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3.3. Contemporary NHS
The NHS has been viewed with a certain amount of ambivalence in the public mind. It has had many supporters but also many detractors. On the one hand, people appreciate its free service, achievements and success in terms of patient demand. Consumers receive help when they need it and they do not have to suffer or even die as was prevalent years ago. Better diets have been formulated; standards of living and medicine have risen. Moreover, there is greater awareness in the population than previously, mainly due to people’s use of the Internet to look up required information.
On the other hand, the NHS is criticized very much; especially because of its alleged inefficiency, inadequate standards, long waiting lists, treatment discrepancies throughout the country, and excessive bureaucracy. Medical staff complains about things such as low pay, long hours, cuts in services and management weaknesses. There is a shortage of doctors and nurses as well. It is believed that many of the mentioned problems could be solved by funnelling more finance into the NHS. It is inevitable that the NHS will require more finance to fund its free services and increasingly expensive medical equipment and procedures.
There are many suggestions on how to improve the NHS. One of them is by increasing NHS taxation. Setting charges for some services could mean better overall service but there will be objections - paying for service hits at the principle of free health care. Another suggestion such as the better management of existing funds could cut costs, but not enough. There has also been speculation about combining private insurance with a public service but this would not provide any solution for the poorer people who would still be dependent on a free NHS. There have been endeavours by the Labour Government to involve the private sector more closely in the running of the NHS through Public-Private Partnerships. However, this idea was adapted from the previous Conservative government. Most of the public regard this as privatization of the NHS. However, the public sector has had difficulties for many years. For instance, waiting lists have been growing and in hospitals there is consistent lack of extra capacity and lack of finance for modernization. Therefore, some efforts have been made to involve the private sector in providing medical care. Until 1997, the Conservative Government supported cooperation between the private and public sectors on a commercial basis. The private sector was seen as complementary to the NHS. The Government’s aim was to release pressure on state funds and help patients by giving them a choice. They intended to allow NHS patients to be treated in the private sector at public expense.
When the Labour party came to power in 1997, they also liked the idea despite their old Labour ideology. Resulting from this, some NHS hospitals are now co-owners of certain expensive equipment, which they share with private hospitals. This enables the NHS to allow its patients be treated in the private sector at public expense. The private sector within the NHS is not used very extensively; it is limited only to minor medical cases. Long-term care which tends to be expensive is pursued by the NHS itself. This topic has been discussed for a long time.
The Labour Government, however, regularly involves the private sector in NHS matters. Patricia Hewitt, the current Secretary of State Health, has tried to explain the intention of using the private sector many times. The main reason is that use of the private sector enables the government to ensure patients proper treatment quicker, and with more choices than under the NHS. In May 2005 she claimed that the fact that the private sector could carry out some NHS operations would lead to shorter waiting lists and times. The idea was that the operations would be carried out by the private sector but paid for by the NHS. At that time it functioned this way and the percentage of such operations pursued by private sector was 5%.16 In the five years following 2005, the number should rise to 10 or 15 %. She promised that by 2008 no patients would wait longer than 18 weeks after their GPs had made referrals for treatment. The Secretary of State Health declared:
"This is delivering on, not departing from the fundamental founding principle of the NHS..” 17
Reactions to the Hewitt’s opinions were generally the same. Doctors and NHS managers were afraid of putting the NHS in danger because the private sector would take work away from the NHS hospitals resulting in their possible closure. Some people considered this as a complete destruction of the NHS due to assigning work to the private sector.
