Chronology:

Labour's Decade - 1998 - 2007

"When the NHS celebrated its 50th anniversary with much pomp, commemorative stamps, and a service in Westminster Abbey, a new Labour government was busy reversing many of the policies of its Conservative predecessor. The internal market was abolished, as was general practitioner fundholding. The NHS would indeed be modernised, but it would be on the basis of cooperation not competition.

Who then—in the euphoria of the celebrations when Frank Dobson, the secretary of state for health, could claim that "the NHS remains the envy of the world"—would have anticipated that within a couple of years policy would go into reverse gear? Who then would have predicted the emergence of a new model for the NHS based on choice, competition, payment by results, and a plurality of providers, let alone the emergence of institutions like foundation trusts?"  Rudolf Klein

Editorial, British Medical Journal, 5 July 2008  BMJ 2008;337:a549

Changes in British Society

In general the economy was sound.  The UK, like many other countries experienced terrorism, often fuelled by radical Islamic influences.  The devastation in New York 9/11, atrocities in Spain and the London Underground, and the Iraq war cast long shadows. Following the Kyoto Protocol in 1997, climate change and carbon emissions became a national and international issue affecting policies on energy and transportation and a further hesitant step forward was taken in Bali in 2007. Globalization, the pressures of the European Community, and the digital revolution were also driving change. The introduction of the Euro in 1999 fuelled the national debate on our place in Europe and a European constitution that ebbed and flowed throughout the decade. To bring Britain in line with the Community ambulances changed colour from white to an eye catching yellow. 

Population movement increased. First London and then the whole country experienced an influx from the European Union.  Early in the decade tens of thousands of young French arrived.  Even before the EC expanded eastwards many workers from Eastern Europe and especially Poland arrived, filling jobs that the indigenous population did not want and creating new businesses. Local authorities complained of the pressure on their services from a substantial increase in the local population.  Retired English travelled to France and Spain for the quality of life. Emigration from the UK increased steadily to nearly 200,000 in 2006. Public reaction to economic migration and asylum seekers changed the political landscape throughout Europe. In 2004 the Department of Health issued an emergency multilingual phrase book, covering 60 common medical questions, produced by the British Red Cross Society  translated into 36 languages. 

Some migrants came from areas with a high prevalence of AIDS, tuberculosis and hepatitis B.   While Bevan had explicitly accepted that the NHS should be available to everyone, resident or visitor, government now took the view that it was not intended to be available free of charge to those who did not live in the UK. Government repetitively proposed to tighten regulations.  Front line staff had little time or inclination to ask their patients too many questions.

["How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? For if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody. Happily, this is one of those occasions when generosity and convenience march " (In Place of Fear, Bevan, 1952)]

The World Health Organization's twenty-year plan to bring ‘health care to all’ failed.  Famine, flood, civil war and genocide offset the efforts of aid agencies.   More than 2 billion people had no basic sanitation. The European Region’s Health for All, equally ambitious, was also far from fulfilment. (Moore W. The impossible dream. Health Service Journal 2000: 6 January: 8-9.)  The campaign for the reduction of third world debt made only limited progress, and poverty, famine, wars and the AIDS crisis seemed worse day by day. 

Within England the north/south divide seemed to be increasing.  The need jobs to commit 24 hours a day 7 days a week to one's employer stressed some.  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 while pressure led to the establishment of  smoke free public places and offices. To the profit of pharmacies, a gullible public spent increasingly on ineffective "alternative" medicines, while a split in the anti-vivisection movement led to the use of violence and terror tactics. For the young, adventure holidays and gap years proliferated, with a rising use of recreational drugs and clubbing. Institutional and financial malpractice, threats to the pension schemes and banks (Northern Rock) created anxiety.

Major constitutional reform, changes to the House of Lords and devolution to a Scottish Parliament and a Welsh Assembly were soon under way; health was the biggest single issue to be handled by the devolved assemblies.  The longstanding differences between NHS services in the four countries increased.   In 1998 Labour devolved power to an elected Parliament in Scotland, an elected assembly in Wales and an elected assembly in Northern Ireland. Four different health services emerged.  In England there was an accent on improving performance and setting targets, in Scotland a professionally led integrated system based on clinical networks, in Wales, partnership between the NHS and local authorities.  Both in Scotland and Wales benefits were provided benefits that were not available in England, for example in the care for the elderly, drug availability and in prescription costs.  The differences in funding, under the Barnett formula were apparent. 

