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National Health Service History
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Established in 1948, the object of the NHS was to provide a comprehensive health service to improve the physical and mental health of the people through the prevention, diagnosis and treatment of illness. An introductory booklet [2] said the NHS would "make all the health services available to every man, woman and child in the population, irrespective of their age or where they live, or how much money they have; and to make the total cost of the Service a charge on the national income in the same way as the Defence Services and other national necessities." This has hardly changed
since.
Topics covered
NHS core principals
Plans - Labour's NHS Plan & Lib/Con White Paper
National priority areas and NICE
The superstructure of the NHS, its management finance and organization, should ideally be based on clinical matters,
the need for primary care, a district hospital and a regional centre. However since the start of the NHS political philosophy and the economic health of the country have had a significant impact.
What the NHS does depends on three factors
the needs of people
the forms of care and treatment that work and are required
the money available
World-wide the diseases in the community change continuously. Indeed the provision of health services is a "wild problem" as the issues shift with time, and no sooner is one problem solved than another emerges. That is part of the its fascination.
Rheumatic fever and the resultant rheumatic heart disease have all but disappeared. Drug therapy has reduced tuberculosis to a shadow of its former self and women no longer die in their thousands in childbirth or after a septic abortion. Appendicitis and bleeding stomach and duodenal ulcers are far less common. Medical science led to immunization that has virtually eliminated infections diseases of childhood, so that we have largely forgotten the ravages of polio and measles. Other conditions, such as AIDS have appeared. Yet the deaths from road accidents are much the same over 50 years in spite of the increase in traffic. People are healthier and live longer
so the care of chronic disease such as arthritis and the problems of the elderly - cancer and dementia - are more significant. There is debate about how far medicine or social changes have been responsible for this. Probably it is 50 : 50. “Choose your parents well and eat healthily” is undoubtedly good advice. Affluence may have eliminated some conditions such as rickets but it has influenced others such as alcoholism and obesity (which may require new forms of surgery). Ethical issues have always existed, but genetic medicine and fertility treatment have given these a new twist. Air travel aids the spread of disease and sometimes brings in infected food products. Immigration brings other conditions into the country, for example thalassaemia. A significant number of cases of AIDs (particularly of heterosexual origin) in
As the disease pattern has changed, so has the capacity to help. Sometimes a disease, for example diabetes, can more readily be handled outside hospital. Sometimes the movement has been from primary into secondary care. Surgery for arthritis and heart disease made these conditions appropriate for hospital. New forms of treatment spur new activities for the NHS. As treatment becomes easier, as in the case of keyhole surgery, more people come forward for care, increasing costs and activity. Historically, the introduction of anaesthesia in the 19th century trebled the number of operations within a month!
Proponents of new forms of care may argue that in the long run they will save money. This is often a fallacy. We save people from dying cheaply when young and as a result they die more expensively later on, sometimes after several previously lethal conditions have been treated. Something like half of the entire lifetime costs of an individual to the NHS are in the last month or two of life. So the introduction of new drugs, from penicillin to Aricept, has increased costs. Technology in the imaging department (e.g. MRI scanning) and in treatment (e.g. interventional radiology and angioplasty) have increased bills not just immediately but in the future.
200 years ago when neither the local doctor nor the hospital could do much, the way health care was organized hardly mattered. Once anaesthesia and aseptic surgery were available, hospitals became important and by the early years of the
20th century the idea of a district hospital providing all usual forms of hospital care for a local population was accepted. The introduction of motor ambulances in the 1914-1918 war encouraged the transfer of serious cases and by the 1920s it was realized that some forms of treatment, for example radiotherapy for cancer, could not be provided everywhere. University and specialist hospitals were the answer. Continually increasing specialisation has accelerated this process. For example general surgeons gave up orthopaedics and uro-genital surgery. Hospitals then needed three surgeons, not one. Cancer was once largely a matter for the surgeon but now it requires the surgeon, radiotherapist, oncologist - and the MacMillan nurse. To provide a service round the clock needs five of each specialty, not one. Patients may have better outcomes and leave hospital sooner but the hospital staff multiplies like rabbits. Our more leisured society also affects this. Doctors, many women with family commitments, are no longer expected to work all hours of the day and night. Indeed European Work regulations embargo long hours, even were tired doctors safe doctors. If the staff is not expanded hospitals will not provide good care.
