Change of the Health Service from 1948 - Book Report/Review Example

 Change of the Health Service from 1948 Introduction Since its time of creation in 1948, it is approaching sixty-one years since the NHS was created, and during this period, a service that was the envy of the world has declined dangerously. The decline is such that the UK produces some of the worst health outcomes of any developed country, and the system is insular, inward-looking and extravagantly wasteful. There is no dearth of talent in the service, and the doctors and nurses remain hugely committed to their patients. They put in long and stressful hours, but they are being let down by a system that is dysfunctional. Since 1997, the government has made excellent progress: NHS funding has doubled and will soon be three times what it was at the end of the 1990s. This indicates that there has been a change in the NHS since its inception, and it has been argued that pouring money into an unreformed, poorly managed system has inevitably created waste – and will continue to do so. There is an array of arguments regarding these changes in all spheres. However, there has also been considerable debate and counter-arguments and consequently a volume of literature, so that the pattern of changes and its consequences over time may be evident on a closer look. In other words, the historical development of the NHS and social care may represent structurally the reasons for changes in its presentation, and clues to them may be available through critical analysis of the health policies and their analysis based on theoretical underpinnings, academic concepts, policy initiatives, issues related to them. If a change is suggested, there is an element of comparison between the previous policies and the recent ones in order to examine the types and extent of changes in the NHS, which might be radical (Gorsky, 2008). Focus Question To what extent can it be argued that the health service has changed radically since its creation in 1948? Historical development of the NHS and Social Care All health systems have a mix of financing mechanisms which are, in the terminology of Derek Wanless, social insurance, private insurance, out-of-pocket payments and taxation. As is well known, Aneurin Bevan, Minister of Health in the Labour government, nationalised the hospital system in 1948 (Campbell, 1987). Since local government was no longer to co-ordinate the NHS or to run its own hospitals or clinics, national rather than local taxes came to fund the service largely by default. Bevan also favoured this in principle for three reasons. The first was that national taxation was more redistributive, and the second was that he regarded free access to health care to be a citizen’s right and not something conditional on the payment of contributions. Finally, there was the question of how, politically and administratively, the non-insured could be turned away from a universal service. He favoured a fully tax-financed system so strongly that he strove to disassociate the NHS from the other welfare services launched on 5 July 1948, ‘the appointed day’ and conventional birthday of the welfare state (Bone 2008). The welfare state in Britain, of which the NHS is a major and enduring part, is complex. It originates from the Beveridge Report, which was the major plank of post-World War II social reconstruction. The report provided a set of welfare principles for improved social justice for British citizens. It thus paved the way for a legislative framework to tackle five areas of serious need that the report had identified. These are want; disease; ignorance; squalor; and idleness. The market economy had failed the population in the inter-war years when much of it experienced unemployment, poverty, poor educational standards, poor health and poor housing. Market forces had failed to supply these important social goods and to deliver essential services. The government thus felt that large-scale, collectivist state intervention was required to meet this unmet need and that only this mechanism could effectively and fairly deliver the volume and quality of services that were required by the postwar population (Lindsey, 1962). These early social policies on the relief of need were based on citizenship theory. It was seen that total reliance on market exchange as the basis for providing welfare had produced a nation that was socially divided through the unfair way in which it distributed opportunities to its people. This argues that although at a fundamental level the welfare state provides a necessary safety net, it is also a desirable thing for moral reasons. These theoretical principles looked forward to a change of the then situation (Appleby, 1999). This line of thinking contends that the welfare state would relieve the effects of poverty and other dire forms of social need and protects the most vulnerable people in society and lessen social inequality through redistribution of the national wealth from those who have a comfortable standard of living to those who have not. Moreover, it was designed to promote an ethically conscious society in which citizens are prepared to contribute willingly through various forms of