Analyzing the Tragedy of Dr. Faustus

Alfonso Villarreal Mrs. Bohn World Literature Honors April 9, 2012 Analyzing the Tragedy of Dr. Faustus The struggle between good and evil is arguably the most significant theme in the play. This struggle is most evident within the main character Faustus. He is torn and undecided about whether or not he should repent for sinning and return to God or follow through with the contract he signed with Lucifer. His internal struggle lasts almost the entire play, as part of him wants to be good serving God while the other part seeks the power Mephastophilis promises. Metaphastophilis himself has mixed motives and symbolizes this theme.On one hand he pursues Faustus’ soul, intending to carry it to hell while on the other he persuades Faustus to reject the contract because of the horrors he would encounter in hell. This theme, mostly existing within Faustus, provides interest and intrigue as to wonder if whether or not the highly intellectual doctor will finally come to his senses and repent. The play would be significantly less enjoyable if it followed a less interesting man, a man who morally feels no regret in giving up any chance of a positive afterlife for temporary powers. This indecision within Faustus also provides the central drama of the play.The struggle between good and evil is best symbolized by the Good and Evil Angels. Each angel struggled to pull Faustus towards its side as Faustus himself struggled between his human reason or logic and his lustful desire for power. Good and evil battle once more when Faustus encounters the Old Man in the final scene. The Old Man is another symbol which replaces the Good and Evil Angels from earlier scenes. He persuades Faustus to repent and renounce his powers while it’s not too late. Marlowe uses mythological allusions in a rather clever way in this particular work.They provide the audience with a more interesting play and extends the limits of the play’s subject if even slightly. One of the most s ignificant allusions was one performed in Faustus’ visit to Charles V’s court. Charles V pleads Faustus to perform sorcery for him, an allusion of Alexander the Great and his lover. Faustus performs a simple trick and Alexander suddenly appears before the emperor’s eyes. The purpose of this allusion is to show another great feat performed by Faustus and one that certainly brings interest to one of the most powerful men in the world.Marlowe was in some aspects a Renaissance writer and his work was a product of the age. He uses these allusions in the play to illuminate the transition between old beliefs and new ideas and knowledge. This transition served as one of the essential elements in the movement and Marlowe applies it with ease in his great work. â€Å"What art thou, Faustus, but a man condemned to die? † (IV, v, 25) The quote above addresses many essential aspects of the play. One of these aspects is the struggle between good and evil, a theme repre sented most by Faustus and his indecision. This quote indicates this theme of the play more than any other.Yes, Faustus is speaking his most troubled thoughts. What is he if not a fool who sold his soul for a temporary power only to perish in an eternal fire? Again it is evident that he struggles with his two most important principles, his lust for power and his reason. He ponders whether or not he made the right choice. The fact that he even struggles with this is ironic at the very least. One of the most intelligent men of his time is too blind to see the horror in Hell. This quote is also significant in that it represents his tragic fall as his corrupt morality prevents him from repenting in time and ultimately dooms him to an eternity in Hell.

Media Coursework Report Essay

For my AS Media coursework, I chose to use fashion as the genre of my magazine. To help with my pre-production, I had to perform my own qualitative and quantitative research into fashion magazines and find out what my target audience of 15-19 year old girls would want from it. I went on to create the preliminary products which included the front cover and contents page, and from these the main products which were the alternative front cover and double page spread. These were all produced using Photoshop. I began by creating a questionnaire, as this is an effective way of finding out what my target audience will be looking for in a fashion magazine. I included 8 questions which asked some general questions into what the participant is interested in, and some into what they would like to see in a fashion magazine, to help me create my front cover and contents page. I gave 20 questionnaires out to other students aged 16-19 as this fits my target audience. By analysing the results of the questionnaire, I found out a range of information to help my design my front cover. The participants chose  £2.50 as the appropriate price and for the magazine to be produced monthly, which I will apply when creating the front cover. 80% of participants said they would be more likely to pick up the magazine if there was a celebrity on the cover. Therefore, I will ask a friend to pose as a celebrity to make it more appealing to my target audience. 50% of participants wanted to see interviews in the magazine and 30% wanted genre-specific features (in this case, it will be fashion, clothes etc.) which I will make sure to include in the contents page. I formed a focus group with other AS Media students in my class. They were all females, ranged from the ages 16-17, and had an interest in fashion, making them representative of my target audience. I asked them if I should put just one image on the front cover, or add smaller ones around the page to show what’s included inside. The feedback I received was very helpful, and led me to use just the one main photo for my preliminary front cover and  my main front cover, to keep the brand consistent. This keeps it looking professional and stops the page from looking overcrowded and trashy. By textually analysing fashion magazines currently on the market, I discovered a recurring theme among them. The bigger magazines (Vogue, Elle) have been around for much longer, and their cover stars overlap the masthead. However, when analysing Look, I noticed that the masthead overlapped the cover star, suggesting that this magazine is new and lesser known. From this, I decided to have the whole masthead of my magazine visible by audiences for my preliminary front cover as it is new and allows audiences to recognise the brand in future. I then chose to overlap part of the masthead on my main front cover with the cover star, as it is a later issue and audiences should then be able to recognise it. The content analysis allowed me to see what’s included in fashion magazines. This helped when compiling the contents page. Obviously the main part of a fashion magazine is the fashion itself. However, it also includes items related to hair and beauty, interviews, articles, advice and special features. I made sure to include all of these when designing my contents page, but I chose to keep the main focus on fashion. I decided to target my magazine towards teenage girls aged between 15 and 19. I thought this was a good range, as girls in their teens will have a more developed sense of style. From my institutional research, I discovered that many fashion magazines were targeted towards women in their 20s and 30s, and decided to aim mine at a teenage audience. Audiences for fashion magazines such as Vogue and Elle were predominantly female; therefore it was important to include items in the contents and on the cover that would attract a female audience. I also tried to use feminine colours where appropriate in the magazine to indicate the target audience. I also made sure my focus group was a good representation of my target audience, thus making sure they had a clear interest in fashion and fit the age category, which they did. I created my preliminary and main products using Adobe Photoshop which had all the necessary tools I needed to create a realistic and professional  magazine. By comparing my magazine in relation to Vogue, I am able to see the strengths and weaknesses of my production. I began by selecting the images I would use for each page. I used a Fujifilm Finepix S2950 to capture the photos. The models used direct mode of address as this is the most effective way of attracting the audience. I used a hairdryer to create the effect of wind blowing the model’s hair. I chose to use an image with a light background, with a model wearing spring clothing. I think this helped to make the cover look more professional as Vogue often incorporates the colours of the magazine to fit the season. I increased the contrast of the image to make it look brighter and more appealing. I then went on to create puffs around the image, and used only ‘Century Gothic’ font to keep it simple and sophisticated. I used a dark blue for the text as it contrasted well with the pink clothing that the model wore. I made sure to include small details as well, including the bar code, price and date to make the product more realistic. I was very pleased with the outcome of my preliminary front cover as it looked professional in relation to magazines on the market today, and had a similar style to that of Vogue magazine. My next task was the contents page, and from the research I did I was able to see what needed to be included. I wanted to keep it consistent, and so I used the same masthead from the front cover and used it at the top of the contents page. This was used in InStyle’s contents page. I also used the same colour scheme as the front cover, to show that the two are related. I kept the text in columns and split the content into sections, which is what I noticed InStyle and Vogue did when I researched them. I also noticed in the Vogue contents page that there was some information about the front cover image, so I decided to include that in my own, with information on where to buy the clothes. I was quite pleased with the result of my contents page, as I spent a lot of time on it. However, I felt that there was too much white space that could have been filled in. It may have been a good idea to add in some borders to give the page some depth. For the alternative cover, I made sure I kept the same font style and size for my masthead. This is because it is important to keep the brand recognisable. I asked my focus group if this was a good idea and they  agreed, saying it would keep it consistent and professional. All magazines do this, but fashion magazines such as Vogue and Elle often change the colour every month to fit with the theme. I have decided to do the same in my own production, by changing the colour of the masthead and the puffs to a maroon colour, to tie in with the month and season. It also contrasted well with the cover model’s blue dress. Like Vogue, I made sure I kept three puffs around the edges of the main image, to stop them from overlapping. I am really pleased with the outcome of this as I think it could pass as a real magazine. I then went on to create the double page spread in A3 size, and selected my image to cover the whole background. This meant there was no white space left around the edges, but there was still space to put some text. I wanted the image to take up dominant space on the page to catch the reader’s eye, which is what I noticed was used in Vogue’s double page spread. I brightened the image and removed some blemishes on the model to try and reach a flawless image, as perfection is one of the main selling points for a fashion magazine. I set the text out in two columns, as this is the layout that most magazines use, including Vogue. I used ‘Rage Italic’ for the headline, which is what I used for the headline on the cover, to keep a consistent house style. I also added page numbers to the bottom corners, as these small details help to build up a realistic product. I feel that my magazine is very similar to a professional product and would stand out in the market place. It follows the codes and conventions of a typical fashion magazine, and is aesthetically pleasing for the target audience. If I were to change anything, I would make the front cover masthead slightly larger, to make it more eye-catching.

