Some changes to the NHS FROM BIRTH TO PRESENT (or ‘What the Baby Boomers Paid For’)

March 1950

JS Collings’ survey of English general practice, funded by the Nuffield Trust, is published in The Lancet.

He finds that: “the overall state of general practice is bad and still deteriorating”; “some [working conditions] are bad enough to require condemnation in the public interest”;  inner-city practices are “at best… very unsatisfactory and at worst a positive source of public danger”.

August 1954

The Bradbeer Committee publishes a report on the internal administration of hospitals for the Central Health Services Council. (CCGs by another name)

The resulting guidance is supportive of the system typical in voluntary hospitals (which avoids the hierarchy of local authority hospitals). It draws on the former’s concept of a ‘tripartite administration’ of medical, nursing and lay elements, but with the lay element (in the person of the group secretary) given overall responsibility for implementing policy and coordinating the activities of the group.

May 1960

The Royal Commission is appointed in March 1957 to settle an ongoing dispute between the medical profession and the Government over pay, which even leads to the Conservative Government planning for a ‘phased withdrawal’ from the NHS.

March 1966

With falling GP morale, the negotiations on the Charter for General Practice provide financial incentives for practice development, plus substantial rewards.

A milestone in defining the role of general medical services, the 1966 GP contract addresses major grievances of GPs and provides for better-equipped and better-staffed premises, greater practitioner autonomy, a minimum income guarantee, and pension provisions.

February 1970

Crossman re-writes Robinson’s proposals in the second Green Paper on the NHS.

Partly in response to criticisms of Robinson’s 1968 plan, Richard Crossman makes extensive revisions to the first NHS Green Paper, leading to the publication of the second Green Paper on the NHS.

Crossman rejects the idea of local authorities managing the health service, proposing instead that area authorities should remain directly accountable to the Department of Health and Social Security.

But he retains the idea that the number and areas of the new health authorities should match those of the new local authorities, adding that regional health councils could undertake those activities for which the areas are too small.

July 1973

NHS reorganisation: after years of debate, structural changes are made in the NHS Reorganisation Act.

In an effort to generate better coordination between health authorities and local authorities, the NHS Reorganisation Act sees the traditional tripartite structure replaced by a unitary structure with 90 health authorities reporting to 14 regional health authorities. Under the reforms, regional, area and district heath authorities replace regional hospital boards, taking over public health and other services from local authorities in the process.

September 1976

Sharing resources for health in England: Report of the Resource Allocation Working Party is published.

The report is the first systematic attempt to address the major inequity between health spending in London and the south east of England and the much lower levels  – broadly half – spent elsewhere in the country. RAWP proposes using mortality in each area as an indicator of health care need.

The formula is in use from 1977 to 1990 and gradually manages to redistribute resources from the metropolitan regions to the poorer regions in the north.

December 1987

The White Paper, Promoting better health, suggests improvements in patient choice and the widening of services provided by pharmacists and nurses.

This White Paper forms the basis for the new GP contract in 1990, which sets out quality and financial incentives to improve the processes of delivering care, with extra pay for undertaking health promotion, screening and other preventative actions. It leads to major increases in the skills and size of primary health care teams.

January 1989

Split between purchasers and providers of care proposed. (Dad of CCGs)

The White Paper, Working for patients (NHS reforms), proposes to introduce a split between purchasers and providers of care, GP fundholders and a state-financed internal market, in order to drive service efficiency.

November 1991

The Patient’s Charter stresses the patient as a customer with rational expectations.

Secretary of State for Health, William Waldegrave, House of Commons, oral answers to questions: Health, 5 November 1991.

The Patient’s Charter outlines the rights of patients regarding the receipt and quality of service they should expect to receive.

February 1997

Primary Care Act

The Primary Care Act enables new possibilities for delivering primary care. GP practices are encouraged to increase flexibility and choice.

December 1997

Labour comes to power and publishes the White Paper, The new NHS: Modern, dependable.

The White Paper, The new NHS: Modern, dependable, led by Frank Dobson, aims to replace the internal market and GP fundholding with a more cooperative, integrated system while retaining the purchaser–provider split. Organisational change is foreshadowed.

