healthcare Flashcards
Beveridge report
- titled “Social Insurance and Allied Services,”, published in 1942, laid the foundation for the welfare state.
- to tackle the “Five Giants” of want, disease, ignorance, squalor, and idleness.
Beveridge report - social insurance scheme
- A comprehensive system of social insurance was proposed to provide financial protection against the “Five Giants.”
- provide benefits for unemployment, sickness, maternity, widows, and retirement.
- introduction of family allowances to support families with children and alleviate poverty.- universal and non-contributory
- Also wanted full employment
Beveridge report - education and housing
- improve access to education, vocational training, and lifelong learning opportunities for all.
- Recommendations were made to address the housing shortage, improve housing standards, and provide affordable and decent housing for all.
Beveridge report and NHS
- The Beveridge Report recommended the establishment of a National Health Service to provide universal healthcare services free at the point of use.
- The NHS was envisioned as a public service funded by taxation and managed centrally to ensure equitable access to healthcare for all.
- Preventative and curative treatment
- NHS integral- their potential to maintain the fitness and earning capacity of workers thereby reducing ‘want’ and demands on the social security system
- Supported a system administered by local authorities
- Health was joint responsibility of state and individual – state should not stifle incentives for individuals to act responsibly and undertake additional voluntary provision.
overall growth in spending on NHS
- Between 1949–1950 and 2018–2019 UK public spending on health increased almost 12-fold in real terms, and more than doubled as a share of national income, from 3.5% to 7.2%
Blair/ Brown NHS spending growth
- The NHS received an average annual real growth rate of 6% in the Blair/Brown era (1997–2010).
Drastic NHS spending increase by 2007/8
the growth in NHS funding would run at the rate of 6.1 per cent for the following four years. And in the 2002 Spending Review, he increased the rate to 7.3 per cent for the following five years
NHS funding under coalition
increased funding by only 1% per annum between 2010–2011 and 2014–2015.] Between 2014–2015 and 2018–2019, the Conservative Government spending rose annually by 1.6%, though a more generous 3.3% average annual increase up to 2023–2024 was subsequently announced.
how much spending is needed for nHS
- recent report stated that a 4% real average growth in public spending on health per year would be needed to avoid a real risk of degradation (2021 article)
Prescription charges-
- prescription charges were introduced in the United Kingdom in 1952. Initially, a flat-rate charge, to raise £10 mill in revenue. abolished briefly in 1960s by Labour but then reintroduced.
- 1951 the Chancellor of the Exchequer, Hugh Gaitskell, announced charges for dental work and optical service
increase to prescription charges
- Thatcher government dramatically increased charges way above the rate of inflation
o Prescription charges raised a larger share of NHS revenue, reaching a peak of 4% of health spending in 1990.
exemption to prescription charges
- Cancer patients exempted from prescription charges in 2009
original privatisation in the NHS
- From the outset, consultants were allowed to treat private patients in addition to their NHS work, including in NHS ‘pay’ beds, which Beveridge himself defended.
- GPs remained independent contractors rather than employees and were permitted to undertake private work, though the scope for this was very small.
why privatisation of NHS is bad
- Wendt- private cost sharing reduces health service utilization and increases inequality. The higher the share of private out-of-pocket funding, the greater the privatization of risk in the case of sickness (Hacker, 2004) and therefore, especially for lower-income groups, the barriers to entering the health system.
how doctors salary effects provision
- Wendt-The control over doctors’ income is highest when paying a government salary- a fee-for-service payment may set an incentive for the doctor to see his or her patients as often as possible, a reimbursement per capita or a fixed salary might set an incentive for reducing the workload.
figures for privatisation as a percentage
- in terms of health care, the figures for ‘pure public’ moved from 71 per cent in1979/80 to 64 per cent by 2007/08, while the ‘pure private’ category increased from 9 per cent to 13 per cent.
private option has always existed
- Still free at point of use, universal coverage, free prescriptions for lower income groups. * Option of exit or going private has always existed
spending on Private care treatement
- the proportion of PCT spending on independent sector providers in England rose by 150 per cent from £2.1 billion in 2006/07 to £5.2 billion in 2011/12, but this varied from almost zero for emergency care to as much as 20 per cent for some procedures such as elective hip replacements and hip repairs
Thatcher - private health insurance growth
- Governments provided tax incentives to encourage private health insurance, which helped to increase the proportion of the population covered by such schemes from 4% to 13% between 1979 and 1989.
Thatcher- growth in private health spending
- between 1980 and1990 private spending on health rose as a proportion of total health spending by 5.2 percentage points
what introduced the internal markets into the NHS
- the 1989 White Paper Working for Patients, and the NHS and Community Care Act of 1990,
the internal market under Thatcher
Thatcher - The top-down bureaucracy of NHS authorities would be dismantled. Instead of authorities using government funds to provide services, purchasing authorities would have funds to buy services and providing authorities would produce and sell them and compete for a market share. Purchasers could pick and choose between providers, and contract for the best services available.
* the separation of the purchaser and the provider roles: health authorities would in future be responsible only for buying health care from the providers. The providers, both hospitals and com¬ munity services, would be transformed into autonomous trusts, whose budgets would depend on their competitive efficiency in getting contracts from purchasers.
