BS2912 Public Administration in Britain

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BS2912 Public Administration in Britain

• 9 The NHS

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BS2912 Public Administration in Britain9 The NHS

• Defining Health and Illness
•        Positive (e.g. WHO definition a state
  of complete physical, mental and social
  well-being and not merely the absence of disease
  or infirmity
•       NegativeIndividuals are regarded as
  healthy when not suffering from a particular
  disease or illness.

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BS2912 Public Administration in Britain9 The NHS

•       MeasurementOfficial measures tend to
  measure mortality (death) and morbidity
  (illness).
• But life expectancy can measure health
  more positively.
• General Household Survey (GHS) as well as the
  Census ask questions more directly about
  health/long standing disabilities

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BS2912 Public Administration in Britain9 The NHS

• Life expectancy massively increased
  (1901?1991) Men (45.5 ? 73.2) Women (49 ?
  78.8)
• Infant Mortality rate has dropped massively
  (1901?1991) 142 per thousand ? 8 per thousand
• Decline of major infectious diseases (cholera,
  typhoid, measles, whooping cough,
  tuberculosis)

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BS2912 Public Administration in Britain9 The NHS

• Was this due to improved living conditions or
  to medical interventions ?
• replaced by diseases of affluence i.e.
  cancers (1 in 4), CHD (Coronary Heart
  Disease) and strokes (1 in 2)

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BS2912 Public Administration in Britain9 The NHS

• Is the nation unfit...
• - 29 surveyed reveal less than good health
  (Blaxter)
• - GHS find 50 take no exercise
• - 1/3 population fail to reach basic fitness
  levels
• - 90 adults have at least 1 risk factor for
  heart disease/stroke (smoking, eating,
  drinking)

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BS2912 Public Administration in Britain9 The NHS

• Mental illness and stress-related diseases on
  the increase
• - 15 GP consultations for mental health problems
• - 70 women, 50 men will consult their GP for
  a mental health problem

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BS2912 Public Administration in Britain9 The NHS

• The demographic Time-Bomb
•  
• note the long-run affects of World Wars !
• Fertility at replacement level ( or just
  below)
• Elderly now about 16 of population,
  projected to rise to 20 by 2030
• Elderly Elderly (i.e.80s) may well triple and
  soon form 5 of the population

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BS2912 Public Administration in Britain9 The NHS

• Look at the dependency ratio (6 working to 1
  retired in 1961, in 2011 ratio will be 41. Now
  add in the effect of university population (grown
  from 4 to 32)
•  
• International and regional variations - what does
  epidemiology reveal ?Factor 1...................
  ......................Factor 2...................
  ......................Factor 3...................
  ......................Factor 4...................
  ......................

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BS2912 Public Administration in Britain9 The NHS

• Standardised Mortality Rates
•  
• Used to compare different regions
• different social classes
•  
• Formula SMR Actual x 100
• ----------
• Expected

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BS2912 Public Administration in Britain9 The NHS

• Social Class Differences
•  
• Famous (infamous) Black Report (suppressed by
  the government of the day)
•  
• Present government is acknowledging the problem.
•  
• Highlighted by the fact that the imr (Infant
  mortality rate) is twice as high in Social
  Class V as in Social Class I

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BS2912 Public Administration in Britain9 The NHS

• Ethnic inequalities
• CHD for Asian groups significantly higher
•  
• High incidence of diabetes in Afro-Caribbean
  and Asian Communities
•  
• Higher incidence of reported rates of mental
  illness
• for Afro-Caribbean groups (but treat with
  caution!)

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BS2912 Public Administration in Britain9 The NHS

• Gender inequalities
• Womens health only taken seriously in the last
  decade or so.
• 15,000 women a year die from breast cancer
• As women participate more fully in the labour
  force, all social data (crime statistics,
  health statistics e.g. alcoholism)
  approximates to male data.
• At what period of time were women healthiest ?
  And why ?

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BS2912 Public Administration in Britain9 The NHS

• You are the Minister of Health in a newly
  elected government (you can choose any
  political party you like!)
•  
• Why is health care at or near the top of the
  political agenda?
•  
• What are the priorities in health care ?
•  
• How are you going to pay for them ?
•  
• How do they interact with other government
  policies ?

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BS2912 Public Administration in Britain9 The NHS

• Have you any thoughts about how health care is
  organised (i.e. before you study this course)
•  
• More philosophically... what is the role of
  the state ?
•   What are the major health problems ( and your
  solutions) affecting school
  children 18-25 middle aged men the
  elderly

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BS2912 Public Administration in Britain9 The NHS

• The pre-NHS Health Service
•  
• 1. The private sector voluntary hospitals
•  
• Established in 18th 19th. C by subscriptions
  or by philanthropy (but some London hospitals
  date from Middle Ages). Originally catering for
  the poor, they
• eventually came to rely upon charging for
  services. 

