In this paper it is argued that courts must, where appropriate, take into account the fact that National Health Service hospitals are under‐funded when they determine the standard of care owed by such hospitals and their professional staff to patients. Although this suggestion is inconsistent with the traditional view of the courts, its adoption would bring negligence cases into harmony with judicial review decisions. It would also cohere with a new understanding of accident causation within complex organisations, (...) which suggests that many of the injuries suffered by patients in under‐funded hospitals are the result of systemic failures that cannot necessarily be attributed to those who are the last actors in the causal chain leading to damage. (shrink)

It is an article of almost religious faith in the United Kingdom that the National Health Service is far superior to a competitive market in health care services. In this brief and informal paper I show that the opposite is true. In contrast to market provision, the existence of the National Health Service entails the following. First, consumer sovereignty is virtually destroyed, since what services the consumer receives and how much he pays (through (...) taxation) are determined by the government of the day in consultation with vested and ideological interests. Second, a person may be denied a life-saving service despite having contributed more than his fair share to National Health Service over the course of his working life. Third, people often spend less on health care than they would like to spend, because any additional contributions (via increased taxes) are not linked to any benefit specifically for the person who makes them. Fourth, provision of services free at the point of need which is not linked to what a person pays encourages a wasteful misuse of resources. Fifth, absence of competition between health care providers leads to high cost and poor quality of service and a tendency to produce a standardised service rather than a tailored one; and government attempts to address this problem usually make it worse. Sixth, people’s freedom to engage in particular activities or lifestyles is likely to be curtailed because the costs of those activities are artificially socialised. I also point out that issues of inequality or poverty are much better addressed by means other than a nationalised health service. (shrink)

Many countries, including Australia, have established a national scheme that supports the recognition of a single ethical review for multi-centre research conducted in publicly funded health services. However, local site-specific governance review processes remain decentralised and highly variable. This short report describes the ethics and governance processes required for a negligible risk national survey of physiotherapy-led airway clearance services in Australia. We detail inconsistencies in research governance document preparation and submission (platforms, processes, forms and signatories) and report (...) the time cost and likely impact of these inconsistencies on health services research outcomes. Processes and strategies that facilitated success in this project are identified and summarised as helpful hints to other researchers looking to embark on negligible risk research in public health facilities. (shrink)

The "Socialist Calculation Debate" is little known outside the economics profession, yet this inter-war debate between liberal and socialist economists on the practical feasibility of socialism has important implications for all contemporary public sector bureaucracies. This article applies the Mises-Hayek critique of central planning that emerged from this debate to the crisis presently facing the British National Health Service. The Mises-Hayek critique suggests that the UK government's plan for a renewal of the National Health (...) class='Hi'>Service will fail because of the epistemological pathologies that face any centrally planned system. It is argued that the key lesson of the Socialist Calculation Debate is that market prices and private property rights are essential for the efficient allocation of resources and the attainment of the best possible health outcomes. (shrink)

This paper examines some of the key characteristics of a socialist health care system using the example of the British National Health Service (NHS). It has been claimed that the NHS has socialist principles, and represents an island of socialism in a capitalist sea. However, using historical analysis, this paper argues that while the NHS claims some socialist ends, they could never be fully achieved because of the lack of socialist means. The socialist mechanisms which were (...) associated with earlier plans for a national health service such as a salaried service, health centres, elected health authorities and divorcing private practice from the public service were discarded in negotiation. Moreover, even these would have achieved socialism merely in the sense of distributing health care, without any deeper transformation associated with doctor-patient relationships and prevention. In short, the NHS is more correctly seen as nationalised rather than socialised medicine, achieving the first three levels of a socialist health service identified here. It can be said to have socialist principles in the limited distributional sense and has some socialist means to achieve these. However, it lacks the stronger means to fully achieve its distributional goals, and is very distant from the third level of a radical transformation of health care. (shrink)

