Discussing principles of universal healthcare in the NHS

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The NHS was set up in 1948 in response to illness and poverty within the UK brought on by the Second World War. The vision was that the NHS would provide healthcare that is universal, comprehensive and free at the point of delivery (Klein 2004). This would suggest that the NHS would treat everyone regardless of class, origin, financial status and illness and free it would be free to all. This essay will discuss these principles with reference to current NHS policy.

The inception of the NHS was influenced by the release of the Beveridge Report in 1942 (Ham, C. 2009, pp.13-14). This report suggested that there were large amounts of sickness and ill health within communities following the war and formed the notion that a service providing healthcare to the whole population without charge would reduce sickness and ill health. Beveridge (1942) also stated that as health in the UK increased the money required to fund the NHS would reduce and people would live in a healthier society with healthier workforces. However, what the Beveridge Report (1942) did not account for was the rise in life expectancy and the consequent rise in demand on NHS. As a result, instead of the expense of the NHS decreasing as suggested in the Beveridge report (1942) the opposite happened. This is identified in the Office of Health and Economics (2008) paper titled 'Sixty years of NHS expenditure and workforce' and shows that the NHS's expenditure in its first year was £447 million in contrast to the year 07/08 where its expenditure is estimated to be £114,541 million. Dixon et al (1997) points out the fact the NHS experiences many demands in demographics, new technologies, and increasing expectations which lead to the increase in expenditure of the NHS that is not attainable even with increases in funding. This suggests that the ability to provide a comprehensive service is jeopardised in that if the NHS does not have the funding to sustain itself it questions how the NHS can keep up with expensive and continuously advancing medicine. Furthermore, with the expenditure the NHS requires to function effectively the ability to provide healthcare free at the point of delivery becomes vulnerable. Even the NHS Choices website states that not all healthcare is free as we have to pay for optical, dental, and for some people prescription charges. The argument presented is that exceptions to the principle free at the point of delivery, regardless if everything else is free, is a clear indicator that it is no longer free and therefore should not be regarded as such.

However, The Institute for Innovation and Improvement attempts to provide some solutions to vast expenditure allowing the savings made to be utilised elsewhere in the health service. In their publication 'Prevention is better than cure' suggests that prevention is more cost effective than treatment itself and points out, initiatives should aim to reach out to people to educate, advise and motive them to assist preventing them having complications later in life. An example of a prevention strategy is the smoking cessation service that can be accessed by anyone at GP surgeries and pharmacies (NHS Choices, no date). This illustrates organisations attempting to find ways to reduce later life complications and effectively reduce expenditure caused by these complications. The money saved from these interventions can be spent on more services to move towards a more comprehensive health service and also prolonging the funding required to provide these services free at the point of delivery.

The Griffiths report (1983) provided Thatcher government with grounds to introduce general management and their Ring Wing ideology of internal markets and privatisation into the NHS (Ham, C. 2009, pp.32-39). The Griffiths report (1983) identified that the NHS was failing to use its resources effectively and efficiently. Therefore, the report suggested that the NHS required general managers to be appointed within the NHS structure. According to the report these managers would monitor budgets and cost effectiveness of the department, motivate staff, and to lead the department to continually look to improve the service. Furthermore, the Griffiths report (1983) pointed out the need for outsourcing to create competition. The Health Authorities outsource services with the reasoning that it would create competition and drive down the costs (Ham, C. 2009). Baggott (1997) evaluates the impact of the internal market. Baggott (1997) suggests that the purchasers of services were restricted due to the budget in place and the providers were concerned with cutting cost. The article suggests that this resulted in a geographical difference in services provided and that some services that had been cut from the area were only provided on ability to pay privately. This goes against every founding principle of the NHS. The use of private companies within the NHS has continued with the Department of Health (2007) actually acknowledging this compromise on universalism in their publication 'Post code lottery of care' that states that there is still unequal distribution of care dependant on the wealth of the area. However, on the positive side of things it means that the PCTs can invest in services which are needed by the local community instead of putting money into services unnecessarily. Furthermore, if the NHS services in an area does not provide a particular need of a patient but a nearby private establishment does the Labour government stated in their NHS 2000 plan that the private company could be used for that patient but paid for by the NHS (NHS plan 2000).

