Mohammed T. Abou-Saleh

658 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYTHE POST-WAR NATIONAL HEALTH SERVICEThe last of the series of British Medical Association (BMA)reports pressing for reform in 1942 coincided with the Beveridgereport and was followed in 1944 by the NHS White Paper,enacted in 1946 and effective in 1948.The National Health Service, as then set up, was tripartite.Primary care services—general practitioners, opticians, dentistsand pharmacists—were answerable to local executive committees;maternity, child welfare, health visiting, health education,immunization and ambulances remained the responsibility ofthe local authority; and hospitals were administered by RegionalHospital Boards with teaching hospitals retaining boards ofgovernors directly answerable to the Ministry of Health. One ofthe assumptions when the NHS was set up was that increasinghealth in the population would cause health expenditure to leveloff. It never did, and in 1956 the Guillebaud Committee,appointed to find ways of avoiding a rising charge upon theexchequer, concluded that there was no evidence of inefficiency orextravagance in the NHS. In fact, the committee was concernedabout a lack of capital expenditure (a concern again of relevancemore recently). In 1962, this problem was addressed in theHospital Plan.Meanwhile, in the mental health field, the idea of communitycare was gaining ground. Tinker 10 attributed this to five factors.First, there was a general dissatisfaction with institutional careand a search for alternatives. Some of the experiments in the‘‘therapeutic community’’ work of the Second World War hadchallenged the accepted authoritarian culture of the mentalhospital 11 . In addition, the advent of electroconvulsive therapy(ECT), antipsychotics and effective antidepressants facilitated themove away from custodial care to medical treatment at home orin ordinary hospitals. Next, there were beginning to be practicalproblems in running residential establishments, including staffrecruitment. Then there was concern about the cost of institutionalcare and, finally, a recognition that mentally ill people wereentitled to live in as normal a way as permitted by moderntreatments. The 1959 Mental Health Act liberalized the treatmentof mentally ill people and opened the way for a move away fromthe old psychiatric hospitals to the new concept of psychiatricunits attached to the district general hospitals of the 1962 HospitalPlan.The large institutions were, in any case, rocked by a series ofscandals about the mistreatment of patients. This resulted in theestablishment of the Hospital Advisory Service (later the HealthAdvisory Service), effectively an inspectorate to monitor standardsand spread good practice.In general practice, a financial allowance for practices indeprived areas combined with other factors to promote the rapiddevelopment of local health centres and group practices from themid-1960s. Local authorities produced their own health andwelfare plans but there was poor coordination with the hospitalauthorities and the general practitioners’ executive committees.Within the local authorities, the Seebohm report (1968) wasfollowed by the Social Services Act, which required the setting upof social services departments. The Department of Health andSocial Security was created in 1968 by the amalgamation of theMinistries of Health and Social Security, a merger that lasted forsome 20 years.ReformsIn 1974, for the first time since its inception, the NHS itself wasreorganized. The chief elements of this reorganization were theseparation out of health and social services functions, theintegration of all health functions under one management andthe establishment of area health authorities, generally coterminouswith local authorities, to facilitate joint planning.Community Health Councils were also created to represent theviews of consumers. Unfortunately, the reformed service did notwork well. There were too many layers of responsibility andtaking decisions seemed to be delayed whilst information andresponsibility were passed up and down the tree. There was anincrease in clerical and administrative staff without a correspondingincrease in managerial efficiency. During this period,important government reports were produced, including BetterServices for the Mentally Ill 12 and A Happier Old Age 13 .In 1982 the Area Health Authorities were abolished and newdistrict health authorities combined the functions of the old areasand districts. In some areas, co-terminosity with local governmentwas lost. A new government was determined to cut publicexpenditure and the rate of growth of the NHS slowed. Followingthe Griffiths report 14 , a general management structure wasestablished within the NHS and Family Practitioner Committeesbecame independent. Government payment for continuing carewas channelled to the private sector and social services andhospital provision for this group of patients/residents was eitherreduced or failed to keep pace with demographic changes 15 .Psychiatric services were coping with the implementation of the1983 Mental Health Act, which set up time-consuming quasijudicialprocedures for reviewing patients who were detained inhospital under compulsory orders. The new Act also set up aMental Health Act Commission to review treatment of detainedpatients and to advise on certain types of treatment.MARKET FORCES: A RADICAL DEPARTURE?Then came the most radical reform of the NHS attempted to thatdate, a reform not just of the service but of the basic philosophy of‘‘service’’ underlying it. Some suspected that it was the beginningof the end for the National Health Service. The 1990 NationalHealth Service and Community Care Act introduced the conceptof an ‘‘Internal Market’’. The new health authorities becameplanners and purchasers of health care at ‘‘arm’s length’’ from theproviders, which were initially directly managed units (DMUs),and became semi-independent Trusts. The health authorities wereprovided with a budget for the local population and placedcontracts for care with Trusts or the private and voluntary sectorin order to obtain the best ‘‘value for money’’. Quality was, atleast in theory, specified in the contract and monitored.Competition and other features of business life were ‘‘introduced’’into the NHS, not least by setting up groups of‘‘fundholding’’ general practitioners, who were enabled to maketheir own contracts for secondary care. Some of the changes werepotentially positive, such as the setting up of Trust Boards tomanage local services and an emphasis on sound financialregulation through corporate governance. Unfortunately, thebottom line was very clearly financial and in many cases clinicalservices were sacrificed to balance the books.These proposals were pushed through in the teeth of strongopposition from staff and groups representing the consumer.Honigsbaum 16 analysed the situation in 1990 and concluded thatif patient care suffered, then ‘‘the nation may decide that therestraints imposed are not worth the savings they produce. Today,as in 1911 and 1948, it is the public interest that willpredominate’’. The medical profession were excluded from theplans for this reorganization. Klein concluded that, if a newpolitical settlement were not reached between the government andthe profession, it seemed unlikely that the NHS would survivelong into the twenty-first century 17 .