Reform of the National Health Service
From 1974 to 2006 the NHS was in an almost continuous state of what some call redisorganisation. All the reorganisations have had as their objectives:
- design around the patient
- devolved responsibility
- clinical leadership
- better integrated care
- better quality of care
- less bureaucracy/management/costs
Sadly there is very little evidence that structural change produced any of these benefits, although it was seldom left in place long enough for anyone to be able to tell. Alan Maynard, Sir Iain Chalmers and others have produced A surrealistic mega-analysis of redisorganization theories. Furthermore there is extensive evidence that restructuring has quite prolonged negative effects, most of which are underestimated because they are difficult to measure. By 2006 the Labour Party had reached the conclusion that reorganisation was not helpful, but our new government wants to learn this lesson for itself.
There is rather more academic analysis of History and public-management reform by Tony Cutler and in the triumph of hope over experience by Nigel Edwards
Department of Health Health Reform. Health Reform Evaluation Programme
A Short and Partial History of Reform of the NHS in England
DO THE NHS REFORMS MAKE SENSE? Julian Le Grand 2006
The Department of Health and the Civil Service: from Whitehall to Department of Delivery to where? Scott Greer and Holly Jarman
Ten years of health reform: from market, to plan, to market again? Kieran Walshe
Inspiration, Ideology, Evidence and the National Health Service David Hands 2010
The chronological table below is confined to reforms which actually happened and the documents which they relate to directly. It only attempts to include matters relating to health care. If you want more on public health see A Chronology of State Medicine, Public Health, Welfare and Related Services in Britain: 1066 - 1999. Reports calling for, analysing, or opposing change may be found on our history page. Dates of events are approximate - change takes time and it is often difficult to decide which date is most appropriate, especially as it is sometimes unclear when a change which was announced actually came into effect. This table does not include anything said to be in the nature of a pilot project or an experiment.
Year |
Events |
Legislation and documentation |
| 2012 | ||
| 2011 | Publication of the Health and Social Care Bill. Reorganisation of PCTs into clusters and Strategic Health Authorities grouped into sub-national organisations. The word "region" is officially proscribed. Bonfire of quangos. | |
| 2010 | Coalition government promises they will stop the top-down reorganisations of the NHS that have got in the way of patient care. They then proceed to plan the biggest top-down reorganisation the NHS has ever seen. | Equity and excellence: liberating the NHS |
| 2009 | NHS complaints system reformed again. Healthcare Commission replaced by Care Quality Commission. PCTs separate themselves into commissioning and providing arms. | |
| 2008 | Alan Johnson commits himself to avoiding structural reorganisation - but turns his attention to Primary Care, which escaped most of the previous reorganisations. Patient Forums replaced by Local Involvement Networks. | Our NHS Our Future |
| 2007 | The first year since 1993 when major reform was not proposed or implemented - though it was the year when many earlier reforms began to bite. | |
| 2006 | Department of Health - Payment by Results National tariff 2006/07 Strategic Health Authorities reduced from 28 to 9 PCTs reduced to 151 |
|
| 2005 | Modernisation Agency replaced by NHS Institute for Improvement and Innovation. Department of Health - Treatment Centres Department of Health - Direct Payments |
A Patient-led NHS Healthcare reform in England, Update and next steps. |
| 2004 | Patients Forums Commission for Healthcare Audit and Inspection First wave Foundation Trusts established |
NHS Improvement Plan. |
| 2003 | Monitor established Community Health Councils abolished NHS Modernisation Agency Regional Directorates of Health and Social Care abolished |
Building on the Best; Choice, Responsiveness and Equity in the NHS |
| 2002 | Abolition of NHS regional offices Reorganisation of health authorities, from 96 to 28 strategic health authorities in England, Patient advisory and liaison services Commission for Patient and Public Involvement in Health established |
Wanless report: Securing Our Future Health: Taking a Long-Term View National Health Service Reform and Health Care Professions Act Delivering the NHS Plan |
| 2001 | Regional Directorates of Health and Social Care (4) |
|
| 2000 | Abolition of the NHS Executive Primary Care Trusts (first wave) - eventually to reach 300 National Service Frameworks Food Standards Agency |
