The timelines below follow the NHS from 1940 to 2017 and identify many of the main developments:

http://nhstimeline.nuffieldtrust.org.uk/

This website includes many of the main legislative changes since the 1940s and includes an interactive component, which will help you to explore particular issues in more depth.

http://www.nhs.uk/NHSEngland/thenhs/nhshistory/Pages/the-nhs%20history.aspx

This website is useful for providing some of the key legislative developments and also the medical milestones, running from 1948 to the present.

Timeline:

1980

• The Black Report on Health Inequalities – established social class differences in health.  Thus those defined as social class 5 have poorer health than those in social class 1.

1982

• NHS reorganisation

1983

• Griffiths Report on NHS management

1986

• Project 2000 which moved nurse training into higher education
• Cumberledge Report, reform of primary health care

1987

• Improving Better Health, white paper for improving patient choice

1988

• NHS Review chaired by Margaret Thatcher

1989

• White papers, Caring for People and Working for Patients established a broad framework for NHS reforms.  Including the internal market, the purchaser/provider spilt and GP Fundholding.  It also led to:

1990

• National Health Service and Community Care Act
• New GP contract with a greater Health Promotion focus

1990

• John Major replaces Margaret Thatcher as Prime Minister

1991

• White paper Health of the Nation identifies a number of important areas for improving health
• The Patients Charter, advocating the view of the patient as a customer

1994

• NHS reorganisation, the number of regional health authorities were reduced

1996

• NHS white paper, Primary Care: Delivering the Future

1997

• The NHS Primary Care Act, increasing choice in primary care
• May: Election of a  Labour government
• NHS White Paper, The New NHS: Modern and Dependable   

1998

• Acheson Report into inequalities in health
• A  first class service: Quality in the new NHS aimed to end ‘unacceptable variations’ in care and setting up the National Institute  for Health and Clinical Excellence
• The Bristol Royal Infirmary inquiry was set up to investigate the failings in providing care to children   requiring cardiac surgical services.  It reported in 2001.
• NHS Direct set up to provide a national help line
• The Acheson  Report into inequalities in health, found inequalities by socioeconomic and ethnic group and gender across a wide range of measures

1999

• Royal Commission on Long Term Care reviewed funding options for Long Term Conditions for older people
• NHS reorganisation, abolished GP Fundholding and established new Primary Care Groups   
• White Paper Saving  lives: Our healthier nation, follow up to the 1991 white paper    

2000

• The NHS Plan a 10 year modernisation programme of investment and reform

2001

• Commission for Health Improvement created, the first organisation to formally assess NHS hospital’s performance
• The Health and Social Act, sets out the NHS plan     
• Introduction of hospital star rating system

2002

• NHS reorganisation, District Health Authorities are replaced by Strategic Health Authorities and Primary Care Trusts
• Wanless Review, established the need for increased health and social care resources

2003

• New contract for GPs and hospital consultants, changing delivery of services to patients
• Agenda for Change, standardisation of pay/conditions for the majority of NHS staff

2004

• Establishment of first 10 Foundation Trusts, with more control over their budgets/services
• Plans for GP practices to be involved in commissioning health care services through ‘practice based commissioning’ policy
•  White paper on public health, Choosing Health: Making healthy choices easier

2006

• NHS reorganisation, Strategic Health Authorities decreased from 28 – 10 and number of Primary Care Trusts decreased from 303 – 152
• White paper Our health, our care, our say: A new direction for community services, to encourage patient choice and move services from hospital to community

2007

• Gordon Brown replaces Tony Blair as Labour Prime Minister
• Conservative party publish a white paper setting out their vision for the NHS
• Smoking ban introduced in England

2008

• NHS Next Stage Review, by Professor Sir Ara Darzi, a 10 year vision for the NHS
• Scotland’s ‘Equally We’ report, into health inequalites 

2009

• NHS Constitution
• New health and social care regulator created, The Care Quality Commission
• NHS Chief Executive David Nicholson warns NHS needs to prepare for major efficiency savings, of £20billion by 2014

