History of NHS – 1980-2000

History of NHS – 1980-2000

1980s. Inequalities in Health – Black (1980) and Griffiths (1983) Reports

Key events: Black Report confirmed inequalities according to socio-economic status. Griffiths NHS Management Inquiry Report and White Paper ‘Working for Patients heralded the Internal Market in 1990s. One minor NHS reorganisation. HIV/AIDS spread around the world. Seat belts finally made compulsory.

1980. Public Health. The Black Report commissioned by Labour (in 1977) showed inequalities in access to health services, morbidity and mortality, between social groups (and regions of UK) – and the gap was widening. This was true for both sexes and all ages.

Unfortunately every time the analysis is repeated the difference in longevity between the advantaged and disadvantaged is widening further. This is the Achilles heal of the NHS. Until it is sorted, the NHS cannot be said to fulfilling the original dream. It is vital that we do not stop trying to level up our society, and create high quality healthcare for all, not just the privileged few.

1980. Public Health. The WHO announces the eradication of smallpox.

1981. Pandemic. HIV/AIDS. First AIDs Cases reported in USA.

1982 (April-June) Falklands War

1982. Management. NHS Reorganisation (Minor). Health Services Act 1980. The first Thatcher government considered excess bureaucracy had been created by the 1974 reforms and removed Area Health Authorities (AHAs).

1982. Government. Private Finance Initiative. PFI involves contracting out the design, building, financing and operation of public services to private sector companies through long-term contracts. The initiative introduced competition between private providers to build and finance hospitals. Some consider the system controversial. But the Labour government continued with them upon its election in 1997.

1983 Conservative Government (Margaret Thatcher MP)
1983 Birth of internet
1983–1985 Famine in Ethiopia

1983. Public Health. Seat belt use made compulsory in the UK.

1983. Mental Health. (Second) Mental Health Act 1983 introduced the issue of consent and set out when people can be detained, or ‘sectioned’.

1983. Management. Griffiths Report ushered in a more business-like model in NHS management; with professional, well paid, general managers taking over cost control; and clinical and professional staff (except medical and surgical consultants) becoming responsible to managers.

The Health Services Supervisory Board (HSSB) was created to set policy. It was chaired by the Secretary of State but removed him/her from day-to-day involvement. This morphed into the NHS Management Board in 1985. This board, in turn, became the NHS Executive in 1996 and was disbanded in 2002 to form four Regional Directorates of Health and Social Care (themselves abolished in 2003, with functions absorbed back into the Department of Health)

1983. Regulation. Medical Act 1983 provided the current statutory basis for the General Medical Council’s functions.

1983. Regulation. United Kingdom Central Council (UKCC) for Nursing, Midwifery and Health Visiting replaced the General Nursing Council for England and Wales, the Central Midwives Board and seven other bodies.

1984-85 UK miners’ strike
1985 July 13: Live Aid
1986 Chernobyl disaster in Ukraine

1986. Epidemic. Bovine spongiform encephalopathy (BSE; ‘Mad Cow Disease’) affected cows in the UK in the 1980s and 1990s. A variant crossed into humans.

1986. Public Health. First AIDS Health Campaign: ‘AIDS: Don’t Die of Ignorance’ to raise awareness of HIV.

1986. Clinical. Cardiac Thrombolysis. A study, published in The Lancet, was the first to demonstrate the efficacy of cardiac thrombolysis (streptokinase) in acute myocardial infarction.

1987 Conservative Government (Margaret Thatcher MP/John Major MP)
1987 World population reaches 5 billion

1987. Government. ‘Promoting Better Health’ government white paper focused on health promotion and prevention reforms. The government reviewed payments systems for GPs to encourage efficiency and boost preventive medicine, leading to changes in the GP contract in 1990.

1987. Clinical. SSRI antidepressant fluoxetine (marketed as Prozac) becomes commercially available.

1988 December 21: Pan Am Flight 103 destroyed by bomb and falls over Lockerbie, Scotland
Flora Swire was one of 270 killed. She was an outstanding Nottingham medical student taught by Andy Stein, co-founder CKDEx

Flora Swire, killed on Pan Am 103. She was 23 years

We as doctors and health professionals should rise above hate, and focus on our patients, equity and equality
That is what she would have wanted

1988 Construction of the Channel Tunnel begins

1988. Public Health. Breast and Cervical Cancer Screening. Mammograms introduced for women aged over 50, and cervical cancer screening for women aged 20 to 64 years.

