1 / 48

The framework of the NHS: a public health perspective

The framework of the NHS: a public health perspective. Session 1: 3 October Professor DG Cramp. Recommended text.

kirsi
Download Presentation

The framework of the NHS: a public health perspective

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The framework of the NHS: a public health perspective Session 1: 3 October Professor DG Cramp

  2. Recommended text A highly recommended book that has relevance to what Professor Cramp teaches in the ‘Information for Decisions’ and ‘Health Policy and Information Management’ modules and available at the bookshop is: Public Health for the 21st Century Ed. Orme J et al. Open University Press. 2003.£19.99. ISBN 0335211933 p/b.

  3. ‘Those who cannot remember the past are condemned to repeat it ‘ George Santayana (1922)

  4. The beginnings… • Infectious disease always endemic • In 18C smallpox, typhus, tuberculosis • 1831-2 massive outbreak of cholera • No idea causation - ‘poisonous miasma’ • Government acted - ‘Boards of health’ set up with certain powers • Epidemic waned – returned 1848

  5. Edwin Chadwick 1800-90 • 1842 - ‘Report on the Sanitary Conditions of the Labouring Population of Great Britain’ • Primarily evidence doctors working in the Poor Law countrywide together with statistics collected by William Farr • Bad feeling between Edwin Chadwick and the medical profession because of his obsession that squalor and deprivation were the prime cause of ill-health – ‘retired early’

  6. Public Health Act 1848 • Central Board of Health in London to sit for 5 years • Local Boards of Health (if 10% of rate payers agreed) with powers to improve water supply and sewage disposal by taking over from companies and individuals • Not compulsory so not applied country wide being set up in only 182 towns

  7. Impact of 1848 Act • Opponents to the Act brought it to an end - vested interests • Others thought wrong for Government to interfere in people’s private lives – “We prefer to take our chance of cholera and the rest than be bullied into health” The Times

  8. State intervention in public health • Further outbreak of cholera in 1854 • Dr John Snow showed cholera spread by water (Broad Street pump) • 1858 public health put under control of Privy Council and Sir John Simon appointed Medical Officer of Health • 1864 Pasteur & germ theory of disease

  9. Government role • By mid-1860s government realised must play major role in public health • Death of Prince Albert from typhoid 1861 possibly helped ? • But not until 1869 was Simon able to persuade government to set up Royal Sanitary Commission

  10. Report of Commission • Reported that provision of clean water and sewage disposal patchy and recommended laws that would be “uniform, universal and imperative” • Response formation Local Government Board to oversee administration of public health and the 1872 Public Health Act

  11. 1872 and 1875 Acts • 1872 Act divided country into ‘sanitary areas’ each with a medical officer of health • 1875 the Disraeli government passed a second Public Health Act and also the Artisans’ Dwelling Act – together the most wide-reaching legislation to date

  12. 1875 Public Health Act • Consolidated all previous laws under one act • Compelled councils to provide clean water, drainage, sewage disposal and street lighting • Councils had to employ medical inspectors

  13. Some progress • District nursing begun by a wealthy Liverpool merchant, William Rathbone and by 1887 most large cities had a similar service (voluntary charity) • Developing concerns over midwifery lead ultimately Midwives Act 1902 • Development of club practices

  14. Changes in attitude • 1906 Liberal government with massive majority and aim to tackle social evils • Charles Booth survey in London 1889 - 1903 - ‘Life and Labour of the People’ • 1899 Seebohm Rowntree in York • Poor state of volunteers to fight in the Boer war • Clear ill-health related to poverty

  15. Liberal reforms 1906-14 • 1906 - local authorities given power to provide free school meals • 1907 - school medical inspections • 1909 - Old Age Pension Act • 1909 – Labour Exchanges set up • 1911 – National Insurance Act that included free medical treatment

  16. N.I. Act 1911 Part I • Part I: Workers in manual trades earning less than £160 per year to pay 4d per week to which the employer added 3d and the government 2d. • Workers entitled to 10s per week if off sick for up to 26 weeks. Free medical treatment from a panel doctor.

  17. 1911 Act administered by ‘local insurance committees’ with representatives from approved societies (friendly societies, insurance offices, TUs, LAs and GPs) who initially given significant powers over remuneration of doctors who required to register on a local list (panel) and ability to direct patients to join a doctors list

  18. Opposition from the BMA • Over remuneration and possible interference, as with club practice system, which would mean a loss of independence and cause medical standards to drop • Government concessions: power of committees over remuneration removed and doctor on local list (panel) would receive 6s capitation fee for each patient under their care; the principle that patients could choose their own doctor was established

  19. By 1914 At the outbreak of the 1914-18 war over 90% of GPs participated in the National Health Insurance scheme and some 43% of the working population were covered but dependants and the unemployed were still excluded

  20. Health and welfare 1919-39 • Ministry of Health Act 1919 single department set up to centralise health matters that previously concern of 7 also Registration of Nurses Act 1919 • Housing and Town Planning Act 1919 gave LAs power to build council housing • But by 1922 the economy was in trouble, the government short of money and reluctant to finance social reforms

  21. The infrastructure 1919-39 • 3000 hospitals including voluntary,Poor Law hospitals, cottage hospitals (GPs) • Local Government Act 1929 abolished Poor Law Boards and their hospitals became municipal hospitals • 1930s world-wide depression the health status of the many extremely poor

  22. Yet! • By 1939 Britain one of most advanced countries in social provision • Most manual workers (not dependants) covered by social insurance schemes • Social services complex and growing • State elementary schools and municipal hospitals familiar landmarks • M&CW clinics and school milk

  23. Main problem fragmentation • Administrative muddle • Health care a chaotic mixture leading to recognition that system needed reform • SMA and TUs said that health services should be provided by the state • Others voluntary organisations, private insurance, support for the poor only….