Last year (1998) saw the celebration of the 50th Anniversaryof the British National Health Service (NHS). One ofthe few completely nationalised systems of health carein the world, the NHS is seen by many as a moralbeacon of what it means to provide equitable medicaltreatment to all citizens on the basis of need andneed alone. However, others argue that it has failedto achieve the overall goals for which it was created.Because of scarce resources, some urgently needed careis (...) not available at all, while that which is receivedis sometimes second class. For these reasons, it isclaimed that the NHS should be scrapped and replacedby other systems of health care delivery.This paper outlines the history of the NHS,indicating some of the problems and innovations whichhave led to its current organization and structure.The philosophical foundations of the NHS are then articulated and defended on the grounds that it stillrepresents a morally coherent and economicallyefficient approach to the delivery of health care.Scarce resources are the key problem facing the NHS,making rationing inevitable and it is shown thatthis is not incompatible with the moral foundations ofthe service. However, there can be little doubt thatthe NHS is now becoming dangerously under-funded. Thepaper concludes with arguments about why this is soand what might be done about it. (shrink)

OBJECTIVES: To identify ethical dilemmas experienced by occupational and physical therapists working in the UK National Health Service (NHS). To compare ethical contexts, themes and principles across the two groups. DESIGN: A structured questionnaire was circulated to the managers of occupational and physical therapy services in England and Wales. SUBJECTS: The questionnaires were given to 238 occupational and 249 physical therapists who conformed to set criteria. RESULTS: Ethical dilemmas experienced during the previous six months were reported by (...) 118 occupational and 107 physical therapists. The two groups were similar in age, grade, and years of experience. Fifty of the occupational therapy dilemmas occurred in mental health settings but no equivalent setting emerged for physical therapy. Different ethical themes emerged between the two groups, with the most common in occupational therapy being difficult/dangerous behaviour in patients and unprofessional staff behaviour, and for physical therapists resource limitations and treatment effectiveness. No differences were found in the ethical principles used. CONCLUSION: The ethical dilemmas reported by the therapists were primarily concerned with health care ethics, rather than the more dramatic ethics reported in much of the biomedical ethics literature. Differences were found between the two professional groups when ethical contexts and themes were compared but not when ethical principles were compared. This suggests that educators and researchers need to be aware of work settings and the interdisciplinary nature of employment as well as ethical principles held by individual therapists. (shrink)

This paper is sadly opportune. The general public is angry and bewildered if not hurt by the variety of strikes which are brought more or less forcibly to their attention. People used to understand what lay behind a strike - a demand for more pay, better conditions - but today a political element often intrudes, and it is this that worries those who ask themselves whether this or that dispute is either lawful or morally acceptable. Professor Dworkin, a lawyer, first (...) sets out the legal issues surrounding strikes and then advances the ethical arguments, closely relating them to the legal framework. The most interesting part of the paper, however, may well be that devoted to the moral obligation of example, in particular the example to be set by members of the medical profession and by all those caring for the sick. As public attitudes to industrial disputes `become dulled and quiescent' it is absolutely necessary that there should be a reappraisal of the moral standards of the past which coincide with a respect for the law. In the last century the term `anomie' was used to describe a `society which has shaken off its former restraints such as religion, respect for law and order and a definite moral code as to what is right and wrong'. We are living in that sort of society today, and one need not be a professional `ethicist' to recognize the signs, and hopefully, to work for the return of `ethical' values. (shrink)

The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to ‘universalise the best’. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalise care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the ‘done thing’ without explicit policy directives and in a manner (...) largely invisible to patients, to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories. (shrink)

Claims that there are good arguments for a public health service that do not amount to arguments for a national health service, but for something that looks far more like a transnational health service.