C
The passing of the National Health Service Act 1946 provided the legislation for the NHS which came into being on July 5th 1948. The current framework in
The UK has always prided itself on the strength of its primary care, seeing it as a guarantee that people will receive a good service wherever they live, believing that a measure of continuity of care is beneficial, and that it is cost effective for a primary care physician to influence who is referred to hospital (the gatekeeper function) and to deliver care in the community whenever possible. Attempts are made to achieve equity in the distribution of practitioners.
Primary care services are provided by general practitioner practices, dentists, pharmacists and opticians. The majority are independent contractor
but an increasing number of GPs are salaried. There are something like 32,000 GPs in
Most GP practices are paid to carry out specified duties under a national contract for General Medical Services. The contract is between the primary care trusts and practices that may be individual GPs, or more commonly partnerships or companies that include GPs. A contract introduced in 2004 allows practices to transfer responsibility for providing some services – including out-of-hours care. A second contract is used by about half the GPs. The NHS (Primary Care) Act 1997 allowed for the establishment of Personal Medical Services (PMS). This provides more flexibility for practices to work in different ways and develop specific services for local needs.
The NHS inherited a disparate collection of hospitals and over 60 years these have been brought into a system based on an early decision to aim for district general hospitals serving natural areas of population, supported by university and specialist hospitals at a greater distance. The Hospital Plan of 1962 was explicit about this, and subsequent plans have taken account of the changing distribution of the population, and developments in medical science. This is quite unlike the situation in countries such as the USA where hospital development is driven more by the market than by planning based on health care needs.
Most people reach hospital by GP referral, though accident and emergency departments, or NHS Direct (a phone and web based helpline). Hospital services are provided by NHS trusts, a pattern of management created in 1991 under the Conservative NHS reforms to manage and provide hospital care, mental health care and ambulance and special services. Trusts are self-governing bodies with their own board of directors. They work within a legal framework that lays down certain financial, quality and partnership requirements. There may be more than one hospital in an NHS trust. Some trusts also act as regional or national centres of expertise for more specialised care,
and most are attached to universities and help to train professionals. Trusts can also provide services in the community – for example through health centres, clinics or in peoples’ homes.
NHS foundation trusts were first established in 2004 and
are approved by an independent regulator, Monitor.
It is government policy that all provider trusts should achieve foundation
status, difficult as many have substantial financial and managerial problems. They differ
from earlier trusts primarily by having a
Council of Governors as well as a Board of Directors, the former having the function of representing the interests of the community and of local partnership organizations. They have financial freedoms, earned by a record of financial probity
They are not allowed to sell off or mortgage NHS property and resources needed to provide key NHS services. Each Foundation Trust has an individual constitution designed to meet its own circumstances.
Underpinning the NHS is a set of core principles. In 1952 Bevan wrote "The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged." (In Place of Fear, a collection of essays).
Some things have been modified over the years, for example in 1948 the NHS owned almost all the capital stock from which hospital services (but not GP services) were provided. Now it is considered less important to provide the services by purely NHS owned facilities. The Department recently expressed the core values as
A universal service for all based on clinical need, not ability to pay.
Providing a comprehensive range of service
Shaping its services around the needs and preferences of individual patients their families and their carers
Responding to different needs of different populations
Working continuously to improve quality services and to minimise errors
Supporting and valuing its staff
Public funds for healthcare will be devoted solely to NHS patients
Working together with others to ensure a seamless service for patients
Helping to keep people healthy and working to reduce health inequalities
Respecting the confidentiality of individual patients and providing open access to information about services, treatment and performance
In 2000 the Labour Party published a ten year plan to reshape the NHS in England. The Conservative Lib/Dem government aims to make further modifications outlined in a White Paper, Equity and Excellence, liberating the NHS [9]
Labour aimed to give give more power and information to patients,
increase capacity with more hospitals, beds, doctors and nurses with
Historically there there has been a raft of statements about service improvement, for example in the 1960s mental illness and mental handicap services received much attention. (These
diagnostic labels are now out-dated). The major causes of avoidable ill-health and premature death, cancer, coronary heart disease and stroke, and mental health were listed as priorities both in The Health of the Nation (1992) [5] and in the white paper ‘Saving Lives: Our Healthier Nation’ of 1999. Stress is also being placed on smoking cessation, obesity and sexual health.