Pollitt, C. et al (1991), produced a study regarding the effectiveness of the implementation of the Griffiths report recommendations from professionals within the NHS. The study by Pollitt, C. et al (1991) found that the general managers felt that they sometimes had to forget that there were patients in the hospital and push to drive to get long term patients back out into the community. This suggests that those patients requiring longer care are not getting a comprehensive service from the NHS in that their treatment time is not sufficient for their needs. Another drawback to the appointment of general managers was that they did not appreciate clinical matters which caused tensions and rifts to widen within the general management and clinician relationship (Pollitt, C. 1991, p.71). However, Ham,C. (2009) suggests that general managers have proved their worth in that they are necessary in order to implement, carry forward policies and push to meet targets and performance standards. With this in mind, it is important that health professionals beginning employment within the NHS are aware of the pressures regarding targets enforced by general managers. Health professionals will have to do their upmost to ensure that patients are getting the most out of the service before they are discharged in order to maintain a comprehensive service.

The Black Report (1980) was an in-depth report into the inequalities between social classes in the UK. It clearly highlighted that people living in poverty had a higher mortality rate than the wealthier people in society. As a result, the Black Report (1980) suggested interventions to be put in place by the government in order to help these people improve their health status. The report suggested that the Government should make children and the disabled a priority and also that the Government should look to put in place preventative and educational strategies in place to assist in reducing inequalities in health. When this report was published the Thatcher Government were in power. Smith, T. (1990) states in his article that the Government rejected the proposals set out by the Black Report with their argument that the proposals were impractical and unachievable. Smith, T. (1990) also suggests that the Thatcher Government asserted their Right Wing ideologies that it is the people's responsibility to look after their own health and not to expect the Government to intervene. Although this article is outdated it highlights how the Government's reaction was interpreted by the people at the time. Evidence of the Governments dismissal of the report is highlighted in Patrick Jenkin's (Secretary of State for Social Services) foreword within the Black Report (1980). He clearly suggests that the proposals are 'unrealistic' and clearly states that he will not endorse the proposals. Taking this into consideration it is clear that the Government at the time was not prepared to assist the poor in order to help them progress, improve their health, and improve their social status. As a result the inequalities between the wealthy and working class would remain. Considering these findings it is clear that the NHS and the Thatcher Government failed to provide a universal service.

The issue of inequality was highlighted again in 1998 by the Acheson report following the Labour party being elected into power. This report illustrated many similarities to the Black report. The Labour government, with their intrinsic state intervention ideology, they set about tackling these inequalities rather than dismissing them (Bambra, C. et al 2005, p.190). It can be seen in the NHS plan (2000) that many of the inequality issues such as accessibility are being tackled within the NHS. Within the NHS plan (2000) there is a clear emphasis for health provisions to be moved out of the direct NHS setting such as GPs surgeries into the community to assist with accessibility. There are many health provisions in place that can be accessed at local pharmacies such as the minor ailments scheme, smoking cessation, weight loss programmes (NHS Choices, no date). NICE (2008) published a paper regarding the smoking cessation schemes in place in pharmacies. The paper suggests that pharmacies are more accessible for patients in deprived areas who possibly find accessibility difficult. Moreover, the paper suggests that pharmacies have the ability to treat a larger number of patients due to location and later opening hours. This is a clear demonstration of the Government actively putting policies in place to achieve the principle of a universal NHS by extending accessibility. As a result healthcare professionals may find themselves working in the community rather than in a hospital setting. Therefore, professionals such as physiotherapist may find themselves working in the community setting where there may not be the same equipment found in the hospital setting. Therefore, these professionals will need to adapt and find ways to achieve successful programmes without the assistance of expensive equipment.

However it should also be noted that there is an underlying cost saving benefit for the Government when implementing community projects. Baqir (2011) has recently published a paper looking at the minor ailments scheme in place in the North East of England. Their results demonstrated an approximate saving of £80,000 per annum as a result of the scheme. The study points out that the majority of this savings comes from freeing GP resources allowing GPs to focus their attention to more complex patients. It should be noted that this source may pose bias as it was funded by The School of Pharmacy, Health and Wellbeing who would obviously have a vested interest in the pharmacy sector gaining health contracts. In spite of these efforts to tackle inequalities in healthcare The Marmot Review (2010) demonstrates that these inequalities in health still exist today suggesting that the health initiatives and policies laid out by the Governments have not eradicated this issue bringing into question the NHS principle of universalism.