taxation towards services that they do not often use themselves. Consequently, the welfare state was a by-product of a strong economy and of economic growth. In order to achieve its ambitious social policy intentions the 1945 Labour government needed an economic policy that would make its plans affordable (Gorsky, 2008). The NHS is a prime example of a monolithic organisation that remained relatively unappealing to private capital and private investment. It is the largest employer in Europe with 1.3 million employees, one of the biggest employers in the world. Its building stock is very varied in its quality and some dates from the 19th century. The performance of its key functions, though consistently high, are very vulnerable to criticism in part because the NHS is so highly politicised. Although the post-war governments of both major persuasions have behaved in similar ways towards the NHS, each finds it possible to construct highly negative political capital about it when in opposition. These factors rendered only selective parts of it attractive to prospective private investors or buyers (Bone, 2008). By the 1970s the state also found itself in possession of a range of public services that over a 30-year period had become increasingly extensive and sophisticated. At the foundation of the welfare state it had been intended to provide public services to meet a range of basic human needs. But these service organisations such as the NHS had burgeoned into massive, almost monopolistic, institutions that began to provide far more extensively than had been envisaged (Chappel et al., 1999). The remit for services thus extended beyond meeting basic needs to catering for the complex personalised requirements of the population. Therefore, it was only when the economy became unable to pay adequately for this plethora of public service institutions that a new powerful debate about them began. In parallel, the economic triumphs of 1950s and 1960s were replaced by paramount economic failure (Berridge, 2007). The arguments that emerged were based on two principal propositions that concerned the entire intellectual rationale for the welfare system. It was felt by the policy makers that the ideological beliefs that the welfare state was devised for a former era and that its services were irrelevant to a modern capitalist economy and therefore needed a drastic overhaul. This was accompanied by economic arguments that suggested that Keynesian economics had not managed to halt Britain’s economic decline and were in similar need of refurbishment. This was a paradigm shift. At the time of its establishment in 1948, the National Health Service was recognised as a remarkable experiment in health care (Cutler, 2003). Alone among its capitalist partners, the United Kingdom offered comprehensive health care to its entire population. On the basis of finance from general taxation, all of its services were free at point of use. This huge public service was recognised by outsiders as the outstanding example of ‘socialised medicine’ in the western world. Particular interest attaches to the conspicuously political character of the UK health service. To a greater degree than elsewhere, funding and policy became the province of the politician and the civil servant. Everywhere else health care was subject to political intervention, but the UK was unusual in the extent to which politicians assumed command and took over the levers of control for the entire health care system (Cutler, 2006). Thus NHS can be defined as a system to provide universal, comprehensive, and free health care, with ultimate responsibility residing in the minister appointed by the governing party. The social historians see this in a little different manner. It has been said that the dominant genre has therefore been a top-down history of the politics of the service, which has been driven by the politicians, officials, doctors, intellectuals, and pressure groups who drive the policy process. Arguments have risen from time to time from different quarters, sometimes the functions have been shown to be manifestations of incarcerations of social solidarity and distributional justice (Doyal and Doyal, 1999). Sometimes, it has been criticised that the functions are guided by inflexible bureaucracy and paternalism. If one approaches the literature, it would be very evident that few studies deal with the history of the NHS spanning over such a long time, and surprisingly, there is really a paucity of literature that has been contributed to by people from within the discipline. Some studies have been conducted based on the principles of the welfare state. Timmins (to 1993) has treated NHS with a journalistic insight within the broader accounts of social policies (Timmins, 2007), and Lowe (to 2005) treated the NHS within the same purview from an analytical perspective that can be termed as ‘reluctant collectivism’ (Lowe 2005). Ross (to 1951) did the earliest survey of the national health service that argued from the historical perspective and analysed the way policy should respond to financial austerity (Ross 1952). Subsequent major studies by Eckstein (to 1959) (Eckstein 1959) and Lindsey (to 1961), that