This section will provide you with an overview of recent policy changes relating to the NHS and medical practice within the UK; we’ll begin by briefly covering the establishment of the NHS, before moving on to the fundamental changes which impact the healthcare system today. As well as key information, we’ll provide suggestions for further research, to support you to answer questions regarding the NHS and its development.
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Although it’s highly unlikely that you’ll receive a direct question relating to the establishment of the NHS, having a brief understanding of this will support you to discuss the NHS and its development more generally.
The establishment of the NHS in 1948 is a key milestone in medicine in the UK, as it marks the bringing together of a range of healthcare professionals and services, including hospitals, pharmacies, opticians and dentists, for the first time to provide free access to healthcare.
The establishment of the NHS has been transformational for healthcare within the UK, delivering ‘huge medical advances and improvements to public health’, and has improved individuals’ health and life expectancy.
The devolved nations have individual responsibility for healthcare, with the National Assembly for Wales, the Scottish Parliament and the Northern Ireland Assembly each responsible for funding and policies respectively; this means there are differences in policies between the four nations, despite all falling under the NHS umbrella. The Institute for Government provides more information about the devolution of the NHS, including information on funding and the approach to COVID-19.
The following are UK policies and developments, which predominantly affect NHS England only, due to the devolution of healthcare within the UK. You’ll find suggested links for researching healthcare in Wales, Scotland and Northern Ireland in the ‘Devolved Healthcare’ section.
Previously, all NHS trusts were expected to gain foundation trust status; although these expectations have now changed, a large proportion do have trust status (according to NHS Confederation statistics there are currently 153 in England), and this remains an important development in the management and delivery of hospital services. In addition to this, it’s likely that you’ll attend a teaching hospital or undertake placements within a foundation trust, therefore, an understanding of why there are NHS trusts and NHS foundation trusts is useful.
The Health and Social Care Act 2003 initiated the creation of NHS foundation trusts in England, with the aim of decentralising decision making and allowing trusts more power to respond to the needs of their patients. It provided foundation trusts with more independence and power over services, management and financial decisions, than they previously had as trusts.
Tony Blair, the prime minister at the time, faced opposition to the introduction of the foundation trusts, including from his own party. However, by April 2004 the first ten foundation trusts were established. You may find it useful to explore this further during your preparations, or to research why the expectations for all NHS trusts to become foundation trusts has changed, depending on your areas of interest.
The Health Foundation provides more information about what the additional financial and management freedoms include and how foundation trusts are governed.
The Health and Social Act 2003 also introduced two new, independent inspectorates; however, by 2009 the Commission of Healthcare Audit and Inspection (CHAI) was abolished and the Commission for Social Care Inspection (CSCI) merged with two other regulators to form Care Quality Commission (CQC).
The NHS Constitution document outlines NHS England’s key principles and values, as well as the rights and responsibilities of the public, patients and staff; it states that the decisions and actions of anyone providing NHS services must legally be guided by this Constitution.
During your interview, you may be asked about these core principles or values, your rights, duties and responsibilities in your future role, or how this guidance will impact your practice. In addition to this, as a doctor, you will be required by law to apply the Constitution to your practice; therefore it’s essential that you are aware of this.
Initially published in 2009, The NHS Constitution (2009) lays out the core values of the NHS, developed in collaboration with staff, patients and the public. These core values underpin the seven key principles, which ‘guide the NHS in all it does’, and are also presented in the guidance. It also shares the ethos that the NHS belongs to everyone and is founded on these core principles and values that unite us all.
Also taken from The NHS Constitution for England (2015), the following are the six core values, which underpin the principles above:
In short, the NHS should provide a free, fair and effective service, to meet the needs of all. You can find more information about the key principles and values in The NHS Constitution for England (2015) guidance, along with additional NHS pledges which ‘go above and beyond’ the legal promises, despite not being legally binding themselves.
The guidance is also legally required to be updated every ten years, to ensure that these core principles and values are reviewed and continue to be influential. More crucially, the principles and values, the rights, duties and responsibilities, and the pledges, cannot be changed without a ‘full and transparent debate with the public, patients and staff’; therefore, offering a level of protection to the NHS from change, and quite possibly a discussion point in your interview.
As you may be aware, the Care Quality Commission (CQC) is an independent, health and social care regulator for England. Direct questions about the CQC are unlikely, however, having a basic understanding will support you to discuss the NHS or its development more generally, and specifically in relation to regulating and improving the service.
Three regulators – the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission – were merged to create the CQC in 2009. As the health and social care regulator for England, the CQC is responsible for inspecting and regulating services provided by the NHS and local authorities, and private and voluntary organisations, including hospitals, GPs and doctors, and mental health services. You can find a full list of the services that the CQC regulates here.
As well as ensuring that health and social care services are safe and effective, the CQC also develops publications relating to health and social care quality issues, including annual assessments, inspection reports and ‘major reports’ on care in England.