Compulsory competitive tendering - forced to open up certain services to competition from private sector providers eg catering and cleaning
Thatcher- change to GPs
General practitioners could become fund-holders, purchasing services from hospitals and other providers.
o NHS mimicking market to improve efficiency and the non-market value of distributing access to resources according to need.
o Financial incentives not for profit but to improve efficient use of public funds
NHS trusts
Hospitals could become NHS Trusts, with independence from health authorities, and freedom to develop in their own way, subject only to winning enough custom. (linked to control)
o The concept of NHS trusts was introduced in the early 1990s as part of the “NHS and Community Care Act 1990.” This legislation aimed to decentralize decision-making within the NHS and give hospitals and other healthcare providers greater autonomy and flexibility in managing their services. The first NHS trusts were established in 1991, and they were designed to operate independently, with their own management structures and boards of directors, while still being part of the NHS
New Labour and private health insurance/ private spending
- the New Labour Governments sought to discourage private health insurance and abolished tax relief while increasing public spending. During this period (1997–2010), the proportion of private spending fell by 6.5 per-centage points
New Labour - public-private partnerships
- Blair Government’s application of the Conservatives’ private finance initiative in the NHS. This involved public-private partnerships in the design, building, finance and maintenance of facilities.
o enabled much-needed capital developments (new hospitals), but more expensive than public finance options, made large profits for investors and reduced funding available to the NHS organisations who ran services.
New Labour - state funded independent healthcare growth
- the percentage of state-funded independent health care provision in England grew from under 3% in 2006–2007 to over 4% by 2009–2010.
Labour government and competition
- The Labour Government elected in 1997 first abolished the goal of competition and internal market but kept purchaser/ provider split
o Labour established Monitor as an independent regulator to oversee and regulate competition, pricing, and procurement in the NHS, enforce compliance with competition law, fair trading, and anti-competitive practices, and promote collaboration, integration, and cooperation between NHS providers, commissioners, and partners to improve quality, access, and outcomes in healthcare delivery and patient care.
created Primary Care Trusts (PCTs) to take on the role of commissioning healthcare services, planning, and purchasing care for their local populations
Labour government and foundation trusts
o introduced Foundation Trusts as autonomous, self-governing public benefit corporations within the NHS to give NHS providers greater freedom, flexibility, and responsibility for managing their affairs, resources, performance, and services, and promoting innovation, improvement, and excellence in healthcare delivery, while ensuring public ownership, accountability, and protection of NHS assets, values, and principles
NHS foundation trusts were introduced following the “Health and Social Care (Community Health and Standards) Act 2003.” This legislation aimed to give successful NHS trusts greater freedom from central government control and allow them to become self-governing organizations
Labour changes to fundholding
o Fundholding abolished – primary care groups would bring together GPs and other primary care providers- evolve over tune, it was envisaged, from having devolved responsibility for managing the budget for health care for their patients but formally still part of the health authority to becoming free-standing trusts (PCTs) still accountable to the health authority but with added responsibility for providing community health services for their populations
Labour- state role in provision
o Health authorities worked in partnership with the Primary Care Groups, for drawing up three-year Health Improvement Programmes, i.e. for ‘deciding on the range and location of health care services’. In practice, therefore, the ability of PCGs to use their budgetary power might be severely constrained. If the Health Improvement Programme revolved around developing services at a local hospital, a PCG dissatisfied with the services of that hospital might find that its health authority would not allow it to switch to another provider
Labour- state role in financing provision
o the White Paper (1997) was very clear. This was that PCGs would work within a ‘single cash-limited envelope’. That is, their budgets would be calculated to cover their population’s share of all NHS services, including prescribing- prescribing had always been excluded from the NHS’s own overall cash limits, on the grounds that it was demand driven and thus uncon¬trollable. So this brought in tighter control
Labour - role of international community in NHS
- invite overseas providers, importing their own specialists rather than using NHS consultants, to enter the field. Starting in 2002, these were invited to bid for the setting up of Independent Treatment Centres: specialised clinics for carrying out elective surgery and diagnostic proce¬dures. By the end of 2005, there were 32 such ITCs run partly by independent operators and partly by NHS trusts
Foundation Trusts as privatisation?
- According to Milburn, the Bill introducing FTs could in no way be reasonably described as privatization, or as a step in that direction. They were said to be a ‘new model of public ownership’ that were ‘wholly part of the NHS’… According to Klein (2005: 59), FTs are within the public sector, and are a ‘long way from privatization’. However, critics argued that they can borrow from the private sector, set their own pay, have freedom to retain any surpluses, and that provider autonomy may be a transition point on the way to full-scale privatization
- The FT regulator, Monitor, can be seen to have been ‘largely privatized’ initially with two-thirds of its first year budget spent on management consultants.
Labour - privatisation of NHS hospitals
- In 2007, the Labour Government invited bids to take over the management of a failing NHS hospital at Hinchingbrooke. The government chose a shortlist of three private companies, and in November 2010 (after the general election) Circle Health won the contract (Leys and Player 2011). This privatization saw a hospital run by a company registered in the Virgin Islands However, Mathieson (2012) argues that Hinchingbrooke represents ‘management outsourcing’ or an ‘operating franchise’ rather than privatization as it is time-limited.
coalition- private spending
4 percentage point increase in the share of private spending
Coalition - role of private healthcare growing in trusts/ hospitals
- The Coalition added legal requirements for NHS organisations to open services to competitive tendering while at the same time allowing the more autonomous foundation trusts (established by the Blair Government) to generate more private income.
coalition - size of state funded independent healthcare
- the percentage of state-funded independent health care provision in England grew to over 7% in 2015–2016.
coalition- private/public partnerships
- promoted public-private partnerships, joint ventures, and collaborations between NHS providers and private sector companies to deliver integrated care, shared services,
coalition - any qualified provider
- the ‘any qualified provider’ initiative in which competition was to be introduced by local commissioners for key areas of community service provision was seen to be entrenching a private marketplace beholden to European competition law (Hunter 2013). However, NHS and third sector providers could apply to be on this list alongside those from the private sector so it is was not automatic that any shift in resources would occur.
