The National Health Service: Structural Changes and Indemnity

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As we move into an increasingly privatised and 'marketised' health care system, it is helpful to reflect on the history of the National Health Service in order to remind ourselves of its purpose and to contemplate the impact of change.

NHS Hospital

History of the National Health Service


The key aim of the National Health Service was to provide free and equitable health care to the population in accordance with the National Health Service Act (1946) in order to raise the general health/quality of life of the poorest and most vulnerable in the community. Over time there has been a greater understanding of the impact of wider social factors on health and wellbeing. For example, research found that Barrow in Furness, a town in North West England with areas of deprivation, has the highest number of deaths from mesothelioma (an industrial disease) in the country (Clayson, 2010). Black (1980) found that there were connections between being poor and morbidity and mortality, in relation to health inequalities in cardiovascular disease. Furthermore, those from materially deprived backgrounds were identified as being more likely to suffer and die, from particular types of cancer (Department of Health, 2000). The primary risk factors that were isolated were the same as for coronary artery disease, namely – smoking, poor diet and social/material deprivation. Therefore the focus of health care has been on prevention, screening, faster diagnosis/treatment, improving the quality of services and increasing life.

Conventionally the responsibility for public funded health care in England and Wales rested with the Secretary of State for Health, supported by the Department of Health. The Department operated at regional level through Regional Health Authorities, the duty for commissioning health services at local level was with Area Health Authorities. Subsequently, they were replaced with 192 District Health Authorities following the Health Service Act, 1980 (Walshe et al., 2004). A key consequence of further restructuring in 1990 was that the National Health Service and Community Care Act (1990) introduced the ‘internal market’ and competitive tendering for services (Boyle, 2011). On a practical level these changes meant that the commissioning and delivery of services were now separated, therefore organisations became more ‘independent’. District Health Authorities were established as ‘purchasers’ of health services rather than providers. Now health authorities managed budgets, and bought in healthcare from hospitals/other organisations. General Practitioner fund holders provided General Practices with the option of taking responsibility for the purchase of limited services for patients, as well as providing primary care services (National Health Service Choices, 2012). In 2000 the District Health Authorities were superseded by Primary Care Trusts.

Recent Restructuring


Under the system introduced in April 2013 the Department of Health is no longer the headquarters of the NHS and it does not directly manage any NHS organisations. Clinical Commissioning Groups (CCGs) took over from the PCTs and there are 211 CCGs in England. All GP practices belong to a CCG (as do some other health professionals such as nurses). CCGs commission most of the health facilities in their respective communities. They can commission ‘any’ service provider that meets NHS standards and costs. These could be NHS hospitals, charities, social enterprises and private sector providers. However, they must be assured of the quality of care they commission (The structure of the NHS in England, 2013). The secretary of State for Health now has ultimate responsibility for the provision of a ‘comprehensive’ health service in England and ensuring the whole system works ‘together’ to respond to the priorities of communities and meet the needs of patients. Within the present system, the role of NHS England is to improve health outcomes and:

  • Provide national leadership for driving up the quality of care
  • Oversee the operation of clinical commissioning groups
  • Allocate resources to clinical commissioning groups
  • Commission primary care and specialist services

Indemnity


When thinking about these changes a number of questions arise. For example, when an individual suffers clinical negligence in the health service what is the position regarding indemnity? What about the private companies doing NHS work – do they have NHS indemnity? The NHS LA indemnifies all NHS bodies in England (including NHS England and the CQC), excluding primary care delivered by GPs (NHS LA, 2013). Furthermore, since 1 April 2013 it will also directly indemnify independent health care sector providers of NHS care – including private sector health care companies, social enterprises and other organisations (if they request this). In summary then it appears that if a Claimant has suffered an injury whilst receiving care from an NHS body then the facility will be indemnified by the NHS LA. It is also possible that private organisations commissioned to undertake NHS work may have such indemnity, but this would need to be clarified with the NHS LA.


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