The British National Health Service 1948–2008: A Review of the Historiography

The legacy of Dr Marjory Warren's publications

While the contributions of Dr Marjory W. Warren to geriatric medicine are widely acknowledged, their specifics have become obscured by the passage of time. The primary objective of this narrative review of her medical publications was to clarify the contributions she made for this field of medical practice. A total of 82 publications were found. In them Warren presented a then novel and hopeful approach to the management of older patients that included making care plans derived from comprehensive assessments, implementing team-based interventions, and ensuring continuity of care. These innovations, though, took years to implement and included what would now be considered a number of paternalistic and hierarchical aspects. Objective patient outcome data was rarely presented. While responsible for innovations that remain key to the field, some of what she proposed are either no longer possible (e.g. large in-patient units with prolonged lengths of stay) or have required modifications to align with current practice.

The influence of waiting times and sociopolitical variables on public trust in healthcare: A cross-sectional study of the NHS in England

Objectives

This study aims to assess factors influencing public trust in the National Health Service (NHS) in England, focusing on the impact of waiting times in Accident & Emergency (A&E) departments and for GP-to-specialist cancer referrals.

Study design

A cross-sectional survey-based research design was employed, covering the period from July 2022 to July 2023.

Methods

Data were collected through YouGov surveys, yielding 7415 responses. Our analysis is based on 6952 of these responses which we were able to aggregate to 42 NHS Integrated Care Boards (ICBs) for A&E waiting times and 106 ICB sub-units for cancer referral times. Multiple regression analysis was conducted, with the dependent variable being trust in the NHS.

Results

Waiting times for A&E and cancer referrals did not significantly affect trust in the NHS. However, other sociopolitical factors displayed significant influence. Specifically, being a member of an ethnic minority group, or having voted Conservative in the 2019 general election were associated with lower trust scores. Other variables such as age and local unemployment rate were also significant predictors.

Conclusions

Our findings suggest that waiting times for healthcare services have no effect on public trust in the NHS. Instead, trust appears to be largely shaped by sociopolitical factors. Policymakers should therefore look beyond operational efficiency when seeking to bolster trust in the healthcare system.

What treatment outcomes matter in adolescent depression? A Q-study of priority profiles among mental health practitioners in the UK and Chile

Evidence-based and person-centred care requires the measurement of treatment outcomes that matter to youth and mental health practitioners. Priorities, however, may vary not just between but also within stakeholder groups. This study used Q-methodology to explore differences in outcome priorities among mental health practitioners from two countries in relation to youth depression. Practitioners from the United Kingdom (UK) (n = 27) and Chile (n = 15) sorted 35 outcome descriptions by importance and completed brief semi-structured interviews about their sorting rationale. By-person principal component analysis (PCA) served to identify distinct priority profiles within each country sample; second-order PCA examined whether these profiles could be further reduced into cross-cultural "super profiles". We identified three UK outcome priority profiles (Reduced symptoms and enhanced well-being; improved individual coping and self-management; improved family coping and support), and two Chilean profiles (Strengthened identity and enhanced insight; symptom reduction and self-management). These could be further reduced into two cross-cultural super profiles: one prioritized outcomes related to reduced depressive symptoms and enhanced well-being; the other prioritized outcomes related to improved resilience resources within youth and families. A practitioner focus on symptom reduction aligns with a long-standing focus on symptomatic change in youth depression treatment studies, and with recent measurement recommendations. Less data and guidance are available to those practitioners who prioritize resilience outcomes. To raise the chances that such practitioners will engage in evidence-based practice and measurement-based care, measurement guidance for a broader set of outcomes may be needed.