examined the pros and cons of the so called ‘socialised medicine’ (Lindsey 1962). Works by Watkins (to 1974) critically assessed the 1974 reorganisation (Watkin 1978), and Widgery (to 1977), "a fierce response to the 1970s funding squeeze from the East End socialist GP." (Widgery 1979). Although in these 60 years of existence, the British NHS earned the respect of its people due mainly to the fact that it intended to care for everyone in Britain at an expenditure of less than 6% of the GDP. It aspires to provide care to everyone at less than 6% of the GDP yet providing universal access of care that is high in terms of quality standards. However, the original could not survive for a prolonged period of time. These happened due to increased resource demands for the care of increasing ageing, rapid expansion of technological knowhow, better informed patients, and enhanced expectation of the clients. The path to the NHS was by no means an inevitable and logical progression. There was no smooth process of evolutionary change and a noticeable absence of consensus over most basic aspects of health-care policy. However, there was informed consensus of opinion on maintaining decent standards of health. Compounded with that, it was being increasingly observed that the NHS worked well in its early days, in an exhausted and impoverished post-war Britain, but structurally it has become obsolete and outdated. It has become over centralized and bureaucratic – it has been taken over by the civil servants and bureaucrats. At the beginning of the 1960s there was optimism in the country: economic growth seemed certain and the NHS was an admired institution. But from the mid-1960s, the economic situation deteriorated with poor balance of trade figures and severe deflation (Lindsey 1962). In 1967, the pound was devalued and the third decade of the NHS began in financial crisis. At the close of 1967, Kenneth Robinson, the Health Minister, announced that the government’s views on the structure of the NHS would be set out in a Green Paper. The BMJ pressed for modernisation and reform and for the integration of the management and financing of the NHS. The problem even remains the same now. A 1996 survey on British People found that 56% felt about the need for fundamental changes in the NHS in order to rebuild it completely with dissatisfaction expressed by 41% of the population. The reason was scarcity of the resources, and this was affecting the buildings, pay, staff and equipment shortage, short treatment time, and growing waiting lists. It has been argued that this shift indicates the change of political economy of medicine, and this has essentially been a shift from paternalism to consumerism. NHS was no longer, as originally envisaged, fulfilling the needs; it was viewed as a service that must respond to demands and choices, not just an politically planned instrument (Rivett 1998). Pickstone describes this as a changing political economy of medicine from mid-twentieth century communitariarism (Pickstone 2000). These were, as argues, shaped by notions of inclusiveness and faith in biomedicine leading to consumerism with people's growing assertiveness towards fertility and health. Klein has rightly argued, "thus the state’s role in medical care has shifted from an expression of social solidarity and public service to a means of satisfying the preferences of increasingly autonomous patients" (Klein, 2006). The problem was that the NHS had an insatiable thirst for money in the context of a bureaucracy that was structurally dysfunctional and unable to cope. As medical technology advanced, so did its costs, exacerbating the need for more NHS resources. This situation was compounded by the reluctance of successive governments to get to grips with the situation and radically reform the NHS. This state of affairs continued until 1997, when a new government, committed to putting substantial investment into the NHS, was elected (Le Grand, 2002). At the time of inception in 1948, it was thought that the issue of charging for services was especially sensitive, rousing passions and fears among the people about exploitation by unscrupulous practitioners and purveyors of patent remedies, meanstesting, unaffordable doctors’ bills, and other humiliations connected with charity and the poor law. With the emergence of this consensus over the virtues of the NHS, the political parties might have competed with one another to shower benefits on this favoured child of the welfare state. There certainly existed a greater measure of political agreement, giving expression to a great deal of vacuous rhetoric, but the politicians neither guaranteed the patrimony of the new health service, nor offered effective leadership over policies relating to health and health care. For the most part, the situation between 1948 and 1964 was characterized by resource starvation and policy neglect (Fox 1986). Taking the period from 1950 to 1964 as a whole, if current expenditure on the NHS is deflated using an NHS price index, it is seen that there was an average annual increase in expenditure of about 2.5 per cent, but with half of the increase being concentrated into the last five years. This pattern