‘Creating NHS Local’: The Relationship between English Local Government and the National Health Service

Following recent reforms of both local government and the National Health Service, there is significant emphasis in both services on improving inter‐agency collaboration, user involvement and strategic commissioning. In response, this article reviews historical debates about the relationship between local government and health care, before arguing that these two ‘partners’ need each other now more than ever. If local government is to be a ‘place‐shaper’, then it needs significant influence over local health services, while the NHS needs to learn from the best of local government if it is to gain sufficient local legitimacy to take the difficult decisions it needs to take. Against this background, the article reviews different options for future joint working, exploring various options for enacting a new relationship between local government and the NHS.     

GPs and Contracts: Bringing General Practice into Primary Care

This paper argues that the terms on which GPs entered the NHS, as self-employed contractors, have proved remarkably resistant to the managerial pressures which have come to dominate other sections of the National Health Service. However, this traditional mode of financing and organizing the delivery of a key element of the National Health Service has become increasingly incompatible with wider health policy objectives—the development of an integrated network of good-quality, equitable and well-coordinated primary and community health services which are responsive to local needs. Furthermore, primary health services have themselves come to play a crucially important role in securing other strategic changes in the wider health policy arena, such as securing and sustaining a shift in the traditional balance between hospital and community-based health services and controlling expenditure in a needs-led service. The paper argues that, notwithstanding the change of government, the 1997 NHS (Primary Care) Act and the White Paper "The New NHS" are both integral to the achievement of wider strategic health policy objectives, such as improving the quality and coherence of services, and increasing professional accountability for the financial consequences of clinical decisions. However, the greatest significance of these and other related measures is that they shift the emphasis of health policy from commissioning and purchasing by primary care to commissioning and contracting for primary care. They thereby extend the exposure of GP-based services to managerialist scrutiny and control.     

Nursing Homes in England and their Capacity to Provide Rehabilitation and Intermediate Care Services

The numbers of older people living in residential and nursing home care in the UK have risen exponentially since the early 1980s when the closure of long–stay geriatric wards and changes in social security funding of care home places led to a rapid expansion of the care home industry. While the implementation of the 1990 National Health Service (NHS) and Community Care Act shifted the responsibility for the commissioning and funding of these services to local authority social services departments, the provision of most health services (such as general practitioner care, physiotherapy and specialist nursing services) to nursing home residents remains the responsibility of community–based NHS practitioners. Recently, the attention of policy–makers in the UK has been focused on the need to improve the throughput of the acute sector. Older people who have received treatment but are not yet able to return to their own homes are to be transferred into intermediate care facilities, often by using nursing home beds, with the aim of supporting short–term rehabilitation outside of the acute sector. This paper presents evidence from a study of health service provision to older people living in nursing homes in England. It examines whether nursing homes have the capacity to fulfil the rehabilitation and intermediate care function envisaged by policy–makers. It concludes that shortfalls in the provision of NHS services to nursing homes and difficulties faced by nursing homes in paying for health services themselves may hinder the rehabilitation potential of intermediate care placements in nursing homes.     

Collaboration between Health and Local Authorities: Why is it necessary?

In contrast with current proposals, collaboration with local government was a dominant factor in the 1974 reorganisation of the NHS. Four categories of such collaboration are identified in this paper: the sharing of services; coordination of service delivery; joint planning; and joint prevention. The need for each is discussed in the context of the reorganisation debate and of subsequent events. In essence, the DHSS case for collaboration — and in particular, its emphasis on joint planning — is seen as both a cause of reorganisation and a consequence of the form which that reorganisation eventually took. Emphasis is placed upon the potential role of collaboration as a vehicle for a preventive health strategy and as an important instrument for the development and implementation of major central government policy objectives. Finally prospects for the continuing evolution of joint working are considered in relation to NHS restructuring. It is concluded that the present government's approach to the structure and management of the NHS is likely to undermine its substantive policy objectives especially in the field of community care.     

