The healthcare service in England attempts to improve the overall healthcare service have been ongoing through some of the most radical reforms since its inception as a comprehensive public service since 1948. The noticeable need of a free healthcare service was essential after the state of the country due to the world war. Once the NHS was established it saw many reforms led by diverse types of governments at different times. Despite the scale of the reforms they have preserved their core principle of ‘A free service at the point of delivery’ 1 till this very day. Even though they have adopted the core principle they still face huge challenges; as demands and costs are still rising, the entirety of the service is increasingly being looked at. This paper looks at the reforms the NHS has been through and analyses each reform in the light of Efficiency: the capability of the NHS, whether the reform made the NHS more competent, Equity: bringing fairness and equal right for the patients as well as the staff, Quality: whether adapting the reforms improved the patient’s ability to acquire different types of healthcare services without any predicament and obtain high-quality healthcare services.
This paper was conjured up by the use of reports published by NHS Publications website. Journals and studies on NHS reform via the scientific database PubMed were also utilized. To gain info on the theories the NHS was formed on, management theory books by Max Weber, Henri Fayol and Frederic Winslow Taylor were used.
Each reform improvised the NHS in many ways, in relation to Efficiency the NHS since its inception has seen major investments and new hospitals built, employment of up to date technology allowing more patients to be seen within an applicable time and budgets been controlled efficiently with the aim to reduce costs each year allowing the NHS to run efficiently. In terms of Equity after the publication of the Black report, the NHS has improved on giving equal opportunities to its minor ethnic groups of staff. Also the equal treatment of patients regardless of their social class has been improved since the Blair era. The NHS in terms of quality has become one of the world leading healthcare providers. Measuring their services against standards set by the NHS ensured that they are meeting the set standards. The major investment in staff in 2000 saw a number of lives saved in the past 10 years. The NHS has met quality standards that are accepted by its patients and valued as a first class service.
Overall the NHS has seen many reforms which have lead to the NHS becoming a world class service. Since the reforms in the 1960’s to the latest plans of the new coalition government the NHS has improved immensely in terms of efficiency, equity and quality and the future also looks bright for the NHS.
Healthcare service in England was launched in 1948 with an aim ‘to provide universal healthcare to its citizens which is free at the point of use and available to everyone based on need, not ability to pay’ 1. ‘The NHS was established after World War II where the country needed a stable healthcare service’ 2. The initial idea was that no-one should be deterred from seeking health services by a lack of resources and the founder Aneurin Bevan: Minster of Health stated ‘A free service at the point of delivery’ 3. Till this day they have been providing free healthcare service to the citizens of England.
In 1948 Sir William Beveridge, a British Economist and a Social Reformer conferred details of his radical plans for economic and social reform in post-war Britain. Sir William proposed major healthcare service changes on the basis that the country needed ‘the abolition of want before the enjoyment of comfort and suggested a scheme where every kind of medical treatment would be available for everybody’. 1,3
There has been some form of state-funded provision of health and social care in England prior to the NHS for 400 years.4 Prior to a health system being formed, attaining healthcare service in Britain in the 1930s and 1940s was difficult. Life expectancy was very low and thousands of people died of infectious diseases like pneumonia, meningitis, tuberculosis, diphtheria, and polio each year.4 The poor never had access to medical treatment and they relied instead on dubious and sometimes dangerous home remedies. Either that or they relied on doctors who gave their services free to the poor patients. The Hospitals charged for treatment and although the poor were reimbursed and before they received treatment they had to pay.4 Figure 1 shows the life expectancy that has changed since the NHS was introduced.
Figure 1.Life expectancy changes since 1840 5
The need for free healthcare was widely recognised, but it was impossible to achieve without the support or resources of the government. A study showed that expert’s believed and have written extensively on the reasons of why a health service was needed.6 These included:
The appearance of a view that health care was essential, not something just imparted erratically by charity
The drastic effects of the war that made it possible to have a massive change of the healthcare service being provided, rather than just an incremental alteration
As younger members of the country were becoming increasingly educated in the medical profession they had a view of things could be handle in a more efficient way.
