The winter of 1995-6, as every winter, saw high profile stories in the press of a seasonal NHS Bed Crisis. General Practitioners found themselves unable to find local hospitals with beds free into which to admit urgent patients. The phenomenon of patients lying on trolleys in Casualty for hours until a bed was found seemed to be spreading. Several ill patients were transferred a hundred miles or more to an available bed, only to die shortly after arrival. In particular, the press latched on to the problems of finding Paediatric Intensive Care beds. Because such stories are a recurring seasonal event, it was difficult to objectively interpret their significance. Day time TV became full of Nurses or Doctors saying that their impression was that, this year, the crisis had started earlier than usual. Several possible factors were put forward to explain the overall problem: hospitals were running with higher average bed occupancy - usually 95% or more - which meant there was no slack to take up the predictable seasonal increase in emergencies. There is a Nursing shortage, partly due to demography (fewer young people). The division of the NHS into individual, competing 'Businesses' militates against any sort of cooperation to make the best use of limited wider resources.
In May of 1997 the Conservative government was defeated in a landslide victory to the Labour Party. The manifesto on which this election had been won included affirmation that their policy on health would include abolition of GP Fundholder status, on the grounds that the two-tier system it engendered was unfair. However, they stated that they believed that the Purchaser-Provider split had been useful, especially combined with a greater input from GPs in a contracting role.
Exactly what structure the new government envisaged to replace The 1990 Changes remained unclear through the election and for some months afterwards. They recognised that a further, major upheaval would not be popular amongst healthcare workers, who had only just got used to the last changes. They were also keen to avoid accusations from the Conservatives that they were simply trying to turn back the clock.
Late in 1997 the Labour Party policy was crystallised into a new white paper for England called 'The New NHS'. Scotland, meanwhile, had always had a different system for its NHS in any case but with the imminent arrival of a devolved Scottish parliament a separate white paper (along the same lines) called 'Designed to Care' was published.
The government wishes to see six principles upheld. The NHS should be:
To achieve this, the total NHS budget will be divided among Health Authorities who in turn will pass the money to primary care groups (PCG) each made up of around 50 GPs. In time, these PCGs will be encouraged to assume complete control of all commissioning/purchasing decisions, and Health Authorities will merge to cover larger populations.
Annual contracts between purchasers and providers will be replaced with three- to five- year agreements.
The social and clinical services will be encouraged to work together, instead of using the boundary between each other to resist referrals and thereby contain costs. Measures including common budgets will be considered, and ideas are to piloted in a number of 'Health Action Zones'.
As promised, Fundholding was stopped from April 1999 and replaced entirely by PCGs. Hospital and Community Trusts continue as before, but they are strongly encouraged to devolve budgetary responsibility to clinical teams, and to involve senior professionals more in management. Contract negotiations between purchasing and providing bodies should increasingly take on the form of a dialogue between primary and secondary care clinicians rather than between managers.
A major part of the white paper is given to quality inititiatives. A number of new national bodies came into existence from April 1999:
Commission for health improvements: aka CHIMP. goverment appointed, charged with ensuring that local systems are implemented to 'monitor, assure and improve clinical quality'.
National Institute for Clinical Excellence: aka NICE. body of patient representatives, managers, economists, academics and health professionals giving 'new coherence and prominence to information about clinical and cost-effectiveness'. The aims of NICE are:
The current vision for NICE is that it will issue 10-15 evidence-based guidelines each year covering all aspects of existing medical and prescribing practice. In addition, NICE will make judgements on 30-50 healthcare interventions each year in order to pronounce on their clinical and their cost effectiveness. The judgement will grade each intervention as either (A) for clinically cost-effective use in the NHS (B) for clinical trials only (C) not for routine use.
Health Improvement Programmes: locally produced strategies for improving health and healthcare, drawn up in consultation with hospital and community trusts, patients, primary care groups etc. Must be updated annually, and GPs must ensure that the care they provide - as well as the care they purchase - fits within the overall local plan.
NHS Information Authority out of a restructuring of the old NHS Information Management Executive. The Authority will be responsible for ensuring that the new NHS IT strategy is followed, with the aim of providing an information infrastructure to support the activities and aims of, for example, NICE. The Authority will subsume bodies such as the National Casemix Office and the NHS Centre for Coding and Classification.
The timetable for implementation of 'The New NHS' was given as around 3 years.