In September 2005, the privatization of the NHS was discussed again. Patricia Hewitt pledged that a Labour Government would never allow the NHS to charge for its services. For the BBC Mrs. Hewitt said:
"We are not turning a public service into a private service, and above all, we are not abandoning, and we will never abandon, the principle that health care has got to be available free at the point of need, not based on people's ability to pay."18
Moreover, Hewitt added that “in five years' time it was planned that 1% of the total NHS budget - and around 10% of the budget for non-urgent operations - would be spent in the private sector. ” 19 She considered the percentage as a very small part of the total NHS budget. Besides, it was going to deliver real benefits for NHS. A lot of people have been fighting against the privatization of the NHS. There are various campaigns which exhort people to be involved in the fight. For instance the website Keep Our NHS Public <http://www.keepournhspublic.com/index.php>. Their main aims are:
-
To inform the public and the media what is happening as a result of the government's "reform" programme.
-
To build a broadly based non-party political campaign to prevent further fragmentation and privatisation of the NHS.
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To keep our NHS Public. This means funded from taxation, free at the point of use, and provided as a public service by people employed in the NHS and accountable to the public and Parliament.
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To call for a public debate about the future of the NHS and to halt the further use of the private sector until such a debate is had.20
To see how the political parties and their leaders for health were changed, see Appendix 2.
Regardless the difficulties it has faced, the NHS is the largest organization in Europe21 and employs more than 1.3 million people, which makes it the single largest employer in Great Britain. The World Health Organization (WHO) considers the NHS as one of the best and most efficient national healthcare systems in the world. What is more, in August 2001 the NHS was ranked by WHO as 24th out of 191countries in terms of the efficiency of national healthcare systems.22 The NHS was even ahead of countries such as the USA, Germany and Denmark
It is obvious that the NHS needs to make improvements to cope with the demands of contemporary society. Therefore, it is becoming more modern and up to date, which means apart from the other things, that it is becoming a more open and patient-centered service. On the other hand, the NHS has financial problems as do the health services in other European Countries. It has to cope with shortfall because expenditure is increasingly higher from year to year. The NHS costs £43.4 billion to run per year, which is approximately 15 per cent of government spending.23 The cost of funding the NHS has increased from in the past as the chart24 below shows. The reason is simple. The quality of medical care has continued to increase and there has also been an increase in life expectancy.
YEAR
|
COST (in millions pounds)
| |
1949
|
388
|
1958
|
700
|
1967
|
1,400
|
1971
|
2,270
|
1976
|
5,470
|
1981
|
11,944
|
1985
|
16,304
|
Fig. 3 The NHS costs in the past (Chalmers & Cheyne, 98)
3.3.1. The Structure of the NHS in England
The NHS in England is divided principally into 3 parts; central government, regional health authorities and district health authorities. The centre of the NHS is the Department of Health (DH) which controls and supports the NHS. The next part of the system represents 10 regional organizations, known as Strategic Health Authorities (SHAs) which direct more than 300 Primary Care Trusts (PCTs). The Primary Care Trusts, otherwise called local health bodies, control the majority of the budget (approximately 80 per cent of the total NHS budget), assess local needs and provide and commission services. GPs, dentists and hospitals are the last part of this structure.
Fig. 4 The structure of the NHS
3.3.1.1. The Department of Health
This is a Government organization which takes political responsibility for the health service especially in England. In other parts of the UK responsibility for the NHS falls under the government organization of the respective country; in Northern Ireland this is the Department of Health, Social Services and Public Safety; The Scottish Executive Health Department is the organization in Scotland and in Wales, The Welsh Assembly Government secures matters concerning the NHS.
The residence of the DH is in Whitehall but there are also offices in Leeds and London. The Department of Health has approximately 2,245 staff25. There are several ministers at the DH who are appointed by the Prime Minister but led by the Secretary of State for Health, who is a cabinet minister. The current Secretary of State for Health is Rt Hon Patricia Hewitt. Other posts at the DH are: Minister of State for Reform (at present Lord Warner of Brockley), Minister of State for Health Services (at present Rt Hon Rosie Winterton MP), Minister of State for Public Health (at present Caroline Flint MP), Minister of State for Delivery and Quality (at present Andy Burnham MP), Parliamentary Under Secretary of State for Care Services (at present Ivan Lewis MP).
