Developing Health and Social Care under the Reforms of Tony Blair and Clement Attlee, Prime Ministers of Great Britain and Northern Ireland
Graham, Iain, Journal of Allied Health
THE FOLLOWING ARTICLE, "Developing Health and Social Care under the Reforms of Tony Blair and Clement Attlee, Prime Ministers of Great Britain and Northern Ireland," hy lain Graham, is the inaugural offering of a new feature for the Journal entitled intemational Perspectives. Our partner in this first effort is the Consortium of Institutes of Higher Education in Health and Rehabilitation in Europe (COHERE), which has its headquarters in Gent, Belgium. Including institution memhers from 14 European countries, COHERE has as its statement of philosophy: The "development of quality of higher education for the health care professions will be enhanced hy international cooperation . . . including the addition of an international/European dimension to the educational activities of its members." COHERE also includes its multidisciplinary makeup as one of its major strengths, and members believe that education of the new generation of health care professionals must be interdisciplinary and international. Some of the goals that member institutions of higher education espouse include reinforcement of respective curricula, mutual recognition of educational programs, student and staff mobility among member countries, common standards for quality education, joint development and dissemination of new programs, and cooperation in educational innovation and research.
We live in an era of globalization, and the health care domain is no exception to this trend. Graduates from health profession programs, in the United States and across the world, will be challenged to provide health care services to a growing diverse, international population at home and abroad. Health care practitioners in the United States will need to begin to understand and evaluate international models of service delivery and plan for universal standards of care. Integration of an international perspective in the Journal of Allied Health is a beginning acknowledgment that we in the United States are part of a larger world of health care. Our challenge is not just to practice in an interdisciplinary manner, but to practice as part of an international community.
LAURIE SHERWEN, PhD
School of Health Professions
New Ybrb, New york
In July 1948, the British National Health Service (NHS) was introduced by then Prime Minister Clement Attlee with the aim of offering "free" medical treatment for the entire British population from cradle to grave. Since then, the British public have come to see the NHS and its free health care as a fundamental human right and a corner' stone to their democracy, and subsequent governments have been understandably reluctant to change or reform this popular program. Yet, funding issues, as well as societal changes and technological advances, are threatening the way the NHS performs. While the NHS was intended to be a flexible and responsive service, its restrictive practice culture and attitudes of staff, organizational flaws, and funding issues often work against patients' interests and government ideas of health policy. This paper outlines how the Blair Government has attempted to alter health and social care within the UK and to fundamentally change how the NHS works, with particular effect on its staff. J Allied Health. 2004; 33:42-46.
DURING SUMMER 2003, the British press dedicated many inches of news column to comparing the Prime Ministership of Tony Blair with that of another reformist, Clement Attlee, who had been elected as head of a Labour government at the end of World War II. Understanding the position taken by these Prime Ministers with regard to health care is central to understanding health care within the hearts and minds of the British people and how the values and beliefs of these Prime Ministers were influenced.
The British National Health Service (NHS) plays a crucial role, not only in delivering a health service, but also in representing a fundamental aspect of freedom for the British people. The various pressures facing the NHS are set to increase in the future, however, challenging this notion. Societal changes and technologic advances are threatening the way the NHS performs. What both Labour governments wanted in their management of the NHS was to create a flexible and responsive service, which is harnessed to sustainability and meeting the challenges. Restrictive practice culture and attitudes of staff, organizational flaws and funding issues often work against patients' and users' interests and the ideas of government health policy, however.
Both Prime Ministers set about reforming the structures and systems of care delivery, while realizing that tackling functions of the health care workforce would present difficult obstacles. Changes must be accomplished without belittling the commitment and sacrifices made by NHS staff every day of their working lives-a challenging dilemma. It is perhaps because of this dilemma that government reform between the stewardship of Mr. Attlee and Mr. Blair has focused on structural reform above all other, hoping perhaps that culture and attitude somehow would fall into the correct place. Such changes have to be achieved and managed if reform is to be successful.1
The Institute of Medicine2 established some aims for a 21st-century health care system. It proposed the following characteristics:
* Patient centered
For both Prime Ministers, achieving such aims would depend on managing and developing staff and ensuring fiscal and other management system efficiency. Perhaps hindsight will accord both Prime Ministers with the analysis that their respective reforms moved the health care system toward these characteristics.