Breast cancer screening

1989 Fall of the Berlin Wall
1989 Tiananmen Square protests

1989. Government. ‘Working for Patients’ government white paper outlined very significant changes to the system, especially the ‘Internal Market’. It also focussed on improving patient choice, experience and satisfaction, the recommendations led to changes which would mould the NHS as we know it now.

• Introduction of an ‘internal market’ through the separation of ‘providers’ (e.g. GPs and hospitals) and ‘purchasers’ (commissioning or buying healthcare) – the ‘Purchaser/Provider split’
• Establishment of independent (later Foundation) ‘Trusts’, directly accountable
  to government
• Creation of ‘fund-holding GPs’ enabling them to buy hospital services directly
  (mainly outpatient services, elective operations, care and diagnostic procedures)
• Use of non-legal ‘contracts’ for payment for services between purchasers and
  providers
• Change to a capitation (weighted population) basis (‘tariff’) for purchasing
  services for a given population; in place of direct funding of service
• Introduction of capital charges for buildings/equipment
• Promotion of medical audit and job plans for consultants.

1990s. Internal Market – NHS and Community Care Act 1990

Key events: ‘Internal Market’ (introducing ‘purchasers’, ‘providers’ and ‘GP fund-holders’) started by Conservative Party. This started to happen in the early 90s, and was a key turning point for the NHS. NHS performance markers (‘targets’) devised, along with regulatory organisations, such as the NICE and CHI (later CQC) – made the NHS more efficient (and safer) but also more complex. A lot else happened in this decade.

By 1990, the foundations of the modern NHS were in place. There was a structure, with local commissioning organisations (made up of GPs and lay representatives), purchasing the services of secondary and tertiary care centres.

There was only one major restructuring in the first forty years of the NHS (1974) and one minor in the 1980s. But in the last thirty, there has been an acceleration, with major reorganisations instituted in 1990, 1995 (i.e. two major ones in the 90s, two minor), 2001, 2013 and ‘now’ (2021-2).

Important performance markers (‘targets’) were devised, along with regulatory organisations, such as the NICE and CHI (later CQC). All of this may have made the NHS more efficient (and safer) but also more complex.

A lot else happened in the 90s. This includes the introduction of:

• ‘Internal Market’ (introducing ‘purchasers’, ‘providers’ and ‘GP fund-holders’). This started to happen in the early 90s, and was a key turning point for the NHS
• Independent hospital ‘Trusts’
• Patient’s Charter (suggesting ‘targets’)
• Focus on junior doctors’ hours
• Percutaneous Coronary Intervention (PCI)
• Organ donor register
• Minor Injuries Units
• Stroke Thrombolysis
• NHS Direct
• National Institute for Clinical Excellence – later National Institute for Health and
  Care Excellence (NICE)
• Primary Care Groups (later PCTs)
• Commission for Health Improvement (later Healthcare Commission, then CQC)
• National IT strategy
• National Service Frameworks.

1990 February 11: Nelson Mandela is released after 27 years as a political prisoner
1990-91 Gulf War

1990. Management. NHS Reorganisation (Major). The NHS and Community Care Act 1990 enacted ‘Working for Patients’. This introduced the ‘NHS internal market’ in which District Health Authorities (DHAs) and GP-fund holders (later PCTs then CCGs, then ICSs) were to act as ‘purchasers'(and theoretically planners) of health services. They were to be separated from ‘providers’ (e.g. hospitals and GPs).

Hospitals were encouraged to apply for self-governing ‘trust’ status. If granted they became semi-autonomous and were to act in a more business-like manner.  This meant that service planners had a range (‘choice’) of care providers to choose from and this is commonly referred to as the NHS ‘internal market’. Patients were also to be given a choice of providers, with target performance (see below) telling them which is ‘best.

General practices were given ‘fundholding budgets’ subtracted from the host DHA’s budget. Initially only larger practices, with over 11,000 patients could apply for fund holding status. Some groups of fund holders formed ‘multi-funds’ to share resources and offer a more robust basis for planning services. By 1997, there were 50 multi-funds in existence covering 3 million people.

Concern grew about the cost of management to run this new internal market (not a market really, as the NHS has a monopoly). In fact, the NHS spends only about 3% of its budget on management much less than most industries.

1990. Regulation. Human Fertility and Embryology Act 1990 created the Human Fertilisation and Embryology Authority.

1990. Management. GP Contract Changes. Following proposals in the 1987 White Paper ‘Promoting Better Health’, the new contract incentivised GPs through performance-related payments. Following negotiation, the Secretary of State allowed seniority payments to remain, but GPs did not welcome the new arrangements.

