The NHS Flashcards
Describe Healthcare in the UK in the 16th and 19th centuries
Historically, the poor, infirm and elderly received care from religious orders, particularly the monasteries
In 1543, King Henry VIII dissolved the monasteries, removing the main source of care for vulnerable people
In 1601, under Queen Elizabeth I, Poor Law established alms-houses to care for the poor and sick. This remained the main source of state-sponsored care until the 19th century
Outdoor relief (support the poor at home) and alms-houses were abolished and austere workhouses were established, providing accommodation for the poor, orphans and the elderly
Everyone was housed in single, large institutions, annexes were added to house the sick. Care was rudimentary, often provided by untrained volunteers, and Florence Nightingale, amongst others, commented on the atrocious conditions
Until then nurses had mostly been religious, monastic women or untrained helpers of low repute
Describe Healthcare in the UK in the 20th centuries
Hospitals:
As the pathological basis of disease became better understood, healthcare was increasingly provided by other bodies. A network of charitable and voluntary organisations and local and municipal authorities established hospitals
Charitable and voluntary hospitals dealt mainly with serious illnesses, rather than long-term care. Medical care was provided by visiting specialists who had lucrative private practices elsewhere
Most beds were provided in municipal hospitals by the local authorities of counties and large towns from the rates (taxes) as a service to their rate-payers
Local authorities also provided maternity hospitals, hospitals for infectious diseases (scarlet fever, smallpox and tuberculosis), and institutions for the elderly, mentally ill and handicapped and a variety of community services
Bed rest was a major form of treatment for heart attacks, ulcers, tuberculosis and childbirth. Lengths of stay could be several weeks
A quarter of hospital beds were provided in voluntary hospitals. these varied from small hospitals supported by public subscription, to internationally famous teaching hospitals such as St Bartholomew’s, Guy’s and St Thomas’, which received significant investment income
Some hospitals were developed in conjunction with universities - University College Hospital, King’s College Hospital and the provincial teaching hospitals
Patients were often charged and many hospitals were near bankrupt
Mentally ill people:
Generally sent away to large forbidding institutions, not always for their own benefit, but because that was how the system worked. Admission was often for life
Under the poor conditions, patients became worse but there was a basic standard of food and accommodation
Older People:
Many ended their lives in the Public Assistance Institutions, old workhouses feared by everyone
One of the early achievements in the NHS was the development of geriatrics, which tackled the problem of the “back wards”, seldom visited by doctors, where people ended their days
Community services:
Primary and community care services evolved separately from the hospitals.
Community care, environmental and public health services were the responsibilities of local authorities
In 1911, the government, under Lloyd George, passed the National Insurance Act. This funded a family doctor service for all working men on low pay, enabling them access to a GP from a “panel” of local doctors, free of charge
This “panel system”, although not providing cover to wives, children, or their dependants, made a considerable difference to a large proportion of the poor, entitling them to free, government-funded healthcare
“Panels” were often operated by Friendly Societies that paid GPs as little as possible
Outside the scheme, medical treatment had to be paid for - often according to what the patient could afford. GPs in affluent areas could rely on income from their patients.
In 1919, the Ministry of Health was established and a Scottish Board of Health created to improve public health and to encourage research, treatment and medical training
In the WW1 the army medical services had shown the benefits of organisation and transport. At the government’s request, in 1920, Lord Dawson produced a forward-thinking report on how a health service might be organised
Under the Local Government Act (1929) local authorities took over poor law hospitals, which became municipal hospitals service ratepayers, not paupers (poor)
The quality varied widely from town to town and rural areas were poorly served. Some areas had duplicated services and others had minimal services
Drivers for change:
The main drivers for change included the following:
- The emergence of a view that healthcare was a right, not something bestowed erratically by charity
- Financial difficulties for the voluntary hospitals
- The impact of war made it possible for transformation of the system, rather than incremental modification
- An increasing view among the younger members of the medical profession that there was a better way of doing things
The first step in creating a nationalised health service took place in 1938. The imminent war obligated the government to establish an Emergency Medical Service.
In 1942, the Beveridge Report described a vision for welfare reform based on eradication of the five giants of: idleness, squalor, hunger, disease and ignorance
During the war the Conservatives produced the first White Paper on a health service led by local authorities. The coalition government’s 1944 White Paper stated the aims of the new health service:
- “To ensure that, in the future, every man and woman and child can rely on getting all the advice and treatment and care which they may need in matters of personal health; that what they get shall be the best medical and other facilities available; that their getting these shall not depend on whether they can pay for them. or any other factor irrelevant to the real need.”
After Labour’s election in 1945, the Health Minister, Aneurin Bevan presented to the Cabinet a radically different plan favouring nationalisation of all hospitals, voluntary or council, and a regional framework instead of a local authorities framework.