2010

• Sir Michael Marmot’s ‘Fair Society, Healthy Lives’ report
• February, publication of Robert Francis Inquiry Report into the Mid-Staffordshire NHS Foundation Trust
• May, General Election leads to no overall winner, but a Coalition emerges between the Liberal Democrats and Conservative parties, with David Cameron as Prime Minster
• June, a public inquiry into Mid-Staffordshire announced
• June, white paper, Equity, excellence: Liberating the NHS, led to major criticism
• November, government’s vision of public health, Healthy lives, healthy people

2011

• Increasing opposition to the Health and Social Care Bill, led to the Prime Minster ‘pausing’ its passage through Parliament for a ‘listening exercise’ by the NHS Futures Forum

2012

• March, after 18 months and numerous amendments the Health and Social Care  Act is passed

2013

• February, publication of Sir Robert Francis public inquiry report into Mid-Staffordshire NHS Foundation Trust
• April, ‘new’ NHS comes into being as responsibilities shift to newly created bodies 
• October, Simon Stevens appointed as Chief Executive of the NHS

2014

• May, Care Bill receives Royal Assent
• October, NHS England publishes its Five Year Forward View

2015

• January, Labour announce their Ten Year Plan for Health and Care
• May, Conservative party form a majority government
• November, junior doctors vote in favour of strike

2016

• April, NHS Improvement launches
• June, UK votes to leave the European Union 

The health of the population in the UK has improved dramatically over the last century, in terms of morbidity and mortality.  However these health gains are not equally shared, thus people with higher incomes tend to live longer and healthier lives than people living on lower incomes (Marmot, 2010).  Income tends to be equated with social class and other characteristics tend to make a difference to people’s life chances, including gender, ethnicity, sexuality, age and geography.   The socioeconomic determinants of health clearly link social conditions and health and this is a crucial aspect to improving health (Marmot, 2010).  Thus health inequalities have been defined as the ‘differences in health status or in the distribution of health determinants, between different population groups’. (WHO, 2013a).  The social conditions of health relate to the conditions in which people are born, grow up, live and work and include housing, education, financial security, the built environment and the health system.  The WHO (2013b) argues that these conditions are then shaped by each country’s economic, social and political policies.  It is generally recognised these social determinants are responsible for significant levels of unfair health inequities.  However political ideology drives the UK governmental response to this. It is imperative nurses understand and recognise the impact these social determinants have on health (RCN, 2012).   Therefore tackling health inequalities is an important aspect of UK public health policy and of concern to all health care professionals.

Northern Ireland

Northern Ireland adopted a broad strategy on social justice and equality, since the early 1990s Due regard must be paid to inequalities and this is a legislative duty in Section 75 of the Northern Ireland Act which followed the 1998 ‘Good Friday’ or (Belfast) Agreement.   Targeting Social Need (TSN) was first launched by the Conservative government in 1991 to tackle significant socio-economic differences between the Catholic and Protestant communities in Northern Ireland.  In 1997 the new Labour government strengthened this policy and re-launched it as New TSN and published a white paper in 1998 entitled ‘Partnership for Equality’. 

The New Targeting Social Need (New TSN) was a cross Departmental policy aimed at tackling social need and social exclusion  and has similar strategies to Britain, designed to combat deprivation, disadvantage, poverty and social exclusion.  The policy requires resources to be targeted towards people, groups and areas.in greatest need.  New TSN has three complementary elements: tackling problems of unemployment and increasing   employability; it was concerned with social need in areas such as health and social care and includes Promoting Social Inclusion in (teenage pregnancy and motherhood, ethnic minorities and the Travelling community); and a cross-departmental and evidence based approach to tackling the causes of social exclusion.