1990. Public Health. Food Safety Act 1990. Made it a statutory obligation to treat food intended for human consumption in a controlled way.

1990. Technology. First Laparoscopic Cholecystectomy in UK.

1991. Management. First NHS Trusts. As part of the internal market, hospitals could apply for ‘trust status’, giving them more financial and governance independence. 57 NHS trusts were established on 1 April 1991 under the NHS and Community Care Act 1990.

1991. Management. Junior Doctors Hours. The Government announced no junior doctor should be working more than 83 hours a week by the following April. The UK and European averages at the time were 89 and 59 hours, respectively. Their working hours were limited by law in 2004 to 58 hours a week; and then, by 2009, to 48 hours.

1991-2. Government. Health of the Nation (HoN) White Paper and Patient’s Charter. The report highlighted the responsibilities of health authorities to concentrate on cost-effective strategies for dealing with major causes of ill-health; and emphasised the actions that individuals could take to safeguard their own health. The report led to a Patient’s Charter which set out the rights of patients in the NHS. It was revised in 1995 and 1997, before evolving into the NHS Constitution in 2009.

Broad targets were set for the improvement of health in the nation to be achieved within four years, including: reduced waiting times for an emergency ambulance (14 mins for urban areas, and 19 mins in rural districts); 5 minute wait in A&E; limited cancellation of operations; named nurses, named midwives and health visitors responsible for patients’ care; arrangements for discharge from hospital; waiting times for out-patients (30 minutes to be seen, and no more than two years for treatment).

1992 Conservative Government – John Major MP
1992 February 7: Maastricht Treaty creates the European Union

1992. Research. UK Cochrane Collaboration. This international network was established to prepare, maintain and disseminate systematic reviews of research on the effects of healthcare – as part of a drive towards evidence-based medicine.

1992. Management. Tomlinson Review recommended the merger of Guy’s and Thomas’ hospitals and the closure of Charing Cross, Middlesex, and St Bartholomew’s alongside ten smaller hospitals. The government accepted the report. While Middlesex closed, and Guy’s and Thomas’ did merge, most of the recommendations were not implemented because they were too controversial.

1993. Education. Calman Report reduced the minimum length of consultant training to seven years and introduced explicit curricula leading to a ‘Certificate of Completion of Specialist Training’ (CCST). After this, a UK doctor could be added to the GMC’s ‘Specialist Register’ and apply for consultant posts. ‘Registrar’ and ‘Senior Registrar (or ‘SR’)’ (middle stage of training) grades were merged into the Specialist Registrar (‘SpR’) training grade, and later the Speciality Trainee (‘ST’) grade.

CCST is now called Certificate of Completion of Training CCT.

The GMC now has an alternative route to becoming a consultant or general practitioner: Certificate of Eligibility for Specialist Registration (CESR) or Certificate of Eligibility for GP Registration (CEGPR). This system is for doctors, who have often trained abroad, to recognise their skills and previous experience. More info on these here.

1993. Public Health. Clean Air Act 1993. This dealt with issues such as height of chimneys on trade and industrial premises and the use of authorised fuels.

1993. Technology. Percutaneous Coronary Intervention (PCI) / Stents.

1993 May 10: End of apartheid in South Africa and election of Nelson Mandela
1993 May 6: Opening of the Channel Tunnel

1994. Public Health. Organ Donor Register.

1994. Clinical. First Nurse-led Minor Injuries Unit.

1994 Amazon founded in Bellevue, Washington by Jeff Bezos

1995. Research. Stroke Thrombolysis.

1995. Management. NHS Reorganisation (Major). Health Authorities Act 1995. The fourteen regional health authorities (RHAs) were abolished and replaced in 1996 by the ‘NHS Executive’, and its eight regional offices. The 192 DHAs were replaced by 95 larger ‘Health Authorities’.

1995 March 20: Tokyo subway sarin attack
1995 July 5: Dolly the sheep becomes first successful cloned mammal

1996. Epidemic. Bovine Spongiform Encephalopathy (BSE; ‘Mad Cow Disease’). Research published in March 1996 showed the link between BSE in cows and Creutzfeld-Jakob disease (vCJD). The first victim of a variant of  (vCJD) died in 1995, closely followed by three more similar deaths.