March 1999

The Royal Commission on Long Term Care reviews the options for the ongoing funding of long-term care of older people.

The Royal Commission recommends that all nursing and personal care provided in nursing homes and in people’s homes should be free. Two members of the Commission, Lord Lipsey and Lord Joffe, co-author a minority report that opposes the case made by the majority of the Commission for free personal care for all, financed from taxation.

When the Government responds with The NHS Plan in 2000, a reduced version of this is implemented with nursing care to be provided free of charge, but with personal care remaining means tested. Scotland becomes the only country in the UK to offer free personal and nursing care at home.

July 2000

The NHS Plan – a 10-year modernisation programme of investment and reform.

The NHS Plan outlines a strategy for more doctors, more nurses, more beds and 100 hospital building schemes by 2010, with improved access to hospitals and primary care and a renewed focus – through performance targets – on decreasing waiting times.

A new model of financing is agreed: instead of public money, the Private Finance Initiative takes loans at high interest rates to design, build and operate hospitals building up huge commitments on future revenues. The Plan also sets out revised targets for issues such as waiting times.

April 2004

The first 10 foundation trusts (FTs) are established, with more control over their budgets and services. (Privately operating under market forces)

“We are clear that Government cannot – and should not – pretend it can ‘make’ the population healthy. But it can – and should – support people in making better choices for their health.” (Pay or Wait ?)

Prime Minister Tony Blair, in Department of Health (2004) Choosing Health: Making healthy choices easier. Department of Health.

November 2004

The Government’s public health White Paper, Choosing health, is published.

The public health White Paper, choosing health, reiterates the agenda to promote individual responsibility with a focus on issues such as smoking, obesity, diet and nutrition, exercise and sexual health.

The White Paper supports individual choice, personalised services and coordinated working between the public and private sectors.

January 2011

NHS reorganisation: The Health and Social Care Bill 2010/11 proposes significant reforms to increase the influence of GPs on commissioning, increase competition and abolish strategic health authorities (SHAs) and primary care trusts (PCTs).

The Health and Social Care Bill 2010/11 is introduced into Parliament on 19 January 2011.

It envisages a bottom-up, clinically owned network of GP commissioning groups with ‘real’ budgets to buy care on behalf of their local communities; shifting many of the responsibilities historically located in the Department of Health to a new, politically independent NHS Commissioning Board; creating a health-specific economic regulator (Monitor) with a mandate to guard against ‘anti-competitive’ practices; and moving all NHS trusts to autonomous foundation trust status.

SHAs and PCTs are to be abolished, while integration between NHS and local authority services is to be strengthened through new health and wellbeing boards. The voice of patients is to be empowered through the establishment of a new national body, Health Watch, and local Health Watch organisations. Public Health England, a new body, is the lead on public health at the national level, with local authorities taking the lead locally.

Meanwhile, the landscape of health care provision is to be galvanised by a dose of competitively driven innovation, with an expectation of easier entry and exit to the market for a range of private and voluntary sector providers.

April 2013

The ‘new’ NHS comes into being as responsibilities shift to bodies created by the 2012 Health and Social Care Act.

Primary care trusts (PCTs) are abolished. Their functions pass to NHS England (previously known as the NHS Commissioning Board) and the 211 clinical commissioning groups (CCGS) it has authorised.

CCGs which are only partially authorised are subject to special conditions from NHS England as they take on their new role. Some remain unauthorised, staying in ‘shadow’ form while NHS England takes on commissioning directly. CCGs will be supported by a number of commissioning support units (CSUs), which will provide a range of business functions designed to help CCGs improve services.

Strategic health authorities (SHAs) are also abolished. Health Education England takes on SHAs’ responsibility for education, training and workforce development.

The NHS Trust Development Authority takes on responsibility for providing governance and accountability for NHS trusts and for delivering the foundation trust pipeline.

Four regional and 27 local branches of NHS England take on responsibility for the strategic oversight of provision and commissioning in their areas. Public health responsibilities are transferred to local authorities. Public Health England is established to improve the nation’s health and wellbeing and reduce inequalities.