Health Authorities, Priority-setting and Resource Allocation: A Study in Decision-making in New Labour's NHS

This paper analyses the decision‐making process of health authorities under New Labour in the NHS through a study of their qualitative responses to questionnaires. We find a considerable frustration and cynicism with the government's plans for reform, with its interference at the local level with services, and an acknowledgement of the differences between health authorities’ practice and what they believe the government requires, with, often, only minimal effort being made attempting to achieve new governmental performance targets. We conclude by making suggestions for an alternative strategy less likely to antagonize local health service providers.     

Eligibility Criteria and Entitlements: Defining Need for NHS Continuing Care

The 1995 guidance HSG(95)8 "NHS Responsibilities for Meeting Continuing Health Care Needs" required health authorities to develop local policies and eligibility criteria for a range of continuing care services. The role of criteria in defining health need, and the potential effect on open-ended rights to NHS care, need to be considered in light of the prior erosion of rights associated with changes in continuing care provision. This paper examines whether the development of eligibility criteria has led to a loss of entitlements to NHS care. Analysis of empirical evidence from a study of the policies and criteria of six health authorities found that criteria for fully funded care were generally well defined and restricted access to those with very intense and specialist needs, thereby constituting a loss of rights. In contrast, the criteria for community-based services left eligibility dependent on professional discretion but often failed to clarify the relationship between individual need and levels of service provision. The research found that resource limits are likely to remain a factor in the allocation of services and this will affect the status of the criteria as potential entitlements.     

Decentring the NHS: A Case Study of Resource Allocation Decisions within a Health District

The aim of New Labour's health policy is to shift more of the balance of power and responsibility for services to the local level. But, while the government proclaims a new decentralized NHS, doubts exist about the extent to which the reality on the ground matches the tone of policy. This article reports empirical work examining the level of autonomy purchasers have over budgetary allocation. A case study analysis of purchasing within a single district was undertaken for the financial year 2001/2 which included semi‐structured interviews with key officers responsible for budget allocation. Purchasers approach a new financial year with a starting position that matches the previous year's allocation—the “baseline”, this is adjusted for inflation and, as has happened over the last few years, increased further in real terms by “growth funds” for service modernization and government initiatives. The analysis shows a clear dissonance between policy and practice; although purchasers have complete control over their “baseline budgets”, the study found that this does not “ring true” at the local level. Only about a fifth of growth funds were at the discretion of purchasers as most are taken by national priorities and pay and price inflation. Further decentralization is planned, which includes transferring more control of funds to primary care trusts by 2004, the extent to which these measures will change the perceptions of those working in the service remains to be seen—only then will the government be able to claim a truly decentred service.     

In the Eye of the Storm: Civil Servants and Managers in the UK Department of Health

In the wake of the 2008 financial crisis, the UK government faces some tough choices over public expenditure, and these choices will have important implications for both the future of health policy and the way in which health services are managed. In this article, we examine the organization and leadership of the UK Department of Health and weigh its suitability to meet such challenges. We find an organization that is culturally split between public servants and managers, highly reliant on the ability of its key personnel to bridge these divides, and extremely responsive to the political goals of government ministers. We explore the modern DH using three types of evidence. First, the history of the department shows clear political efforts to reduce civil service discretion and focus the DH on the management of the English NHS. Second, the recent organizational structures of the DH show a bifurcation between policy direction and NHS management tasks. Third, an analysis of the top ranks of the department since 2005 shows the implementation of political preferences that are consistent with managerialism but inconsistent with the perceived characteristics of traditional civil servants. The result is a department which has changed just as frequently as the health service it oversees – a department which has been moulded by successive ministers into one for the management of the NHS. Our findings raise important questions about the value and purpose of long‐term organizational knowledge in policy formulation.     

