Health System Reform in the United Kingdom · 2017. 1. 26. · 1994, Blare amended Article 4 of the founding charter “Sharing the means of production (Article of Nation-alization)”

Review Asian Pacific Journal of Disease Management 2012; 6(1), 11-22

Copyright© 2012 JSHSS. All rights reserved.

Health System Reform in the United Kingdom

Shinya Matsuda1)

1)Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational

and Environmental Health, Japan. Yahatanishi-ku Kitakyushu 807-8555, Japan

AbstractHow to control the increasing health expenditures is a common problem in the developed countries. Themain causes of this increase are ageing of the society and medical innovation. The UK government hasintroduced a market oriented health reform in order to balance the increasing expenditures and the qualityof care. For example, they have introduced the GP Fundholding, Private Financial Initiative (PFI) for con-struction of public hospital, and personal budget system (a patient owns a budget for buying health servicesin the deregulated market). However, there is little evidence indicating the effectiveness of these programs.On the other hand, it is important to strengthen the labor policy in order to maintain the social security sys-tem. For example, programs for increasing the employment rate and those for increasing productivitywork sharing are such policies. From this viewpoint, the EU countries have introduced a series of activeemployment policies, i.e., job training for unemployed persons and work sharing. Furthermore, as otherauthors report in other articles of this volume, the government of the UK has introduced the Fit for Work(FFW) program that intends to medically support workers.

Key words: national health service, market mechanism, United Kingdom, Fit for Work

Introduction

With the aging society, changing disease struc-tures and medical innovation, how to control theincreasing health expenditures is a common issue inthe developed countries. The social security system isbased upon the transfer of incomes from the youngerto elderly generation whichever the tax revenues orinsurance fees are used to fund the system. Therefore,on the other hand, it is important to strengthen thelabor policy in order to maintain the social securitysystem. For example, programs for increasing theemployment rate and those for increasing labor pro-ductivity are such policies. From this viewpoint, the

EU countries have introduced a series of activeemployment policies, i.e., mandatory job training forunemployed persons and work sharing. Furthermore,as other authors report in other articles of this volume,the government of the UK has taken the lead in intro-ducing the Fit for Work (FFW) program that intendsto medically support workers for the purpose ofreturning to their work and continuing employment.Our group has started to investigate this program since2012 and has been studying its feasibility in Japan.However, it is essential to understand the fundamentalsocial security system in the UK to introduce this pro-gram. Hence, the health system reform which has beenconducted since 1970’s in the UK is explained in thisarticle, together with the changing political environ-ment during this period. In addition, the system ofindustrial physicians (Kubo), the social security sys-tem and the employment insurance related withemployment (Muramatsu) and Fit Note (Fujino) arealso explained in this volume.

Received: November 25, 2013Accepted: December 11, 2013 Correspondence: S. Matsuda, Department of PreventiveMedicine and Community Health, School of Medicine, Uni-versity of Occupational and Environmental Health, Japan. 1-1, Iseigaoka,Yahatanishi-ku Kitakyushu 807-8555, Japane-mail: [email protected]

12 Asian Pacific Journal of Disease Management 2012; 6(1), 11-22


Recent Political Trends in the UK

Major Political Parties and Their Characteristics

The major political parties in the UK include theConservative and Unionist Party, the Labour Partyand the Liberal Democrats. The brief summaries oftheir political philosophies for these parties aredescribed as follows. However, the recent trends arecharacterized by the neutralization of the parties andthe difference in their idealistic policies between theparties has become ambiguous.

Conservative and Unionist Party: They tradition-ally value the individual ownership of property andthe freedom of economic activities. They have thestrong Christian view toward family and society whilenot so much enthusiastic about promoting the socialliberalism such as the right for homosexuals. Theyaim to establish the small government. The landedclass, business people and the former aristocracyadvocate the party.

Labour Party: The party was inaugurated in 1906with the Labour Representation Committee (Politicaldivision in the labour union) established in 1900 as itsparent organization. The characteristics of the partywas the socialistic political management by the biggovernment including the publicly-owned proceduresof manufacturing and public interests (Article 4, Plat-form) and the enhancement of the social security sys-tem. However, Blair administration launched in 1997abandoned the publicly-owned procedures of manu-facturing and public interests and aims to realize thenew welfare society based on communities. Theworking class and middle class advocate the party.

Liberal Democrats: They value the human rightsand global warming countermeasures. They are in theposition of promoting the social liberalism such as therights of homosexuals. They are skeptic about eco-nomic policies base on the market fundamentalism.