GPs in UK: From Health Gatekeepers in Primary Care to Health Agents in Primary Health Care

After 75 years of reformed practice, general practitioners (GPs) in the UK have transformed from health gatekeepers who simply provide medical decision-making such as diagnostic and treatment services and referral services, to health agents who proactively provide more relevant health services such as immunizations, health monitoring and health management, etc. In order to discuss this transformation of the role of the general practitioner and the conditions for the evolution of the role, this study chose the documentary analysis method to provide a comprehensive overview of the legal and normative documents related to the general practitioner. Furthermore, this study uses a comparative analysis method to conclude the definition and role characteristics of GPs as health agents. This study summarises the general pattern of evolution of GPs into health agents. The transformation into a health agent relies on the interpersonal trust and rigorous institutional of society on the general practitioner system. The expansion of GPs' clientele and range of services, together with the motivation to proactively provide services, have combined to push for a "qualitative change" in the GP's role as health agent. The transformation of the role of the general practitioner to a health agent is a historical necessity. It responds to the evolution of society's understanding of health and the need for higher levels of health. Therefore, recognizing the role of GPs as health agents is important for optimizing the use of health care resources and improving the health of society by taking advantage of this role.

The shadows of waiting and care: on discourses of waiting in the history of the British National Health Service

Waiting is at the centre of experiences and practices of healthcare. However, we know very little about the relationship between the subjective experiences of patients who wait in and for care, health practitioners who 'prescribe' and manage waiting, and how this relates to broader cultural meanings of waiting. Waiting features heavily in the sociological, managerial, historical and health economics literatures that investigate UK healthcare, but the focus has been on service provision and quality, with waiting (including waiting lists and waiting times) drawn on as a key marker to test the efficiency and affordability of the NHS. In this article, we consider the historical contours of this framing of waiting, and ask what has been lost or occluded through its development. To do so, we review the available discourses in the existing literature on the NHS through a series of 'snapshots' or key moments in its history. Through its negative imprint, we argue that what shadows these discourses is the idea of waiting and care as phenomenological temporal experiences, and time as a practice of care. In response, we begin to trace the intellectual and historical resources available for alternative histories of waiting - materials that might enable scholars to reconstruct some of the complex temporalities of care marginalized in existing accounts of waiting, and which could help reframe both future historical accounts and contemporary debates about waiting in the NHS.

Bioethics in humanitarian disaster relief operations: a military perspective

The ethical dilemmas faced every day by military personnel working within the NHS will potentially be very different to ones that will be faced in the wake of a humanitarian disaster. Allied to this the potentially differing objectives from military personnel when compared with other healthcare workers in these scenarios and a conflict of ethics could arise.Within this paper, the fundamentals of this conflict will be explored and how working within the military framework can affect clinical decisions. This is a paper commissioned as a part of the humanitarian and disaster relief operations special issue of BMJ Military Health.

Sharing whilst caring: solidarity and public trust in a data-driven healthcare system

BACKGROUND

In the UK, the solidaristic character of the NHS makes it one of the most trusted public institutions. In recent years, the introduction of data-driven technologies in healthcare has opened up the space for collaborations with private digital companies seeking access to patient data. However, these collaborations appear to challenge the public's trust in the.

MAIN TEXT

In this paper we explore how the opening of the healthcare sector to private digital companies challenges the existing social contract and the NHS's solidaristic character, and impacts on public trust. We start by critically discussing different examples of partnerships between the NHS and private companies that collect and use data. We then analyse the relationship between trust and solidarity, and investigate how this relationship changes in the context of digital companies entering the healthcare system. Finally, we show ways for the NHS to maintain public trust by putting in place a solidarity grounded partnership model with companies seeking to access patient data. Such a model would need to serve collective interests through, for example, securing preferential access to goods and services, providing health benefits, and monitoring data access.

CONCLUSION

A solidarity grounded partnership model will help establish a social contract or licence that responds to the public's expectations and to principles of a solidaristic healthcare system.

