Introduction
For policies to come into being there must first be a perceived social problem. However, the existence of a problem is not sufficient to guarantee that policy will be implemented (or changed) to affect the problem. Along with the existence of the problem there must also be the means to draw attention to it. This can come about, for example, through the actions of pressure groups, or through media attention. Even when these conditions are met there may be a perceived change in policy or perhaps a change in the emphasis of a policy, but this may be just a token gesture. If, for example, insufficient resources are set aside for the implementation of the policy then any changes made may have no effect (, 1982). This chapter will discuss some of the influences on social and health policies and how they are formulated and implemented in the UK.
Medical System in UK
Similar to other developing countries, UK has maintained to look for further efficient, suitable and competent income of rewarding the health needs of its increasing population. Past efforts towards equal accessibility to and availability of, health facilities in the country have not been successful.
Like any other third world countries UK has traditional and “Western” medical practices present everywhere.(, 1982) Colonialism, and its outcome, has had a foremost effect on guides of utilization of medicines, pharmacy education and services. In UK, in addition to the Western, or formal government, sector, the traditional health care sector, which includes herbalists and spiritual healers, remains an important source of health care that people move between the different health care sectors in addressing their health problems is widely documented. Factors such as the type of problem, availability of services, beliefs about the etiology and appropriate management of disease and the success of treatment determine how and why people resort to care in the different sectors. In UK, a Centre for Scientific Research into Herbal Medicine has been established and initiative as “an attempt to modernize and incorporate traditional herbal knowledge and treatment into the formal health sector”.
UK’s budget in health services has carried on to be confronted excessively to obtainable hospitals and other curative medical care, majorly for the urban minority. The result has been a denial of basic health care services to a large segment of the UK population, especially those in the rural areas. Some basic health indicators show that the health status of UK remains poor. Life expectancy, for instance is below fifty years compared to seventy five in developed countries. About 33 percent of all reported deaths are attributable to infectious and parasitic diseases that are preventable. The mortality rate among fewer than five year olds is high. Although this age group comprises only 25 percent of the population, it contributes almost half of all deaths in UK, 70 percent of these deaths caused by infectious diseases are usually compounded by malnutrition. Diseases such as malaria, measles, pneumonia and diarrhea remain serious health hazards.
There are three different sectors in the medical care of UK such as home remedy, traditional medical sector and modern medical system. In the home remedy sector, usually the first therapeutic intervention resorted to by most people, self-medication is the usual practice. The sick person initially consults friends, relatives, neighbors or experts about treatment modalities known to them for particular illnesses. Some local herbal preparations or patent drugs bought from a drug store or the pharmacy are used. This sector which (1983) has called the “popular sector” can be thought of as a matrix containing several levels: individual, family, social network and community beliefs and activities.
Diseases and illnesses are first described and health care activities initiated by the patient or therapy managing group. Interaction with the other sectors of health care depends on how health problems is perceived and sanctioned by the sick person and most importantly, by relatives and close friends. A range of possible alternatives are thereby opened. The symptoms of illness may entirely be disregarded, treatment modalities known to the sick person or friends of the sick or neighbors in the locality may be instituted or a decision may be made to move beyond this sector to seek the services of either traditional healers or modern medical practitioners.
Traditional Medical System in UK
Traditional medicine has been part of the culture of the people of UK. (Kleinman:1983)The traditional medical system comprises not only herbal cures or remedies for specific diseases but also the people’s medical taxonomy, folk knowledge, guidelines, traditional and values, health behavior rules and patterns, supportive social institutions and identified personnel and structures for delivery of preventive and restorative therapy.
Traditional medicine is not a unified system in UK. There are many types of practitioners available, each with their own method of diagnosis and therapy.(Janzen:1978) There are secular healers who may be referred to as “traditional pharmacists.” They employ or apply herbal medicine prepared from selected leaves, roots or other parts of plants and animals.(:1981) This category of healers includes those who regard themselves as naturopaths. They are more “scientific-oriented” and have introduced Western medical ideas, concepts and techniques into the practice of traditional medicine. The armamentaria at their clinics include clinical thermometers, syringes, microscopes and stethoscopes. White-overall coats, patient record cards and procedures similar to modern medical practitioners distinguish the naturopaths from the other types of healers. There are also plant drug peddlers who travel to towns and villages, as well as sell herbal medicines at work places, bus stops and in the streets.