The DH has many responsibilities but its main purpose is to lead and support the NHS and social care organizations so that they are able to provide the best medical services to the people of England while at the same time being financially feasible for taxpayers. In other words, they try to ensure the highest quality health and social care at the lowest possible cost for taxpayers. The main task of the DH is to set and communicate the overall strategic direction of organizations such as the NHS and social care. Moreover, the DH helps health and social care organizations keep pace with important and major improvements. They monitor standards, safety of services and effectiveness in the NHS and social care organizations, and they collaborate with patients, medical and social staff and other Government departments on issues relating to public health.
The Department of Health was formally established in 1988. From a historical point of view, the Department of Health underwent many changes both in name and function. At first it was called the Ministry of Health (created in 1919), and in 1928 the Ministry published a White Paper that represented the first steps towards a better organised healthcare system. In 1968 the Ministry of Health merged with the Ministry of Social Security to form the Department of Health and Social Security. In 1974 the Department was reorganised again to be able to operate more effectively with the NHS. Finally, in 1988 the Department of Health and Social Security split and became separate departments again - The Department of Health and the Department of Social Security.
3.3.1.2. Strategic Health Authorities
Strategic Health Authorities (SHAs) are organizations which manage the NHS locally. They function as a key link between the Department of Health and the NHS. The have many responsibilities. Firstly, they support PCTs, hospitals and other NHS organizations (e.g. NHS Ambulance Services Trusts, NHS Care Trusts, and NHS Mental Health Services Trusts) and monitor their performance. To prevent falling standards, they have to take pains to improve services. Secondly, they develop strategies for improving health services in the area they are responsible for and support the usage of information technology. Moreover, they ensure service plans which are national priorities such as improving services of feared disease - e.g. cancer. Finally, to provide better care to more patients, they increase the capacity of local services and they recruit more specialists e.g. dentists, because the growth of the capacity of local health services necessitates increasing medical staff. Besides this, the Strategic Health Authorities enable medical staff to train in specialist areas of the health care. Strategic Health Authorities were established by the Government in 2002. There used to be 28 SHAs but in July 2006 this number was reduced to 10. (See Appendix 3 below). The reduction of the Authorities should enable better services for patients especially by means of stronger commissioning functions.
3.3.1.3. Primary Care Trusts
Primary Care Trusts are local organizations which enable the NHS to help and understand the needs of their communities better. PCTs have been functioning since April 2002 and they are subordinate to their local SHA. They are responsible for many things:
-
Assessing the health needs of all the people in their local area and developing an insight into the needs of their local community.
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Commissioning the right services, for instance from GP practices, hospitals and dentists, to meet these needs.
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Improving the overall health of their local communities.
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Ensuring these services can be accessed by everyone who needs them.
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Listening to patients’ views on services and acting on them.
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Making sure that the organisations providing these services, including social care organisations, are working together effectively.
-
Carrying out an annual assessment of GP practices in their area.26
The concluding part of the NHS structure is - General Practitioners (GPs), dentists and hospitals.
3.3.1.4. GPs
GPs or general practitioners are doctors to whom people come first if they are in need of medical treatment. GPs look after the health of people in the local community in which they operate. They provide a wide range of family health services such as advising on health problems, giving vaccinations, doing examinations and administering treatment (e.g. pursuing simple surgical operations); they also prescribe medicine and refer patients to other health or social services. Moreover, GPs provide health education for public; doctors talk to people about the harmfulness of smoking and taking drugs and arrange for specialist consultation.
