The National Health Service (NHS) was formed in the UK on July 5 1949. Its formation was part of the nationalization drive that epitomized post World War II UK which witnessed the establishment of the welfare state and the drive towards production of goods and services for public use instead of profit for private investors and owners. (Yergin and Stanislaw, 1998)[1] Thus reflecting the political economic philosophy of the time, the establishment of a free for all health delivery system within a country outside the Eastern socialist/communist block of nations was quite extraordinary as other systems of health care in most western economies had adopted the insurance system – i.
e. pay for health care when healthy and use the care when ill.
Prior to the nationalization of health care under the NHS, health care providers like voluntary hospitals, municipal hospitals (that also provided mental health services), entrepreneurial cottage hospitals and specialist hospitals were already in existence. Local authorities also had departments responsible for health care services like midwifery and child welfare and also had authority to provide health care under the Poor Law.
The NHS thus did not commence on a clean slate as these already existing health care establishments were inherited under the NHS. Also, health care for workers was covered under the Lloyd George’s National Insurance Act of 1911, though this did not extend to the families of workers. (Rivett, 1998)[2] Though the role of the general practitioner (GP) had been envisaged as crucial in providing non-specialised primary health care covering areas and activities like home visits and attending to patients in GP surgeries, prenatal and antenatal care, child welfare, venereal diseases, and industrial medicine, the reality of pre-NHS health care in the UK was very far from the realization of these ideals.
According to Rivett (n.d.) the NHS in the UK was founded on the following principles:
The NHS has three main interacting parties who have diverse stakes, responsibilities, and expectations in the running of the health service – those who need health care, the skilled personnel who deliver health care, and those responsible for raising money and ensuring that the money is spent properly on the NHS. (Rivett 1998)[4] Undoubtedly, the formation of the NHS has had an immense impact on health care delivery in the UK.
For instance, life expectancy for females has risen from 71 years in the pre-NHS era to 80 years under the NHS. Life expectancy for males has also risen from 66 years in the pre-NHS era to 75 years under the NHS. Infant mortality rate (i.e. babies under 1 year old) has decreased from 34 per thousand to six per thousand. (Secretary of State for Health, 2000)[5]
In spite of the altruistic principles upon which the NHS was founded, it has faced significant challenges of which finance is perhaps one of the most paramount. Rosenberg (1987) has for instance argued that the “implementation of developments has often been slower in the UK than in other countries. Partly this has been due to innate conservatism, but mainly it has been the result of financial restrictions.”[6] The former prime minister of the UK, Tony Blair, summarized the problems faced by the NHS as follows:
“… the NHS retains, in its essential values, huge public support. But over twenty years, it has struggled. Its funding has not kept pace with the healthcare systems of comparable countries. Its systems of working are often little changed from the time it was founded, when in the meantime virtually every other service we can think of has changed fundamentally. So urgent was the need for extra money for the NHS that many of the failures of the system were masked or considered secondary.”[7]
Despite the apparent inability of the public purse to fund a free for all health delivery system under the NHS, government policy in the UK is firmly set against any form of payment of healthcare by workers as done in other western countries like France and Germany. Leaving healthcare in the hands of the market as in the United States has also been decidedly kicked against. (Secretary of State for Health, 2000)
The UK government’s stance may be seen more as a decision of political expediency rather than an economic one, as the issue of free healthcare is a highly charged political debate that is top on the agenda not only of the ruling Labor government but also of the opposition Conservative Party. (BBC News 2004) On both sides of the political divide, it is highly improbable that privatisation of healthcare would be an option. Consequently, the future of the NHS, it appears, would not be based on the recommendations of health professionals and administrators, but rather the manifestos of political parties.