Priests and priestesses of deities and gods are the most common type of healers in UK. They use techniques such as divination and ritual manipulation in their healing practices.(:1977) They cure both organic and spiritually caused diseases. Other groups of such sacred healers are the faith-healers who are usually the heads of the numerous Independent African Churches that exist in UK. They employ prayers, fasting, incantations and herbal medicines, as well as substantial elements of Western and Far East occultism. There are also the mallami who dispense both herbal and prophetic medicines. Among these different types of healers, there are differences in specialization. Some of the healers focus on one or a few illnesses, while others are generalists. Among the specializations are bone-setting, child care and delivery, and psychotherapists. Some are full-time practitioners, while others practice medicine as a secondary occupation.
The fact that traditional medicine had nurtured and sustained the people of UK for thousands of years before the arrival of Europeans into the Gold Coast was blatantly ignored by the British when the country formally became a colonial territory in 1844.(:1985) The role and activities of traditional medical practitioners were nearly eclipsed, not only by the introduction of a Western-oriented medical system as well as the penetration of Christian beliefs and teachings, but also by the incorporation of the local economy into the world economic system. Traditional medical practices were denounced by the colonial administration and, most forcefully, by the various missionary bodies.
The indigenous medical system was condemned as “satanic,” “primitive,” and “unscientific.” (:1985) Such an attitude, reinforced by the policy of Westernization of the medical care of the people and threats and other forms of intimidation, forced most of the local medical practitioners into clandestine practices and caused many to abandon their practices. Neglect of such an important health asset contributed considerably to the underdevelopment of indigenous pharmacopoeias and the loss of healers whose medical knowledge could have been tapped, improved and developed.
The natives of UK exert their efforts to modernize traditional therapies, validate them by scientific procedures, and license “qualified” indigenous healers in the 1930s were prevented. A Society of African Herbalists, formed at Sekondi on December 12, 1931, sought “to raise the local practice of medical herbalism up to a high and refined standard, and to seek for free and unhindered practice of its members.” (:1981) But the colonial government denied this and other requests to seek official recognition. Even though the acting director of Medical Sanitary Services agreed that “a number of native drugs have definite utility in the treatment of disease,” the colonial government contended that official recognition of the healers was impossible.
As an element of his efforts to Africanize his programs and policies, and to resuscitate the self-image and socio-cultural identity of the UK people, President Nkrumah after independence attempted to revive, promote and develop traditional medicine. In 1962 he requested the Pharmacology Department of the University of Science and Technology (UST), Kumasi, to investigate the efficacy of local herbs. (:1981)The government also appointed a university lecturer in 1963 to study, organize and help from an association of traditional healers to advance and improve traditional medicine. The UK Psychic and Traditional Healers’ Association was formed in the same year. The main objective was to bring organization, respectability and a common purpose to healers in the country. Unfortunately, the project at the Faculty of Pharmacy collapsed with the overthrow of the Nkrumah regime.
According to ‘s laudable policy to give priority to the traditional medical system was not pursued after his government fell in 1966. (:1985) The purpose of the Centre was to conduct and promote scientific research relating to the improvement of plant medicine and to cooperate and liaise with the UK Psychic and Traditional Healers’ Association, research institutions, and commercial organizations in any part of the world in matters of plant medicine.
This move was a major landmark in the history of the development of traditional medical resources. (:1978) The Centre now has a clinic that treats people with its own herbal mixtures. The Centre has also conducted clinical studies into anaemia, arthritis, malaria, piles, asthma, hypertension, epilepsy, peptic ulcer, infective hepatitis, rheumatic diseases, sickle-cell, skin diseases and diabetes mellitus. The role of traditional medical practitioners in the deployment of health services by the government, however, has been kept ambiguous, though the Ministry of Health has been stressing the need to rehabilitate and harness the practices of healers into the national health care delivery system.