Old Labour's Left Wing ideologies go against the internal market and privatisation created within the NHS by the Thatcher government (Ham, C. 2009, p.51). However, New Labour recognised that the integration of private companies within the NHS had some advantage (Ham, C. 2009, p.51). It is clear in the NHS plan (2000) that New Labour has moved further right from their left wing ideology and continues to allow the private sectors to have input into the NHS for the benefit of the NHS and the people using it. The plan suggests that the private sectors should work with the NHS and that the NHS should also be able to utilise its own expertise to provide the best possible healthcare to patients. In order for the NHS to become universal and free at the point of delivery the Government decided that if the NHS could not provide a particular service but a private hospital could the NHS would pay for the patient to be treated within the private hospital (NHS plan, 2000). This allows patients to receive their comprehensive treatment which they may not have been able to access previously without having to pay the private treatment costs. This clearly demonstrates the government working towards a comprehensive, universal, and free service which the NHS was founded upon. Nuffield Hospitals are an example of this in working practice. The website for Nuffield Hospitals state that NHS patients can be treated in these private hospitals paid for by the NHS. This is important for healthcare professionals working within private practices in that they should be aware that it is not always private paying clients that are treated in these hospitals. Furthermore, healthcare professionals in this environment must ensure they do not discriminate in these circumstances giving priority to paying clients.

There are treatments being developed that the NHS is unwilling to provide patients as they are not cost effective. Under NICE guidelines, some drugs are just not cost effective enough to warrant funding on the NHS. NHS Choices (no date) clearly states that the NHS does not have unlimited money to spend on treatments and therefore they must decide which treatments are of benefit with regards to their cost and effectiveness and they depend on NICE to provide the evidence to base these decisions. This example highlights the criticism that the NHS is no longer comprehensive. However, with technology and research constantly moving forward and the formation of new but very expensive interventions it would be almost impossible to provide a comprehensive service that is equally distributed to all in need. The above example highlights the conflict between morals, in that the NHS attempts to provide for all eventualities however their funding restricts them in achieving this (NHS Choices, no date).

The Foundation Trusts are a symbol of the Government's intentions to decentralise the health service as they are not regulated by the central government (Department of Health, 2005). The notion that these Trusts are free to do as they please with the tax payer's money is worrying. However, this is not entirely true. They are monitored and inspected by the board of governors (Department of Health, 2005). The Foundation trusts aim is to provide healthcare to meet the population's needs whilst meeting the founding principles of the NHS (Department of Health, 2005). However, when analysing A Short Guide to NHS Foundation Trusts publication made by the Department of Health in 2005 there is no mention of two of the principles. The fact that the Foundation Trusts, who directly affect what services are available to the people of their area, do not consider two of the founding principles of comprehensiveness and universalism is highly significant in highlighting that these two principles are no longer at the forefront of the NHS services.

In summary the NHS is no longer universal, comprehensive or free at the point of delivery. It is not universal due to the fact that different areas pick their own differing services so there is no consistency in what the NHS provides. It is not comprehensive because it fails to offer all treatments available due to lack of funding. It is not free at the point of delivery due to the charges placed upon dental, optical and prescriptions. This essay has pointed out that the NHS and Government does strive to achieve the NHS's founding principles however as a result of the expenditure rising year on year within the NHS it would appear that all three principles cannot be achieved collectively. As pointed out by the NHS choices website there is not enough funding to be able to provide every single treatment to everyone in need of it whilst it is still free of charge. Future recommendations would be that if the Government is unable to provide a treatment to all in need of it, it should not be licensed for supply either on prescription or privately. This compromises the comprehensive principle of the NHS but at least it is equal and fair to all regardless of social status. Furthermore, in order for the companies providing expensive treatment to keep business it would have to strive to lower the price of their services. As a result, this recommendation may have a positive effect on the comprehensiveness of the NHS. The main issue highlighted in findings of this essay is that all three founding principles cannot be achieved collectively. However, what is apparent throughout the evidence presented is that organisations are still striving to achieve the founding principles within the NHS. This would therefore suggest that the principles are still present in the making of current policy, however, they have not been fully achieved.