Though inadequate public funding has been the pivotal problem faced by the NHS, it is bedevilled with other problems that affect the ability of the system to deliver a proper service for the demands of the 21st century. One such problem is the waiting times for care in accident and emergencies (A&E), GP surgery appointments and operations. In 2000, it was expected that by 2005 patients would have a maximum of 48 hours waiting time for a GP appointment, three months maximum for an outpatients appointment, six months maximum for an operation and the halving of A&E waiting times. (Secretary of State for Health, 2000)
By 2007 however, these targets were far from a reality. A 2004 survey found that patients in England and Scotland had to wait for up to eight months for a cataract operation, eleven months for a hip operation, twelve months for a knee replacement, five months to repair a slipped disc, and five months for a hernia repair. (BBC News, 2004) Injection of more funds in health care in the NHS has been viewed by some health care professionals as inadequate to solve the problems of waiting times. A senior surgeon in the NHS is reported to have said that:
“The government is increasing capacity by investing money but I’m concerned as a surgeon that the arrangements are not in the patient’s best interest. The individual patient may get their operation done quicker by the NHS funding treatment in the private sector but it will be with a different surgeon from the one they saw in the clinic.”[8]
Though by December 2007, there had been significant reductions in the waiting times for inpatient and outpatient appointments, the problem delays in the NHS continues to persist. For example, 91.3% of patients in England waited for under 13 weeks for an inpatient appointment and 8.3% waited for over 13 weeks for an inpatient appointment. Also, 95.6% of patients waited for under 8 weeks for an outpatients appointment by December 2007. (Department of Health, 2008)[9]
Evidently, lack of requisite skilled health workers has had an immense impact on the problems of long waiting times in the NHS. Funding the NHS from the public purse however presents problems of recruitment as remuneration has not been enticing enough for health care professionals and for potential training of needed skilled professionals from the communities.
As stated earlier, the nationalization drive in post World War II UK precipitated the establishment of the NHS. Thus, centralized administration at the national level is a typical hallmark of the NHS. Over centralization has been identified as one of the major problems facing the management of the 21st century NHS. (Secretary of State for Health, 2000)
Administration of a health service built for the population and health needs of the mid-20th century UK is still used for the needs of a country that has witnessed seismic growth in its population and especially in the size of its immigrant populations. Consequently, the organizational growth and modernization of the NHS has not kept pace with both population growth and modern organizational and administrative principles. The NHS today could be seen as a colossal, amorphous entity that that seriously needs a structural overhaul.
The Secretary of State for Health (2000) also identifies the following as problematic within the current constitution of the NHS – “a lack of national standards”, “old-fashioned demarcations between staff and barriers between services” and “a lack of clear incentives and levers to improve performance”. (p.10) Thus the need overhaul the organizational structure of the NHS should affect the staff incentives and performance levels and effective communication and networking between the different health services within the NHS.
Bibliography and References:
[1] Yergin, D. and Stanislaw, J. (1998) The Commanding Heights: The Battle for the World’s Economy. New York: Touchstone
[2] Rivett, G. (1998). From Cradle to Grave: Fifty Years of the NHS. London: King’s Fund Publishing
[3] Rivett, G. (n.d.) ‘National Health Service History’. Retrieved February 14 2008 from http://www.nhshistory.net/shorthistory.htm
[4] Rivett, G. (1998). From Cradle to Grave: Fifty Years of the NHS. London: King’s Fund Publishing
[5] Secretary of State for Health (2000). The NHS Plan: A Plan for Investment, A Plan for Reform. London: HMSO (Cm 4818-I)
[6] Rosenberg, C. (1987) The Care of Strangers: The Rise of America’s Hospital System. New York: Basic Books, p.7.
[7] Secretary of State for Health (2000) op cit p.8
[8] BBC News, May 27 2004. ‘NHS Waiting Time Underestimated’. Retrieved February 14 2008 from http://news.bbc.co.uk/2/hi/health/3749801.stm
[9] Department of Health. February 1 2008, ‘Statistical Press Notice: NHS Inpatient and Outpatient Waiting Times Figures’. Government News Network, Retrieved February 14 2008 from http://www.gnn.gov.uk/environment/fullDetail.asp?ReleaseID=349539&NewsAreaID=2&NavigatedFromDepartment=True
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