2010 white paper on NHS
First, all NHS trusts would become FTs, with of aim of creating: the largest social enterprise sector in the world by increasing the freedoms of foundation trusts and giving NHS staff the opportunity to have a greater say in the future of their organisations, including as employee-led social enterprises. Lister (2012) writes that Lansley’s plans require all NHS trusts to become autonomous FTs, with a longer-term goal of getting FTs ‘off the NHS balance sheet’, floating them off as non-profit ‘social enterprises’- if carried through, effectively privatize virtually all the provision of health services in England by 2014
Coalition - cap on private patients
- The original legislation removed the ‘cap’ of FT income from private patients that was set by Labour at the level when FT status was achieved. An amendment limited this cap to 49 per cent
o NHS patients are less attractive prospects – reduced to second-class citizens even in NHS hospitals.
2021 NHS privatisation
shifting from market-driven competition, fragmentation, and privatisation towards integrated, collaborative, and coordinated system focused on partnership working, person-centred care, and population health management
restriction of access to NHS treatments- general mechanism
- Prioritizing or rationing in fact takes place. Some services have been withdrawn from the NHS in some areas—cosmetic operations, infertility treatment, long-term care of the elderly. Some groups of patients are less likely to receive services than others. There is evidence of discrimination against older patients, or smokers may be deemed less likely to benefit from treatment. Mechanisms for rationing include:
o waiting lists
o deflecting demand to other services diluting (e.g. using cheaper drugs)
o denial of some services
centralised control of original NHS
- top-down. the Minister of Health in at least theoretical control of a health service- responsible for national policy, funding and regulation of healthcare services. Centralised control= standard services, practices and treatment protocol\
- a unified and integrated healthcare system, encompassing hospitals, general practitioners (GPs), dentists, opticians, and other healthcare providers, under a single organizational structure.
expert control in NHS from start
- Baldock, Mitton and Manning- From the point of view of Ministers of Health it appeared that medical consultants controlled spending rather than themselves, with resources following medical decisions rather than ministerial ones. Professional networks rather than hierarchies or market competition may be seen as the real power arrangement in this period.
local health control from start of NHS
- organized into regional health authorities and local health boards, responsible for planning, delivering, and managing healthcare services at the regional and local levels- regional and local health authorities had autonomy and discretion in implementing and tailoring healthcare services to meet the specific needs, priorities, and circumstances of their respective communities.
- From 1952 onward, responsibility for control over establishment was transferred to the RHBs. When in 1951 the Ministry launched yet another economy drive, the emphasis was on local responsibility for implementing national policy
NHS admin - all officers were appointed and employed by individual authorities, whether RHBs or HMCs. Although there were national conditions of pay and service, there was nothing remotely resembling a national corps of admin¬istrators or even a national policy for recruitment and training.
integration in original NHS
- The first organization of the NHS was much criticized for its tripartite nature, with no integration of hospital, general practitioner, and local authority public health services. But the NHS in this period did develop integrated local services, domiciliary services for health and social care under Medical Officers of Health
change of NHS budgets in 40s/50s
- the financial crisis of the late 1940s and early 1950s did lead to one basic change. What had started out as a bottom-up system of generating budgets - with demands coming from the local hospital authorities - became a top-down system of dividing out a fixed total: of determining capped budgets for individual authorities… Public control had, inevitably, to follow public money: the Minister of Health was accountable to Parliament for every penny spent in the NHS.
Thatcher’s centralised control
- maintained centralised oversight, regulation, and control through the establishment of national standards, guidelines, frameworks, and regulatory bodies, such as the NHS Management Executive, Regional Health Authorities, and the introduction of performance management, inspection, and accountability mechanisms to monitor, evaluate, and enforce compliance, quality, and performance across the NHS
decentralisation under Thatcher
- Decentralisation and marketisation empowered NHS trusts, hospitals, and healthcare providers with greater autonomy, responsibility, and accountability for managing budgets, resources, performance, and services, making decisions, and engaging with patients, communities, and stakeholders to improve healthcare delivery, outcomes, and experiences.
General attitude of New Labour to control
New Labour – ‘centralise where necessary’, ‘localise’ everywhere else. They move to clinical governance. State increased regulatory power- ‘steers but doesn’t drive’
New Labour - central oversight
- prioritised the reduction of waiting lists and later set targets to reduce waiting times in elective treatment, primary care, A&E, diagnostic tests and cancer care – successful.
- adopted inequality targets, which sought to narrow the gaps in health out-comes between the most deprived and the average and introduced broader welfare policies, such as Sure Start that included health objectives.
third way in NHS
- Primary care groups to bring third way between top-down and internal market (1997), became primary care trusts in 2002. funded directly from central government according to their population size, weighted according to measures of health need.
Labour - devolution to organisations
- NICE, the National Institute for Clinical Excellence, was established in 1999 ‘to provide patients, health professionals and public with authoritative, robust and reliable guidance on current ‘best practice’. Advice covers specific treatments, such as drugs, techniques and procedures, and clinical management of specific conditions (NICE 2002). In 2003 a decision to make NICE guidance mandatory reduced the discretion of Primary Care Trusts. Central government aimed to increase consistency of decision-making, while keeping responsibility for decisions at local level
New Labour performance rating
- Drastically increased funding but linked the increased funding to radically novel system of performance management- regime of star ratings focused on penalising failure by providers to tackle what had been an endemic problem for each health service: namely long waiting times for access to treatment.
o Ratings to help patients and the public make informed decisions about healthcare providers, including hospitals, general practices, dentists, and other services. The star ratings are based on patient feedback and reviews, as well as clinical outcomes and performance indicators, to assess the quality and performance of healthcare providers.
o End of star ratings regime in 2005.
