The NHS provides a vision of service that combines health care that is universal, comprehensive and free at the point of delivery to all in need.
The NHS provides a vision of service that combines health care that is universal, comprehensive and free at the point of delivery to all in need.
Critically evaluate this statement in light of current NHS policy.
The founding principles of the NHS were to create a model of health care that met the needs of the population, whilst wiping out the inequality that occurred between the middle and poorer classes, that were highlighted by the Beveridge report in 1942 (Beveridge 1942).
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The Beveridge report was commissioned by the Conservative Labour coalition government, formed one year in to WW11 in 1940, to survey the existing national schemes of social insurance, and to make recommendations (Beveridge 1942). The report identified the '5 giant evils' of society being; squalor, ignorance, want, idleness and disease, which lead to Beveridge's guiding principles that social security 'must be achieved by co-operation between the State and the individual'(Beveridge 1942), whereby the State will establish and provide a national minimum. Although no recommendations were made at that time with regards to a National Health Service, Beveridge concluded that such a scheme was essential to a satisfactory system of social security (Beveridge 1942). This report could be seen as the catalyst for change in the welfare system that was the basis for the creation of the NHS.
In 1943 Winston Churchill released a speech entitled 'After the War', describing the implementation of measures including a national compulsory insurance for all classes for all purposes 'from the cradle to the grave' (BMJ 1995). This was met by opposition from the Labour party who were in favour of a state run National Health Service as opposed to local health centres and district hospitals (Beveridge 1953). The Coalition governments were agreed however, on not implementing any measures until after the war. Post war, in 1945, Labour won the general election, beginning the social collectivist era. With the country already used to state intervention during the war era with rationing and directed employment, a Keynesian economic model was adopted during post war economic expansion, increasing state intervention in social affairs and forming the basis of the Welfare State.
The Welfare State was formed on several acts of parliament including 1946 national insurance act; 1946 National Health Service act (http://www.legislation.gov.uk/ukpga/1965/51). Ahead of these in 1945 Bevan presented the Cabinet with a slightly altered NHS framework - the Tripartite Administration, in favour of the nationalisation of hospitals, with no responsibility filtering down below central government level (Ryan, M. 1972).
On July 5th 1948 the National Health Service came into being, and although to the general public there were no noticeable changes, no new hospitals etc, services were now free at the point of access. Being financed solely from taxation, and reflecting Beveridge's recommendations for the state to provide a national minimum of health and social care, the NHS addressed inequalities in the rich/poor healthcare divide through the rich contributing more than the poor for the same healthcare benefits. (http://www.nationalarchives.gov.uk/cabinetpapers.htm). This consensus between Left and Right secured the ethos, and future of the NHS, with both Conservative and Labour parties acknowledging the necessity for a national health service, making it Britain's 'most successful nationalised undertaking' (Hart 2006).
In 1949 this changed however with the introduction of the Amending Act, which allowed prescriptions to be charged for. 'On 1 June 1952, charges were introduced for the first time and continued until their abolition on 1 February 1965. Prescription charges were reinstated in 10 June 1968' (http://www.bma.org.uk/health_promotion_ethics/drugs_prescribing/FundingPrescriptionCharges.jsp), more than likely due to prescription costs rising to a staggering 19 million per month in 1951(http://www.nationalarchives.gov.uk/cabinetpapers.htm). This was the first major deviation from the founding principles of the NHS, followed by charges for Dental and Optical care in 1988, as patients were expected to pay upfront for non emergency medication.
Despite the Guillebaud report of 1956 showing the NHS cost efficiency and that any decrease in funding would lead to a less comprehensive, reduced service NHS (Guillebaud 1956), the cost of running the NHS continued to rise. Politically, the Conservative party were prioritising a decrease in public taxation, however with NHS costs continuously rising, and direct charging deemed 'politically unacceptable' (http://www.nationalarchives.gov.uk/cabinetpapers), the Conservatives passed the National Health Insurance act of 1957, doubling national insurance contributions in an attempt to not be seen to be raising income tax (Hall 2003). Doing this was the only way to ensure the future of the NHS, and maintain a service that is both comprehensive and free at point of access.