Musical Performance Anxiety Essay Example | Topics and Well Written Essays - 20500 words

Musical Performance Anxiety - Essay Example We did an analysis of the Mozart effect, Bausch’s Bluebeard, effects of anxiety in athletes, and the various studies conducted on the reliability and veracity of the different phenomena associated with performance anxiety. An important idea in an article that we want to pursue and carry out as one of the main points for this paper is Andrew Steptoe’s ideas and results of his studies on the musician’s negative emotions and the problem of performance anxiety. Steptoe (2001:291) says that the musician is focused in his music, to express the words he wants to relay, the meaning and content, his emotions, and everything in that music – all these dominate his mind. Performance becomes threatened when his thoughts are over-intrusive, or interfere with concentration and become tinged with anxiety. The musician’s thoughts become a part of the exacerbating anxiety. The musician is faced with ‘threats’ such as appearing in public, the unfamiliarity of the hall, other technical sides that need to be fixed, travel arrangements, temperature, the size and the attitude of the audience, financial difficulties and lack of confidence on other participants. The musician also worries about forgetting the lines or the songs, fears of disapproval from friends, teachers or critics, and other anxieties. The musician’s mind is occupied with negative emotions during practice and actual performance. These emotions form the musicia n’s behavioral problems. Performance anxiety is a great concern for the musician. His career is threatened once he prepares for a performance.

Depression Essay Example | Topics and Well Written Essays - 250 words

Depression - Essay Example Low mood is the primary symptom of depression and often clients in pursuit of getting rid of these negative emotions resort to abusing narcotics that do more harm than good. As it is also observed in patient care units, individuals suffering from depression become so heavily dependent on the narcotic that discontinuation is followed by severe withdrawal symptoms. The individual also resort to increasing the amount of drugs taken, which can lead to the individual dying as a result of an overdose. Drug abuse can also result in the individual partaking in activities that may regretted later that can exacerbate the depression experienced by the individual. (Jaekel et.al. 2009) Drug abuse is equally detrimental as depression and can seriously hamper one’s social and occupational functioning. Therefore, in order to help the individual avoid addictive behavior, the clinician must try to effectively treat the depression and if not, client psycho-education is really helpful in getting them to avoid undesirable behavior. Clinicians must explain to them the detrimental repercussions of drug abuse and their vulnerability to it, so that clients do not indulge in such behavior.

World Regional Georgraphy Unit 6 Research Paper Example | Topics and Well Written Essays - 250 words

World Regional Georgraphy Unit 6 - Research Paper Example When the British colonizers came in 1795, the laws became more powerful thus, further racial segregation. During this time, Africans were separated from the white settlers and were forced to live in different areas that were later referred to as reserves. Land Act of 1913 facilitated this separation further (Beinart & Dubow, 1995). The economic woes brought about by the World War II increased the racial segregation in South Africa. When National Party gained power in 1948, the new government enacted the apartheid law that ensured that the white race dominated. This law also ensured that the white lived in different areas from the Africans. South Africans were also divided along the tribal lines and their powers decreased. The Population Registration Act was enacted in 1950 and it required all South African races to be classified as black (Africans), whites or colored. Those who failed to adhere to this law were punished harshly. The Department of Home Affairs was responsible for this act. Another core of the apartheid policy was the Group Areas Act which was formed in 1950. This act marked the areas of land based on the race that occupy the areas. The other laws that placed more restrictions on the black South Africans were the Natives Urban Areas Act and the Natives Labor Act from in 1952 and 1953 respectively (Berridge, 1992). Some political parties were against this apartheid policy and they formed a movement to resist the policy. These parties included ANC (African National Congress) of 1912 and PAC (Pan Africanist Congress) of 1958. These two movements managed to ban the South African government through violent campaigns (Berridge, 1992). SASO (South African Students Association) which was formed in 1960 also joined the other parties in resisting the policy. Apartheid policy ended in 1994 when all adults were allowed to vote during that election. The late Nelson Mandela was voted as the

Tesco Company Essay Example | Topics and Well Written Essays - 1500 words - 1

Tesco Company - Essay Example The company faces financial risk factors as follows: the interest rate risk, credit risk, liquidity risk, foreign exchange risk, capital risk and insurance risk. Current ratio – this ratio measures the ability of a business to meet its current obligations using the current assets. Generally, it is advisable for the ratio of current assets to current liability to be 2: 1. Concerning Tesco PLC, the company’s current ratio for 2012 and 2013 were 0.67 and 0.69 respectively. The ratios clearly show that the company is not liquid enough to sufficiently settle its short-term obligations using the current assets. Debt ratio – this ratio indicates the proportion of a company's total assets that have been financed by the total liabilities. It also shows the value of assets that creditors would claim in case of liquidation. Concerning Tesco Company, the ratios for 2012 and 2013 are 64.9 % and 66.76 % respectively. Both ratios show a high dependency on debt to finance the co mpany's assets with 2013 having the biggest percentage. The interpretation shows that only 3.4% of Tesco's revenue was net profit before tax, whereas, the remaining 96.6% were consumed by operating expenses. Based on the current ratio and the net profit margin before tax, Tesco company exhibits poor liquidity and thus cannot meet its current obligation using the current assets. The profitability analysis shows a high level of the company’s operating expenses thus a lower level of profits expressed as a percentage of the total revenue.

Reflection about Management and Organizational Behavior Term Paper

Reflection about Management and Organizational Behavior - Term Paper Example However, effective leadership also depends upon how leaders mend their approaches to suit the characteristics of their followers. Drawing different leadership-related teachings from literature, the most applicable leadership to the situation at Buddy Delight will be identified and evaluated for its effectiveness and applicability. Buddy Delight, a fast food restaurant at the far end of the high street market in Brookshire, Colorado had to close its 5-year old business shortly after the sudden demise of its previous owner. Just before his death, the owner had expanded Buddy Delight to two more floors of the building; and had hired few employees. The owner’s son took over the business after his father’s demise, and brought about many changes, one of which included appointing a new manager in the restaurant section. During earlier years, all business related activities were managed by the owner, the sole manager of the restaurant. However, increasing number of customers and business resulted in high workload as a result of which the new owner decided to bring in more people to manage the business. New employees were hired again at various positions including managerial and reception, operations and for customer service activities. Dissatisfaction, frustration and low performance surfaced in the ope rations team within few weeks after they welcomed their new manager along with two new chefs in their team. The new manager was highly qualified management graduate and possessed years of managerial experience in the marketing division. He had the ability to command and get the tasks accomplished. The manager was young, energetic and highly innovative, which could have been the reasons that had pleased the owner’s son to hire the manager. This team comprised of 12 employees including 4 chefs and eight waiters that were responsible for working in the main restaurant section that was directly involved in preparing food items as per

Business Plan to create a Maintenance Training in Jakarta Research Paper

Business Plan to create a Maintenance Training in Jakarta - Research Paper Example This document provides an analysis of the market, demand condition and other relevant factors. The plan proposes solutions on how to recruit local staff and potential talent to enter the aviation industry. The scope of the report include corporate strategy, finance, marketing, and human resources. The report includes a feasibility study that examines the relevant risks and other dominant factors and matters which are relevant concerns prior to the commitment of resources into the project. The recipients of this report are the stakeholders that include the government of Indonesia and other players who are going to play various roles. This includes sponsors, institution management and other people at the helm of affairs in the training center. The primary focus of the research will be on the maintenance of investments and comparative analysis with other flight training services. The report invokes some elements of mandatory Full Flight Simulators (FFS) and the use of flight instruction s that will be seconded by ETOPS organization which is headquartered in Toulouse, France. The research concludes that it will be better to maintain infrastructure for Asian Aviation Academy in Asia but retain staff members in France and sending instructors to the Asian unit where necessary. This is because it will be expensive to maintain full-time paid staff members in the Asian unit. Also, it is strongly recommended that Asian Aviation Academy must use local resources to reduce costs and retain attractive offers to consumers in order to gain and maintain market share in contrast with other competitors in the industry. It is recommended that Asian Aviation Academy must commence with the Airbus. To this end, the focus of the business plan is on Airbus. As the company grows and the institution gets rooted in the region, the portfolio could be expanded to train other players like Bombardier, Emirates, ATR and other entities. The market analysis is conducted on the basis of this assump tion. CHAPTER 1 GENERAL CONTEXT This proposal focuses on training staff members in some aspects of the Airbus aircrafts and its relevant aviation management job training. In order to examine it, there is the need to undertake a critical review of the scope of work and the technical components of the Airbus family of aircrafts and devices. The primary focus of the Asian Aviation Academy (hereafter referred to as AAA) will be on the A320 which is the smallest and the most popular airline in the range. To this end, AAA will be positioned to train staff members with the management and running of the A320 aircraft and provide all the basic services in this aircraft. The basic services will provide a model for the integration of other airlines in the range and help to promote an efficient training system and structure. 1.1 Market Analysis In the macrocosmic sense, the aviation industry experienced a major boom after 1980 (Sinha 31). This is because deregulation and other liberalization ar rangements ensured that the number of airlines could be increased in nations. Also, the previous tradition of only allowing governments to own airlines was eliminated with the introduction of reforms and deregulation which allowed private participation in the global airline industry. Asia and the