New Labour NHS national frameworks
- introduction of national strategies, frameworks, and initiatives, such as the NHS Plan, Quality and Outcomes Framework (QOF), and National Service Frameworks (NSFs) to guide, support, and monitor the improvement, transformation, and sustainability of healthcare delivery and outcomes across the NHS.
trust and altruism
LeGrand
The model of trust and altruism assumes that providers of public services are ‘knights’ and, as they are driven by altruism, they can be trusted to do the best that they can for those they serve within the available resources, without any need for external incentives – and indeed, poor performance should be taken to indicate a need for extra resources.).
choice and competition
LeGrand
choice and competition assumes that users choose better performing providers, and that providers respond to the consequences of these choices for their market shares
benefits and critiques of trust and altruism
people feel losses much more keenly than gains of equivalent magnitude. Thus, sanctions for failure can generate the high-powered incentives necessary to overcome organisational inertia, in order to improve quality
it removes these high-powered incentives and, of course, rewarding failure creates perverse incentives
this model has low monitoring costs, is popular with professionals, is common in public services
pros and cons of choice and competition model
Quasi-markets have high transaction costs, but are increasingly popular with governments because pressure on poor performance is perceived to come from the ‘invisible hand’ of the market (Le Grand, 2007). They promise to have more potential to respond to users’ needs than the two centrally driven models below.
4 models of healthcare governance -
Bevan, Connolly +
choice and competition
trust and altruism
targets and terror
naming and shaming
targets and terror
The model of targets and terror holds providers to account against a limited set of targets that clearly signal priorities to those responsible for running organisations, with clear threats of sanctions for failure and rewards for success
pros and cons of targets and terror
The model assumes that providers will respond to clear economic incentives. Prospect theory tells us that of these incentives, sanctions will have a stronger impact than rewards. The targets and terror model imposes external incentives by strong performance management, has monitoring costs and is unpopular with professionals.
naming and shaming
assumes that providers respond to threats
to their reputation, and is a system of performance measurement. Hibbard
and others (2003) show that this model requires an ability to rank providers’ performance, so that the public easily can see which providers are performing well or poorly on a regular basis, enabling change to be monitored. The classic model of naming and shaming is the publication of annual league tables of schools based on the performance of their pupils in examinations
application of models of government in healthcare systems
elements of more than one model can coexist in a system, but they are conceptually distinct, as it is possible for any one model to be used alone.Second, however convincing each model appears to be a priori, if it lacks effective sanctions for failure then it is, in effect, one of trust and altruism. Third, models other than trust and altruism are vulnerable to ‘gaming’, because they create high-powered incentives in relation to inevitably imperfect measures of performance. Indeed, there is no perfect model, and it is a profound mistake to change policies in the belief that such a model is there to be discovered by trial and error.
models of governance in UK NHS
- The dominant model of governance across each country for health services
until 1991 was one of trust and altruism (Le Grand, 2003). From 1991, the model changed towards one of choice and competition, with the implementation of an internal market across the UK - Following the election of the Blair Government in 1997, the model of governance across UK health care systems largely moved back to that of trust and altruism. In England, this was described as the ‘third way’
- However, after 2000 in England, following the UK Government’s commitment to sustained increases in NHS funding, the model of trust and altruism was abandoned, and from 2000–05 the regime of star ratings combined the models of targets and terror with naming and shaming
New Labour - more localised NHS monitoring
- All trusts were required to set up a system for monitoring standards and identifying poor performance. They were further charged with ensuring the implementation of the clinical standards of the National Service Frameworks and the recommendations of the National Institute. All doctors were required to take part in audit; no longer was participation voluntary. The trust’s chief executive was to be made accountable for assuring the quality of the services provided. The trust’s Board was to receive regular reports on the quality of clini¬cal care
2002 white paper - a shift
The emphasis was to Switch from institutional structures - such as the gaggle of new agencies created - to the dynamics of the NHS. Patients
local control In 2002 white paper
NHS Foundation Trusts, first unveiled by Alan Milburn at the beginning of 2002. These were modelled on co-operative societies and mutual organisations. They were to be independent public interest organisations and would ‘replace central state own¬ership with local ownership’. A majority of their Boards of Governors would be elected by local people, while others would be elected by staff. They would enjoy autonomy in running their financial and other affairs. Their income would depend on their ability to attract patients.
on devolution to the frontline- new NHS Foundation Hospitals would enjoy greater independence and autonomy than existing trusts.
the Department of Health would be slimmed down, and concentrate on ‘the core functions of determining standards, distributing and accounting for resources and securing the integrity of the sys¬tem’, while the regulatory system would be strengthened
2002 white paper and oversight
o The command and control model developed in the years after 1997 did not change with the turn of the millennium. On the contrary, it was strengthened. The system of monitoring progress towards central government targets, and dealing with laggards, was reinforced. The Performance Assessment Framework took centre stage. It changed in form but not in intent. The traffic light signals - green, yellow and red - were replaced by Michelin-type stars
New Labour - monitor of trusts
The Boards of Directors of trusts were accountable only, and exclusively, to an Independent Regulator: a non-departmental public body designed to be a ‘circuit breaker’ bet¬ween centre and periphery in the words of one policy-maker. It was Monitor, as the Independent Regulator came to be known, who decided on applications for FT status. It was Monitor who reviewed the performance of FTs, with particular emphasis on their financial viability.