Northern Ireland’s main public health policy is ‘Investing for Health’ (IFH) (2002) and it focuses on the social determinants of health with the goal to improve the health status of all Northern Ireland’s citizens and reduce inequalities in health.  It sought to shift the focus towards tackling the factors which adversely affect health and perpetuate health inequalities.  It also sought to implement action to address the wider determinants of health, using a framework based on inter-sectoral partnership at the governmental and local levels. It adopted a range of approaches to address the issues of: smoking, drugs and alcohol misuse, obesity, suicide and mental health. 

In 2010 it was proposed the ‘Fit and Well – Changing Lives 2012–22’, strategy would replace the IFH public health strategy.  It is based on the same principles, aims and values as IFH, whilst adopting a life course approach.  It is planned to be outcomes focused, with an emphasis on health inequalities and the social gradient to engage and empower individuals, families and communities.  The strategic priorities are focused on early years and supporting vulnerable people and communities.  Whilst the priority areas for collaboration are: support for families and children; equipped for life; employability; volunteering/giving back; use of space and assets and using arts, sports and culture.  This is to be implemented in a whole systems manner with partnership at the following levels, governmental, regional and local. 

In 2013 following consultation on the draft framework of Fit and Well – Changing Lives the strategic framework ‘Making Life Better – a whole system framework for public health (2013-23)’ built on this.  The 2011 review of health and social care ‘Transforming Your Care’ also identified the need to tackle health inequalities and to refocus care provision from acute to community settings.

Wales

Wales also places great emphasis on equity in terms of health inequalities and unequal access to health care, which was acknowledged in Better Health: Better Wales (1998).  It included renewed efforts to tackle poverty and inequality, a health inequalities fund, evaluation of the impact of NHS spending on equity and a new formula to allocate health resources on the basis of need.  The health inequalities fund was established in 2001 to target resources at disadvantaged populations, relating to heart disease, workplace health and lifestyle advice.  Wales has a unified public health system, Public Health Wales which provides specialist public health support.  

Our Healthy Future set the foundation for public health and this was underpinned by a number of national plans.  Thus the action plan aimed at reducing health inequalities, was called ‘Fairer Health Outcomes For All: Moving the Agenda Forward’ (2011) and there were also plans for tobacco control and sexual health and well-being.  The action areas were: building health into all policies; giving every child a healthy start; developing health assets in communities; improving health literacy; making health and social services more equitable; developing a healthy working Wales and strengthening the evidence base.    It aims to tackle avoidable and unfair differences in health, including: alcohol and drugs misuse, unhealthy diets and inactivity; smoking; reducing the number of teenage pregnancies; improving people’s mental wellbeing; increasing immunisation rates and decreasing the number of accident and injuries.  It includes unfair impact on individuals, from service provision or taxation policy.  It supports other government objectives linked to health, including the environment, economic development and child poverty. 

In 2016 the Strategic Equality Plan for 2016-20 set out what actions the government would take across all departments to drive equality and inclusion through its policies, funding and legislation. 

Scotland

Scotland has some of the worst life and health life expectancy rates in Western Europe and tackling them has remained difficult, despite on-going Scottish government commitment to tackle health inequalities, as part of a wider social justice programme. The poverty and social exclusion strategy ‘Closing the Opportunity Gap’ is cross-departmental and it set targets to reduce health inequalities between people in deprived and affluent areas.  In 2008 the ministerial review of the health inequalities strategy ‘Equally Well’ set out four priority areas for action to reduce health inequalities.  These were: children’s early years intervention, mental illness and well-being, the ‘big killer’ diseases such as cancer and heart disease and drug/alcohol problems, especially amongst young men.   The underpinning philosophy was on prevention and to improve circumstances and environments to improve people’s lives and health; to address intergenerational factors which perpetuate inequalities; to engage individuals, families and communities in their own health and to deliver public services that are targeted to those most in need (Ham, 2011).   

This included further development of support services for families with young children, increased investment in the Family Nurse Partnership model, healthy weight initiatives and more help for those with depression and anxiety.  A target was set to increase the proportion of income received by the poorest 30% of households by 2017 and increase healthy life expectancy at birth, in the most deprived areas.  The Scottish Chief Medical Officer has adopted a so called ‘asset-based approach’ which aims to build community capacity, resources and control to improve health and broad political support continues for preventative activity.

