History, structure and functions of the NHS

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History, structure and functions of the NHS

• Mary Dixon-Woods

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Foundations of the NHS

• Born in 1948
• Replaced chaotic pre-war arrangements
• Picture courtesy of the National Library of
  Medicine

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Founding principles of the NHS

• Open to the whole population
• Access solely on the basis of need
• Free at the point of service
• Funded by general tax revenues

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Organising the NHS

• Several transmogrifications over the years
• Griffiths Report (1983) brought in principles of
  general management replaced consensus
  management
• Working for Patients (1989) 1990 reforms,
  internal markets
• The NHS Modern Dependable (1997)
• NHS Plan (2000)
• Shifting the balance (2002)

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What led to Working for Patients (1989)?

• Response to perceived crisis in the NHS
• Political climate at the time
• It argued that the NHS by the late 1980s
• Had no incentive to be efficient
• Was insensitive to consumer views
• Was professionally dominated and inflexible.

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What did Working for Patients propose?

• NHS could use existing resources more efficiently
  and effectively
• An internal market should be created
• Health authorities should no longer be
  responsible for running the services as well as
  planning them

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The purchaser-provider split

• Two types of purchasers
• Health Authorities
• GP Fundholders

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Purchasers health authorities

• Had to buy services for their population
• Services purchased depended on assessed needs of
  the population

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Purchasers GP fundholders

• Got funding top-sliced from HA budget to buy
  selected non-emergency services
• Managed their own drugs budget and funds for
  non-medical staff
• About half of population of England and Wales was
  served by GP fund-holders

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Providers NHS Trusts

• Organisations such as hospitals, Ambulance
  Services, Community and Mental Health Services
• Used to be run by Health Authorities
• Now became self-governing organisations
• Generated funding by selling services

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Overview of 1990 Reforms

• No governmental system of evaluation introduced
  hard to be conclusive
• Main changes organisation of health care, not
  source of finance
• Cost sensitivity improved but bureaucratically
  costly
• Undermined dominance of supplier interests

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The NHS since 1997

• The New NHS modern, dependable (1997)
• Each of the 4 parts of the UK now has
  different arrangements we are just going to look
  at England.

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The New NHS modern, dependable

• Six principles
• Renew and improve the NHS as a national service
• Make delivery of health care a local
  responsibility
• Focus on quality of care

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The New NHS modern, dependable

• Work in partnership
• Drive efficiency and performance
• Rebuild public confidence

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The new NHS Modern and Dependable December 1997

• The new NHS will have quality at its heart.
  Without it there is unfairness. Every patient who
  is treated in the NHS wants to know that they can
  rely on receiving high quality care when they
  need it. Every part of the NHS, and everyone who
  works in it, should take responsibility for
  working to improve quality.

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Key Changes

• Societys expectations
• of NHS
• of professionals, especially doctors
• Serious failings in the NHS
• leading to erosion of public confidence in
  doctors Bristol Heart surgery in children
• Shipman case

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Shifting the Balance of Power (2001) A new
structure for the NHS
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At the top Secretary of State

• John Reid
• Member of the Cabinet
• Responsible to Parliament for provision of health
  services
• Makes a case for funding
• Sets out broad policies for health services

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Department of Health

• Establishes policy, strategies, standards and
  framework for NHS
• Provides guidance on priorities and planning
• Supports efforts to secure funding

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The 4 directorates of health and social care

• The regional directors are responsible for the
  development of the NHS and social care
  (policy-making)
• Also ensure that adequate partnership
  arrangements are in place between health and
  social care providers

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Strategic Health Authorities

• 28 Strategic Health Authorities (StHAs), serving
  populations approx 1.5 m
• Were part of Leicestershire, Rutland and
  Northamptonshire
• Responsible for the performance of the local NHS
• Setting strategies within the national framework
• Manage performance agreements to hold PCTs and
  trusts to account

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300 Primary Care Trusts

• Fund and commission services
• Replaces fund-holding and take on most previous
  functions of Health Authorities
• Aim to involve primary care professionals (inc
  nurses etc) in the planning and commissioning of
  services

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PCTs

• PCTs provide primary care and commission hospital
  services
• Are the lead NHS organisations in assessing need,
  planning and securing all health services and
  improving health
• They may run community hospitals and are
  responsible for building strong links with the
  local health and social care community

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PCTs

• Are expected to become responsible for the flow
  of the majority of NHS funding (75 by 2004)
• PCTs, in order to commission services
  effectively, need to assess population health
  needs, and develop plans and service agreements
  to provide the required services.