o in 2004 the Secretary of State told MPs that in future Ministers would no longer be in a position ‘to com¬ment on, or provide information about, the details of operational management’ in FTs.
how NHS targets changed later on in New Labour
- It was the Department which in 2004 produced a set of national standards. They were pre¬sented by John Reid, who had succeeded Milburn as Secretary of State for Health, as part of a new focus: more emphasis on achieving standards across the service and less emphasis on achieving specific targets - the number of the latter being cut. Eg staff must treat patients with dignity and respect
emphasis on quality under Brown- provider choice
- NHS providers were to publish annual quality accounts as from 2009. To this end, they were provided with a menu of 400 indicators, from which they could choose a la carte but were expected to cover patient safety, clinical effectiveness and patient experience.
Performance indicators, linked to national targets, were cut in numbers and re¬ labelled ‘vital signs’. PCTs could determine their own priorities ‘following consultation with their local communities’
emphasis on quality under Blair- patient voice
- Reinforcing the emphasis on the patient perspective was the introduction of patient reported outcome measures (PROMs). As from April 2009, patients undergoing elective surgery - for example, hip and knee replacements - were given pre- and post-operative ques¬ tionnaires designed to measure the improvements in their quality of life.
2009 NHS constitution - reaffirmed original values
access to NHS services is based on clinical need, not an individual’s ability to pay, embraces the value of compassion and establishes the right to be treated by appropriately qualified and experienced staff as well as the right to be treated with dignity and respect…. it committed successor governments (whatever their party) to the principles and values enshrined in it unless they were prepared to take the dramatic step of tearing it up.
2009 NHS constitution and patient choice
the NHS is pledged to provide the public with the information needed to influence and scrutinise the planning and delivery of services and patients have the responsibility to make a significant contribu¬ tion to their own good health….
2009 NHS constitution and quality control
The Department of Health, Monitor and the Care Quality Commission were to work together to ensure that there were no significant concerns about quality before Foundation Trust status was awarded; legislation was to be introduced to require PCTs to validate provider quality accounts, so underlining the central role of commissioners in overseeing the quality of care provided to patients
NHS organisations were also to be required to publish an annual statement of involvement to demonstrate how they were involving patients and public.
Coalition and regulatory bodies
the coalition government maintained centralised regulation, oversight, and accountability
- established new regulatory bodies, frameworks, and mechanisms, such as Monitor (now NHS Improvement) and the Care Quality Commission (CQC), to oversee, regulate, and monitor the performance, quality, safety, and compliance of healthcare providers, commissioners, and integrated care systems in the NHS
coalition replacement of primary care trusts
Clinical Commissioning Groups est in Health and social care act 2012
responsible for commissioning and purchasing healthcare services for their local populations, including the ability to commission services from a range of qualified providers, including NHS providers, private sector companies, voluntary sector organisations, and social enterprises, based on competition, quality, and value for money
o bring together local GPs and other healthcare professionals to plan and commission healthcare services for their local populations. They are responsible for making decisions about how to spend the NHS budget in their respective areas.
o CCGs are responsible for performance management, quality assurance, and oversight of healthcare providers, services, and outcomes, monitoring, evaluating, and benchmarking performance against national and local standards.
local control since coalition
- There has been an emphasis on devolution, integration, and empowerment of local authorities, health and care systems, and communities to take greater control,
post coalition oversight
- The government has maintained central oversight, regulation, and accountability for the NHS through national bodies, organisations, and frameworks, such as NHS England, Department of Health and Social Care, and Care Quality Commission, to ensure compliance with standards, targets, and requirements, monitor, evaluate, and benchmark performance, quality, and safety of care, and drive improvements.
- CCGs and NHS England will continue to be responsible for commissioning healthcare services, managing budgets, and monitoring, evaluating, and improving performance, quality, and safety of care, while collaborating with integrated care boards, providers, and partners to ensure alignment, consistency, and coherence in service provision.
post coalition - integrated care
- 2021 health and care bill introduced integrated care systems (ICS) - providing a legal basis for collaboration, partnership working, and integration between NHS organisations, local authorities, primary care providers, community services, mental health trusts, and voluntary sector organisations to plan, fund, and deliver joined-up, coordinated, and seamless health and care services across localities, regions, and systems in England.
- ICSs will be governed by integrated care boards comprising representatives from NHS providers, clinical commissioning groups (CCGs), local authorities, and community partners to oversee and coordinate service provision, planning, performance
post coalition centralised control
- More power to secretary of state- The Health and Care Bill enshrines in law the Secretary of State’s statutory duties and responsibilities for the health and care system in England, including oversight, accountability, and stewardship of the NHS + reinforces the Secretary of State’s role in overseeing and holding NHS England, Clinical Commissioning Groups (CCGs), Integrated Care Systems (ICSs), and other health and care organisations and partnerships to account for their performance
initial patient choice in NHS
- Initially, patient choice was somewhat limited, with GPs serving as gatekeepers to secondary and tertiary care services, referring patients to specialists and hospitals based on clinical assessment and medical need rather than patient preference or choice.
social change in the way of patient choice
- Patients’ groups have developed around chronic health conditions, such as Parkinson’s disease; and carers’ groups established to support those who have responsibility in the community. These operate as foci of information for the many NHS users who have long-term illness or impairment.