GPs are non- specialist doctors and there are currently about 35,000 of them in Great Britain.27 In people’s minds, specialist doctors have greater prestige than GP’s, but generally doctors have very high social status as they do elsewhere outside Britain. For instance, a so-called consultant is a type of a doctor who works in a hospital and is considered to have the highest rank on account of being a specialist in a particular area of medicine. Nevertheless, GPs are very important; they are a major part of the NHS system and they keep their panel which is the list of their patients’ names. The more names they have, the more they can earn. They are paid according to the size of their panels. Naturally, there are limits. On average GPs have about 2,500 patients28 on their lists, although they usually see only a small percentage of this number. According to the NHS website, patients (in non urgent cases) can be seen by their GPs ‘within two working days or a health professional as a nurse within one working day.’ 29 If patients do not need an appointment within two working days, they can book an appointment in advance if it is more convenient for them. Nevertheless, patients are expected to notify the surgery if they have to cancel or change the appointment.
3.3.1.5. Dentists
At present, since April 2006, Primary Care Trusts are responsible for commissioning dental services, this includes routine care as well as specialized care services. Routine dental care and treatment is undertaken by dentists and their team in general practice and it includes check-ups, any kind of treatment leading to the maintenance of good oral health, such as fillings, extractions, fitting of bridges and dentures and scaling and polishing. Advising patients on how to take care of their teeth and gums in order to prevent oral health problems in the future is also an important part of their work.
Dental practices may provide a mixture of NHS and private care - the NHS services your dentist provides depend on local oral health needs and the contract they have agreed with your PCT.
For more specialised care such as surgery within the mouth, orthodontics (straightening teeth), domiciliary care (at home), sedation (easing anxiety) and more complicated root canal and bridge work, your dentist may refer you to another dentist either at a hospital or to another general dental practitioner who has an interest in this area.30
If people are looking for a dentist, they can contact their PCT and find out about the availability of general and specialized services within their local area.
3.3.1.6. Hospitals
For further treatment or examination, patients are referred by GPs to specialists and consultants; this usually takes place at local NHS hospitals. Appointments and treatment are free at NHS hospitals and they are usually arranged through a GP. Exceptions are in cases of emergency, where a referral (the appointment of a patient with a specialist or consultant in hospital, arranged by a GP) is not required. The wide-ranging services of hospitals are authorized, on behalf of patients, by Primary Care Trusts (PCTs). NHS Trusts increasingly are being commissioned by PCTs to offer services in the community closer to people’s homes. These services include treatments in which patients are admitted to hospital, day surgery (patients are not required to stay in hospital overnight) and outpatient services (people only attend consultations and undergo special tests).
Hospitals in the NHS are managed by NHS Trusts (sometimes called acute Trusts) which make sure that the quality of health care provided by hospitals is sufficiently high. They also ensure that finances are spent efficiently.
NHS Trusts employ most of the NHS workforce: consultants, doctors, nurses, hospital dentists, pharmacists, midwives and health visitors, managers and IT specialists, as well as people doing jobs related to medicine - physiotherapists, radiographers, podiatrists, speech and language therapists, dieticians, counsellors, occupational therapists and psychologists.
There are many other support staff including receptionists, porters, cleaners, engineers, caterers and domestic and security staff who all make a key contribution to the overall experience of patients.31
Great Britain has some of the most up-to-date hospitals in the world. However, there are a number of hospitals from the nineteenth century which are in urgent need of modernization. Moreover, there is a shortage of beds in some hospitals in Britain, despite the fact that more and more health care is needed due to fact that the proportion of older people in the population has been steadily rising. Nevertheless, wards and hospitals are being closed, and the blame for this situation is placed on government unwillingness to spend more money on health and its inability to successfully manage the funds which do exist. Although the British Government has increased its spending on healthcare each year, it is still not enough and the shortfall has been increasing because of mismanagement.
Unfortunately, there is also a shortage of nurses, mainly due to low pay, rigid working hours and also poor working conditions. Violence by patients might be added to many nurses reasons for quitting. There are several cases of unprovoked attack on nurses while they were performing their duties in a hospital ward. The recent case has occurred at accident and emergency department at Western Isles Hospital in Scotland; a drink-driver assaulted a nurse who was treating him after he was injured in the car crash he had caused.32 Similar cases are depicted on these websites:
“Nurse attack sparks safety demand”
,
“Medical staff call for help against attacks”
“NHS attacks 'must be stopped'”
“Hospital cuts attacks on staff”
“Attacks on health workers rise”
Naturally, every year many nurses start a family and some retire and the average age of nurses has been steadily rising. There are almost 400,000 nurses (including midwives) who currently work for the NHS.33 Annually a number of nurses are recruited from overseas but it does not solve the continuing shortfall.