The NHS Plan |
| 1999 | Primary Care Groups (481) Clinical Standards Board for Scotland National Institute for Clinical Excellence Commission for Health Improvement Walk-in NHS Centres National framework for mental health services Devolution of power to Scotland and Wales |
Saving Lives: Our Healthier Nation |
| 1998 | Abolition of GP fundholding |
Scotland Act Government of Wales Act Information for Health. An Information Strategy for the Modern NHS. 1998- 2005 A First Class Service: Quality in the New NHS Modernising Social Services |
| 1997 | The new NHS - Modern, Dependable National Health Service (Private Finance) Act Designed to Care. Renewing the National Health Service in Scotland |
|
| 1996 | Community Fundholding
Reorganization of regional health authorities to reduce numbers from 14 to 8 regions. Abolition of FHSAs and incorporation of their responsibilities into those of health authorities |
Choice and opportunity Health Service Commissioners (Amendment) Act Community Care (Direct Payments) Act The National Health Service: A Service with Ambitions Primary Care: Delivering the Future |
| 1995 | Health Authorities Act A Policy Framework for Commissioning Cancer Services |
|
| 1994 | NHS Management Executive moved to Leeds |
Developing NHS Purchasing and GP Fundholding: Towards a Primary Care Led NHS |
| 1993 | Calman report: Hospital doctors' training for the future: | |
| 1992 | (UK) Cochrane Centre opened | Tomlinson report on London hospitals |
| 1991 | Establishment of 57 NHS Trusts (more in waves over 5 years), eventually 270, with boards of executive and non-executive directors Reconfiguration of district health authorities as health authorities GP Fundholding - 306 practices Patients Charter Abolition of family practitioner committees: establishment of family health services authorities Purchaser/provider split |
Junior Doctors, the New Deal. Working Arrangements for Hospital Doctors and Dentists in Training |
| 1990 | New GP Contract |
|
| 1989 | NHS Management Board reorganised into the NHS Policy Board and the NHS Management Executive |
Working for Patients: The Health Service Caring for the 1990's Caring for People: Community Care in the Next Decade and Beyond |
| 1988 | Department of Health and the Department of Social Security split Charges for eye tests and dental check-ups |
Community Health Councils (Access to Information) Act Health and Medicines Act |
| 1987 | Disablement Services Authority established as a special health authority Hospital Episode Statistics (HES) introduced, based on finished consultant inpatient episodes |
Promoting better health Access to Medical Reports Act |
| 1986 | NHS Management Board established Crown immunity from the NHS in respect of food and health and safety legislation removed Health and Social Service Journal becomes Health Service Journal |
Cumberlege Report -Neighbourhood nursing Primary health care - an agenda for discussion National Health Service (Amendment) Act A National Strategic Framework for Information Management in the Hospital and Community Health Services |
| 1985 | Project 2000 transforms nursing education QALYs 90 Family Practitioner Committees in England and 8 in Wales became autonomous authorities accountable to the Secretary of State publication of the 10% national sample of hospital activities derived from the Hospital Activity Analysis discontinued |
Hospital Complaints Procedure Act |
| 1984 | General Managers appointed throughout the NHS | |
| 1983 | Start of competitive tendering for ancilliary services | Mental Health Act 1983 Griffiths Report - National Health Service general management |
| 1982 | Abolition of area health authorities and restructuring of district health authorities United Kingdom Central Council for Nursing, Midwifery and Health Visiting established |
|
| 1980 |
Care in the Community |
|
| 1979 | New consultant contract | "Patients first" |
| 1978 | Medical Act | |
| 1977 | Health Services Board established to phase out private beds from NHS hospitals |
The Way Forward |
| 1976 | “Cash Limits” introduced into the NHS, whereby spending authorities could not exceed the sums of money allocated to them. | Resource Allocation Working Party (RAWP) "Priorities for health and personal social services in England" |
| 1975 | "Better services for the mentally ill" The Separation of Private Practice from National Health Service Hospitals |
|
| 1974 | Establishment of Regional Health Authorities and Area Health Authorities Community Health Councils Health Ombudsman |
Glancy Report on security in NHS psychiatric hospitals "Management arrangements for the reorganised NHS" Democracy in the NHS |
| 1973 | The British Hospital & Social Service Review becomes Health and Social Service Journal | NHS Reorganisation Act |
