease. Vaccines can prevent or ameliorate the effects of infection by many pathogens...
& immunisation and ambulanceAmbulanceAn ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...
services together with environmental health services were the responsibility of local authorities. This was a continuation of the role local government had held under the Poor Law.
By the 1950s
1950s
The 1950s or The Fifties was the decade that began on January 1, 1950 and ended on December 31, 1959. The decade was the sixth decade of the 20th century...
, spending on the NHS was exceeding what had been expected, leading to the introduction of a one-shilling
Shilling
The shilling is a unit of currency used in some current and former British Commonwealth countries. The word shilling comes from scilling, an accounting term that dates back to Anglo-Saxon times where it was deemed to be the value of a cow in Kent or a sheep elsewhere. The word is thought to derive...
charge for prescriptions and a £
Pound sterling
The pound sterling , commonly called the pound, is the official currency of the United Kingdom, its Crown Dependencies and the British Overseas Territories of South Georgia and the South Sandwich Islands, British Antarctic Territory and Tristan da Cunha. It is subdivided into 100 pence...
1 charge for dental treatment, in 1952; an exception to the NHS being free at the point of use. The 1950s also saw the planning of hospital services, dealing in part with some of the gaps and duplications that existed across England and Wales. The period also saw growth in the number of medical staff and a more even distribution of them with the development of hospital outpatient services. By 1956, the NHS was stretched financially and doctors were disaffected resulting in a Royal Commission
Royal Commission
In Commonwealth realms and other monarchies a Royal Commission is a major ad-hoc formal public inquiry into a defined issue. They have been held in various countries such as the United Kingdom, Australia, Canada, New Zealand, and Saudi Arabia...
on doctors' pay being set up in February 1957. The investigation and trial of alleged serial killer
Serial killer
A serial killer, as typically defined, is an individual who has murdered three or more people over a period of more than a month, with down time between the murders, and whose motivation for killing is usually based on psychological gratification...
Dr John Bodkin Adams
John Bodkin Adams
John Bodkin Adams was an Irish-born British general practitioner, convicted fraudster and suspected serial killer. Between the years 1946 and 1956, more than 160 of his patients died in suspicious circumstances. Of these, 132 left him money or items in their will. He was tried and acquitted for...
exposed some of the tensions in the system. Indeed, if he had been found guilty (for - in the eyes of doctors - accidentally killing a patient while providing treatment) and hanged, the whole NHS might have collapsed. The Mental Health Act
Mental Health Act 1983
The Mental Health Act 1983 is an Act of the Parliament of the United Kingdom which applies to people in England and Wales. It covers the reception, care and treatment of mentally disordered persons, the management of their property and other related matters...
of 1959 also significantly altered legislation in respect of mental illness
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
and reduced the grounds on which someone could be detained in a mental hospital.
The 1960s
1960s
The 1960s was the decade that started on January 1, 1960, and ended on December 31, 1969. It was the seventh decade of the 20th century.The 1960s term also refers to an era more often called The Sixties, denoting the complex of inter-related cultural and political trends across the globe...
have been characterised as a period of growth. Prescription charges were abolished in 1965 and reintroduced in 1968. New drugs came to the market improving healthcare, including polio vaccine, dialysis for chronic renal failure and chemotherapy for certain cancers were developed, all adding to costs. Health Secretary Enoch Powell
Enoch Powell
John Enoch Powell, MBE was a British politician, classical scholar, poet, writer, and soldier. He served as a Conservative Party MP and Minister of Health . He attained most prominence in 1968, when he made the controversial Rivers of Blood speech in opposition to mass immigration from...