HRM Current Issues Essay Example | Topics and Well Written Essays - 2500 words

HRM Current Issues - Essay Example In this globalised world, an economic problem in one country will not get restricted to that country, but gets spread to other countries. This is what happening today, with the economic recession starting in United States of America, is having a very negative effect all over the world. Many companies are suffering losses and as a result, many employees are losing their jobs. Also, many organizations have quietly cut the salaries and other fringe benefits to their employees. So, the fear that their jobs and salary are at stake and to continue working, the employees are forced to work pushing their limits, leading to stress. With stressed mind, the employees will be hard-pressed to use his/hers physical and mental part, to work effectively for the organization. Stressed mind in the sense, due to the poor match between work load and the capabilities, resources, etc of the worker, the mind of the worker could be become disoriented leading to the damaging of workers biological, psychologi cal or social systems.. Stress is something which can happen to an individual both due to a positive action or change as well as negative action or change. That is, stress can be felt by the employees, if positive actions or changes like promotion, new assignments, new responsibilities, etc happen in his/hers professional life. Also in the same but different way, the employees will become stressed, if he/she faces negative actions or changes both in his/hers professional as well as personal life. The negative events or issues that could trigger stress are unemployment, suspension, failure to meet the targets, pressure, intimidation, abuse, etc from the superior as well as co-workers, divorce, deaths, etc, etc. When the above mentioned negative changes or actions occurs, they will be least expecting it and so they will be unable to handle it. That is, those

5 Paragraph Essay Example | Topics and Well Written Essays - 250 words

5 Paragraph - Essay Example All utility things like automobiles, washing machine, refrigerators etc. breaks down when they are most needed. Indeed, the uncanny coincidence of their breakdown forces one to realize that these objects have a mind of their own which they use for optimal impact against man. Things like personal items have innate tendency of getting lost at the eleventh hour! Gloves, pliers, keys of car, house, locker etc. tend to disappear from their normal place when they are needed urgently. Interestingly, they are often found in the places least expected like the long forgotten corner of the wardrobe or under the mattress of unused bed. How and when they get to be there has remained the mystery for all. Most profound is the knowledge of the objects which refuse to perform their duty once they are brought home by their masters. Cigarette lighters, toys, car clocks etc. are major items that only work once and thereafter refuse to show their talent again. This is perhaps the only category of objects that man has been able to demystify and therefore is less likely to get upset with. One can therefore succinctly state that society of inanimate objects has been successful in declaring their hostility against man. Objects of first two categories show that inanimate things are psychologically much advanced and know how to test human patience or indeed, increase their blood pressure to achieve their objective. Man needs to be much more aware of their cunning intentions so that he is equipped with alternatives that would defeat the evil intentions of the inanimate

