The 19th century saw major social change in response to the need for labour in manufacturing industries. Urban migration was unprecedented. City streets were generally unpaved, filled with refuse and without sewers or gutters. Housing was extremely inadequate with many of the labouring population housed in cramped tenements, back-to-back and cellar dwellings, with little, if any, toileting facilities.
Overcrowding, poor sanitation and living conditions, and low incomes all led to poverty, widespread disease and national degeneration, with the average life expectancy of men being only 48.
Growing social concern around water and sanitation related health issues, coupled with high incidences of death and disease, led the government to attempt to tackle and prevent
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The publicity surrounding these delays and his subsequent death put such political pressure on the government that a wholesale political review was set up resulting in the White Paper Working for patients (which led to the NHS and Community Care Act 1990).
The ‘Working for Patients’ report (Department of Health, 1989) suggested an internal market be introduced to the NHS. The ideology of this being that by introducing market like incentives it would motivate improvements in service delivery efficiency and productivity.
It proposed a Purchaser/Provider separation where District Health Authorities (DHA’s) became purchasers of hospital and community health services from any provider, including private, public or voluntary sector. Acute hospitals, mental health service and other providers became ‘trusts’, they would become service providers, statutory corporations that were no longer controlled by the DHA, GP’s became ‘fund holders’ holding and managing their own budget and were able to retain any surplus funds