Analyzing National Health Services of the United Kingdom - Essay Example

National Health Services (NHS) UK: Implications for future NHS Policy with reference to present policy, practice, research and theory in health and social care partnerships Introduction As the world is getting older, the number of people is also constantly increasing and increasing rapidly. Additionally increasing trend of globalization has led to movement of people from one place to another imposing greater responsibility on the nations to provide at least basic facilities to the people living in their country which has become very difficult in recent times as most of the citizens do not receive those basic amenities like food, education, health services, housing, etc.. National Health Services of the United Kingdom is the world's largest publicly funded health care service provider which was evolved with an aim of providing good healthcare to all i.e. irrespective of wealth (http://www.nhs.uk)1 However it is pertinent to mention that central taxation funds 84% of the NHS provisions and NHS expenditure is 83% of total healthcare funding (Morris, 2006).2 Health and social care are the two important aspects that most of the nations are trying to build their economic growth. As most of the citizens are left out of the reach of the services, it is beneficial if the health and social care activities are carried out with the help of local primary trust, NGOs and government authorities. Health and social care partnership is crucial to the current process of modernization underway in UK welfare services. This is true across a range of policy areas, but is particularly significant with regard to adult and children's health and social care. The present paper is aimed at discussing the present policies of NHS which are in practice with regard to health and social care and to provide viable suggestions for the formulation of policies for NHS in the future. NHS Policy Reforms The health, social care and well being agenda is highly complex and challenging which is one of the most visible and contested aspects of contemporary public policy in the UK which is constantly being criticized by policy makers, citizens, politicians and the media. In the light of ever increasing public demands and expectations, an ageing population, huge advances in medical science and technology and scarce resources, there is a pressing need to design and deliver health and social care services that meet the needs of users and citizens and are efficient and effective. However, achieving consensus on the range and nature of these services is far from easy given the plethora of different interests and stakeholders involved. Skinner et al (2004) mentioned that the requirement of radical change in UK public sector has necessitated significant movement away from traditional structures, approaches, and assumptions resulting in new organizational forms and changed psychological contracts. National Health Service is one of such organizations that is characterized by continuous, radical national and local change in pursuit of a culture change away from bureaucratic and hierarchical processes towards newly valued entrepreneurial attitudes and behaviors.3 South (2007)4 states the NHS is one of the undisputed pillars of the welfare state and UK citizens have special rights to health care free at the point of delivery. It is further stated that the relationship between those providing health care services and beneficiaries has been characterized by professional dominance and paternalism which was changed by the New Labour Government in 1997 that included leadership development within the health and social services as a core component of the modernization agenda (Carr et al, 2009)5. Weeks (2007)6 mentioned that the historical responsibility of health and social care services in England has ebbed and flowed over time. The division of responsibility was to divide the work among the other departments of the government so that health care services take the shape of social services and reaches the citizens of England. It is further stated that the division of responsibility has worked well in some areas of care but was not successful in areas where the health care services were not provided to users with mental health problems. According to Mandelstam (2007)7 NHS was created politically because of a significant shift in thinking during World War II and legally by the means of National Health Service Act, 1946. The White Paper on the policy clearly states the health care services have to be provided to all covering all necessary forms of health care. The consequent National Health Service Act 1946 placed under Ministry of Health with an objective to promote the establishment in England and Wales and the services provided under the NHS policy will be free of charge, except where any provision would provide for making and recovery of charges. New Labour officially abolished the internal market straight after it was elected in 1997 but retained the purchaser/provider split while placing the emphasis on cooperative and collaborative relationships between all stakeholders (Hann, 2007)8 It was considered necessary to modernize the reforms of NHS as House of Commons Health Committee noticed that Community Health Councils were weak in delivering the three functions of advocacy, advice and representation. Moreover it was being positioned outside NHS organizations, with the potential for unnecessarily adversarial relationships to develop, the lack of representation from minority groups and young people and primary care services were not covered by the Community Health Councils which clearly does not follows the mission of NHS which aims to provide health care services to all, irrespective of health in the United Kingdom. As per research conducted by MORI, it was revealed that Community Health Councils didn't even responded to even 3 percent of the complaints and general public was not even aware of the role played by Community Health Councils. Patient and public involvement were the key points which were considered by the Labour government in 1997 that should be addressed in order to eliminate the gap between poor and health and social care. In 2000, the new NHS Plan set out a major modernization agenda for NHS which