Managing Change in Complex Environment Essay Example for Free

Managing Change in Complex Environment Essay History and Background Introduction The United States Postal Service (USPS) is an independent government organization that generates income through mail services. It is currently the second largest civilian employer in the United States. Its primary task is to deliver mail around the country, at a standard price, regardless of geographic location. Over the last two centuries, the USPS has evolved into an efficient organization that financially sustains itself through its delivery operations. With a monopoly on the delivery of non-urgent mail, the USPS provides delivery service of about 40 percent of the worlds mail, or approximately 200 billion pieces of mail annually. Starting in the 1990s, the USPS faced increased competition from rival package delivery and courier services, as well as the Internet. Presently the USPS is facing a financial collapse. The USPS needs to undergo an essential and systematic change in order to maintain its significance in the 21st century. History/Background On July 26, 1775, members of the Second Continental Congress appointed a Postmaster General giving birth to the Postal Department of the United States. The mission of the U.S. Postal Department was much the same as today, process and deliver first class and non-urgent mail to individuals and businesses within the United States. Congress passed various laws that grant the post office a â€Å"statutory monopoly† on non-urgent First Class Mail and the exclusive right to put mail in private mailboxes. Although these laws grant the USPS a market advantaged they also restrict its ability to compete with rival package delivery and courier services, as well as the technological innovations. How it got started The Post Office Department has origins in America dating back to the 17th century, when there was a need for mail between colonial settlements and intercontinental exchange of information with England. In 1775, the Continental Congress named Benjamin Franklin as the first postmaster general and chairman of a committee empowered to make recommendations for the establishment of a postal service. On September 22, 1789 the post office became a new government branch of the United States. At this time there were 75 post offices and approximately 2,000 miles of post roads. The USPS was critical to national welfare and pivotal in facilitating communications for military, congressional representation and newspapers. From the very beginning, the USPS financed operations from revenue it earned and Congress gave it a monopoly to be the only courier service to deliver mail. Key points in evolution The main focus and the efforts of postal officials from the foundation of the Post Office to the present day have been finding the best methods of transporting information and directing mail. For example, in 1791 George Washington stated that that the importance of the postal routes had increased because the country wanted to distribute knowledge of governmental laws. Also, between 1791 and 1861, the U.S increased from 3.9 million to 31.4 million square miles and postal roads grew from 1,875 to 240,595 miles. The Board of Governors of the USPS sets policy, procedure, and postal rates for services rendered. Of the eleven members of the Board, nine are appointed by the President and confirmed by the US Senate. The nine appointed members then select the Postmaster General, who serves as the boards tenth member, and who oversees the day to day activities of the service as Chief Executive Officer. The ten-member board then nominates a Deputy Postmaster General, who acts as Chief Operating Officer, to the eleventh and last remaining open seat. The USPS is often mistaken as a government organization but it is legally defined as an independent establishment of the executive branch of the Government of the United States. Environmental context The external environment elements that significantly influence the USPS are the United States political system, workforce unions, changing technology and market forces. United States Political System In 1970 the U.S. Postal Department evolved into the USPS through the implementation of the Postal Reorganization act. This act required the USPS to be a â€Å"self-sufficient organization within the U.S. Government†. It also added an additional regulatory body into its chain of command, the Postal Regulatory Commission (PRC), but did not make any modification to the Postal Department’s Board of Directors or regulatory congressional statutes. The USPS Board of directors is charged with directing the USPS through the control of expenditures, reviewing practices, long term planning and setting policies and service standards. The PRC has 5 commissioners, appointed through the executive branch and confirmed by the Senate, who have the authority to reject, modify and approve any USPS initiated congressional recommendations. Since congress alone retains the authority to change USPS’ rates, service frequency and employee benefits, any market related changes from the Board of directors is routed through the PRC and congress for consideration. Pressure from Unions There are 4 unions representing around 90% of the USPS workforce: National Association of Letter Carriers, American Postal Workers, National Rural Letters Carriers Association and National Postal Mail Handlers Union. These organizations have successfully contracted collective bargaining agreements for its members for compensation and benefits that have come to exceed the USPS’ ability to maintain with its current revenues. These labor unions are very influential in weighing in on most of the decisions that affect the well-being of the USPS labor force. Presently USPS employees enjoy 79% coverage of their health care costs; the most of any federal agency. Strategic challenge Over the years the USPS has transformed its operating model and is now set up and mandated to operate like a business entity generating its revenue through the sale of postal products and services. The largest issue with the current business model of the postal service is its lack of flexibility essential for a business in a dynamic market. Specifically the USPS has not been able to organizationally adjust to a large decrease in the demand for first class mail service has resulted in decreasing net revenue in recent years. Congressional Influence The USPS congressional charter came with both benefits and operating constraints. Among the constraints the USPS is obligated to provide a uniform price for its services regardless of the geographic location and dispersion of its customer base. The USPS is obligated to deliver six days a week to every mailing address regardless of its mail volume. Additionally the USPS is required to provide free mailing service to the blind and facilitate voting for overseas military personnel. A significant amount of the USPS’ operating costs comes from its requirement to pre-fund retiree health benefits (RHB) for future retirees. Key Issues The USPS is suffering from the combined effects of declining mail volume from new technology and increasing labor costs resulting in a loss of net revenue. These declines are projected to extend into the future. The addition of a significant number of new addresses in the United States each year increases the USPS’ operating costs although volume is decreasing. Business Model While the USPS has enjoyed the benefits of the monopoly on first class letter mail services that congress has bestowed, it has a stagnant business model that prevents the USPS from being able to adapt in the face of technological innovation and other market forces that affect its bottom line annually. The major source of revenue for the post office is the postage it charges for first class and non-standard mail. The advance of modern information systems such as email, smartphones, online banking, and other digital communications decreased the demand for traditional mail services. Compounding this issue is the basic economic principle of supply and demand. New technologies offer cheaper substitutes for the services that the post office provides. Stakeholders Postal Workers – The USPS employs more than 500,000 employees making it second only to Wal-Mart as the nation’s largest civilian employer. While every employee is represented by a labor union, employees are legally restricted from striking. Labor Unions The USPS unions are old, influential and politically connected. Collectively, these unions continually fight for increased employee pay, living allowances and health care benefits. Postal Regulation Commission (PRC) The PRC serves as the middleman between the USPS board of governors and congress. The PRC can reject or modify requests before they reach congress for final approval. Congress Members of Congress exercise control over many aspects of the USPS operations including approving the markets for which it competes as well as representing the interests of its constituents whenever the USPS requests changes to its business model. Public Consumer One of the mandates of the post office is to provide mail service of all addresses. The number of addresses has increased by nearly 18 million nationwide in the past decade and continues to climb as the country recovers from the past recession. A vast majority of the consumers are congressional constituents to whom member of congress are responsible. Competitors The USPS monopolizes, via congressional mandates, the delivery of first class mail, non-urgent mail and small packages. As such it faces very little direct competition from other businesses. However, the USPS has seen significant decreases in its mail volume over the years. The decreased volume of mail is directly related to the global acceptance of technology and use of digital communications which displaced traditional USPS services. Market Forces The USPS full time workers cost the USPS 80% of its revenue. Although they still enjoy a monopoly on first class mail, they are in direct competition with smaller, more efficient, companies who deliver large packages and urgent letters. Strategies Used What it Does Now The USPS has improved its efficiency and effectiveness through both technology and reorganization. The USPS made significant investments in the late 1990’s in fuel efficient vehicles and new facilities as well as a $15 million advertising campaign to improve its image as a progressive and modern organization. A decade ago it took 70 employees one hour to sort 35,000 letters. Today in an hour, only two employees process an identical volume of mail. Though the number of addresses in the nation has increased by nearly 18 million in the past decade, the number of employees who handle the increased delivery load has decreased by more than 200,000 (Potter 2010a). It launched delivery confirmation service and priority mail in order to compete with competitors. The USPS now operates more than 31,000 post offices and the largest