The Modern Medical System in UK
In UK, only the modern medical system has received formal recognition and planning. A variety of alternatives exists in this sector. (, 1978) There is the government-operated/financed health care delivery system, with medical care provided at hospitals, health centers, clinics, health posts, maternity homes and dressing stations. Some quasigovernment-operated health care services are also provided primarily for specific subsets of the UK population, for example, health care services operated by the army, the police and some large firms and corporations for their employees. Many private medical services provided by individual medical practitioners in the form of hospitals, clinics and pharmacies exist. In addition, private health care services are operated by religious missions, for example, the Catholic Mission, the Presbyterian Church and the Seventh Day Adventist Church. These mission health services are financially supported by the government. Many drug peddlers and local drug stores which sell all kinds of patent medicines also abound.
The officially provided modern medical system, which is under the control of the Ministry of Health, provides medical care, maternal and child health services, health laboratory services, mental health services, dental health services, leprosy health services, nutritional health services, environmental health services and health education. ( :1965) The Western model of health care was first introduced into the country around 1844 when British medical officers arrived in the country. Provision of health care, however, was initially limited to colonial administrators, officials of mining companies, merchants and other Europeans, who settled mostly along the coastal areas and in a few interior urban centers. The small number of hospitals and clinics established were concentrated in the new urban centers, port towns, mining areas, and administrative centers. With the exception of some isolated locations in the rural areas where health posts were established by the missionaries for their converts, the colonial administration virtually neglected the health needs of the majority of the people.
This effort was undertaken in an attempt to reduce the high infant mortality rate and protein-calorie malnutrition rampant in the rural areas, as well as to expand family planning programs. However, success was limited. Factors such as a locality’s allegiance to the military government, financial constraints and mismanagement affected the location of health care facilities. Areas that had the greatest need for simple health care services were neglected.
Health care facilities in UK have increased considerably over the years. The major problem is that their distribution in the country has been grossly unequal. Inter-regional, intra-regional and rural-urban disparities continue to exist, owing essentially to the fact that the limited resources for them are frequently located on the basis of political and economic expediency rather than on careful analysis of the relative needs of the different sections of the country. Until recently, the Western-oriented health care model established by the colonialists had informed the policies and strategies of health authorities in post-independence UK.
The government should pay much attention to traditional medical services in the country. (:1977) Efforts should be made to organize the local medical practitioners to contribute to the current program of health for all by the year 2000. Avenues need to be explored as to how best traditional medical practitioners can be integrated into the national health care delivery system. The Centre for Scientific Research into Plant Medicine should be given adequate funding for continued research into local herbs and possible manufacture of local drugs.
Structural changes in the health care system are beginning to emerge from the current health policies being adopted by the Rawlings government. Efforts should be made to mobilize communities to contribute their quota to general health improvement in the country instead of relying solely on the government for the provision of medical services, healthy environments, better housing and a higher standard of living. Health education, family planning and primary health care programs should be given sustained priority by the government.
In 2001 a new government took office in UK.(:1977) Among its pledges was the abolition of the “cash and carry” system, in which people are required to pay for their drug therapy and often other services, and its replacement with health insurance. This is a big undertaking, especially in a poor country. The form that the new scheme will take is currently being discussed. The impact of the cash and carry system on access to medicines has been addressed by many researchers. One consequence of the policy was a greater resort to self-medication as an alternative to seeking medical advice, which was more marked in poorer sectors of society. Like in the United Kingdom, health problems and health behaviors follow a socioeconomic status gradient. For both the British and UK governments, addressing inequalities in health status between sectors of the population and, in UK in particular, inequities in access to care are a priority. In both countries, health care reforms and policy priorities have implications of pharmacy services. It is in the interests of the profession to identify new opportunities and strategies for their achievement.
The Development of Health Policy in UK
Any examination of the evolution of government policy towards the provision of health and social services in the early part of the 19th century needs to address three issues. First it must address why government did not or could not provide an appropriate and comprehensive service as of right for all of the nation’s citizens, particularly those who had fallen on hard times. Second, the debate must provide an insight into the principle of deterrence that underlined government interventions. Third, interventions by government should be considered in terms of their overall contribution towards the future evolution of health and social services.
