History of the National Health Service (England)
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.
Before the National Health Service was created in 1948, patients were generally required to pay for their health care. They were also asked to pay for their parking spaces. Free treatment was sometimes available from unofficial hospitals and charity hospitals, such as the Royal Free Hospital. 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 or Welfare 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 who 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.
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 Association 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. This White Paper includes the founding principles of the NHS: it was to be funded out of general taxation and not through national insurance, and services would 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).
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 quickly came to the decision that the 1944 white paper's proposal for local authority control of voluntary hospitals was not workable, as the local authorities were too poor and too small to manage hospitals. He decided that "the only thing to do was to create an entirely new hospital service, to take over the voluntary hospitals, and to take over the local government hospitals and to organise them as a single hospital service". This structure of the NHS in England and Wales was established by the National Health Service Act 1946 which received Royal Assent on 6 November 1946. Bevan encountered considerable debate and resistance from the BMA who voted in May 1948 not to join the new service, but brought them on board by the time the new arrangements launched on 5 July 1948.
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: GPs 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: Maternity and Child Welfare clinics, health visitors, midwives, health education, vaccination & immunisation and ambulance 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.
After the publication by the British Medical Journal on December 24, 1949 of University of Cambridge consultant paediatrician Douglas Gairdner's landmark paper detailing the lack of medical benefit and the risks attached to non-therapeutic (routine) circumcision, the National Health Service took a decision that circumcision would not be performed unless there was a clear and present medical indication. Both the cost and the non-therapeutic, unnecessary, harmful nature of the surgical operation were taken into account.
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; this was 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:
- 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 Minister 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.
1970s and early 1980s
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 1970s 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.
Thatcher government reforms
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, Margaret Thatcher, announced a review of the NHS. From this review and in 1989, two white papers 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 trusts, which encouraged competition but also increased local differences.
Blair government reforms
These innovations, especially the "fund holder" option, were condemned at the time by the Labour Party. 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 9 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 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 Trusts have been given the target of sourcing at least 15% of primary care from the private or voluntary sectors over the medium term.
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.
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