Reorganising the NHS: lessons from the past

Norfolk and Norwich University Hospital NHS Trust

In July 2010 the new UK government published a white paper on the National Health Service, Equity and excellence: liberating the NHS, laying out plans for a radical re-organization of the NHS. A key element in the plans is closing the 150 existing PCTs (Primary Care Trusts) and 10 Strategic Health Authorities, and transferring their £80bn healthcare commissioning budget to perhaps 600 consortia of local GPs. The plans aim to save 45% of NHS management costs. Polly Toynbee, writing in The Guardian, notes various criticisms made of the plans, including their transitional cost, the loss of strategic planning, and the likelihood of large healthcare companies moving in to what will become effectively a fully free market in healthcare provision. “GPs favouring local providers can be challenged in court if their consortium rejects a cheaper offer from a loss-leading large company: cue extreme disruption for local hospitals losing out to private bidders.” The plans also risk a radical revision of the relationship between patients and GPs – potentially undermining patient trust: “Once patients suspect GPs’ pay depends on keeping bills low, it spells the end of trust.”

A 2003 paper by John Mohan looked at  the geography of hospital provision in pre-NHS Britain. Whilst most acute hospital treatment was provided by voluntary hospitals, the 1929 Local Government Act had given local authorities the power to provide general hospital services, in addition to duties in relation to the treatment of infectious diseases and care for the chronically sick. There was no national or regional planning (some voluntary cooperation aside), and the timing, location, quality and quantity of both voluntary and municipal provision varied. Some central government grants meant municipal provision was not entirely dependent on local wealth. Using data from the wartime Hospital Surveys, Mohan examines the pattern of hospital utilization and waiting lists in 1938. In the voluntary sector, Mohan finds some support for what was sometimes called the ‘inverse care law’ – that those areas with the greatest need were often those with the lower level of facilities. By contrast, with strong evidence that “municipal services were most developed in areas of greatest need”, municipal provision contributed to equity – “it becomes clear that state action was central to improving access”.

Overall, Mohan concludes that his findings “demonstrate very clearly the extent to which access to hospital treatment prior to the NHS was a function of residence.” It was these concerns which prompted the creation of the NHS, yet in recent years there has been a growth of charitable funds, “heavily concentrated in a small number of high-profile hospital trusts” (and in medical research and acute hospitals, rather than primary or community care), whilst alongside the expansion of private finance there have been new initiatives like “foundation hospitals” with freedom from central government control. Mohan concludes that “Differential charitable resources available to communities, and the diversifying financial bases of hospitals, will undoubtedly produce greater pluralism but whether they will maintain the NHS’s commitment to equity remains to be seen.”

View the Wójcik (2009) article here Mohan, John (2003), “Voluntarism, municipalism and welfare: the geography of hospital utilization in England in 1938“, Transactions of the Institute of British Geographers, Volume 28, Issue 1, Pages 56-74

Polly Toynbee, The Guardian: This is no careful plan: the NHS is being wired for demolition at breakneck speed Polly Toynbee, guardian.co.uk, 17 July 2010, “This is no careful plan: the NHS is being wired for demolition at breakneck speed

Robin de la Motte

1 comment

  1. An excellent summary of the implications of the coalition government’s health policy. What is also perhaps not fully realised is that handing budgets to GPs is in itself a de facto privitisation of the health service, as GPs are private businesses.

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