The health care needs of the population were met through four discrete forms of service. First there was a range of practitioners such as barbers, surgeons, bone setters and midwives, performing their own specialised forms of treatment. Second, there were cruder forms of public health service dealing with areas such as vermin control or the maintenance of water supplies. These services were often overseen by local magistrates and funded from local taxation. Third, there was assistance provided by church charities such as alms houses and early forms of hospital for the chronically disabled, the poor, the widowed and the orphaned, although this form of service steadily decreased in power and influence with the rise in secularism. The fourth and largest provider of service, as it still is today, was the informal network of friends and family supporting their dependants without any form of outside intervention.
The need for public education programmes addressing issues such as hygiene and cleanliness highlights the ideological debate between collective and individual action that existed at the time and continues to the present. Radical reformers argued that public health was directly influenced by a combination of environmental and social conditions and required community or government accountability for its enforcement. In spite of this, the beginnings of sanitary reform can be traced to early philanthropists and intellectuals from the middle classes, such as Florence Nightingale. The earliest form of a recognisable health visiting service, in Manchester and Salford in the 1860s, began as a group of middle class women collectively trying to meet the health needs of the poor through education about hygiene and sanitation ( and , 1998).
Health Care Policies in the UK
The Secretary of State for Health has overall responsibility for providing health services, which it discharges through NHS authorities who are their agents. Special Health Authorities, National Health Service Trusts and Family Health Services Authorities administer services at local level, but these authorities do not simply carry out the secretary of state’s wishes. NHS authorities have important policy-making responsibilities in their own right, and they interpret national policies to suit local circumstances. On the other hand, unlike local authorities, they lack the legitimacy derived from elections and have no significant independent sources of revenue.
Health policy is not determined by ministers alone; the medical profession is also involved in the management of health services at several different points. Within the Department of Health and through the department’s consultative machinery, professions contribute to policy making. Family Health Services Authorities include a GP among their membership and receive advice from local medical committees. Under the NHS reforms they have also started appointing independent medical advisers. Also, NHS trusts usually include a medical director on their boards and rely extensively on advice received from their medical staff.
The pace of change in the provision of welfare intensified in the late 1980s. Services such as housing have become increasingly marginalised, whilst legislation on education has had the effect of introducing more elements of supposed consumer choice into the public sector. In the health services developments include both a greater move towards a form of market system within the health service, and greater incentives for individuals to switch to private health care as an alternative to the NHS. Thus the third term of office for the Conservative government reinforced the concept of selective measures in welfare services and the use of the private sector wherever possible. In part the Conservative government was able to use a growing disillusionment with the welfare state amongst politicians, academics and society itself to support its changes. Systematic study of the scope and effect of social provisions has developed over the past 40 years, since the inception of the welfare state, to reveal the inequalities that still exist within the system. Thus access to education has proved to be far from equal, poverty exists despite the introduction of income support and a contributory system of benefits, and inequalities in health between the social classes remain despite the introduction of a national health service. In addition there had been growing discontent with the ways in which the services are delivered.
The income maintenance system and the health services have both been criticised for being too impersonal, too remote from the needs of those they serve, too intimidating and too bureaucratic. Consumers have voiced discontent with a variety of services (the officialdom of the housing authorities or of social services, for example), whilst those on the left have been critical of the social controls within the delivery of welfare services.
The Conservative government’s commitment to restricting state services to those who demonstrate genuine need, measured by means tests, and to increasing private provision as an alternative to state services must be seen within the context of existing concern over the ability of social policy to provide for the needs of all.
The research has been concerned on the lack of an effective measurement of Service improvement initiatives within the NHS which will be essential in indicating sustainability and improvement projects. Health care has deemed it difficult whether improvement is taking place and what exactly is improving due to the complexities of its nature but it remains an imperative that this be performed. Health care measurement involves a variety of factors that will indeed prove it difficult to be tracked. It involves, more than just procedures or a measurement of skills and knowledge, a determination of outcomes in a community level. Indeed, the success of a service improvement initiative in the field of health care would not be without sufficient reliable data that should be yielded through the duly participation of teams, organizations and individuals. Without the proper means to measure improvement, projects within the NHS is at the risk of losing track in their mission, goals, objectives, aims and above all, priorities. In this regard, an effective measurement framework will maintain organizational direction.
In the absence of such measurement, the research seeks to create a evaluation or framework that will then allow such venture to be completed. In doing so, it will firstly review existing evaluation techniques and analyze how it may possibly measure the effectiveness of a service improvement initiative.
