This assignment will outline the main principles of the 1948 National Health Service and will provide a commentary on the organisation and structure of the NHS.
To begin this assignment will provide context by briefly exploring healthcare provision prior to the development and implementation of the NHS.
Godber (1988) suggests that prior to the development of the NHS the ‘Poor Law’ had provided health care support for the indigent in Britain for nearly a century and this included institutions and infirmary wards with a medical officer in charge to provide healthcare with the larger ones gradually taking on the functions of general hospitals for the acutely ill. Voluntary hospitals, which were often run by charitable organisations developed specialist services. Hospitals for patients with communicable diseases, tuberculosis, and mental illness and handicap had long been provided by local authorities; originally for public safety. Hospital surveys carried out during the Second World War revealed not only shortages of beds and buildings in a poor state, but that services were not provided in the areas which most needed them (Powell, 1992).
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From 1911 personal health care for low income workers was provided through National Health Insurance; however this did not cover hospital care. Other medical care was often delivered by general practitioners and payment for services was a matter for the individual, therefore it was often the rich or affluent that had access to healthcare rather than the lower classes.
The Beveridge Report of 1942; which was a very influential report on social insurance and allied services, identified five evils within the society of the day: want, ignorance, disease, squalor and idleness. It was recommended in this report that a compulsory system of state insurance (to which employers, employees and the state would contribute) would be established to cover sickness, unemployment, retirement pensions and support for young families (National Archives, 2011a). The Beveridge Report (1942) pointed to the establishment of a comprehensive national health service as a necessary underpinning to a national social insurance scheme. The Labour Party had a long-standing commitment to a national health service and when they came into office in July 1945, Aneurin Bevan was appointed Minister of Health. Within a matter of weeks, Bevan produced a plan for a fully nationalized and regionalized National Health Service (National Archive, 2011b).
At the conclusion of the Second World War Britons wanted a change in how healthcare was delivered particularly as medical care had made big advances in the war, soldiers had been offered higher standards of care than they were likely to encounter after demobilisation (Portillo, 1998). Civil servants and politicians had identified a growing momentum towards change and began looking at opportunities for transformation in how health care was provided.
The National Health Service
Britain’s National Health Service came into effect on the 5th of July 1948; it was the first health system to supply free medical care to the whole population and the first healthcare provision that was based not on an insurance principle but on the provision of services available to everyone (Klein, 2006). The transformation from fragmented and inadequate care provision to a structured and accessible body was unique and although planning had taken many years with varying obstacles; such as the outbreak of war and changes in political leadership, the implementation of a progressive and universal way of delivering care to all was finally introduced. As such, the new health service arguably constituted the single biggest organizational change and greatest improvement in health care ever experienced in the nation’s history (Webster, 1998).
The NHS brought together all of the hospitals; regardless of ownership, and also the doctors, nurses, pharmacists, opticians and dentists that were once paid through charity or private funds into one organization.
The Main Principles of the NHS
Underpinning the NHS is a set of core principles and Bevan (1952) stated that the essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged. With the development of a national health service the three main core principles cited by Bevan (1948) were that it met the needs of everyone, it should be free at the point of delivery and that it should be based on clinical need, not on the ability to pay. These principles ensured that every member of the British nation from young to old and from rich to poor were able to receive free health care for any medical condition, a phenomena that was unusual to say the least in comparison to how heath care had been delivered previously. The introduction of the National Health Service ensured medical treatment and poor health was not overshadowed by concern regarding finances and payment or that members of society lived in fear of medical expenses they could not afford.
Beckett (2004) suggests that within a month of the vesting day of the National Health Service, in 1948, 97 per cent of the general public were “signed up” for treatment. This was viewed as a triumph for the minister of health, Aneurin Bevan, as it was perceived that he had built a system of care and disease prevention on a set of principles never seen before in any global society. These core principles ensured that everyone would have their healthcare needs met and even today the three principles remain the foundations from which modern health care services are delivered; in essence homeless people requiring care for frostbite or dental pain can receive access to health care as can wealthy property developers who have had a skiing accident or have the need for a wisdom tooth to be removed.
The National Health Service may be perceived to be free to those requiring medical care and treatment, however the service requires funding to ensure practitioners employed are pad and that resources such as medicines, equipment and treatment areas are funded. To do this from inception the NHS has been funded by a system of taxation levied by the government, contributions are made through systems of national insurance contributions and income tax with small amounts being made through private practice under the NHS umbrella (Rivett, 1998).