The hospitals having financial problems, funds not sufficing.6
Having looked at the reasons to why a health service was needed the government made plans and core principles were established: 6
Regardless of persons status they were eligible for health care, even people temporarily residing or visiting the country.Â People could be referred to any hospital.
The healthcare service was financed almost 100% from central taxationÂ
Care was entirely free at the point of use6
The main achievement was that the poor who in the past went without medical treatment now had access to free healthcare.6
NHS today and NHS employment
NHS is one of the largest organisations in the world with an annual budget of around Â£80 billion employing more than 1.7 million people and treating over one million people every 36 hours.7 In general, healthcare service being provided within England to every single citizen is a difficult commission to undertake and consequently the system needs efficient health personnel’s to help run the system economically.
Today the view of the healthcare service in England is that the NHS is a world leader and provides first class service that other countries envy. ‘Countries all over the world seek to learn from the comprehensive system of general practice, and its role as the medical home for patients, providing continuity of care and coordination’.8 Other countries look at English NHS system and use them as a guideline to run their healthcare system.
The healthcare service in England has been run in a structural way with the Secretary of state and Department of Health controlling the overall NHS in England. The secretary of state for health has the responsibility of reporting to the prime minister. There are10 Strategic Health Authorities (SHAs) in England which are controlled by the Department of Health, they oversee all the activities within the NHS and the SHAs supervise all the NHS trusts in its area. Primary care plays a major role in community healthcare and is central to the NHS. Services under NHS trust (Secondary Care) include Hospitals, Mental Health services, Learning disability services and Ambulances. The overall structure of the NHS is shown below in Figure 2. 9 Although this is the current NHS structure with the new government in power, changes are to follow.
Figure.2 overall structure of the Healthcare system in England 5
Since its inception in 1948 the NHS has seen many reforms in terms of managing the way they provide healthcare service. The DoH has a lot of control and influence the major decisions taken in the reforms.
The overall expectations of Healthcare service in England are of a high calibre, which requisites high-quality management capacity.10 In the 1980’s and early 1990’s prominence was on recuperating management. The recent focal point has been on development of leadership within NHS. With the new government, new ideas and plans will be imposed to see improvements in quality of healthcare being provided, cut down on costs making it more efficient and in terms of equity provide equal service to everyone. Table 1 briefly enlists the reforms that have taken place since its inception in 1948.
Table.1 Reforms in the NHS: 1948-2010
Period the reform’s were in place
Reform and theory of Management
Managers as diplomats
Scientific Management and the Salmon report
Classical Management, Systems Approaches and the 1974 Reorganization
The Griffiths report and Managerialism
Working for Patients and the Internal Market
The NHS Plan (DOH 2000) and the ‘Third Way’.
NHS White Paper 2010: Equity and excellence: Liberating the NHS
Healthcare service and Reforms in other Developed Countries
Healthcare reforms within developed countries can be analyzed in order to compare whether the healthcare services in England have been successful in its bid to ensure efficiency, equity and quality.
