The sixth decade of the NHS saw Labour in power, with every possibility of maintaining it for years to come. There was no let up in the speed with which health care was developing, and the introduction of new technologies driven by the spirit of enquiry, commercial gain, competitiveness and globalisation. Basic research, for example the early steps in nanotechnology and a demonstration that spinal nerve fibres in the rat could regrow given the right stimulation systems, supplemented rapid advance in pharmaceuticals and the technology of imaging. Patient expectations continued to rise, and media coverage of health affairs continued to increase.
Labour won at the the polls in 1997 partly on the promise that it would "save the NHS". With the exception of the NHS, almost everything nationalised in the Attlee government's (1945) sweeping extension of the role of the state had been returned to private ownership. Devoid of at the time of good ideas, unwilling then to invest much in the NHS and with a distaste for the Conservative NHS Reforms, organisational structures were changed once more. The NHS that had been in a state of almost continuous state of reform and restructuring for two decades continued this path. The massive investment of managerial effort spent on the Conservative NHS Reforms became abortive. The first Labour Secretary of State for Health, Frank Dobson, displayed all the characteristics of "old Labour". Where possible, the clock was turned back.
The NHS showed little improvement and the long-standing belief that the NHS was the best health service in the world was abandoned. The Government conceded that it was under-funded, had fallen behind other western European systems, and that rationing of health care existed. When Alan Milburn replaced Frank Dobson in 1999 small but steady increases in funding were replaced by major additions projected over many years ahead and yet more in organisation and funding systems.
Expansion of medical schools and nurse education was put in hand. Kinder things were said about the private sector and it became acceptable to look to the experience of other countries and, perhaps, use their expertise. Nobody would have predicted that it would be Labour that would seek partnership with private health care. It was refreshing to have it acknowledged that problems existed.
Globalization, the pressures of the European Community, and the digital revolution were driving change. The north/south divide seemed to be increasing, and the housing market took off once more. The need in some jobs to commit 24 hours a day 7 days a week to one's employer was a source of stress. In the countryside, crises hit agriculture (BSE, foot and mouth disease) and the provision of rural services became a major political issue. Within the urban areas our multi-ethnic society was increasingly apparent. Racially motivated riots (Oldham), protests against a global economy and violence in the streets - sometimes black on black, and even against NHS staff soured the atmosphere. The fashion for body-piercing and cropped tops changed the townscape. For the young, adventure holidays and gap years proliferated, with a rising use of recreational drugs and clubbing. Population movement was increasing. London experienced an influx from the European Union, with tens of thousands of young French people - and many other nationalities from eastern Europe, Russia and even China - finding work in the service industries and the City. Retired English traveled in the opposite direction for the quality of life in France and Spain, or week-ended near Calais. Public reaction to economic migration and asylum seekers changed the political landscape in Europe, as well as in Britain. Many came from areas with a high prevalence of AIDS, tuberculosis and hepatitis B. International terrorism and the devastation in the USA on 9/11 had ripple effects on transportation and the stock market. The revelation of institutional and financial malpractice, and threats to the pension schemes, followed.
The World Health Organization's twenty-year plan to bring ‘health care to all’ failed of achievement. Famine, flood, civil war and genocide offset the efforts of aid agencies. More than 2 billion people still had no basic sanitation. The European Region’s Health for All, equally ambitious, was also far from fulfillment. The campaign for the reduction of third world debt made only limited progress, and poverty, famine, wars and the AIDS crisis seemed to be worse day by day. Africa and Zimbabwe seemed to present insoluble problems.
Labour returned to power in 1997 after many years of Conservative administration and was re-elected in 2001. Major constitutional reform, changes to the House of Lords and devolution to a Scottish Parliament and a Welsh Assembly were soon under way. The state of public services, and the NHS had been major election issues. Labour's pledges on health, for example on waiting lists, came to haunt the party. Many groups in the NHS, including the doctors, welcomed Labour's return to power; there was much good will in evidence. The new Secretary of State for Health, Frank Dobson (1997-1999), was sincerely devoted to the NHS, but was "Old Labour". Private practice, competition and the Conservatives' internal market were high on his list of targets.
