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Your NHS Monday, 20 September, 1999, 17:36 GMT 18:36 UK
The NHS: the Conservative legacy
The Conservative Governments of 1979, 1983, 1987 and 1992 oversaw far-reaching reforms of the National Health Service (NHS) which created much controversy. Supporters claimed the reforms brought increased efficiency and effectiveness, but opponents said they undermined the founding principles of the health service.

Under Margaret Thatcher, the government encouraged people to use private medical services (The Health Service Act 1980 being the first step). However, the public remained committed to the NHS and grew concerned when waiting lists increased and wards closed.

There was also concern about the level of spending on the NHS. With an ageing population and increasing use of expensive new technology, experts said that the NHS needed above inflation increases of at least 1% a year simply to stand still.

Efficiency drive

The government, influenced by the Griffiths Report (1983), blamed inefficient management and structures within the NHS for the cash problems. The National Health Service and Community Act of 1990 was the proposed solution. It reformed both management and patient care by introducing an 'internal market'.

Health Authorities (Health Boards in Scotland) and some general practitioners became purchasers. They had finite budgets and were responsible for assessing local health care needs. The aim was that GP fundholders and Health Authorities could use their purchasing powers to choose between competing providers and so obtain the best deal for patients. Contracts could be signed with hospitals and other health service organisations in either the public or private sector.

At the same time, hospitals and other health services, such as mental health units, became providers. Hospitals were restyled as self-governing NHS Trusts, with their income depending on contracts with purchasers.

Private finance

The central aim of the reforms was to produce a more cost-effective NHS. As well as the internal market, contracting-out was introduced. This forced the NHS to put in-house services out to tender and award contracts to the lowest bidder. The Private Finance Initiative (PFI)(1992) involved private firms or consortia putting up the capital for major NHS projects. Private firms could pay for the design, construction and operation of buildings and support services. Health unions complained that PFI was privatisation by the back door.

Under John Major, the Conservatives put forward policies which they claimed would make the health service more accountable to patients. They introduced hospital performance tables, the Patient's Charter which aimed to clarify health organisations' duties towards patients (1992) and A Code of Practice on Openness in the NHS (1995). They also extended the jurisdiction of Health Service Commissioners (1996). But, at the same time, the Conservatives were blamed for reducing accountability by allowing hospitals to bypass Health Authorities.

Other structural reforms saw the eight English Regional Health Authorities abolished from April 1996 and replaced by eight regional offices of a new NHS Executive, based in Leeds. Likewise, 100 new Health Authorities (HAs) replaced the previous structure of District Health Authorities and Family Health Service Authorities, the aim being to reduce bureaucracy and improve services.

With no regional structure in Scotland, Wales and Northern Ireland, responsibility was left with health departments at national and local trust level.

Community care

The Community Health Care Reforms introduced from April 1993 changed the way society cared for the elderly, the mentally ill, the physically disabled and people with learning difficulties.

The stated aim was to release people from long-stay institutions and house them in the community where they could be more independent and have a greater say in how they lived and the services they used. But there was criticism from health and social care experts that the changes were not properly funded. They believe care in the community is more expensive than hospital care and that the extra funding has not been forthcoming.

Another Conservative reform was the abolition of free eye and dental check-ups in 1989.

However, despite the changes, the Conservatives argued that the NHS was 'safe in their hands' and that the basic principles of a universal and largely free health care service had been preserved. Their critics, however, claimed they created a two-tier health system, whereby patients of some GP fundholders got faster access to health care and where the NHS was starved of the resources it needed with the result that those who could afford to were encouraged to go private.

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