Social Democratic Solidarity and the Welfare State: Health Care and Single-Tier Universality in Sweden and Canada

Although it is not generally done, it is useful to compare the history of the evolution of universal health coverage (UHC) in Canada and Sweden. The majority of citizens in both countries have shared, and continue to share, a commitment to a strong form of single-tier universality in the design of their respective UHC systems. In the postwar era, they also share a remarkably similar timeline in the emergence and entrenchment of single-tier UHC, despite the political and social differences between the two countries. At the same time, UHC was initially designed, implemented, and managed by social democratic governments that held power for long periods of time, creating a path dependency for single-tier Medicare that was difficult for future governments of different ideological persuasions to alter.

Covid-19: Refracting decision-making through the prism of resource allocation

Medical decision-making has, across the history of the NHS, made a transitional journey from a model characterised by paternalism to one which places emphasis on partnership and patient autonomy. This article assesses the extent to which the circumstances generated by the Covid-19 pandemic affect the mode of critical care decision-making. It observes that clinical judgment influenced by protocols, algorithms and resource constraints do not lend themselves to full identification with either of the two frameworks familiar to the NHS. The unique mode of decision-making engendered can only be understood on its own terms.

Commentary: Serving the nation, serving the people: echoes of war in the early NHS

It is something of a cliché to speak of Britain as having been transformed by the traumas of World War II and by its aftermath. From the advent of the 'cradle to grave' Welfare State to the end of (formal) empire, the effects of total war were enduring. Typically, they have been explored in relation to demographic, socioeconomic, technological and geopolitical trends and events. Yet as the articles in this volume observe across a variety of examples, World War II affected individuals, groups and communities in ways both intimate and immediate. For them, its effects were directly embodied That is, they were experienced physically and emotionally-in physical and mental wounds, in ruptured domesticities and new opportunities and in the wholesale disruption and re-formation of communities displaced by bombing and reconstruction. So it is, perhaps, unsurprising that Britain's post-war National Health Service, as the state institution charged with managing the bodies and behaviour of the British people, was itself permeated by a 'wartime spirit' long after the cessation of international hostilities.

Strengthening Primary Health-Care Services to Help Prevent and Control Long-Term (Chronic) Non-Communicable Diseases in Low- and Middle-Income Countries

The prevalence of long-term (chronic) non-communicable diseases (NCDs) is increasing globally due to an ageing global population, urbanization, changes in lifestyles, and inequitable access to healthcare. Although previously more common in high- and upper-middle-income countries, lower-middle-income countries (LMICs) are more affected, with NCDs in LMICs currently accounting for 85–90% of premature deaths among 30–69 years old. NCDs have both high morbidity and mortality and high treatment costs, not only for the diseases themselves but also for their complications. Primary health care (PHC) services are a vital component in the prevention and control of long-term NCDs, particularly in LMICs, where the health infrastructure and hospital services may be under strain. Drawing from published studies, this review analyses how PHC services can be utilized and strengthened to help prevent and control long-term NCDs in LMICs. The review finds that a PHC service approach, which deals with health in a comprehensive way, including the promotion, prevention, and control of diseases, can be useful in both high and low resource settings. Further, a PHC based approach also provides opportunities for communities to better access appropriate healthcare, which ensures more significant equity, efficiency, effectiveness, safety, and timeliness, empowers service users, and helps healthcare providers to achieve better health outcomes at lower costs.

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McKinsey and the 'Tripartite Monster': The Role of Management Consultants in the 1974 NHS Reorganisation

The first major reorganisation of the National Health Service took place in 1974, twenty-six years after the service had been established. It has long been perceived as a failure. This article draws on archival records and a witness seminar held in November 2016 to provide a more nuanced assessment of the 1974 reorganisation and understand more fully why it took the form that it did. In particular it identifies the reorganisation as an important moment in the ongoing story of management consultants engaging with health policymakers, and explores the role of McKinsey and Co. in detail for the first time. Key explanatory factors for their involvement are identified, including the perceived lack of expertise and manpower inside the civil service and the NHS, and perceptions of their impact and effectiveness are discussed. Many debates about the use of management consultants today were directly foreshadowed during the early 1970s. Alongside this, the role of other groups of policy actors, including civil servants, politicians and medical professionals, are established and the extent to which British health policymakers have had to work within existing cultural, political, legislative and practical constraints when trying to initiate change is demonstrated. The fact that many of the 'mistakes' that were made have been repeated in the course of subsequent reforms, speaks to the poor institutional memory of Whitehall, and the Department of Health and Social Care in particular. In the run up to 1974 management consultants could make only a limited contribution to an imperfect compromise.

