Britain’s National Health Service (NHS), set up by the Department of Heath in July 1848 as a healthcare provision, is based on its citizen’s needs not ability to pay. The Department of Health oversees the NHS with funds provided through taxpayers (History of the NHS, n. d. ). Launched as a single organization, the NHS was founded around 14 regional hospital boards in three segments consisting of hospital services; family doctors, dentists, opticians and pharmacists; and local authority health services, including community nursing and health visiting (Ibid).
As with any public service agency, changes are imminent. Since 1948, the NHS has undergone major changes in the organizational structure of the agency and in the manner in which patient services are provided. While the NHS proved beneficial to Britain’s citizens, there remained negatives in the program. In spite of improvements and successes, the NHS food was still rationed, building materials were short, and there was a significant economic crisis and a shortage of fuel. In spite of efforts to improve conditions, the war created a housing crisis in addition to the post-war reconstruction of cities.
The New Towns Act (1946) created major new centers of population, but each center was in need of health services. During the period from 1948 to 1957 (History of the NHS), the agency underwent administrative difficulties, financial problems, criticism over minimal fees charges to recipients (e. g. “a flat rate of ? 1 for ordinary dental treatment”) (Ibid), problems balancing all responsibilities and demands of the government and public, and maintaining medical professional and community health issues. By 1960, the NHS began to see positive changes. The introduction of improved drugs lead to better treatment to citizens.
It was during this period that the polio vaccine was introduced along with “dialysis for chronic renal failure and chemotherapy for certain cancers were developed” (NHS, n. d. ). As time progressed, through 1967, problems concerning doctor’s pay arose. However, some of the problems were resolved through the Royal Commission. Like the reformation in pay structures, improved management conditions also became a significant concern. In fact, the NHS introduced a Hospital Activity Analysis to enable medical professionals and managers “better patient-based information” (NHS, n.
d. ). Furthermore, the 1960s brought about a change in segmentation as medical staff was divided into specialty groups, leading to additional criticism (e. g. the 1962 Porritt Report called for unification) (NHS). Also launched in 1962 was Enoch Powell’s Hospital Plan, a ten-year program approving the development of district general hospitals for areas with populations of about 125,000 (NHS), advocating new postgraduate education centers, and giving nurses and doctors a better opportunity for education and future employment and stability.
In 1967, recommendations for developing a senior nursing staff structure and moving forward with advancements in hospital management were made in the Salmon Report, while the Cogwheel Report marked the first report on the organization of doctors in hospitals. By 1968, the NHS boasted clinical and organization optimism. However, the optimism was short-lived. Medical progress was notable (e. g. inclusion of endoscopy and Computerized Axial Tomography scanning), including an extension of investigative groups.
Also prevalent during the period of 1968 to 1977, transplant surgery became widely used, pharmaceutical improvements were evident, and intensive care units gave the NHS a renewed sense of how medical care would be provided to its citizens. This renewed spirit was short-lived with the mergence of Lassa Fever. The general practice charter encouraged the formation of primary health care teams, new group practice grounds and a rapid increase in the number of health centers.
Additionally, this period saw a change in the Government’s Hospital Plan as new hospitals began to provide even more people with improved and local services. Also indicative of progressive changes is the arrival of information technology through “health service computerization and clinical budgeting” (NHS). Nevertheless, advancements did not remove the continued debate concerning the organizational structure of the NHS. In 1974, a new system was introduced, but conflict continued combined with an increase in inflation.
When inflation reached 26 percent, a wage restraint was enacted. According to the NHS, “industrial action hit the NHS while consultants were also alienated by proposals to reduce private practice within the service” (NHS, n. d. ). NHS historical sources relate that by 1978 the NHS “had become a victim of its own success” (n. d. ). Changes were imminent. The introduction of new technology and multifaceted treatment methods led the NHS and its governing forces to realize additional advancements were imperative.
By the late 1980s, the NHS reported highly recognized advances, including the areas of primary health care, genetic engineering, successful drug advancements, and the introduction of the MRI of which the agency states: “the number of operations for fractured neck or femur and osteoarthritis of the hip was reaching almost epidemic proportions…increasing numbers of heart and liver transplants were being performed and surgical treatment for heart disease was becoming more common” (n. d. ).
In spite of the positive changes, the NHS continued to face on constant dilemma –financial stability. Increasing demand for services exceeded the resources available, leading to the mandated audit process of what NHS professionals were doing. By 1987, the NHS’s medical staff was in debt (NHS, n. d. ), waiting lists were increasing, and hospital wards were being closed (n. d. ). The NHS reports the period of 1988 to 1997 as its “most significant cultural shift since its inception with the introduction of the so-called internal market” (NHS, n. d. ).