The Forgotten Anniversary? An Examination of the 1944 White Paper, “A National Health Service”

The 1944 Wartime Coalition White Paper, “A National Health Service”is unlikely to be celebrated among the spate of golden anniversaries of welfare reforms in the 1990s. However, a study of this document may be of interest for two main reasons. First, it has some parallels with the reformed National Health National Health Service of the 1990s and, second, there have been recent calls for a local government-based health service, as was envisaged in 1944. The White Paper is examined in the context of evolving plans for the NHS, and is compared with the actual shape of the NHS as introduced by the Labour Minister of Health, Aneurin Bevan, in 1948. Four themes are drawn out. First, the White Paper should not be seen as the embodiment of a political consensus. Second, a Conservative Health Service would have differed from the NHS in fundamental aspects. Third, the conceptual advantages of a local government-based health service were out-weighed by practical politics. Fourth, although the Labour Party made a difference to the shape of the NHS, that shape did not simply follow from party policy. This implies that medical pressure was successful, to some extent, in defining the limits of the new service.     

Is the Mongolian Health Sector Ready for a Sector‐Wide Approach?

Mongolia has experienced major social and economic changes since the early 1990s. Large-scale reforms have been introduced in all sectors over the last 10 years. Implementing health reforms requires a more coordinated approach and the Mongolian health sector has been exploring an option of implementing a Sector-Wide Approach (SWAp) to the health sector. This article aims to develop and apply an analytical framework for assessing the feasibility of implementing SWAp in the Mongolian health sector. Review of published and unpublished evidence at the national and international levels is undertaken and complemented by semi-structured interviews with key respondents from Mongolian Ministry of Health. A framework for assessing the feasibility of SWAp in Mongolia has been developed which comprises the key elements and stages of development of SWAp in a particular context. This framework has been then applied to assess the feasibility of implementing SWAp in the Mongolian health sector. The main SWAp elements are in place. Emerging central level capacity, increasing donor confidence and willingness to move towards sector-wide management is now becoming more evident in Mongolia. It looks like Mongolia is ready for a national level government-led SWAp with the potential to implement a fully-fledged SWAp in the health sector. The essential ground-work for starting a SWAp is in place, but further capacity strengthening is needed. A framework for implementing health SWAp in Mongolia is suggested. It is important to consider the improvement of existing government systems in future SWAp arrangements to ensure local ownership.     

Integrating Health and Social Care at the Micro Level: Health Care Professionals as Care Managers for Older People

A common problem in the provision of coordinated long‐term care is the separation of health and social care. The present government has been increasingly concerned with promoting convenient, user‐centred services and improving integration of health and social care. One arrangement that could contribute to this for some older service users is for health care staff to act as care managers, coordinating the provision of both health and social care. This paper presents the findings of a survey of arrangements in place in local authorities for health staff to work as care managers for older people. This was designed to provide details about the range and scope of care management activities undertaken by health care professionals. Key areas of enquiry included: which kinds of health care staff undertook care management and in what settings; how long the arrangements had been in place and how widely available they were; whether there was a distinction between the types of cases and care management processes undertaken by health care staff compared with their social service department counterparts; and what management and training arrangements were in place for the health care staff.     

Quacks and Clerks: Historical and Contemporary Perspectives on the Structure and Function of the British Medical Civil Service

The British government's requirement for expert medical advice from the 1850s led to the development of a medical civil service, which reached its peak in size and authority in the 1970s. By this time the Chief Medical Officer (CMO) had direct management of a staff of over 170 medically qualified civil servants, who provided expertise on the development and implementation of new medical treatments as well as on broader health protection and promotion issues. The successive Whitehall efficiency reviews from 1979 onwards culminated in 1994 in the merger of the parallel medical and civil service reporting hierarchies in the Department of Health, effectively reducing the CMO's ability to call upon the support of medical civil servants, at a time of increasing new health threats such as AIDS and MRSA. This article uses government reports to chart the rise and fall of the British medical civil service. It discusses how, in the last ten years, the British government has become more imaginative in its use of temporary specialist medical advisers (tsars) brought in from the NHS, in relaxing the formal civil service hierarchies, and quietly abandoning the statutory Standing Medical Advisory Committee (SMAC). This article suggests that when the government has failed to give adequate support to its CMOs, the medical civil service has suffered from poor morale, experienced recruitment difficulties, and the ability to respond to health crises has been compromised. It highlights the chronic lack of historical awareness in the development of health policy in Britain.     