Thatcher and Major Administration (1979 ~1997)

The UK had been in a difficult economic era dueto distressed domestic economy because of the wardespite of victor country, the diplomatic environmentin which the series of independences occurred in theUK colonies, and the two oil shocks experienced from1960’s to the late 1970s, although the situation tempo-rarily improved because of the economic reconstruc-

tion in 1950’s. In addition, the UK financial servicesled by the City were a kind of the landlord and finan-cial capitalism which benefits from lending assets tosomeone (so called “gentlemanly capitalism) and itdid not make enough investments to the north-centralindustrial area. It was considered that this two-tieredeconomic structure in the UK resulted in being leftbehind the innovation in the manufacturing industryand the cause of losing a competitive advantageagainst Japan and Germany. Because of the intensiveprogressive taxation, high rate of the property tax, toostrong labor unions, too many workers for public ser-vices and the national budget excessively focusing onsocial welfare under the administration of Labourparty, the UK fell into the economic depression called“British Disease.” Thatcher came in the UK govern-ment when people actively discuss the “Decline of theBritain.” Thatcher proactively utilized this “Declineof the Britain” in her political campaign and for exam-ple, she moved forward drastic reforms by arguing“The country which has strong labor unions andexcessively focuses on social welfare is economicallydepressed. To cope with this situation, the neo-liberalreform will be necessary.” For example, as the seriesof economic reforms, Thatcher Administration priva-tized national companies, liberalized foreign capitalactivities in the City, restricted the strike rights ofworking people, reduced a large number of public ser-vants, and suspended the aid for promoting localindustrial development, which is a public investmentin the UK. Medical services were also included in theirtarget to be reformed and the administration aimed toreduce the medical-related budgets and streamline themedical services by enhancing the competition ofmarket-oriented principles. However, these reformsdeteriorated the working environment in medicalpractices and many of healthcare providers conse-quently flew outside the country.

It is also the fact that the series of the above men-tioned reforms revitalized the UK economy andbrought the increase in the middle class. However,Thatcher Administration was forced to step down in1990 because the opposing position of the UK towardthe EU countries with more social democratic trendscaused a protest among people having the pro-EUstance within the UK, and there were objectionsagainst the reforms requiring public’s burdens such asthe trial of the poll tax implementation and theincrease in educational expenses.

13Health System Reform in the United Kingdom


Although the following Major Administrationbasically took over these reforms in the Thatcherstyle, they controlled the consensus-building govern-ment in order to address the domestic criticism. Nev-ertheless, the financial gap between the newer middleclass and the lower-income class widened in the pro-cess of the market-oriented reforms. The newer mid-dle-class people were able to build their assets byutilizing their financial resources and real estate whilethe lower-income group couldn’t. This financial gapeventually increased the dissatisfaction in the society.On the other hand, people in the UK, especially in themajority of the newer middle-class people had astrong feeling of distrust toward the Labour Partywhich seemed largely controlled by the labor unionsand therefore Major Administration was able to main-tain the relatively stable control of the government.The policies of Major Administration were character-ized by the further implementation of the privatizationand they announced the policy in which the construc-tion and management of public facilities were left tothe private companies. For example, the PrivateFinance Initiative (PFI) was implemented in 1992based on this policy.

Blair and Brown Administrations (1997 ~ 2010)

In the late 1980’s, there was a movement thatsome members of the Labour Party began to seek thenew people’s party appealing the improvement of thetraditional dependence on the labor unions to the mid-dle class?Blair and Brown, called “modernizer (mod-ernist)” were the core members of the movement. In1994, Blare amended Article 4 of the founding charter“Sharing the means of production (Article of Nation-alization)” which had been observed for a long time bythe party as if it were a golden rule and rewrite theArticle to allow the business activities based on themarket and competitions by deleting this wording.This amendment generated huge protests among left-ists within the party, but Blare gained supports fromthe public, especially in the middle class by appealingthis amendment as a symbol of the New Labour (newLabour Party). In 1997, Blare who came in the gov-ernment advanced measures based on the concept offree economy including holding down the income taxin his economic policy, encouraging a low inflationand decreasing the public expenditure and debt. How-ever, these measures were a kind of mixed economy

which can be achieved based on the balance betweenregulations and deregulation.

On the other hand, Blair Administration set a goalto revitalize the community based on the solidarity ofresidents in their social policy and tried to achieve theestablishment of the new Welfare State which can bebuilt on individual rights and responsibilities. Forexample, they did not intend to aid (negative welfare,dependent welfare) the vulnerable sections of the soci-ety. They intended to support the people who had beenwaiting for being motivated to “participate in the soci-ety” including setting up a family and working (posi-tive welfare, independent welfare) and to carry out thePublic-Private Partnership (PPP) between the publicand private sectors in the social services. Blare put thetop priority on education in order to achieve such civilsociety. He presented this kind of policy of centrism as“The Third Way” to the public. In calling for this thirdway politics, Blair worked with Professor Giddens ashis key adviser. The summary of the third way politicsis presented in Figure 1.