This rising cost of the NHS was at odds with the Beveridge report projection that as people became healthier, the cost of running the NHS would decrease. In the 1962 Porritt Report, the medical profession whilst believing the philosophy and concept of a National Health System was sound, it was not encompassing, with the separation of the NHS into hospitals, general practice and local health authorities, and began the debate on the structure of the NHS (Porritt 1962). It could be argued that by keeping the areas of care separate, the government paved the way for the privatization of services and independent contractors that may increase costs and exploit the NHS (Pollock 2006).
In 1964 Labour regained power. Prescription charges were initially abolished, but reinstated only a year later. In order to address the potential inequality in access to medicines for the poor means testing and certain exemptions had been introduced. Prescription charges were waived for certain chronic conditions, pregnant women, children under 16, adults over 60, and those on means tested benefits such as income support, jobseekers allowance, and the NHS low income scheme (http://www.bma.org.uk/health_promotion_ethics/drugs_prescribing/FundingPrescriptionCharges.jsp) thus leveling any disadvantage those in most need may face and continuing a universal service.
1979 saw the entrance of Thatcher and the Right Wing government. This period of 'Thatcherism' held a strongly anti-collectivist view, encouraging healthcare autonomy, however even they never 'openly handed it over to corporate business' (Hart 2006).
The Griffiths report in 1984 suggested the restructuring of the NHS, with managers put in place to manage budgets without any 'training in public health or the principles of health care delivery' (Pollock 2006), which began the decline into the business paradigm of the NHS, and the privatization of services. Between 1999 and 2003, Millburn the then Secretary of State for Health invited a bidding war between private firms to take over NHS clinical services, with the idea being to drive down costs and increase efficiency. A few years later junior minister John Hutton would argue that 'only by introducing competition and choice could Britain secure the values on which the Welfare State was founded' (Hart 2006). However, with hospital fund holders now having to buy in external services, the same levels of care are not universally available, with patients now only having access to certain care if there was a contract in place for it. Some health authorities brought in limits to the amounts of available care and differences were made between health care and social care, the latter being charged directly to the patient for (Pollock 2006), and expensive conditions, those chronic or some transplants became increasingly unavailable. This defies the original principles of the NHS by being neither free at point of access, nor not included in what is supposed to be a comprehensive service. By allowing services to be bought and sold, Pollock believes that they 'accelerating erosion' within the NHS and removing the right to healthcare, the basis on which the NHS was created (Pollock 2006).
A potential turning point in health care came in 1980 with the Black report, which identified that for healthcare to be universal it was necessary to not only look at a medicinal model of health. Such a Cartesian view of the body will be reflected in the services provided, such that 'the health care services will give priority to such matters as surgery, the immunological response to transplanted organs, chemotherapy and the chemical basis of inheritance' (Black 1980), and it is in fact necessary to 'evidence of a wide variety of health conditions and their social, environmental and psychological as well as physiological significance' (Black 1980). Black placed increasing importance not just on the provision of medicines, but also on social strata, pay, living standards, levels of unemployment and education when considering the health of a nation. It became clear that even 40 years after Beveridge's report there was still 'demonstrable deprivation' occurring in Britain (Hills 1994).
In 2008 health secretary Alan Johnson commissioned another report, which echoed the previous findings of Black in 1980, that healthcare will not be universal and comprehensive until the social gradients have been addressed by actions that 'must be universal, but with a scale and intensity that is proportionate to the level of disadvantage' (Marmot 2010).
The report recommended these 6 actions as ways of addressing the social gradient;
Give every child the best start in life.
Enable all children young people and adults to maximise their capabilities and have control over their lives.
Create fair employment and good work for all.
Ensure healthy standard of living for all.
Create and develop healthy and sustainable places and communities.
Strengthen the role and impact of ill health prevention. (Marmot 2010).
However, 30 years on from the Black report, these social inequalities remain a problem, suggesting that whilst the awareness of these social factors exists, they have still not been overcome. As we can see from this graph, updated in 2009, there are still enormous gradients in health, with males from manual working backgrounds twice as likely to die as those from professional ones.
These social gradients can be small or large scale, for example, government derivatives in Scotland and Wales have most recently deviated to a more encompassing service allowing free prescriptions to all, not just those in most need, making the service universal and comprehensive regardless of social classification, employment and pay. However by doing so, they have increased the difference in universal access between location, as it is now easier and cheaper to receive non emergency health care in Scotland and Wales but not for the population residing in England. Whilst this may be an ideal to aim for, it may not be the most feasible model of healthcare, due to the ever increasing percentage of Gross Domestic Product (GDP) that the NHS takes up, which currently stands at 8.5%, reaching an astounding 120 billion pounds (Harker 2011).