Estratégias que viabilizam o acesso aos serviços de Atenção Primária à Saúde no Reino Unido

Este artigo apresenta algumas características organizativas e operacionais da Atenção Primária à Saúde (APS) inglesa. Seu objetivo é evidenciar pontos relevantes no funcionamento das clínicas da APS que facilitam o equilíbrio dinâmico entre o atendimento à demanda espontânea e as ações programáticas em saúde. Ele tem como base um estudo etnográfico, realizado no Reino Unido no período de 2013/14, no qual se analisou o modelo de pagamento por desempenho no país. Os tópicos abordados incluem: (a) composição das equipes da APS inglesa; (b) organograma funcional de uma clínica de APS; (c) consulta de 10 minutos dos médicos de família e horário de funcionamento da clínica; (d) recepção; (e) equipe de enfermagem; e (f) sistema de tecnologia da informação. Cada um desses itens possui referências para as quais é possível explorar websites e tutoriais de modo a compreender melhor alguns aspectos das clínicas da APS inglesa. O Reino Unido profissionalizou o acesso dos pacientes aos serviços da APS. Isto ocorreu por meio de um contingente maior de pessoal administrativo, menor proporção população/médico de família, maior autonomia da equipe de enfermagem e um robusto sistema de tecnologia da informação. No Brasil, a Estratégia Saúde da Família (ESF) necessita percorrer caminho semelhante a fim de aprimorar a qualidade da APS no país.

A Historical View on Health Care: A New View on Austerity?

It is an axiom of contemporary conversations about austerity and health care that the relationship between the two is essentially direct. Cutting funds damages health care systems and hurts the health of individuals who rely on them. Though this premise has provoked necessary discussion about global politics, the global economy and their impact on individual well-being, it is nonetheless intrinsically problematic. Assigning health and health care as objects of austerity not only obscures the complexity of health care systems and the opacity of health's definitional borders, but also misunderstands austerity, its manifestations and its significance. The ambition of this essay is to bring health care back into the debate, in order to establish the greater dynamism of the contemporary austerity and health care relationship. This historical reconstruction will challenge the significance of our current situating of austerity as health care's bogeyman, press for a reconsideration of our contemporary definitions of the key factors involved here (health, health care and austerity) and finally conclude with some thoughts on how we might more productively approach the problem of health now.

Cost awareness in urology: A nationwide survey

Introduction:

In the current economic climate with continuous expenditure reviews and financial constraints, clinicians should remain conscious of making cost-effective choices on consumables and medications. In this survey, we evaluated the cost awareness amongst UK urologists. This is an observational study in which urology clinicians were asked to estimate the cost of 10 commonly used medications and consumables in urology by completing a questionnaire.

Methodology:

The survey was primarily conducted at the BAUS Annual Meeting 2017 with subsequent responders at local hospitals and urological courses. The costs of consumables and medications were verified with the relevant companies and the 73rd edition of the British National Formulary.

Result:

There were 139 responders from across the UK (46 consultants, 64 training registrars, 13 trust grades doctors and 16 senior house officers (SHOs)). In total, 16 and 60% of all estimates were within ± 25% and ± 100% of the true cost of the items respectively. Approximately 97.1, 95.7 and 97.1% overestimated the cost of a 14Ch urethral catheter, Ciprofloxacin and Sildenafil, respectively; while 78.4 and 84.9% of responders underestimated the cost of a JJ ureteric stent and Solifenacin, respectively. On multivariate analysis, SHOs significantly overestimated the cost of urethral catheters, suprapubic catheterization kits and JJ ureteric stents compared to other clinician grades.