included reforms to promote greater patient and public involvement which was criticized by the internal authorities managing the proceedings of NHS as the previous policies was being replaced by Patient Advice and Liaison Service (PALS) and a network of patient forums. The main reason for creating PALS was to eliminate the gap between the beneficiary and health care by the providing information regarding heath (South, 2004) 9. The newly elected Labour government decided eliminating the divide between health care services funded and provided by the NHS from social services which was run by local councils. The Health Act 1999 came into force in April 2000 and in particular Section 31 of the act created an enabling power to create "partnerships" between health and social care agencies. Davies (2007) mentions that the concept of partnerships has become the cornerstone of policy for modernizing institutions across the whole field of civil and public life. NHS's one of the core principles include the partnerships with the local authorities, voluntary and private sectors as part of health and social care policy. The change is policy was brought out because of its practical benefits which include developing commissioning through cooperation rather than competitive tendering, so getting the best from all local groups instead of limiting choice and creating local tensions; providing joint training to foster understanding of wider local issues and others' way of working; helping join up the health and government agenda on strategic planning aligning local delivery plans with local authorities community plan processes; setting a framework for pooling budgets, providing joint services and developing joint strategic approaches to community involvement and enabling joint data gathering and developing common indicators and targets.10 The NHS was divided into primary and secondary care services wherein primary care services were delivered by primary care trusts which included local general practitioners, surgeons, dentists and opticians. Hospitals were responsible to deliver the secondary care to the patients. Care trusts were created to enable integrated delivery of health and social care services which would come under the best value regime for social care functions and be subject to NHS and social services regulatory inspection. Nine care trusts have subsequently been created with the first set up in 2002 mostly specialist mental health trusts and combined commissioning and provision (Weeks, 2007). Primary care trusts are responsible for funding the healthcare of all patients registered with GPs. PCTs hold the responsibility to delegate budgets to GP practices to commission acute, community and emergency care (Davies, 2008)11. Commissioning is the process of by which the health needs of a population are assessed and responsibility is taken for ensuring that appropriate services are available which meet their these needs. Practice Based Commissioning was initiated with a view of providing great variety of services from greater number of providers at the place convenient to the patients, increased support of clinician to clinician dialogue about improving and developing care processes, early and continuing involvement of practitioners in service department, and an additional set of levers to aid demand management (Maynard, 2005).12 Practice Based Commissioning will give GPs more responsibility for local health budgets, while individual budget pilots will test how users can take control of their social care. These will act as a driver for more responsive and innovative models of joined-up support within communities, delivering better health outcomes and well-being, including a focus on prevention. The following is the structure of NHS authorities and trust which aims to deliver health care services to all (Schabloski, 2008). Fig. 1: Structure of NHS Authorities and Trusts Health Care Systems from other nations and comparative analysis with NHS, UK The NHS underwent major reforms in a bid to provide best health care services to its citizen, free of cost, except in few cases. However it would be useful to assess the effectiveness of NHS in the United Kingdom if it is compared with other health care systems in the world. A critical review of the health care statistics shows that the United Kingdom spends 6.6% of the GDP on health care as compared to 13.4% (United States) and 10% (Canada) (www.huppi.com)13. In 2000, World Health Organization reported that France was ranked top with higher per capita spending with the population of 64,057,792 whereas United Kingdom was placed at 18th with population of 60,943,912 which shows that though the NHS receives 84% of the central taxation as fund, it is very low as compared to that of France in terms of spending as well as population (Gonzalez, 2008)14. Snape and Taylor (2004)15 mentioned that the measures introduced in England since the Labour Government came to power in 1997 in order to facilitate, encourage and enforce collaboration were both extensive and thorough which has the potential to penetrate the core business of NHS and local authority organizations. Schabloski (2008) mentioned about the health care systems existing in various countries which do have best policies in regard to health and social care. Canada provides universal access to health care to 33.2 million people. Canada is a good example wherein the government provides health care services through private professional, private not for profit, private for profit and public facilities which is funded by public taxation and administered under provincial legislative framework. Canada provides long term care and other social service benefits to its population ranging from residential care facilities, and home based care. As mentioned above, French health care policy is regarded as the best in the world placed at top in the WHO ranking as per capital spending catering to the needs of 64 million people residing in its jurisdiction. Over here also, the responsibility of health care service is divided among national, regional and departmental levels of government supporting both public and private health care providers. Japan with the population of 127.3 million and third largest economy in the world, has broad health coverage featuring a