NHS England

Illustration ​England’s National Health Service (NHS) is designed as a health system financed and regulated by the state. It was established with the central objective to provide equal access to health care by making health care services free at the point of use. The NHS budget is negotiated with the treasury on a yearly basis and primarily financed by general taxation with a small share from national insurance contributions (NICs).

Since it was introduced in 1946 the structure of the NHS has changed considerably. Major changes in the last decades include (1) the division between purchasing (commissioning) and providing public funded health services (purchaser-provider split), (2) the expanded use of private and voluntary sector provision (regulated competition), (3) more choice of provider for patients, (4) more autonomous management of hospitals through foundation trusts (FTs), (5) new types of contracts for the remuneration of outpatient health services and (6) the establishment of several independent bodies like the National Institute for Health and Clinical Excellence (NICE) in 1999, Monitor in 2004 or the Care Quality Commission (CQC) 2009 and Health Education England (HEE) in 2013.

The way in which problems of primary health care provision in rural and/or deprived areas are perceived as well as the strategies used and measures taken by the government in order to ensure adequate provision of these services will be analysed based on five categories. The first category includes the aspect of problem perception and problem definition while the other four categories focus on strategies and measures tackling the problem(s).

The first category deals with the emergence of the problem(s), their perception by the various stakeholders and important laws affecting these problems with various tangible measures: When did the problem occur? How is the problem defined? Which laws affect the problem? Are these influences intentionally or coincidental?

Questions related to the role of (local) actors, institutional reorganisations, and changes in the (hierarchical) structure of the NHS fall into the second category. Core questions in this regard are i.e.: To what extend are decision-making, powers, and control over resources decentralised and/or rearranged in order to tackle the problem? Are new organisations established? Are others abolished? On which level? Why?

The third category comprises all measures that set material incentives to health professions. How are health professionals contracted? Are there changes in the remuneration of health professions? Are instruments like cheap loans, investment allowances, additional payments, perks or other benefits used to attract health professionals?

The next category includes the organisation of primary health care provision. Topics are the structures of healthcare provision and the division of labour between the various health professions. These include the establishment of new forms/organisations to provide health care services as well as changes in the portions of traditional form of health care provision (i.e. single practice, group practice, surgery). Furthermore we look into changes in the distribution of tasks between health professionals. Are i.e. competencies delegated from physicians to nurses? Are new health professions established?

Last but not least the regulation of medical demography and changes in medical training may also be used as strategy to tackle challenges in the provision of primary health care services. Thus, this last category summarizes instruments that aim at strengthening general practice in comparison to other disciplines, change curricula, and make the access to studying (general) medicine easier.

DFG-ANR Project RegMedProv