Conclusion:

Cost awareness among UK urologists is poor. Expensive items (e.g. JJ ureteric stent, Solifenacin) tend to be underestimated while inexpensive items (e.g. catheter, Ciprofloxacin, Sildenafil) tend to be overestimated. This lack of appreciation of value may have an impact on drug and consumable expenditure.

Level of Evidence:

Level 3

"Deliver Me From This Indignity!": Cottage Hospitals, Localism and NHS Healthcare in Central England, 1948-1978

Victorian and Edwardian cottage hospitals, compared to infirmaries and workhouse institutions, have been neglected by social historians. Yet, they provided an infrastructure dedicated to localism and healthcare for the aged under the new National Health Service (NHS) after World War Two. This article focuses on two renowned Midlands cottage hospitals built in mid-Northamptonshire at Pitsford. In their patient case-histories we can engage with: dignity standards, medical regime, ward designs, staffing levels, budget provisions, and patient voices. These popular institutions had a well-deserved reputation for delivering high-quality geriatric medicine from 1948 to 1978. Human vignettes detailing the physical indignities of ageing nonetheless proliferate in the records. The longevity of these basic issues was to prove to be a recurring tension in NHS financial planning. Budget models lacked enough funds for aged patients to receive 'stable' bedside care. Instead, NHS accountants allocated resources to ensure the future 'sustainability' of the system itself. A new paradigm highlights the inherent financial contradictions and empty political promises that those needing geriatric care often experienced, and still do. Throughout, the rediscovered cottage hospital records contain important historical lessons for the present impasse about how to define, deliver and secure dignity for elderly patients in today's NHS.

'Save our NHS': activism, information-based expertise and the 'new times' of the 1980s

This article examines activism in defence of the National Health Service (NHS), which emerges in the 1960s to defend local hospitals from closure. From the mid-1980s, a new form of campaigning developed, which sought to protect the Service nationally. Tracing this campaigning illuminates, first, that small groups played a significant role in negotiating political change, and in contributing to cultural change which, in turn, has become politically powerful. Second, this demonstrates that the 1980s were 'new times' in welfare politics, as Thatcher's changes fostered voluntary interest in information-led expertise, and a new vision of the NHS as a significant, much valued, national institution.

Resource Allocation for Equity in the British National Health Service, 1948-89: An Advocacy Coalition Analysis of the RAWP

Britain's National Health Service (NHS) is a universal, single-payer health system in which the central state has been instrumental in ensuring equity. This article investigates why from the 1970s a policy to achieve equal access for equal need was implemented. Despite the founding principle that the NHS should "universalize the best," this was a controversial policy goal, implying substantial redistribution from London and the South and threatening established medical, political, and bureaucratic interests. Our conceptual approach draws on the advocacy coalition framework (ACF), which foregrounds the influence of research and ideas in the policy process. We first outline the spatial inequities that the NHS inherited, the work of the Resource Allocation Working Party (RAWP), and its new redistributive formula. We then introduce the ACF approach, analyzing the RAWP's prehistory and formation in advocacy coalition terms, focusing particularly on the rise of health economics. Our explanation emphasizes the consensual commitment to equity, which relegated conflict to more technical questions of application. The "buy-in" of midlevel bureaucrats was central to the RAWP's successful alignment of equity with allocative efficiency. We contrast this with the failure of advocacy for equity of health outcomes: here consensus over core beliefs and technical solutions proved elusive.

Can history improve big bang health reform? Commentary

At present, the professional skills of the historian are rarely relied upon when health policies are being formulated. There are numerous reasons for this, one of which is the natural desire of decision-makers to break with the past when enacting big bang policy change. This article identifies the strengths professional historians bring to bear on policy development using the establishment and subsequent reform of universal health coverage as an example. Historians provide pertinent and historically informed context; isolate the forces that have historically allowed for major reform; and separate the truly novel reforms from those attempted or implemented in the past. In addition, the historian's use of primary sources allows potentially new and highly salient facts to guide the framing of the policy problem and its solution. This paper argues that historians are critical for constructing a viable narrative of the establishment and evolution of universal health coverage policies. The lack of this narrative makes it difficult to achieve an accurate assessment of systemic gaps in coverage and access, and the design or redesign of universal health coverage that can successfully close these gaps.