Attempts to handle reforms of the healthcare system in the European countries have been an ongoing process for 30 years. Although the reforms have taken throughout the 30 years in different ways, their main emphasis has been on improving the cost-effectiveness of the healthcare service. In the early 1980’s the EU countries were looking at cost containment. The feature in the 1990’s was to endorse efficiency in terms of introducing competition and markets in the healthcare system. Since 2000 the focus has switched to effectiveness; promoting various notions of healthcare in terms of quality.11
Over the course of the 20th century the countries of Europe have established significant success in improving the healthcare service for their citizens. However they still face challenges in the form of restraining costs, improving quality and providing universal healthcare access, these have put the European healthcare services under immense pressure.11
Looking at another OECD: USA, A report on ‘A review of health care reform in the United States’ assessed whether the USA have been successful in providing healthcare. The findings showed that United States spent more per capita on health care than any other OECD country, yet its health outcomes lagged behind other countries.12 This shows they are struggling with efficiency issues and are still countering challenges in providing quality healthcare service that is expected from the citizens of the USA. Especially in the last few years Healthcare reform has been a major activity of the federal government, in order to revolutionize and develop the service overall. The 3 goals of optimizing cost, access and quality still remain a challenge within the healthcare society in the U.S.12 They concluded that USA still faced many challenges in running the national healthcare service, a key challenge they face is the utter complexity of the system, with its numerous public and private providers.12
Another OECD country reviewed in terms of healthcare service being provided and the reforms that have taken place is China. A report from on ‘From a national, centrally planned health system to a system based on the market: lessons from China’ concluded: ‘China is the country that has undergone the highest number of health care reforms. Since 1978, China saw many reforms and they also followed the way as the EU countries, with the healthcare system starting from governmental, centrally planned and a collective system to ending up as a heavily market influenced system. Now, thirty years later, the Chinese government openly concede that the reforms were unsuccessful and seek innovative and fresh directions.’13 This illustrates that China is also in a healthcare crisis and looking to implement different strategies in order to gain control of China’s Healthcare system.
Having reviewed the healthcare service being endowed in these developed countries, it demonstrates that they are all on an identical level as the healthcare service being provided in England and all face similar challenges. All these developed countries are looking to develop the countries overall healthcare service in terms of efficiency, equity and quality.
NHS Plan 2000 and the future of NHS
Since the last reform: The NHS plan 2000 14, a lot has transformed in terms of funding and operating the healthcare system in England. Especially with the new coalition government’s idea of cutting budgets it is a difficult time the NHS is going through and will necessitate a lot of expertise and world class management to get through today’s financial and economical predicament.
An additional indication that will be taken into deliberation is the election of the new plans set out in the NHS White Paper 2010. As the new coalition government has come into authority there have been huge changes to overall budgets for the public services and this possibly will have a consequence on the way the NHS operates in England. 15 The reforms have encompassed a significant impact on the organisation and deliverance of health care service in England. Wide array of transformations have been pioneered in an attempt to ensure the NHS is ‘managed’ more resourcefully and effectively. This report will examine whether these reforms have on the whole improved the healthcare system in England in terms of efficiency, equity and quality and if the public’s requirements have been convened.
To examine the healthcare reforms in England since its inception and to assess whether these reforms have improved factors of efficiency, equity and quality in providing healthcare.
- To review the reforms in the NHS since its inception in 1948
- To examine whether these reforms improved efficiency, equity and quality of healthcare
- To assess the key features of healthcare reforms proposed by the current government and their implications on the NHS
- To put forward plans for the future of the NHS
A number of sources were consulted to conjure up this paper and examine the healthcare reforms in the NHS. Scientific search engines and databases such as PubMed, Google Scholar and Science Direct (Date accessed 20/10/10) were used to gain literature reviews but results from Google Scholar and Science Direct were dismissed as they were too vague and irrelevant to this topic. With PubMed following keywords were inserted ‘Healthcare’, ‘Reforms’ and ‘England’. The data was also set from 1948 to 2010 when searching for reports as this would set the inclusion criteria. The reports and journals since 1948, when the NHS was established were used. Even though history before 1948 was looked at for study purposes, reports before NHS establishment; these were regarded as the exclusion criteria as reports weren’t looked at prior to 1948. Healthcare service within Britain was looked at in general but for the results of this report, the inclusion criteria was healthcare service in England as it just looked at the healthcare service being provided within England. The exclusion criterion was healthcare service in Scotland, Wales and Northern Ireland.
For the first part of the report, the introduction: where the report looked at the history of the NHS. The resources used included looking at general management books looking at management theories. The classical theories of Max Weber, Frederic Taylor and Henri Fayol were the backbone of the NHS and that is why these were used.