vehicle fleet in the world, with an estimated 218,684 vehicles. What They Want to Do Concerned with increasing costs and decreasing revenues, the USPS petitioned for the following changes: * Stop Retiree Health Benefits prefunding – in 2011 the prefunding amount exceeded net operating losses. * Retirement System Overpayment – In 2010 Government Accountability Office disputed overpayment freezing approximately $6.9 billion. * Delivery Frequency – Shifting from six to five days weekly delivery would save approximately $3 billion annually. This measure is supported by 75% of USPS consumer base. * Change prices – Mandates currently cap the USPS ability to adjust to market conditions dynamically. * Restructure labor costs – Current collective bargaining decision do not consider the USPS financial health yet mandate compensation and benefits to be paid at levels comparable with private sector organizations with the burden falling on the taxpayers. * Consolidate infrastructure – A proposal in 2009 to close 3,000 postal outlets to reduce excess capacity yielded only a closure of 157 following consumer complaints and congressional intervention. Part II Diagnosis Lewis (2011) states that the USPS’ problems are a result of a restrictive business model and its inflexibility to operate in a dynamic market place. As stated earlier, the USPS response to this problem is a direct plan to cut expenses and increase revenues to overcome their mounting deficit. Although this plan does address the USPS’ immediate insolvency concerns, it fails to address their underlying issues. Through the use of Senge’s system approach and the McCaskey’s Organizational Design model, this paper will expose USPS’ root problems. Strategic Issues/Strategies/Goals-Objectives The USPS’ strategic issues are a loss of revenue due to declining mail volume, extensive costs due to a bloated and expensive unionized-workforce and the use of an outdated-legislatively constrained business plan. Their proposed strategy to mitigate these issues centers on cutting their expenses, consolidating infrastructure, renegotiating labor cost/employee benefits and increasing rates. In addition, the USPS intends to evolve their business plan to incorporate technological innovations. This strategy aligns with their long term goal of providing a â€Å"trustworthy, dependable, reliable and secure means to communicate on a national level† (Lewis, 2011), by implementing a long term sustainable business model that promotes flexibility and economic growth in a dynamic market. Environment In FY11 the USPS’ total revenues were $65 Billion dollars while their total expenses were $75 Billion dollars. Under congressional law the USPS is required to be a â€Å"self-sufficient government agency†. Under this direction the USPS is obligated to cover its costs without government assistance. The USPS does this by generating revenues from a monopoly market while operating more like a private business then a government agency. Its government backed monopoly advantage comes with extensive congressional restrictions on rates, delivery procedures and labor benefits. The USPS’ monopoly restricts the direct competition in the delivery of first class mail, use of specific delivery routes and personal mailboxes. It does not protect the delivery of urgent mail and large packages. FedEx and UPS are direct competitors in this market and have a competitive advantage due to their efficiencies, technological innovations and ability adapt to market needs. Key Success Factors The USPS’ key to success is their ability to meet their customer’s needs, generate enough revenue to cover their costs , maintain the flexibility to adjust in a dynamic market and optimize a scalable infrastructure that facilitates the efficient and economic delivery of their services. Task Requirements There are multiple ways that mail is accepted into the delivery process. For the purpose of observing the USPS organizational structure, the simple method of customers placing the mail in their residential, or post office, curbside mailbox will be examined. In either case this process begins and ends with the customer sending or receiving mail at a mailbox. The mail item is received by the postal carrier, and then consolidated at the local post office, where it is inspected manually or automatically checked for correct postage. It is then routed to a hub for delivery to a particular region in the country. The mail is then sent to a final processing plant where it is sorted for the specific route for delivery. Finally the mail is sent to the distant end post office for delivery to the end customer. The mail is moved in a linear manner between each node in the process chain. Along the interdependency continuum of the USPS’ functional units we observed a sequential relationship. Throughout the process each entity produces an output that is a necessary input for the next link in the chain. The USPS’ key to success in this linear process is the secure delivery of mail for a nominal fee. For their part, the workers must be honest and ensure mail is properly safeguarded as it makes its way through each step in the chain. The workers only have to be ‘good enough’ for their specific task in the process. This means that there is very little incentive for them to innovate or make improvements to the process from within. Any efficiencies gained, in any one link in the process, are not readily propagated throughout because of the sequential nature of the process. Because of the nature of change within the organization, and the employee compensation structure, their only incentive is to maintain the status quo. This analysis is represented in the interdependency/coordination mechanism model below. The analysis shows a misalignment between the levels of interdependence between the functional units and the coordination mechanism used. The USPS coordinates through rules and regulations. Using the systems approach of focusing on successes rather than the failures of the organization, we compared the USPS current coordination level to its closest successful competitor, FEDEX. As depicted FEDEX has a coordination level that aligns with it level of interdependency. The preferred and optimal approach is to align the organization’s level of interdependency horizontally with the coordination mechanism. The USPS needs a higher coordination mechanism to match the current level of interdependence in order to facilitate efficiencies in the system. Process/ Systems Snowfall and showers may not be able to stop postal carriers from their appointed delivery routes, but their financial problems may halt at least 50% of all postal offices. The U.S. Postal Service, weakened by a public turning to digital communications, is down 22 percent in volume from just five years ago, a decline which is expected to continue, driven in part by rigid competition from carriers such as FedEx and UPS. The Postmaster General has responded with a list of cost-cutting proposals, such as eliminating Saturday delivery and closing up to 3,700 local post offices which would be replaced with automated centers operating out of local businesses. The Postmaster General has also proposed laying off as many as 120,000 workers, and pulling workers out of more costly federal pension plans. Pre-funding retiree benefits has cost the Postal Service $21 billion in the last three years. The underlying issue is that all those moves cannot be made without congressional approval. In order to make these immediate and dramatic changes, the Postal Service would require access to its own funds as well as the authority to act as its own corporation. The transition from a government ran entity to a privatized organization requires Congress to give the USPS flexibility to take action and make changes without all the bureaucracy. The below modified Senge Model (Limit to Growth) demonstrates how the USPS is constrained from making changes. In short, the USPS is limited by congress to making quick and reactive changes that focus on the problem rather than the underlying issue. Creating change and making it work are all resisted by a condition called the â€Å"Status Quo† and the USPS is no exception. USPS employees feel protected under the current unionized culture. They feel threatened by the prospect of losing benefits and are unwilling to pay the high personal price necessary for change. We have demonstrated that this change is necessary for the long term health of the organization. The real question is, â€Å"does the current status quo fit the new change requirements?† An organization in dire need to make radical adjustments to become current cannot be fixed with antiquated congressional imposed constraints. PART III Change Management Plan The USPS acknowledges its need to cut costs and increase revenue. It believes this will fix the problems. USPS starts to address this by taking reactionary measures, but fails to take the necessary steps to address the root issue. We argue that there is a more fundamental problem within the USPS organization which requires a systems approach to identify and solve. Senge says â€Å"it is impossible to change the system from inside the system.† By â€Å"complicating up† the USPS management structure we identify the core problem and faults in its system. Due to the short time needed to enact this change we propose a top down approach that pushes change while mitigating assumed employee resistance such an approach will generate. Our plan uses the Lewin and Kotter models to shape the USPS organizational transition. Through the Lewin model we identify a three phase approach to address changes that simultaneously focuses on employee and organizational issues. Throughout each p hase an information plan is propagated to employees to facilitate transition to the next phase. Conclusion The bottom line is that the USPS current costs of doing business outweigh its current methods of productivity. Without changing the strategic management model, the USPS will continue to lose revenue and be unable to react effectively to market demands. Its proposed cost cutting solutions only scratches the surface of the underlying problem of restrictions on organizational management and coordination. Our uses validated organizational change models. We justify our plan which uses the Lewin model and shows a close association to Kotter’s organizational change model. Our plan leads the USPS to long term success, maintains its relevance in today’s market and allows it to make appropriate changes through periodic reevaluations. References Lewis, T., Montgomery C., Shuler, J. , (2011), The US Postal Service , Naval Postgraduate School, Monterey, CA. Senge, P., (1990), The Fifth Discipline, Doubleday Publishing, New York 15May 2012: http://about.usps.com/news/national-releases/2011/pr11_124.htm 15 May 2012: http://www.cato.org/pubs/journal/cj31n1/cj31n1-9.pdf 19 May 2012: http://www.referenceforbusiness.com/industries/Transportation-Communications-Utilities/United-States-Postal-Service.html