This paper explores public sentiment towards strike action among healthcare workers, as a result of their perceived inadequate pay. By analysing survey data collected in England between 2022 and 2023, the study focuses on NHS nurses and junior doctors, due to their critical role in delivering essential public services. Results indicate higher public support for strikes by nurses and junior doctors compared to other professions such as postal workers, teachers, rail workers, airport workers, civil servants and university lecturers. However, variation (...) in support for strikes by healthcare workers is observed across societal segments. Significant disparities in support are linked to individual political affiliations, left–right ideological positions and trust in the NHS. In short, nonconservative voters, individuals leaning towards left‐wing politics and those with greater trust in the NHS demonstrate higher likelihoods of supporting strikes by health workers. These findings carry implications for future strike decisions and highlight specific target groups for enhanced communication efforts to garner increased public support. (shrink)

A clinical trial on mitochondrial replacement therapy is currently being conducted and if this technique proves effective, National Health Service England will fund MRT through the highly specialised services funding stream. This paper considers whether MRT should be publicly funded by the NHS. Given the current financial pressure the NHS is experiencing, a comprehensive discussion is essential. There is yet to be a thorough discussion on MRT funding, perhaps because this is a small-scale issue and presumed to (...) be covered by the HSS budget. However, the source of funding has not been confirmed due to the trial’s incompletion. Upon its completion, reasoned decisions need to be made over the allocation of scarce NHS resources. It is therefore important to consider the following arguments in advance. Three arguments given against NHS funding of MRT will be evaluated. The first argument against NHS funding examines the HSS overspending its budget in an underfunded NHS, suggesting funding must be carefully reprioritised. Second, the ethical issue of allowing public access to a technique with insufficient evidence behind it will be explored. The final point considers the option of privately funding MRT and how this would affect the treatment’s development. After illustrating the weaknesses of such arguments, it will be concluded that MRT should be funded by the NHS. (shrink)

Resumen Ésta es la primera traducción al español de las guías “Atención después de la investigación: un marco para los comités de ética de investigación del National Health Service (NHS) (borrador versión 8.0)”. El documento afirma que existe una fuerte obligación moral de garantizar que los participantes enfermos de un estudio clínico hagan una transición después del estudio hacia una atención de la salud apropiada. Con “atención de la salud apropiada” se hace referencia al acceso para los (...) participantes a la atención de la salud, proporcionada principalmente por el National Health Service (en adelante NHS), el sistema de salud del Reino Unido, y/o a la intervención en estudio, también llamada producto o tratamiento en investigación. Las guías “Atención después de la investigación” están dirigidas principalmente a los miembros de los 79 comités de ética de investigación del NHS y a quienes presentan sus estudios de investigación ante estos comités. Se trata de un documento borrador muy avanzado, trabajado en numerosas reuniones, durante más de 3 años, que ha sido discutido por participantes de estudios y miembros de la comunidad, miembros y presidentes de comités de ética de investigación del Reino Unido, especialistas internacionales en ética de la investigación, representantes de la industria y otras partes interesadas. La redacción de las guías es producto de la colaboración de Neema Sofaer y Penney Lewis, ambas investigadoras del King’s College London, en el Centre of Medical Law and Ethics del Dickson Poon School of Law, y Hugh Davies, Asesor en Ética de la Investigación de la Health Research Authority (HRA) del NHS. El traductor del presente documento, Ignacio Mastroleo, participó del workshop en la Fundación Brocher (Ginebra, Suiza, diciembre de 2011) donde se revisó el borrador versión 7.0 y contribuyó en la revisión del borrador de la versión 8.0 durante el 2012. -/- Abstract This is the first Spanish translation of the guidelines “Care after research: a framework for NHS RECs (8th draft)”. The document states that there is a strong moral obligation to ensure that participants in a clinical study who are ill transition after the study to appropriate healthcare. The terms "appropriate healthcare" refer to participants’ access to health care, mainly provided by the National Health Service (NHS), the health system in the UK, and/or to the intervention study also named investigational treatment or product. The guides "Care after research" are mainly directed to members of the 79 NHS committees of research ethics (RECs) and to those who submit their research to these committees. This is a very advanced draft document, worked in several meetings, for more than three years, that has been discussed with study participants and community members, members and chairs of RECs in the UK, international specialists in research ethics, industry representatives and other stakeholders. The drafting of the guidelines is the result of the collaboration of Neema Sofaer and Penney Lewis, both researchers at King's College London, at the Centre of Medical Law and Ethics of Dickson Poon School of Law, and Hugh Davies, Research Ethics Advisor of the Health Research Authority (HRA) of the NHS. The translator of this document, Ignacio Mastroleo, attended the workshop at the Brocher Foundation (Geneva, Switzerland, December 2011) where draft version 7.0 was revised and contributed in the revision of draft version 8.0 during 2012. (shrink)