1996. Social Care. Community Care (Direct Payments) Act 1996 gave local authorities the power to make direct payments to people aged 18-65 years who had been assessed as needing community care services.

1997 Labour Government – Tony Blair MP
1997 August 29: Netflix launched

1997. Management. NHS (Primary Care Act) 1997 facilitated the piloting of different types of primary care contracting arrangements and established mechanisms for the direct employment of GPs (‘salaried GPs’).

1997. Public Health. First Minister of Public Health. The post had disappeared by the time of the COVID-19 (C19) – which probably contributed to our poor performance.

1997. Government. ‘The New NHS: Modern, Dependable’ government white paper. The purchaser/provider split continued, with ‘purchasing’ rebranded as ‘commissioning’. It also proposed publishing comparative information on NHS trust performance, which evolved into ‘targets’, e.g. the 4-hour A&E wait – drawing categories from the Patient’s Charter.

Health authorities were to adopt a more strategic role, with a three-year Health Improvement Plan (‘HimP’), involving local Trusts, PCGs and LAs. Two new arms lengths bodies, the CHI (inspector) and NICE (standard maker) were to form. The CHI were to inspect hospitals every 3-4 years. NICE was also to oversee the production of health policy standards called National Service Frameworks (NSFs).

The idea was that NICE would ‘tell doctors what to do’ and the CHI would ‘check that they did it’. Doctors didn’t necessarily see it that way.

The white paper was enacted in 1999, when the CHI, NICE and NSFs started.

1997. Epidemic. Avian Flu outbreak. An outbreak of Influenza A virus subtype H5N1 occurred in Hong Kong. Another outbreak of a different variant (Influenza A virus subtype H7N9) occurred in 2013, with a higher mortality.

1998 April 10: Good Friday Agreement brings an end to The Troubles in Northern Ireland

1998. Employment. Working time regulations. Junior doctors were initially exempt from the 48-hour average working week outlined in the regulations, but their working hours needed to fall in line by 2009.

1998. Public Health. Sure Start programme. During his comprehensive spending review speech, the Chancellor Gordon Brown, announced a programme to improve support for children in the early stages of their life.

1998. Public Health. Independent Inquiry into Inequalities in Health Report (Acheson Report) found that despite an overall downward trend in mortality from 1970–1990, the upper social classes experienced a more rapid improvement. This showed little progress had been made since the Black Report in 1980.

1998. Information Technology. NHS Direct. A telephone service for non-emergency health problems was rolled out across England in 2000, followed by Wales in 2001; replaced in 2013 by ‘NHS 111’ in England, Wales and Scotland.

1999 World population reaches 6 billion

1999. Public Health. ‘Saving Lives: Our Healthier Nation’ white paper set a national target of 300,000 lives saved over the next decade with a specific focus on: cancer, coronary heartdisease and stroke, accidents, and mental illness.

1999. Public Health. National Institute for Clinical Excellence (NICE). Created to serve the English and Welsh NHS, NICE is an independent organisation providing national guidance on health promotion and the prevention and treatment of illness.

1999. Management. NHS Reorganisation (Minor). Health Act 1999. Formally abolished GP fundholding and made provision for the establishment of primary care trusts (PCTs, which would evolve from primary care groups, PCGs). PCGs were to be based on about 50 GPs serving 100,000 people. The Commission for Health Improvement (CHI) was formed as the first organisation to assess the clinical performance of NHS hospitals. It was subsumed by the Healthcare Commission in 2001, which became the Care Quality Commission (CQC) in 2009.

1999. Management. NHS Performance Assessment Framework (PAF) was established with the aim of delivering a broader view of performance in the NHS.

1999. Information Technology. NHS Information Authority (NHSIA) (Establishment and Constitution) Order 1999 brought together four NHS IT and Information bodies in England. It became part of Health and Social Care Information Centre (HSCIC) in 2005.

1999. Public Health. Food Standards Agency Act 1999. The aim of the agency was to would promote high standards throughout the food chain, from the point of production to the point of consumption.

1999. Management. National Service Frameworks (NSFs). These 10-year plans for chronic conditions which included an NSF were issued for mental health in 1999, and for coronary heart disease in 2000. Experienced clinicians advised the Chief Medical Officer (CMO), becoming Health Directors, or ‘tsars’, driving clinical policies for cancer, heart disease, mental health, and older people’s services. NSFs were discontinued in 2013.

Other resources

The Health Foundation have an extremely good timeline here.
The Nuffield Trust has a detailed history of the NHS here.
The BBC has historical charts here.