Reform of the National Health Service Chronology

From 1974 to the present day the NHS has been in an almost continuous state of what some call redisorganisation.  The Labour Government realised in about 2006 that structural reorganisation was largely futile but the Coalition government – though claiming to oppose Top-down Reorganisation in the Coalition Agreement  -seem determined to make their own mistakes . This Reform of the National Health Service Chronology is a work in progress!

Reorganisations generally claim as their objectives:

  • design around the patient
  • devolved responsibility
  • clinical leadership
  • better integrated care
  • better quality of care
  • less bureaucracy/management/costs

Sadly there is  little evidence that structural change has produced any of these benefits, although few changes were left in place long enough for anyone to be able to tell what effect they had. As Charles Webster pointed out as long ago as 1998 the pace of change got faster and faster.   Alan Maynard, Sir Iain Chalmers and others produced A surrealistic mega-analysis of redisorganization theories. There is lots of evidence that restructuring has quite prolonged negative effects, most of which are underestimated because they are difficult to measure.  See the academic analysis of History and public-management reform by Tony Cutler,  Triumph of Hope over Experience by Nigel Edwards, the Health Reform Evaluation ProgrammeA Short and Partial History of Reform of the NHS in EnglandTen years of health reform: from market, to plan, to market again? Kieran Walshe 2007 and The Department of Health and the Civil Service: from  Whitehall to Department of Delivery to where? Scott Greer and Holly Jarman.

The urge to reform is concentrated in England. The rest of the UK has been relatively stable since devolution: see divergent health policies inside the UK  and Inspiration, Ideology, Evidence and the National Health Service David Hands 2010

The chronological table below is confined to reforms which actually happened and the documents which they relate to directly. It only attempts to include matters relating to health care. If you want more on public health see A Chronology of State Medicine, Public Health, Welfare and Related Services in Britain: 1066 – 1999. Reports calling for, analysing, or opposing, change may be found on our history page. Dates of events are approximate – change takes time and it is often difficult to decide which date is most appropriate, especially as it is sometimes unclear when a change which was announced actually came into effect. This table does not include anything said to be in the nature of a pilot project or an experiment.

Reform of the National Health Service Chronology

The Nuffield Trust have produced a very nice illustrated interactive timeline and Geoffrey Rivett a more comprehensive National Health Service History. Charles Webster did an excellent lecture on NHS reorganisation in 1998.