undertook three initiatives:
- The Hospital Plan published in 1962 proposed the development of district general hospitals for population areas of about 125,000 and laid out a pattern for the future district by district
- The Church House speech predicted that many of the large mental health institutions would close within ten years
Concern continued to grow about the structure of the NHS and weaknesses of the tripartite system. Powell agreed the creation of a Royal Commission on doctors’ pay, which resulted in a statutory review body. Further development came in the form of the Charter of General Practise, negotiated between new Health Minster Kenneth Robinson
Kenneth Robinson
Sir Kenneth Robinson PC was a British Labour politician who served as Minister of Health in Harold Wilson's first government, from 1964 to 1968, when the position was merged into the new title of Secretary of State for Social Services.-Early life:The son of Dr Clarence Robinson and a nurse, Ethel...
and the BMA, that provided financial incentives for practice development. This resulted in the concept of the primary health care
Primary care
Primary care is the term for the health services by providers who act as the principal point of consultation for patients within a health care system...
in better housed and better staffed practises, stimulating doctors to join together and the development of the modern group practice.
In 1969, responsibility for the NHS in Wales was passed to the Secretary of State for Wales
Secretary of State for Wales
The Secretary of State for Wales is the head of the Wales Office within the British cabinet. He or she is responsible for ensuring Welsh interests are taken into account by the government, representing the government within Wales and overseeing the passing of legislation which is only for Wales...
from the Secretary of State for Health who was thereafter just responsible for the NHS in England.
Development of the NHS (England) and NHS Wales since 1970
The NHS in England was reorganised in 1974 to bring together services provided by hospitals and services provided by local authorities under the umbrella of Regional Health Authorities, with a further restructuring in 1982. The 1970s1970s
File:1970s decade montage.png|From left, clockwise: US President Richard Nixon doing the V for Victory sign after his resignation from office after the Watergate scandal in 1974; Refugees aboard a US naval boat after the Fall of Saigon, leading to the end of the Vietnam War in 1975; The 1973 oil...
also saw the end of the economic optimism which had characterised the 1960s and increasing pressures coming to bear to reduce the amount of money spent on public services and to ensure increased efficiency
Efficiency (economics)
In economics, the term economic efficiency refers to the use of resources so as to maximize the production of goods and services. An economic system is said to be more efficient than another if it can provide more goods and services for society without using more resources...
for the money spent.
Through the 1970s and 1980s
1980s
File:1980s decade montage.png|thumb|400px|From left, clockwise: The first Space Shuttle, Columbia, lifted off in 1981; American President Ronald Reagan and Soviet leader Mikhail Gorbachev eased tensions between the two superpowers, leading to the end of the Cold War; The Fall of the Berlin Wall in...
, it became clear that the NHS would never get the resources necessary to provide unlimited access to the latest medical treatments, especially in the context of an ageing population. This led to the beginning of a major process of reform, starting about 1980, which is still continuing in 2009.
Reforms under the Thatcher government
The 1980s saw the introduction of modern management processes (General Management) in the NHS to replace the previous system of consensus management. This was outlined in the Griffiths Report of 1983.This recommended the appointment of general managers in the NHS with whom responsibility should lie. The report also recommended that clinicians be better involved in management. Financial pressures continued to place strain on the NHS. In 1987, an additional £101 million was provided by the government to the NHS. In 1988 the then Prime Minister
Prime minister
A prime minister is the most senior minister of cabinet in the executive branch of government in a parliamentary system. In many systems, the prime minister selects and may dismiss other members of the cabinet, and allocates posts to members within the government. In most systems, the prime...
, Margaret Thatcher
Margaret Thatcher
Margaret Hilda Thatcher, Baroness Thatcher, was Prime Minister of the United Kingdom from 1979 to 1990...
, announced a review of the NHS. From this review and in 1989, two white paper
White paper
A white paper is an authoritative report or guide that helps solve a problem. White papers are used to educate readers and help people make decisions, and are often requested and used in politics, policy, business, and technical fields. In commercial use, the term has also come to refer to...
s Working for Patients and Caring for People were produced. These outlined the introduction of what was termed the "internal market", which was to shape the structure and organisation of health services for most of the next decade. In spite of intensive opposition from the BMA, who wanted a pilot study or the "reforms" in one region, the untried untested internal market was introduced.