As new providers have emerged and patients have been encouraged to exercise choice, it has become essential to ensure that national standards are observed. A range of measures to raise quality and decrease variations in service were introduced in 1998 by the White Paper A First Class Service [6]. These included National Service Frameworks (NSFs), evidence-based programmes spelling out what patients can expect to receive from the health service in a major area or disease group. They are implemented as part of trusts' local delivery plans.
NICE is a national body set up in 1999 as a special health authority to promote high quality of treatment and technology and the effective use of available resources in the NHS. It is the independent organisation providing national guidance on the use of specified medicines and treatments and the care and treatment of NHS patients with specified diseases. NICE tries to avoid treatment being dependent on where you live.
whether a particular medicine or treatment is recommended for use within the NHS in
the appropriate treatment and care of patients with certain specified diseases and conditions within the NHS in
Whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use – Interventional Procedures Guidance.
The organizational structure has changed repeatedly over the last 60 years, sometimes seeming to come full circle. The existing structure (above) is set for radical alteration by 2012/3 an early chart of the changes being below. Internationally a good health services can be organized on many principles, for example insurance, central taxation, local authority management and private sector involvement. All countries try to deliver that Holy Grail, comprehensive, good, accessible health care at a cost that society can and is prepared to afford.
The lines of accountability are changing. The separation, within the NHS, of those whose function is to purchase or commission health care, and those whose function is to provide it
remains.. This has opened the door for new providers, some in the private sector.
The Parliament in
There has always been, and currently is, active debate about how far the NHS could be “freed from political interference”. However ultimately the NHS is funded by the taxpayer. This means it is accountable to parliament. Currently, with the exception of NHS foundation trusts, it is managed by the Department of Health which is directly responsible to the Secretary of State for Health. It is policy that all trusts should have this degree of independence by 2012/3
The Secretary of State for Health is a member of the Cabinet and has overall responsibility for the work of the Department of Health. He/she works together with a group of ministers for health and the Permanent Secretary/NHS Chief Executive.
The Department of Health’s purpose is to support the Government to improve the health and well being of the population. It is responsible for modernising the NHS as well as improving standards of public health.
Its role is:
setting overall direction and leading transformation of the NHS and social care
setting national standards
securing resources and making major investment decisions to ensure that the NHS and social care have the capacity to deliver
working with key partners to ensure quality of service such as the strategic health authorities and the Care Quality commission (CQC).
The Department is set for internal reorganisation to make a clear distinction between commissioning branches and provider branches.
There are a number of special health authorities and other bodies which are either part of the NHS or closely associated with it. They include the NICE, the Health Protection Agency (HPA) and Prescription Pricing Authority. These organisations are either accountable to the Secretary of State, or have formal agreements with the Department of Health. In general they provide national services.
The
previous strategic health authorities in
PCTs are being clustered and superseded by clinical commissioning consortia, responsible for planning and securing health services and for improving the health of the local population. These will be accountable to the NHS Commissioning Board, and advised by a variety of local bodies, in particular Health and Wellbeing Boards that will coordinate commission by by local authorities and the NHS.
When the NHS began there was an uneven distribution of money spent on health care with the south receiving far more than the north, and cities than the country. GPs were poorly distributed. There were some over doctored areas and other under doctored ones. Much effort has gone into the correction of this, but there is still a disparity in the number, quality and accommodation of GPs in different areas. Conurbations generally do worst. Similarly there was a disparity in hospital services – here the large cities did best in terms of the number and quality of hospitals. Equity being a corner stone of the NHS – we are all tax payers - many mechanisms have been used to improve this. In the 1970s, under Labour, the Resource Allocation Working Party [7] started the process of moving money to the north. Most new medical schools have been placed in areas with deficient services for doctors tend to practice in the area in which they have trained.
The quality of NHS premises has long lagged behind those of other western countries. In recognition of this a major building programme started with Enoch Powell’s Hospital Plan (1962) [8] and has been accelerated in recent years. It affects both the hospitals and primary health care. Latterly it has been largely financed not directly by the Treasury, but by the Private Finance Initiative (PFI), or public-private partnership. This has meant that NHS building costs do not fall on the normal government balance sheet, but that the NHS is essentially leasing buildings that are designed, built and operated by the private sector. While there are some advantages in using the experience of the private sector in getting hospitals built rapidly, the ultimate cost
is high and it may be difficult to change buildings as requirements change. Many trusts will be financially challenged by PFI contracts over the coming years.