Legislation and documentation
2015  Devolution of the NHS in Greater Manchester.  Sustainability and transformation plans Memorandum of Understanding
2014  Five Year Forward View Five Year Forward View of the NHS in England.
2013 Strategic Health Authorities and Primary Care Trusts abolished. NHS England, NHS Trust Development Authority, Healthwatch and Public Health England established.
2012 Public Health moved into Local Authorities. Establishment of Clinical Commissioning Groups and the NHS Commissioning Board Health and Social Care Act 2012 NHS Mandate
2011 Publication of the Health and Social Care Bill. Reorganisation of PCTs into clusters and Strategic Health Authorities grouped into sub-national organisations. The word “region” is officially proscribed. Bonfire of quangos. Community services split off from PCTs
2010 Coalition government promises they will stop the top-down reorganisations of the NHS that have got in the way of patient care. They then proceed to plan a reorganisation “so large it can been seen from Outer Space”. Equity and excellence: liberating the NHS
2009 NHS complaints system reformed again. Healthcare Commission replaced by Care Quality Commission. PCTs separate themselves into commissioning and providing arms. NHS Constitution
2008 Alan Johnson commits himself to avoiding structural reorganisation – but turns his attention to Primary Care, which escaped most of the previous reorganisations. Patient Forums replaced by Local Involvement Networks. Our NHS Our Future
2007 The first year since 1993 when major reform was not proposed or implemented – though it was the year when many earlier reforms began to bite. Local Government and Public Involvement in Health ActMental Health Act
2006 Payment by Results National tariff ; Strategic Health Authorities reduced from 28 to 9, PCTs reduced to 151 Supporting practice-based commissioning in 2006/07 by determining weighted capitation shares at practice level Our Health, Our Care, Our SaySupporting
people with long term conditions to Self Care
2005 Modernisation Agency replaced by NHS Institute for Improvement and Innovation. Department of Health – Treatment CentresDirect Payments A Patient-led NHS; Healthcare reform in England, Update and next steps.
2004 Patients Forums; Commission for Healthcare Audit and Inspection; First wave Foundation Trusts established NHS Improvement Plan.
2003 Monitor established; Patient Choice; Community Health Councils abolished; NHS Modernisation Agency;Regional Directorates of Health and Social Care abolished Building on the Best; Choice, Responsiveness and Equity in the NHS; Health and Social Care (Community Health and Standards) Act
2002 Abolition of NHS regional offices; Reorganisation of 96 health authorities into 28 strategic health authorities in England; Patient advisory and liaison services; Commission for Patient and Public Involvement in Health established; Payment by Results Wanless report: Securing Our Future Health: Taking a Long-Term ViewNational
Health Service Reform and Health Care Professions Act;
Delivering the NHS Plan
2001 Regional Directorates of Health and Social Care (4) Bristol Royal Infirmary report ;Shifting
the Balance of Power
;Health and Social Care Act
2000 Abolition of the NHS Executive.  Primary Care Trusts (first wave) – eventually to reach 300.  National Service Frameworks.  Food Standards Agency The NHS Plan
1999 Primary Care Groups (481); Clinical Standards Board for Scotland; National Institute for Clinical Excellence; Commission for Health Improvement; Walk-in NHS Centres; National framework for mental health services; Devolution of power to Scotland and Wales Health Act;  Saving Lives: Our Healthier Nation
1998 Abolition of GP fundholding Scotland Act;  Government of Wales Act;  Information for Health. An Information Strategy for the Modern NHS. 1998-2005;  A First Class Service: Quality in the New NHS; Modernising Social Services
1997 The new NHS – Modern, DependableNHS
(Primary Care) Act
National Health Service (Private Finance) Act ;Designed to Care; Renewing the National Health Service in Scotland
1996 Community Fundholding; Reorganization of regional health authorities from 14 to 8 regions.Abolition of FHSAs and incorporation of their responsibilities into those of health authorities Choice and opportunity; Health Service Commissioners (Amendment) Act; Community Care (Direct Payments) Act; The National Health Service: A Service with Ambitions ;Primary Care: Delivering the Future
1995 Health Authorities Act; A Policy Framework for Commissioning Cancer Services
1994 NHS Management Executive moved to Leeds Developing NHS Purchasing and GP Fundholding: Towards a Primary Care Led NHS
1993 Calman report: Hospital doctors’ training for the future:
1992 (UK) Cochrane Centre opened Tomlinson report on London hospitals
1991 Establishment of 57 NHS Trusts (more in waves over 5 years), eventually 270, with boards of executive and non-executive directors; Reconfiguration of district health authorities as health authorities;  GP Fundholding – 306 practices; Patients Charter; Abolition of family practitioner committees: establishment of family health services authorities; Purchaser/provider split Junior Doctors, the New Deal. Working Arrangements for Hospital Doctors and Dentists in Training
1990 New GP Contract National Health Service and Community Care Act Access to Health Records Act
1989 NHS Management Board reorganised into the NHS Policy Board and the NHS Management Executive Children Act; Working for Patients: The Health Service Caring for the 1990’s;Caring for People: Community Care in the Next Decade and Beyond
1988 Department of Health and the Department of Social Security split;Charges for eye tests and dental check-ups Community Health Councils (Access to Information) Act; Health and Medicines Act; Access to Medical Reports Act
1987 Disablement Services Authority established as a special health authority; Hospital Episode Statistics (HES) introduced, based on finished consultant inpatient episodes Promoting better health;
1986 NHS Management Board established; Crown immunity from the NHS in respect of food and health and safety legislation removed; Health and Social Service Journal becomes Health Service Journal Cumberlege Report -Neighbourhood nursing Primary health care – an agenda for discussion; National Health Service (Amendment) Act; A National Strategic Framework for Information Management in the Hospital and Community Health Services
