Since 1948 the NHS has undergone significant changes in its structure and mode of operation. There is a distinct shift as witnessed by a change from the fully public model of care delivery towards increasing private participation in the NHS system. The increasing health care consumption and cost pressures have, to an extent, compromised on the original 1948 manifesto of totally free health care access to all. While the restructuring of the NHS listed in the white paper ‘Equity and Excellence: Liberating the NHS’ is in response to changing demands, care should be taken in the form of having enough performance monitoring and quality checkpoints that ensure that private participation does not erode some of the fundamental strengths and qualities of the NHS, the most basic of which is to enable equity of access to quality healthcare.
The NHS was launched on July 5th 1948 by the then health secretary Mr. Aneurin Bevan with a view to provide healthcare for all based on citizenship and need and not based on the ability to pay. It was fully funded by taxation. The NHS therefore became the central umbrella organization that provided all medical and related services free at the point of access to all UK citizens (NHS, 2011). Since its inception the NHS has transformed significantly and today it has become the world’s largest publicly funded healthcare system (NHS, 2013). The NHS employs more than 1.5 million people (White, 2010, pg 3). Though the original manifesto of the NHS was to provide quality medical care for all those in need irrespective of their ability to pay, the NHS has underwent a series of changes and reforms over the last several decades. The aging society, increasing health care demands, and the financial pressures it creates on the healthcare system have in effect necessitated some significant reforms in the way the NHS operates. This paper will discuss these changes in structure and functional aspects of the NHS as highlighted in the white paper ‘Equity and Excellence: Liberating the NHS’ (DH, 2010) and some fundamental reforms in context of the passing of the Health and social care bill 2011.
In the first 25 years from 1948 there was a clear distinction in that community health services were managed separately by the local authorities while hospitals were managed by the NHS. Some structural changes in the NHS were bought about in 1974 and since then both community health services and hospitals have together come under the purview of the NHS (Webb, 2002, pg 4). Under the original 1948 manifesto cost was not a factor and doctors were advised to provide the best care for the patient without any cost considerations (Leathard, 2000). Growing medical bills and budgetary deficits have constrained the government in fully implementing their primary manifesto of providing free treatment at the point of access, and gradually since 1951 charges were introduced for dentures and spectacles (Leathard, 2000, pg 34). Similarly since 1952, prescription costs were introduced. Over the years prescription charges have witnessed an incremental increase and as of April 2012 prescription charges are at 7.65 (Politics .co.uk, 2012). Widespread protests against the prescription charges have contributed to several exceptions in the prescription drug charges including for children under 16, pregnant women, elderly people above 60, etc. More recently people with chronic conditions such as cancer have been included into those under the exempted category. While in Wales and Northern Ireland prescription charges have been completely abolished, the English government has, however, indicated that no further free prescription programs would be introduced but that the new policies would focus on brining more fairness into the prescription charging system (Politics.co.uk, 2012).
Transition to a Market System
Chronic underfunding and gaps in services and the pressures to improve the overall operating efficiency have gradually led to the NHS from being a total public ownership entity towards a market based system. In fact this shift towards a market based system could be traced way back to the Thatcher administration that introduced the policies of ‘general management’ and ‘outsourcing’ which bought about a fundamental shift. General managers were people who were specialized in hospital management and provided a neat layer of interfacing between the health policy makers and the doctors and nurses who implement the policies. Outsourcing of non medical services such as hospital cleaning, catering saw for the first time the entry of the private sector into the NHS system (DH, 2005). Since then private sector participation in the NHS has improved significantly. By the late 1990’s, for instance, long term care by NHS was already taken over to a large extent and managed by private for profit service providers. Long term elderly care is no longer free of cost. Increasing private participation could be inferred from the statistics that from over 137,200 residential care homes in 1985 the numbers had dropped to 64,100 by 1998 (BBC, 1999). Elderly care in these settings is not free and is totally means based with those earning more than ?16,000 per annum having to bear the entire expenses while the state provides maximum assistance for those under ?10,000 categories.
NHS Spendings review points out that between 1998 and 2010 there was an average 5.75% increase in health expenditure while the NHS is slated to receive .4% real terms growth between 2010 and 2014. This indicates the degree of financial pressure under which the NHS is operating. As (Appleby et al, 2009) points out, the pressure on NHS will continue to increase with growing challenges due to a mixture of factors including an aging demography, high cost pressure of new medical technologies, and the expectation for higher quality standards. It is estimated that the NHS has to make considerable cost cuttings by way of improved operational efficiency to the tune of ?15 to ?20 billion in order for it to be able to continue providing equitable access to healthcare services to all the citizens(Nicholson, 2009). It is under these dire circumstances that the UK government proposed some fundamental structural and functional reforms to the NHS that are listed in the white paper ‘Equity and Excellence: Liberating the NHS’.