In 1990, the National Health Service & Community Care Act
National Health Service and Community Care Act 1990
The National Health Service and Community Care Act 1990 is a piece of legislation which governs health care and social care in the United Kingdom...
(in England) defined this "internal market", whereby Health Authorities ceased to run hospitals but "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients. The "providers" became NHS trust
NHS Trust
A National Health Service trust provides services on behalf of the National Health Service in England and NHS Wales.The trusts are not trusts in the legal sense but are in effect public sector corporations. Each trust is headed by a board consisting of executive and non-executive directors, and is...
s, which encouraged competition but also increased local differences.
The Blair government
These innovations, especially the "fund holder" option, were condemned at the time by the Labour PartyLabour Party (UK)
The Labour Party is a centre-left democratic socialist party in the United Kingdom. It surpassed the Liberal Party in general elections during the early 1920s, forming minority governments under Ramsay MacDonald in 1924 and 1929-1931. The party was in a wartime coalition from 1940 to 1945, after...
. Opposition to what was claimed to be the Conservative
Conservative Party (UK)
The Conservative Party, formally the Conservative and Unionist Party, is a centre-right political party in the United Kingdom that adheres to the philosophies of conservatism and British unionism. It is the largest political party in the UK, and is currently the largest single party in the House...
intention to privatise the NHS became a major feature of Labour's election campaigns.
Labour came to power in 1997 with the promise to remove the "internal market" and abolish fundholding. In a speech given by the new Prime Minister, Tony Blair
Tony Blair
Anthony Charles Lynton Blair is a former British Labour Party politician who served as the Prime Minister of the United Kingdom from 2 May 1997 to 27 June 2007. He was the Member of Parliament for Sedgefield from 1983 to 2007 and Leader of the Labour Party from 1994 to 2007...
, at the Lonsdale Medical Centre on 9th December 1997, he stated that:
The White Paper we are publishing today marks a turning point for the NHS. It replaces the internal market with "integrated care". We will put doctors and nurses in the driving seat. The result will be that £1 billion of unnecessary red tape will be saved and the money put into frontline patient care. For the first time the need to ensure that high quality care is spread throughout the service will be taken seriously. National standards of care will be guaranteed. There will be easier and swifter access to the NHS when you need it. Our approach combines efficiency and quality with a belief in fairness and partnership. Comparing not competing will drive efficiency.
However in his second term Blair renounced this direction. He pursued measures to strengthen the internal market as part of his plan to "modernise" the NHS.
Driving these reforms have been a number of factors. They include the rising costs of medical technology and medicines, the desire to increase standards and "patient choice", an ageing population, and a desire to contain government expenditure. Since the National Health Services in Wales, Scotland and Northern Ireland are not controlled by the UK government, these reforms have increased the differences between the National Health Services in different parts of the United Kingdom. (See NHS Wales and NHS Scotland
NHS Scotland
NHS Scotland is the publicly funded healthcare system of Scotland. Although they are separate bodies the organisational separation between NHS Scotland and the other three healthcare organisations each commonly called the National Health Service in the United Kingdom tends to be hidden from its...
for descriptions of their developments).
Reforms have included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous clinical
Clinical governance
Clinical governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. The term became widely used in health care following the Bristol heart scandal in 1995, during which anaesthetist Dr Stephen Bolsin exposed the...
and corporate governance
Corporate governance
Corporate governance is a number of processes, customs, policies, laws, and institutions which have impact on the way a company is controlled...