The National Health Service
In July 1945, the Labour Party was elected to power, defeating Sir Winston Ghurchill's Conservative Party with an absolute and overwhelming majority for the first time in United Kingdom history. On his appointment as the new Prime Minister, Clement Attlee said, "We are facing a new era. Labour can deliver the goods." The new government was elected on Labour's "Let us Face the Future" platform. The program of public ownership and social reform was the most detailed ever presented by any political party in the United Kingdom. In 1997, Tony Blair's New Labour Party was duly elected after 17 years of Conservative governments. Similar to Attlee, Blair led a party to victory that shook the political establishment, with the electorate voting overwhelmingly against the Conservatives. Many once "true blue" English shire counties and suburban constituencies turned "red" with both elections. As with the Attlee win in 1945, Blair's victory, promising reform and modernization, caused the loss from the House of Commons of many Conservatives of cabinet rank. One notable difference between the two victories was that the Celtic parts of Great Britain, Scotland and Wales, did not return a Conservative member to the House of Commons in Blair's victory.
Similar to Attlee, Blair has set about fundamentally reforming and modernizing British society. Attlee's government brought about public ownership of all public services and utilities. Building on Margaret Thatcher's Conservative government reforms, Blair's government has begun to redesign these systems radically and, some would argue, replace the reforms brought in by Attlee 50 years ago.
These snippets of information give only a shallow reflection of what is occurring in the United Kingdom today. The British newspapers have noted the similarities and the differences between the Attlee and Blair governments. The provision of health and social care to the British people was a major feature of both Prime Ministers' manifestos. Both took directions that caused major review and alteration of the system of health and social care provision and delivery. Both are men of their time, answering the demands placed on them by their time; both followed risk in their attempts to change systems. This article describes how the Blair government has attempted to alter health and social care within the United Kingdom and fundamentally change how the NHS works, with particular effect on its staff. A fuller account of change can be found in the references.
In july 1948, the NHS, regarded as the most sweeping reform of the Attlee government, was introduced. The aim of the service was to offer "free" medical treatment for the entire population from the cradle to the grave. It was introduced with great opposition from the medical profession, but saw a British public eager and willing to support it. Since that time, the NHS has become a sacred cow, with politicians unsure and frightened to change or reform it. Successive British governments have dabbled with it since its conception in 1948, including Margaret Thatcher. None have initiated a process of change in the manner Blair's government has proposed in the NHS Plan.
The review of England's health and social care services is to lead to a primary care-led, patient-centered care system. New ideas and services such as nurse practitioners, mental health primary care workers, and NHS direct and walk-in centers are to revolutionize health and social care making it a truly 24-hour, 7-day-a-week reality.3
Redefinition of what it is to be a practitioner, manager, or academic is within the plan, with the expectation that all roles will revolve around the patient/client and that the use of research will be fundamental to the execution of good care. Holistic care will be ensured by the use of National Service Frameworks and health improvement plans that will aim to converge good care and heighten responsiveness. These frameworks for governing practice will contribute to new curriculum and lifelong learning requirements among practitioners. The focus of the reforms, be they within professional education or practice, will be on quality for staff and client groups. These reforms anticipate adapting the NHS to become a knowledge-based community with education and learning at the center of it. The nature of professional work will change as a consequence.
This reform is a major undertaking. Currently nearly 1 million people work for the NHS. It costs £5 million/hr to run,4 and £2 billion is spent annually supporting staff development and training. To achieve service change and reform, the NHS workforce has been challenged by the Blair agenda to review its work practices and activity to ensure that patients are delivered the best, most cost-effective care possible. The NHS workforce needs to be transformed to provide the sort of care that will be needed in the future. The emphasis for the workforce is on the following:^
* Teamwork across professional boundaries and organizational structures
* Flexibility to make use of the range of skills and knowledge that staff have
* Streamlining workforce planning and development that stems from the needs of patients not professionals
* Maximizing the contribution of all staff to patient care, and removing barriers that say only physicians and nurses or Assistant House Physicians can provide particular types of care
* Modernizing education and training to ensure that staff are equipped with the skills they need to work in a complex, changing NHS
* Developing new, more flexible careers for staff of all professions
* Expanding the workforce to meet future demands
On reading the Plan in its entirety, it can be concluded that the Blair reforms are in reality about curtailing the growth of, or even cutting back on, spending on health care, while maintaining coverage and quality of service. These same themes appear in the Beveridge Report on Social Insurance and Allied Services,6 which introduced the National Health Act in 1948. Baly7 suggested that the introduction of the NHS by Attlee was not a revolution, but a pragmatic fusion of the health services as they had evolved by 1946. What was dramatic and even reactionary was that they became fixed by legislation at the point they had developed so far. The state accepted fuller responsibility for social welfare, ensuring it would determine policy rather than merely fill the gaps left by private enterprise and charity. The people of the United Kingdom would have health and care as a fundamental right. This right could be guaranteed only if financing was secure and put into the hands of government. What is not highlighted during the reforms of 1948, however, was the reality of an expected plurality of funding for health and care by the Beveridge report. His was a liberal rather than a socialist measure. Beveridge believed health care could not be totally financed by general taxation and believed there would be ample opportunity for personal thrift, private insurance, and voluntary services to be expanded to provide a complementary system of financing. Such a financing scheme would lead to good accountancy of costs and wide provision of service. The Blair reforms could be acknowledging a reality first understood by Beveridge in 1946,6 but due to the circumstances and views of the time, Attlee could not countenance when the NHS Act received royal assent in 1948 that health care would be met by general taxation.
