NHS ORGANISATION AND REORGANISATION

The original management structure of the NHS, which persisted from 1948 until 1974, had 14 Regional Hospital Boards and 35 Teaching Hospital Boards reporting direct to the Ministry of Health. Between them, these Hospital Boards supervised about 400 Hospital Management Committees, who in turn supervised the hospitals. Primary Care services were run by 117 Executive Councils, and Community Care by the Local Authorities.

In 1974 this was reorganised into 5 tiers of management: Area Health Authorities (AHAs), controlled by District Health Authorities (DHAs), in turn controlled by Regional Health Boards which were finally accountable to the four Departments of Health and Social Security (one each for England, Wales, Scotland and Northern Ireland) and thereby, parliament. Individual hospitals were administered by AHAs, with day-to-day running performed by Hospital Management Committees. GPs and Dentists were employed by Family Practitioner Committees, which were answerable direct to the DHSS. The hospital Consultants were employed, and had contracts held by, the Regional Health Board. Lastly, a small number of highly specialised hospitals - about 5 - became Special Health Authorities, being answerable direct to the DHSS.

Since 1948 there have been several reorganisations of the NHS, notably those in 1974 and 1989. Some of the more significant changes have been the abolition of Area Health Authorities, the introduction of general management in 1983 in response to the Griffith's Report, the GP New Contract of 1987, the introduction of the Nursing 2000 plan and The Community Care Act.

One of the most important changes centred on the algorithm for distribution of central NHS funding. Until the mid 1970s, the amount of money allotted to individual Regional Health Boards/Authorities had been calculated as 'Last Year's plus a percentage', thus perpetuating the particular carve-up of resources decided upon at the inception of the NHS, 30 years earlier. In 1976 a Resource Allocation Working Party (RAWP) was instituted, charged with the task of deciding how to reallocate the total NHS budget across the country. This resulted in a relative diversion of money away from London to the Provinces, but this was based largely on demography rather than any assessment of differences in actual local need. In 1977 a report was commissioned to study the interplay of social class on Health Needs. This led to the publication of the Black Report 'Inequalities in Health' in 1980, and ultimately to some form of social weighting being added to resource allocation calculations.

Immediately prior to the 1989 Government White Paper :'Working For Patients', the broad structure of the NHS was:

Note that each District Health Authority has an average of 9 hospitals. The typical pattern is for these hospitals to comprise:

One District General Hospital (DGH) which has full on-site diagnostic and investigative laboratory and radiology services to support an A&E department and several hundred beds. They provide a more or less common core service of all in-patient and out-patient facilities for general surgery, orthopaedics, ENT, general medicine, elderly care, paediatrics, psychiatry, obstetrics and gynaecology. Most DGHs also provide a wide but typically not quite complete range of additional speciality services such as opthalmology, urology and neurology. Patients within the geographic catchment area of a particular DGH who require a referral to a speciality not provided by the local DGH will be referred instead to a neighbouring district. Service planning for certain highly expensive services, or services where it is not sensible to train many practitioners (for example Neurosurgery) are coordinated to some degree by the Regional Health Authorities.

Any number of small outlying hospitals, usually each with less than 100 beds, and mainly catering for continuing psychiatry or long term care of the elderly and ESMI. They usually also include at least one for mental handicap. District Health Authorities covering a large (and geographically diffuse) rural population will usually also have a number of outlying 'Cottage Hospitals' which provide minor surgical and/or obstetric services and usually some out-patient services operated as branch clinics by the same consultants that inhabit the DGH.

The 'typical pattern', however is oft departed from and there may be two or even three DGHs in a given DHA and both may have an A&E service whilst only one site has Orthopaedics. These less-than-rational patterns of service planning are part of the NHS historical legacy: local opposition to closure of any hospital is usually severe.