The Health and Social Care Act 2012 initiated a substantial restructuring and reform of the NHS; some elements which were introduced have since been changed or adapted – for example, the introduction of Monitor and the NHS Trust Development Authority, which were later merged and became NHS Improvement – but others bodies remain in use and, therefore, understanding their function will help with your knowledge of the NHS structure.
First proposed in 2011, the Health and Social Care Bill 2010–11 faced heavy opposition and thousands of amendments before it was passed in 2012. The changes did not occur instantly, as there was a transition period before the new structure came into full effect, however, the following are key changes introduced as a result of the Health and Social Care Act 2012:
Clinical Commissioning Groups (CCGs) are authorised by NHS England (initially the NHS Commissioning Board when introduced); both of which replaced Primary Care Trusts (PCTs) in 2013.
CCGs are groups of general practices (GPs), which commission services for their local communities; NHS England states that they are responsible for approximately sixty percent of the NHS budget. With the introduction of Integrated Care Systems, through the NHS Long Term Plan (2019), a single CCG will represent each area.
NHS England lists the following services as commissioned by CCGs:
In your preparations, you may want to consider what the perceived benefits are of GPs choosing and commissioning the services required for their local communities, and contrast this with why CCGs were contentious and opposed by some when first introduced. You may need to research and explore CCGs in more detail to enable you to do this.
Health Education England (HEE) is a non-departmental public body for the Department of Health and Social Care. It was introduced under the Health and Social Care Act 2012 to oversee the education, training and development of staff within the health sector. You can explore the programmes led by the HEE and the work they do here.
Originally proposed within the Healthy Lives, Healthy People (2010) strategy, Public Health England (PHE) began operating in 2013, as a result of the Health and Social Care Act 2012, with the aim of providing advice on public health issues.
PHE are responsible for supporting the government, NHS and public with their expertise, and ‘exist to protect and improve the nation’s health and wellbeing, and reduce health inequalities’. This includes responsibilities such as:
Likewise, Healthwatch England was established through the Health and Social Care Act 2012, and began operating in 2013. It is an independent body responsible for representing people who use health and social care services; sharing their views to help shape and improve the support and services they receive. They also support users to access services in their area and promote the involvement of users in decision making with health and social care services.
In your interview preparations, you may want to consider what the benefits of incorporating patients’ and the public’s views and the influence this could have on the NHS.
The NHS Long Term Plan (2019) outlines the aims for NHS England for the ten years to 2028. Your awareness and understanding of the document is important, as it demonstrates the priorities for NHS England over that time period, including plans for how funding will be spent. Knowledge of the NHS Long Term Plan will not only support you to answer questions relating to it specifically, but also relating to the wider goals and priorities within the NHS, and areas identified for improvement.
Some of the key aims, taken from the ‘overview and summary’ of the NHS Long Term Plan, are as follows:
The following are policies, guidance or changes, which you may also want to research to deepen your understanding of recent developments within the NHS and support your discussions during your interview:
The Nuffield Trust has produced a ‘NHS Reform Timeline’ which details the evolution of the NHS from Sir William Beveridge’s report in 1942, proposing a national health service, to the NHS Long Term Plan in 2019. You may find this a useful tool to deepen your understanding and guide your research into the changes and developments within the NHS.
As mentioned in the ‘The Creation of the NHS’ section, responsibility for healthcare within the UK is devolved, with only England falling under the remit of the UK government; the National Assembly for Wales, the Scottish Parliament and the Northern Ireland Assembly each have individual responsibility for their healthcare systems. Therefore, the policy changes discussed above and within the Nuffield Trust NHS Reform Timeline predominantly affect the NHS in England only.
For more information about the differences between the healthcare systems in England, Wales, Scotland and Northern Ireland, you can find a breakdown from NHS Healthcare Careers here.
To explore the NHS in Wales, Scotland and Northern Ireland, including key elements such as the structure, funding and policies, the following are useful starting points:
The Wales Centre for Public Policy produced an article, ‘Is healthcare in Wales really that different?’, which outlines who manages NHS services in Wales, how services are funded and how NHS Wales is regulated, among other things.
The following pages on the NHS Wales website may also be useful:
Our NHS Scotland has produced ‘How it Works’, which details how legislation relating to the NHS is developed, and how funding and services are delivered within Scotland. They also have a timeline which guides you through the milestones in NHS Scotland’s history.
You can also visit ‘About NHS Scotland’ for more information about structure, NHS Boards and the 2020 vision for NHS Scotland.
The following pages on the Health and Social Care Board website provide information about healthcare delivery within Northern Ireland:
The above information aims to give you a basic understanding of recent developments in relation to NHS policy and structure, allowing you to further research areas that are of interest to you or which you need to improve your knowledge of. As mentioned previously, the Nuffield Trust NHS Reform Timeline is a useful tool for identifying additional key topics which you can then explore in more detail if you wish.