ANALYSIS
The principles have since been defined more clearly by the policies adopted to implement them. These policies have changed over the years in response to changes in the wider environment. Since the outset, tension has existed between national and local decision making, with practice changing from one administration to another. Additions and modifications have also taken place. The most important for England are the seven principles in the 2013 NHS Constitution for England. 6 The first two are rewritten versions of the founding principles, with the addition of a wider duty to promote equality. The other five relate to achieving the highest standards of excellence and professionalism, putting patients at the heart of everything, working across organisational boundaries in partnership, providing best value for taxpayers ’ money, and accountability. These principles were reconfirmed in 2023. No other UK country has published a constitution, but each has broadly similar statements of values or principles. Our discussions produced other suggestions for principles, including recognising the importance of supporting staff and ensuring their welfare. This is the topic of another BMJ Commission article, and we will limit ourselves to discussing the five founding principles. The changing environment Enormous changes have occurred since the 1940s. Some of the most obvious affecting the NHS are: demography, where an aging and more diverse population requires a wider range of services; epidemiology, where the greatest burden of disease is now longer term conditions and disability; science and technology, where options for diagnosis and treatment have expanded enormously and personalised medicine is becoming reality; and in the economy, where cheap alcohol, processed food, high stress working conditions, and growing inequalities increase risks to health. The aging population and changing disease patterns have resulted in more comorbidities, with patients needing support from several services. The increase in longer term conditions, together with a move to a more personalised service, mean that much healthcare needs to be long term and relational, not transactional and episodic. Despite this, the NHS (like other industrialised health systems) still uses service models based on hospitals and episodes of care, which were designed for the different needs of a younger population in the 1940s (more infectious disease, trauma, and acute illnesses). This is a major source of inefficiency in the NHS. In effect it is using a 20th century model to address 21st century problems. In addition, we now know that most ill health can be linked to external causes (poverty, housing, education, nutrition, and others) and this requires a new focus by wider society and the NHS on preventing disease and creating health. The current position Box 1 describes the problems one clinician describes in delivering a comprehensive health service. We expect that most health workers will recognise these problems. In recent years, the decades-long improvements in life expectancy in England have slowed dramatically, 7 waiting lists are at their highest levels ever, 8 and confidence in the NHS has fallen. Austerity and covid-19 have played major roles in this. As a result, more people in England who can afford it are using the private sector. 9 As the UK champions policy for universal health coverage globally — so that everyone everywhere has access to healthcare — theUK ’ s own system is in crisis, as are others in western Europe. 10
Box 1: A clinician ’ s view of the barriers to providing a comprehensive healthcare system Funding and resource allocation Funding constraints affect the range of services, the availability and quality of care, and the consistency with which services can be offered. Personalised medicine and advances in healthcare make it increasingly costly to offer and make available all healthcare opportunities. The effective and efficient allocation of resources is variable across the NHS, resulting in health outcomes that range from excellent to inadequate. Fragmented care Integration and coordination of care across primary, secondary, and specialised care services is often lacking, leading to a disjointed patient experience. Health inequalities Health inequalities arising from socioeconomic, ethnic, cultural, and environmental factors are significant causative factors for poor life expectancy, morbidity, disease prevention, access to services, and Providing a comprehensive service requires that technology can be exploited safely and effectively across the whole range of services, particularly in electronic care records, digital consultations, health applications, and other digital solutions, enhanced with the closely governed use of artificial intelligence. This requires significant investment, training, and infrastructure support. Workforce shortages The NHS, like other health systems globally, faces severe shortages of doctors, nurses, and other allied healthcare professionals. Adequate staffing levels are crucial for providing comprehensive care, addressing the needs of the population, tackling health inequalities, and meeting demand. Appropriateness of the founding principles The key test for whether the founding principles are still appropriate is whether they can (in the words of the 1946 Act) “ secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness. ” The five founding principles are connected, and work together to provide an overarching framework for the system, although they can sometimes be in conflict (as seen below). Bevan said that a comprehensive service would “ ensure that every man and woman and child can rely on getting all the advice and treatment and care which they may need in matters of personal health. ” 11 What constitutes a comprehensive service is not simple, however. Services can be provided in a variety of ways: in the community or hospital, for example, or through prevention rather than treatment. Opinions differ on what constitutes effective and necessary treatment and care, and different parts of the community have different needs. Moreover, the financial implications are significant. In the first year of its existence, the NHS spent £32m on optometry against a budget of £1m, prompting the government to introduce charges for dentistry, prescription, and optometry. Successive governments have introduced policies to manage the tensions between providing a comprehensive service and it being free at the point of need. These include: measures of life quality. Technological advances • Exemptions from dentistry, optometry, and prescription charges for children, people drawing a pension, those with disabilities or long term sickness, pregnant women, new mothers, and those in receipt of certain benefits. Only the English NHS still charges for prescriptions. The Scottish NHS provides eye tests and dental examinations free of charge.
the bmj | BMJ 2024;384:e078903 | doi: 10.1136/bmj-2023-078903
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