The Health Foundation is an independent charity working to improve the quality of healthcare in the UK. We are here to support people working in healthcare practice and policy to make lasting improvements to health services. We carry out research and in-depth policy analysis, fund improvement programmes in the NHS, support and develop leaders and share evidence to encourage wider change.
The Health Foundation has created Policy Navigator website as a tool to be used by policy makers and enthusiasts to learn about how our current policy landscape has developed and to learn from the past. The Navigator website seeks to build an accessible repository of health policy developments grouped by theme. The six timelines are Provider landscape, Adult Social Care & Integration, Choice & Competition, Commissioning, Public Health, the provider landscape and Regulation.
Since the creation of the NHS in 1948, the NHS has been in a constant state of reform (or more simply in a state of change) both as a response to technological and medical advances, the financial climate and as a result of central reorganisation.
To better understand the development of the NHS and the complexity involved in the provision of health care, Policy Navigator charts some of the major developments in health and social care from the emergence of the first hospitals in the eleventh century right up to the present day. In recent times, Policy Navigator primarily focuses on developments in England rather than across the devolved administrations and the focus is on domestic policy rather than international developments. Where possible we have linked to open-access, electronic sources but this has not always been possible, particularly for some of the older entries.
We will be aiming to update the website quarterly and would be really grateful for any feedback or suggestions. While there is a wealth of material, we are aware there are likely to be omissions.
A number of Health Foundation staff past and present have been involved in this project including Emma Spencelayh, Meenara Islam, Ben Blankley, Jeff Steer, Anna Howells and John Gillespie. We would like to thank other staff internally for their support with proofreading and commenting on material.
We would like to thank Geoffrey Rivett, David Walden and Alex Mold and Virginia Berridge from the Centre for History in Public Health at the London School of Hygiene and Topical Medicine for their much valued feedback and suggestions. We are extremely grateful for their support. Any errors or omissions are those of the Health Foundation.
If you are interested in further historical resources, you can find out more at Geoffrey Rivett’s comprehensive website on the history of the NHS http://www.nhshistory.net/cvrivett.htm and you can find out more about the Centre for history in public Health here http://history.lshtm.ac.uk/
We have chosen six themes to provide an overview of health policy in England since the eleventh century. The six themes are Provider landscape, Adult Social Care & Integration, Choice & Competition, Commissioning, Public Health and Regulation.
Adult Social Care & Integration
Today adult social care refers to a broad range of services and providers including residential care homes, nursing homes and supported living. Adult social care in England includes all forms of personal care and practical assistance provided for people in need aged 18 and over. This timeline charts the emergence of formal social care services and explains how we have ended up with the split between health and social care that we have today.
The concept of social care was relatively late in developing. Its origins lie in the 1601 Poor Law Act which sought to consolidate all previous legislative provisions for the relief of ‘the poor’ and the Poor Law Amendment Act of 1834 which introduced a new, more punitive approach to receiving state support.
As the 19th century progressed, there was an increasing focus on improving public health, and the state had a growing role in improving the health of the population as well as investigating concerns about poor conditions in workhouses. While health and healthcare became gradually separated from the provisions under the Poor Law, it wasn’t until 1948 that other forms of public assistance were completely detached from the Poor Laws
The decision to nationalise hospitals as part of the NHS rather than giving the administration of hospitals to local government marked the start of a perennial debate over the boundaries between NHS organisations and local authorities and the separation between health and social care services. A debate that is still very much alive today.
Commissioning is essentially the planning and purchasing of services to meet the needs of the population. One of the reasons the NHS was established was because of the gross disparity of services across the country and between different client groups. The introduction of the internal market by the Conservatives led to the separation of purchasing from provision. While the name for ‘buying services’ changes, there was a planning function for many years before ‘commissioning’ was established as a concept under the Labour government. Some services are commissioned nationally, others at a regional level and some more locally depending on the scarcity of the diseases and the highly specialised nature of the services.
