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Chapter: Hospital pharmacy : Hospital pharmacy within the National Health Service

The NHS became a reality in the UK on 5 July 1948. It provided general practitioner (GP) and hospital care, free at the point of delivery on the basis of need.



The NHS became a reality in the UK on 5 July 1948. It provided general practitioner (GP) and hospital care, free at the point of delivery on the basis of need. There was optimism that good healthcare would mean a healthier nation and thus a decreasing demand for health spending. This hope of reduced demand has not been fulfilled, with demographic change, increased expectation and the ability to do more meaning an ever-increasing requirement for funding. An early response to this increase was the introduction of fees  prescription charges and dental treatments. However, the majority of care has remained free, with the NHS funded from general taxation. The 2010 White Paper, Equity and Excellence, reconfirmed the coalition government’s commitment to a comprehensive service free at the point of use based on clinical need.


Twenty-six years after its formation, the first of the major reorganisations of the NHS in England took place; the 1974 change was preceded by changes in the service in Wales and Scotland. In England, a triple-layer NHS was established above the individual hospitals. Regional health authorities (14 in all) were made responsible for area health authorities (90) which, in turn, managed district management teams (206). Within area health authorities, a parallel structure of family practitioner committees overseeing general practice was established. This change gave the opportunity to organise pharmacy services beyond individual hospitals, creating cooperation in an area pharmaceutical service along the lines of the Noel Hall report.


During the 1980s and 1990s further changes occurred with area health authorities removed and general management brought in by the Griffiths report. This change resulted in a reduction of the influence of senior medical and nursing staff within hospitals, with decision-making moving to general managers. A very different climate has prevailed in more recent times, retaining strong leadership but bringing clinicians in as key partners with general managers. The NHS and Community Care Act in 1990 introduced purchasers and providers of care. This split meant that responsibility for delivering healthcare (the operations, the clinics, and so on) and arranging healthcare for local populations (setting the targets for how many operations, asking for certain new services) was divided between different organisations that no longer had a direct management link. Hospitals, community health services and ambulance services became trusts. Trusts had more local control to allow them to work within the ‘market’ and to arrange their own finances. General practices could become fund-holding, responsible for their prescribing bud-get, arranging and paying for elective surgery (planned work such as hernia repairs and hip operations) and for practice staff. Though never a true ‘market’, there were opportunities for GPs to change the hospital to which they referred patients. This ‘internal market’ was criticised for creating a raft of invoicing and activity counting.


In 1997, a Labour government was elected with a commitment to ‘put right’ the NHS. The internal market was abolished but with no return to line management controls from the centre. A ‘third way’ of partnership and collaboration was to be brought in. A White Paper The New NHS: Modern, Dependable set out the revised structure. The purchaser–provider split was to stay, as were hospital trusts, but fund-holding was abolished, replaced by primary care groups that could evolve to primary care trusts (PCTs). In addition to these structural changes, the issues of quality of care and of health inequalities and reducing avoidable deaths were raised in A First Class Service. and Our Healthier Nation. The ‘new NHS’ saw the terminology of the market removed. Service agreements replaced contracts and purchasing was replaced by commissioning.


In 2001, further significant changes to the structure of the NHS in England were identified in the document Shifting the Balance of Power Within the NHS: Securing Delivery. PCTs became the norm and strategic health authorities were established (28 at first, later reduced to 10). During the following years, further steps were taken to improve the NHS, though with the devolved responsibilities the changes were for England, with an increasing difference between the other UK countries.


In 2002 the Secretary of State for Health announced the plan to create foundation trusts NHS organisations that would have greater freedoms, including the freedom from health authority performance management. The first foundation trusts came into existence in 2004, though perhaps the free-doms first envisaged were rather weaker in reality.


At the same time as these structural changes, the NHS saw very significant levels of investment. Government had made a commitment to see NHS expenditure grow in real terms and to reach European average as a percentage of gross domestic product. Redesign around the needs of the patient was a recurring phrase. Many targets for change on both broad and detailed levels were set out:


·      reduced waiting times; for example, no more than a 6-month wait for an operation, to be achieved by 2005, later further reduced to an 18-week maximum by the later 2000


·      maximum waiting time for accident and emergency departments – 98% of patients to be sent home or to a ward within 4 hours


·      national standards to see good care everywhere


·      best-practice spread, supported by the National Institute for Health and Clinical Excellence (NICE)


·      more patient and user involvement in the NHS


·      breaking the demarcation barriers between professions, including allowing nurses and pharmacists to prescribe


·      significant investment and significant expectations.



Creating the additional capacity to reduce waiting lists also led to the creation of independent sector treatment centres privately run facilities providing NHS care, commissioned by PCTs. By 2005 there were around 25 such centres. Chapter 2 deals with this in greater detail.

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