The NHS and the Labour Government

Throughout the sixth decade of the NHS Labour was in power yet the private sector was involved in NHS provision as never before.  In 1998 long waiting times for outpatient and inpatient treatment were major issues.  Ten years later this was replaced by the perception that there was poor access to the family doctor service and hospital infection was out of control. In basic research the early steps in nanotechnology, stem cell research and developments in genetic medicine were taking place and supplemented rapid advance in pharmaceuticals and the technology of imaging.  Patient expectations continued to rise and media coverage of health affairs to increase.  Each expensive new technology not only raised costs but increased demand as treatment became more effective and less traumatic.  Government faced the dilemma of reconciling national standards, for reasons of parliamentary accountability, with a perceived need to decentralise decision making.  Slowly at first, and then increasingly rapidly, Labour attempted to deal with the obvious and major defects of the NHS, too few doctors and nurses, poor buildings, and waiting lists that would be unacceptable in other major western nation. 

Total staff in England  (excluding high street dentists, pharmacists and ophthalmic practitioners) 1996 1,056,501 1997 1,058,606 1998 1,071,562 1999 1,098,348 2000 1,118,958 2001 1,167,166 2001 1,124,934 2003 1,283,901 2004 1,331,857 2005 1,336,030 2006 1,338,779 2007 1,331,109   above - source NHS Information Centre on the left - source: BMJ 2004; 328: 729 and Department of Health)

Towards a new model of NHS

In 1999 Frank Dobson told the NHS to adopt a single Logo to imply focus and a consistency of service.  It was soon hard to remember the days when this did not greet one daily.  Yet the nature of the NHS was about to change radically.

In each decade there are central concepts affecting the organisational pattern of the NHS.  In the seventies there was consensus management.  In the eighties the general management function.  Now, spurred by scandals in the financial sector and industry, good governance became a guiding principle. In 1992 the Cadbury Report had identified principles of good governance in organisations - integrity, openness and accountability.  This was taken further in the Nolan Report (1997).  These principles were absorbed into NHS management.  Trusts would be monitored and assessed on their conformity to them.

New initiatives and new policies altered the NHS substantially, as health advisors in No 10 and economists and operational research staff in the Department of Health played a substantial role in shaping policies.  Increasingly the NHS was seen as a concept - tax funded, largely free at the point of use, but provided by a variety of organisations.  No longer was it a service where provision was in the public sector, in facilities that it owned.  The service moved from a system in which providers took no risk and patients just waited until they were treated, to one where the search for efficiency spurred a new series of incentives.  To professionalism, peer review, central direction, performance reporting and accountability were added competition, commissioning (including practice based commissioning), trusts, patient choice, and payment by results.. _{Dixon J. Editorial, BMJ 2008,336; 844-5}.   Some policies (trusts and payment by results) had at least some effect for the good.  Others (e.g. practice based commissioning) were less certain in their effects.

There was bipartisan support for many policies such as NICE, an independent quality inspectorate (the Healthcare Commission), a purchaser/provider split, foundation trusts, concentration on long term illnesses, patient choice, involving primary care in commissioning, a tariff system to pay providers and a more personal service. Some stability could be expected, irrespective of the party in government.

The NHS now provided care largely free at the time of delivery, funded from central taxation, and gained access by

• contacting NHS Direct or NHS Direct Online

• going to a 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

Each of route of access might lead into the local 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 (see the Darzi report 2007). 

• as patient choice and "choose and book" systems were expanded, the hospital might be in the private sector

In addition, more specialised services would be based on other specialised hospitals that could provide skills and experience that was not normally available

Labour, as had the Conservatives before them, looked at what could be learned from managed care organisations in the USA, such as Kaiser Permanente. The NHS took notice. Characteristics of Kaiser included integration of funding with provision of service, integration of inpatient care with outpatient care and prevention, focus on minimizing hospital stays by emphasizing prevention, early and swift interventions based on agreed protocols, and highly coordinated services outside the hospital, teaching patients how to care for themselves, emphasis on skilled nursing, and the patients' ability to leave for another system if care is unsatisfactory.  Kaiser did NOT have a purchaser/provider split.

While Frank Dobson, the first of the Labour Secretaries of State, was firmly opposed to the private sector, through the decade it played an increasing role in the NHS. As the NHS moved from a services provider to a commissioning led organisation. (See speech by Patricia Hewitt, 19 September 2006), the opportunities grew. The increasing involvement was opposed by substantial parts of the Labour Party, unions, NHS management, and the medical profession, but more and more functions were affected. Payment by results (PbB), foundation trust hospitals, independent sector treatment hospitals and private sector providers opened a more sophisticated and aggressive form of the internal market than the Conservatives had tried in the 1990s. Before 2000 the NHS used the private sector largely as a pressure release valve, particularly at the end of a financial year and often at high cost to handle an immediate problem.  Now the private sector was becoming integral to all segments of the NHS.