The research has stemmed from the premise that measuring or evaluating or improvements within NHS brought by a service improvement initiative sheds light on the dynamics of health care system changes, quality health care and the improvement of patients as well as clients welfare through efficient waste-free performances. Through a measurement framework, one may be presented a guide as to what initiatives work and what does not. It will further guide to the creation of new initiatives.
This chapter will detail several methodologies that will be deemed as effective tools in the building of a measurement framework for service improvement initiatives within the NHS. It will tackle on the abilities and capacities of these methodologies to measure improvement.
Measurement of Service Improvement Initiatives exists in order to inspire positive changes in a practitioner. In this research’s case, the evaluation framework for service improvement initiatives is the medical practitioners within the National Health Service.
and (2003) believe in the capability of Measurement and evaluation to “strengthen performance improvement practices” and assess if they had been effective in their interventions and programs in the field. and believe that Measurement and evaluation of Service Improvement initiatives in the Health care field is increasingly complicated and difficult due to its nature of its diversity which they name as “geographical settings, cultures, and health systems, coupled with a scarcity of resources”. These limitations and hindrances will deem it difficult for an Improvement Measurement or evaluation undertaking to be possible due to the lack of availability. For one thing, it is truly challenging to make a standard of how health care should be employed given the diverse and variety of situations. According to and , there are key aspects that needed to be taken note before Measurement and Evaluation for performance improvement may be considered. Notable of which is the standardization of care “by describing the desired performance and the determination of whether selected interventions are closing performance gaps and contributing to the achievement of organizational health goals” (2003, )
and emphasize that some countries do not regulate their health practices especially in less-developed countries. This is due to the fact that the regulations are not enforced and executed as a whole. There is also the problem of datedness as the practices may not be the most prescribed today are still currently employed. Measurement and evaluation would be truly a problem in a setting that does not make it a point to record and note the activities and any other evidences related to performance standards. Some information or guidelines are also ignored and bypassed allowing performance to be unrated and unrecorded. So far, they have tried to adapt easier methods of measurement and evaluation through “critical or clinical pathways, care maps, and self- and peer-assessment checklists”. (2003, )
The United Kingdom Department of Health and Human Services (DHHS) would concur that Performance measurement is a must as it will “clarify goals, document the contribution towards achieving those goals, and document the benefits received from the investment in each program.” The DHHS emphasized how it is important to keep a record or keep track of the performances in the Health field as a means to determine whether the set goals or the Health Service’s mission and visions are being followed. Agreeing with and , the DHHS also believe that Measurement would not be effective or made possible if it does not have sufficient sound data that will be used to “reliably measure public health or human service outcomes”. The DHHS affirms that data acquisition in Health Services is complex, limited and oftentimes difficult which is why researchers must look into other aspects of Health care such that will depend on two things. (, 1998)
In the case of Health care, there are two several things that need to be taken in consideration. The behavior itself and the outcomes the behavior will produce. While behavior may be measured in an individual level through the correct following of a certain order in a clinical procedure, outcomes is measured in a more “systems and organizational level” as it will deal with the effects of the said behavior to the patient. Measuring outcomes is also more complicated as there are several factors or “intervention” that may affect this. (2003, )
In measuring outcomes or finding out how they had come to be, the study of procedure and the measures directly leading to such outcomes may be the most appropriate method.
Measuring individual performance and behavior through a test of skills and knowledge is always the easier way to study service improvement initiative although again, that is merely studying the theory of the Health care rather the practice or the application of the theory (training, skills and knowledge), which may be studied through the evaluation of better or high quality care. This will take into account a health practitioner’s interventions and relationships with colleagues and the environment as a whole.
