NHS History and Evolution
NHS and the UK - is it the same everywhere?
There are 4 versions of the NHS in the UK - in Northern Ireland, the NHS is called the Health and Social Care Services instead
NHS responsibility was passed over to the govt of each nation (Scotland, Wales, England, Northern Ireland) —> each has a different version of NHS
causes disparities
services will differ in each version (not much portability) — similar to each state in the US
ex. England requires you to pay for prescription medicine, but Scotland, Wales, and N. Ireland do not
Before NHS
access to hc was largely dependent on ability to pay for treatment
different services that all had varying levels of quality and access
workhouses - “poor law” —> people feared going to the workforce (poor work conditions)
1867 Metropolitan Poor Act - ensured that infirmaries were housed on separate sites from workhouses
made healthcare free to individuals who do not live in workhouses
voluntary hospitals provided access to care
Early Health Professionals
physicians
1858 established General Council of Medical Education and Registration of the UK
surgeons
students began their education as apprentices and paid a few to become a student or “dresser” (since they used to be barbers)
no formal education
apothecaries
later became GPs
1815 Apothecaries Act - established training education requirements
nursing
1860 - Nightingale established training school for nurses in St Thomas’s Hospital (London)
Hospitals
voluntary hospitals often focused on treating specific conditions or certain groups of people
voluntary hospitals provided access to healthcare
early 1900s - 1/3 of all hospitals were run by volunteers
foundling hospital in London - children who were abandoned
Bradford Royal Eye/Ear Hospital in West Yorkshire
Florence Nightingale worked in volunteer hospital to educate women of moderate means
believed nurse’s duty was to ventilate/warm the ward and ensure cleanliness → also comforted soldiers and promoted hygiene to prevent illness/disease
National Insurance Act
1911 David Lloyd George
provided (mostly industrial) workers with some level of protection against the risk of falling ill and being unable to work - did not include family, or women/children
covered workers because they were healthier → less expensive
via contributing insurance - workers eligible to see approved doctors and receive treatment for certain conditions (ex. TB)
1946 - 21 million people in Britain had access to a GP through national insurance - 40% of population
Key Contributors to NHS and Free Treatment
Local Government Act of 1929
made local authorities responsible for Poor Law hospitals (workhouse infirmaries)
those who could pay for treatment could be charged, but those who couldn’t were still able to access medical treatment for free
hope that people could receive treatment without stigma of Poor Law treatment
quality of services - varied based on location and the specific service
“Poor Law Hospitals” to be declared as ‘hospitals’ → standards had to be improved → would cost/need more money
Key driver in establishment of NHS: disparity between services provided by local govt. and voluntary hospitals → saw inequities and how few options there were
pressure for creation of national health service building for decades → support from all parties
Emergency Hospital created after WWII → provided solid foundations for assimilating hospitals into what became the NHS
NHS was initially set up to deal with single conditions or illness
in present day, there are much more complex → multiple conditions, living longer, etc.
1942-1979 NHS Development
following WWII → wanted social welfare services
Sir William Beveridge’s Report (NHS) - Social Insurance and Allied Services
proposed social safety net in the form of welfare state funded by compulsory contributions from citizens
focused on elderly and children
identified 5 major problems that prevented people from bettering themselves:
want (caused by poverty)
disease (caused by inadequate healthcare provisions)
squalor (caused by poor housing - too many people in one area proliferates disease)
ignorance (caused by lack of education)
idleness (caused by lack of jobs or ability to gain employment)
Aneurin Bevan - Minister in Health 1945 —> National Health Service Act of 1946 was introduced
this act set up the NHS - contains provision that NHS services should be provided free of charge unless that Act expressly provided for a charge
5 major problems that prevented people from getting healthy and bettering themselves
want (caused by poverty)
disease (caused by inadequate hc provisions)
squalor (caused by poor housing)
ignorance (caused by lack of education)
idleness (caused by lack of jobs or ability to gain employment)
1948 National Health Service
Founded in July 1948 as a tax-funded universal healthcare system
GPs remained self-employed and largely independent - majority of doctors opposed the NHS and were afraid of not getting paid as much
Free at the point of use - do not need to pay to see an NHS doctor
people in ENGLAND still use the NHS to pay for some things - prescriptions, dental, eye
Should we Charge?