Has NHS reorganisation saved lives? A CuSum study using 65 years of data

OBJECTIVES

To determine if NHS reforms affect population mortality.

DESIGN

Retrospective study using routinely published data.

SETTING & PARTICIPANTS

Resident population of England and Wales 1948 to 2012 MAIN OUTCOME MEASURE: All cause age sex directly standardised mortality England and Wales 1948 to 2012.

METHODS

Using the CuSum technique and Change-Point Analysis to identify sustained changes in the improving age-standardised mortality rates for the period 1948-2012, and comparing the time of these changes with periods of NHS reform. Where observed changes did not fit with NHS reform, changes external to the NHS were sought as a possible explanation of changes observed.

RESULTS

CuSum plotting and CPA showed no significant changes in female mortality trend between 1948 and 2012. However, this analysis identified a sustained improvement in the male mortality trend, occurring in the mid-1970s. A further change in the rate of male mortality decline was found around the Millennium.

CONCLUSION

The 1974 NHS reorganisation, changing service arrangements predominantly for women and children, is considered an unlikely explanation of the improved rate of male mortality decline. Thus, centrally led NHS reorganisation has never had any detectable effect on either male or female mortality and must be considered ineffective for this purpose. But some evidence supporting the view that increased funding improves outcomes is found.

Use of the extended therapy outcome measure for children with dysarthria

Increasing demand on healthcare resources has led to a greater emphasis on the examination of the impact of service delivery on outcomes. Clinical assessments frequently do not cover all aspects of change associated with interventions for those with complex conditions. This paper reviews the need for more comprehensive outcome measurement suitable for clinical practice and benchmarking. It describes an extension of the Therapy Outcome Measure for specific use in reflecting the impact of the broad range of interventions commonly required when managing children with dysarthria. Three case histories are used to illustrate the approach, and data from four speech-language pathology services are used to illustrate the value of benchmarking.

Introducing the therapy outcome measure for AAC services in the context of a review of other measures

PURPOSE

This article discusses the importance of outcome measures in improving Augmentative and Alternative Communication (AAC) services, reviews existing methods and introduces a new approach.

METHOD

Three methods were used in this study. 1. A literature review identifying outcome measures used in AAC research. 2. A questionnaire to AAC services in the UK which aimed to identify the objectives of their services and the outcome measures commonly used. 3. A working group of AAC experts provided additional information and interpretation. Central properties and conceptual framework were considered.

RESULTS

The literature review and questionnaire identified 23 outcome measures none of which cover the conceptual frameworks associated with all of the overall objectives of AAC provision. The review has informed the further development of a particular outcome measure the AAC Therapy Outcome Measure (AAC TOM) ensuring that basic principles of the International Classification of Functioning (ICF-WHO) are retained and the measure can be used in benchmarking.

CONCLUSION

An outcome measure needs to reflect change associated with service delivery. AAC services endeavour to impact on all of the domains of the ICF. A new measure is required in order to reflect the nature of these services. This article introduces an outcome measure which is in the process of being trialled by some services in the UK.

‘To regulate and confirm inequality’? A regional history of geriatric hospitals under the English National Health Service, c.1948–c.1975

The post-war history of hospital care for older people in Britain in the first phase of its National Health Service (NHS) emphasises a detrimental Poor Law legacy. This article presents a regional study, based on the South West of England, of the processes by which Victorian workhouses became the basis of geriatric hospital provision under the NHS. Its premise is that legislative and medical developments provided opportunities for local actors to discard the ‘legacy’, and their limited success in doing so requires explanation. Theoretical perspectives from the literature are introduced including political economy approaches; historical sociology of the medical profession; and path dependence. Analysis of resource allocation decisions shows a persistent tendency to disadvantage these institutions by comparison with acute care hospitals and services for mothers and children, although new ideas about geriatric medicine had some impact locally. Quantitative and qualitative data are used to examine policies towards organisation, staffing and infrastructural improvements, suggesting early momentum was not maintained. Explanations lie partly with national financial constraints and partly with the regional administrative arrangements following the NHS settlement which perpetuated existing divisions between agencies.

