location: nan, 'Thailand 
year: 2001 source: HSRI 
title: Health systems reform in England 
abstract:Health Systems Reform in EnglandHistory of NHS	In England, the health system is national Health service (NHS). In 1997, NHS had about one million employees with a budget of 45 billion pounds, making it one of the largest organizations in the world.	 Before the NHS,  health care was in the form of  fragmented services run by various organizations. There was no single main institution responsible for coordinating the services. 	In 1911 the government enacted  the law “ National Insurance Act” with the aim to serve the work force, but the provision did not cover their immediate family members.	In 1942 Sir William Beveridge gave a report which was the start of the policy of comprehensive health care for all people. Anerin Bevan, Secretary of State for Health of the Labour government, succeeded in negotiating with the doctors and brought about the law to start National Health Service in 1946.	 NHS was originated on July 5th 1948.  NHS  is the second institution next to the Monarchy that  the British people take pride in.  Anerin Bevan was the architect of it and was considered the best political achievement  by the Labour party.Problems and drives that led to health care reform	 The principle of  the NHS is free comprehensive health care at the point of use regardless of the status of the people, i.e. equity. NHS is funded by general taxation. The  problems and  drives to reform the NHS can be traced back to the beginning of NHS due to two original conflicts:The conflict between centralized and  autonomous  management of its organization structures.The conflict between the medical profession and the government. The government funds NHS and wants some control but the doctors give service and want professional autonomy without scrutiny from the government.NHS success became its own enemy in a few years of it running. When the government promised to give free delivery of care, the obvious problem was the inability to meet the financial obligations when faced with increasing health care cost and demand. There have been accusations all along that every government has not given enough funding to the NHS.The complaints had increased since Margaret Thatcher came into power in 1979, leading to the radical reform in 1990.	The British government spends less money for health system compared to that of other developed European countries, amounting to 6.6% of GDP whereas other developed European countries spend about 8-9% and the USA, 15-16%. NHS has produced comparative health outcomes to other countries; however, the British people are still not satisfied.Reform Process NHS changed very little during the 1950s and NHS drifted without clear direction until 1962 when strategic management was introduced to guide the development.In 1974, there was the first structural reform, introducing more planning and integration of the services. The reform was apparently unsuccessful. There was no genuine attempts to challenge the medical profession, which was the centre of real power in the NHS. Eventually the conflict between the doctors and management remained. There was no mechanism to get the doctor to account for their work to the management.In 1979, there was another attempt to reform NHS, leading to the second structural reform in 1982. However there were only a few changes to the organization.In 1983, the conservative government brought in successful businessmen as advisers. One of them was Sir Roy Griffith, who was asked by the government to report on the conditions and ways to improve the  efficiency of NHS. The 24-page report by Sir Roy Griffith was very powerful in bringing about huge changes in NHS. General managers were speedily introduced into NHS in 1984, commencing the era of bargaining with the medical profession.In 1988, Magaret Thatcher announced a radical reform, leading to the significant White Paper: Working for Patients, which proposed unprecedented radical reform of health system. It was followed by the National Health Service and Community Care Act 1990 to start the reform.One of Thatcher’s political ideals is that government institutions and bureaucracy are inefficient and need transformation into a more corporate and market system in order to be more efficient.Strategies of NHS reform 1990	The process of change was inevitable  because of mounting public pressures to the government. The main strategies used was managerialism . All kinds of management techniques were used such as quality assurance , performance indicators, management for excellence, etc. Market competition was instituted.	The strategies for this 1990 reform were as follows:Delegation of power and setting up of autonomous bodies such as NHS Trusts and GP fundholdingInternal market.New funding systemDecreasing the power of medical professionStrengthening primary care system by giving importance to GPs and creating GP fundholding.Essence of 1990 reform	 The essence of 1990 reform was the creation of the split between providers and purchasers of health care. Hospitals were encouraged to become autonomous by being a NHS trust, answerable directly to the Secretary of State for Health. At present all hospitals in England are autonomous NHS trusts.	GP fundholding would act as purchasers of health care on behalf of the patient. It received and could manage its own budgets and could enter into contracts with any provider the GP fundholder saw as giving the best deal.. If the money was saved from the efficient management of the budget. The fundholder could use the money left for developing the practice, which was a new power they never had before.	What bound the provider and the purchaser was a contract, leading to an internal market.	The process of decreasing the power of the doctors was done by having systems like medical audit and doctors’ accountability of their actions to the management. The doctors was no longer free to do whatever they like as it may cause purchasers not to buy the hospital services.Human Resources and Manpower DevelopmentPhilosophy of  human resourcesServices and human resources planning have to go together. The policy about human resources in NHS is still not clear in the midst of many changes that are taking place in NHS. Prior to 1970s there had been no clear direction of the services. Each health care  profession  was quite independent of one another. In 1980 the Medical Manpower Steering Group reported that planning for medical manpower was extremely difficult due to the uncertain future of the NHS.Future Medical Manpower	There were 102610 doctors in the NHS in 1996 which was 1.7 per one thousand population.. According to the Medical Workforce Standing Advisory Committee report by the Department of Health, a study on  future delivery patterns and needs for doctors, it  found that 76% of NHS doctors were British graduates. It also recommended that , under the present situations, the chance of  having a surplus of doctors was slim and there should be 1.7% annual increase of the number of doctors. The methods to achieve this aim were as follows:to recruit more overseas doctors.to maintain the number of present working doctors.To produce more doctors byincreasing the number of medical schools expanding the existing medical schoolsincreasing the new intake of medical students by 1,000 per year.Future Direction of Manpower Development	In 1998, the government  produced a document called Working Together: Securing A Quality of Workforce for the NHS, which stated that every  hospital trust and employer would have to complete the manpower planning by April 2000, including the plan for producing and developing  most health care professionals in the NHS   to have a link between the education of  manpower and the delivery of services.	 