Healthcare Reforms in England Issues of Efficiency

Healthcare Reforms in England Issues of Efficiency The healthcare service in England attempts to improve the overall healthcare service have been ongoing through some of the most radical reforms since its inception as a comprehensive public service since 1948. The noticeable need of a free healthcare service was essential after the state of the country due to the world war. Once the NHS was established it saw many reforms led by diverse types of governments at different times. Despite the scale of the reforms they have preserved their core principle of A free service at the point of delivery 1 till this very day. Even though they have adopted the core principle they still face huge challenges; as demands and costs are still rising, the entirety of the service is increasingly being looked at. This paper looks at the reforms the NHS has been through and analyses each reform in the light of Efficiency: the capability of the NHS, whether the reform made the NHS more competent, Equity: bringing fairness and equal right for the patients as well as the staff, Quality: whether adapting the reforms improved the patients ability to acquire different types of healthcare services without any predicament and obtain high-quality healthcare services. Methodology This paper was conjured up by the use of reports published by NHS Publications website. Journals and studies on NHS reform via the scientific database PubMed were also utilized. To gain info on the theories the NHS was formed on, management theory books by Max Weber, Henri Fayol and Frederic Winslow Taylor were used. Results/Discussion Each reform improvised the NHS in many ways, in relation to Efficiency the NHS since its inception has seen major investments and new hospitals built, employment of up to date technology allowing more patients to be seen within an applicable time and budgets been controlled efficiently with the aim to reduce costs each year allowing the NHS to run efficiently. In terms of Equity after the publication of the Black report, the NHS has improved on giving equal opportunities to its minor ethnic groups of staff. Also the equal treatment of patients regardless of their social class has been improved since the Blair era. The NHS in terms of quality has become one of the world leading healthcare providers. Measuring their services against standards set by the NHS ensured that they are meeting the set standards. The major investment in staff in 2000 saw a number of lives saved in the past 10 years. The NHS has met quality standards that are accepted by its patients and valued as a first class service. Conclusion Overall the NHS has seen many reforms which have lead to the NHS becoming a world class service. Since the reforms in the 1960s to the latest plans of the new coalition government the NHS has improved immensely in terms of efficiency, equity and quality and the future also looks bright for the NHS. Introduction: Healthcare service in England was launched in 1948 with an aim to provide universal healthcare to its citizens which is free at the point of use and available to everyone based on need, not ability to pay 1. The NHS was established after World War II where the country needed a stable healthcare service 2. The initial idea was that no-one should be deterred from seeking health services by a lack of resources and the founder Aneurin Bevan: Minster of Health stated A free service at the point of delivery 3. Till this day they have been providing free healthcare service to the citizens of England. In 1948 Sir William Beveridge, a British Economist and a Social Reformer conferred details of his radical plans for economic and social reform in post-war Britain. Sir William proposed major healthcare service changes on the basis that the country needed the abolition of want before the enjoyment of comfort and suggested a scheme where every kind of medical treatment would be available for everybody. 1,3 Pre NHS There has been some form of state-funded provision of health and social care in England prior to the NHS for 400 years.4 Prior to a health system being formed, attaining healthcare service in Britain in the 1930s and 1940s was difficult. Life expectancy was very low and thousands of people died of infectious diseases like pneumonia, meningitis, tuberculosis, diphtheria, and polio each year.4 The poor never had access to medical treatment and they relied instead on dubious and sometimes dangerous home remedies. Either that or they relied on doctors who gave their services free to the poor patients. The Hospitals charged for treatment and although the poor were reimbursed and before they received treatment they had to pay.4 Figure 1 shows the life expectancy that has changed since the NHS was introduced. Figure 1.Life expectancy changes since 1840 5 The need for free healthcare was widely recognised, but it was impossible to achieve without the support or resources of the government. A study showed that experts believed and have written extensively on the reasons of why a health service was needed.6 These included: The appearance of a view that health care was essential, not something just imparted erratically by charity The drastic effects of the war that made it possible to have a massive change of the healthcare service being provided, rather than just an incremental alteration As younger members of the country were becoming increasingly educated in the medical profession they had a view of things could be handle in a more efficient way. The hospitals having financial problems, funds not sufficing.6 Having looked at the reasons to why a health service was needed the government made plans and core principles were established: 6 Regardless of persons status they were eligible for health care, even people temporarily residing or visiting the country.ÂÂ   People could be referred to any hospital. The healthcare service was financed almost 100% from central taxationÂÂ   Care was entirely free at the point of use6 The main achievement was that the poor who in the past went without medical treatment now had access to free healthcare.6 NHS today and NHS employment NHS is one of the largest organisations in the world with an annual budget of around ÂÂ £80 billion employing more than 1.7 million people and treating over one million people every 36 hours.7 In general, healthcare service being provided within England to every single citizen is a difficult commission to undertake and consequently the system needs efficient health personnels to help run the system economically. Today the view of the healthcare service in England is that the NHS is a world leader and provides first class service that other countries envy. Countries all over the world seek to learn from the comprehensive system of general practice, and its role as the medical home for patients, providing continuity of care and coordination.8 Other countries look at English NHS system and use them as a guideline to run their healthcare system. NHS Structure The healthcare service in England has been run in a structural way with the Secretary of state and Department of Health controlling the overall NHS in England. The secretary of state for health has the responsibility of reporting to the prime minister. There are10 Strategic Health Authorities (SHAs) in England which are controlled by the Department of Health, they oversee all the activities within the NHS and the SHAs supervise all the NHS trusts in its area. Primary care plays a major role in community healthcare and is central to the NHS. Services under NHS trust (Secondary Care) include Hospitals, Mental Health services, Learning disability services and Ambulances. The overall structure of the NHS is shown below in Figure 2. 9 Although this is the current NHS structure with the new government in power, changes are to follow. Figure.2 overall structure of the Healthcare system in England 5 NHS Reforms Since its inception in 1948 the NHS has seen many reforms in terms of managing the way they provide healthcare service. The DoH has a lot of control and influence the major decisions taken in the reforms. The overall expectations of Healthcare service in England are of a high calibre, which requisites high-quality management capacity.10 In the 1980s and early 1990s prominence was on recuperating management. The recent focal point has been on development of leadership within NHS. With the new government, new ideas and plans will be imposed to see improvements in quality of healthcare being provided, cut down on costs making it more efficient and in terms of equity provide equal service to everyone. Table 1 briefly enlists the reforms that have taken place since its inception in 1948. Table.1 Reforms in the NHS: 1948-2010 Period the reforms were in place Reform and theory of Management 1948- 1960 Managers as diplomats 1960s Scientific Management and the Salmon report 1970s Classical Management, Systems Approaches and the 1974 Reorganization 1980s The Griffiths report and Managerialism 1990s Working for Patients and the Internal Market 2000 The NHS Plan (DOH 2000) and the Third Way. 2010 NHS White Paper 2010: Equity and excellence: Liberating the NHS Healthcare service and Reforms in other Developed Countries Healthcare reforms within developed countries can be analyzed in order to compare whether the healthcare services in England have been successful in its bid to ensure efficiency, equity and quality. Attempts to handle reforms of the healthcare system in the European countries have been an ongoing process for 30 years. Although the reforms have taken throughout the 30 years in different ways, their main emphasis has been on improving the cost-effectiveness of the healthcare service. In the early 1980s the EU countries were looking at cost containment. The feature in the 1990s was to endorse efficiency in terms of introducing competition and markets in the healthcare system. Since 2000 the focus has switched to effectiveness; promoting various notions of healthcare in terms of quality.11 Over the course of the 20th century the countries of Europe have established significant success in improving the healthcare service for their citizens. However they still face challenges in the form of restraining costs, improving quality and providing universal healthcare access, these have put the European healthcare services under immense pressure.11 Looking at another OECD: USA, A report on A review of health care reform in the United States assessed whether the USA have been successful in providing healthcare. The findings showed that United States spent more per capita on health care than any other OECD country, yet its health outcomes lagged behind other countries.12 This shows they are struggling with efficiency issues and are still countering challenges in providing quality healthcare service that is expected from the citizens of the USA. Especially in the last few years Healthcare reform has been a major activity of the federal government, in order to revolutionize and develop the service overall. The 3 goals of optimizing cost, access and quality still remain a challenge within the healthcare society in the U.S.12 They concluded that USA still faced many challenges in running the national healthcare service, a key challenge they face is the utter complexity of the system, with its numerous public and private providers.12 Another OECD country reviewed in terms of healthcare service being provided and the reforms that have taken place is China. A report from on From a national, centrally planned health system to a system based on the market: lessons from China concluded: China is the country that has undergone the highest number of health care reforms. Since 1978, China saw many reforms and they also followed the way as the EU countries, with the healthcare system starting from governmental, centrally planned and a collective system to ending up as a heavily market influenced system. Now, thirty years later, the Chinese government openly concede that the reforms were unsuccessful and seek innovative and fresh directions.13 This illustrates that China is also in a healthcare crisis and looking to implement different strategies in order to gain control of Chinas Healthcare system. Having reviewed the healthcare service being endowed in these developed countries, it demonstrates that they are all on an identical level as the healthcare service being provided in England and all face similar challenges. All these developed countries are looking to develop the countries overall healthcare service in terms of efficiency, equity and quality. NHS Plan 2000 and the future of NHS Since the last reform: The NHS plan 2000 14, a lot has transformed in terms of funding and operating the healthcare system in England. Especially with the new coalition governments idea of cutting budgets it is a difficult time the NHS is going through and will necessitate a lot of expertise and world class management to get through todays financial and economical predicament. An additional indication that will be taken into deliberation is the election of the new plans set out in the NHS White Paper 2010. As the new coalition government has come into authority there have been huge changes to overall budgets for the public services and this possibly will have a consequence on the way the NHS operates in England. 