As mentioned earlier, what will make measurement and evaluation in the health practice possible is a set of standards (and at the same time, who sets the standards) which will be performed through a research on the perspectives of the service providers as well as the consumers themselves. It should be a study in finding out what their “preferences” they are which would be developed into the standards that needed to be achieved. It is important then to meet a consensus with regards to this standards and preferences. (2003, )
Ideally, performance improvements would mean “expanded service coverage, improved effectiveness of care, or increased client satisfaction” (2003, )
Positive change or improvement should be nurtured in order to contribute to the continuous betterment of a working individual. With the aid of measurement for Improvements, one may be able to pinpoint how changes take place, what changes are important and what are not. Sorting out changes yield benefits especially in service improvement. Measurements for Improvement is about identifying the right information that will identify progress, growth and development as well as agents of justification that enhancement has taken place. Measurements of Improvement concretize and quantifies what otherwise is as abstract as a feeling of change. They are able to show through scientific data that such change has indeed taken place and provide visual and hard data of such evidences of growth to demonstrate a change. Measurements for improvement allow individuals to track and reward change as well as identify the lack thereof. (, 2005)
The contribution of Measuring Service Improvement is also in a greater sense, for technical needs. Health care resources can only be limited that it must be deployed in the best and most effective manner such that a performance measure ensures. Performance Measurement is also a way to allow local agencies and government programs to come together. In this manner the national health system may take notice and may indeed track the progress of the state of its Health care in the nation.
The DHHS notes that the United Kingdom local governments have already been employing a method of performance measurement. In their experience, they emphasize that Measuring Improvement in Health Service needs to be “specific and result oriented, meaningful and understandable, adequate in data, valid, reliable and responsive” If the Service Improvement Initiative has taken note in establishing these guidelines then a credible Measurement report may be established. This will allow health systems to truly determine if there has been progress or in a certain sense, if goals are being met. Monitoring performance leads to several implications about the state and welfare of a nation’s health system and allow them to continue improving. (, 1998)
Institutions have been established for the sole goal of determining Healthcare Improvement such as the Institute for healthcare Improvement (IHI) which was founded 1990. They are supposed to make efficient health care improvement not just in the United Kingdom, but also outside it. The Institute teams up with various health care organizations and conduct “education, research, clinical trials and demonstration projects” in order to set up goals that Health care services will follow and will eventually lead to Performance improvement. IHI works towards “improved health status inc communities through greater access to care, clinical outcomes improvement and cost reduction”. IHI has so far collaborated with 367 teams scattered all over 256 health care organizations both national and international. The teams work for specific areas of health care and they are said to contribute by “dramatically improving outcomes and reduced costs” through its collaborations in several areas of adult care, drugs, reproductive health, waits and delays before health care is administered, satisfaction of patient and “improving efficiency and access to care” as a whole. It continues to strive more to involve other areas. The IHI is particularly focused in reducing the instances of waste in health care work and resources. They believe that the root of health care problems is solved through finding and ridding of waste. This, IHI believes, allows efficiency in performance improvement while ensuring quality health care without having to waste in resources and in the demand of services as a whole. Finally, as IHI itself only works if it is performed through collaborations, they believe in the necessity of cooperation in order to Measure Service Improvement Initiatives. By merging with Health care organizations and by ensuring that they too are willing to move towards the improvement of its services, performance improvement may be truly activated as the Health care Organizations help in supplying the data needed for institutions such as IHI in order to sustain improvement and quality health care services (, 1998).
(2005) has some models and frameworks that exist in order to measure service improvements. It has the Model for Improvement which is supposed to help in “setting objectives and targets”. Their models are specialized in setting up perceived goals and mission and then accomplishing them. Models such as the PDSA or the Plan, Do, Study and Act exist in order to plan the changes or improvements needed to be made, before they are acted upon. This allows improvements to be planned and to be focused and set through “aims and targets, measures and then plan the introduction of changes that will result in improvement” Another model for improvement is RAID which stands for: Review, Agree, Implement and Demonstrate.
In this model, the situation is firstly assessed through Review, then a consensus is met through Agree and then executing the planned changes through Implement and finally reveal the changes made through Demonstrate. The models of improvement in NHS emphasize how planning and focus should be the topmost priority. This involves the prior knowing of what is being trying to be fulfilled, determining whether a change can be considered an improvement and then identify the changes that can be made once improvement has manifested itself. (, 2005)
NHS has also emphasized that Measurement for improvement is supposed to make efficient and effective the positive changes. They emphasize how objectives and measures need to be connected and how it should reflect “other initiatives in the health community”. This link has been emphasized in their models of improvement. (, 2005)
Despite these efforts, the research yielded few resources, most of which are dated. This implies that the Evaluation or Measurement of Service Improvement Initiatives in Health care is not yet as present and centralized. The resources are scattered and subjective to needs. This research will then do well in attempting to put up a framework that may be used by various health care services. The research however revealed that the NHS had been performing efforts in Measuring Performance Improvement only the information related to it remains insufficient. The Literature Review has also realized the difficulties and complexities in the particular measurement of health care. It is not as easy as measuring improvement in a business organization where data can be easily present, provided and recorded. Health care deals with situations and activities that may be difficult to record as they must pass the subjective minds rather business organizations which will have a set of measurements beforehand. Health care involves several factors that are difficult to quantify but measuring improvement must nonetheless be performed as proved by this Literature Review. Inevitably, the measurement of performance improvement or service improvement initiatives leads to quality health care as well as the focus and realization of goals. It also significantly makes efficient health care and its resources and minimizes the instances of waste.