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In 1997 New Labour won the election mainly on the premise of their healthcare policy, advocating a social health model, with increased funding for better quality of services. In 1999 they opened NHS walk in centres where anyone could go for non emergency health care. This increased the universality of the health care system, as patients could now be seen same day, without an appointment, and without being placed on a waiting list. However, this could be seen as a response to the current governments cutting of any benefits for those purchasing private medical insurance (tax relief for the over 60's and employers exemption from National Insurance contributions), creating a fall of 440,000 in coverage, and thereby potentially increasing demand on the NHS (Emmerson 2001).
This was most likely to hit the poorest areas of the country hardest, as data shows that, although private medical insurance was more common amongst the richer classes, they were also more likely to have an employer pay for it, so the changes in taxation affected them the least.
Geography can play a vital role in access to care, as demonstrated by Gubb in 2007.
"There are real variations in the time waited by patients both geographically and across medical specialities. For example, just 25% of orthopaedic patients are seen within 18 weeks, compared with 79% of those receiving thoracic medicine; and just 33% of patients in the South East Coast SHA are treated within the target compared with 60% in the East Midlands SHA" Gubb 2007.
However, this is one target the Labour government at this time was aiming to reduce, as by decreasing waiting periods across the board the equality of the service was increased, thereby making it more universal in its nature. This was achieved, and by 2007, nearly 100% of patients were offered a GP appointment with 48 hours, compared to the 75% in 2002 (http://www.civitas.org.uk/nhs/download/waitingtimes.pdf).
In 2009 the Department of Health released their 2nd quarter statistics, again showing a huge variation in appointed care between the different Strategic Health Authorities. In London, over 160,000 patients were waiting for a first outpatient appointment, with nearly 1,400 having waited a period of 12 weeks, in comparison, the North East SHA showed the lowest statistics with 46,000 patients waiting in total, but only 48 having waited for a period of 12 weeks. In terms of waiting times however, the West Midlands showed the highest proportion in length of waiting time, with 193 patients still not receiving an appointment at the 17 week plus mark. (http://www.performance.doh.gov.uk/waitingtimes/index.htm).
It could be postulated that the patients in those areas waiting the longest for treatment, are not receiving the same level of service as those with faster access to services and treatment. The services provided are still comprehensive, but are not universal by nature if different areas of the country are receiving different standards of care.
In addition, the 2008/9 NHS Atlas of Variation identified a distinct variation between the comprehensiveness of the service being offered. It showed up to a 50 fold variation in the levels of care in different Strategic Health Authorities (http://www.rightcare.nhs.uk/atlas/qipp_nhsAtlas-LOW_261110c.pdf). Whilst talk of 'post code lotteries' remains something of an anathema, it is clear from this report that there is a huge variation in the quality and standard of care being offered between trusts. More importantly, however, it would seem that patients are not receiving the same basic care all round. For example, the National Institute of Health and Clinical Excellence recommend all persons with diabetes to have a 9 key care process to assess the progression of their condition, and its impact upon their nervous system, central and peripheries, by monitoring weight, blood pressure, blood glucose and other checks, the treatment of which has been shown to reduce diabetic complications. However, there is a 35 fold variation between SHAs offering this basic standard of care. Taking this one step further, the lack of basic care increases the patients' likelihood of heart attack, stroke, kidney failure and limb amputation, and yet there is a two-fold variation amongst the SHA's in the incidence of major amputations per 1000 patients with diabetes, due to a lack of a specialized Multi Disciplinary Diabetic Team (MDT) in some authorities (http://www.rightcare.nhs.uk/atlas/qipp_nhsAtlas-LOW_261110c.pdf).
In conclusion, the current NHS offers a service that is still free at point of access, and still comprehensive albeit not immediately nor to all locations. However it would be fair to say that the current arrangement provides the most promising way of 'promoting distributional equity' (Bevan 1989). A continuum of care is still provided, covering patients from the cradle to the grave, and thus fulfilling the original philosophy, however, until the factors underlying social deprivation (class stratification, employment, education etc) are fully resolved the NHS cannot be completely universal. The WHO commission states that 'social injustice is killing on a grand scale' (W 2008), and yet it seems to be the main factor standing between our vision of an ideological NHS, and the current reality.
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