15 The reforms have encompassed a significant impact on the organisation and deliverance of health care service in England. Wide array of transformations have been pioneered in an attempt to ensure the NHS is managed more resourcefully and effectively. This report will examine whether these reforms have on the whole improved the healthcare system in England in terms of efficiency, equity and quality and if the publics requirements have been convened. Aims: To examine the healthcare reforms in England since its inception and to assess whether these reforms have improved factors of efficiency, equity and quality in providing healthcare. Objectives: To review the reforms in the NHS since its inception in 1948 To examine whether these reforms improved efficiency, equity and quality of healthcare To assess the key features of healthcare reforms proposed by the current government and their implications on the NHS To put forward plans for the future of the NHS Methodology: A number of sources were consulted to conjure up this paper and examine the healthcare reforms in the NHS. Scientific search engines and databases such as PubMed, Google Scholar and Science Direct (Date accessed 20/10/10) were used to gain literature reviews but results from Google Scholar and Science Direct were dismissed as they were too vague and irrelevant to this topic. With PubMed following keywords were inserted Healthcare, Reforms and England. The data was also set from 1948 to 2010 when searching for reports as this would set the inclusion criteria. The reports and journals since 1948, when the NHS was established were used. Even though history before 1948 was looked at for study purposes, reports before NHS establishment; these were regarded as the exclusion criteria as reports werent looked at prior to 1948. Healthcare service within Britain was looked at in general but for the results of this report, the inclusion criteria was healthcare service in England as it just look ed at the healthcare service being provided within England. The exclusion criterion was healthcare service in Scotland, Wales and Northern Ireland. For the first part of the report, the introduction: where the report looked at the history of the NHS. The resources used included looking at general management books looking at management theories. The classical theories of Max Weber, Frederic Taylor and Henri Fayol were the backbone of the NHS and that is why these were used. Another source to produce this paper was the Department of health (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/index.htm) where the publications and reports about the NHS in general were looked at. This paper used a lot of publications produced by the Department of health and the NHS publications as these sources are reliable; these were seen as good foundation to work from. One of the main publications used was The NHS white paper: Equity and excellence: Liberating the NHS presented to Parliament by the Secretary of State for Health, this was a key entity in writing up this paper. As the paper didnt contract with experiments and clinical trials, it didnt look at a lot of statistics; the majority of its content was obtained from qualitative data. Results/ Discussion Having carried out the required literature searches and reading journals, reports and Department of Health Publications, results were gathered and have been shown below with the discussion of the key topics. The results look at each reform taken place in the NHS and then goes onto analyse the plans set by the new government. Having looked at the reforms and the new plans the paper than talks about efficiency, equity and quality related to each reform. Reforms in the healthcare service in England The healthcare service in the UK has undergone a number of reforms since its inception in 1948. Prior to 1948, healthcare service was provided in England but due to the increasing pressures for efficiency and quality in health services it lead to these developments and reforms in healthcare being provided. A more overtly management-oriented approach to the healthcare service delivery was adopted based on classical management theories to gain more control of the healthcare service in England. 16,17 Classical theories and Scientific Management: 1960s The NHS was based on the classical theories of Frederic Winslow Taylor, Henri Fayol and Max Weber. 16-19 Table 1: Frederic Winslow Taylors four main scientific management principles. Replacing rule-of-work thumb methods with methods based on a scientific of the tasks Scientifically train each individual rather than leave them to train themselves Cooperate with each worker to ensure that the scientific method is being followed Divide workload equally between managers and staff Table 2: Henri Fayols Modern Operational Management approach. Division of work- Specialization for efficiency Authority Responsibility- Both are related, the latter arising from the former. Discipline-Requires good superiors at all levels Unity of Command- Employee should receive orders from one superior only Unity of Direction- Each group of activities with the same objective must have one head and one plan Subordination of individual to general interest- When the two are found to differ, management must reconcile them Remuneration-Should be fair and satisfactory Centralization-Extent to which authority is concentrated or dispersed Scalar chain/line of authority-Needs to be sensible, clear and understood Order : Right thing/person in the right place Equity- Equal opportunity for everyone Stability of tenure- Unnecessary turnover is both the cause and effect of bad management Initiative- Thinking out and execution of a plan Thinking out and execution of a plan Table 3. Max Webers Bureaucratic approach. Power-Ability to get things done, often by the use of threats or sanctions Authority- Ability to get things done because of the position that justified someone in terms of legitimacy Formal approach Hierarchical authority Extensive roles and procedures- Uniformity of decisions and actions Job description- Clear-cut division of labour and High level of specialization Discipline These classical theories contributed a lot to the healthcare service in England and still do to this day.16-19 The classical writers thought of the NHS in terms of purpose and formal structure. They created a formal structure on which the NHS could run on. They also looked at job design, scientific selection and development of workers. The classical theories generally serve as a backbone to the present day NHS management. Although the classical theories made a big contribution to the healthcare service in England it had its limitations and wasnt the most effective way. One drawback was that it wasnt evidence based; it didnt look at the way staff did their tasks and didnt look at the well being of staff, the human and social aspects of work. It just treated them like machines. The theories didnt look at motivating the staff and developing them in their own interests, had they done this staffs work quality wouldve enhanced thus providing an efficient service to patients and overall improve the quality of healthcare service in England. Overall the classical theories were too concrete and fully based on rules and procedures. In terms of efficiency the theories bought a set way of running the healthcare service in England. Once the NHS was established it introduced equity as well as healthcare service was now available to anyone. The NHS was just established and with these set in place in the 1960s the qua lity of service would improve from now with further reforms to come. Salmon Report: 1960s One of the first reforms took place since the NHS was established was in the 1960s. The Salmon Report bought findings and changes which included that workload should be equally distributed between managers and practitioners.20 The NHS would also get rid of matrons and replace them with a hierarchy of nurse managers. The introduction of several additional layers to the management hierarchy; in order to improve efficiency in operating the NHS. This lead to responsibility being equally distributed and the service met its aims and objectives more efficiently. Another change was that nurse managers would contribute to the overall management of the service through the medium of consensus management teams and thus improve efficiency and quality within the NHS. Having nurse managers lead to them taking control of set responsibilities and helped in general running of tasks at ward level leading to an improvement in general quality in the healthcare service being provided. 1974 Reorganization: 1970s The aim of this reform was to attain greater integration of the healthcare service in order to provide more stability and increase efficiency. The reorganisation also introduced more central control in order to: 21 ensure policies were implemented improve accountability encourage delegation develop democratic decision-making process These changes lead to a more structured way for managers to follow and enhance the quality of the healthcare service. By the mid 1970s quality was improving but there were still concerns of equity in the NHS. There were still clear differences of health sufferers in terms of social class; figures showed that people in lower social classes more likely suffered from diseases. There were several possible explanations for these inequalities. Natural and social selection. This would depend on the view that people who are fittest are most likely to succeed in society, and classes reflect this degree of selection. Poverty leads to ill health, through nutrition, housing and environment. Cultural and behavioural explanations. There are differences in the diet and fitness of different social classes, and in certain habits like smoking. 22,23 Overall in the 1970s the quality of healthcare service was still improving, equity issues were still a concern and in terms of efficiency they were recuperating the NHS. The Griffiths Report: 1980s This reform was a major point in NHS history, the Griffiths Report identified problems such as the healthcare service was institutionally inactive and that the local health authorities were filled with directives without being given any clear procedures to follow.24 The Griffiths report stated that changes were difficult to achieve but gave recommendations to improve the NHS. It introduced a more formal and modern way of management. It gave increased participation for managers in setting and controlling budgets. The report also gave greater emphasis on cost awareness in order to improve efficiency. A Clear and quick decision-making process was introduced to improve quality of service provided to patients. The managers in local authorities were given a more clearly defined direction and the overall staffs were better informed.24 The Internal Market Working For Patients: 1990s Another reform in the 1990s took place, this bought a new dimension to the NHS; large publicly-owned hospitals could opt to become self-managed trusts. This meant that health services could be bought by private investors i.e. patients themselves thus allowing them to take control of the way they want the service. Even large GPs could become fund holders and be both purchasers and providers of care.25 This reform lead to introduction of greater flexibility thus allowing more effective matching of patients needs and care. Money followed the patients through the system of purchasing and providing of healthcare service, this led to equity being improved as patients had more selection of services. This reform led to higher competition in providing quality healthcare service, the costs decreased and the general quality increased. The NHS Plan 2000 The NHS Plan 2000 made key findings : the NHS is a 1940s system operating in the 21st century and that it lacked of national standards. It also said that there were barriers between staff and providing services. There were a lack of clear guidelines and the NHS structure has over-centralization.14 Plans to diminish problems and propose new plans such as introducing Modern Matrons to improve the management of services, a strong leader with clinical experience and with clear authority at ward level, improve efficiency by setting standards and controlling resources these were there aims.14,26 The figure below shows the comparison of the 1948 and the new NHS model outlining the key differences. Figure.4 the key difference between the 1948 model and The NHS Plan 2000 model 14 The NHS Plan 2000: Achievements This reform set out specific targets which were achieved in order to improve efficiency, equity and quality of healthcare service in England: Over 100 new hospitals by 2010 and 500 new one-stop primary care centres Clean wards and better hospital food 7,000 extra beds in hospitals Over 3,000 GP premises modernized Modern IT systems in every hospital and GP surgery 7,500 more consultants and 2,000 more GPs 20,000 extra nurses and 6,500 extra therapists Childcare support for NHS staff with 100 on-site nurseries.26 These targets were achieved in 2008 and it led to the improvement of efficiency as the number of GPs and consultants employed were increased. The modernisation of technology and IT systems led to quality of service being improved as high investment in high quality equipment made the NHS one of the worlds top quality service. Since 2000 NHS has improved the overall service and met its objectives. NHS Implications: Equity and excellence: Liberating the NHS With the new coalition government coming into election another set of reforms have been proposed as they hope to improve the overall healthcare service in England. The main aims and objectives to improve the healthcare service are varied and very detailed but to summarise it these are the points covered:15 Increase health spending in real terms in each year of this Parliament 15and also that there goal is an NHS which achieves results that are amongst the best in the world 15. However the government will uphold the foundation that the NHS was formed on; a comprehensive service, available to all, free at the point of use and based on clinical need, not the ability to pay 15. The government than goes into detail of what they arrange to initiate to make an efficient healthcare service: acknowledge the fact that patients come first and therefore will give them greater choice and control. An example of this is that a patient will be able to choose any GP practice, consultant, and choice of treatment consequently improving equity of the service. The government endeavours to develop the healthcare outcomes: set objectives such as reduce mortality and morbidity, increase safety, and improve patient experience and outcomes for all 15. By doing this they are ensuring they are driving efficiency and improving the service. In order to achieve the objectives that the government sets, the ability for service providers to have more autonomy, responsibility and accountability will be a means to achieving efficient results. A big change will be the establishment of a NHS Commissioning Board. The board will be accountable for making sure health outcomes are achieved, allocate resources and have the lead on quality improvement and to tackle inequalities that exist in the NHS. Overall the reforms in the NHS Paper 2010 will provide the NHS with greater incentives to increase efficiency, equity and quality. Efficiency The healthcare system in England has on the whole perceived a huge improvement in terms of efficiency since its inception in 1948. A system has been established where it endows with one of the best services in the world but there are still room for improvements. An analysis of the services gives evidence such as the NHS building 100 new hospitals since 2000, therefore improving the efficiency and allowing better access for patients. 