The NHS is a massive employer with some 1.4 million staff in the
Because the NHS is virtually a monopoly employer, and because the state pays much of the cost of educating doctors and nurses, government has always been involved in deciding the numbers in training, attempting to match training places to the likely requirements of the NHS. Only too often it has got the numbers wrong because it takes about 15 years to train a consultant and 4 years or more a nurse. Demands change over this period and require changing staff skills. Modernising Medical Careers – improving the way doctors are trained to become specialists or GPs - is the latest of many attempts to match training to new clinical requirements. It has run into substantial difficulties. For nursing, the Department of Health and the Nursing and Midwifery Council have been consulting on modernizing nurse education – a follow-up to Project 2000 a decade ago - aiming for a new syllabus in Autumn 2011. A major new pay system, Agenda for Change, covers almost all staff other than doctors and dentists. It is designed to ensure equal pay for work of equal value, to facilitate service re-design and to support recruitment and retention.
The Department of Health has devolved future much responsibility for such negotiations to an NHS employers’ body. Consultants’ pay is still determined by an independent review body.
The NHS is funded largely through taxes levied by the Government. The total cost in
The way in which resources are allocated is constantly being refined.
Funds are allocated directly from the Department of Health. Revenue funding is allocated on the basis of the relative needs of their populations. A weighted capitation formula is used to determine each
area's target share of available resources, to enable it to commission similar levels of health services for populations in similar need. The current formula has the following components:
Hospital and community health services
HIV/AIDS
GP practice infrastructure, e.g. practice staff wages, premises and equipment
general practice prescribing
GP remuneration.
The components of the formula are used to adjust each primary care trust’s “crude” population according to their relative need (age and additional need) for health care and the unavoidable geographical differences in the cost of providing healthcare (market forces factor).
The weighted capitation formula is regularly reviewed. The majority of the funding is on the basis of a recurring allocation made at the start of the financial year. Most of the revenue funding is channelled to the front line via unified allocations. These are cash limited. The rest of the funding is for family health services and is non-cash limited
Capital funding systems are changing to one of interest bearing debt and Trusts will have a borrowing limit. Operational capital is allocated to all NHS trusts and
areas. The funding is provided to maintain and enhance existing capital stock
and fund small to medium sized developments. The allocation of operational
capital is based on their level of depreciation.
The health service is staff intensive and more than 50% of the money is spent on acute services – medical and surgical care in hospital. 12% is spent on mental health services, 10% on services for the elderly, 5% on people with learning disabilities and 5% on maternity services. Health care for people over 65 years old accounts for around 40% of the total expenditure.
NHS trusts get most or their income from commissioners on the basis of the care they provide. A small percentage of their income is from private health care. They also receive funding to provide training for health professionals and benefit from income-generating schemes such as shops and car parking. NHS trusts have to break even. If a trust fails to do this it may agree a recovery plan with the strategic health authority or in the case of foundation trusts with Monitor.
Recently there have been changes to NHS ‘financial flows’ with trusts being paid a standard national tariff for the activity they undertake in a given year on a cost per case basis. Trusts whose costs are above national averages need to make efficiencies to enable them to break-even. This system is known as payment by results (PbR) though in fact it is payment by activity. New
commissioning arrangements as a result of the Coalition proposals create
uncertainty in trusts. Patient Choice is increasingly enabling the patient to choose the provider at the time of referral. All these changes impact on the way funds flow around the NHS and the financial wellbeing of hospitals.
The future planning system following the White Paper of 2010 is still uncertain
although subject to legislation the future pattern is becoming clearer.
PCTs who were the lead planners are being replaced at local level by clinical commissioning consortia, but the NHS Commissioning Board will take on many of the more specialised functions of the erstwhile strategic health authorities. Other inputs into planning with be new Health and Wellbeing Boards, and local clinical groups.
Within Trusts the planning of service provision will continue with the preparation of annual plans.
Better results are usually obtained for rarer conditions if the patients are concentrated in centres with particular expertise. Not every district general hospital can have an ENT or an ophthalmic service, let alone cardiac surgery and radiotherapy. Such specialised services are generally of high cost services, but with low volume use. For example services for rare cancers, are provided from a small number of centres and commissioned by PCTs working together.