The global financial crisis started with Lehman’sfall hit the UK economy. Although measures taken byPrime Minister Brown temporarily improve the UKeconomy, the increase of the unemployment rate andthe instable economic situation which correlated withthat of the EU escalated the distrust toward the EUamong the people, especially in the middle class. Dueto the restricted freedom of firing permitted inemployment contracts because of the pro-EU stanceby the Labour Party and the increased employmentcost, employers increasingly got frustrated. Further-more, with the inappropriate comments by Brown, theLabour Party had a rapid slide in their support ratingas a consequent.

Cameron Administration (2010~)Due to the economic depression, distrust toward

the EU and getting weary of the long-term administra-tion by the Labour Party for about 10 yr, the LabourParty was defeated in their election in 2010 and thecoalition government of the Conservative Party andthe Liberal Democrats launched its administration.This was because the Conservative Party alone couldnot establish the single-party administration. How-ever, there are many differences in their politicalbeliefs between the Conservative Party which valuesthe Christian view of family and society and the Lib-eral Democrats which values the liberality including



the measures for environment and the social accep-tance of homosexuals. Especially for the policiesbased on the market fundamentalism, the Conserva-tive Party takes the position to enhance these policieswhile the Liberal Democrats clearly shows their oppo-sitions. This is the current situation that these differ-ences make the handling of the government difficult.However, it is the national consensus to maintain themedical and welfare policy including NHS (NationalHealth Service) beyond the bounds of the parties(Conservative, Liberal Democrats, Labour Parties)and the problem is merely a difference in methodolo-gies between the parties to improve the efficiency andquality of the policy. In this regard, Cameron Admin-istration also gives weight on the right and responsi-bility of the people and communities along with Blairand for example, they aims to achieve the big society

in which more authorizations are to be granted to vol-unteer organizations, community groups and localgovernments in order to address the UK social issuessuch as poverty and unemployment.

Health System Reform in the UK

Based on the descriptions regarding the historicalbackground of the UK political trend in the previoussection, this section again explains how the health sys-tem reforms were conducted in the UK. In order todescribe this section, Boyle S 5) was used as referenceinformation.

The health system provided in the UK is calledNational Health Service (NHS) which has been imple-mented since 1948 based on the Beveridge Report(1942). The NHS provides the people in the whole

Figure 1 The Third Way

Fukushima2): Table 3-1 The New Civil Society Described by Prof. Giddens (Historical background). EuropeanCapitalism, Break from the American market fundamentalism. Kodansha Gendaishinsho 1628. Kodansha, Tokyo.Citation from the page 180 with a permission of reprint.



nation with comprehensive medical services financedby tax incomes from preventive cares to rehabilita-tions (Fig.2).

People in the UK need to decide and register theirGeneral Practitioner (GP) in advance and have to seethe registered GP for a usual medical care first. In theUK, the gatekeeping system has been introduced inwhich the patient will then be referred to specialists athospitals when the GP considers it necessary.Although patients do not need to pay for the medialcare provided by their GP or at hospitals, there will bean individual payment for medicines and dentistry.

Medical services in the UK are controlled underthe budget system and therefore the proportion ofmedical expenses in the national income is lower thanother developed nations. However, the increase in themedical expenses became a controversial issue in theprocess of deterioration in the economic situation afterthe oil shocks in 1970’s. On the other hand, the inef-ficiency of the public healthcare system, as repre-s en t e d by t h e l o ng e r wa i t i n g pe r io d fo rhospitalization, was also a problem. For the purpose ofimproving the inefficiency of the medical services inparallel with controlling medical expenses, theNational Health Service Community Care Reform(Fig.3) was implemented in 1990 by Thatcher Admin-istration. Until then, district authorities (correspond-ing to Japanese prefectural government) had an

overall responsibility in managing healthcare financeand providing medical services. After the implemen-tation of this reform, functions of district authoritieswere divided into a provider and a purchaser to intro-duce the internal market (quasi market) in the regionalmedical services. In this internal market, the districtauthority is responsible for negotiation and purchas-ing the service provided by the hospital as an indepen-dent management agency (NHS Trust Hospital). Inaddition, as a measure of improving business effi-ciency, hospitals with poor financial condition (=inef-ficient hospital) were closed and divisions/resourcesfor cleaning, linens, food services and nursing aidwere outsourced to private human resources compa-nies. Major continued the privatization of public hos-pitals after succeeding Thatcher. Private sectorsconstructed hospitals and the Private Finance Initia-tive (PFI) was introduced into the NHS Trust Hospi-tals. In this scheme, the construction of hospitals andits management will be conducted in private fundingand Trust Hospitals will pay rent-fees or managementfees to the operating company to provide medical ser-vices. The contract generally will be valid for 30 yearsor more.

