Four Pillars of NHS in the United Kingdom

Introduction

The National Health Service (NHS) underpins much of the quality of public health that many in the UK experience. Established in 1948, the NHS is the healthcare system run by the government in the four devolved nations of the UK. With origins that date back to the 19th century, it can be defined as comprehensive healthcare, central to the understanding of universal healthcare based on the ideals of normative equity or need. The model is characterized by state ownership and financing, services provided wholly by the public sector, and open to all on equal terms with services aimed at preventing disease and promoting good health, rather than just providing treatment.

Launched at a time when infant mortality until the age of five was high and general infectious diseases accounted for large numbers of deaths, the introduction of a universal healthcare system was part of the call by the then Liberal government to create a land fit for heroes and to reflect the ambitions of a post-war society that had been asked to make many sacrifices.

One of the key principles is that the NHS should be accessible to all and that care should be free at the point of use. The NHS should provide comprehensive and patient-centered care, using the best available evidence and a single episode of care. This is central to the provision of healthcare; the significance lies in a belief that no one should bear the costs of ill health alone. Full details on the principles enshrined within the NHS Constitution are documented coupled with the NHS Outcomes Framework. This document also details the key elements of a healthcare quality framework. The NHS continues to be a beacon of hope, particularly for those less well-off, and is recognized as a cornerstone of British social policy. It was established to provide a high standard of care to all, regardless of their ability to pay, from the tariffs collected from general taxation. The NHS and the pillars upon which it is built are formally recognized in the NHS Constitution - the Four Pillars.

The Four Pillars of the NHS

The National Health Service (NHS) currently in operation in the United Kingdom rests upon four pillars. These four pillars of the NHS are: organizational, financial, workforce, and service delivery. These four aspects are at the foundation of the organizational structure of health provision; in reality, they interplay to determine an effectively working healthcare system. Additionally, their overarching point is to give life to the four core principles of the NHS: that it meets the needs of everyone; that it is free at the point of delivery; that it is based on clinical need, not the ability to pay; and that it is funded through general taxation.

The four pillars that make up the NHS are currently working on a model of service delivery that, while focusing on 'one-stop shop' solutions, takes an integrated and multidisciplinary approach to patient care in large regional health centers that are able to provide a wide range of services. These healthcare models are driven by the promotion of innovation at every strategic level, from a service delivery perspective to payments and financing; furthermore, innovation has given rise to new funding and organizational models able to drive the work of these four pillars, anticipating future human resources, technological, and organizational needs, as well as the emerging pathology. The resulting change is coming at a price, leveraging greatly on innovation while still getting the best from a model of service delivery built on the combination and interaction of all four identified pillars.

Impact and Challenges of the Four Pillars

The impact and effectiveness of the Four Pillars can be seen in each of the following areas. In terms of clinical effectiveness, the safe care pillar contributes to significantly better patient outcomes and drives down harmful events which, in turn, is better for patients and the return on investment to the taxpayer. The integrated care pillar reduces overhead costs and delivers efficiency and access benefits to the system. Concentrating on patient experiences, the patient-focused care pillar delivers increased choice, local flexibility, and options across the country through expanded social prescribing, and reduces unwarranted variation in patient outcomes. Preventative services supported by the public health focus result in improvements in life expectancy and child health outcomes. Despite this indicative list of gains, the NHS is facing insurmountable pressures and difficulties which challenge the ability of the Four Pillars framework to support the delivery of the NHS values at times.

Two key challenges influence the impact of the Four Pillars, which are population and funding. The fundamental components of what underpins safe and good care are slowly being eroded as the NHS attempts to balance previous financial errors. Demographic shifts continue to lead to increases in demand despite the efficiencies gained, and the political pressure to increase the provision of services arrives at times with funds flow issues. Potential gains through the advancement of technology were not entirely successful, with sustained and substantial workforce issues enduring. The failure of these reforms leads to less emphasis and the abandonment of the bigger reforms needed. This has implications for what the NHS values and their priorities. Prioritization amongst patient groups has always had the potential for public outcries, and as such, only limited attempts have been made. New funding would see workforce challenges diminish and could increase access, but only a sustained funding increase providing capacity to balance the public purse holdings, worker requests, and the health needs of the host country. For efficiencies, initially, the GP contract review did deliver significant progress, and as such, the NHS is coming from a high baseline. More recently, the Working at Scale policy represents an advancement in integration needed for service equity. Unlike the contract, the elements that could improve care given its nature are not fully within the control of the enacting party. Proper investment in social care and legislative reforms that enable better housing arrangements are still required, and at such levels, cannot be afforded; otherwise, a choice process needs to be made. The fourth aspect of policies involves reduction in demand. These activities should be ongoing and as such evolve with time. Preventative services will, as most policy changes, have an impact across a 10+ year time horizon due to the slow shift in health improvement outcomes. Overall, the piloting of the Four Pillars has led to multiple benefits for the NHS, but a step change in how the system is supported offers gains in line with the organization’s values and priorities.

Conclusion and Future Directions

The NHS was established in the mid-20th century, with a set of core principles designed to promote fairness, efficiency, quality, and responsiveness. We have highlighted the relevance and importance of these founding principles, explaining how they influence professional codes of medical ethics today. At the same time, we have detailed how the NHS has evolved over the last decades in response to considerable social, political, economic, and institutional change. This process of adaptation is widely recognized as essential, even if values remain fixed. We have demonstrated how all of these approaches to reform and innovation can be understood as attempts to strengthen, or at least to protect, at least one of the Four Pillars. We have also highlighted the novelty, scale, and complexity of the challenges facing the NHS in the 21st century, exploring how these challenges are interconnected. The lack of any insurmountable, objective contradictions between the Four Pillars implies that their use of the value of care should be flexible enough to balance these interconnected challenges.

Our survey of challenges facing the NHS towards the end of 2014 indicated the breadth of current critical concerns and the growing public perception that the NHS was struggling, even before the election of 2015. The challenges faced by the NHS and the new government are, confusingly, both unique and unprecedented in scale and complexity, and yet, as we have also shown, repetitive facets of the ongoing story. Our exercise in this paper has helped to illuminate policy problems — past, present, and potentially future — in relation to two assets that are still combined within the NHS: a nationalized industry of health, illness, care, and cure based on local organizations, and a national service to patients. It has also demonstrated the potential of the Four Pillars to provide clear points of reference for negotiation and deliberation across many diverse discourses and contexts. The way we preserve the NHS is, in the end, a matter of collective political will, to do with how we demarcate and construct a precise value of care. An expression of medical vision of good care offers a range to argue the need, probably most convincingly, to safeguard the Four Pillars for the NHS.

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