private delivery system with a public financing scheme. Its universal health care system is financed by a combination of public and private funds organized around three types of insurance viz. the society managed health insurance and mutual aid association plans, the government managed health insurance, and citizens' health insurance.16 Need for Partnerships - NHS Policy The NHS Confederation is working with members, policy makers and experts in order to identify effective ways of meeting the efficiency challenge and innovations in clinical practice (NHS Confederation, 2009)17. Morris and Dawson (2006) mentioned that the factor central to the future of UK Health Policy is the role the state will play in terms of healthcare provision and the promotion of improving health status for the population. The boundary between health and social services has been a permanent feature of provision which came into the existence as part of the establishment of NHS in 1946 where it was decided to nationalise the hospital service so that local authorities are involved in providing services in secondary care. Though the initiative survives various criticisms from different sectors, the strong and effective partnerships with other agencies and services need a degree of local ownership that may be difficult to sustain in the face of strengthened national targets (Snape and Taylor, 2004). There have been special problems in delivering personal health services for people with long-term conditions: Many factors contribute to these deficiencies, but lack of co-ordination between health and social care professionals - and within primary, secondary and tertiary healthcare - is a major factor. Demographic revolution is another important factor as the population of baby boomers in increasing and they are more vulnerable to the risk of long-term conditions. While the current generation of elderly people tend to be accepting of or grateful for care, the baby boomers will have higher expectations and will not tolerate current health and social care services. At the same time, however, the decline in births in the 1980s means that there will fewer younger people to care for them. This explains the urgent need to change from a reactive to a proactive integrated model of care delivery, as outlined in the Department of Health and PSA targets for 2008 (Department of Health 2005). It is reported by the House of Common Health Committee (2010) that partnership working can play an important role in increasing productivity and transforming service delivery.18 The partnership approach stresses the vital role of local partnership work and seeks to better join up social care and health making these services more responsive and adaptable to local needs. The LGA and ADSS strongly welcomed the Department of Health White Paper "Our Health, Our Care, Our Say" providing a potentially unifying vision for integrated health and adult social care which recognizes local authorities' local leadership role for health and well being, advocating partnership working in localities between councils and Primary Care Trusts building on local area agreement as a key mechanism for joint planning and delivery (House of Commons, Health Committee, 2006)19. Problems faced by single provider in supplying the demand from the patient especially with complex needs (Van Raak et al. 2005) and high cost as well as discontinuities of care especially for elder people (Mur-Veeman et al. 2008) are other factors that drive integration of health and social care. Brown (1992) argued that such integration will provide less duplication of work, more flexible, coordinate and continuity tasks thus creating more efficient and effective work. It is important to mention that net international migration fluctuates yearly with increasing trend averaging 100,000 persons per year. The population of United Kingdom is estimated to increase from 59.2 million in 1998 to 63.6 million by 2021. Older people are the heaviest users of health and care services with utilization increasing with age as recent analysis of health indicators for people aged between 55 -64 showed that there were signs of increasing or unchanging health problems in relation to cancers, obesity, common chronic illness, self reported health and blood pressure levels. There is a need for change in the policy because of increasing population trend supported by continuous influx of people in the United Kingdom and increase in the demographic profile between the age group of 55-64 (Dunnell, 2001)20. The future policy has to include several aspects pertaining to social inclusion with regard to migrating people, older people, medical facilities at places convenient to patients, etc. so that the vision of NHS to provide health care facilities to all, free of cost is achieved, with the help of social partnership. NHS LIFT (Local Improvement Finance Trust) was founded so as to encourage investment in primary care and community based facilities and services to achieve the NHS plan target of 500 one stop primary care centres. A partnership for health, a public private partnership between department of health and Partnerships UK was initiated to invest money in NHS LIFT so as to attract additional private funding (Davies, 2008)21. Pollock et al (2006) mentioned that there are many parallels between NHS R&D strategies and there is an increasing emphasis on public private partnerships both in the provision of health services and R&D. It is further mentioned that the new partnerships and networks have the potential to add much-needed strategic direction to NHS R&D activity. The partnership has the potential to enhance the protection of research subjects through a sharing of roles and responsibilities between the medical profession, academic and healthcare organizations and the law along with public involvement. However it is important that all these stakeholders work in coordination with each other duly supporting each others opinion and values so as to achieve the objectives of the industry and that the objectives of NHS and public are realized22. Benefits of Partnership Policies The recent trend in increasing diseases has made it impossible for the medical fraternity to relax and depend on the previous policies for the development in medical facilities. National Health