National Health Service
National Health Service (NHS), a British institution, set up and run by the state, which aims to provide all aspects of health care for all citizens free at the point of use. It includes all levels of provision, from school nurses to the largest hospitals.
The National Health Service was established in 1948 as a major part of the “welfare state” created by the Labour government of 1945-1951. It was a part of the social reforms recommended by the civil servant Sir William Beveridge, in the Beveridge Report of 1942. Previously, health care in the United Kingdom consisted of a mixture of charitable and private provision, the latter paid for by private and state-sponsored insurance.
The aim of the founders of the NHS was that the state should care for its citizens “from the cradle to the grave”. Its establishment involved the compulsory takeover of almost all health provision in the country. This was made simpler by the extensive powers of direction which government agencies had exercised during the war.
However, the NHS has been politically controversial from its outset: it was opposed by doctors before it began, and the government minister responsible for it, Aneurin Bevan, said that he had “stuffed their mouths with gold” in order to preclude opposition. In fact, he was compelled to compensate family doctors for their future inability to sell their practices when they retired; such sales had traditionally produced their retirement income. Bevan subsequently resigned in 1951, from a different Cabinet post, over the imposition of charges for “teeth and spectacles”. He was accompanied by his fellow ministers, Harold Wilson and John Freeman, although Wilson failed to abolish the same charges when he became prime minister in 1964. The charges are payable today, and in the 1980s the universal entitlement to free dental and ophthalmic tests was removed. A charge has also been introduced to drugs dispensed on a doctor’s prescription, although prescription charges were abolished in Wales in April 2007. There are exemptions from all these charges for people on low incomes and other nominated groups, such as children, students, and pregnant women. Changes to legislation were announced in 2003 to cut down on overseas visitors receiving free treatment. Only those permanently resident in the United Kingdom are eligible for free treatment, although pensioners who choose to spend up to six months living in another European country are eligible. Accident and emergency treatment remains free to all.
Throughout the existence of the NHS, the private provision of health care has survived and mostly thrived. At one time, people sought private provision for the fringe advantages it offered, such as private rooms in hospital and the opportunity of a longer consultation with the specialist; it is now popular in addition because the increasing pressure on resources in the state system means that the private sector often provides much faster treatment and because modern insurance schemes, often paid for by employers, make private care affordable.
III STRUCTURE AND REFORM OF THE NHS
At its inception, the NHS was a centrally directed institution. The Secretary of State for Health controlled the service through a hierarchy of Regional, Area, and District Health Authorities, which provided the institutions of the NHS such as hospitals; and through a network of Family Practitioner Committees which organized the provision of General Practitioner (GP, family doctor) care. Patients were dealt with as they always had been, by attending their GP and being referred to a specialist at the hospital if such treatment was necessary. NHS management dealt with budgetary and financial matters, and these only impinged upon doctors’ work to the extent that facilities were or were not available.
In the 1970s, the concern that individuals mistreated by state bodies had no realistic source of redress led to the appointment of an ombudsman or Health Service Commissioner who was appointed with a brief to investigate complaints from the public of bad administration in the NHS. The holder of the post has always, in fact, been the same person as the Parliamentary Commissioner for Administration, the ombudsman for government generally.
Financial management in the NHS was, and remains, subject to consultation with non-financial concerns. The professional workers in the NHS are represented on local advisory committees, which give their views on the requirements of the local patient population. That population has its say in the Community Health Councils, which are formed from a variety of local interests. To an extent, these means of consultation have been sidelined by reforms in 1990 which concentrated on bringing financial decisions nearer to those who are affected by them, so that they might directly influence decision-making.
The 1990 reforms were intended to make the practices of the NHS more financially disciplined. The health care budget is enormous, and demand appears limitless; the intention of the reforms was to make it more apparent what resources were spent on what services, and to introduce an element of competition into the provision of services, thus reducing costs.
Besides some structural reforms (the Family Practitioner Committees became Family Health Service Authorities, and the Area Health Authorities were abolished), the reforms centred on creating “purchasing” and “providing” authorities. In each District Health Authority area, there is now a provider, who manages the service, and a purchaser, who determines what services are required for the patients in its area and negotiates with providers from its own and other District providers to obtain the service as efficiently as possible. The contracts so made are not enforceable at law, but there is an arbitration procedure.
In a further step, most provision is now made by trusts, which each consists of a health service unit. This is usually one or more hospitals, although it may be a bundle of services such as the mental health care in an area. The trust is to an extent autonomous and negotiates itself with the purchasing authority. Trusts can, in theory, make tenders for work done by other trusts; in practice, this does not mean the closure of the other Trust’s infrastructure, but rather its takeover by new management.
The most radical reform has been the creation of fund-holding general practices (comprising one or more GPs). In these cases, GPs are paid a sum to spend on each patient’s entire health care, and thus the GP becomes the purchaser of services so far as his or her patients are concerned. Partly as a consequence of these developments, and partly due to new concepts of health care delivery, the old distinction between primary GP care and hospital services is to an extent breaking down. Whereas GPs were once, in effect, gatekeepers, determining what and what not to pass on to the specialist services, they now provide a broader range of care at their practices. This has gone as far as the provision of minor surgery in some medical centres.
At the same time, smaller hospitals have tended to close or amalgamate with larger ones in the hope that the hospital system will consist of only the best examples of inpatient care. The fact that, for example, accident and emergency (“casualty”) provision may now be a considerable distance away for many people, has been justified by the observation that when there were much more, smaller, units, the expertise is shown in them was not always up to the best standards. The process began with the smallest cottage hospitals and extended to encompass all but the largest institutions. Some specialities, such as child health or maternity care, have retained their own dedicated institutions. Another development is the use of less inpatient treatment and shorter periods of stay for patients in the hospital.
Although the reforms may seem to have devolved much of the financial power within the NHS to a level nearer the grass roots, the service remains quite closely tied to the political centre. The health authorities and the trusts are controlled by people appointed by the Secretary of State for Health; even in the case of fund-holding GPs, their accession to that status is decided upon by the government-appointed Family Health Services authorities.
There is no simpler way to provide a service than to budget for and make provision according to hierarchical directives; inevitably the complexity of the new system has attracted controversy because it has required the appointment of more managers to run it. There is also criticism over the claim that a more commercial approach to health care has bred a commercial attitude in managers, particularly with regard to their own remuneration; and that making finance a priority, and allowing competition within the service, sits ill with a universal service providing equal treatment for all. It seems unlikely, however, that the principle of health care free at the point of use will be jeopardized. Whatever the organization and mode of delivery of the service, the evident public support for the NHS suggest that it will remain a permanent feature of social and political life in the United Kingdom.