reflected the general course of public expenditure, itself affected by a rate of growth in the economy averaging at about 2.3 per cent during the 1950s, which is less than the growth rate in other comparable Western economies. These changes might have been due to popular consumerism as a motive force (Le Grand, 1999). Political economy approaches emphasised instead the vulnerability of the British Welfare State within the context of national and global capitalism. Some of the most telling criticisms of the NHS from 1948 to 1997 come from Ken Jarrold. He says, "If I had to choose one phrase to describe the NHS from 1948 to 1997 it would be relative decline. Throughout this period, governments did not face up to the challenge of adequate investment in the NHS. As Derek Wanless’ first report demonstrated, the NHS has been starved of resources." (Jarrold, 2005). This criticism went beyond this and pointed out that this is a service "that was staff centred rather than patient centred. Towards the end of the period, this was increasingly challenged but the predominant theme was that the NHS was not primarily concerned about patient interests." (Jarrold, 2005). It was observed also that there was quite an amount of disorganisation in the services that was supposed to provide coordinated services to the patients. This was argued to be negative characteristics of the service. It was criticised that there was no service framework in 1997. Jarrold has again said, "There was little attempt to define how services for key patient groups should be delivered in accordance with best practice. Staff and patients did not have agreed pathways and standards against which to judge the services provided in their area and there were no national service frameworks . . . a lack of focus on health and a deep reluctance to discuss connections between poverty and health. The problem was that for the first 49 years of the NHS the focus and attention of most managers was on support and administrative services. Very little management attention was devoted to patient care." (Jarrold, 2005) Therefore, it can be stated that the founding of the NHS was full with arguments and debates in order to find out whether there actually existed any broad consensus in the favour of reform. It was also questioned whether changes in the NHS were the results of conflicts between progressive and reactionary forces. Theoretically, this was viewed as a result of alliance between paternalistic bureaucracy and technocracy of the medical field, and it was also viewed as their championing of rationalization and integration (Mechanic, 1995). There was also a perception that interwar hierarchical regionalism also played its part leading to a trend towards an organisation that was spatial in terms of medical services oriented to expertise. This means also that the centralized bureaucracy along with their poor management failed to address and undermined the core problems of NHS. This also calls for policies that would dismantle the bureaucracy through decentralisation and depoliticisation. These policies would be much more radical in order to introduce a failure regime in order to create competition in the service in the interests of the citizens. This change in the framework could also root out poor management beginning with the senior NHS managers (Oliver, 2001). The results were emergent grouping of academics in the medical field, local government health officials and industrialists including urban hospital councils. Webster stated that NHS resulted from the confrontation between the labour party, impacted by public opinion, and counteracted by the more conservative forces (Fry 1988). During Churchill administration, it was apparent that the initial financial projections were by and large wrong, and it was found that planning underestimated the costs and suppressed demand soared up. Politically, due to people's high satisfaction levels, it was a hot area, and politicians paid high attention to education and social security at the cost of negligence demonstrated towards NHS. In the 1950s, only the acute hospital sector made progress. In comparison, the capital investment was clocking a lower rate in the 1930s. There were steps to develop a full-time consultant service. In general, there was understandably the potential to develop an integrated service that can fulfill the reasons to distribute the staff (Verow and Hargreaves, 2000). In the 1980s there was considerable emphasis on improved of management in the service, and it was being increasingly perceived that there must be a needs-based policy to allocate funds at the regional and peripheral levels. The resource would also need to be allocated for utilisation across boundaries. This needed modification of the allocation formula taking into account of mainly needs, which were indicated by the demographic characteristics such as differences in mortality rates, age distribution, and indicators of socioeconomic status (Enthoven, 2000). This process still has been noted to be continuing. Added to that, a number of managerial measures were introduced in both the hospital and community health sectors. There were efforts to monitor "primary care more