New health and wellbeing boards are established. An independent consumer champion – Healthwatch England– is also created.

October 2014

NHS England publishes its Five Year Forward View.

For the first time, the partner organisations that deliver and oversee health and care services including NHS England, Public Health England, Monitor, Health Education England, the Care Quality Commission and the NHS Trust Development Authority set out a shared vision for the future of the NHS in England. The Five Year Forward View outlines how the NHS needs to change over the next five years if it is to reduce health inequalities, improve the quality of care and meet an estimated £30 billion gap in funding by 2020/21.

Advised by the Nuffield Trust and other independent experts, the report outlines a number of options for how local health communities can create new ways of organising and delivering patient care. With no ‘one size fits all’ care model in mind, the report examines how groups of GPs may combine with nurses, other community health services, hospital specialists and mental health and social care to create integrated out-of-hospital care – so-called ‘Multispecialty Community Providers’.

A further new option will be the integrated hospital and primary care provider – so-called ‘Primary and Acute Care Systems’, which would combine for the first time general practice and hospital services (in a similar way to the Accountable Care Organisations now developing in other countries).

England’s new general practice contract five-year framework: an investment in primary and community care

The Contract commits historic levels of funding to create new ‘primary care networks’

The contract framework commits £1 billion to the capitated contracts held by individual general practices over the next five years. is short explainer takes a look at the changes to the GP contract made in 2019.

One of the many workforce solutions offered by the contract framework is to rapidly develop expanded teams of community-based health professionals attached to PCNs by 2023/24

In the first year, PCNs will be 100% reimbursed for at least one social prescribing link worker and one clinical pharmacist, at a 70% recurrent reimbursement rate. In subsequent years, PCNs will receive funding to introduce physician associates, practice-based physiotherapists and paramedics

The contract promises to modernise the pay-for-performance ‘quality and outcomes framework’ introduced in 2004,

The most visible patient-facing change will be increased access to primary care via digital technology (either provided by their practice or sub-contracted to an online GP provider).

Many across the health and care sector heralded the GP contract framework as the most significant policy change in primary care in over a decade.

And then April 2020

‘O’ and don’t forget the report of the Royal Commission on the NHS published on 18 July 1979.

 Services to patients

(1) Proved screening programmes should be expanded.

(2) The wearing of seat belts should be made compulsory for drivers and front seat passengers in motor vehicles.

(3) Health education should be expanded, but some of the increased resources must be spent on developing more effective methods and on monitoring and validating existing and new techniques.

(4) Education authorities should examine seriously existing arrangements for health education in schools.

(5) Health education should be emphasised in the forward planning of health authorities.

(6) Funds for the Health Education Council and the corresponding bodies in Scotland should be increased to allow

them to make more use of television.

(7) The health departments should make public more of the professional advice on which policies and priorities are based.

(8) All professions concerned with the care of the elderly should receive more training in understanding their needs.

(9) Further experiments in different ways of meeting the needs of elderly and other patients requiring long-term care should be undertaken urgently.

(10) The legal position regarding responsibility in the use of deputising services in Scotland should be brought into line with that elsewhere in the UK.

(11) Health authorities should keep under review the operation of the deputising services in their areas and, if they are unsatisfactory, improve or replace them.

(12) Where this does not happen already, the full costs of attendance of GPs’ receptionists at training courses should be met by the family practitioner committee or health authority concerned.

(13) Before a maximum or minimum list size is adopted, considerable research on an optimum range of list sizes should be undertaken.

(14) There should be a review of the controls on the appointment of GPs exercised by the medical practices committees.

(15) The health departments should consider offering an assisted voluntary retirement scheme to GPs with small lists who have reached 65 years of age.

(16) The health departments should discuss with the medical profession the feasibility of introducing a compulsory retirement age for GPs.

(17) The health departments should continue their current plans for the expansion of community nursing.

(18) Research is required into a number of aspects of primary care.

(19) National or regional panels should be set up to provide external assessors for each new appointment of a principal in general practice.