Pregnancy care is chargeable for migrants who do not have indefinite leave to remain in the UK. Women who are not ‘ordinarily resident’, including prospective asylum applicants, some refused asylum-seekers, unidentified victims of trafficking and undocumented people are required to pay substantial charges in order to access antenatal, intrapartum and postnatal services as well as abortion care within the National Health Service. In this paper, we consider the ethical issues generated by the exclusion of pregnancy care from (...) the raft of services which are free to all. We argue that charging for pregnancy care amounts to sex discrimination, since without pregnancy care, sex may pose a barrier to good health. We also argue that charging for pregnancy care violates bodily autonomy, entrenches the sex asymmetry of sexual responsibility, centres the male body and produces health risks for women and neonates. We explore some of the ideological motivations for making maternity care chargeable, and suggest that its exclusion responds to xenophobic populism. We recommend that pregnancy care always be free regardless of citizenship or residence status, and briefly explore how these arguments bear on the broader moral case against chargeable healthcare for migrants. (shrink)

The Private Finance Initiative (PFI) is a specific example of health care privatization within the British National Health Service. In this essay, I critically assess the ways in which various Private Finance Initiatives have increased health care efficiency and effectiveness, as well as encouraged medical innovation. Indeed, as the analysis will demonstrate, significant empirical evidence supports the conclusion that Private Finance Initiatives are a driving force of innovation within the British Health Care System.

The culture of ‘culture’ in National Health Service policy implementationThe widespread reference to ‘culture’ in UK NHS policy and organisational literature suggests that culture has, in itself, become a cultural phenomenon. This article draws on anthropological thought to explore this trend, and finds it stems from the way that the term ‘culture’ has become analytically empty. Lack of rigour in the way that culture is conceptualised allows it to be used both to suggest an evolved consensus among (...) the workforce, and to validate the imposition of values and beliefs by management. Such manipulation of ‘culture’ is evident in recent NHS policy demanding cultural change to ensure a flexible, empowered and self‐regulating workforce — the type of workforce not only valued by health services, but pivotal to a post‐Fordist economy. The findings from an ethnographic study are drawn upon to consider the relationship between nurses’ cultural practices, corporate culture shaped by NHS policy, and the requirements of the economic domain. It is suggested that a commitment to post‐Fordist priorities of flexibility, empowerment and self‐regulation is not necessarily matched by any shift in the traditional location of power. The article concludes that greater analytical rigour is necessary to challenge the way in which ‘culture’ is manipulated by policy makers. (shrink)

GILLETT K. Nursing Inquiry 2010; 17: 197–207From ‘part of ’ to ‘partnership’: the changing relationship between nurse education and the National Health ServiceWorldwide, many countries have moved towards incorporating nurse education into the higher education sector and this inevitably has implications for the relationship between nurse education providers and local health service providers. This study explores the changes to the relationship in the UK between nurse education providers and the UK National Health Service (...) over the past 20 years and demonstrates how two political ideologies have been central to those changes. The two ideologies of interest are the introduction of internal markets to the National Health Service by the Conservative government at the end of the 1980s and the New Labour response to the fragmentation of public services caused by Conservative neoliberal policy, which was to introduce the notion of ‘partnership working’. This study reviews the wider debate around partnership policy and applies that debate to evaluate the way that nurse education providers and the National Health Service are working in partnership to provide clinical practice placements for nursing students. (shrink)

