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The Reorganized National Health Service the Reorganized National Health Service The Reorganized National Health Service The Reorganized National Health Service Sixth edition Ruth Levitt Office for Public Management London, UK Andrew Wall Visiting Senior Fellow Health Services Management Centre University of Birmingham, UK John Appleby Director, Health Systems Programme King's Fund, London, UK Stanley Thornes (Publishers) Ltd ©1976, 1977 Ruth Levitt; 1984, 1992 Ruth Levitt and Andrew Wall; 1995, 1999 Ruth Levitt, Andrew Wall and John Appleby. The right of Ruth Levitt, Andrew Wall and John Appleby to be identified as authors of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission in writing from the publisher or under licence from the Copyright Licensing Agency Limited. Further details of such licences (for reprographic reproduction) may be obtained from the Copyright Licensing Agency Limited of 90 Tottenham Court Road, London W1P OLP. First edition published in 1976 by Croom Helm, revised July 1976. Second edition published in 1977 by Croom Helm, revised 1979. Third edition published in 1984 by Croom Helm. Fourth edition published in 1992 by Chapman & Hall. Fifth edition published in 1995 by Chapman & Hall. Sixth edition published in 1999 by: Stanley Thomes (Publishers) Ltd Ellenborough House Wellington Street Cheltenham Glos. GLSO 1YW United Kingdom 99 oo 01 02 03 I 10 9 8 7 6 5 4 3 2 A catalogue record for this book is available from the British Library ISBN 0 7487 3894 0 Typeset by Acorn Bookwork, Salisbury, Wiltshire Printed and bound in Great Britain by Martins the Printers Ltd, Berwick upon Tweed CONTENTS______ Preface IX Selected abbreviations x Ministers of Health and Secretaries of State XIV 1 Introduction 1 References 6 2 Background to today' s National Health Service 7 2.1 Health services before 1948 - a brief history 8 2.2 Creation of the National Health Service 11 2.3 Early problems 13 2.4 Preparing for the first reorganization 15 2.5 The new arrangements 16 2.6 Introduction of 'general management' 17 2.7 Working for Patients and Caring for People 18 2.8 The Health of the Nation 21 2.9 The 1990 changes in practice 21 2.10 The new NHS 23 Conclusion 25 References 25 3 Central government and the National Health Service 28 3.1 The functions of government departments 28 3.2 The role of health ministers 29 3.3 Accountability 29 3.4 The Department of Health 31 3.5 The regions 35 3.6 A change of culture 37 Conclusion 3 9 References 3 9 4 Health authorities 40 4.1 Planning services 1948-91 40 4.2 The new purchasers: districts after 1991 41 4.3 Joint commissioning 45 CONTENTS 4.4 The new NHS 46 4.5 Health authority membership 47 Conclusion 50 References 50 5 NHS trusts 51 5.1 Hospitals 51 5.2 Setting up NHS trusts 53 5.3 The first few years of NHS trusts 56 5.4 Trust management 57 Conclusion 58 References 59 6 Primary care 60 6.1 General practice up to 1996 60 6.2 Primary care groups 66 6.3 The organization of general practice 67 6.4 General dentistry 69 6.5 Pharmaceutical services 70 6.6 Optical services 71 Conclusion 72 References 73 7 The NHS in Scotland, Wales and Northern Ireland 74 7.1 Scotland 74 7.2 Wales 80 7.3 Northern Ireland 84 Conclusion 87 References 87 8 Financing the National Health Service 89 8.1 Sources of funding 89 8.2 How the government pays 90 8.3 Distributing the funds 92 8.4 Capital and revenue 97 8.5 The cost of the NHS 101 8.6 Controlling ex:penditure 104 8.7 Private health care 105 Conclusion 106 References 107 VI CoNTENTS 9 Services for patients 109 9.1 Planning in the NHS 109 9.2 Planning procedures, policies and priorities 111 9.3 Planning for commissioning, purchasing and providing 116 9.4 Primary care 119 9.5 Prevention of ill health 121 9.6 Health and safety at work 125 9.7 Acute hospital services 127 9.8 Mothers and babies 130 9.9 Children 132 9.10 People with learning disabilities 133 9.11 The physically disabled 135 9.12 Mentally ill people 136 9.13 Elderly people 138 Conclusion 141 References 141 10 Effectiveness, performance, quality and outcomes 144 10.1 Evidence-based medicine 144 10.2 Health outcomes 146 10.3 Performance 148 10.4 Value for money 149 10.5 Accountability 152 10.6 Quality 155 10.7 Clinical governance 156 Conclusion 158 References 159 11 Staffing - doctors and nurses 161 11.1 Doctors 161 11.2 Nursing 180 Conclusion 189 References 189 12 Other staff and human resource issues 192 12.1 Dentists 192 12.1 Ophthalmic staff 196 12.3 Pharmacists 198 12.4 Other professional staff 199 12.5 Scientific and technical staff 205 ------vu CONTENTS 12.6 Ancillary staff 207 12.7 Estates staff 208 12.8 Ambulance staff 209 12.9 Managerial, administrative and clerical staff 