One of the fundamental changes to the organization of the NHS as listed out in the White paper is the devolution of the ‘Primary care Trusts’ (PCTs) (Nuffield Trust, 2010). The PCTs which were instituted in 2002 to supervise primary care provision is no longer a valid entity. Its function has been taken over by Clinical commissioning groups (CCG) comprising mainly of local GPs. The idea behind such a reform is to increase local empowerment. Furthermore the PCTs were in the past struggling with frequent restructuring. One of the underlying motives behind such a transformation is to place greater responsibility with the local GPs as they are directly involved in service referrals. Also since GPs are directly involved in both commissioning and care provision they are better positioned to make effective assessments and to prevent unnecessary hospitalization and other services. In other words, the establishment of the GP consortia which is one of the highlights of the ‘Equity and Excellence: Liberating the NHS’ white paper, is expected to increase the integration between the GP’s , specialists and other service providers paving way for an integrated care delivery mechanism that is both cost effective and efficient.
Furthermore, the white paper also refers to the formation of a NHS commissioning board that supervises the overall equitable access to NHS services, commissioning, and the proper allotment of resources. This would ensure that micromanagement is not an issue at the NHS. The new policy framework also dissolves several quangos thereby resulting in greater operational savings. By these means the new reforms are slated to save up to 20 billion in terms of efficiency of operations by 2014. Projections indicate that up to 45% savings could be realized in the form of management related cost savings (DH, 2010, pg 5).
One of the distinctive factors of the current NHS reforms compared to the original NHS policies is the shift from a purely public system towards a more market centric healthcare system. The focus on increasing the participation of the patient and providing them the choice as to their service providers and the treatment that they want are particularly prominent aspects of the new healthcare bill. . The inclusion of the ‘choice of any willing provider’ in the ‘Health and Social Care Bill’ lays stress on the increased freedom for the health consumer (DH, 2010, pg 17). It also emphasizes the increasing competition among contracted health service providers which is ultimately good for improving the overall quality of health care delivery.
Reduction in bureaucratic control and empowerment of the care providers imply that the primary care providers’ could function independently and effectively to meet the needs of the patients. Effective monitoring is the key to any functional system. For a huge organization such as the NHS monitoring the functioning of the various agencies and systems is very vital for achieving streamlining of operations, process efficiency and achieving high quality of care. One of the key aspects of the new reforms is entrusting local health watch organizations with the responsibility of managing and addressing the feedbacks from the health consumers. These organizations also support the patients in making their decisions about service providers. These organizations will directly report the performance measures of service providers and patient feedbacks to local as well as national authorities helping to address any consumer grievances and quality concerns at the earliest(DH, 2010, pg 19).
While there are proponents for this new system there are also concerns expressed by politicians, professionals and general public who are worried that the competition between medical service providers would engender compromise on quality of services contrary to improving the same. This is particularly so when these decisions are made on the bidding approach and when lower cost of service provision is the main criteria. One particular instance is the drug and alcohol support services that are vastly privatized in the UK. These private organizations are paid ?3000 if the addicts are rehabilitated and remain free of drugs for 3 months and a further ?5000 if they remained drug free for a whole year. There are complaints that under these circumstances, in these private organizations, the focus is not entirely on rehabilitation and saving the patient is not the primary concern. As a case in point, an extreme heroin addict was just discharged from the clinic without any alternative intervention. Methadone prescription for detoxification was not even tried as the private company would not be remunerated for such an intervention (Pemberton, 2013). . Furthermore since the entire drug and alcohol services is taken up by the private organizations there was no further referral or intervention possible for such cases. These are instances that point out the risks in adapting a privatized and highly fragmented setup. Furthermore there are concerns that under the concept of ‘payment by results’ that is advocated under the new NHS policies, there is even more risk that the private agencies would just focus on achieving end points of care. While this approach would be okay for acute clinical conditions it leaves a lot to be desired in the management of chronic conditions where there is no visible endpoint.
From the time of its institution in 1948 to the current period, the NHS has undergone significant changes in its mode of operation. Presently, there is a distinct shift in healthcare focus as witnessed by a change from the fully public model of care delivery towards increasing private participation in the NHS system. Growing elderly population and increasing strain on its health services have forced the NHS to adopt these new and novel approaches. These include a fundamental change in its mode of care delivery with the increasing private sector participation in care delivery. Though maintaining free point of access care delivery is one of the main mottos of the original 1948 NHS manifesto, the increasing health care consumption and cost pressures have, to an extent, compromised on this objective. Today many services such as prescription drugs, long-term care are no longer free and there is increasing private sector participation as contracted service providers. The purely fragmented approach of private sector service providers who are driven by a contractual obligation and cost centered focus, would definitely compromise the quality of services and the original advantages that the NHS offered. While the growing needs and the changing demands have necessitated such drastic transformation of the NHS system, care should be taken in the form of having enough performance monitoring and quality checkpoints in place that ensure that private participation does not erode some of the fundamental strengths and qualities of the NHS, the most basic of which is to enable equity of access to quality healthcare.
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