A 1989 White Paper, Working for Patients, was passed into law (Community Care Act 1990). Leading up to the beginning of the 1990s, the NHS saw the emergence of the internal market while health organizations became NHS trusts (independent, competing organizations with their own managements). By 1991, the NHS reported 57 Trusts, with all care provided by Trust at the end of 1995. All of the changes marked what the agency calls the “New NHS” and defines this change as “modern, dependable” (NHS, n. d. ). The new NHS operates under “six principles” of which include:
• The renewal of the NHS as a genuinely national service, offering fair access to consistently high quality, prompt and accessible services right across the country; • To make the delivery of healthcare against these new national standards a matter of local responsibility, with local doctors and nurses in the driving seat in shaping services; • To get the NHS to work in partnership, breaking down organizational barriers and forging stronger links with local authorities; • To drive efficiency through a more rigorous approach to performance, cutting bureaucracy to maximize every pound spent in the NHS for the care of patients;
• To shift the focus onto quality of care so that excellence would be guaranteed to all patients, with quality the driving force for decision-making at every level of the service; • To rebuild public confidence in the NHS as a public service, accountable to patients, open to the public and shaped by their views. (“Six Principles”) Of all influences on the changes in the social policies of Britain the NHS and Community Care Act 1990 has had the greatest impact. In fact, before the Act, most of Britain’s health and public services were planned and provided by health and local authorities (Commissioning the New NHS, 1998).
The Act divided the role of health and local authorities by changing their internal structure thereby giving local authority departments responsibility for assessing the needs of the local population and then purchasing the necessary services from providers (1998). However, under the terms of the Act, a select number of health and social services authorities opted out of what would mean competing with other providers to work together in other sections of the community (e. g. voluntary groups and housing associations) (1998).
Under a “mixed economy of care” (NHS), social policies evolved to also include a service specification inviting providers to “tender for the contract to provide those services” (Commissioning the New NHS, 1998). This mixed economy was intended as a tool to give citizens a variety of health care choices. However, according the Department of Heath’s report (1998): Some local authorities chose to purchase services as part of a ‘block contract’ (where a certain service is provided for a fixed price and a fixed length of time).
Purchasing services in this way may actually reduce choice for the individual, as frequently no alternatives (outside those provided by the block contract) are made available. Key Elements of Housing Policy Post-war housing policy is believed to have been a “notable success” (Ball, 1983). Since the days following the war, the physical housing situation in Britain has improved dramatically. In the period of the 1950s to 1980, Britain had seen a significant net gain of 200-250,000 dwellings each year (p. 2).
In fact, Ball (1983) reports that “millions of slums have been demolished” and “thousands of other dwellings have been renovated to [meet] modern standards” (1983). Britain’s housing conditions have seen a significant improvement, specifically into the 1980s. In fact, the change was so dramatic that less than 5 percent of dwellings were overcrowded. Improvements in housing includes the inclusion of a bath/shower and an inside toilet. Of all policies in post-war Britain, the 1977 Housing Policy Review was the best moment of all changes in housing provision.
By the early 1980s, however, satisfaction disappeared and a growing housing crisis became a concern once again. According to Ball (1983), Britain’s post-war housing record has been poor compared with other West European countries. While all experienced a housing boom from the late 1950s to the early 1970s, Britain’s population size resulted in its trailing behind other countries’ house building rates (see Table 1), most predominately those with a similar welfare state social democratic tradition. Key elements of the housing policies includes the Department of Health’s responsibilities to:
• Identify local market information on the supply of housing, care and support services for older and disabled people; • Access support on developing and implementing regional and local housing with care action plans; • Obtain advice on public and private sector capital and revenue streams to inform business investment decisions; • Disseminate guidance on the DH’s Extra Care Housing fund and grant allocation arrangements; • Facilitate the adaptation of good practice to local settings; • Support successful applicants with the development process and share their learning with unsuccessful applicants;
• Access knowledge management tools to support practice development and service improvement. • Secure funding to research, test and evaluate new and innovative models of housing with care solutions support; • Offer training and consultancy resources to support service development and change management processes; and • Convene regional LIN meetings to identify and share what works (Department of Health, 2007). According to Gummer (2005), in the 25 years since the UK’s “right to buy” housing policy, approximately 2 million families have become homeowners, changing the way Britain’s housing policies and market is perceived.
The “right to buy” policy opened opportunity to “a whole new group” giving them “a stake in the community that they had never had before” (p. 69). However, in spite of the positive changes, Gummer (2005) reports that Britain continues to receive criticism with the most cited concern being “that the sale of council houses means there is a shortage of homes to let” (p. 69). Contrary to the positives, negative critism has surfaced, including a Contract Journal article (Penny, 2005) stating that “social housing schemes could be about to receive a much-needed shot in the arm — as well as a much-needed boost from the private sector” (p.