Another source to produce this paper was the Department of health (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/index.htm) where the publications and reports about the NHS in general were looked at. This paper used a lot of publications produced by the Department of health and the NHS publications as these sources are reliable; these were seen as good foundation to work from. One of the main publications used was ‘The NHS white paper: Equity and excellence: Liberating the NHS’ presented to Parliament by the Secretary of State for Health, this was a key entity in writing up this paper.
As the paper didn’t contract with experiments and clinical trials, it didn’t look at a lot of statistics; the majority of its content was obtained from qualitative data.
Having carried out the required literature searches and reading journals, reports and Department of Health Publications, results were gathered and have been shown below with the discussion of the key topics. The results look at each reform taken place in the NHS and then goes onto analyse the plans set by the new government. Having looked at the reforms and the new plans the paper than talks about efficiency, equity and quality related to each reform.
Reforms in the healthcare service in England
The healthcare service in the UK has undergone a number of reforms since its inception in 1948. Prior to 1948, healthcare service was provided in England but due to the increasing pressures for efficiency and quality in health services it lead to these developments and reforms in healthcare being provided. A more overtly management-oriented approach to the healthcare service delivery was adopted based on classical management theories to gain more control of the healthcare service in England. 16,17
Classical theories and Scientific Management: 1960’s
The NHS was based on the classical theories of Frederic Winslow Taylor, Henri Fayol and Max Weber. 16-19
Table 1: Frederic Winslow Taylor’s four main scientific management principles.
Replacing rule-of-work thumb methods with methods based on a scientific of the tasks
Scientifically train each individual rather than leave them to train themselves
Cooperate with each worker to ensure that the scientific method is being followed
Divide workload equally between managers and staff
Table 2: Henri Fayol’s Modern Operational Management approach.
Division of work- Specialization for efficiency
Authority &Responsibility- Both are related, the latter arising from the former.
Discipline-Requires good superiors at all levels
Unity of Command- Employee should receive orders from one superior only
Unity of Direction- Each group of activities with the same objective must have one head and one plan
Subordination of individual to general interest- When the two are found to differ, management must reconcile them
Remuneration-Should be fair and satisfactory
Centralization-Extent to which authority is concentrated or dispersed
Scalar chain/line of authority-Needs to be sensible, clear and understood
Order : Right thing/person in the right place
Equity- Equal opportunity for everyone
Stability of tenure- Unnecessary turnover is both the cause and effect of bad management
Initiative- Thinking out and execution of a plan
Thinking out and execution of a plan
Table 3. Max Weber’s Bureaucratic approach.
Power-Ability to get things done, often by the use of threats or sanctions
Authority- Ability to get things done because of the position that justified someone in terms of legitimacy
Extensive roles and procedures- Uniformity of decisions and actions
Job description- Clear-cut division of labour and High level of specialization
These classical theories contributed a lot to the healthcare service in England and still do to this day.16-19 The classical writers thought of the NHS in terms of purpose and formal structure. They created a formal structure on which the NHS could run on. They also looked at job design, scientific selection and development of workers. The classical theories generally serve as a backbone to the present day NHS management.
Although the classical theories made a big contribution to the healthcare service in England it had its limitations and wasn’t the most effective way. One drawback was that it wasn’t evidence based; it didn’t look at the way staff did their tasks and didn’t look at the well being of staff, the human and social aspects of work. It just treated them like machines. The theories didn’t look at motivating the staff and developing them in their own interests, had they done this staff’s work quality would’ve enhanced thus providing an efficient service to patients and overall improve the quality of healthcare service in England. Overall the classical theories were too concrete and fully based on rules and procedures. In terms of efficiency the theories bought a set way of running the healthcare service in England. Once the NHS was established it introduced equity as well as healthcare service was now available to anyone. The NHS was just established and with these set in place in the 1960’s the quality of service would improve from now with further reforms to come.