The timelines show the extraordinary state of flux that purchasing or commissioning organisations have experienced over the last few decades. We have had Clinical Commissioning Groups, Primary care Trusts, Primary Care Groups and GP-fundholders (to name but a few) each with slightly different functions, sizes and geographical reach. Over the course of the next Parliament, we may find we need to add another body. If we do, the chances are, it may have been tried before.
Choice & Competition
Choice regarding healthcare providers was largely determined by financial status and social standing until the introduction of the NHS in 1948, which introduced the provision of services free at the point of use for all (with some exceptions such as prescriptions).
Competition has been a contentious issue since the founding of the NHS, and it remains so today.
Ever since it was founded in 1948, the NHS has effectively been a large monopoly, albeit with national contracts to general practices as independent providers of primary care. There was a drive to introduce competition for the provision of clinical care in the NHS from the early 1990s onwards. The NHS has made use of non-NHS providers such as general practitioners since its inception; however, it is only during the last 15 years that non-NHS providers have been able to compete directly with NHS providers to provide NHS-funded clinical services. NHS spending on non-NHS providers has increased during the current parliament.
The role of competition and by extension the role of the independent sector in delivering NHS-funded clinical services has been one of the major dividing lines during the recent election period. There is a lot of confusion over what competition and ‘privatisation’ means for the NHS. The portrayal of the debate in the media has focused on the extent to which the Health and Social Care Act 2012 has opened up the NHS to private provision, which plays into the public concern that the NHS could be eroded or that people might be required to pay for services.
The timelines chart the various developments that have led to our current approach to competition from the 1940s onwards. Unlike some policy areas that we have covered in the Navigator website, the choice and competition theme charts incremental policy change. Over the course of the next Parliament we could see something quite different.
Regulation refers to the different organisational bodies or strategies in place to regulate health care in England. Regulation of the health service has been relatively slow to develop on an institutional basis and much change and innovation occurred during the 2000s. In contrastthe origins of professional regulation in England can be found in the fifteenth century when petitions were made to King Henry V asking that only those with appropriate qualifications should be allowed to practise medicine..
Regulators that assess organisations rather than those that assess professionals have had a somewhat rocky and unstable history. During the 2000s, regulators were particularly vulnerable to change and abolition. Regulatory bodies as we know them today, such as Monitor or the Care Quality Commission (CQC) have undergone a number of modifications and changes in function. The timeline for regulation as per the commissioning timeline highlights instability and organisational change.
Providers of health care in the UK have taken many different forms since the eleventh century. The Policy Navigator Providers timeline explores the origins and development of the current provider landscape focusing predominately on the development of our hospital infrastructure. The provider landscape timeline is the one that goes back the furthest and begins when hospitals emerged following the Norman Conquest in 1066. The provider landscape has clearly changed enormously since then but the timeline explains how we have ended up with the provider network we have today. More recently, we know that NHS providers are under strain and there is a pressure to transform to new models of care that are more suited to the future needs of the population.
Public health refers to measures to prevent disease, prolong life and promote the health of populations. Our public health timeline covers the response to disease outbreaks, the introduction of public health services and campaigns, and England’s experience of environmental threats to health over time. While currently, there can be a focus on health services at the expense of population health, throughout the 19th century, it was arguably public health developments (and not developments in the provision of health services) that had some of the greatest impact on health outcomes. The timeline charts developments in sanitation and the environment, the bacteriological revolution, ‘social hygiene’ and ‘new public health’. There are however a number of overlaps between this timeline and the others that focus on the development of the provider landscape and broader developments in health care.
Given the nature of the timeline, developments are charted in chronical order and focuses quite heavily on legislation and government developments. As such, the timeline focuses more on the ‘victor’s and celebrated individuals rather than the alternative paths. We could just have alternatively chosen other drivers such as economic progress, fear of the poor and scientific developments.
This timeline gives a very high-level overview and will no doubt contain some omissions. We hope though that it will give a flavour of some of the major developments in public health and record some of the more modern policy changes that have been taken at a national level. For an easily accessible book we can recommend public health in history by Berridge et al http://tinyurl.com/opzzt5n and the Faculty of Public Health’s chronology of state medicine available online via http://www.fph.org.uk/uploads/r_chronology_of_state_medicine.pdf