________________________________________________________________________
Notes 2
1. Sked, Alan and Chris Cook. Post-War Britain: A political history; New Edition 1945-1992. Penguin
Books. 1993. p.19
2. Sked, Alan and Chris Cook. Post-War Britain: A political history; New Edition 1945-1992. Penguin
Books 1993. p.41
3. qtd. in Sked, Alan and Chris Cook. Post-War Britain: A political history; New Edition 1945-1992.
Penguin Books 1993, p. 41-42
4. http://www.spartacus.schoolnet.co.uk/TUbevan.htm
5. qtd. in Rivett, Geoffrey. From Cradle to Grave: fifty years of the NHS, chapter 1
6. qtd. in Sked, Alan and Chris Cook. Post-War Britain: A political history; New Edition 1945-1992.
Penguin Books. 1993. p. 45
7. qtd. in Sked, Alan and Chris Cook. Post-War Britain: A political history; New Edition 1945-1992.
Penguin Books 1993. p. 45
8. qtd. in http://www.spartacus.schoolnet.co.uk/Lhealth48
9. http://www.nhs.uk/england/AboutTheNhs/Default.cmsx#nhswalkin
10. http://www.nhs.uk/england/AboutTheNhs/Default.cmsx#nhsdirect
11. http://www.nhs.uk/England/AboutTheNhs/Default.cmsx#pharmacists
12. http://www.nhs.uk/England/AboutTheNhs/Default.cmsx#pharmacists
13. http://www.nhs.uk/england/AboutTheNhs/Default.cmsx#secondarycare
14. http://www.nhs.uk/England/NoAppointmentNeeded/AccidentEmergencySearch.aspx
15. http://www.nhs.uk/england/AboutTheNhs/Default.cmsx#mentalhealth
16. http://news.bbc.co.uk/2/hi/health/4542009.stm
17. qtd. in http://news.bbc.co.uk/2/hi/health/4542009.stm
18. Hewitt, . Patricia. 23 Sept. 2005. qtd. in http://news.bbc.co.uk/2/hi/health/4274164.stm
19. http://news.bbc.co.uk/2/hi/health/4274164.stm
20. McDowall, David. Britain in Close-up, Longman Group UK Limited 1993, p.194
21. http://www.keepournhspublic.com/index.php
22. Oakland, John. British Civilization: An Introduction. Routledge 2002, p. 176
23. Oakland, John. British Civilization: An Introduction. Routledge 2002, p.173-174
24. Chalmers, SAS & Larry Cheyne Scotland and Britain 1830-1980, Hodder & Stoughton Ltd.1992, p. 98
25. www.dh.gov.uk/AboutUs/HowDHWorks/DHObjectives/fs/en?CONTENT_ID=4105906&chk=v5flCI
26. http://www.nhs.uk/England/AboutTheNhs/Default.cmsx#primarycaretrusts
27. Oakland, John. British Civilization: An Introduction. Routledge 2002, p. 174
28. Oakland, John. British Civilization: An Introduction. Routledge London and New York 1989, p. 140
29. http://www.nhs.uk/England/Doctors/Default.aspx
30. http://www.nhs.uk/England/AboutTheNhs/Default.cmsx#dentists
31. http://news.bbc.co.uk/2/hi/uk_news/scotland/highlands_and_islands/6398313.stm
32. http://www.nhs.uk/England/AboutTheNhs/Default.cmsx#nhstrusts
33. http://en.wikipedia.org/wiki/Nursing_in_the_United_Kingdom
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