Professional Documents
Culture Documents
NHS Structure
NHS Structure
A Brief History
President Truman said “the only thing new under the sun is the history we do not
know”, (as cited in Miller 1974 p.26). I believe this argument holds within the
NHS, and many current issues are historical ones manifesting in new contexts.
There was an initial aim for equality; though the NHS was established in 1948
but as Aneurin Bevan’s widow reminds us its roots lay much deeper:
Its founding coincided with the recent invention of Penicillin. Along with this and
other medical advancements, the NHS helped facilitate the virtual irradiation of
communicable disease in the UK (Bud, 2007). This was not without consequence:
We’re all glad now that it works, but then you’ve got the reverse side of
the medal, because I’m now accused of being partly responsible for the
population explosion which is one of the most devastating things that the
world has got to face for the rest of this century. (Florey, as cited in
Ligon, 2004 p. 3)
Different ideologies debated the best ways to gain efficiency; initial support for a
service free at the point of need was divided; not in the least amongst medical
professionals. In order to help get agreement from the GMC and then parliament
GP ‘gatekeepers’ were employed as independent businessmen and “capitation
was the defence against the perils of state servitude.” (Pater, 1981 p. 142)
Research has also strived to establish the best methods; when Winston Churchill
Primary Care
At the frontline of the service is primary care; this was traditionally provided by
subcontracting through the GMS contract. However since 1977 37% of GP’s have
signed up to PMS schemes, which allow payment through salaries. (Wellards,
2008 p.10) This has helped extend care to areas where traditional GP practices
had sometimes opted not operate, particularly in the deprived inner cities; and a
large strength of the system is that strives to provide universal coverage. (DH,
2006)
The notion of primary care as the gatekeeper has altered, following the
demonstration of some success in GP fundholding in the 1990’s (Dusenko et al.,
2006) practice based commissioning was rolled out in 2005, resulting in the
purchaser provider split. This was marketed as a way of giving patients more
choice, aiming to increase productivity through quasi competitive market forces,
termed the politically softer contestability. (Warwick, 2007) Government gives
primary care 75% of revenue hoping to use purchasing power to obtain cost
efficiency savings whilst enabling response to differential local demand, however
in practice the market is seldom allowed to fail. (Maynard, 2005) Trusts get
bailed out and savings have been limited, particularly to rural areas, where there
is little real choice and benefits from marketization must also be weighed against
opportunity costs imposed by continual change. (Mannion, 2005; Warwick, 2007)
A topical area, leading on from the QAF in its ‘real world’ application is that of
nurse substitution (Lankshear et al., 2005) and there has been a Cochrane
review into this subject:
Nurses form the backbone of the NHS (see appendix fig 2). This review is
significant because it fundamentally questions the NHS’s application of this
resource to basic primary care. There is an opportunity cost to this which I
believe the NHS wastes.
Laurent et al.’s findings are also synonymous with similar reviews in that they
highlight gaps in our current knowledge base. A large criticism of health systems
in general is that they operate without proper evaluation of either clinical let
alone managerial practice (Maynard, 2005). A 2007 analysis of 1016 systematic
reviews from all 50 Cochrane Collaboration Review Groups found that “44% of
the reviews concluded that the intervention was ‘likely to be beneficial’, 7%
concluded that the intervention was ‘likely to be harmful’, and 49% concluded
that evidence ‘did not support either benefit or harm’. 96% recommended
further research.” (El Dib et al., 2007 p.689)
This problem is compounded by the fact that it’s hard to address efficiency in
any context without collecting relevant data to base evaluation upon. PROMS
data has only begun to be collected in NHS hospitals from April 2009 (DoH,
2008). This has not been done since the time of Florence Nightingale and the
Lunacy act of 1845 (Maynard 2005). Primary care lags even further behind in this
respect, there is data but it is limited to a practice level; large numerical studies
of individual GP activity are generally based on prescribing data and there is no
national collection system. (Hippsley-Cox et al., 2007; Maynard 2005)
Secondary Care
Much secondary care revolves around procedures and many attempts to address
technical and allocative efficiency, thus containing costs have been through
industrialisation; borrowing ideas from other sectors to reduce variance and
move away from a “craft like model of production.”(Walshe & Smith, 2006 p.6)
The medical profession has resisted this approach to ‘cook book’ medicine,
claiming the context is different and highlighting problems in managing co-
morbidities (Buse, 2005), however Variance is a real issue, for example the
activity rates of the top 25% of surgeons are 60 to 85% higher than the bottom
25% (Bloor et al., 2004) and there are relevant comparators:
for ideas about accommodating friends and family; and the organised
religions for ideas about the provision of comfort. (Morton & Cornwell,
2009 p. 429)
Addressing Resistance
become proactive but cultural change takes a long time. (Gladwell, 2000; Scott
et al., 2003)
I believe secondary care generally lends itself more readily to measuring and
subsequently industrialisation. Further moves towards performance related pay;
as opposed to current payment by results; which Street & Maynard (2007)
believe to be essentially an activity based tariff, could theoretically have more
potential benefit here if outcomes are measured more effectively, yet to date
PbR has largely focused on the primary sector (Maynard & Bloor, 2003).