Salmon Report: 1960’s
One of the first reforms took place since the NHS was established was in the 1960’s. The Salmon Report bought findings and changes which included that workload should be equally distributed between managers and practitioners.20 The NHS would also get rid of matrons and replace them with a hierarchy of nurse managers. The introduction of several additional layers to the management hierarchy; in order to improve efficiency in operating the NHS. This lead to responsibility being equally distributed and the service met its aims and objectives more efficiently. Another change was that nurse managers would contribute to the overall management of the service through the medium of consensus management teams and thus improve efficiency and quality within the NHS. Having nurse managers lead to them taking control of set responsibilities and helped in general running of tasks at ward level leading to an improvement in general quality in the healthcare service being provided.
1974 Reorganization: 1970’s
The aim of this reform was to attain greater integration of the healthcare service in order to provide more stability and increase efficiency. The reorganisation also introduced more central control in order to: 21
ensure policies were implemented
develop democratic decision-making process
These changes lead to a more structured way for managers to follow and enhance the quality of the healthcare service. By the mid 1970’s quality was improving but there were still concerns of equity in the NHS. There were still clear differences of health sufferers in terms of social class; figures showed that people in lower social classes more likely suffered from diseases. ‘There were several possible explanations for these inequalities.
Natural and social selection. This would depend on the view that people who are fittest are most likely to succeed in society, and classes reflect this degree of selection.
Poverty leads to ill health, through nutrition, housing and environment.
Cultural and behavioural explanations. There are differences in the diet and fitness of different social classes, and in certain habits like smoking’. 22,23
Overall in the 1970’s the quality of healthcare service was still improving, equity issues were still a concern and in terms of efficiency they were recuperating the NHS.
The Griffiths Report: 1980’s
This reform was a major point in NHS history, the Griffiths Report identified problems such as the healthcare service was institutionally inactive and that the local health authorities were filled with directives without being given any clear procedures to follow.24 The Griffiths report stated that changes were difficult to achieve but gave recommendations to improve the NHS. It introduced a more formal and modern way of management. It gave increased participation for managers in setting and controlling budgets. The report also gave greater emphasis on cost awareness in order to improve efficiency. A Clear and quick decision-making process was introduced to improve quality of service provided to patients. The managers in local authorities were given a more clearly defined direction and the overall staffs were better informed.24
The Internal Market & Working For Patients: 1990’s
Another reform in the 1990’s took place, this bought a new dimension to the NHS; large publicly-owned hospitals could opt to become self-managed trusts. This meant that health services could be bought by private investors i.e. patients themselves thus allowing them to take control of the way they want the service. Even large GP’s could become ‘fund holders’ and be both purchasers and providers of care.25 This reform lead to introduction of greater flexibility thus allowing more effective matching of patients needs and care. Money ‘followed the patients’ through the system of purchasing and providing of healthcare service, this led to equity being improved as patients had more selection of services. This reform led to higher competition in providing quality healthcare service, the costs decreased and the general quality increased.
The NHS Plan 2000
The NHS Plan 2000 made key findings : the NHS is a 1940s system operating in the 21st century and that it lacked of national standards. It also said that there were barriers between staff and providing services. There were a lack of clear guidelines and the NHS structure has over-centralization.14 Plans to diminish problems and propose new plans such as introducing Modern Matrons’ to improve the management of services, a strong leader with clinical experience and with clear authority at ward level, improve efficiency by setting standards and controlling resources these were there aims.14,26 The figure below shows the comparison of the 1948 and the new NHS model outlining the key differences.