- The internet enhances the sharing of information. People now frequently choose alternative therapies rather than medicine or as well as medicine.
courts challenging medical authority
o In 2016, NHS England decided not to commission PrEP, a drug that significantly reduces the risk of HIV transmission, citing that it was not responsible for commissioning preventative services.
o the National AIDS Trust (NAT) initiated a legal challenge against NHS England, arguing that the refusal to commission PrEP was unlawful and constituted a breach of the NHS’s legal obligations to provide comprehensive HIV prevention services under the National Health Service Act 2006 and the Equality Act 2010.
o In 2016, the High Court ruled in favor of NAT, declaring that NHS England had the power to commission PrEP and that its decision not to do so was unlawful.
media playing a key role in publicising NHS issues
o The Stafford Hospital scandal emerged in the late 2000s and early 2010s- widespread neglect, poor care, and high mortality rates at Stafford Hospital. Media coverage of the scandal sparked public outrage
o The Francis Inquiry, led by Robert Francis QC, was commissioned to investigate the failings at Stafford Hospital and make recommendations for improvement.
o As a result of the Stafford Hospital scandal and the Francis Inquiry’s recommendations- changes included strengthening regulatory frameworks, improving clinical governance and accountability, enhancing transparency and openness, and promoting a culture of continuous learning, improvement, and patient engagement within the NHS.
patient choice under Thatcher
- Patient choice started under Thatcher- allowing patients to choose their GP and hospital, access private healthcare services, and exercise consumer rights in the NHS.
Patient choice under new Labour
all patients were to be offered a free choice on referral of any provider, public or private, who met NHS standards and prices.
Payment by results
2003
o Tariffs: each healthcare activity or procedure is assigned a tariff, which represents the payment amount that healthcare providers receive for delivering that specific service.
o Activity-Based Funding: an activity-based funding model, where healthcare providers are reimbursed for the volume and complexity of the services they deliver to patients. This means that providers receive payment for each individual patient contact, consultation, diagnostic test, procedure, or treatment episode, rather than receiving block grants or fixed budgets.
o The PbR system includes quality and performance metrics to ensure that healthcare providers maintain high standards of care and achieve positive patient outcomes.
o PbR system aims to promote patient choice and competition by allowing patients to choose their healthcare provider and encouraging providers to compete for patients based on quality, efficiency, and value for money.
choose and book under New Labour
o Choose and Book is an online booking system that allows patients referred by their GP to book their first outpatient appointment at a hospital or clinic of their choice, based on availability, waiting times, location, and patient preferences.
Personal Health budgets
New Labour
o Offering patients with long-term health conditions and disabilities Personal Health Budgets provide patients with a designated budget, funded by the NHS, to plan, manage, and purchase their healthcare and support services, tailored to their individual needs, goals, preferences, and outcomes, with guidance, advice, and support from healthcare professionals and care coordinators.
patient choice scheme
New Labour
o Under the Patient Choice Scheme, patients have the option to choose a private healthcare provider for their treatment, which is funded by the NHS, based on clinical suitability, quality, safety, waiting times, and patient preferences.
- Any Qualified Provider (AQP) model
coalition
o empower patients with greater choice and control over their healthcare by allowing them to choose from a list of qualified providers who meet the required standards and criteria for delivering NHS-funded services.
o opening up NHS-funded services to a wider range of qualified healthcare providers, including independent sector providers, to deliver high-quality, accessible, and efficient services.
- Friends and Family Test (FFT)
coalition
Introduced across NHS services to collect, measure, and monitor patient feedback, experiences, and satisfaction with healthcare services and providers through a simple, standardised questionnaire, rating, and recommendation system.
patient online
coalition
* Patient Online was launched to empower patients to access, manage, and control their healthcare records, information, appointments, prescriptions, and services online through secure digital platforms, portals, and applications.
patient choice post coalition
- The government has promoted the adoption and integration of digital health and technology solutions, innovations, and platforms, such as NHS App, Patient Online, and e-Referrals, to facilitate and support patient choice
pre devolution NHS funding
- Even before devolution in 1995/6 - “Scotland received 25 per cent more, Wales nearly 18 per cent extra and Northern Ireland 5 per cent more per head than England”
NHS Scotland in 1948 was accountable to the Scottish Office and not the Minister of Health.
Healthcare is beyond just policy - behaviour
- impact of individual behaviour on health, and on inequalities in health. The clearest example is smoking, which brings risks of heart disease and cancer and is related to social circumstances, with people in poorer circumstances more likely to smoke. Exercise and healthy eating are also related to socioeconomic patterns, with better- off people more likely to do regular exercise and to eat a diet rich in fibre, fruit, and vegetables that conforms to the government’s health advice.
advice about healthy living tended to increase health inequalities: it was more readily adopted by advantaged people than by disadvantaged.
Healthcare is beyond just policy- financial situation implications
- Damp housing, poor heating/insulation, traffic pollution, and unsafe play spaces for children are among the problems people face trying to make a healthy environment for their children on low incomes.
- Baldock and Manning - People in good social circumstances could improve their health by exercise, non-smoking, good diet. But people in poor social circumstances who made healthy choices did not gain as much benefit. There was a lower return from healthy choices, with health overwhelmed by factors they could not control.
healthcare beyond just policy - the third way
- Blair government policy is for: ‘striking a new balance . . . a third way . . . linking individual and wider action’ (Department of Health 1999). The emphasis on individuals improving their own health remains, but governments now acknowledge the difficulties arising from poverty, poor housing, pollution, low educational standards, unemployment, and low pay
geographical inequality
- The accusation of ‘postcode lottery’, in which treatment depends on where you live
class health inequality
- There is a wide gap in infant mortality too, with the rate for social class V now double that for social class.