amendments made to allow charges for NHS services (prescription, dental, optical)
Prescriptions free in the other UK countries
Legislation providing prescription charges - passed by Labor Govt. through NHS Amendment Act
allows for charge (and exemptions) to be introduced by regulations/acts
power introduced it in 1949 —> charge not put into place until 1952
aside from 1965-1968 - prescription charge continues to apply in England since then
1951 - charges for dentistry and optical care introduced
Early medical care
Physicians
foundation of the College of General Practitioners in 1952 —> more govt. action to assist development of general practice
led to the provision of interest-free loans to help GPs develop practice premises, as well as mechanisms to control distribution of GPs
Mental health
before 1950s - most mental health care provided in asylums and psychiatric institutions
shift from hospitals/institutions to home —> medical advances (ex. antipsychotic drugs) and poor patient care
mental health act 1959 - deinstitutionalize mental health (closed all mental health institutions in England)
mental health diseases - largest category of NHS spending
Costs and NHS
costs increased as more individuals enrolled in NHS
February 1953 - inquiry to NHS (and expenditures) —> set up Guillebaud Committee —> supported by London School of Economics
emphasis on preventing further increase in expenditure rather than introducing cuts
report lays to rest - many fear that service is extravagant or can’t be afforded
additional costs implied - aging population - could be financed easily by economic growth
Expansion of Hospital Care
1962 Hospital Plan for England and Wales
introduced general hospitals to serve particular local areas - inpatient and outpatient services on a single site
unleashed wave of new hospital buildings and refurbishment
Enoch Powell - sponsor of Hospital Plan
pledged 570 million pounds over 10 years
GPs/PCPs and NHS
early 1960s - GPs complaining of neglect and impoverishment, poor morale and recruitment
led to Family Doctors Charter - received support from profession (power in numbers - thousands threatened to resign)
1966 GP Contract - addressed major grievances of GPs and provided better-equipped and better-staffed premises, more autonomy, minimum income guarantee, and pension provisions
Administration of NHS
Kenneth Robinson’s Green Paper - Administrative Structure of the Medical and Related Services in England and Wales → years of argument about organizational structure of NHS
1966 - Green Paper recommended creating 50 area boards into a single organizational tier → would take responsibility for all health functions in each administrative area
Ministry of Health merged with Ministry of Social Security → Department of Health and Social Security (1968)
Response to criticisms of Robinson’s 1968 plan - Richard Crossman made extensive revisions to first NHS Green Paper → publication of second green paper on NHS (1970)
Divisions of Care
Before 1973 - management of hc services split between local authorities and NHS
regional boards managed hospital services, reported to govt. → local authorities responsible for managing primary care services and social care
NHS Reorganization → structural changes made in NHS Reorganization Act: new local NHS bodies set up to manage all health services in that area
includes hospital services, general practices, and community health services
was a strategic direction for the NHS → more unified health service
Resource Allocation and Costs Rising
sharing resources - increase efficiency and saves money
NHS financial problems worsen during 1978-79 due to oil crisis —> widespread strike of British people to impose a pay freeze and control inflation
concerns about cost and management of resources
Access and quality of care
end of 1970s - concerns of difference in mortality rates between social classes
report on health inequities developed in 1980
health inequalities still prevalent today
Quality controls
regulation to ensure NHS provides high quality care, finances are well managed, and staff meets professional standards
Regulation groups: (middle man - regional)
Care Quality Commission, NHS England
Professional regulators: General Medical Council, Nursing and Midwifery Council, Health and Care Professions Council
Rankings measures
Patient rights and information
Accessibility
Outcomes
Range and reach of services provided
Prevention
Pharmaceuticals
1980-2000
NHS restructuring abolishes the area health authorities → area tier of NHS management abolished → district health authorities are now responsible as regional health authorities
aim - simplify structure
Mental Health Act of 1983 - detention of people deemed to be mentally ill and a risk to themselves or others, with or without their consent
allows people who are being assessed as mentally ill to be detained in a hospital and given treatment
1983 - Griffiths Report - observed that the NHS doesn’t really have people in charge but the govt. is still being paid a higher salary
Project 2000 - 1986 → reform to nursing training
apprenticeship style of nurse training; spend time in higher education and some time in clinicals
1989 - “Working for patients” - white paper → more significant changes to system to improve patient choice, experience, satisfaction, and recommendations
changes that molded the NHS as we know it now
creation of internal market facilitated through NHS and CCA of 1990
NHS and Community Care Act 1990 creates internal market and purchaser-provider split → purchasers (health authorities) are handed budgets to purchase services from providers (mainly acute hospitals and mental health facilities)
2000s
publication of NHS plan - introduced targets to reduce waiting times (ex. goal to limit emergency waiting time to 4 hours, and 18 weeks for referrals to hospital treatment)
creation of NHS foundation trusts - hospitals w greater independence from govt. and more accountability → significant increase in funding
2001-present
Exposure of significant failures of care at Mid-Straffordshire NHS Foundation Trust in mid-200s → spotlight on quality of care of NHS
reforms to include more hospital inspection, protection for whistleblowers and new safe staffing guidelines
the Health and Social Care Act 2012 - brought in reforms to NHS
large scale re-organization and how funding distribution
clinical commissioning groups (CCGs) → tailored health services at local levels → use of competition to improve services
patient choice → slight increase in private providers
How is the NHS Changing?
structure hasn’t changed as the health needs of population has changed
trying to bring organizations together to help meet our needs - metal health, social care, community care, general practitioners, primary care networks
2020
~1,500 hospitals in England = where most emergency and elective care are carried out
most hospitals are old buildings; deteriorating conditions
govt. announced New Hospital Program (NHP) committed to build 40 new hospitals by 2030
2022 Health and Care Act
make it easier for organizations to work together
make integrated health systems
boards: how NHS budgets for area
partnerships: NHS brought together with local authorities to help improve health in that area
NHS England funding: taxes
Local and federal taxes
new powers and legal framework - before this act, the local levels couldn’t do anything about these problems
easier to get care where individuals need it; at a local level
most reforms focus on changes to structure of health and the healthcare system
collaboration vs. competition
Secretary of State for Health and Social Care - more powers to intervene in decisions about changes to local services, and to direct NHS England
emphasizes responsibility of NHS organizations to tackle health inequalities
Integrated Care Systems (ICS)
40 integrated care systems across England - brings together hospitals, community services, general practices, councils and commissioners → plan services together
integrated care can sometimes involve authorities and voluntary sector → works towards these objectives alongside NHS
4 main goals of integration
improving population outcomes
tackle inequalities
productivity and value for money
social and economic development