closely and to give greater emphasis to disease prevention and health promotion." (Davies, 1987). To be able to implement these ideas there was new contract with the GPs the year 1990. It is evident therefore that contemporary reforms in the NHS were grounded on the processes of "continuing operational changes affecting resource allocation, the organization of the Department of Health, institutional accountability, and GP contract provisions." (Berridge et al., 2006). OECD contains that policy-makers should address the following key challenges: Ensure that public money is spent efficiently to contain the tax burden. Increased expenditure on health and education has been accompanied by reforms aiming to ensure that resources are better used, but further improvements can be made (OECD, 2005). This has been directly linked to the productivity of the NHS. Patricia Hewitt succinctly puts is as follows, "Statisticians argue about productivity within the health service. As we explained in a report last week, the old measures – by failing to take account of improvements in quality and the increasing number of people’s lives we are saving – understated NHS productivity. But even if the real productivity growth is around 1% – as we believe – rather than negative, it needs to be far higher." (Hewitt, 2005). It has been observed that the Government is trying to handle the deficits and improve the productivity, a lot needs to be done, and that is possible only through reforms. Literature suggests that references of British reforms are known to state three changes with great implications from the ideological point of view (Lawson, 1992). These changes desired to separate the financing and purchasing from its provision, thus intending to create a market internally. There was provision of a great amount of autonomy for the hospitals and other health care organizations, which could better be managed and administered publicly by the local health authority (Davidson and Shuttleworth, 2004). These were allowed to be self-governing trusts. This allowed more autonomy in their budgets, where they were enabled to sell services to any other health authority, hospitals, or even to the private sector. GPs who had larger numbers of clientele were enabled to take 25% of their charges from their patients and to subscribe paid services from any provider (Coulter, 2002). Conclusion All these were necessary to cover long-drawn deficits. By virtually all criteria, over the 1948-64 periods, the NHS could not be regarded as a drain on national resources. Its costs were contained without difficulty and thus resources were denied for obvious and urgent prerequisites, such as those connected with demographic change, medical advance, capital investment, or policy changes needed to keep up with rising expectations and the pace of improvement in the health arena (Berridge et al., 2006). Furthermore, the real inferior status of the health service was disguised by the political rhetoric, leading to a sense of complacency. Owing to the effectiveness of this propaganda, reinforced by the evident improvement on the previous system, habitual stoicism and misplaced confidence among the public concerning the prospects for improvement, and a general disinclination to criticize a cherished national institution, the new health service drifted into a political limbo and thereby risked becoming a neglected backwater of the welfare state. A monolithic bureaucracy with no competition creates a top-down system that is systemically unresponsive to customers. There is no provision for incentive to publish data on health outcomes, nor there is any incentive for clinical teams to take their expertise out of their local area. This when compounded with a poorly managed cost-driven system would lead to periodic bouts of cost-cutting. Thus there was a necessity of internal market within the NHS ro be able to introduce some incentives into a centrally planned, system that is at the same time hierarchical and have the potential to maintain a universal as well as a free access to health services for all. This market concept led to ability to purchase services for the people the districts, instead of from higher-level service managers. Most pieces of the policy agenda have been put in place by the government. There are many adjustments required, and much play-testing and piloting, but the general thrust is right. Integration of the healthcare system with the social care system has been neglected (Jagdish, 1978). Research shows that citizens are perplexed by the poor integration between these two services (de Lusignan, 2003). There are some significant inconsistencies in policy. The most obvious one is the tension between PbR, which incentivizes managers to pull volume into their hospitals, and the Out-of-Hospital White Paper, which advocates less activity in hospitals, and more treatment in the community. The policy agenda has previously concentrated too much on the acute care agenda. Not only has the primary care sector been neglected, but so too has chronic disease. This has not only been a problem for patients, but has also alienated some clinicians. 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