In addition, the new system was introduced withrespect to general practitioners. In this system, GP willhave the right and the budget to purchase medical ser-vices provided by hospitals for their registered

Figure 2 National Health Service

(Before reformed by Thatcher)



patients (which is called the GP Fund Holder). Thisreform partially brought a positive effect such asimproving the position of general practitioners andcontrolling the amount of prescribed medicines. How-ever, costs for clerical works increased due to thisreform, sufficient competitions based on the marketfundamentalism did not occur as expected and noimprovement effect was observed in quality and costs.

Blair’s Reform and Following Situation

The Labour Party which took power in 1997 fol-lowing the Conservative Party set their goal for estab-lishing the comprehensive service delivery system,not the competitive system, based on the partnership,not competitive system, among those concerned andpresented the public with the following 6 principleswith regard to the NHS (Our Healthier Nation, 1997).1. People in the whole nation can access to high-qual-

ity medical services.2. Providing medical services which meet the

national standard based on the responsibility of thelocal government.

3. Establishing a partnership between NHS and localgovernments (Establishment of Local healthimprovement programme).

4. Eliminating bureaucracy and achieving to provideefficient medical services based on the evaluationof performances

5. Focusing on the quality of services.6. Rebuilding the people’s trust toward the NHS as

the public medial services.To advance the reform in accordance with the 6

principles above, Blair Administration established the3 frameworks: the National Service Framework(NSF) for ensuring an access to the high-quality med-ical services; the National Institute of Clinical Excel-lence (NICE) for providing the medical services ofhigh cost-effectiveness; Commission for HealthMovement (CHI), currently called as the Commissionfor Quality Control (CQC) for evaluating the qualityof the medical services. Each of these frameworks isexplained as below.

NSF: The NSF is a project which sets the standardof medical services and the service model for eachtherapeutic area and also supports the implementationafter being programmed. The performance index isdefined in the service model and the progress of itsimplementation will be monitored during the agreedtime period. For example, treatments for cancers havea layer model which consists of the first-line therapy(appropriate referral and follow-up), the second-linetherapy (general treatment) and the third-line therapy(professional treatment/specialty care).

NICE: NICE in an organization in which clini-cians and the NHS staffs systematically evaluate thecost-effectiveness of the medical services to investi-gate that they should be included in the service pro-

Figure 3 Health System in the UK

(After the NHS Community Care Reforms)



vided by the NHS. Activities and guidelines providedby the NICE are not only important for the NHS mea-sures, but they also have a great impact on foreigncountries including the EU because the NICE activi-ties and guidelines are considered to be the institution-alized Medical Technology Assessment (MTA).

CHI: Varieties of organizations in the UK havebeen trying to evaluate the quality of medical servicessince 1980’s, but these efforts never be reflected to thepolitical measures due to no standard infrastructures.In addition, there was no need for evaluating the qual-ity of the business operation because of the nationalhealthcare services. The CHI was established as aframework to improve the situation and to evaluate thequality of medical services provided by the NHS andof its business operation. In order to advance the CHIprojects, the NHS Performance Assessment Frame-work was established at a national level and it definesindexes for each therapeutic area focusing on 6themes: Improving health condition, fair access, pro-viding appropriate care in an effective manner, effi-ciency, evaluation by patients and their caregivers,and clinical outcome.

Blair Administration attempted to improve themanagement skill at a community level to achieve thepolicy objectives. For example, they introduced thesystem of the Primary Care Group (PCG) or the Pri-mary Care Trust (PCT) in which a group of healthcareproviders (about 50 members consisted of generalpractitioners, local nurses, physical therapist, etc.)manages the budget related with comprehensive med-ical services, not the system in which individual gen-eral practitioners manage the budget. In implementingthe new system, they put focus on the commissioningfunction of the PCT. Regarding the definition of com-missioning, the NHS defines it a process of ensuringthe target patients get the medical/welfare services tomeet their needs in an effective manner. In particular,it is the process in which the PCT take responsibilitiesin evaluating the need of the target patients, coordinat-ing the necessary service for them based on the eval-uation results and priorities, and managing the statusof the service provision. In addition, the new systemvalues preventive services more compared to the pre-vious system and people can consult with nurses abouttheir health conditions for 24-hours a day via a tele-phone or internet in the newly provided service (NHSDirect).