Over the last 50 years, the NHS has changed its organizational structures and the range of processes deployed within them as it has tried to adjust to various pressures to achieve its overriding aim and curtail costs. Yet, despite any compelling economic imperative to limit funding, it rarely has been possible for any government to curb spending for more than 1 or 2 years in succession.8
If the NHS is to continue to command public and professional support in the future, it will have to respond to these pressures. According to Blair, this response will require some fundamental changes in the way the NHS operateshence the NHS Plan. In many respects, Blair is reacting to public opinion in the manner that Attlee did so many years before. Both Prime Ministers had to initiate change in the way health care was organized and delivered. Both had to face their critics and the reactions of the opposition.
In many respects, Blair and Attlee faced similar key tasks for health care reform. The context is different, and the expectations of the public and notions of rights and responsibilities have changed. Both Prime Ministers faced circumstances of change brought about because of major societal change or economic crises. Both launched health policies aimed at raising finance to provide a comprehensive service, yet at the same time control costs. Both introduced measures to review and reform systems of care delivery to try to ensure a locally responsive service to manage demand and ensure access to services.9-15
As we move further into the 21st century, the NHS must attempt to anticipate and adapt to various changes as best it can. With regard to the internal environment, change is occurring, albeit slowly and with difficulty. Analysis of much historical material and the various government white papers on health and social care reveals key themes that still need to be resolved. The following points denote some of the concerns that reformists have to deal with:16,17
* The balance of professional interests and service development
* The balance of decision making between local and national levels
* The balance between public involvement and the wider political agenda for health and social care
Attlee introduced the NHS to the British public as part of a scheme of introducing new social structures within a landscape of change after World War II. To a large extent, these social reforms, from education to health and welfare benefits, were interdependent. It was envisaged that legislation would be comprehensive and sufficient enough to lay the five giants of squalor, ignorance, want, disease, and idleness to rest and stop destitution.
This new architecture would provide the British people with a system of health care delivery among other systems to ensure well-being and other human rights could be realized. No sooner had it been adopted and initiated was it realized that the estimates to run the service were rising, and the whole subject of health care became political dynamite. Already Dr. Echen was pointing out what has become a perennial issue in health care: that future health needs are always an uncharted sea, but administrators often rationalized the possible into the desirable.18
In contrast to Attlee, Blair faces a far more literate and numerate population. Modern media leads debate and helps form public opinion in a manner Attlee never had to think about. Within the general scene, health care costs are rising throughout the world. Baker9 suggests that the United Kingdom is good at balancing the books mainly due to the fact that the NHS is a monopoly Governmentfunded system. No other system has come as close to financial balance during the last 2 decades. The problem for the United Kingdom is that all the growth in health care expenditure is borne by the government through general taxation. In contrast to Attlee, for Blair and his successors, consideration will need to be given to whether an alternative funding system, or systems, needs to be adopted, as Beveridge first suggested in 1946.6
Ever since Prime Minister Lloyd George introduced National Insurance Welfare for working men in 1906, the British government's primary interest in health has been to ensure a healthy population. The role of the professionals is keen within this scenario, particularly that of medicine. The intention of the NHS Act of 1948 was to bring patients and practitioners together. Change within the internal environment of the NHS requires imposition of change on the behaviors of the practitioners-hence the NHS Plan. Attlee never had to worry about the roles and the work practitioners undertook. The central implication of the NHS Plan is that practitioners will have to accept explicitly what in effect they always accepted implicitly-a responsibility for service delivery and development. Such a role would have to extend beyond the clinical care of individual patients to planning whole systems of care, having budgetary responsibility for them, and being called to account for the clinical quality of care offered.19
Overall, it is clear that Blair will have to engage with the health care practitioners to deliver the government's aspirations and agenda. In other words the practitioners may have to accept that government may define their role and responsibility. Certainly the government is in a paradox here. They need strong and capable health care practitioners, but also require those same practitioners to respond to their bidding.