- life expectancy at birth for social class I, the ‘professional’ class, increased almost six years over the last quarter of the twentieth century, while the rise for social class V, ‘unskilled manual workers’, was less than two years. The gap between these two classes stood at almost ten years by the end of the century.
waiting times under Blair
In 5 years since 1997:
o waiting times had been cut, so that 9 out of 10 people now had their operations within three months.
o The 2002 departmental report peppered its text with such examples. Eastbourne Hospitals NHS Trust had introduced a fast track referral path¬ way for cancer scans which had cut waits from 14 to 5 days
variation between trusts
2005
o Of the 37 NHS acute hospitals inspected, 11 got a clean bill of health, with high standards of cleanliness across the board, but in four cases the report commented that ‘The lack of cleanli¬ness is widespread and standards are unsatisfactory.’
The National Plan in 2000 was that 75 per cent of elective surgery admissions should be day surgery, and the Modernisation Agency actively promoted this goal. Yet four years later, the figure was still only 67.6 per cent, with once again (no surprise) great varia-tions between trusts - touching 100 per cent at one end of the distribution, less than 10 per cent at the other end.
Wendt- typifying healthcare systems
NHS-type countries (with the subgroups of early and late developed NHS systems) on the one side and SHI-type countries on the other:
health service provision -social insurance type
Austria, Belgium, France, Germany and Luxembourg (which are all social insurance countries).
o high level of total health expenditure and also a high share of public funding.
o The share of private out-of-pocket funding is moderate.
o The high level of health expenditure is translated into a moderate level of inpatient and a high level of outpatient healthcare.
o Good access- high level of autonomy of self-employed doctors and high freedom of choice for patients. - mainly paid on a fee-for-service basis, they have an incentive for ‘more active treatment’ to improve their income chances
Universal coverage controlled access type
Denmark , GB and Sweden (early founded + Ireland which was founded late)
o Universal coverage. – equity of access
o medium level of total health expenditure.
o The share of public health funding is high, and private out-of-pocket funding is moderate
o The access to doctors is highly regulated, and doctors face strict regulation regarding their income chances- smaller incentives to improve
o Access to healthcare providers is restricted- low level of outpatient health service providers, but also by the restricted access to GPs and specialists
restricted access type countries
Portugal, Spain and Finland (late developed)
o particularly low level of total health expenditure (per capita) which is (except for Finland) related to the weaker economic position of these countries.
o Private out-of-pocket payments are on a high level
o a high control of patients’ access to medical doctors-
o GPs receive in general a fixed salary, income chances are even more highly restricted than in Cluster 2.
o the inpatient provider level is particularly low
countries that cannot be typified according to Wendt
- Greece and the Netherlands cannot be grouped in any of the three clusters
o The Netherlands (before 2006) - high share of private funding, a low level of out- patient healthcare, entitlement on the basis of social insurance contributions and comparatively strict access regulation.
o Greece the highest out-of-pocket payments but, has little legal regulation of access to healthcare provider
why we can’t focus too much on health inequality
- Bambra- Cant focus too much on inequality - This has meant that the Scandinavian countries are effectively victims of their own success, as while they have substantially improved the health of all, the high level of health of the middle classes has meant that relative social inequalities remain. The lowest socioeconomic groups in the Scandinavian countries are objectively better off in absolute terms than the lowest socio- economic groups in the other welfare state regimes
US healthcare
- the publicly funded programmes for people on low incomes (Medicaid) and those aged 65 and over (Medicare) mean that government contributes almost half of total health spending in the US, but the predominant approach is that of employer-based health insurance and private health-care provision.
- Government controls over spending mean that the UK commits less than 8 per cent of its GDP to health care, compared to almost 15 per cent of GDP in the US
45 million Americans aged under 65 are uninsured at any one time. These differences in coverage help to explain why the health of US citizens is no better than that of their UK counterparts
Kaiser system Cali- integration
integration is prime reason hospital time is minimised
- Kaiser integrates the financing of health care with provision of services. It does so by collecting insurance premiums from its members, and allocating these resources to those responsible for running hospitals and providing medical services. Hospital managers and doctors know that they have to work within the envelope of resources earned by the insurance plan, and they share responsibility for the success of the pro- gramme.
- Kaiser integrates the financing of health care with provision of services. It does so by collecting insurance premiums from its members, and allocating these resources to those responsible for running hospitals and providing medical services. Hospital managers and doctors know that they have to work within the envelope of resources earned by the insurance plan, and they share responsibility for the success of the pro- gramme.
Kaiser system Cali- prevention and
integrates prevention, treatment and care. This is most evident in relation to people with chronic diseases like diabetes and heart failure who receive structured care from multidisciplinary teams based in the community. These teams practise from medical offices that are much larger than the surgeries in which primary care teams in the NHS - avoid the need for hospital stays purely for diagnostic purposes.