. In addition medical training
Modernising Medical Careers
Modernising Medical Careers is a programme for postgraduate medical training introduced in the UK from 2005 onwards. The programme replaced the traditional grades of medical career before the level of Consultant. The different stages of the programme contribute towards a "Certificate of...
has undergone an unsuccessful restructuring which was so badly managed that the Secretary of State for Health was forced to apologise publicly. MMC is now being revised but its flawed implementation has left the NHS with significant medical staffing problems which are unlikely to be resolved before 2009. Some new services have been developed to help manage demand, including NHS Direct
NHS Direct
NHS Direct is the health advice and information service provided by the National Health Service for residents and visitors in England, with advice offered 24 hours a day, every day of the year through telephone contact on the national 0845 46 47 number, web based symptom checkers at and via...
. A new emphasis has been given to staff reforms, with the Agenda for Change
Agenda for Change
Agenda for Change is the current National Health Service grading and pay system for all NHS staff, with the exception of doctors, dentists and some senior managers...
agreement providing harmonised pay and career progression. These changes have, however, given rise to controversy within the medical professions, the media and the public.
The Blair
Tony Blair
Anthony Charles Lynton Blair is a former British Labour Party politician who served as the Prime Minister of the United Kingdom from 2 May 1997 to 27 June 2007. He was the Member of Parliament for Sedgefield from 1983 to 2007 and Leader of the Labour Party from 1994 to 2007...
Government, whilst leaving services free at point of use, has encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative
Private Finance Initiative
The private finance initiative is a way of creating "public–private partnerships" by funding public infrastructure projects with private capital...
, an increasing number of hospitals have been built (or rebuilt) by private sector consortia; hospitals may have both medical services (such as "surgicentres"
Independent Sector Treatment Centre
Independent sector treatment centres are private-sector owned treatment centres contracted within the English National Health Service to treat NHS patients free at the point of use, like any other NHS hospital. They are sometimes referred to as 'surgicentres' or ‘specialist hospitals’.ISTCs are...
), and non-medical services (such as catering) provided under long-term contracts by the private sector. A study by a consultancy company which works for the Department of Health shows that every £200 million spent on privately financed hospitals will result in the loss of 1000 doctors and nurses. The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced.
In 2005, surgicentres (ISTCs) treated around 3% of NHS patients (in England) having routine surgery. By 2008 this is expected to be around 10%. NHS Primary Care Trust
NHS Primary Care Trust
An NHS primary care trust is a type of NHS trust, part of the National Health Service in England. PCTs commission primary, community and secondary care from providers. Until 31 may2011 they also provided community services directly. Collectively PCT are responsible for spending around 80% of the...
s have been given the target of sourcing at least 15% of primary care from the private or voluntary sectors over the medium term.
As a corollary to these intitiatives, the NHS has been required to take on pro-active socially "directive" policies, for example, in respect of smoking
Tobacco smoking
Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...
and obesity
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
.
The NHS has also encountered significant problems with the IT
Information technology
Information technology is the acquisition, processing, storage and dissemination of vocal, pictorial, textual and numerical information by a microelectronics-based combination of computing and telecommunications...
innovations accompanying the Blair reforms. The NHS's National Programme for IT (NPfIT), believed to be the largest IT project in the world, is running significantly behind schedule and above budget, with friction between the Government and the programme contractors. Originally budgeted at £2.3 billion, present estimates are £20-30 billion and rising. There has also been criticism of a lack of patient information security. The ability to deliver integrated high quality services will require care professionals to use sensitive medical data. This must be controlled and in the NPfIT model it is, sometimes too tightly to allow the best care to be delivered. One concern is that GPs and hospital doctors have given the project a lukewarm reception, citing a lack of consultation and complexity. Key "front-end" parts of the programme include Choose and Book
Choose and Book
Choose and Book , is an E-Booking software application which has been introduced to the National Health Service in England...
, intended to assist patient choice of location for treatment, which has missed numerous deadlines for going "live", substantially overrun its original budget, and is still (May 2006) available in only a few locations. The programme to computerise all NHS patient records is also experiencing great difficulties. Furthermore there are unresolved financial and managerial issues on training NHS staff to introduce and maintain these systems once they are operative.