In reading the NHS Plan, as in reading the Beveridge Report of 1946, there is much to admire and praise. Blair's reforms encourage partnership and cocreated health policy, integrated services and public health leadership, establishment of national standards of care and an increasing reliance on evidence for practice. Similar to Attlee, however, before him, Blair faces obstacles of policy implementation, if not policy clarification. Both Prime Ministers knew what to present to the British public within their time and context; what they could not ensure was the implementation of their respective policies in a way that would guarantee that the daily personal strains and stresses of the NHS workforce would be addressed. For this to occur, Blair and his successors will have to ensure further change is backed by the provision, of the necessary means of achievement for the workforce to change and develop. The Institute of Medicine's2 key target areas, which signal the characteristics of a 21st century health care system, continue to steer the Blair reforms.
In contrast to Attlee, Blair has to work on a greater stage to achieve such an aim, wherein lie many uncharted seas of health care reform and provision. According to Harrison and Dixon,18 there are six problem areas not faced in the NHS Plan:
* The wider environment
* Service configuration
* Demand management
* Organizational and contractual frameworks
* Relationships with the service
* Developing staff
Each of these problems portrays areas of complexity and potential difficulty to be addressed. Both Prime Ministers were purposeful in their vision to provide the British people with a health service based on need, not ability, to pay. Achieving this presents many problems, however. Both Prime Ministers attempted to capture their goals of health care in legislative systems, processes, and structures. The onward advances of medical technologies and knowledge development, together with designing new systems of care delivery to execute these advances, remain weak, however. The reforms of 1948 and 2003 have been instigated with little factual information as to what is possible. The NHS is said to be data rich but information poor. We do not know why users seek access to professionals or why they do not or why hospital provision remains central to service organization of health care when it is only part of what is required.20 These and many other questions need to be answered if health care is to be reformed to everyone's satisfaction.
Health care service represents perhaps the embodiment of the essence of being a human being. Attlee saw free health care as a fundamental human right. As such, it should be protected and nurtured, and reforming it requires detailed debate and discussion. For the British, the NHS represents a cornerstone to their democracy, and they are conservative about it and trust it always to be there. For a government trying to manage and develop it, other considerations come into play. How can value for money and sustainability be assured? Therein lies the tension, but also the creativity for change. For the NHS to move into the 21st century, old relationships and attitudes must change. To achieve what the government seeks to achieve, it not only has to change the architecture and landscape of health care, but also it has to change the hearts and minds of its workers and users. The British people need to accept responsibility for this change as well as demanding health care as a right.
*The health system reforms now discussed relate to England only. Wales, Scotland, and Northern Ireland have separate agendas.
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lain Graham, PhD, MEd, MSc, BSc, RN
Dr. Graham is Joint Head, Institute of Health and Community Sttidies, Bournemouth University, Bournemouth, Dorset, United Kingdom.
Accepted November 10, 2003.
Address correspondence and reprint requests to Dr. lain Graham, Joint Head, Institute of Health and Community Studies, Bournemouth University, Royal London House, 4th floor, Christchurch Road, Bournemouth, Dorset BH1 3LT, UK; telephone 44-01-202-504-114; fax44-01-202-504-131; e-mail: firstname.lastname@example.org.…
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Publication information: Article title: Developing Health and Social Care under the Reforms of Tony Blair and Clement Attlee, Prime Ministers of Great Britain and Northern Ireland. Contributors: Graham, Iain - Author. Journal title: Journal of Allied Health. Volume: 33. Issue: 1 Publication date: Spring 2004. Page number: 42+. © Association of Schools of Allied Health Professions Winter 2008. Provided by ProQuest LLC. All Rights Reserved.
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