Policy Changes in Community Mental Health: Interventions and Strategies Used in Sweden over 20 Years

The deinstitutionalization of mental health care has changed the responsibilities of involved authorities and has led to a continuous need for new treatment forms and interventions. This article describes this development in Europe, and in particular how these new conditions have been handled in Sweden over the past 20 years at the level of governmental policy‐making. Three major policy documents from 1994, 2009 and 2012 were included in this study. To increase our understanding of the policies' contents, we have used theoretical concepts concerning governance, implementation and political risk management. Although our main interest was to find out how the government handles interventions for users of the mental health care system, we found that the policy work is progressing stepwise. The first document, from the deinstitutionalization era, did not discuss interventions clearly. Instead, it was mainly concerned with both practical and economical areas of responsibility. The second document, from the post‐deinstitutionalization era, was more focused on what services should be delivered to the users, while the most recently published document to a greater extent addressed the question of how the support is supposed to be designed. The trend in European community mental health policy has been to advocate services in open forms that are integrated into the society's other care systems. This is also the case in Sweden, and continuous work is being done by the government to find strategies to support the development, and to meet the needs at both political and local levels.     

Partnership Working and Eligibility Criteria: What Can We Learn from the Implementation of Guidance on Continuing Health Care?

Current government policy places great importance both on clinical governance and on partnership working between health and social services. Separately and together, these policy emphases require greater clarity in and between organizations about who should provide what care where than has often been achieved in the past. A study of the implementation of continuing health care policies suggests that clarity about appropriate long–term health and social care provision was difficult to achieve in the 1990s quasi–markets, because there were too few financial and structural incentives for agencies to cooperate in developing and implementing precise and comprehensive eligibility criteria. This problematic interplay between financial and structural factors is being addressed by a number of government initiatives designed to stimulate joint working, although the difficulty of drawing a clear boundary between health care (free at the point of delivery) and social care (which can be means–tested) remains.     

Users as Citizens: Collective Action and the Local Governance of Welfare

Self-organization amongst users of community care services preceded the consumerist developments of the 1980s and early 1990s, but can be considered to have been "legitimized" by top-down objectives relating to "user involvement". Nevertheless, the objectives and value bases of disabled people's organizations and organizations of users (or survivors) of mental health services have not always been consistent with those of consumerism, and user groups have experienced tensions in determining the extent to which they should respond to official agendas. Drawing on theories of new social movements and of citizenship, this paper considers the developing place of user organizations within systems of local governance. It looks at the way in which groups have sought to assert the legitimacy both of experiential knowledge and of their position as citizens in the face of official responses which have constructed them as self-interested pressure groups. It draws on empirical research investigating local groups of disabled people and of mental health service users conducted in the first part of the 1990s. It discusses the significance of shared identity as a basis for collective action alongside more pragmatic motivations to influence the nature of health and social care services. In the context of appeals to "community" and "partnership" which are starting to replace the discourse of markets and contracts as the key metaphor for both policy-making and service delivery, the article considers likely future roles for groups comprising people often excluded from community.     

Older People and the Health–Social Care Boundary in the UK: Half a Century of Hidden Policy Conflict

The boundary between health and social care services has been an important focus of both social research and policy reform in many western and northern European countries. In the UK there is a history of particularly sharp divisions between the centrally funded NHS and locally run social services. A consequence for older people, especially those with less acute or "intermediate" needs, is that they may be rationed out, ignored, or treated inappropriately on either side of the boundary. This paper seeks to go beyond explanations in terms of financial, administrative and professional divisions by using now-available public records to show how the boundary between health and social care was set in stone in the immediate postwar years and resulted in a constant battle between the two services over the needs they would meet. The first part of the paper examines a largely hidden history of health and social care policy. The second part examines the new NHS Plan and the extent to which it is likely to resolve the problem of the boundary.     