Services
Sanitation
Apart from the poor law amendment, one of the most important areas of government health policy was the provision of public health services that were created to promote the prevention of disease. Throughout the 19th century infectious diseases such as cholera and typhoid posed a major threat to the general population. Medical intervention was at this time largely powerless to intervene because little was understood about the nature of disease. Although normally only the most poverty-stricken areas of towns were affected, particularly virulent epidemics swept through whole communities, affecting both rich and poor. While home conditions were obviously bad for most people, the situation at work was even worse. Most factories employed large numbers of people in buildings that had poor ventilation, no sunlight and miserable hygiene facilities. Within these insanitary conditions diseases such as cholera were able to find a strong foothold. The cumulative effect of these poor conditions, along with the effects of poor quality of food and inadequate sewerage systems, prompted the government to set up boards of health. Early health boards instituted strict cleansing regimes during cholera outbreaks and also provided soup kitchens.
Hospital Services
During the 18th century ever increasing numbers of people moved from their agrarian bases to the new industrial cities, whose populations were rapidly increasing. The population of Bristol, for example, rose from 20 000 to 60 000, Glasgow from 13 000 to 80 000. Manchester, by 1801, had trebled its size to approximately 85 000 in less than 25 years. These demographic changes, along with the growth of university-trained doctors, allowed for the creation of new voluntary hospitals in many British cities. Funding for these came from a combination of contributions from local industry and charitable organisations. The first such hospital to be opened, the Westminster in London, was quickly followed by similar establishments in Edinburgh, Bristol, York and Liverpool.
Voluntary hospitals made a valuable contribution to health care. They were, however, far from the ideal model. In the first instance they operated on a privileged system of patronage in that the sick were required to bring a letter of recommendation from a subscriber to the hospital in order to gain admission. Second, voluntary hospitals did not provide services for maternity care, sick children, the dying, or people with tuberculosis, epilepsy, syphilis or any other infectious disease. The only form of institutional service for these people was in the workhouse infirmaries.
The voluntary hospitals developed closer affinities with medical faculties in universities and care was gradually extended. The number of beds within each hospital increased and out-patient departments evolved, in which patients could be properly assessed and accurate reviews made of their progress. Nevertheless, care in hospital continued to focus on acute and treatable conditions, creating pressure for specialist hospitals. As a result new specialist services emerged, including new institutions catering for maternity care, sick children, eyes and particular diseases.
Mental health care
Hospital services for the mentally ill evolved in a slightly different way to other health services in Britain. By the turn of the 19th century there were two forms of provision. There were private madhouses which operated as profit-making businesses, providing a service for those who could afford such provision. In addition, approval had been given to local counties to build county asylums for people with mental health problems. However, due to a lack of available funds and of motivation within the authorities, very few were actually built in the first decades of the century. People in need of mental health services either remained at home or, if that was not possible, they were accommodated along with the old, sick or homeless as inmates in the poor law workhouses or with criminals in gaols. With the passing of the 1845 Lunatics Act every county was compelled to provide purpose-built accommodation for the mentally ill, thus enabling the decanting and, at the same time, reclassification of large numbers of poor law paupers. It was originally intended that the milieu of these new asylums would focus on treatment and maximising the potential of cure for patients. The provision of in-patient services was supposed to be interpreted as a period of retreat or natural time out. None of this ever materialised.