In 1948, the NHS was finally born
Describe the overview of NHS provision of care today
Principles:
The NHS was founded in 1948 based on the 3 following principles:
- That it met the needs of everyone
- That it be free at the point of delivery
- That it be based on clinical need, and not ability to pay
Since then some services are now incurring charges; pay for prescriptions in England and Northern Ireland, dental and optical services
Healthcare in the UK is provided using a GP gateway model, with the exception of walk-in services such as A&E or Genito-Urinary Medicine
Primary care:
Refers to the first point of contact in the healthcare system. In the NHS, the main source of primary healthcare is general practice
The aim is to provide an easily accessible route to care, whatever the patient’s problem. Based on caring for people rather than specific diseases
The best known providers of primary care services are General Practitioners (GPs) - coordinate the care of the many people who have multiple health problems
Primary healthcare involves providing treatment for common illnesses, management of chronic illnesses and prevention of future ill health through advice, immunisation and screening programs. When necessary, GPs refer patients to specialists working in secondary care
GPs usually work in practices with other GPs and are not employed by the NHS but are contracted to provide services to NHS patients
Secondary care:
Refers to care provided by medical specialist and other health professionals who generally do not have first contact with patients. Generally provided in hospitals except psychiatry
Tertiary care:
Refers to super-specialised care provided by health professionals to patients referred by secondary health professionals (cancer management, neurosurgery, cardiac surgery, plastic surgery and palliative care). Normally provided only in teaching hospitals or other specialist hospitals
Quaternary care:
Refers to care which is so specialised that only a few people with very rare problems will ever need it. It covers experimental medicine as well as uncommon diagnostic and surgical procedures
Describe how the NHS in England functions
Commissioning of Services:
In England, each hospital essentially operates as an independent business
The decision as to which healthcare provider is allowed to provide which services is made by Clinical Commissioning Groups (CCGs), which consist mainly of local GPs and managers
Legislation that came into effect in 2013 made it possible for external providers (e.g. charities and private companies) to offer NHS services. So for example, a local CCG could decide to award a contract for cataract surgery to a private company rather than to the local hospital if the reasoning is good (able to provide better quality of care).
The process of awarding contracts is known in the NHS as commissioning
Because CCGs are local groups and consist mainly of GPs, they cannot commission GP services themselves.
Similarly they can’t commission services that need to be provided on a more global scale because of their specialist nature, such as heart and lung transplant surgery or eye cancer care for two reasons:
- They don’t have the skills and knowledge to understand exact nature of those services
- Those services are provided on a regional or national basis
Instead, both primary care services and specialist services are commissioned by a higher body, used to be called the NHS Commissioning Board but now known as NHS England
Block Contract vs. Payment by Results:
Before 2005, hospitals were paid a fixed amount of money every year, designed to cover the cost of healthcare - block contract
If a hospital needed more money then the government would simply pay more money to that hospital
Conversely, if a hospital spent less then it would have to pay it back to the government.
The problem was that there was no incentive for hospitals to save money or work efficiently
In 2005, the Labour government introduce the principle of Payment by Results whereby a tariff would be set nationally for each clinic and each procedure. Hospitals would no longer receive a fixed amount of money but would instead be paid for each activity they undertook.
The tariff would be set roughly at the average of the cost across all trusts meaning some hospitals would make a loss and others would make a profit. The idea was to encourage those who made a loss to work more efficiently
The main problem with Payment by Results when it was introduced was that it ensured that hospitals were paid for what they did and that they were encouraged to perform efficiently, but it did not encourage hospitals to provide quality of care. Actions therefore needed to be taken so that hospitals did not just focus on making a profit but also provided quality care to patients. Such actions included:
- Giving patients the choice of where they wanted their care to be provided: The hope being that patients would make the choice on the basis of the quality of care they expected to receive
- Imposing targets that had to be reached (e.g. max 4 hour wait in A&E, max 18 week wait for elective surgery)
- Ensuring that hospitals were penalised for poor quality care
- Introducing incentives to provide enhanced standards of care
- Increasing competition between healthcare providers
The role of private sector in the provision of healthcare:
Private practice doctors (referred to s private healthcare):
- Refers to doctors working for private hospitals who provide healthcare to individual private patients, bypass the NHS waiting list
External providers contracted to do NHS work:
- Refers to private companies, charities or other organisations who have been officially commissioned to provide healthcare to NHS patients at NHS tariffs
- NHS care provided free to patients by non-NHS providers commissioned by the CCGs
Describe the arguments for and against privatisation of the NHS
Private companies are run for profit. There is a risk that they will therefore favour making profits over providing quality care.
The counter argument to this is that the NHS has been run on a not-for-profit basis for many years and has not always provided the best quality care (Mid-Staffordshire Trust). In addition, though there is some anecdotal evidence that some private companies engage in dubious practices or do not deliver in line with expectations, this is not widespread but NHS has its own share of dubious practices too
Private companies may cherry-pick the easy cases that are the most profitable, leaving the NHS burdened with the more complex, loss-making cases. However, private companies should not take on complex cases that they can’t handle
Those companies would be asked to handle the simple high volume work to ensure that work is being done efficiently without interference from other work such as emergencies
To resolve this, more complex cases that the NHS (with more expertise) has been trained to handle well should be recalculated to cover their cost
Privatisation will lead to fragmentation of care. If different aspects of care are given to different providers then healthcare may be provided in more venues, meaning patients will have to travel to different places, not convenient and may cause issues with patient records. To resolve this, a central database was introduced however this may lead to a compromise of patient safety and confidentiality but patients may opt-out
Simple cases are required to train doctors and privatisation may fragment care
Risk of conflict of interest amongst doctors as doctors working in the NHS often are those that provide external care, competing against the same hospital trust. The commissioning of such services therefore has to be done in an open and transparent manner