40). Penny (2005) argues the impracticability of Britain’s urging to commit to a social housing PFI. “Unless you know exactly what you are taking on, anyone involved in such a scheme could be taking a huge risk,” argues Penny (p. 40). The author, among others, believe that the proposed new NHS LIFT approach indicates the public sector retains an interest in the scheme of which Penny also argues will “sidestep tenants’ objections to being put into the hands of a firm being run solely to generate profit” (Ibid).
Despite obvious objections, the Contract Journal (Penny, 2005) does see positive aspects of moving to NHS LIFT-style management and asserts that a move flexible program would benefit the public in more ways than better housing alone. Based on references concerning LIFT-style initiatives (NHS LIFT Guidance, 2007; Penny, 2005; Millet, 2005) the program addresses almost all concerns in social housing, including the continued coverage of health and schools. As time progresses, Britain’s housing policy changes continue to be focus of debates on just how much of the changes are for the good of citizens and how much is political agenda.
One must question the validity of various housing programs, including the current and forthcoming plans for housing for the elderly. One such program is the Wanless Telecare proposal (Housing LIN Policy Briefing, 2006) that the Audit Commission defines as “any service that brings health and social care directly to a user, generally in their own homes, supported by communication and information technology. Data is collected through sensors, fed into a home hub and sent electronically to a monitoring center” (2006, p.
1). According to the Briefing document (2006), Britain’s government believes the Telecare program can help older people to remain in their homes for longer (p. 1). However, while the program proposal defines the costs associated with implementing the program as “modest” (2006, p. 2), they are high, specifically to the homeowner. The set up fee of a basic home safety package costs about ? 360 plus monitoring costs of ? 5 per week. Home health monitoring is more expensive, around ? 700 and ? 10 per week monitoring costs.
Given these high figures, combined with the already luminous housing problems with the elderly, how can such a program benefit citizens? According to the Audit Commission’s review of the Telecare housing safety program, “Telecare equipment and services provide the opportunity to react to hazardous events and to alert and prevent deterioration in an individual’s ability to care for themselves” (2006, p. 3). One specific pilot study (West Lothian: Opening Doors for Older People, 1999 quoted in Department of Health White Paper, 2006) for the inclusion of Telecare surveyed 10,000 households in the West Lothian district age 60 or over.
The survey purpose was to reveal the validity of Telecare inclusion as a possible means of “reengineering” services for older people to include the development of extra care housing and changes to home care services. According to the survey, implementing Telecare on its own without wider system improvements is a wasted opportunity. In fact, the survey revealed: • Telecare is not a cut price alternative to personal care, but sits alongside it • A technology driven approach does not work • A focus on cost saving/shunting does not work • A high level of commitment at senior level is required
• West Lothian has found ‘minimal interest’ from the local NHS in telecare/telemedicine possibilities (Department of Health, 2006; Audit Commission, 2004; Brownsell et al, 2001). Understanding the changes in Britain’s housing policy since 1979 enables its citizens to better equip themselves for what future changes may come. In fact, Britain’s housing policies have fluctuated, indicating a positive change and declining to criticism and little faith of its citizens. While the government is consistently working toward bettering its housing policies, there remains many avenues yet to be explored. References:
Audit Commission (2004). Older People: Implementing Telecare. London: Audit Commission. Ball, M. (1983). Housing Policy and Economic Power: The Political Economy of Owner Occupation. Methuen: London. Brownsell, S et al (2001). An attributable cost model for a telecare system using advanced community alarms. Journal of Telecare and Telemedicine, Volume 7. _______________ (1998). Commissioning the new NHS, 1999/2000. Department of Health, HSC (98) 198. Department of Health (2007). Official website. Crown, retrieved January 11, 2007 from http://www. dh. gov. uk/Home/fs/en Department of Health White Paper (2006).
Our health, our care, our say: a new vision for community services. London: The Stationery Office. Gummer, J. (2005, Nov 5). “Right to buy” was the right move for everyone. Estates Gazette, Issue 544, 69. Millet, C. (2005, Oct 10). Social housing set for LIFT-style deals. Contract Journal, Vol. 430 Issue 6545, 1. ______________ (2007). NHS LIFT Guidance. Crown, retrieved January 10, 2007 from http://www. dh. gov. uk/ProcurementAndProposals/PublicPrivatePartnership/NHSLIFT/N HSLIFTGuidance/fs/en Penny, E. (2005, Oct 10). Editor’s Comment. Contract Journal, Vol. 430 Issue 6545, 40. United Nations Statistical Yearbook 1978