The 50th anniversary of the foundationthe NHS, on 5th July 1998, was celebrated widely. The Prime Minister delivered a powerful endorsement of the NHS. A modernisation fund for information technology, to shorten waiting lists, increase staff numbers and refurbish hospitals, was announced. A NHS web site was established for the anniversary, later replaced by a definitive site providing information on the NHS in general and local services in particular.
In July 1998, Frank Dobson announced substantial extra money for the NHS - £21 billion over three years. The weather looked set fair but as Labour began to implement its new management structure, financial clouds began to gather. New jargon clouded the issues, joined-up thinking, modernisation, clinical governance and collaboration between health and social services. People's experience of care however seemed to get worse rather than better.
Health was the biggest single issue to be handled by the devolved assemblies and the longstanding differences between NHS services in the four countries increased. Fundholding persisted until 2000 in Northern Ireland. Scotland moved, in 2001, to a substantially different management structure, abolishing the purchaser/provider split. Wales was more generous on prescription charges. The differences in funding became more apparent, in 1998 £1,038 per head in Northern Ireland, £904 in Scotland, £823 in Wales and £741 in England. Scottish spending approached the European average; English did not.
In spite of a series of cash injections and the hard work of its staff, the NHS failed to perform as Labour hoped. By its second term, in the autumn 2001, it was clear that the targets set for hospital care were not being met, and the increasing centralization of management was not the answer. A report on NHS funding by Derek Wanless repeated the strains created by technological progress, an aging population and rising patient expectations. Margaret Thatcher, in the late eighties, had insisted that the NHS could not expect greater resources without evidence that they would be used to good effect. Gordon Brown the Chancellor, made the similar statements and in the April 2002 budget taxation through National Insurance contributions was increased and a long term programme of higher levels of NHS funding was set in place.
Since the early 1990s a central aim of health policy, under both Conservatives and Labour, had been a move towards a "primary care led NHS". Primary care services treated perhaps 90% of episodes of illness and did so cheaply and universally, acting as the gatekeeper to the ever more complex and expensive hospital services. Finance had been devolved to GPs first through the fundholding scheme, and GPs had acted responsibly with the money under their control. Now Primary Care Trusts took on commissioning. Government encouraged changes in the location in which care was provided and the movement of money from secondary to primary health care. Those to whom care was being devolved, however, sometimes had neither the skills nor the desire to take on responsibilities from an overstretched hospital service, particularly if resources seemed slow to follow. Primary care, nevertheless, was changing in its nature, utilising new skills, expanding its facilities and moving towards a pattern far less dependent upon the 24 hour commitment of individual GPs, and more upon larger geographical systems.
Structurally, continual organisational change had created a structure that was as divided as the tripartite service of the first 25 years of the NHS.
| 1948-1974 | 2002 | ||
| GP Services | Executive Councils | Primary Care Trusts | |
| Community Nursing | Local Authorities | ||
| Mental Illness Services | Hospital Management Committees | Mental Health Trusts | |
| Acute Hospital Services | Hospital Management Committees | Acute NHS Trusts |
Under Alan Milburn the next Secretary of State, the pattern of the NHS was so changed that traditional descriptions of the NHS required review; c.f. Redefining the NHS (January 2002). Increasingly managed health care was introduced, and patient choice was restricted for "preferred providers" impeded patient flow. Paradoxicallyin the US managed care was found increasingly ineffective in the face of consumer refusal to accept ever increasing barriers to care.
The NHS might now be described in the following way. People received care largely free at the time of delivery, funded from central taxation, and gained access throughout the UK by
turning up at their local hospital accident and emergency department where they would be assessed by a triage nurse
booking an appointment with the GP with whom they were registered, providing acute care, care for chronic conditions and health promotion
Within primary care there would be a range of facilities including community nursing services and some specialised clinics. Each of route of access might lead into the local hospital (secondary) care system. The local hospital might be
A university-type hospital with a wide range of specialist units or
A district general hospital covering most normal requirements but part of a referral and clinical network involving hospitals with more specialised facilities
'National service frameworks', guidelines and protocols, sometimes available through a developing national electronic health library, increasingly governed the care provided. Those providing health care were increasingly subject to inspection backed by a variety of sanctions. Organisations concerned with safety and cost-effectiveness increasingly assessed new drugs and technology.