Kaiser care pathways
- minimize the time patients stay in hospital by actively managing their care at all stages. A good example is the field of orthopaedics where care pathways have been developed for patients undergoing hip and knee replacements specifying what should hap- pen on each day of hospital treatment. Lengths of stay for these conditions are typically around four days in Kaiser compared with 12 days in the NHS. discharge from hospital is planned either on or before admission, with a strong emphasis placed on early rehabilitation and patients are taught what they should do after surgery
admin of devolved NHS pre devolution
- Before political devolution in 1999, the administration of each health service in Scotland, Wales and Northern Ireland was the responsibility of the respective secretary of state… the convention of collective responsibility of the UK Cabinet meant that there was little scope for the Secretary of State for Scotland to pursue policies that diverged from those applied to England, except for matters “where English ministers did not particularly care what happened in Scotland and where there seemed to be no implication for policy across the border”.
devolution health funding pre devolution
- The three Secretaries of State for Scotland, Wales and Northern Ireland were allocated a global sum for their public services, and were free to allocate money to their chosen spending priorities. The Barnett Formula used in making global allocations to the devolved countries began to operate in Scotland and Northern Ireland in 1979, and in Wales in 1980 (when political devolution was first being considered). This formula, in principle, uses data on crude populations to allocate increases in spending on public services in England to the devolved countries
two systems of funding - devolved powers and England
o The arrangements for devolution mean that, in effect, there have been two different systems for determining health service budgets over much of the period for which this study reports funding and performance: one system applied to England only; the other to the devolved countries. The NHS budget for England is the outcome of UK Cabinet agreements following negotiations between HM Treasury and the Department of Health for England.
two systems of NHS funding governance post devolution
o Only in England are government departments accountable to HM Treasury for the performance of public services funded by UK taxpayers; in the case of the devolved governments, funding for these services is based on the Barnett Formula. Neither the NHS in Scotland nor Wales was subject to the Treasury’s PSA targets
although the Department of Health, Social Services and Public Safety of Northern Ireland performed comparatively poorly against its PSA targets when these were reviewed in 2011, “it is not clear that any penalties were incurred, or indeed that much action followed, as a result of that poor performance”.
provider competition - devolved nations
- Prior to devolution, the intended model of governance in all four countries had been one of provider competition. This was tried in each UK country, from 1991, in the form of an ‘internal market’
- From 2002, in England, the government’s policy changed to reintroduce provider competition into its NHS. They introduced important structural differences compared with the previous internal market (for example, a much greater emphasis on provider autonomy and diversity).
- over the same period, the governments of Scotland and Wales abandoned the policy of provider competition and the purchaser/provider split. Northern Ireland retained a purchaser/ provider split but without competition between providers.
o the health services in Scotland and Wales have reverted to being traditional state monopolies run by organisations funded to deliver care to their local populations.
Funding redirected in devolved nations
- Scotland has used its funding for other purposes, including free personal social care.
privatisation in devolved nations
- Scotland (2011), Wales (2007) abolished prescription charges, while Scotland also abolished fees for eye and dental checks (2006)
two systems of oversight and control - devolution
- The devolved countries have direct political accountability (to the assemblies in Wales and Northern Ireland and the Scottish Parliament); political accountability for these services in England is through elections to the Westminster Parliament, which hinge on a mix of English and UK-wide issues
modes of governance in devolved nations
2003 - in Wales, the system of performance management for its NHS was criticised by the Wanless Report as lacking the “incentive systems to drive properly creation or imitation of best practice” Moreover, there was no system of “naming and shaming
In Scotland, Propper and others (2010) describe the regime for managing reduction of hospital waiting times from 2000 as one in which there was neither “naming and shaming” nor “the coupling of performance against targets and managerial sanctions that operated in England- there was the perception of “perverse incentives… where ‘failing’ Boards are ‘bailed out’ with extra cash and those managing their finances well are not incentivised”.
- England alone has opted for the model of choice and competition
comparison of patient choice across devolved nations
England - choices for provider, consultant, time/date/ site either exist as yes or at providers discretion
Scotland and Wales- no provider choice
Dutch health insurance model
The Dutch health insurance system is characterized by its mandatory health insurance coverage for all residents. It operates under a model of social health insurance, where private health insurers compete within a regulated market
All residents of the Netherlands are required by law to have basic health insurance coverage, which covers essential medical services.
insurers receive additional funds to compensate for covering individuals with higher healthcare costs.
individuals can purchase supplementary insurance for additional coverage, such as dental care or alternative therapies.
health care demand side
demographic change
problem of affluence- we eat more salt and preservatives, food no longer a luxury- we eat more + don’t work in physical labour
healthcare - supply side
new tech - costs more
labour shortages
rationing
difference in outcomes because of Barnett formula
Barnett Formula does not entail a 1:1 spending equivalence.- does not guarantee that each region or nation will receive an equal amount of spending for every unit of population or need. Factors such as historical spending patterns, political considerations, and negotiations between central and devolved governments can influence the final allocation of funds.
The Barnett Formula only calculates the total amount that Scotland gets for spending in devolved areas proportional to spending on those same policy areas at Westminster. How the Scottish government then spend that money is up to them.
foundation trusts v nhs trusts
Foundation trusts have some managerial and financial freedom when compared to NHS trusts. The introduction of foundation trusts represented a change in the history of the National Health Service and the way in which hospital services are managed and provided. At the time of introduction, they were described “as a sort of halfway house between the public and private sectors”.[12] This form of NHS trust is an important part of the United Kingdom government’s programme to create a “patient-led” NHS with an internal market. The stated purpose is to devolve decision-making from a centralised NHS to local communities, in an effort to be more responsive to their needs and wishes. But after Gordon Brown prevented plans by Alan Milburn to make them financially autonomous[4] they have been much more in the public sector and less autonomous than was originally expected
Each foundation trust has a council of governors. This is made up of elected governors and appointed governors.[16] Elected governors are chosen by a secret postal ballot of the membership, which is open to the general public