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BS2912 Public Administration in Britain9 The NHS

• 2. General practice fee-led services
•  
• Doctors were independent professionals who
  charged for their services.
• 1911 National Insurance Act led to sickness
  benefits, free GP services and free
  prescriptions for the employed working class
  (but not for their dependants).
• Note this only applied to GPs, not to
  specialist hospital services.

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BS2912 Public Administration in Britain9 The NHS

• 3. The public health service municipal health
  services
•  
• Local authorities provided hospitals for 2/3 of
  the population, many of them old Poor Law
  institutions.
•  
• Local authorities had control of public health
  provisions water supply, sanitation, food
  safety, pollution control. This was followed by
  personal services (school health, midwifery,
  child welfare).
•  
• Overall, the system was fragmented and
  uncoordinated, and many individuals (dependants,
  long term unemployed) were not covered. A broad
  consensus evolved during WW2 that a
  comprehensive, national system be established.

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BS2912 Public Administration in Britain9 The NHS

• Birth of the NHS (1948)
•  
•  Landslide Labour victory helped set climate
  within which the NHS was born.
•  
• Aneurin Bevan charged with creating (i.e.
  advancing plans) for the NHS. Had to assuage
  the fears of the medical profession for a
  salaried profession by stuffing their mouths
  with gold.

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BS2912 Public Administration in Britain9 The NHS

•        Original structure was tri-partite i.e.
•  
• - Hospital services
• - Executive Councils, General Practitioner
  
• Services
• - Local Government Health Authorities,
  community health

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BS2912 Public Administration in Britain9 The NHS

• Particular features ...
•        National ( and could therefore become
  more integrated and rational)
•        Paid for out of taxation ( with some IN
  top-up)
•        Always a mixture of political control v.
  technical rationality

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BS2912 Public Administration in Britain9 The NHS

• Particular features ...
• National ( and could therefore become more
  integrated and rational)
• Paid for out of taxation ( with some IN top-up)
• Always a mixture of political control v.
  technical rationality

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BS2912 Public Administration in Britain9 The NHS
Problems   Overlap, duplication, lack of
coordination with the structure leads
to..  
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BS2912 Public Administration in Britain9 The NHS

• 1974 reorganisation
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• Three tiers of health service management below
  then DHSS (Dept. of Health and Social Security)
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• Regional Health Authorities responsible for
  
  planning
• Area health authorities and devt. of
  services
• District health authorities

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BS2912 Public Administration in Britain9 The NHS
Resource Allocation Working Party (RAWP)   In an
attempt to develop a National Health service and
to give a sense of political direction, in the
1970s the government instituted RAWP
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BS2912 Public Administration in Britain9 The NHS

• Priorities to be based upon need not historic
  costs
• Assess needs ( but how?) and then move
  progressively towards them.
• Do we use morbidity rates ? Mortality rates ?
  Indices of social deprivation ?
• Problems of London, specialist services,
  cross-boundary flows.
• RAWP seen as rather too blunt an instrument.
  Meanwhile, social class inequalities remained

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BS2912 Public Administration in Britain9 The NHS
Combination of these, and labour relations
problems, led to   Royal Commission on the
Health Service (1979)   Noted that the NHS had no
clear objectives so stated these as
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BS2912 Public Administration in Britain9 The NHS

• to encourage and assist people to stay healthy
• provide equality of entitlement to health
  services
• provide a broad range of services to a high
  standard
• to provide equality of access to those services
• to provide a service free at point of use
• to satisfy reasonable expectations of users
• to remain a national service responsive to local
  needs

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BS2912 Public Administration in Britain9 The NHS

• Action of Royal Commission recommendations
• 117 recommendations made - something for
  everybody
•  
• Action taken immediately
•  
• Abolition of tier of management below region
  (Areas)
• Recommendation for a limited list of
  medicines to contain prescribing costs.

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BS2912 Public Administration in Britain9 The NHS

• Action taken eventually
• Community as a whole to share the costs of the
  elderly
• Better coordination of primary care services
• Improvement of community health in deprived urban
  areas

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BS2912 Public Administration in Britain9 The NHS

• Action taken eventually
• More sensitivity to the needs of patients in
  hospitals
• improved complaints mechanisms for patients
• Abolition of FPCs and transferral of functions
  to health authorities

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BS2912 Public Administration in Britain9 The NHS

• Is the NHS under-funded ?
• On the one hand, UK spent a lower of GDP on
  health than many other countries (5.9
  average 7.2 USA 10.7)
•  
• On the other hand, no evidence that we are less
  healthy for so doing - if we spent more,
  would we be healthier?

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BS2912 Public Administration in Britain9 The NHS
The Wanless Report (April, 2002) http//www.hm-t
reasury.gov.uk/mediastore/otherfiles/letter_to_che
x.pdf