Primary and secondary care was funded and overseen by a Primary Care Trust covering the local residents. GPs and their staff were paid under contracts negotiated nationally, but susceptible to local modification. Hospitals received money under service agreements and many funds encouraging particular improvements. The Primary Care Trusts were overseen by Strategic Health Authorities with wide planning functions and at top level by a regional office of the Department of Health. Health care was not always provided by an organisation entirely within the NHS with hierarchical responsibilities to the centre.
Ethical problems abounded, particularly in the fields of genetic medicine and in vitro fertilisation. The increasingly expensive forms of treatment available made it important to involve the public as far as possible in discussions about their health service, a cause espoused by the King's Fund. People increasingly wished to be consulted on the nature of their care. They could seek information on Internet and obtain second opinions. The GMC sent doctors advice on the importance of consent, advice to patients and the ethical problems that might arise, as at times did the BMA. The extent to which the professions gave patients adequate information and obtained informed consent was raised in the context of a clinical trial of the respiratory management of premature babies in North Staffordshire. An enquiry led by a public health physician, Dr Rod Griffiths, appeared critical of health professionals and compared current standards of clinical trials with those of only ten years previously. The enquiry was itself criticized in the BMJ for when an enquiry could become a quasi-judicial exercise, impeccable standards of evidence and procedures were necessary; this appeared not to have been the case.
Attempts were made to develop general ethical principals, for example, those of the Tavistock Group.
RightsPeople have a right to health and health care BalanceCare of individual patients is central, but the health of populations is also our concern ComprehensivenessIn addition to treating illness, we have an obligation to ease suffering, minimise disability, prevent disease, and promote health CooperationHealth care succeeds only if we cooperate with those we serve, each other, and those in other sectors ImprovementImproving health care is a serious and continuing responsibility SafetyDo no harm OpennessBeing open, honest, and trustworthy is vital in health care
The media covered health issues extensively from several points of view.
became increasingly important. Even though Britain lagged the US, by the start of the decade in 1998, 6 million in the UK had access to the web at home or at work, often the younger and more affluent. Development was faster in the US than in the UK and by 2002 studies showed that roughly half of those in the States with serious illnesses such as cancer used the Internet as a source of information. Typically they used a search engine to find and check a number of sites dealing with their specific concerns, often finding networks of patients with their own problem. Internet is the most powerful way of creating a patient-led health system.
Health organisations such as the Mayo Clinic were early as in the field. So was the US Government and some states. The UK government’s attitude was initially cautious, and health web pages in the UK were initially seen more as a problem than an opportunity. By 2000, however, the NHS, the Department of Health and the British Medical Association had effective sites. One could now rely on every significant body having a web presence. Indeed sometimes the only way to find out about the role of the many new organisations in health care was to look at their web site (to which this site often links). A National Electronic Health Library was developed as a resource primarily for professionals. Journals increasingly offered on-line editions, sometimes free, and Stanford University's Hire-Wire Press hosted several hundred electronic versions of scientific journals and provided a search system.
Reputable sites often provided clear information on common conditions that proved helpful both to patients and to relatives and friends; it was often a computer-savvy person who did most of the searching. Those newly diagnosed often contacted on-line support groups and on-line helpers, knowledgeable and experienced internet users with the same condition. Some sites attempted to link only those pages or sites that had been subjected to some form of review process, difficult because by 2000 there were over 10,000 health related web sites. While there might be much rubbish on the net, that was true of most other forms of publication and users were generally discriminating. People might make direct contact with doctors via health web sites (c.f. www.drgreene.com). Some sites were commercial in slant, had an axe to grind or were off the wall. As the private sector had created most of the sites, they were not entirely altruistic. Some sought to improve the image of an institution, others had a marketing orientation. The best sites allowed searches at a detailed level even, for example, "the genetic basis of the activity of erythromycin" and increasingly patients used the net to become better informed.