A critical account of the rise and spread of 'leadership': the case of U.K. healthcare

This paper considers the rise of 'leadership' in discourses relating to the British health service, and the application of the term to increasingly heterogeneous actors. Analysing interviews with NHS chief executives from the late 1990s, and key policy documents published since, we highlight how leadership has become a term of choice among policymakers, with positive cultural valences which previously predominant terms such as 'management' now lack. We note in particular how leadership is increasingly conferred not only on those in positions of formal power but on frontline clinicians, patients and even the public, and how not just the implementation but the design of policy is now constructed as being led by these groups. Such constructions of the distribution of power in the health service, however, contradict the picture drawn by academic work. We suggest, therefore, that part of the purpose of leadership discourse is to align the subjectivities of health-service stakeholders with policy intentions, making their implementation not just everyone's responsibility, but part of everyone's sense of self. Given the realities of organizational life for many of the subjects of leadership discourse, however, the extent to which leadership retains its current positive associations and ubiquity remains to be seen.

Towards a new moral paradigm in health care delivery: accounting for individuals

For years, commentators have debated how to most appropriately allocate scarce medical resources over large populations. In this paper, I abstract the major rationing schema into three general approaches: rationing by price, quantity, and prioritization. Each has both normative appeal and considerable weakness. After exploring them, I present what some commentators have termed the "moral paradigm" as an alternative to broader philosophies designed to encapsulate the universe of options available to allocators (often termed the market, professional, and political paradigms). While not itself an abstraction of any specific viable rationing scheme, it provides a strong basis for the development of a new scheme that offers considerable moral and political appeal often absent from traditionally employed rationing schema. As I explain, the moral paradigm, in its strong, absolute, and uncompromising version, is economically untenable. This paper articulates a modified version of the moral paradigm that is pluralist in nature rather than absolute. It appeals to the moral, emotional, and irrational sensibilities of each individual person. The moral paradigm, so articulated, can complement any health care delivery system that policy-makers adopt. It functions by granting individuals the ability to appeal to an administrative adjudicatory board designated for this purpose. The adjudicatory board would have the expertise and power to act in response to the complaints of individual aggrieved patients, including those complaints that stem from the moral, religious, ethical, emotional, irrational, or other subjective positions of the patient, and would have plenary power to affirm the denial of access to medical care or to mandate the provision of such care. The board must be designed to facilitate its intended function while creating structural limitations on abuse of power and other excess. I make some specific suggestions on matters of structure and function in the hope of demonstrating both that this adjudicatory model can function and that it can do so immediately, regardless of the underlying health care delivery system or its theoretical underpinnings.

The changing landscape of medical education in the UK

The UK shares many characteristics with other western developed countries, including a current adherence to the view that defining educational outcomes enables improvements in learning and teaching and a more effective management of the learning and assessment process. There are, however, some features that make UK medical education unique or that give it a distinctive flavour. This article looks at the various forces that shape medical education in the UK and the structures that underpin its delivery, and discusses the distinctive climate that is produced, in which doctors, students and medical teachers are expected to work. We examine and assess these special features of UK medical education and report on the ways in which medical education and medical educators are adapting to the complex and constantly changing environment. We conclude that the healthcare and higher education systems in the UK face unprecedented economic and political challenges over the coming years. Medical educators working within these systems have an important role in ensuring that these challenges are met and that standards are maintained and improved. A stronger professional architecture to support careers in medical education is needed to ensure that those involved in teaching medical students and doctors have the necessary training, time, resources and incentives to do it effectively.