COVID-19 and care homes in England: What happened and why?

In the context of very high mortality and infection rates, this article examines the policy response to COVID-19 in care homes for older people in the UK, with particular focus on England in the first 10 weeks of the pandemic. The timing and content of the policy response as well as different possible explanations for what happened are considered. Undertaking a forensic analysis of policy in regard to the overall plan, monitoring and protection as well as funding and resources, the first part lays bare the slow, late and inadequate response to the risk and reality of COVID-19 in care homes as against that in the National Health Service (NHS). A two-pronged, multidimensional explanation is offered: structural, sectoral specificities; political and socio-cultural factors. Amongst the relevant structural factors are the institutionalised separation from the health system, the complex system of provision and policy for adult social care, widespread market dependence. There is also the fact that logistical difficulties were exacerbated by years of austerity and resource cutting and a weak regulatory tradition of the care home sector. The effects of a series of political and cultural factors are also highlighted. As well as little mobilisation of the sector and low public commitment to and knowledge of social care, there is a pattern of Conservative government trying to divest the state of responsibilities in social care. This would support an interpretation in terms of policy avoidance as well as a possible political calculation by government that its policies towards the care sector and care homes would be less important and politically damaging than those for the NHS.     

The Reformed National Health Service: A Commentary

This article presents an overview of the current state of the reforms of the British NHS instigated by the NHS and Community Care Act (1990) following the White Paper Working for Patients (1989) and introduced in England and Wales in 1991 and in Scotland and Northern Ireland in 1992. The reforms were not only wide ranging—affecting virtually all aspects of health care organization and delivery—but also ongoing. Moreover, there has been little systematic evaluation of the impact of the reforms. While making reference to other aspects of the reforms this survey article concentrates on two important issues of central concern to the NHS—efficiency and equity—and highlights some of the associated research and literature.     

国家汲取能力、政策导向和中国城镇卫生保健的筹资与服务不公平

改革以后,中国政府在承担卫生保健职能方面的意愿和能力发生了变化,本文考察了这些变化对城镇卫生保健筹资和服务公平性的影响。文章着重分析了两个相关问题：在多大程度上,卫生保健的筹资具有累进性？在多大程度上,医疗服务的利用是公平的？第一节解释为什么在改革开放期间中国政府承担卫生保健的意愿与能力都有所下降,并探讨这些变化对卫生总费用的结构产生了什么样的影响。接下来的两节分别对中国城市卫生保健筹资和服务利用的不平等程度进行了实证分析。第四节进一步指出,筹资与服务方面的不平等将本来就处于弱势的社会群体置于更加不利的地位。总之,以市场为导向的卫生体制改革不但没有解决医疗费用上涨问题,反而加剧了这一问题;它因此损害了卫生保健筹资的公平性,降低了弱势人群对卫生服务的获取,增加了因病致贫的几率。     

Privileged policies versus lack of care and engagement: the lives of retired veteran cadres in a residential community of Jinan Municipal Party Committee,China

Abstract

The Retirement System for Veteran Cadres (Lixiu) is one part of China’s dual-track retirement system. According to some official policies, retired veteran cadres should enjoy a number of privileges in terms of pension, health care, use of government vehicle, housing and peculiar political rights. Based on participant observation and semi-structured interview, the study looks into the life of the population in a residential community of Jinan Municipal Party Committee, Shandong Province. By incorporating Maslow’s hierarchy of needs theory, the study finds that in China, services for retired cadres still fall short of the expectations of policy. Establishment of ‘big communities’ with the idea of ageing-in-place is suggested.