Out of area treatment arrangements cover those situations where an individual is admitted to a hospital away from home, usually as an emergency where there is no pre-arranged service level agreement in place. Funding for these ad hoc cases is built into the host PCT’s service agreement with their local hospital(s).
The more that freedom is granted to local management, the more it is desirable to have an inspection and regulation system, particularly when one wishes there to be a measure of equity across the system as a whole.
The arrangements for monitoring and performance management in the NHS
at present are that:
each organisation has its own system for monitoring service delivery and trusts certify compliance to the
Care Quality Commission
Commissioners hold provider organisations to account for the delivery of services which they have commissioned
With the exception of Foundation Trusts (accountable to Monitor), the Department of Health holds the strategic health authorities to account for the performance of the NHS within their area.
In the case of Foundation Trusts Monitor is the economic regulator and has a strict compliance regime.
Many professional organisations have registration and
inspection systems, particularly as far as educational facilities are
concerned.
Strategic health authorities routinely collect data from area on performance against key Government targets. The strategic health authority tracks the trusts’ performance and monitors any lapses. For example, the number of patients who wait more than they should for an outpatient appointment; the percentage of patients who are not seen within four hours in A&E; the number of patients who are able to access a GP within 24 hours.
The Care Quality Commission was established in 2009 as a successor to the Healthcare Commission (established in 2002) and other bodies concerned with social services. It is an independent registration and inspection body of the NHS. It monitors how standards that are set by the Government, through its health policies, National Service Frameworks, and clinical guidance provided by the National Institute of Clinical Excellence (NICE), are being met. It:
registers all providers of health and social services
It reviews health care organisations in the NHS every three or four years (clinical governance reviews)
investigates serious service failures
reports on key issues, such as coronary heart disease and national service frameworks
assesses and reports on performance in the NHS
publishes data on staff and patient surveys
jointly inspects with other bodies
manages the clinical audit programme.
register and inspect private healthcare provision
conducts NHS value for money studies
validates and publish performance assessment information and statistics on the NHS, including waiting list information
publishes performance ratings for all NHS organisations
publishes reports on the performance of NHS organisations both locally and nationally
independently scrutinise patient complaints, and
publishes an annual report to Parliament on national progress on healthcare and how resources have been used.
inspects NHS foundation trusts and report its findings to the independent regulator, recommending special measures where it has serious concerns about the quality of services provided.
The Audit Commission is an independent body responsible for ensuring that public money is used economically, efficiently, and effectively.
It is proposed to abolish it. Its current function is the audit of local authority and NHS bodies. It is responsible for appointing external auditors to audit financial statements and to carry out reviews of governance arrangements and performance in all local authorities, strategic health authorities, trusts and other public bodies such as the police and fire authorities. In the course of producing its national studies it may send out questionnaires to collect data and visit a sample of NHS trusts. The Audit Commission may act as auditor for Foundation Trusts.
Unlike many other countries, private health care makes only a minimal though growing contribution to care in the UK. Competing with a health service that is good, free and increasingly efficient is difficult. Private organisations provide virtually no emergency services, little primary care, and are mostly concentrated on outpatient consultations, elective surgery and some forms of mental health care. Most specialists seeing patients privately spend the bulk of their time on the NHS.
However the NHS has changed from being the provider of all NHS services to commissioning, funding, defining and monitoring some that are provided by outside organizations. There is hardly an activity within the NHS that is not now provided in some places by the private sector. Hospitals built under the private finance initiative are operated by private consortia. Independent treatment centres offer day surgery under contract to the NHS. NHS Logistics that moves NHS supplies about is now operated by a private company. Many GPs, of course, have always been independent contractors. Even the function of commissioning services may be undertaken by selected firms on behalf of commissioners.
1 From Cradle to Grave, 50 years of the NHS. Rivett G.C. 1998,
2 The National Health Service. 1948.
3 A Framework for Action. Lord Darzi. 2007. Healthcare for
4 The NHS Plan, A plan for investment, A plan for reform 2000, London HMSO
5 The Health of the Nation. A strategy for health in
6 A First Class Service – Quality in the new NHS. Green Paper, 1998,
7 Sharing Resources for Health in
8 National Health Service. A hospital plan for
