As we approach the end of 2015, many will be in a reflective mood. And while it may have been an eventful year for the NHS, for the Nuffield Trust it is one of particular significance: we launched our new strategy and mark 75 years since our inception.
We’ve seen all manner of changes to the health service during this period: the creation of the NHS, countless new governments, multiple restructures, and great medical and technological advancements. Here we look back at five highlights from the Nuffield Trust’s contribution to the NHS over the last three-quarters of a century.
1942: Paving the way for the regionalisation of hospitals
The pithily named Nuffield Provincial Hospitals Trust was set up in 1940 with the objective of coordinating the activities of all hospitals operating outside London. With the country embroiled in the Second World War, little academic research was being devoted to topics beyond warfare, and health care was no exception. People, including those working in the health ministries, had limited knowledge of how hospitals operated outside the capital.
It is not to exaggerate to claim that the Trust in its early days working in association with the Ministry of Health had the pre-eminent influence on the way in which hospitals are now regionalised, which was perhaps the first major step in the rationalisation of our health resources.Gordon McLachlan, Secretary of the Nuffield Provincial Hospitals Trust, 1955–86.
A comprehensive hospital service that provided care for all people within an area did not exist; instead, hospitals operated in isolation. During the war, having a more organised way of delivering health services was deemed paramount.
The first step was to survey all existing hospitals. The Trust undertook this in partnership with the health ministries in 1942. The surveys became the health sector’s ‘Domesday Book’, mapping out where hospitals outside of London were; how many beds and staff they had; and what services they had on offer.
The surveys informed the process of regionalisation of hospitals, which the 1946 NHS Act built upon.
1972: Injecting evidence into the NHS
During the early seventies, much like today, there was increasing concern about the rising cost of providing health care. In an attempt to meet demand, many providers were turning to expensive medical technology. Yet amid this period of experimentation, little was being done to hold hospitals to account over the effectiveness and value of their treatments.
From all his reflections it’s little short of astonishing that any of us get to stop off at all between the service and the funeral fires.The Guardian, 1972
In 1972, Archie Cochrane, Director of the British Medical Research Council’s Epidemiology Unit, gave a lecture entitled ‘Effectiveness and efficiency: random reflections on health services'. The lecture was based on a monograph commissioned by the Nuffield Trust, which had awarded Cochrane its 1971 Rock Carling Fellowship.
The monograph posed a radical critique of the way that ineffective and sometimes damaging treatments were being provided in medical practice with little or no evidence to prove their efficacy. He argued that this chasm of evidence in health care provision was causing inefficiencies across the system, and made a strong case for the evaluation of new and existing treatments in randomised control trials (RCTs).
The legacy left by Cochrane’s report is vast, revolutionising policy-making and the delivery of health care today. Much of this legacy, of course, has been carried forward by the Trust and our continued work in the innovative methods of health care evaluation.
1985: Introducing competition into health care provision
For the first several decades of its existence, the NHS provided very little choice for patients, or flexibility within the service. The ‘purchaser/provider’ split to which we’re accustomed today (where health authorities commission services from competing providers for local populations) was an alien concept. Rather, patients got what they were given, and with public spending tightly monitored, it looked unlikely to change.
Professor Alain Enthoven, a leading scholar in health care economics from the US, had long remarked that this system was inefficient, and rife with perverse incentives.
The NHS is caught in the grip of forces that make change exceedingly difficult to bring about, a 'gridlock' of its own... Managers have no powerful incentive to make efficiency improving changes. In fact there are many disincentives to 'rocking the boat'.Alain Enthoven, Reflections on the management of the National Health Service, 1985.
In his paper, he presented a model in which District Health Authorities would be re-cast as purchasers of services on behalf of their populations. Under this model, providers were given the freedom to buy what they considered to be the best services for their patients from wherever it could be supplied within the NHS. Managers would be freed from bureaucracy, but held to account for the overall results they achieved.
In 1989, following the report, a Conservative Government white paper proposed the introduction of a split between purchasers and providers of care. For the first time, the NHS became truly a nationally administered, centralised service. Many claim that Professor Enthoven’s paper was a significant factor in the development of the policy.
2010: Comparing the four health systems of the UK
Since political devolution in 1999, the four health systems in England, Scotland, Northern Ireland and Wales have diverged, receiving different levels of investment and pursuing different policies.
Despite hotly contested policy differences in structure, targets, competition, patient choice and the use of non-NHS providers, no one country is emerging as a consistent front-runner on health system performance.Andy McKeon, Senior Policy Fellow at the Nuffield Trust (2014)
This deviation left the UK with somewhat a natural experiment: four health systems in close proximity, varying in their approaches to health care.
The Nuffield Trust has a long history of comparing performance and policy approaches across the four UK health systems. In a report from 2010 (the only longitudinal analysis of its kind), we examined the four countries in terms of their funding, inputs and performance before and since devolution.
This research found that there have been significant improvements in the performance of the health services across all four countries, with particular progress linked to tougher sanctions and targets in Scotland. An updated study in 2014 found that, since 2010, waiting times in Wales had risen as austerity has set in.
These analyses remain among the most significant, independent studies of health care performance in the UK since devolution.
2012: Predicting the scale of the health service’s financial challenge
Since the inception of the NHS in 1948, spending on the UK NHS as a share of national income has more than doubled, with an increase of four per cent a year on average in real terms. However, in 2014/15 this period of growth ground to a halt.
The most comprehensive analysis yet published of the prospects for health funding after 2015.Health Service Journal (July 2012)
In 2012, the Nuffield Trust embarked on a project to understand the scale of the financial challenge facing the NHS and how it can best be met. Alongside our own work, we commissioned the Institute for Fiscal Studies (IFS) to consider some scenarios for spending on the NHS and social care in England and set out what this might imply for other public service spending and taxation. Alongside this research, the Trust produced A decade of austerity? The funding pressures facing the NHS from 2010/11 to 2021/22 in December 2012, which provided need modelling on the data on NHS financial pressures.
The research found that, even if health is protected from possible future cuts in public spending, it is clear that funding increases will not return to the levels experienced in the past.
Foreshadowing the current financial climate, the report concluded that public funding for health will be tight until at least the end of the decade. We found that only a long-term freeze in other public service budgets or large tax rises could enable a return to 4.0 per cent average annual growth to which the NHS had been accustomed.
These interventions have had a profound effect on health policy and health care over the last three-quarters of the century. Here's to the next 75 years.
Wilson S (2015) ‘1940 - 2015: Our contributions to health care history’. Nuffield Trust comment, 7 December 2015. https://www.nuffieldtrust.org.uk/news-item/1940-2015-our-contributions-to-health-care-history