BS1032 Public Administration in Britain 9: The NHS.

BS1032 Public Administration in Britain

9: The NHS

BS1032 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’

Negative

Individuals are regarded as healthy when not suffering from a particular disease or illness.


Measurement

Official 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


• Life expectancy massively increased (19011991) Men (45.5 73.2) Women (49 78.8)

• Infant Mortality rate has dropped massively (19011991) 142 per thousand 8 per thousand

• Decline of major infectious diseases (cholera, typhoid, measles, whooping cough, tuberculosis)


• 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)


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)


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


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.80’s+) may well triple and soon form 5% of the population


Look at the dependency ratio (6 working to 1 retired in 1961, in 2011 ratio will be 4:1. 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.........................................


Standardised Mortality Rates Used to compare:

* different regions* different social classes

Formula: SMR = Actual x 100 ---------- Expected


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


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!)


Gender inequalities

• Women’s 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 ?


• 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 ?


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


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.


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 GP’s, not to specialist hospital services.


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.


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’.


Original structure was tri-partite i.e.

- Hospital services - Executive Councils, General Practitioner

Services - Local Government Health Authorities,

community health


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


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


Problems Overlap, duplication, lack of coordination with the structure leads to..


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

• Area health authorities } and devt. of services

• District health authorities


Resource Allocation Working Party (RAWP) In an attempt to develop a National Health service and to give a sense of political direction, in the 1970’s the government instituted RAWP:


• 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


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:


•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


Action of Royal Commission recommendations117 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.


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


Action taken ‘eventually’

•More sensitivity to the needs of patients in hospitals

•improved complaints mechanisms for patients

•Abolition of FPC’s and transferral of functions to health authorities


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?


The Wanless Report (April, 2002)

http://www.hm-treasury.gov.uk/mediastore/otherfiles/letter_to_chex.pdf

BS1032 Public Administration in Britain 9: The NHS.

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