  24. However the second world war would change attitudes • The Emergency Medical Service (EMS) • Wartime collectivism • 1942: The Beveridge Report • 1944: ‘A National Health Service The White Paper - Proposals in Brief’

  25. Birth of NHS • New Government 1945 • 1946 The National Health Service Act • 5 July 1948 ‘vesting day’ • NHS as a national system funded from general taxation

  26. NHS up to 1969 • Final demonstration that demand for services ever increasing • Inexorable rise in costs • Charges first introduced • GP Charter 1964

  27. NHS in the 1970s • Attempts to control public expenditure • First major reorganisation • National Health Services Act 1977 • Politicisation of health • Progressive use of SIs by SoS for Health (formerly Minister for Health)

  28. Centralisation • In the 1980s ‘the NHS became truly a nationally administered, centralised service’ (Klein)

  29. Concerns • maintaining quality and containing costs • attempts to reconcile would need radical change • problem of risk aversion in the NHS • influence of management consultancy firms (essentially accountancy firms) • Griffiths Report 1983

  30. The Maxwell criteria: Kings’ Fund quality initiative 1984 • efficacy - does it work? • effectiveness -how well does it work? • efficiency - is it the best way to do it? • equity - is it fair? • accessibility - to everyone? • acceptability - is it what they want? • appropriateness - is it what they need?

  31. Enter Alain Enthoven • “Reflections on the Management of the Health Service” on the heels of the Griffiths Report (1983) • perceptive analysis of the NHS • main recommendation that if radical structural change desired by policy makers the HMO most promising model

  32. Internal market • Reorganisation again • National Health Service and Community care Act 1990 embodied changes • Ongoing operational problems • Emphasis on ‘value for money and ‘good business practice’ • Patients’ Charter

  33. New Labour and the NHS 3 important policy papers government set out vision for reshaping service emphasising quality The New NHS - Modern – Dependable 1997 A First Class Service 1998 Quality Care and Clinical Excellence 1998

  34. Government strategy Implemented through the Health Act 1999 and delegated legislation with detailed provision in: Clinical governance: Quality in the New NHS 1999 Supporting Doctors, Protecting Patients 1999

  35. Revolution continued • contracting: opportunity to negotiate for quality standards and targets • The Patients Charter 1995 • total quality management (TQM) and benchmarking: back to Deming

  36. What is clinical governance? • “Creating an environment in which excellence in clinical care will flourish” (Scally & Donaldson BMJ 1998;317:61-5)

  37. Quality improvement • standards and guidelines (NICE, NSF) • evidence based practice • readiness to adopt new (better?) processes and procedures in practices • inter practice audit based on good, robust data collected and collated efficiently

  38. Obstacles to evidence based practice • primary care questions inadequately addressed • lack of time to reflect • access to information in timely fashion • question of patient perspective in decision making (Dowie) and resource allocation (Maynard)

  39. EBM ”…the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. This practice means integrating individual clinical experience with the best available external clinical evidence from systematic research" (Sackett et al., 1996).

  40. Clinical effectiveness ...the application of interventions which have been shown to be efficacious to appropriate patients in a timely fashion to improve patients' outcomes and value for the use of resources (Batstone G and Edwards M. Journal of Clinical Effectiveness 1996; 1: 19-21)

  41. 3 important legal aspects • Duty of quality • National Institute for Clinical Excellence (NICE) • Commission for Health Improvement (CHI)

  42. Duty of quality • Section 18 of the Health Act 1999 provides: ‘It is the duty of each HA, PCT and NHS Trust to put and keep in place arrangements for the purpose of monitoring and improving the quality of health care which is provided to individuals’. • Intention to ensure the implementation of clinical governance arrangements

  43. This ‘duty of quality’ Placed upon HAs, PCTs and NHS Trusts is new – previously no statutory duty existed. The only legal duty would have been the primary duty at common law to exercise reasonable care and skill in providing services. Interestingly breach of duty under s 18 would not give rise to civil action for damages

  44. NICE Created as a SHA under s 11 of the NHS Act 1977 by SI and responsible to SoS • NICE guidelines will be taken to set the standard and quality of care patients entitled to expect • Failure to provide recommended services will expose NHS institutions to challenge by judicial review

  45. CHI • Set up under Section 19 of the Health Act 1999 • Accountable to Parliament through the SoS and subject to the jurisdiction of the Parliamentary Ombudsman • Wide ranging remit

  46. Professional regulation Embodied in: ‘The National Health Service Reform and Health Care Professions Act 2002’.

  47. Regulation Defined as ‘sustained and focused control exercised by a public agency over activities which are valued by a community’

  48. S.3 National Health Service Act 1977 'It is the Secretary of State's duty to provide throughout England and Wales to such extent as he considers necessary to meet all reasonable requirements - hospital accommodation ... medical, dental, nursing and ambulance services [etc.]'

More Related