Many countries are experimenting with planned (or quasi-) markets to discover if they can efficiently deliver health care in keeping with societal objectives. This paper examines the information requirements of this approach. Information is necessary in order to compare the performance of providers, to support billing, and to monitor access to care. It should be accurate, unambiguous, and resistant to manipulation. We draw on a project to find out how information on hospitalisation could be used in contracting in the (...) British National Health Service. We conclude that the existing British system fails to provide robust measures of how many patients are treated, for what conditions, and with what treatments. We identify some promising remedies, others that are more difficult, and some which may be impossible to implement in any planned market, given the uncertainty of clinical practice. (shrink)

Through a case study, this paper addresses ethical issues and dilemmas faced by a Family Therapist working in a Child and Adolescent Mental Health Service (CAMHS) in the National Health Service. When there are legal and societal obligations on parents/carers to ensure that the needs of children and young people are met within a family context, working with a young person in a health care setting oriented to the individual raises ethical dilemmas around consent. (...) When the values of young people and their parents conflict, legal, ethical and political issues can be raised. These have implications for the duties of health care professionals and the rights, interests and autonomy of the individual young people and their parents. The importance of justice to CAMHS practitioners' ethical decision-making about when to prioritize the individual over the family, or vice versa, is emphasized. (shrink)

This paper falls into three parts. In the first part I will briefly review the current process of reform that the United Kingdom National Health Service is undergoing. Two fundamental motivations for reform, the desire for increased efficiency and for an increased responsiveness to patients' needs and preferences will be discussed in greater detail. The second part attempts to provide a perspective on the moral debate concerning health care reform by introducing the distinction between ‘civil association’ (...) and ‘enterprise association’ as proposed by the political philosopher Michael Oakeshott. In the final part, this distinction will be used to analyze the moral and political constitution of the National Health Service, in order to establish the relevance and scope of concerns with efficiency and patient and public accountability. A framework within which the current reforms can be assessed is thereby outlined. Keywords: access to health care, civil association, enterprise association, freedom of choice, health care reform, United Kingdom National Health Service CiteULike Connotea Del.icio.us What's this? (shrink)

Resistance is a concept understudied in the context of health and healthcare. This is in part because visible forms of social protest are sometimes understood as incongruent with professional identity, leading healthcare workers to separate their visible actions from their working life. Resistance takes many forms, however, and focusing exclusively on the visible means more subtle forms of everyday resistance are likely to be missed. The overarching aim of this study was to explore how resistance was enacted within the (...) workplace amongst a sample of twelve healthcare workers, based in the United Kingdom; exploring the forms that such action took and how this intersected with health and healthcare. In depth-interviews were conducted and results were analysed utilizing Lilja’s framework ( 2022 ). Our findings suggest that resistance took a number of forms, from more direct confrontational acts, to those which sought to avoid power or which sought to create alternative or prefigurative practices or norms. These findings speak to the complexities, ambiguities, and contradictions of resistance, as carried out by healthcare workers in the workplace. While many acts had clear political motives, with issues like climate change in mind for example, participants also described how the act of providing care itself could be an act of resistance. While saying something about our participants, this also said something about the healthcare systems in which they worked. These findings also raise a range of normative issues. Perhaps needless to say, there appears to be substantial scope to expand and interrogate our findings and apply the idea of resistance to health and healthcare. (shrink)