(20) GPs should make local arrangements specifically to facilitate audit of the services they provide and the health

departments should check progress with these developments.

(21) The introduction of the A4 records system in general practice should be given high priority.

(22) FPCs and health authorities should use vigorously their powers to ensure that patients are seen by their GPs in surgeries of an acceptable standard.

(23) The British National Formulary should be reissued soon in portable, loose-leaf form with separate information on drug costs, and be kept up-to-date.

(24) The health departments should introduce a limited list of drugs as soon as possible and take further steps to encourage generic prescribing.

(25) The health departments should consider whether high running costs are acting as a significant disincentive to GPs to work in health centres.

(26) The health departments should consider urgently measures to assist the development as a priority of health centres or other suitable premises to attract GPs to London and other inner city areas where sites are particularly expensive or difficult to obtain.

(27) Health authorities when establishing health centres in inner city and deprived urban areas should experiment with offering salaried appointments and reduced list sizes to attract groups of doctors to work in them.

(28) Additional financial resources should be provided to improve the quality of primary care services in declining urban areas.

(29) The establishment of pharmacies in health centres should be encouraged.

(30) Charges for NHS and non-NHS items and details of eligibility should be prominently displayed and publicised by

opticians.

(31) Serious consideration should be given to widening the range of items which can be prescribed and dispensed under the general ophthalmic services.

(32) More chiropody training places should be provided and services to the elderly in the community increased.

(33) Until the implications of a shift in policy towards prevention have been identified dental student entry numbers should not be altered but flexibility in meeting demands should be achieved through the increased use of dental ancillary workers.

(34) The dental profession and Government should experiment with alternative methods of paying general dental practitioners in addition to a capitation system for children.

(35) The dental profession and Government should make rapid progress to the introduction generally of an out-of-hours treatment scheme.

(36) Dental care for long-stay hospital patients should be as readily available as it is for men and women in the community.

(37) Dental teaching hospitals should be funded directly by region or health department.

(38) The present technical college/dental hospital training schemes for dental technicians should be expanded.

(39) A standardised national basis for the collection of dental data should be introduced.

(40) Manpower in the community dental service should be increased.

(41) The Scottish system for recording all information about the dental treatment of children in the same way should be adopted in the rest of the UK.

(42) The availability of dental services to the handicapped should be further improved by the payment of fees authorised on a discretionary basis by the dental estimates boards.

(43) The Government should introduce legislation to compel water authorities to fluoridate water supplies at the request of health authorities.

(44) The health departments should pursue an active policy in restricting advertising which may lead to undesirable dietary habits, particularly in children.

(45) The dental profession should consider ways of overcoming the problems of long-term clinical research in dentistry.

(46) A small committee representing Government and the other interested parties should be set up to review the development of dental health policy.

(47) The health departments should promote more research both on the acceptability of day admissions to patients and on the benefits to the NHS.

(48) All hospitals should provide facilities for patients and relatives to be seen in private.

(49) All hospitals should provide explanatory booklets for patients before they come into hospital.

(50) Hospitals should ensure that the availability of amenity beds is routinely made known to patients when they are given a date for admission.

(51) Health authorities should review forthwith wakening times for patients in the hospitals for which they are responsible.

(52) The health departments should now state categorically that they no longer expect health authorities to close mental illness hospitals unless they are very isolated, in very bad repair, or are obviously redundant due to major shifts of population.

(53) The Government should find extra funds to permit much more rapid replacement of hospital buildings than has so far been possible and they should stick to their plans.

(54) Community health councils should have right of access to family practitioner committee meetings and their equivalent in Scotland and Northern Ireland. If FPCs are abolished as we propose CHCs should have access to the committees which take over their functions.

(55) CHCs should be given more resources to enable them to inform the public fully about local services.

(56) More resources should be made available where necessary to allow CHCs to act as the “patient’s friend” in complaints procedures.

(57) Health departments and health authorities should continue to give financial support and to encourage voluntary effort in the NHS.

(58) Financial support should be given to encourage the setting up of patient committees in general practice.