Because of inadequate data,  planning was very difficult. However King’s Fund had the following recommendation:There must be a long term  and realistic planning , taking into consideration the boundaries between health care professionals so that there may be ways to predict the number of professionals needed.There must be a concrete link between the training of health care professionals and the services requirement in the NHS. There should be emphasis on overall management of the NHS system and the cooperation between the managers and the professionals. There should be a comprehensive analysis and synthesis of data and research on human resources.Technology Control and Regulation	New technology has to be assessed strongly and continually for its cost effectiveness, efficiency , safety and use-appropriateness.	There has been increasing evidence that some technology is unnecessary and misused. Most western developed countries have  a system of intensive regulation of medical technology in four dimensions:SafetyEfficacy StatusEffectiveness in general practiceEfficiency England uses the budgets limit measure to regulate medical technology. An organization, called National Coordinating Centre for Health Technology Assessment at Winchester, is responsible for disseminating information about technology  assessment and distribution. In addition, the Royal Colleges of various medical specialties have their own registration of medical equipment and training of the use of medical technology. The Department of Health also has a committee called Standing on Health Technology Assessment to advise on the need for new technology.	However there is no central body to control expensive medical technology. Nor is there a law for such matter. Only through advice, cooperation, negotiation and peer pressure is control and regulation being done.Consumer Roles and ProtectionPhilosophy and evolution of the relation between NHS and its ConsumersThere are three models for health care system:Market Model: health care is treated as a kind of  goods which is regulated by  market mechanism of  demand and supply. Consumers have choice to choose the goods, but in reality health care does not seem to follow the market mechanism alone.Professional Model: This is based on the fact that doctors know best and should make the decision for the patientsBureaucratic Models: The state must intervene to provide health care  in order to have equality and to protect the best interest of the public.England uses the mixture of second and third models, although it seems that the first model has been in operation since the 1990 reform. In fact the public still have little choice. People have some choices regarding GP and hospital accessibility but once they are with the professional, they are hardly involved in making decision about the care.Compared to other public organizations, NHS lacks direct democratic accountability as there is no public representative  unlike local authorities, etc. NHS has indirect accountability through the House of Commons, which accounts for the public through health ministers.In 1974 Community Health Councils were set up to represent the public so that people and consumers were more involved in health care.In 1983 the Griffrith’s Report greatly affected the relationship between professionals and patients as market mechanism was introduced into the health care system. An example in the report: “ Businessmen have a keen sense of how well they are looking after their customers. Whether the NHS is meeting the needs of the patient, and the community, and can prove that it is doing so, is open to question”.In 1991 the government introduced the Patient’s Charter.Consumers ‘s Roles	There are three issues regarding the role of the consumer:1 Involvement in decision making process the careInvolvement in planning, developing, monitoring and auditing the servicesPublic Involvement	Consumer Protection is a big issue although the government is not very concerned gives little support with no new law. However the Department of Health has established the Centre for Health Information Quality.	In summary the public needs to be more involved and requires further developments.  The culture of “ doctors know best” is no longer acceptable by the people. People want information so that they can be more involved in making decisions.Ways of Public Involvement	1.Community Health Councils	2. Public Opinions	3. Quality Assurance4  Self- Help and Campaign GroupsComplaints and Compensations	There are several ways that consumers can voice their complaints and seek redress:Family Health Service Authorities would accept complaints about general practitioners, dentists, pharmacists that do not comply with the agreement.District Health Authorities have mechanism to accept and monitor complaints about hospitals and community services.In 1979, the Royal Commission on NHS criticized that the complaint pathways were too complicated and there should be a simple system that people could understand and consumers could voice their complaints.       In 1973 Davies Committee proposed a national practice guideline on how to manage complaints in the hospital as well as setting up the independent health ombudsman. The proposal had been ignored until 1985 the Hospital Complaints Act required health authorities to set up a system to deal with complaints. In addition to NHS mechanism, there are professional bodies like the General Medical Council, the United Kingdom Central Council for Nursing, to which people can submit their grievances directly. Ultimately people can go to court to seek redress and compensations.	The House Committee on Public Health is another place where people can voice their complaints on the condition that complainants would not go to court for compensations. The committee would deal with public mismanagement and would not interfere with clinical judgement.	