Social Issues
At the creation of the National Health Service (NHS), the intention was to provide universal health services available to all with every person receiving the same standard of service. Indeed, , the Minister for Health, describing the NHS to the House of Commons in 1946, stated that there was to be ‘no limitation on the kind of assistance given — the general practitioner service, the specialist, the hospitals, eye treatment, spectacles, dental treatment, hearing facilities, all these are to be made available free’ (quoted in 1991).
However, despite the optimism surrounding the beginnings of the NHS, the realities then and now suggest that health services are not experienced by all in the same way. The distribution of health resources, the different patterns of illness suffered and other contributing factors ensure that different groups within the UK have unequal health needs and experience the unequal provision of health care. It is therefore important to be able to distinguish between the ideal that services are available to all free at the point of use with the reality of vastly different experiences.
Health Care Inequalities in UK
Although most of UK’s population lives in rural areas, the vast majorities of pharmacists as other health professionals lives and work in the cities. Although not dissimilar in kind to the Britain’s “post-code prescribing”, these discrepancies have a far wider impact in terms of service provision. A sizeable proportion of the population does not have access to pharmacy services. This presents a problem to the profession in terms of providing a nation-wide service with any uniformity. Urban-rural inequalities in health status and service provision are common in developing countries. They are not restricted to health care and their solution is seen in terms of wider socioeconomic development. Shortages of health professionals are further exacerbated by the significant numbers who seek professional opportunities abroad.
In most industrialized countries pharmacies are the principal source of medicines, but in developing countries there are other outlets. These are accepted as a necessity if people in remote areas are to have access to much needed drug therapy. The Pharmacy Council in UK which oversees the registration of pharmacists licenses and provides some training for chemical sellers. In addition to these licensed chemical sellers, the activities of “drug peddlers”, especially among rural communities, have been described by many researchers. They are commonly itinerant, sell medicines alongside other products and generally have no formal training.
In developing countries it is widely acknowledged that medicines elsewhere designated as “prescription-only” are widely available from pharmacies without a prescription. Stricter regulation on the availability of medicines as part of health care reforms in developing countries could reduce the potential opportunities for pharmacists to contribute to therapeutic management of common diseases, just as the new prescribing roles of pharmacists in Britain enhance their health provider activities.
Other Health Care Issues in UK
Because of the relationship that exists between health, productivity and equitable development, health improvements form a key element of development. UK, after independence, has implemented several policies aimed at improving the health status of its people. Its seven-year and five-year development plans in the early days of independence, as well as economic policies in recent decades contain various measures to reduce the economic burden of disease, with a particular focus on morbidity, mortality and malnutrition among children. Indeed, the economic reforms and structural adjustment programs that have been pursued since 1983 have gradually been accompanied by reforms in the health sector. These put more emphasis on primary health care and stressed the importance of prevention. The Government of UK embarked on a health sector reform in the early 1990s to improve the accessibility and quality of services. The Health Service Act of 1996 and the Medium Term Health Strategy based on Vision-2020 are further moves towards an efficient health care delivery system (, 1997)
For reasons of both efficiency and equity, there is ample scope for public interventions in health care markets. Subsidized expansion of facilities, health care providers, health education, and health insurance could not only improve efficiency in supply, but also promote equity. In particular, rural health care demand might be responsive to the proximity of providers, while extended insurance could account for care that would otherwise be unaffordable. To foster the health of its population, UK has set up an extensive network of public health care facilities, including hospitals, clinics, health centers, that offer subsidized care. In this way the public sector supplies health care as well as health insurance in kind. Yet, current public health care provision is still biased towards hospitals in urban areas supplying curative care, and puts less emphasis on prevention and basic health care in rural areas ( and , 2001). Local communities though become more involved in public health through direct provision of subsidized care to their members as well as through prevention and health promotion initiatives. Notwithstanding these efforts, many rural communities still experience high levels of morbidity and mortality due to lack of access to and poor utilization of health services, poor coverage of child welfare services and lack of technical support for initiating their own health programs ( and , 1998). In addition to supplying
In the above perspective, and given its poverty reduction agenda in the area of health, the Government of UK considers an identification of opportunities for an efficient and equitable increase of health care utilization a key development issue. The current paper wants to contribute to the debate by presenting recent data on the supply and demand of curative health care, and by an empirical exploration of equitable access opportunities.
References
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