For improving the comprehensiveness of the ser-

vices, GP clinics (GP Surgery) which basically haveperformed solo practices were reorganized to theclinic performing group practices step by step and ingeneral, a group of 5 GPs and Practice Nurses jointlysee patients in that structure. Practice Nurse is a so-called Nurse Practitioner who is responsible for amedical check-up for infants, health management forpregnant women, protective inoculation, managementfor patients with a chronic disease, etc.

Furthermore, the traditional Regional HealthAuthority was reorganized into the Strategic HealthAuthority (SHA) to implement local medical policiesmore effectively. This was because the governmentbelieved that it was desirable to develop the policiestaking into more consideration the status of eachregion in order to achieve the health policy which wasdesigned at a national level, and as a consequence, thedecentralization of the authorities was necessary.Additionally, the government allowed the SHA levelto have strategic management functionality while theyleft the operational management of the policy objec-tives to the PCT in the reform.

However, they had a hard time to improve thequality-related issues in medical services which wasrepresented by the longer waiting period for hospital-ization. The root cause of the problem was that thebudget for medical expenses was too small. In order toresolve the situation, Blair Administration announcedthe public commitment for raising the medical budgetin the NHS Plan 2000 and then they actually increasedthe medical budget considerably. They set the targettimeline of 2010 and carried out the following objec-tives?• Increasing the number of hospital bed by 7,000 in

the whole nation.• Constructing 100 new hospitals and establishing

500 One-stop Primary Care Services.• Modernizing 3,000 and more GP clinics• Newly introducing 250 CT scanners• Increasing healthcare providers: 7,500 Hospital

Doctors (Consultants) , 2,000 GPs, 20,000 nurses,6,500 therapists (OT/PT/ST), 1,000 capacity formedical college

While increasing the resource investment foroverall healthcare, several important reforms wereconducted to improve the efficiency of medical ser-vices. First, the system of the Foundation Trust (FT)was introduced in order for individual hospitals tomanage the operation at a considerable discretion. To



be a member of the FT, a hospital needs to meet theconditions including the stability of their financial sta-tus or medial experiences and once a hospital is certi-fied with the FT they can obtain loans from privatefinancial institutions. The certified hospital is alsoable to prepare and coordinate facilities or resources atmore considerable discretion.

Second, resources for the medical services at hos-pitals were reallocated to the Primary Care. For theresource reallocation, it was essential to improve theefficiency of the medical care at hospitals. Objectivesfor achieving the reallocation were set and the moni-toring system for these objectives was introduced.This is the previously-mentioned framework of theCHI. In addition, it was recommended that hospitalsspecialize in the therapeutic areas of which medicalcare needs to be conducted at hospitals and that med-ical care which can be delegated to the Primary Carebe addressed at GP level. For the purpose of achievingthis system, the PCT was required to establish at leastone Community Health Center (Polyclinic) in the areaand as a result of it, the system building was carriedout to provide both the first-line therapy and a certainlevel of the second-line therapy at a community level.

The third one was further implementation of theprivatization. In the NHS Plan 2000, it was agreedbetween the Health Authority and the association ofprivate healthcare providers that three areas of elec-tive surgeries, emergency medical care and sub-acutehealthcare (such as rehabilitation) can be provided bythe private healthcare providers in the NHS funding.After 2002, the utilization of private companies fur-ther advanced and the Independent-sector TreatmentCenters have been increasingly constructed whichperform the elective surgeries including cataract oper-ations, hip replacement surgeries, replacement ofknee joints, cardiac operations, etc. At the centers,people in the UK are able to undergo a surgery underthe contract with the NHS. With the increasing utili-zation of the private sectors in the primary care area,profit-oriented organizations are able to provide theGP services under the NHS. For example, it is alsopossible for a GP surgery to outsource the after-hoursvisits only to the private company. However, there hasbeen a concern about the excessive utilization of theprivate sectors in terms of an increase in the medicalexpenses and the Preferred Practitioner Model wasintroduced in 2009 in which the NHS designates a ser-vice provider.

The fourth one is a change in the payment method.For example, the previous payment method to the tra-ditional Trust Hospitals was based on the Block con-tract which predicted what kind of, and how manysurgeries would be performed. However, the Paymentby Result (PbR) was introduced to make a paymentbased on the performance as a result of refining theHealthcare Resource Group (HRG), which is the UKDiagnosis Related Group (DRG), and the creation ofcost data. The cost for each HRG was initially definedas the average national cost, but it was changed to thebest performance level over time. Besides, the Pay forPerformance (P4P) system has been implemented topay an additional bonus to hospitals with excellentperformances. The Quality Account system has alsobeen introduced as recommended by the Darzi Reportto be described later. In this system, each hospitalmeasures the performance level of clinical indicatorsdefined by the CQC (the former CHI) and submits themeasurement result to the NHS authority at a quarterlybasis. Each hospital receives the payment which isadjusted based on the result.