In the past doctors had to pay premium to a Medical Defence Union to cover their malpractice insurance. However since the 1990 reform, health authorities would have to bear the malpractice compensations in case there is a legal case against doctors. There is evidence of increasing complaints against doctors through various organizations.Health Ombudsman	Health ombudsman could deal with any complaints about the NHS services except cases  that are in court. The main “ weapon” of health ombudsman  is publicity. Health ombudsman would publish two reports annually and these would be circulated to various media. The reports will  also be studied by the House Committee on Health with increasing publicity. Which in turn increase the power of health ombudsman. The House Committee could summon the Health Authorities to account for the management and the response to the complaints, which could be quite disconcerting despite the lack of legal power.Complaint Process	Previously the complaint process was quite complicated through several channels such as Family Health Services, General Medical Council, Hospital Trusts. Each channel has different mechanism. In 1996 , a new integrated complaint mechanism  was formally proposed:First Step: Local Resolution.Second Step: Independent Review. If the complainant is not satisfied, he or she can request an independent review.Third Step: Health Ombudsman. If the previous two steps have not brought satisfactory resolution, the health ombudsman could be requested for helpAnalysis	Any health care reform would deal with two issues:Funding mechanismDelivery of the care.In essence, the reform would aim at good quality of care at low cost, which is comprehensive and equitable.. The strategy often used is managerialism.The British government, in response to funding pressure, has brought about a policy: “ The health of the Nation 1992” in order to reduce sickness. The health targets set are such as reducing coronary heart disease and stroke by40%, breast cancer 25%, lung cancer 30%in men and 15% in women, suicide 15% in year 2000. Community becomes more important with emphasis given to prevention as it is more economical.The evaluation of the 1990 reform indicated that the reform did not achieve the objectives. Waiting list remained as long as before. People did not have more choices as promised by the reform. District Health Authorities had not changed their policy of purchasing care due to limited budget.The internal market had created its own problems like skimming, skimping and rationing. Skimming occurred when the purchasers would accept only healthy people because of cheaper investment and hence money was saved.Skimping happened mainly to the providers which want to save the money by not giving full treatment. It especially affected the disadvantaged patients who did not know their right or had no power to voice their complaints, undermining the original principle of NHS of equity. Medical audit and the patient’s charter would be ways to reduce skimping. Rationing was inevitable with limited resources and high demand. The main problem is how to prioritize and who will make decision about the priority. There is still no satisfactory answer to this question.The other objective of 1990 reform was to increase the satisfaction of the health care personnel. This had not happened as there was more resistance from the doctor and other health professional personnel had been demoralized be more and more changes without apparent benefits apart from more paper work.Professor Klein had summarized that this reform had brought about superficial changes in that hospital became more beautiful, furniture was new, receptionists were more polite. He questioned whether there was nay real change in how the doctor treated the patient. However this reform was a good start for people to demand accountability from the doctor, hoping that it would eventually lead to better services.NHS after 1997	When the Labour party took office in 1997, it announced a nee White Paper: The new NHS : Modern, Dependable. GP fundholding was abolished and GPs would form primary Care Groups. However it had not abolished the internal market. Emphasis was given to quality with more cooperation that competition amongst the health care units.Consumers’ Roles	Nowadays consumers have more power through increased information. There are more channels to voice their complaints and  to seek redress. That does not necessarily mean that the power of doctors is automatically reduced. Reduction of the power of doctors is to be achieved by various self regulation, quality assurance, peer reviews, etc.Manpower Training and Development	England still faces the problem of manpower planning and development because there has been no systematic planning since the start of NHS. Only for the last 20 years has there been an attempt for serious planning.. This is an important lesson for Thailand. Technology Control and Regulation	It is noticeable that England has no law to control and regulate technology, but uses the means of budget limits and technology assessment by several organizations with indirect pressure for technology control and regulation.Lessons for ThailandWhat we can learn from the reform in England is as follows:Reform is inevitable due to natural increasing pressures from the society.Reform will take place quicker if political parties are involved and law ensues.Reform will not make everything better but , to be fair, it has not worsened everything.What is interesting is why the British government, whether Conservative or Labour party, still uses general taxation as the main funding mechanism of NHS although other developed European countries use social insurance to fund health system. General taxation has served England well and it is interesting to see the effect if it were to be adopted by Thailand.There must be a systematic future planning for manpower development.There must be control and regulation of expensive technology with consideration of efficacy, effectiveness and efficiency and safety.Consumers and the public have to be more involved through independent organizations and increased information.There must be a simple mechanism for the public to voice complaints and seek redress.Recommendation:To study in detail the history of health system in Thailand.To decrease the power of medical profession and demand their accountability.To increase the power and information of consumers.To use politics and finance to direct reform justly.To raise awareness of health care reform to be a national agenda.To work together for the Health System Reform Law.To research on health economics more thoroughly.To set up an autonomous organization to work with the government for the health system reform.To put into practice what is agreed upon.