Service, United Kingdom faces profound changes and challenges wherein the roles and responsibilities, mode of services change instantly. It is evident that social partnership is increasingly benefiting the medical fraternity as one of the key tool which is developing positive and productive relationships with staff organization. Various benefits of social partnership working include better quality services for patients, better prepared to meet the financial challenges in the current economic climate, better staff morale and motivation, increased productivity and employee relations, ability manage change effectively and increased innovation through joint problem solving (Social Partnership Forum, 2009)23. Social partnership working will provide the patients to receive free medical facilities at their place of convenience and thus helping in achieving the goals and targets set by the NHS. Models of Integration Gwanmesia (n.d)24 mentioned that partnership working can be theorized on power-relationship in which a competent communicator with vision; the ability to empower and team build, coherently directs member to achieve a common objective. It is further stated that Tony Blair set up the Social Exclusion Unit (SEU) as a part of his partnership policy to help "improve Governments action to reduce social exclusion by producing joined-up solutions to joined-up problems". According to Morris (2006) 25 the state expects individuals to "self care" to make healthy lifestyle choices and to possess the means to act responsibly which implies a measure of individual agency and autonomy which fails to locate individuals as embedded in socioeconomic reality. There are several determinants of health in joined up policy which provides valuable reasoning as to why social partnership policy is needed in order to involve government and private agencies in the noble cause of providing free and quality health care to the poor. Scotland, Wales and Northern Ireland promoted the modernization of health and social care so as to meet the needs of community through decentralization (Greer, 2004). Moreover the Local Health Care Cooperatives (LHCC) has been providing the services in Scotland in collaboration with Joint Future and Community Health Partnerships (CHPs). The Welsh model is clearly set out in the 'Making the Connections' agenda (WAG 2006) and 'One Wales' report (2007) which mainly emphasizes on providing citizen centered and client focused services and to ensure that services are grounded within the needs of people and communities. Implications for future NHS policy and practice David Nicholsan, Chief Executive of NHS emphasizes the importance of quality service to the patients and the same remains a challenge to turn it into reality for patients and staff. The five national priorities of NHS includes improving cleanliness and reducing healthcare associated infections, improving access through achievement of the 18 week referral to treatment pledge and access; keeping adults and children well, improving their health and reducing health inequalities; improving patient experience and staff satisfaction and engagement and preparing to respond in emergency (NHS, 2008-09)26. However the process of change is beginning in the infrastructure of health and social care, where decision support tools and clinical information systems are being used to support the care-delivery system. Case management and disease management along with self-care and the promotion of better public health are key contributors to the delivery of care (Department of Health 2004; Department of Health 2005[b]). Though the increase in UK population is gradual, it is important to mention that the ageing population will be the category where the UK Health Department will have to make necessary amendments since the 45 to 59 age group is projected to increase by nearly one quarter from 1998 to 2021 (Dunnell, 2001). The Department of Health has been demonstrating the commissioning policy which involved three levels of commissioning viz. macro, meso and micro level; each of them associated with different risks and benefits. The commissioning policy is efficient in transferring the roles and responsibilities to PCT, GP and other health care workers so that the work is divided and carried out efficiently making it easy for the patients to receive medical facilities at places of their choice (Wade et al, 2006)27. Practice Based Commissioning has to be reformulated in order to make amendments in regard to powers assigned to the Commissioner so that decisions about health care facilities are made quickly. What facilities and how they should receive it will be more correctly answered by the beneficiary himself only. Involvement of public while making health policies will reduce the burden of policy makers and will also help to assess the type of health care facilities required by the general public. However it is not possible to involve all the population in discussing the policies, it again is the role of social working partners who will be playing the role of representatives of general public as their experiences and the field level and interaction with the general public. Health Committee (2007) mentioned that the creation and fostering of active citizens' groups, voluntary and community organizations, and social enterprise is a key to improving services, reducing health inequalities, and building strong communities. It is further recommended to train and support both individual and community capacity for patient and public involvement so as to reduce health inequalities and formulate better policies providing quality health care facilities.28 The difference of opinion pertaining to the jurisdictional areas is also one of the main areas which need to be addressed. Primary care trusts were created in order to deal with such geographical problems so the patients are not deprived of free health care. Jon Glasby's (2004) suggestion of a foundation trust model with the entire local electorate as members and with elections of the boards and governors at the same time as local government elections would combine government policies on foundation and care trusts, producing a way forward acceptable to health and local government, increasing public interest and introducing democratic procedures into