The fifth reform includes the empowerment ofindividual patient and development of healthcare pro-viders who support the empowerment. For example,the Expert Patient Programme was initiated to supportthe improvement of the self-care ability of the patientswith a chronic disease and the development of NPOswhich support the preventive care by patients has beenconducted. In addition, the role of a pharmacist hasbeen increasingly focused in supporting the self-careactivities by the patients with a chronic disease andadvices from a pharmacist with regard to the usage ofthe Over The Counter (OTC) drugs have received ahigh evaluation. Regarding the empowerment of thepatients, the advisory system called the NHS Directhas also been introduced. The NHS Direct providesthe 24-hour services for healthcare consultations andinformation sharing to people in the UK via a tele-phone or Internet. In 2010, it was reported that therewere 5 million telephone consultations and 42 millionInternet accesses in a year. However, this system didnot contribute to a reduction of GP’s burden whichwas the initial objectives in the reform and some crit-icize that it rather stimulated the potential needs andresulted in overload of GPs.

The sixth one is laying weight on the quality.While the free-of-charge medical services havereceived the widespread support from public citizens,



people were concerned about another issue relatedwith the quality of the UK medical services which wascharacterized by the long waiting period for hospital-ization. The safeguard obligation of the quality wasstipulated in Health Act in 1999. For the purpose ofensuring the obligation, the CHI (reorganized to theCQC in 2009) to take a role in securing the quality wasestablished, the star system (evaluation based on thenumber of stars: currently abandoned) was imple-mented as a comprehensive evaluation for the definedindex, and the payment method linked to the quality-related systems such as P4P or Quality Account wasintroduced. Additionally, the patient murder by Har-old Simpson, GP and the excessive deaths due to in-hospital infection from Clostridium difficile resultedin increasing the public interest toward the quality ofmedical services.

The NHS reform implemented by the LabourParty was characterized by the setting of reform objec-tive in the white paper and the laws which are issuedevery year. (For example, The New NHS in 1997:Modern, Dependable? A First Class Service in 1998:Quality in the New NHS Our Healthier Nation in1999? NHS Plan 2000 in 2000?The Health and SocialCare Act in 2003?Keeping the NHS local-a Newdirection of Travel in 2003?Our health, our care, oursay in 2006?The World Class Commissioning Frame-work, and Trust, Assurance & Safety in 2007).

In order to monitoring the implementation statusof these objectives, medical services were gettingmore computerized. The information about medicalperformances is systematically collected through apersonal computer in the GP surgery office in associ-ated with daily clinical practices and then the collectedinformation will be analyzed.

The important aspect in considering the recenttrends in the NHS reform is the Darzi Report (HighQuality Service for All) published in 2007. Adheringto the content of the 1997 NHS White Paper, includingthe enhancement of the preventive care service tomaintain the people’s health, the empowerment ofpatients, provision of effective treatments and focuseson patient safety, this report newly proposed that thePCT should establish the commissioning system forthe comprehensive medical service which meets theneeds of individual patient in cooperation with thelocal government, the NICE should expand the targetmedical services for performing the quality evaluation(e.g. social welfare), and the systematic evaluation to

assess the quality of care and the information discloserfor the evaluation result (Quality Account) should beestablished. The government actually took these pro-posals into practice afterwards. In addition, the pro-posal saying “Clinicians should be a primary player inthe reform” in this report led to the establishment of theClinical Commissioning Group (CCG) subsequently.

