In this essay I intend to discuss how relevant the original three core principles of the NHS are today, and will be into the future of the 21st Century. This will be in regard to technological and political developments that have taken and are currently taking place. On the 5th July 1948 the National Health Service was born. This was developed in response to The Beveridge Report of 1942 that named five ‘Great Evils’ rife in Great Britain following World War II. These were want, disease, ignorance, squalor and idleness.
Although Winston Churchill and his Coalition Government commissioned the report in 1941, it was Clement Attlee and his Labour Government who outlined the measures that would be taken. The National Health Service has the following three core principles: Universal – standards are to be the same nationwide, Comprehensive – to cover all areas of healthcare and finally free at point of entry to all. On the 5th July 1948 when the NHS was born it had the following resources, 1143 Voluntary Hospitals – these accounted for 90,000 beds and 1545 Municipal Hospitals – these accounted for 390,000 beds.
Of these beds 190,000 were mental health beds and a further 66,000 were geriatric beds. Not one additional doctor or nurse was employed, what changed was the way the system operated. Point of access was free and the patient no longer paid every time they needed healthcare – instead it was paid collectively through their taxes – making the system much fairer and more accessible to all. The management structure in 1948 consisted of 14 Regional Hospital Boards (RHBs), 36 Boards of Governors (BGs), 388 Hospital Management Committees (HMCs) and 38 Executive Councils (ECs).
At this time the service was low tech and healthcare provision was very basic, and the doctors and nurses that worked within it mostly managed the NHS. Due to the NHS becoming free access to all at point of entry the demand for provisions increased dramatically. During the 1960s staffing levels increased and new technologies like heart and lung machines and kidney dialysis were being introduced. The first kidney transplant was performed in 1960 and the first heart transplant in 1968. A set of sextuplets was born in 1968 following fertility treatment.
Costs for newly developed drugs were rising, but this was all in the main funded by the government. The first major restructuring of the NHS took place in the 1970s. This was when NHS Managers came to the forefront of the NHS (much opposed by many clinicians). First attempts were made to rationalize spending into local areas. Technology was advancing – in 1972 CT scans were introduced and in 1978 the first test-tube baby was born. In the 1980s ‘The NHS Management Enquiry’ introduced general management in charge of clinical staff and in 1989 reforms were introduced to differentiate between the providers and the purchasers of healthcare.
Under the Margaret Thatcher Conservative Government, bed numbers were reduced and funding cutbacks were harsh. Private finance was also being introduced into the system. Advancements in science brought us the MRI scan and in 1987 the first heart, lung and liver transplant was performed. In 1986 the public health campaign over AIDS awareness was the biggest in the history of the NHS. When we reach the 1990s the new Labour government makes many reforms. GP fundholding and NHS Trusts were established showing a major move in this area. Fundholding was subsequently abolished and Primary Care Groups set up.
Postcode lotteries became a political issue and the NHS was beset by scandals such as incorrect cancer results and dirty hospitals. In 1998 NHS Direct is launched – a nurse-led service available over the phone. A new century brings huge changes in the NHS. Significant funds are given in addition to bring the system up to date. Regulators are established to oversee NHS practise – Healthcare Commission and Commission for Social Healthcare Inspection, as well as ‘guiders’ such as National Institute of Health and Clinical Excellence (NICE) and National Patient Safety Agency.
The twenty-eight Health Authorities combine into ten Strategic Health Authorities and the Primary Care Groups become Primary Care Trusts. Drop-in centres are established – providing a more accessible service to all. The NHS is promoting public and patient involvement and in 2006 Extended Patient Choice is introduced – where a patient can choose from four different providers for secondary treatment. In 2007 the NHS launches Patient Choices – a huge website, which encourages patients to choose and book, access their own medical records and it is the most popular health website in Europe with nine million visitors a month.
The Structure of the Government and NHS management and organisation is as detailed below: This diagram shows how that Structure works together with Primary and Secondary care and outside agencies: The Primary Care Trusts are a major part of the NHS and control 80% of the NHS budget. The Primary Care Trusts are local to their communities and make the decisions on how money is best spent in their areas. They are responsible for commissioning to other health care providers these of which are detailed below: •Acute Care Trusts of which there are one hundred and sixty-seven.
Responsible for the hospitals and overseeing that they run smoothly and efficiently, managing their own budgets and responsible for the main bulk of NHS employees – these are skilled workers (doctors, nurses, radiographers etc. ) and un-skilled workers (catering staff, cleaners, maintenance staff etc). •Ambulance Trusts of which there are twelve covering England, and Scotland Wales and Northern Island having there own trusts. Responsible for the transport of patients either as Category A – emergency case (life-threatening), or Category B and C – non-life threatening.
The control centre decides which category the jobs belong in. •Mental Health Trusts of which there are fifty-eight. These provide care for people with mental health problems. They are generally accessed initially by the GP, usually under primary care such as Counselling and Psychotherapy or other patients may need to access more specialized secondary care. •Care Trusts. These are to provide health and social care, and work together with the local Authority to provide this. •Foundation Trusts of which there are one hundred and twenty-nine.