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PCTs

• Receive their budget directly rather than through
  the StHAs
• They get a unified budget (not separate amounts
  for separate items of activity)
• If one area overspends, something else has to be
  cut back

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PCTs

• The majority of expenditure is on commissioning
  hospital and mental health services
  (three-quarters of the budget).
• Running costs, community services provision and
  infrastructure make up approximately 10 of
  expenditure, and prescribing 15.

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PCT Board structure

• Between 8-14 members
• Not more than 7 officer (executive) members, and
  non-officer members in the majority
• Medical and nursing representation
• Precise composition varies, as does
  organisational structure

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PCTs

• Board structure means that health professionals
  are NOT in the majority (unlike fundholding)
• They MUST encourage public involvement
• Their decisions have far-reaching implications
  for primary and secondary care

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PCTs

• Have a duty of clinical governance
• Are directly accountable for financial control
  and must break even

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PCTs have to

• Integrate primary and community health services
• Work with social services on both planning and
  delivery of services
• Soon we will see super-PCTs or Care Trusts
  that will bring even closer integration of health
  and social care

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Commissioning process replaces purchasing and
involves

• Health needs assessment
• Identification of the most effective and
  efficient ways of meeting these needs
• Translation into financial service plans and
  specifications

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PCT must address NSF requirements
Standards 3 4 Preventing CHD in high risk
patients
3. General practitioners and primary care teams
should identify all people with established
cardiovascular disease and offer them
comprehensive advice and appropriate treatment to
reduce their risks 4. General practitioners and
primary health care teams should identify all
people at significant risk of cardiovascular
disease but who have not developed symptoms and
offer them appropriate advice and treatment to
reduce their risks
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CHD NSF milestones and targets

• smoking cessation through specialist smoking
  cessation clinics set up by April 2001
• at least 75 of eligible patients receiving
  thrombolysis within 30 minutes of hospital
  arrival by April 2002, and within 20 minutes by
  April 2003
• increase CABGs from 450 to 750/million population
  p.a. and PTCAs from 375 to 750/ million
  population p.a.
• reduce by 40 deaths in lt75s by 2010, baseline
  1996

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PCTs must address NICE guidance

• From 2002, the NHS has three months from the
  publication of a NICE technology appraisal to
  make funds available for the provision of the
  approved technology, if a doctor considers it
  appropriate.

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Service agreements

• Within available resources, PCTs manage the
  development and negotiation of service agreements
  (replace contracts)
• Service agreements last 3 years - contracts
  usually ran over 1 year

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318 NHS Trusts

• Acute hospital trusts (providing care in the
  hospital setting)
• Community trusts (e.g. employing health visitors
  and district nurses, and providing learning
  disability services - these functions are now
  often carried out by primary care trusts)
• Mental health trusts
• Ambulance service trusts

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NHS Trusts

• NHS trust income is obtained through a
  combination of service agreements with PCTs
• the provision of undergraduate/ postgraduate
  training

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NHS Trusts

• Provide services, working within delivery/service
  agreements with PCTs.
• High performing Trusts can earn greater freedoms
  and autonomy in recognition of their achievements
  (eg star rating scheme)

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NHS Trusts key tasks

• Provision of services
• Contribute to strategy and planning
• Involve senior clinicians in designing service
  agreements
• Develop clinical governance
• Work under new statutory duties of quality and
  partnership with other NHS organisations
• Develop and involve their staff
• Maintain control over their estate
• Have to break even

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Bringing together of health and social services

• Partnership in Action (Dept of Health, Sept
  1998) for the first time, joint national
  priorities for health and social services were
  set.
• breaking down the Berlin wall between health
  and social care.

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Bringing together of health and social services

• We will see further integration eg hospitals, GPs
  and social workers have to work together to
  reduce the growth in emergency admissions for
  over-75 year olds
• Appointment of Regional Directors for Health and
  Social Services

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Comments on the reforms since 1997

• Difficult to offer comments at this stage as
  everything is still evolving
• Partnership sounds wonderful in theory but its
  management may be very challenging
• Reforms represent yet another strain on those
  working in the health services

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Comments on the reforms

• Not clear that the primary-care led model is the
  best one
• Will require careful evaluation