the heart of the local NHS. The NHS has the capacity to tackle health inequalities by providing excellent services accessible to needy persons by ensuring NHS organizations provide treatment, screening and health promotion services. The UK government has to formulate policies pertaining to health care facilities accorded to ethnic population. House of Commons Health Committee (2009) reported that there are differences in health between ethnic groups and also claimed that inequalities in health exist between young and old. It is further reported that old people receive poorer treatment and are denied access to certain medical procedures which needs to be addressed while making health policies. The report further states that gender inequalities are also the area which has to be taken care so that women don't have to receive poorer treatment.29 Socio economic factors are the main reason behind the health inequalities in United Kingdom. Few specific aspects of inequalities in health are attributed to differential access and standards of health care. Factors pertaining to lifestyle are also some of the reasons causing health inequalities. Few of lifestyle factors include smoking, alcohol consumption, nutrition, exercise, sexual behavior, etc. It is further reported that the health in the United Kingdom is improving but the gap between healths inequalities have widened across certain social and economic factors - 4% among men and 11% among women (House of Commons Health Committee 2009). The future policy should be capable of addressing the issues or factors that are the causes of health inequalities in the United Kingdom. The policy should concentrate more on how the involvement of partnership framework will eliminate the inequalities and how social working partnership can provide accessibility to the poorer irrespective of all the aforementioned inequalities. Practices vary across different sites within the same NHS Trust and the main factor associated with this seemed to be the nature and extent of multi professional collocation. Shared and informal approaches are maintained where partnerships are collocated and the interaction was described as "ships passing in the night" in areas which did not have social care collocation (Hudson 2002). Conclusion The NHS being the world's largest funded public health care service provider, it constantly aims at providing better health services which is its main challenge. And in order to overcome the challenge, the policies of NHS are checked and repealed for in order to update it and provide best health care to its citizens free of cost. However while formulating the policy, it is necessary to address the issues pertaining to discipline and grievances which needs to be adapted in new circumstances, should provide social welfare to the people suffering from mental health, disability and others not covered under Health Act. As part of the integration, NHS will have extended responsibility of providing identifying stakeholders, entering into contract, providing training, redressal of patient as well as employee grievances and managerial problems (Weeks, 2007). The core task is to examine policy proposals from UK Government and the European Commission in Green Papers, White Papers, Draft Guidance, etc. It is suggested to scrutinize the proposals and policies such as framework of audiology which sought to address the extremely long waiting times for patients wishing to upgrade their analogue hearing aids which revealed that patients had to wait for more than two years to receive treatment and it was proposed to include the audiology framework in 18-week targets. Lord Darzi indicated his report "Our NHS, Our Future" that NHS should operate in future and announced number of intermediate actions such as measures to tackle Healthcare Acquired Infections (HCAI) in hospitals and establishment of Innovation Council in the NHS. Another core task is to identify and examine areas of emerging policy or the area where existing policy is deficient and accordingly provide proposals for amendment (House of Commons Health Committee, 2008)30. There is support for the possibility of more optimistic view of collaborative care partnership working even though theory, research and practice do confirm several obstacles to health and social care partnership working. There is a need for coordination between different groups providing health care services to the people. Rising hospital admissions and falling lengths of stay have reduced the time for recovery and rehabilitation, leading to increasing demands on social services, especially for residential and nursing home placements, thereby reducing resources that could have helped to support people in their own homes and contain rising hospital admissions. Guy's (1986) optimistic hypothesis can be considered as it tries to look at commonalities between members of different professions and applying the professional values of trust and service to users to form the basis of health and social care partnership. It is further suggested that social inclusion will eliminate the differences beneath professional or hierarchical groups and that professionals and bureaucracies can join forces in a collective effort to achieve their goals and this could lead to more effective service delivery and user outcomes. The policies and practices of NHS have always considered the patients need for better health care services and therefore, in order to eliminate the barrier of inequalities among gender, ethnic and lifestyle factors, etc., it is necessary that NHS devise a policy in view of providing health care facilities eliminating the gap and social care partnership would be helpful in realizing 'free for all' vision. References 1. About the NHS, (2009) NHS Choices, http://www.nhs.uk 2. Bornat, J. and Leece, J. (eds) (2006), Developments in direct payments. Bristol, Policy Press. 3. Brown, M. and McCool, B.P. (1986), Vertical integration: exploration of a popular strategic concept. Health care management review. 11(4): 7 - 19. 4. Carr, S.M., Lhussier, M., Reynolds, J Hunter D.J. and Hannawy 2009) Leadership for health Improvement - Implementation and Evaluation, Journal of Health, Organization and Management, Vol, 23, No 2, pp. 200-215 5. 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