Changes in Healthcare During the Past 30 Years: Can the National Health Service in the United Kingdom Survive?

Abstract

At the turn of the century, the National Health Service (NHS) in the United Kingdom (UK) was considered one of the top public healthcare systems in the world. Not only was it comprehensive and inclusive, but it was also free at the point of delivery for the entire UK population. It was also largely available to visitors and the families of residents that lived outside the UK. During the past 30 years, the NHS has received more and more funding both in cash terms and as a percentage of the gross national product. Despite this, the general consensus is that the NHS is delivering a poor service. The current government is facing unprecedented strike action from all areas of the workforce including doctors and nurses. This editorial asks the following questions: Where has the money gone? What has caused the current crisis? Can the current NHS model survive in today's highly technological healthcare environment? Categories: Health Policy Keywords: secondary care, primary care, defensive medicine, global healthcare system, national health service Editorial The approach to this editorial is largely a personal view based on working in the National Health Service (NHS) for over 40 years and working abroad, seeing how other publicly funded healthcare systems work. The past 30 years have included time as an NHS consultant witnessing the changes on the 'shop floor' but also many years of involvement in local and regional management. The editorial marks a few of the key moments in the NHS and how these may have influenced the ability of the NHS to meet the demands of the general public. The emergence of the NHS in 1948 Three years after the end of the Second World War, the NHS started. It was a bold move that was initially resisted by many doctors who previously had run a private healthcare system. A service that would be free at the point of delivery would increase access and, therefore, demand for healthcare. Postwar , the country was heavily in debt. Where would the staff required for this come from? Training of doctors and nurses was stepped-up, but large numbers came from overseas, especially from Asia, to fill the gaps and provide a service. Most doctors were 'generalists' as the scope of medicine was very limited. The first antibiotics had just been introduced, surgery was basic, and there was no open-heart surgery. The predicted cost of starting the NHS was 176 million pounds sterling. This more than doubled in the first year. Doctors were paid on an annual contract, and the day's work was determined by the number of patients that needed to be seen. General practice (GP) or primary healthcare was the backbone of the NHS providing the majority of patient-doctor contacts and relatively few patients being referred to secondary or hospital healthcare. This continued for almost 50 years at which time healthcare options expanded steadily at an ever-increasing cost. The past 30 years As a medical student and junior doctor, one was unaware of the costs. The job was to learn medicine and become a doctor in one's chosen field. Hours of work were loosely defined. The job revolved around getting the work done and being available for your patients. There was no European Working Time Directive (EWTD), and hospital doctors worked in close-knit teams called firms. Despite the fact that most medical schools only offered approximately one month of training in GP during the five years at medical school, approximately half of the medical school intake went into GP after a few years of working as a junior doctor. Some doctors emigrated, mostly to seek overseas experience and return to the NHS. Many doctors took on secondary roles; for example, a GP might give anaesthetics once a week or run the local hospital. Anaesthetists would work across all specialties. Likewise, general medical physicians and general surgeons would cover all aspects of their specialty. Sub-specialty training was just starting. Intensive care was just starting. At first, these were ordinary wards that were converted into ICUs by taking out half the beds and putting in a secure oxygen and air supply. I remember on post-on-call ward rounds, a consultant from the firm refused to see patients that had gone to the ICU in the night, seeing 'no point as 1