| 1972 | National Health Service (Scotland) Act Chronically Sick and Disabled Persons (Scotland) Act NHS Reorganisation White Paper Briggs report on nursing |
|
| 1971 | "Better services for the mentally handicapped" National Health Service Reorganisation |
|
| 1970 | Hospital Advisory Service established | Chronically Sick and Disabled Persons Act The National Health Service. The Future Structure of the National Health Service |
| 1969 | Secretary of State for Wales took over responsibility for health and welfare in Wales Scottish Consultants Review of In-Patient Statistics (SCRIPS) introduced in Scotland |
Bonham-Carter Report - Functions of the District General Hospitals Administrative Structure of the Health and Personal Social Services in Northern Ireland |
| 1968 | Ministry of Health and Ministry of Social Security joined to form DHSS Prescription charges re-introduced |
Seebohm Report on Social Services First scandals in long stay hospitals Health Services and Public Health Act |
| 1967 |
|
The Cogwheel Report - Organisation of Medical Work in Hospitals National Health Service (Family Planning) Act |
| 1966 | New GP contract | Salmon report - nursing structure National Health Service Act |
| 1965 | Prescription charges abolished Hospital Activity Analysis (HAA) introduced in England and Wales The British Hospital and Social Service Journal becomes The British Hospital & Social Service Review |
A Charter for Family Doctors |
| 1964 | Welsh Office set up | |
| 1963 | Hospital and Social Service Journal becomes The British Hospital and Social Service Journal | Health and Welfare: The Development of Community Care Nursing Homes Act |
| 1962 | Scottish Board of Health became the Scottish Home and Health Department. | Enoch Powell's plan for the development of District General Hospitals |
| 1961 | Platt Report -Joint Working Party on the Medical Staffing Structure in the Hospital Service | |
| 1960 | Mental Health (Scotland) Act Professions Supplementary to Medicine Act |
|
| 1959 | Mental Health Act | |
| 1958 | Optician Act | |
| 1957 | Hospital In-Patient Enquiry becomes compulsory | Royal Commission on the Law Relating to Mental Illness and Mental Deficiency |
| 1956 | Guillebaud Report: Cost of the National Health Service Jameson Report on Field of Work, Training and Recruitment of Health Visitors Medical Act Dentists Act |
|
| 1954 | Bradbeer report on internal administration of hospitals | |
| 1953 | Hospital Inpatients Enquiry introduced | |
| 1952 | National Health Service Act | |
| 1951 | National Health Service Act Midwives Act |
|
| 1950 | Medical Act | |
| 1949 | Introduction of prescription charges | National Health Service (Amendment) Act Nurses Act |
| 1948 | 5 July The appointed day Public Assistance Journal and Health and Hospital Review becomes Hospital and Social Service Journal |
Children Act National Assistance Act |
| 1947 | National Health Service (Scotland) Act | |
| 1946 | National Health Service Act | |
| 1944 | A National Health Service | |
| 1942 | Beveridge Report -Social Insurance and Allied Services | |
| 1939 | Emergency Medical Service established | Cancer Act |
| 1937 | Maternity Services (Scotland) Act Report of the Voluntary Hospitals Commission |
|
| 1936 |
Midwives Act |
|
| 1930 | Poor Law Officers Journal becomes Public Assistance Journal and Health and Hospital Review | Poor Law Act Mental Treatment Act |
| 1929 | Powers under the Poor Law transferred from small local Boards of Guardians to the councils of much larger areas, i.e., of counties and county boroughs | Local Government Act |
| 1927 | Poor Law (Consolidation) Act | |
| 1926 | Royal Commission on National Health Insurance | |
| 1924 | National Health Insurance Act Royal Commission on Lunacy and Mental Disorder |
|
| 1921 | Public Health (Tuberculosis) Act | |
| 1920 | Interim Report on the Future Provision of Medical and Allied Services Blind Persons Act |
|
| 1919 | Ministry of Health Act Scottish Board of Health Act |
|
| 1918 | National Health Insurance Act Maternity and Child Welfare Act |
|
| 1913 | Highlands and Islands Medical Services established | Highlands and Islands Medical Services Act Public Health (Prevention and Treatment of Disease) Act |
| 1912 | 15th July National Health Insurance | |
| 1911 | National Insurance Act | |
| 1892 | The Poor Law Officers Journal established | |
| 1875 | Power to establish municipal hospitals | Public Health Act |
| 1855 | Appointment of John Simon as Medical Officer to the General Board of Health |
With thanks to Prof Kieran Walshe, Prof Charles Webster, and Geoffrey Rivett on whose work most of this table is based. The errors are mine, and I would be grateful if they could be pointed out to me.