The British Government is implementing some major alterations to the way health services in Great Britain are organised. As well as the introduction of competition between health care providers, their financial interests are to be linked to their output, in efforts to use market forces to increase efficiency and cut costs. This paper looks at the possible impact of these changes of health care organisation on ethical medical practice. This is investigated with particular reference to the country (...) whose health service has embraced most closely these elements of the market--the United States of America. The question to be answered is whether high standards of ethical care are ensured by factors somehow intrinsic to the medical profession, and are therefore immune to changes in the economics of health care. This assumption is shown to be questionable in light of what is known about the determinants of ethical medical practice. (shrink)

In this paper I put forward an ethical argument for the provision of extensive patient choice by the British National Health Service. I base this argument on traditional liberal rights to freedom of choice, on a welfare right to health care, and on a view of health as values-based. I argue that choice, to be ethically sustainable on this basis, must be values-based and rational. I also consider whether the British taxpayer may be persuadable with (...) regard to the moral acceptability of patient choice, making use of Rawls’ theory of political liberalism in this context. I identify issues that present problems in terms of public acceptance of choice, and also identify a boundary issue with regard to public health choices as against individual choices. (shrink)

‘Zero tolerance’ of avoidable infection events is explicit in UK and international policy documents describing strategies for the control of healthcare-associated infection. I consider what principles governing avoidable infections acquired in healthcare institutions might be reasonably rejected from the contractualist perspective of Thomas Scanlon. Many hospital infections can be cost-effectively avoided. There would seem to be additional reasons to take the prevention of avoidable infection acquired in hospitals seriously in addition to optimizing the cost-effectiveness of healthcare. These include the irretrievable (...) nature of the harm of some of the infections; the reasonable rejection of avoidable harm when the patient could not rationally consent to the risk of harm and the social consequences such as loss of trust in healthcare providers. Despite these reasons, a principle of ‘zero tolerance’ has implausible implications, promotes unrealistic patient expectations and can be reasonably rejected from the perspective of those who will suffer unacceptable opportunity costs. However, the contractualist perspective would also seem to reject a principle of tolerance of harm when there is a feasible reconfiguration of institutional arrangements that reduces the risk of harm without a redistribution of a proportionate or greater burden to others. (shrink)

This paper argues that public sector organizational failure may be best understood from a perspective of collective denial. The rise of this phenomenon is examined using testimony from a Public Inquiry into the downfall of a UK hospital, where falling organizational standards led to unethical decision making and an unacceptable number of patient deaths. In this paper, we show how collective denial, over time, became a process that resided within the fabric of organizational life. To explore the organizational processes associated (...) with collective denial, and how and why it occurs, we identify the influence of a ‘narrative of silence.’ This narrative allows ever more serious failings to be justified as organizational members lose contact with reality entering a downward spiral with no recovery. The combined impact of assumptions about leadership capability, enculturated professional identities, and organizational loyalty create an environment where a narrative of silence can develop. (shrink)

This article explores the attitudes of consultants in a large UK teaching hospital to the need for formal clinical ethics support. Data obtained through an anonymous online questionnaire illustrate the ways in which consultants deal with clinical ethical dilemmas and their confidence in such decision-making. In the absence of formal ethics support a large proportion of consultants who took part in the survey said that they would consult with colleagues when faced with a clinical ethical dilemma and the majority considered (...) that this satisfactorily resolved the issue. However, 80% of respondents stated that they would find a form of ethics support within the Trust to be useful. Consultants also noted the reasons for, and barriers to, using ethics support. The response rate to the survey was low, perhaps indicating a lack of interest in the topic or that clinical ethics discussion is of low priority. (shrink)

Science and Ethics inextricably intertwinedDawson and Yentis argue that research ethics committees have an obligation to consider the science of applications because this is inextricably entwined with ethics. They lament the fact that the recent English ministerial review of RECs suggests that science should be assessed by others for RECs and not by the committee members themselves. In fact, these views are not as incompatible as they might first appear.The plain truth of the matter is that in a maximum membership (...) of 18, at least a third of whom must be lay members, the capacity of each of the 186 RECs currently in the UK to review …. (shrink)