Health Policy
Question Received:
Response:
20th September 2000
This is an extensive topic. In Britain, an interesting period to investigate would be from the commencement of the National Health Service (NHS) on 5th July 1948, up to the major review that took place in the late 1980s. It was this review that led to the implementation of the NHS and Community Care Act 1990, closely followed by the establishment of the Audit Commission and NHS Executive (the regulatory bodies).
The following information could form the basis of an essay about the development of health care policy:
Historical Background
One starting point could be background information on how the health and social needs of citizens was met before 1948 under the Poor Law measures, and how the new NHS was created out of the need to address this issue. A review could be made of the significant public health measures that were in place before 1948 such as the provision of clean, uncontaminated water, and an effective means of sewage disposal. These services became available as a result of the enterprising work of municipal borough engineers during the Victorian period, and had a profound effect on overall health standards. The increasing supply of electricity to homes and places of work might also be included as this service enabled individuals to achieve increased comfort and safety in their homes and at work.
Funding
A comparison could be made between the level of financing of the NHS as a proportion of the Gross Domestic Product (GDP) and the amount for example spent on defence. An appreciation of the way in which the industrial base of the nation has changed since 1948 and the effects this has had on health and social service provision could be included. It will be appropriate to acknowledge the influence of the voluntary sector and how the state and the voluntary organisations have, even long before 1948, worked together to provide care for the sick and needy. It would be useful to highlight the difference between hospital funding prior to 1948 and the funding arrangements that came into place after this date. In addition, the role of the workhouse or the workhouse-infirmary could be included to show just how sparse and bleak the circumstances were for those who could not care for themselves. Interesting contrasts could be drawn between those problems and today's challenges such as the rising number of elderly people in our society, the problems relating to alcohol and drug abuse, and the amount spent on health and social service provision.
Delivery of Care
A central feature of the NHS Act of 1946 was a tripartite system involving hospitals, family practitioners, and local authorities. Up until 1974 local authorities governed general practitioners and the community nursing service. Thereafter, family practitioner committees were established and community nursing became part of the tripartite structure (Potter and Perry, 1995).
The administrative structure and decision making process of the NHS was modified in 1974 and again in 1983 (The Griffith report). However, it was in 1990 that, due to an apparent under-funding in the public sector, the most significant changes were introduced. The concept of the ‘internal market’ began to emerge as way towards ensuring greater efficiency and cost effectiveness within the NHS. Some general practitioners became fund-holders, purchasing care for their patients from hospital and community services. Some hospitals and services provided for under community healthcare became NHS Trusts (provider units) with the autonomy to manage their own affairs at the local level. Those not obtaining Trust status became Directly Managed Units (DMUs).
This administrative backdrop to care delivery, with a new emphasis on primary care, could be included in the essay. Look also at the recent introduction of Community Management Teams (CMTs). If possible draw from the findings of the Royal Commission on the NHS which was published around the mid 1980's.
Mental Health & Learning Difficulties
The 1980s saw the closure of many of the large hospitals and institutions that previously provided care for the mentally ill and people with learning difficulties. Care in the community was seen as the most appropriate way forward, with individualised support for people whose needs are such that hospital care is not appropriate. Health and social services, together with the voluntary agencies, were to provide a network of support. The impetus behind such a radical shift in care could be touched on.
Health Promotion and the Prevention of Disease
The move towards helping people to see health as a positive concept that requires personal involvement in order to be realised and maintained, and as something which should not be taken for granted, has come into focus more sharply over the past 10-20 years. The concept of health promotion and levels of prevention such as primary, secondary and tertiary are areas that could be considered. It will be useful to consult the Health of the Nation document (HMSO 1992) as this provides valuable information concerning aims to reduce the mortality and morbidity from the main diseases affecting UK citizens. The document provides a useful indication of the areas worthy of funding. It is worth noting that the importance of health and approaches towards the achievement and maintenance of health often feature within school curricula, and in the media.
Legislation
A great deal has been achieved through legislative powers designed to make the environment safer and reduce the incidence of acute and chronic health breakdown. A few examples are the sale of food and drink, the law which prohibits driving whilst under the influence of alcohol, seat belt legislation, the compulsory Ministry of Transport vehicle tests, speed restrictions, health and safety legislation, the control of substances hazardous to health (COSHH), and emission controls.
The Influence of Technology and New Developments
Major advances have been made in the fields of diagnostics and pharmaceuticals, apart from the profound effects which the introduction of plastics and disposables have had on clinical practice. New forms of diagnostic imaging have enabled more precise and accurate diagnoses to be made. The wide range of drugs now available enables many people to be treated for conditions that previously would have killed them. Many people take drugs to modify the progress of a disease and in doing so are able to lead a long and fulfilling life. The use of disposable equipment means that instruments are clean and sterile before use and staff time is no longer required for cleaning and sterilising instruments. Of course, such enhanced facilities carry a heavy price tag.
Information technology has been taken up within the health service with the intention of making the service more efficient and in keeping with other organisations. NHS Direct and walk-in centres providing advice on health and illness. All are new services designed to make the service more accessible and sensitive to the needs of citizens.
Summary
The NHS and Social Services have grown and expanded in response to human needs and in relation to the proportion of funds available from central government. As society advances and expectations rise, demand increases. To meet the health needs of its citizens the state provides the bulk of the service requirements, but it does so in close co-operation with the voluntary sector, and more recently, in some areas, through collaborative links with the private sector. How far health and social service provision has advanced since 1948 and the extent of the general health of the nation can be judged by analysing the figures on infant mortality during this period.
Finally, it is easy to overlook manpower provision within the service and the cost involved in providing this. In spite of the many managerial changes and reorganisations that have taken place within the service, it is worth remembering that in the end many of the needs that sick people have can only be met through human contact over an extended time.
Reference
Potter, P.A. and Perry, A.G. (1995) Foundations in Nursing Theory and Practice. Edited by Hazel B.M. Heath. Turin: Mosby, an imprint of Times Mirror International (Chapter 2, p 21).