1985 Project 2000 transforms nursing education; QALYs; 90 Family Practitioner Committees in England and 8 in Wales became autonomous authorities accountable to the Secretary of State; publication of the 10% national sample of hospital activities derived from the Hospital Activity Analysis discontinued Hospital Complaints Procedure Act
1984 General Managers appointed throughout the NHS
1983 Start of competitive tendering for ancilliary services Mental Health Act 1983; Griffiths Report – National Health Service general management
1982 Abolition of area health authorities and restructuring of district health authorities; United Kingdom Central Council for Nursing, Midwifery and Health Visiting established
1980 Health Services Act; Care in the Community
1979 New consultant contract “Patients first”; Nurses, Midwives and Health Visitors ActRoyal Commission on the National Health Service
1978 Medical Act
1977 Health Services Board established to phase out private beds from NHS hospitals National Health Service Act ;The Way Forward
1976 “Cash Limits” introduced into the NHS, whereby spending authorities could not exceed the sums of money allocated to them. Resource Allocation Working Party (RAWP); Health Services Act ;”Priorities for health and personal social services in England”
1975 “Better services for the mentally ill”;Nursing Homes Act;  Separation of Private Practice from National Health Service Hospitals
1974 Establishment of Regional, District and Area Health Authorities; Community Health Councils; Health Ombudsman Glancy Report on security in NHS psychiatric hospitals; “Management arrangements for the reorganised NHS”; Democracy in the NHS
1973 The British Hospital & Social Service Review becomes Health and Social Service Journal NHS Reorganisation Act
1972 National Health Service (Scotland) Act; Chronically Sick and Disabled Persons (Scotland) Act; NHS Reorganisation White Paper; Briggs report on nursing
1971 “Better services for the mentally handicapped”
1970 Hospital Advisory Service established Chronically Sick and Disabled Persons Act ; The Future Structure of the National Health Service
1969 Secretary of State for Wales took over responsibility for health and welfare in Wales; Scottish Consultants Review of In-Patient Statistics (SCRIPS) introduced in Scotland Ely Hospital Report; Bonham-Carter Report – Functions of the District General Hospitals; Administrative Structure of the Health and Personal Social Services in Northern Ireland
1968 Ministry of Health and Ministry of Social Security joined to form DHSS; Prescription charges re-introduced Seebohm Report on Social Services; First scandals in long stay hospitals Health Services and Public Health Act
1967 The Cogwheel Report – Organisation of Medical Work in Hospitals; National Health Service (Family Planning) Act
1966 New GP contract Salmon report – nursing structure; National Health Service Act
1965 Prescription charges abolished; Hospital Activity Analysis (HAA) introduced in England and Wales; The British Hospital and Social Service Journal becomes The British Hospital & Social Service Review A Charter for Family Doctors
1964 Welsh Office set up
1963 Hospital and Social Service Journal becomes The British Hospital and Social Service Journal Health and Welfare: The Development of Community Care; Nursing Homes Act
1962 Scottish Board of Health became the Scottish Home and Health Department. Enoch Powell’s plan for the development of District General Hospitals
1961 Powell’s Water Tower speech Platt Report -Joint Working Party on the Medical Staffing Structure in the Hospital Service
1960 Mental Health (Scotland) Act;  Professions Supplementary to Medicine Act
1959 Mental Health Act
1958 Optician Act
1957 Hospital In-Patient Enquiry becomes compulsory Royal Commission on the Law Relating to Mental Illness and Mental Deficiency
1956 Guillebaud Report: Cost of the National Health Service; Jameson Report on Field of Work, Training and Recruitment of Health Visitors; Medical Act;  Dentists Act
1954 Bradbeer report on internal administration of hospitals
1953 Hospital Inpatients Enquiry introduced
1952 National Health Service Act
1951 National Health Service Act; Midwives Act
1950 Medical Act
1949 Introduction of prescription charges National Health Service (Amendment) Act; Nurses Act
1948 5 July The appointed day; Public Assistance Journal and Health and Hospital Review becomes Hospital and Social Service Journal Children Act; National Assistance Act
1947 National Health Service (Scotland) Act
1946 National Health Service Act
1944 A National Health Service
1942 Beveridge Report -Social Insurance and Allied Services
1939 Emergency Medical Service established Cancer Act
1937 Maternity Services (Scotland) Act;  Report of the Voluntary Hospitals Commission; Education (Deaf Children) Act 
1936 Public Health Act;  Midwives Act; Cathcart Report
1930 Poor Law Officers Journal becomes Public Assistance Journal and Health and Hospital Review Poor Law Act, Mental Treatment Act
1929 Powers under the Poor Law transferred from small local Boards of Guardians to the councils of much larger areas, i.e., of counties and county boroughs Local Government Act
1927 Poor Law (Consolidation) Act; Nursing Homes Registration Act
1926 Royal Commission on National Health Insurance
1924 National Health Insurance Act ; Royal Commission on Lunacy and Mental Disorder
1921 Public Health (Tuberculosis) Act
1920 Interim Report on the Future Provision of Medical and Allied Services; Blind Persons Act
1919 Ministry of Health Act;  Scottish Board of Health Act
1918 National Health Insurance Act; Maternity and Child Welfare Act
1914  Elementary Education (Defective and Epileptic Children) Act 
1913 Highlands and Islands Medical Services established Highlands and Islands Medical Services Act; Public Health (Prevention and Treatment of Disease) Act, Mental Deficiency Act
1912 15th July National Health Insurance
1911 National Insurance Act
1892 The Poor Law Officers Journal established
1890 Lunacy Act
1875 Power to establish municipal hospitals Public Health Act
1867 Metropolitan Asylums Board established  Metropolitan Poor Act, Poor Law Amendment Act
1855 Appointment of John Simon as Medical Officer to the General Board of Health
1848 Public Health Act
1845 Poor Law (Scotland) Act, County Asylums Act, Lunacy Act
1834 Poor Law Amendment Act
1808 County Asylums Act
1774 Act for Regulating Private Madhouses
1601 Poor Law

With thanks to Prof Kieran Walshe, Prof Charles Webster, and Geoffrey Rivett who inspired this table. The errors are mine, and I would be grateful if they could be pointed out.  Anyone interested in a similar approach to the study of education reform is directed to Education in England.