These are new types of hospital run by local managers, staff and members of the public. They have much more freedom over there own budgets and the decisions that they make. These represent the governments step towards de-centralization of the system. There are a number of key aspects of the debate surrounding the political and ethical issues around provision and access to health services. In 1948 the NHS had an annual budget of ? 437 million, in 2008/9 (most recently published figures) it was ten times that at over ? 00 billion. This is funded nationally from Central Government and almost all comes directly through taxation. The costs are rising faster than the rate of inflation mainly due to an increasingly ageing population (40% of expenditure is spent on over 65s), an increasing numbers of immigrants (567,000 last year) and the fact that 1 in 4 babies are born to women who were born outside of the UK. This raises a whole host of ethical and political issues around the provision of funding and access to the health services.
When the NHS was born in 1948 many diseases linked with poverty and malnutrition were common in society. Ricketts, Scarlet Fever, and Rheumatic Fever have all virtually been eradicated due to scientific breakthroughs with treatments and drug therapies. Tuberculosis would have been included within this group but is again on the increase – commonly seen in pockets of immigrants within communities. Vaccinations have almost seen the disappearance of childhood diseases such as Measles, German measles and Mumps. New diseases have been introduced into our society such as AIDS.
Woman do not die in childbirth in their thousands anymore, and the introduction of Sexual Health Clinics means with easier to access contraception and better education, less risk of this and also of dying from a septic abortion. Infant mortality rates are much lower with advances in medicine, technology and neonatal care. In addition to this we are all encouraged to eat better – however a better diet generally means we live longer and the ageing population in our country is a major cause of expenditure.
Costs for conditions such as dementia, cancer and arthritis ave spiralled – the way science and social changes have restructured our society as a whole is another debate entirely. Ethical issues have always been a problem but with an increasingly immigrant population, resources become more stretched as diseases such as Thalassaemia requiring long-standing care are introduced into our country. There are also major ethical issues relating to fertility treatment and genetic treatments. There are a substantial number of access issues within the NHS, and these are increasingly affecting a growing number of the UK population as it is today.
Communication can be a major barrier. Migrants enter the UK and as they have never had a Health Service in their home country, they have no idea how to access it at the Primary Care level, and quite often not even the basic language skills to find out. In a lot of cases they are frightened to ask as they are scared they we will deported back to their home country. Cultural beliefs can make people ashamed and embarrassed to go and see their GP – this is particularly high in elderly Asian women.
Another access barrier can be age – around 25% of people under the age of 25 will suffer from depression/mental illness at some time, but they will rarely do anything about it. This is due to not understanding depression/mental illness and feelings of embarrassment amongst peers and family. This can also account for a lot of elderly people not accessing the NHS. Another reason elderly people will not go to see a Doctor is the fear of the unknown -and also the Great British ‘stiff upper-lip syndrome’.
Some patients can be discriminated against due to obesity, smoking, drinking – different Health Authorities have different criteria’s for accessing certain services and if you do not fulfil them you could ultimately miss out on secondary care. Other treatments can be in what is generally coined a ‘postcode lottery’. This again is dependant on individual Health Authorities and can affect services such as fertility treatment and also access to funding for certain drugs can be highly variable across the Authorities.
Transport can also be an issue for some people as it is not always readily available and people do not know how to access it. The NHS lost £600 million (2007-2008 – latest figures available) through missed appointments. The NHS is currently trying to deal with these issues and bring the NHS forward into the 21st Century. On the 21st January 2009 the NHS Constitution was published and clearly defines the roles staff, patients and the public have in developing the NHS and understanding rights and responsibilities. It is in a clear and simple language and defines expectations about all organisations involved in NHS care.
Lord Darzi developed it after the NHS Next Stage Review, and it is evidence based on what matters to patients, the public and NHS staff. Thousands of people were consulted and extensive research processes involved shareholders, think tanks and experts as well as those detailed above. The Conservative/Liberal Democrat Coalition Government which came to power in 2010 brought with it pre-election promises by the Conservative Party that the NHS was to be ‘safe’ with them. Very quickly the new Government produced a white paper – Equality and Excellence – liberating the NHS.
Many experts argue that the radical changes to be implemented are untried and untested and are urging Andrew Lansley the Health Secretary to slow down. Stating that funding will have to be cut across every part of the NHS – Primary Care Trusts and the Strategic Health Authorities are to be phased out and GPs will be given back control of 80% of the NHS budget by 2013. All hospitals are to become Acute Care Trusts by 2014 and control their own budgets, with much more freedom. Obviously this will save the NHS massive expenditure on managerial staff with these sweeping cuts but one has to ask, has this not been tried before?
In the early 1990s the then Conservative government had GPs become fundholders and the successor labour government subsequently abolished this as it was not working. As a patient and customer of the NHS I have to ask the question, if I cannot get an appointment with my GP for a month now, what an earth will it be like by the time we reach 2013? Big changes are on the horizon for the NHS and I have to ask the question, if there are problems within the service now, how big will they become with massive losses on the budget? As for the three core principles standing the test of time? I am afraid only time will tell.