• In primary care commercial organisations tendered to provide family practitioner services, and companies such as Boots might cooperate in the provision of space for clinics, such as smoking cessation. 
• Hospital trusts increasingly contracted out services. The private finance initiative was funding hospital building and privately managed independent treatment centres handled NHS patients.  At Lymington in the New Forest, a new consultant led community hospital with beds, run by a PCT, was managed by a private sector company, Partnership Health Group.  Patients might have a choice of a private hospital for NHS care. Conversely UCLH contracted its 15th floor to an American healthcare organisation, collecting both rent and payment for imaging and other services.
• The Department of Health opened the purchasing/commissioning of care to the private sector in 2006. A privately owned manager, under contract to the PCT, might be charged with obtaining best value for money
• The supply of equipment to the NHS, sometimes directly purchased by NHS Trusts locally, but often supplied by NHS Logistics, became the responsibility of a new NHS Business Services Authority, and the NHS Supply Chain was outsourced to DHL, which took over staff, depots and used the NHS Logo, a decision precipitating the first major strike in the NHS for 18 years.

Private patients

The UK spends less than almost any other Western country on private health care, although about 15% of its total health spending involved the private sector. The number of those in the UK with private medical insurance had remained static for several years but increased again in 1998 to 3.5 million and in 2000 to 5 million, about 12.6% of the population when those with cover through their employers were included, but subsequently started to fall.  More were insured in the south than the north, and the growth in the numbers was even larger among those paying for private treatment out of their own pocket, sometimes on fixed cost 'pay-as you go' packages provided by private hospitals.  Some 13 million people appeared to use the private sector.  Cataract removal for £2000, knee replacement for £7,000 or a heart bypass for £10,000 might be a practical proposition.  Major providers of private facilities included BMI Healthcare, BUPA and the Nuffield Hospitals.  About 850,000 operations a year were carried out in the private sector, in some 200 hospitals, two-thirds of the beds being owned by major groups. As the private sector became more involved in the provision of NHS services, there was a fall in the number of people prepared to pay out of their own pocket for private care.

Ethics and Patient participation

Ethical problems abounded, particularly in the fields of genetic medicine and in vitro fertilisation. In 2008 Parliament considered  the possibilities now opening, for example in the creation of 'rescue babies' whose stem cells could help a sibling.  People increasingly wished to be consulted on their care, and could turn to Internet.  The GMC sent doctors advice on the importance of consent and the ethical problems that might arise.  The Council stated in 2008 that doctors must be prepared to set aside their religious and other personal beliefs if these compromised the care of patients, instancing face veils worn by a  doctor if that was an obstacle to communication and trust, abortion or cremation.

Attempts were made to develop general ethical principals, for example, those of the Tavistock Group.

In a consumer society people expected more and Labour attempted to increase people's participation in their individual care and in the management of the NHS.  Community Health Councils were replaced by a Commission for Patient and Public Involvement in Health in 2003 and this was scheduled for abolition in 2008 to be replaced by a new system, LINKs.  The encouragement to join foundation trusts as members was a further approach.

^{Medicine and the media}

The media covered health issues extensively

1. Thoughtful examinations of the NHS when compared to alternative systems of health care e.g.  Panorama on 26 March and 3 June, before the election of June 2001.

2. Health care as a whole;  e.g. the Sunday Times regularly featured alternative medicine, dealing with everything from allergy to cancer. Within the professions, where evidence-based medicine was in vogue, it was recognised that much information was spurious junk medical advice. 

3. Scandals in which patients had received poor care, from individuals or from a health system more generally. Criticism of incompetent doctors, of difficulties in gaining access to health care, the restricted availability of expensive drugs and clinical procedures, and the funding of the NHS as a system, was continuous.

Internet

This was the decade in which an effective country wide NHS information system centred on clinical need, was under development. Appropriate technology was at last becoming available.  It was recognised that a complex and inefficient paper based system, attempting to share clinical information between organisations and their medical staff, would slow the improvement of the service.  The assessment of the quality of care, and contracts that required information about who had done what for whom, increased the importance of IT.  Finally, new services such as pharmacist prescribing and walk-in centres made a coherent IT system essential. An NHS Information Authority was established to manage the development of national health information systems.  It oversaw the introduction of the NHS number, new numbers for babies, payments for GPs and national screening programmes.  It was later phased out to be replaced by the NHS Connecting for Health and the Health and Social Care Information Centre (2005).

