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’