England

In 1997 the Labour government health policy had a central focus of tackling health inequalities.  In 2004 it set a target to reduce the gap in life expectancy in the population by 10% by 2010.  It also recognised the importance of improving the life chances of children, to tackle inequalities (Every Child Matters, 2003).   Economic well-being was one of the key goals here, with the aim to halve child poverty within a decade.  However neither target was or has been met.

The 2010 - 2015 coalition government stated it was committed to decreasing health inequalities and it did broadly support the Marmot Review. However public health policy seems to have shifted towards focusing on ways of changing health behaviour by encouraging personal responsibility for health and transferring this responsibility to local authorities (Healthy Lives, Healthy People, 2010).  Thus, direct responsibility for improvements in health lies with local authorities and Health and Well-being Boards.  The aim is for them to maximise the health benefits in all policies.  There is also an awareness of the interdependent nature of different government departments and policies and how they impact on health outcomes.  However Ham (2011) argued that the Coalition government’s economic policy and public expenditure cuts were likely to lead to a widening of health inequalities.     Buck (2017) agrees and adds there has been little focus, reach or ambition in this policy area.  Rather the focus has been on diversity and equality, especially amongst the NHS workforce and at cross-government level there has been no discernible, coherent or systematic approach to health inequalities, since 2008 (Buck, 2017).  

Common themes across the four UK countries include: recognition of the complexity of tackling health inequalities; the importance of early year’s interventions and the need to give children the best possible start in life; the use of evidence based practice; the need to work across government departments in partnership and approaching this from the framework of Marmot’s social determinants of health.    

Divergent themes across the four UK countries include: health, housing and changes to the UK welfare benefits system.  The other three countries are concerned about the operation of the welfare benefits reforms in their countries as well as the differing approaches to reducing poverty, unemployment and inequalities.

CONSERVATIVE

• Health policy
  • Increase NHS spending by a minimum of £8bn in real terms over the next five years.
  • Make it a priority in the Brexit negotiations that the 140,000 staff from EU countries can carry on their contributions to NHS and social care.
  • Build and upgrade primary care facilities, mental health clinics and hospitals.
  • Recover the cost of medical treatment from non-UK residents.
• Social policy
  • Include value of family home in means test for people receiving social care at home
  • Cost of care to be capped and people guaranteed to keep £100,000 of assets once care bill paid
  • Allow deferral of care bills until after death to ensure no-one is forced to sell family home

LIBERAL DEMOCRATS

• Health policy
  • 1 pence on income tax to raise £6bn per year to be spent only on the NHS and social care services.
  • Mental health waiting time standards to match those in physical health care.
• Social policy
  • Better integration of health and social care and implement a cap on the cost of social care

LABOUR

• Health policy
  • Scrap NHS pay cap and commit to over £30bn in extra funding over the next parliament
  • One million people to be taken off NHS waiting lists by guaranteeing access to treatment within 18 weeks
  • Free parking in NHS England for patients, staff and visitors
  • Increase funding to GP services and ring fence mental health budgets
• Social policy
  • Reverse privatisation and return health services into public control
  • Lay the foundations of a National Care service and put an extra £8bn into social care over the next five years

SCOTTISH NATIONAL PARTY

• Health policy
  • Additional NHS spending across the UK and commitment to increasing NHS Scotland budget by £2bn
  • Additional £1.7bn to be invested in Scotland’s health and social care partnerships over next parliament
  • Call on new UK government to increase health spending per head of population in England to current Scottish level which is 7% higher
• Social policy
  • Maintain and always protect free personal and nursing care in Scotland

This chapter has illustrated the importance of viewing health policy in a political context, which includes a broad analysis of health policy, when providing holistic care for your patient.  This includes all the dimensions of health, plus politics, economics, social and environmental processes.  When you have the opportunity to assess a patient try and structure your assessment, with this framework in mind.  Afterwards reflect on this with your mentor.