Figure.4 the key difference between the 1948 model and The NHS Plan 2000 model 14
The NHS Plan 2000: Achievements
This reform set out specific targets which were achieved in order to improve efficiency, equity and quality of healthcare service in England:
Over 100 new hospitals by 2010 and 500 new one-stop primary care centres
Clean wards and better hospital food
7,000 extra beds in hospitals
Over 3,000 GP premises modernized
Modern IT systems in every hospital and GP surgery
7,500 more consultants and 2,000 more GPs
20,000 extra nurses and 6,500 extra therapists
Childcare support for NHS staff with 100 on-site nurseries.26
These targets were achieved in 2008 and it led to the improvement of efficiency as the number of GP’s and consultants employed were increased. The modernisation of technology and IT systems led to quality of service being improved as high investment in high quality equipment made the NHS one of the world’s top quality service. Since 2000 NHS has improved the overall service and met its objectives.
NHS Implications: Equity and excellence: Liberating the NHS
With the new coalition government coming into election another set of reforms have been proposed as they hope to improve the overall healthcare service in England. The main aims and objectives to improve the healthcare service are varied and very detailed but to summarise it these are the points covered:15
‘Increase health spending in real terms in each year of this Parliament’ 15and also that there ‘goal is an NHS which achieves results that are amongst the best in the world’ 15. However the government will uphold the foundation that the NHS was formed on; ‘a comprehensive service, available to all, free at the point of use and based on clinical need, not the ability to pay’ 15.
The government than goes into detail of what they arrange to initiate to make an efficient healthcare service: acknowledge the fact that patients come first and therefore will give them greater choice and control. An example of this is that a patient will be able to choose any GP practice, consultant, and choice of treatment consequently improving equity of the service.
The government endeavours to develop the healthcare outcomes: set objectives such as ‘reduce mortality and morbidity, increase safety, and improve patient experience and outcomes for all’ 15. By doing this they are ensuring they are driving efficiency and improving the service. In order to achieve the objectives that the government sets, the ability for service providers to have more autonomy, responsibility and accountability will be a means to achieving efficient results.
A big change will be the establishment of a NHS Commissioning Board. The board will be accountable for making sure health outcomes are achieved, allocate resources and have the lead on quality improvement and to tackle inequalities that exist in the NHS. Overall the reforms in the NHS Paper 2010 will provide the NHS with greater incentives to increase efficiency, equity and quality.
The healthcare system in England has on the whole perceived a huge improvement in terms of efficiency since its inception in 1948. A system has been established where it endows with one of the best services in the world but there are still room for improvements.
An analysis of the services gives evidence such as the NHS building 100 new hospitals since 2000, therefore improving the efficiency and allowing better access for patients. 27 Even though there continue to be a lack of quality and accessibility to services across the country. The patients haven’t been able to impose enough pressure to force improvements. The NHS need to give patients more control over the health services they have access to improve efficiency. In 2008 investment in the NHS as a whole rose from Â£43.9bn per year in 2000, when the NHS Plan was launched, to Â£92.6bn. another measurement of efficiency is looking at numbers of early deaths from cancer, coronary heart disease and suicide; they continue to fall as services improve; over 98% of patients at Accident and Emergency (A&E) Departments are seen within 4 hours; and hospital waiting lists are lower than ever, with half a million fewer patients waiting since lists were at their peak.28
One key way to achieve the set objectives is to cut down NHS management’s costs by 45% over the next four years enabling them to free up investment for further improvements.28 Much has been achieved during the last five years of investment and reforms. For example, the significant investment in NHS staff, along with more flexible working, is facilitating healthcare professionals to take advantage of the freedom thus improving their commitment to the NHS. ‘NHS staff working flexibly and using improved technology are better able to respond to patients’ needs and changing expectations and are achieving improvements in quality and productivity across the system’.27
Since 1948, the NHS budget on average has risen over 4% in real terms each year; this is something they hope to resolve as the NHS will face a sustained and substantial financial constraint if it continues. They hope to avoid the financial crisis that happened in the NHS in the 1970’s. ‘The NHS hopes to release up to Â£20 billion of efficiency savings by 2014, which will be reinvested to suppor
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