What kind of outcomes did the NHS reform asdescribed above by the Labour Party’s Administrationachieve? It is the fact the NHS medical servicesimproved in terms of the amount and quality, andcomputerization and transparency in medical prac-tices have advanced by utilizing the private sectors asthe Conservative Administration did. The number ofsurgeries significantly rose because of the increase inthe budget. For example, there have been significantincreases in the number of surgeries performed in2009-2010 compared to that in 1998-1999, 73% forcataract operation, 47% for hip replacement surgery,227% for Percutaneous Coronary Intervention (PCI),increase from 0.5 million to 2 million cases for exam-inations with MRI, increase from 1.25 million to 3.72million cases for examinations with CT. In addition,because of the newly introduced economic incentiveto the extension of the service hours, 77% of GP in theUK extended their clinic hours and the people’s accessto the GP services has improved as a result in 2009.The reform brought other improvements in the qualityof medical services which Blair Administration set asobjectives. For example, resolution of the long wait-ing period for hospitalization in 100 thousand patients(achieved in March, 2000), and decreases in the timebetween clinic appointment and consultation(decreased to 4.3 week in 2010 compared to 12.7 weekin 2002). However, on the other hand, there is a criti-cism that the majority of the increase in the NHS bud-get has been used for staff salaries and productivityand efficiency in the service have not improved. Somealso criticize that the introduction of the PrivateFinance Initiative (PFI) to hospitals, continuing fromthe former Administration does not contribute to thecost reduction. The most effective measure for thecost reduction was selling of real estate whichaccounted for 10% of the NHS property and there areopinions that while this measure strengthened themanagement practices, it also restricted the access toa hospital in local regions (widening gap in providinghealthcare services between regions). Furthermore,the preparation of evaluation criteria for the quality of



medical services started and the disclosure system forthe evaluation result (Quality Account) was intro-duced when the information systems at hospitals werenot sufficiently established. This causes the increasein the clerical works at hospitals, as a result of it, work-loads and resource cost have increased. In the chapterof Conclusion in “Health in Transition –United King-dom– published in 2011, it was conclude that theLabour Party’s Administration contributed to increas-ing the number of elective surgeries and decreasingthe number of waiting patients, but they failed toachieve the Value for Money reform. The importantaspect here is the series of there reforms had been con-ducted supported by the favorable economic condi-tion. In 1980, the medical fee and the proportion ofpublic sector-related expense in the overall healthcarecost for each person was £231:89%, while £1168:74%in 2000. However, due to the increase in the NSH bud-get and impacts from economic depression followingthe Lehman’s fal l , these values changed to£1852:83% in 2008.

NHS Reforms by Cameron

With regard to the NHS reforms by CameronAdministration, there is no major difference in thefundamental policy compared to that of the LabourParty’s Administration. They set out the goal ofenhancing the privatization and decentralization, andindependent individual and communities were desiredas the premise for achieving this goal. However, asdescribed in the last part of the previous section, thefinancial condition is very difficult at the time of Cam-eron Administration unlike the Blair and they cannotafford to offer great deals in the NHS reform.

In the 2010 White Paper “Equity and Excellence”issued by the Cameron Administration, they call for“more freedom, more transparency” and announce thefollowing proposals of the NHS reform.• Enhancing the public health service • Establishing the Health and Social Care Informa-

tion Center• Evaluating social care areas by the NICE• Abandoning NHS Trust hospitals and complete

transition to FT• Strengthening the quality evaluation by CQC

(Enhancement of Quality Account)• Strengthening the monitoring of financial and

healthcare quality by Monitor

The proposed reforms are not greatly differentfrom the previous policies of the former Administra-tion. However, because of the poor financial condi-tion, these reforms focus on generating financialresources and refining its allocation by the improve-ment of efficiency as the premise of achieving theirpolicy objectives. For example, they will streamlinethe medical services at hospitals to generate £20 bil-lion for financial resources (Efficiency Fund) andtransfer the allocated resources from the funding to thecommunity care. The first measure for this financialplan is to dismantle the PCT and to establish the CCG.

The PCT was a breakthrough challenge to com-prehensively respond to the multiple needs of elderlypeople, but due to the two separate financial resourcesin the NHS (healthcare) and local government (wel-fare) for providing the medical services, the commis-sioning function of the PCT staffs responsible forcoordinating the two separate financial resources didnot work successfully. Based on the analysis of thecause, it was concluded that a person who has moreclinical skills should take responsibilities for the com-missioning to generate the patient flow from hospitalto community care to receive medical services.According to these results from examinations, Cam-eron Administration finally dismantled the PCT andestablished the new organization, the CCG.

Figure 4 explains the structure of the CCG.Because of the NHS reorganization, it has beendecided the healthcare policies should be imple-mented in the hierarchy consisted of 4 Regionaloffices and 27 Local offices. Each Local office has itsCCG on a regional basis (212 groups in the wholenation). The CCG consists of GP, Nurse Practitioner(NP), social worker, etc. and both of the NHS andlocal governments allocated the budget for the CCG.Among doctors in a GP group, those who are assignedto take a role of commissioning in addition to the dailyclinical services need to purchase services of primarycare, hospital, welfare (caring), and mental health forpatients as their customer based on the assessmentresult made by the multi-professional team, and sys-tematize the provision of medical services. The atten-tion is particularly focused on here is the CCG valuesthe role of private sectors to provide medical servicesand the Personal Budget system is available. The Per-sonal Budget system allocates the budget for users topurchase the welfare service, for example, and usersthemselves are allowed to purchase the necessary ser-



vice from private markets. It is sated that objectives ofthe reform intend to control the cost of the services bystimulating the price competition and to increase theamount of the services to be provided.