Softer strategies will also need to be adopted to help instil a more open culture.
Financial constraints in the coming years will mean more will have to be done
with less; however if medicine continues along its flat of the curve trajectory,
rationing will increasingly become an issue, if it wasn’t already (Beaglehole &
Bonita, 2004). This will undoubtedly have implications throughout the NHS,
possibly effecting tertiary care most of all.
Continued research is important and can have significant impact; however unlike
with treating communicable disease many new treatments of chronic disease
have incremental benefit, for significant outlay (Lee et al., 2002; Bud, 2007).
Again the NHS needs to spend its money wiser and again it doesn’t know all that
much about how to best apply technologies we already have let alone new ones
(Lankshear et al., 2005). This need for improved evaluation and efficient
implementation of both clinical and managerial resources caused the
Government to commission a large review to build agreement on the best
institutional arrangements for a new single fund for health research. There were
many good recommendations, including:
Rationing problems has always been there; penicillin’s first human recipient
dying after initial improvement because there was simple not enough to give him
(Bud 2007). My issue is not of rationing itself; rather that NHS still does so
relatively badly. (Maynard, 2005):
As we have seen, healthcare will generate need and unless we are prepared to
continually pay more for it, these have to be controlled. (Maynard, 2005) The
argument thrown against socially governed medicine is that market forces are
both more inclined to and more efficient at catering for need and allowing for
choice particularly of an individual. The UK’s health is affected by wider issues
which are essentially political; being about the sort of society we want, about
levels of investment in research, and education as these are likely to have
greater impact on public health in the long term. (Crisp, 2009)
The NHS in England is directed by the Secretary of State who is the head of the
Department of Health and holds a cabinet post. He is aided by junior ministers
and civil servants. The government collects progressive direct income tax and
national insurance, redistributing funds to individual departments. Indirect
regressive taxes are also placed on items deemed bad for health, especially
cigarettes and alcohol; unfortunately no attempt is made at hypothecation of
either type. (Wellards, 2008)
Redistribution
Implimentation
However taxed based public systems are certainly not the only option available
and should equity even be the main aim?
My views on the strengths of a public health service stem from a belief, informed
by my interpretation of current evidence, that it is more efficient relative to
private insurance at providing care for the most at least cost. I would argue the
Americans spend 16% of their GDP on healthcare for marginal additional benefit,
compounded with the many problems of private insurance including
administrative costs and coverage in particular (24% v’s 16% in the UK).
(Enthoven & Fuchs, 2006; Reinhart 2005).
This view could be contrasted with one of a public system being limited in its
ability to adapt and respond to provide what is really valued by an individual. In
a sense private systems are more optimistic, catering for life as opposed
focusing on preventing mortality. We are not born equal, genetic and
behavioural factors are likely to have more influence on a person’s quality of life,
why strive for equality? (Maynard, 2005).
Maynard (2005) believes inherent problems and possible solutions are not
necessarily mutually exclusive, that we should accept this and where possible we
should seek to bridge the divide, implementing what is shown to work. Certainly
the right sentiment but results are open to interpretation and as we have seen in
this essay evidence based healthcare can be difficult to assess let alone
implement and change in the NHS is slow.
Conclusion
We saw that the NHS began in an environment of conflicting ideologies and this
state endures. Supply induces demand, yet resources in the NHS are finite. In
primary care we looked at attempts at cost containment through marketization
and at improving efficiency via pay for performance. With secondary care we
discussed difficulties in using hard and soft approaches to exploit efficiency
savings through industrialisation. In tertiary care we looked at rationing, seeing
that there will be and discussed how arm’s length bodies play an important role
in evidence based practice. Finally with governance we touched on ideological
Whilst the context has changed with time the fundamental philosophy of the NHS
being free at the point of need remains very relevant. It should not be forgotten
that many people still choose to work within the NHS out of a desire to help
others as well as for self-interest. Aneurin Bevan said “no society can
legitimately call itself civilised if a sick person is denied medical aid because of
lack of means.” (1951, p. 100) Whilst the NHS is difficult to manage and change
happens slowly, I believe its greatest strength is that upholds an egalitarian point
of view.
Appendix:
Fig 1. NHS Structure in the UK (www.nhs.uk, n.d., 2009)
The above structure highlights the purchaser / provider split, here Tertiary Care
is combined into Secondary Care and arms-length bodies such as N.I.C.E. come
under the umbrella, reporting into all sectors.
Fig 2. Staff Groupings in NHS 2006 (Adapted from Wellards, 2008 p.17)
All Doctors
GP Practice Staff 9%
7%
Scientific,
Theraputic Ambulance Staff
& Technical 1%
Acronyms
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