The quality of health service information, particularly patient activity information, had long been a source of concern.  From the earliest days of the NHS financial allocations depended upon its accuracy. The introduction of Hospital Activity Analysis in the 1960s and the work under the chairmanship of Edith  Körner in the 1980s were early examples of attempts to improve matters. Yet in 2002 the Audit Commission still found grounds for concern in its report Data Remember: Improving the quality of patient-based information in the NHS.  

Labour inherited a strategy for NHS IT dating back to 1992 which had taken some fundamental steps, for example a unique identity number in a standard format for every patient, and a NHS-wide data network.  However the problems that had been experienced, general practice computing being a notable exception,  reduced support for the programme.  In 1998 a white paper,  Information for Health, created new momentum and shifted the emphasis to the clinical from the administrative.  It committed the NHS to provide life-long electronic health records for everyone with round-the-clock, on-line access to patient records and information about best clinical practice for all NHS clinicians.  Computerised medical records and prescriptions, electronic referrals and hospital test results, and arrangements with community support would all become quicker and more reliable.  Using NHSnet every GPs would be connected by 2000, but though the principles were agreed to be sound, targets were missed.

A new impetus followed a  seminar in Downing Street in February 2002 attended by industry representatives, and the Wanless Report in April 2002 which criticised NHS IT as piecemeal and poorly integrated. In July 2002   Delivering 21st century IT support for the NHS was published. An unprecedented investment in IT began, which would cost some £18 billion over ten years (though early estimates were far smaller).  It was the world's largest and most ambitious health programme, creating comprehensive electronic health records compiled at the point of care, and to be made available to users in primary, secondary, tertiary and community care.

The programme's details emerged in the summer of 2002 and a National Director was appointed in October that year, Richard Granger.  Procurements stressed speed, competition and payment to contractors only if they delivered working systems. In April 2005 the programme was renamed NHS Connecting for Health. The programme was handled in a top down fashion to overcome the previous piece-meal approach. The service was organized in two parts, a national spine and five local service providers that aggregated the health service into five regional clusters. In 2004 BT was awarded the contract to provide the national infrastructure (National Application Service Providers [NASPs] ), as well as the contract to be one of four Local Service Providers (LSPs) responsible for local level services.  Three other firms won contracts to provide services in four other areas. (see map below).  LSPs were responsible for IT systems and services used locally, such as GP and trust systems. They would also make sure local applications could ‘talk to' and share information with the national systems. The programme would connect 30,000 GPs and 270 acute, community and mental health trusts.

National Application Service Provider contracts were awarded to BT for the NHS Care Records Service, Atos Origin (formerly SchlumbergerSema) for Choose and Book (The Electronic Booking Service), BT for N3 (the New National Network). BT would act as a system integrator, and BT Syntegra for new software to manage information and payments under the Quality and Outcomes Framework.  The system would involve

Increasingly health services were concerned with chronic diseases. Improving their management and the many admissions for which such diseases were responsible, became a high priority for government and led to an examination of the methods adopted by US managed care organisations. Many medical routines developed to handle acute illnesses were ill suited to chronic disease management.  Two new approaches were introduced, disease management and the chronic care model.

Disease management was provided by large companies unrelated to doctors' practices, paid by health insurers.  They use sophisticated information systems to identify patients with chronic diseases, and establish close communication with them, educating them and their families on self-care, track their progress and intervene if problems seek likely to arise.  The chronic care model, in contrast, is based within the doctors' practices, reorganised to create informed patients with self-management skills, and developing multidisciplinary teams to monitor patients at risk. (Casalino JAMA.2005; 293: 485-488.)

The pharmaceutical industry was interested in diseases requiring long term medication and in the US provided some such care.   In theory systematic, integrated evidence-based and long-term care of chronic high cost diseases such as asthma, rheumatoid arthritis and diabetes might be more effective. However, the management of specific diseases by a separate organisation risked the fragmentation of care, as patients with multiple unrelated pathology might be directed to specialised units. 

Evaluation studies were mounted in the USA and pilot projects were established, advised by the US based Evercare, in the hope that surveillance might reduce admission. Doctors and managers might agree goals, identify high risk patients, and establish intensive nurse led outreach.  Financial incentives might be introduced, for example to encourage joint working by hospital specialists and primary care. Early pilots did not, however, suggest that intensive case management of the vulnerable elderly would reduce emergency admissions substantially.