Regarding the FT, a new form of hospitals, thereform has been advanced to expand the targeted hos-pitals and enhance its activities. The government aimsto reorganize all of the Trust hospitals to FT by 2016.In addition, the increasing number of FT which isresponsible for the acute phase inpatient care have anoutpatient center and clinics as the outreach and theNHS pay-beds or the NHS amenity-beds has beenallowed to provide private care in Trust hospitals witha certain condition. Furthermore, private hospitals inthe UK had limited roles in the past, but recently therehas been an increase in the cases that the NHS coversthe healthcare services provided at the non-NHS hos-pitals for the purpose of enhancing the more efficientservices (£6.8 billion in 2008).

As described above, the current UK is again car-rying out the health system reform based on the mar-ket fundamentalism under Cameron Administrationmaintaining the framework of the NHS.

Conclusion

We reviewed the content of the health systemreform conducted in the UK after the ThatcherAdministration came in the government. Because ofaging of the population, change to the disease struc-ture focusing on chronic diseases, increasing publicneeds to quality of the medical service and its perfor-mance and advance in healthcare technology, medicalexpenses are rapidly increasing. It is the common sys-tem among the developed countries in which publicpeople share the medical expense based on the princi-ple of solidarity, even though there is a type of differ-ence in the expense, such as tax or social insurance feedepending on its resource. However, it is becomingdifficult to maintain this kind of system due to theslowdown in the economic growth in developed coun-tries.

As explained in this article, the UK adopted themethodology based on the market fundamentalismand intends to resolve the issues they are facing byimproving the efficiency in the health system. How-ever, the current Cameron Administration is trying to

Figure 4 Clinical Commissioning Group in the UK

Doctors in GP group purchase the primary care service, hospital service, welfare (caring) service, mental healthservice from the service provider and provide to patients.



develop further policies to control the public expendi-ture because a series of reforms has not worked suc-cessfully as expected by the Authority. These policiesinclude a measure for controlling the medical expenseby focusing on the primary care and enhancing self-care by patients. In addition, under the slogan “BigSociety”, the government aims to integrate the formalcare and informal care including the enhancement ofthe community care. The reform which has been con-ducted in the UK over 30 years is the one being dis-cussed for implementation into Japan and therefore, itis worthwhile for examining the content, effectivenessand limitations of the UK reform in determining themodality of health system reform in Japan.

To address the increasing medical expenses, it isnecessary to strengthen the policy for ensuring thefinancial resource in addition to the above mentionedmeasure for controlling the medical expense. In orderto increase tax incomes and insurance fees, a govern-ment has no choice but to increase the working popu-lation or improve productivity for each worker. Asreported by other authors of our study group in thisjournal, the UK has implemented Fit for Work (FFW)which is the system to comprehensively support “peo-ple to keep working”, “to maintain the productivity ofworking people”, and proactively enhances the sys-tem. This framework will be considerably useful forexamining how the industrial health system in Japanshould be in the future. As indicated by the framework

of the FFW, clinical medicine and industrial healthshould be comprehensively examined in the agingsociety with chronic diseases as the primary disease.We would like to expect the study for developing theJapanese FFW will be conducted at our university.

This study was conducted in accordance with“The Study for Health Insurance Reforms in ForeignCountries and its feasibility Japan (H24-Policy-Gen-eral-001; Representative of the Study: Shinya Mat-suda)” funded by Health and Labor Sciences ResearchGrant in 2012 (Research Project for Promoting PolicySciences).

References

1) Kuroiwa. T: The United Kingdom Making Deci-sion: New Leader. (Tokyo:Bungeishunju, Ltd.1999): 222

2) Fukushima.K: European Capitalism:Break from theAmerican Market Capitalism. (Tokyo:Kodansha-gendaishinsho 1628, Kodansha, Ltd. 2004): 246

3) Hayashi. S: Truth (of Wealth) in Britain.(Tokyo:Kodansha-gendaishinsho, Kodansha, Ltd.2009): 198

4) Gibe. H: Power of Inconsistency. (Tokyo:Nihonkeizaishuppansha, Ltd. 2012): 197

5) Boyle S: United Kingdom (England) Health SystemReview. Health Systems in Transition 13: 2011: 483

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Health System Reform in the United Kingdom · 2017. 1. 26. · 1994, Blare amended Article 4 of the founding charter “Sharing the means of production (Article of Nation-alization)”