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The concluding chapter considers the ways in which the NHS has been viewed and evaluative in previous anniversaries, noting enduring themes. The four analytical axes are then reviewed in the light of evidence presented in this edited collection. Finally, a summative assessment of the NHS is offered which points to issues that the NHS will face in the future.
This chapter discusses the health policies of the United Kingdom’s devolved nations. These are placed in their historical and contemporary contexts, with due attention paid to the respective particularities of Wales, Scotland and Northern Ireland alongside an acknowledgement of commonalities within the UK as a whole. Even before the crucial decade of the 1990s, administrative devolution allowed for divergence in health policy, especially in Scotland. Political devolution, in principle at least, reinforced this trend, and a further component of the chapter is an attempt to explain why this should be so, and what this might mean for all the constituent parts of the UK.
Although NHS anniversaries have been widely celebrated, adult social care has tended not to receive the same attention. As a result, the history of adult social care is largely overlooked – and even people working in adult social care may know little about the origins and evolution of their current services and roles. Using the four analytical axes set out in the introduction to this book, we explore the different forms of governance (hierarchies, markets and networks) which co-exist within adult social care; the mixed economy of care; relationships between the centre and localities; and relationships between the state and professionals (including the position of the bulk of the workforce, who might not meet standard definitions of a ‘profession’). In each case, adult social care is very different to the NHS, making attempts to integrate care – while laudable – extremely difficult to achieve in practice.
As the NHS marks its 50th anniversary, questions about the financial sustainability of a tax-funded, free at the point of use service are being raised once more. The pressures on the health service are intense. Spending increased to deal with the COVID-19 pandemic, following a decade of historically low funding growth. The decade of austerity left the NHS with limited capacity to manage the health shock. COVID-19 exposed and magnified the risks associated with prioritising short-term efficiency and cost control over resilience. Over the next decade building a resilient health service which is able to both reduce the care backlog and respond to a rapidly ageing population with rising health need will require funding to increase by more than inflation and GDP. But the NHS can’t go it alone, it needs to be part of a health eco-system that includes better funded public health and social care services. This raises profound questions about the size of the state and levels of taxation.
The NHS has often been seen as a ‘sickness’ service, not least because most determinants of health lie outside healthcare. Yet, the NHS has sought, over its 75 years, to address health inequalities, often through resource allocation and access to services. The analytical axes and evaluative perspectives (from Chapter 1) are then applied to the ways in which the NHS has address health inequalities.
In its 75th anniversary year, this book examines the history, evolution and future of the NHS.
With contributions from leading researchers and experts across a range of fields, such as finance, health policy, primary and secondary care, quality and patient safety, health inequalities and patient and public involvement, it explores the history of the NHS drawing on narrative, evaluative and analytical approaches.
The book frames its analysis around the four key axes from which the NHS has evolved: governance, centralisation and decentralisation, public and private, and professional and managerial.
It will address the salient factors which shape the direction and pace of change in the NHS. As such, the book provides a long-term critical review of the NHS and key themes in health policy.
This introductory chapter outlines the key analytical dimensions which frame this edited collection. The NHS has been analysed in various ways through its 75 years. We do so through four analytical axes and evaluative perspectives. We assess the NHS in terms of four axes: governance (markets, hierarchies and networks), public/private, central/local, and professional/state. The policy ‘success’ of the NHS is also considered through temporal, intrinsic and extrinsic measures.
Since the inception of the NHS, general practice services have been delivered by GPs working as independent contractors rather than employees. As the NHS reaches its 75th birthday, services are under huge strain, and policy solutions have focused upon augmenting services with new technologies and new types of staff, as well as longer opening hours. Access to care is a particular problem, and in this chapter we consider these contemporary policy solutions through the lens of access as a ‘human fit’ between services and the population served. We argue that this lens allows us to see past technocratic questions as to whether more appointments have been delivered or timely access achieved, to ask more fundamental questions about what general practice is for, and how should it be conceptualised in planning for the future. We argue that making general practice fit for the next 75 years requires a renewed focus on generalist and holistic care.
This chapter explores OECD data to comparatively locate the NHS in relation to a range of key measures in terms of its position today, its position before the COVID-19 pandemic, and then at two other time points. It concludes that the NHS rates comparatively strongly on equity, but that its services are under severe pressure both because of the pandemic, but also because of the wider societal context of social inequality within which it has to function – a context which has grown worse over the last decade. In order to understand and address the difficulties facing the NHS, we have to look wider than health services, and begin to address these wider societal challenges.
NHS governance is often presented as a story of markets and hierarchies or centralisation and decentralisation. This chapter argues that it is a history of steadily increasing claims to authority over the practise of healthcare, as seen in the incessant deployment of tools that might look like anything from data gathering to competition but that steadily allocate a greater formal role to the centre in planning care and its delivery.