209 12.10 Personnel management 210 Conclusion 215 References 216 13 The public and the National Health Service 218 13.1 Community health councils 218 13.2 Public opinion 222 13.3 Patient's Charter 223 13.4 Complaints 224 13.5 The work of voluntary organizations 226 13.6 Medical research and intervention 227 13.7 Ethics 228 Conclusion 23 0 References 23 0 14 The NHS in an international context 232 14.1 Equity of provision 233 14.2 Quality of service 239 14.3 Financing health care 241 14.4 Developing countries and Eastern Europe 247 Conclusion 247 References 248 15 The NHS and the future 249 15.1 Priority-setting 249 15.2 The resource question 254 15.3 Organizational structure 255 Conclusion 257 References 25 7 Index 259 Vlll------ PREFACE The National Health Service reached its 50th anniversary in July 1998. This is a remarkable achievement that has been made possible by a unique combination of political, professional, social and cultural values in the UK. In this book we explain clearly and critically what the NHS is, how it works, why it looks and works the way it does, how it has come to its present state and what its future options are. Reorganization has become a constant feature for the NHS, as politi­ cians, professionals and the public seek to influence or improve the structure and operations of the NHS and to shape the outcomes it can produce. Strategic thinking is always a challenge for the NHS, and we indicate where there are some persistent problems which still need to be resolved. Providing health services publicly and privately raises important questions about the key goals of effectiveness, efficiency and quality. These questions are increasingly in focus, as the social and ethical priorities for proper distribution of appropriate services have to be argued. We acknowledge with thanks the use of copyright material quoted from HMSO, The Stationery Office and other sources. Ruth Levitt Andrew Wall John Appleby March 1999 IX SELECTED ABBREVIATIONS ACAS Advisory, Conciliation and Arbitration Service ACC Association of County Councils ACHCEW Association of Community Health Councils for England and Wales ADC Association of District Councils AIDS Acquired immune deficiency syndrome ALA Association of Local Authorities AMA Association of Metropolitan Authorities ASC Action for Sick Children (formerly NAWCH) ASH Action on Smoking and Health BDA British Dental Association BMA British Medical Association BSI British Standards Institution BTS Blood Transfusion Service BUPA British United Provident Association CDSC Communicable Diseases Surveillance Centre CE Chief Executive CEPOD Confidential Enquiry into Perioperative Deaths CHC Community health council CHD Coronary heart disease CHI Commission for Health Improvement CMDS Core minimum data set/Community contract minimum data set COHSE Confederation of Health Service Employees (see UNISON) CPN Community psychiatric nurse cso Central Statistical Office CSSD Central sterile services department CT Computed tomography D&C Dilatation and curettage DGH District general hospital DGM District general manager DH Department of Health DHA District health authority DHSS Department of Health and Social Security DMC District medical committee DMO District medical officer DMU Directly managed unit DN District ~urse DoH Department of Health DPH Director of Public Health X SELECTED ABBREVIATIONS DRG Diagnosis-related group DSS Department of Social Security EBS Emergency Bed Service (London) ECR Extracontractual referral EFL External financing limit EL Executive letter ENB English National Board for Nursing, Midwifery and Health Visiting ENT Ear, nose and throat FCE Finished consultant episode FHS Family health services FHSA Family health services authority (formerly FPC) FPA Family Planning Association FPC Family practitioner committee GDC General Dental Council GDP General dental practitioner GDP Gross domestic product GDS General dental services GHS General household survey GIFT Gamete intra-fallopian transfer GM General manager GMC General Medical Council GMP General medical practitioner GMS General medical services GMSC General Medical Services Committee GPFH General practice fundholder HA Health authority HM Hospital Activity Analysis HAS Health Advisory Service HAZ Health action zone HC Health circular HCHS Hospital and community health services HES Hospital episode system HFEA Human Fertilisation and Embryology Authority HIP Health improvement programme HIPE Hospital Inpatient Enquiry HIV Human immunodeficiency virus HMO Health maintenance organization (USA) HR Human resources HRG Healthcare related groups/Healthcare resource group HSC Health and Safety Commission HSI Health
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