From 1948: The structure of the NHS
Under the 1946 National Health Service Act, it was recommended that the health minister had the duty to promote in England and Wales a comprehensive health service which was to be developed with the purpose of improving the physical and mental health of the population and to oversee the move towards prevention, diagnosis and treatment of disease and illness. The services to be provided to meet these aims were to be free of charge and for the first time, the Minister of Health was made personally accountable to Parliament for hospital and other specialised services in addition to being indirectly responsible for family practitioner and local health services (Levitt et al., 1999). He was indirectly responsible for family practitioner and local health services.
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The structure of the newly formed National Health meant that all hospitals were nationalised and they were managed by either regional hospital boards or boards of governors who were accountable directly to the minister for health. Funding was provided directly by the ministry of health to the regional health boards and this in turn was given to the hospital management committee’s who had the responsibility for the management of budgets and funding for services (Levitt et al., 1999).
As family practitioner services had refused to be managed and overseen by the newly formed National Health Service and Ministry of Health, executive councils were formed to ensure services such as general medical, dental and ophthalmic resources were delivered, these were referred to as Primary Care services. Local authority departments were made responsible for community health services, including health visitors and district nurses, vaccinations and immunisations, maternal and child welfare, ambulance services and services for the mentally ill and those with learning disabilities who were not in hospital (Bristol Royal Infirmary Inquiry, 2001).
From 1948: The Changing Organisation of the NHS
During the early stages of the NHS it is identified that there was a three part structure that had three branches which included; hospitals, primary care and local authority health services. This structure prevailed until 1974 when a more integrated arrangement was introduced which held three distinct levels of management at a regional, area and district level. A change of government to conservative leadership in the 1970 general election meant that the three part structure of the NHS that had been prevalent since the beginning of the service implementation became replaced in favour of new local authority control. General practitioners, hospitals, health centres and nursing services were brought under the control of a single area health authority which reported to regional health authorities (National Archives, 2011c).
An American economist in the 1980’s produced a highly critical report of the NHS suggesting that it was inefficient, riddled with perverse incentives and also that it had become a culture that was resistant to change (Enthoven, 1985). Due to the damning nature of this report the organisation of the NHS once again changed and it was suggested by Enthoven (1985) that the NHS would be more efficient if it was organized on something more like economic market principles. Enthoven (1985) argued for a split between purchaser and provider, so that Health Authorities could exercise more effective control over costs and production as a result the NHS administration was broken up into trusts from which authorities bought services. The role of Regional Health Authorities was taken over by 8 regional offices of the NHS management executive and this process ensured that the NHS became truly a nationally administered and centralized service (Klein, 2006).
With changing governments there has been ongoing change reflected within the organizational structure of the NHS. Within recent years the labour government had attempted to alter the structure of the NHS by introducing strategic health authorities and Primary Care Trusts. In recent months with the election of the coalition conservative and liberal government yet more new organizational changes to the NHS have been identified.
Ramesh (2011) has identified that the NHS will undergo a radical pro-market shakeup with hospitals, private healthcare providers and family doctors competing for patients who will be able to choose treatment and care in plans laid out by the government today. These changes will aim to reduce the numbers of management staff that are present within the current labour determined legacy within the NHS and the new approach will also allow NHS hospitals to chase private patients as long as the money is “demonstrably” ploughed back into the health service (Ramesh, 2011).
Andrew Lansley, the health secretary for the current coalition government presented to parliament in July 2010 a white paper which set out ambitious plans for the NHS. These plans had a simple aim: to deliver health outcomes for patients which are among the best in the world, harnessing the knowledge, innovation and creativity of patients, communities and frontline staff in order to do so (Lansley, 2010). The White Paper, Liberating the NHS (Department of Health, 2010) suggests that it will abolish all of England’s 152 primary care trusts, which currently plan services and decide how money should be spent; these radical proposals would save the taxpayer more than £10bn over the next decade and under the plans, GPs will be responsible for buying in patient care from 2013, with a new NHS commissioning board overseeing the process (Department of Health, 2010).
The work of Beveridge and Bevan in the 1940’s was undoubtedly pioneering and visionary with many members of society being able to access healthcare for the first time regardless of their financial means. The implementation of the NHS ensured that healthcare was available to everybody regardless of means and that it would be free from the point of delivery, principles that remain in essence part of modern day healthcare and National Health Services.
The NHS has seen many governmental changes since 1948, it has been re-organized and the structure has altered, however regardless of this it has remained a service that all British people can access and a service that many other countries have been unable to replicate. The foundation of the NHS was challenging and there were many critics, however the foresight of political leaders such as Bevan and Beveridge ensured health care remains free at the point of delivery in this country.
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