BOX 4-1
Beveridge—The Five Giants

  • Want         - or the need for an adequate income for all
  • Disease     - or the need for access to health care
  • Ignorance  - or the need for access to educational opportunity
  • Squalor     - or the need for adequate housing
  • Idleness     - or the need for gainful employment

described these needs as being not only health but also “want, ignorance, squalor, disease, and idleness” (Box 4-1) (Beveridge, 1942). The belief was that all of these needs had to be addressed to make any progress on any one of these needs. All hospitals and health care providers (except physicians, who remained independent) were nationalized to standardize the system.

The NHS is funded through general taxation, and care is provided free at the point of care. Every citizen is expected to register with a general practitioner. Although some treatment options are not covered because of coverage decisions by NHS’s standard-setting body, primary care is free.

Until 1997, the NHS was essentially a monopoly of care provision. Long waiting lists for services came as a result of very low funding levels for the NHS. In 1997, the Labor Party moved to modernize the system and reduce the waiting times. The new system was more patient centered and gave people more choices, but also reduced waiting times. This was what NHS termed “joined-up care,” which also included efforts to integrate services for people living with chronic health conditions.

The new system also moved control and responsibility for health outcomes from the national level to the local level. The NHS is organized into 10 different regions called “strategic health authorities.” These authorities, in turn, provide oversight to 152 primary care trusts. Each trust is responsible for health assessments and for organizing all of the health care services needed for the population in its catchment area. Each primary care trust, then, represents a local health economy of between 400,000 and 500,000 residents. Primary care trusts are thus similar to geography-based health plans in the United States. Unlike U.S. health plans, however, the trusts engage in population-based health planning (see Figure 4-1 for the NHS model).

Despite the reorganization, the system still has large health inequalities. In light of these inequalities, one of the top five reform goals of the reorganized NHS is the reduction of health inequalities, and the government is working to establish specific targets to reduce these inequalities. This is a



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