27 Even though there continue to be a lack of quality and accessibility to services across the country. The patients havent been able to impose enough pressure to force improvements. The NHS need to give patients more control over the health services they have access to improve efficiency. In 2008 investment in the NHS as a whole rose from ÂÂ £43.9bn per year in 2000, when the NHS Plan was launched, to ÂÂ £92.6bn. another measurement of efficiency is looking at numbers of early deaths from cancer, coronary heart disease and suicide; they continue to fall as services improve; over 98% of patients at Accident and Emergency (AE) Departments are seen within 4 hours; and hospital waiting lists are lower than ever, with half a million fewer patients waiting since lists were at their peak.28 One key way to achieve the set objectives is to cut down NHS managements costs by 45% over the next four years enabling them to free up investment for further improvements.28 Much has been achieved during the last five years of investment and reforms. For example, the significant investment in NHS staff, along with more flexible working, is facilitating healthcare professionals to take advantage of the freedom thus improving their commitment to the NHS. NHS staff working flexibly and using improved technology are better able to respond to patients needs and changing expectations and are achieving improvements in quality and productivity across the system.27 Since 1948, the NHS budget on average has risen over 4% in real terms each year; this is something they hope to resolve as the NHS will face a sustained and substantial financial constraint if it continues. They hope to avoid the financial crisis that happened in the NHS in the 1970s. The NHS hopes to release up to ÂÂ £20 billion of efficiency savings by 2014, which will be reinvested to suppor Healthcare Reforms in England Issues of Efficiency Healthcare Reforms in England Issues of Efficiency The healthcare service in England attempts to improve the overall healthcare service have been ongoing through some of the most radical reforms since its inception as a comprehensive public service since 1948. The noticeable need of a free healthcare service was essential after the state of the country due to the world war. Once the NHS was established it saw many reforms led by diverse types of governments at different times. Despite the scale of the reforms they have preserved their core principle of A free service at the point of delivery 1 till this very day. Even though they have adopted the core principle they still face huge challenges; as demands and costs are still rising, the entirety of the service is increasingly being looked at. This paper looks at the reforms the NHS has been through and analyses each reform in the light of Efficiency: the capability of the NHS, whether the reform made the NHS more competent, Equity: bringing fairness and equal right for the patients as well as the staff, Quality: whether adapting the reforms improved the patients ability to acquire different types of healthcare services without any predicament and obtain high-quality healthcare services. Methodology This paper was conjured up by the use of reports published by NHS Publications website. Journals and studies on NHS reform via the scientific database PubMed were also utilized. To gain info on the theories the NHS was formed on, management theory books by Max Weber, Henri Fayol and Frederic Winslow Taylor were used. Results/Discussion Each reform improvised the NHS in many ways, in relation to Efficiency the NHS since its inception has seen major investments and new hospitals built, employment of up to date technology allowing more patients to be seen within an applicable time and budgets been controlled efficiently with the aim to reduce costs each year allowing the NHS to run efficiently. In terms of Equity after the publication of the Black report, the NHS has improved on giving equal opportunities to its minor ethnic groups of staff. Also the equal treatment of patients regardless of their social class has been improved since the Blair era. The NHS in terms of quality has become one of the world leading healthcare providers. Measuring their services against standards set by the NHS ensured that they are meeting the set standards. The major investment in staff in 2000 saw a number of lives saved in the past 10 years. The NHS has met quality standards that are accepted by its patients and valued as a first class service. Conclusion Overall the NHS has seen many reforms which have lead to the NHS becoming a world class service. Since the reforms in the 1960s to the latest plans of the new coalition government the NHS has improved immensely in terms of efficiency, equity and quality and the future also looks bright for the NHS. Introduction: Healthcare service in England was launched in 1948 with an aim to provide universal healthcare to its citizens which is free at the point of use and available to everyone based on need, not ability to pay 1. The NHS was established after World War II where the country needed a stable healthcare service 2. The initial idea was that no-one should be deterred from seeking health services by a lack of resources and the founder Aneurin Bevan: Minster of Health stated A free service at the point of delivery 3. Till this day they have been providing free healthcare service to the citizens of England. In 1948 Sir William Beveridge, a British Economist and a Social Reformer conferred details of his radical plans for economic and social reform in post-war Britain. Sir William proposed major healthcare service changes on the basis that the country needed the abolition of want before the enjoyment of comfort and suggested a scheme where every kind of medical treatment would be available for everybody. 1,3 Pre NHS There has been some form of state-funded provision of health and social care in England prior to the NHS for 400 years.4 Prior to a health system being formed, attaining healthcare service in Britain in the 1930s and 1940s was difficult. Life expectancy was very low and thousands of people died of infectious diseases like pneumonia, meningitis, tuberculosis, diphtheria, and polio each year.4 The poor never had access to medical treatment and they relied instead on dubious and sometimes dangerous home remedies. Either that or they relied on doctors who gave their services free to the poor patients. The Hospitals charged for treatment and although the poor were reimbursed and before they received treatment they had to pay.4 Figure 1 shows the life expectancy that has changed since the NHS was introduced. Figure 1.Life expectancy changes since 1840 5 The need for free healthcare was widely recognised, but it was impossible to achieve without the support or resources of the government. A study showed that experts believed and have written extensively on the reasons of why a health service was needed.6 These included: The appearance of a view that health care was essential, not something just imparted erratically by charity The drastic effects of the war that made it possible to have a massive change of the healthcare service being provided, rather than just an incremental alteration As younger members of the country were becoming increasingly educated in the medical profession they had a view of things could be handle in a more efficient way. The hospitals having financial problems, funds not sufficing.6 Having looked at the reasons to why a health service was needed the government made plans and core principles were established: 6 Regardless of persons status they were eligible for health care, even people temporarily residing or visiting the country.ÂÂ   People could be referred to any hospital. The healthcare service was financed almost 100% from central taxationÂÂ   Care was entirely free at the point of use6 The main achievement was that the poor who in the past went without medical treatment now had access to free healthcare.6 NHS today and NHS employment NHS is one of the largest organisations in the world with an annual budget of around ÂÂ £80 billion employing more than 1.7 million people and treating over one million people every 36 hours.7 In general, healthcare service being provided within England to every single citizen is a difficult commission to undertake and consequently the system needs efficient health personnels to help run the system economically. Today the view of the healthcare service in England is that the NHS is a world leader and provides first class service that other countries envy. Countries all over the world seek to learn from the comprehensive system of general practice, and its role as the medical home for patients, providing continuity of care and coordination.8 Other countries look at English NHS system and use them as a guideline to run their healthcare system. NHS Structure The healthcare service in England has been run in a structural way with the Secretary of state and Department of Health controlling the overall NHS in England. The secretary of state for health has the responsibility of reporting to the prime minister. There are10 Strategic Health Authorities (SHAs) in England which are controlled by the Department of Health, they oversee all the activities within the NHS and the SHAs supervise all the NHS trusts in its area. Primary care plays a major role in community healthcare and is central to the NHS. Services under NHS trust (Secondary Care) include Hospitals, Mental Health services, Learning disability services and Ambulances. The overall structure of the NHS is shown below in Figure 2. 9 Although this is the current NHS structure with the new government in power, changes are to follow. Figure.2 overall structure of the Healthcare system in England 5 NHS Reforms Since its inception in 1948 the NHS has seen many reforms in terms of managing the way they provide healthcare service. The DoH has a lot of control and influence the major decisions taken in the reforms. The overall expectations of Healthcare service in England are of a high calibre, which requisites high-quality management capacity.10 In the 1980s and early 1990s prominence was on recuperating management. The recent focal point has been on development of leadership within NHS. With the new government, new ideas and plans will be imposed to see improvements in quality of healthcare being provided, cut down on costs making it more efficient and in terms of equity provide equal service to everyone. Table 1 briefly enlists the reforms that have taken place since its inception in 1948. Table.1 Reforms in the NHS: 1948-2010 Period the reforms were in place Reform and theory of Management 1948- 1960 Managers as diplomats 1960s Scientific Management and the Salmon report 1970s Classical Management, Systems Approaches and the 1974 Reorganization 1980s The Griffiths report and Managerialism 1990s Working for Patients and the Internal Market 2000 The NHS Plan (DOH 2000) and the Third Way. 2010 NHS White Paper 2010: Equity and excellence: Liberating the NHS Healthcare service and Reforms in other Developed Countries Healthcare reforms within developed countries can be analyzed in order to compare whether the healthcare services in England have been successful in its bid to ensure efficiency, equity and quality. Attempts to handle reforms of the healthcare system in the European countries have been an ongoing process for 30 years. Although the reforms have taken throughout the 30 years in different ways, their main emphasis has been on improving the cost-effectiveness of the healthcare service. In the early 1980s the EU countries were looking at cost containment. The feature in the 1990s was to endorse efficiency in terms of introducing competition and markets in the healthcare system. Since 2000 the focus has switched to effectiveness; promoting various notions of healthcare in terms of quality.11 Over the course of the 20th century the countries of Europe have established significant success in improving the healthcare service for their citizens. However they still face challenges in the form of restraining costs, improving quality and providing universal healthcare access, these have put the European healthcare services under immense pressure.11 Looking at another OECD: USA, A report on A review of health care reform in the United States assessed whether the USA have been successful in providing healthcare. The findings showed that United States spent more per capita on health care than any other OECD country, yet its health outcomes lagged behind other countries.12 This shows they are struggling with efficiency issues and are still countering challenges in providing quality healthcare service that is expected from the citizens of the USA. Especially in the last few years Healthcare reform has been a major activity of the federal government, in order to revolutionize and develop the service overall. The 3 goals of optimizing cost, access and quality still remain a challenge within the healthcare society in the U.S.12 They concluded that USA still faced many challenges in running the national healthcare service, a key challenge they face is the utter complexity of the system, with its numerous public and private providers.12 Another OECD country reviewed in terms of healthcare service being provided and the reforms that have taken place is China. A report from on From a national, centrally planned health system to a system based on the market: lessons from China concluded: China is the country that has undergone the highest number of health care reforms. Since 1978, China saw many reforms and they also followed the way as the EU countries, with the healthcare system starting from governmental, centrally planned and a collective system to ending up as a heavily market influenced system. Now, thirty years later, the Chinese government openly concede that the reforms were unsuccessful and seek innovative and fresh directions.13 This illustrates that China is also in a healthcare crisis and looking to implement different strategies in order to gain control of Chinas Healthcare system. Having reviewed the healthcare service being endowed in these developed countries, it demonstrates that they are all on an identical level as the healthcare service being provided in England and all face similar challenges. All these developed countries are looking to develop the countries overall healthcare service in terms of efficiency, equity and quality. NHS Plan 2000 and the future of NHS Since the last reform: The NHS plan 2000 14, a lot has transformed in terms of funding and operating the healthcare system in England. Especially with the new coalition governments idea of cutting budgets it is a difficult time the NHS is going through and will necessitate a lot of expertise and world class management to get through todays financial and economical predicament. An additional indication that will be taken into deliberation is the election of the new plans set out in the NHS White Paper 2010. As the new coalition government has come into authority there have been huge changes to overall budgets for the public services and this possibly will have a consequence on the way the NHS operates in England. 15 The reforms have encompassed a significant impact on the organisation and deliverance of health care service in England. Wide array of transformations have been pioneered in an attempt to ensure the NHS is managed more resourcefully and effectively. This report will examine whether these reforms have on the whole improved the healthcare system in England in terms of efficiency, equity and quality and if the publics requirements have been convened. Aims: To examine the healthcare reforms in England since its inception and to assess whether these reforms have improved factors of efficiency, equity and quality in providing healthcare. Objectives: To review the reforms in the NHS since its inception in 1948 To examine whether these reforms improved efficiency, equity and quality of healthcare To assess the key features of healthcare reforms proposed by the current government and their implications on the NHS To put forward plans for the future of the NHS Methodology: A number of sources were consulted to conjure up this paper and examine the healthcare reforms in the NHS. Scientific search engines and databases such as PubMed, Google Scholar and Science Direct (Date accessed 20/10/10) were used to gain literature reviews but results from Google Scholar and Science Direct were dismissed as they were too vague and irrelevant to this topic. With PubMed following keywords were inserted Healthcare, Reforms and England. The data was also set from 1948 to 2010 when searching for reports as this would set the inclusion criteria. The reports and journals since 1948, when the NHS was established were used. Even though history before 1948 was looked at for study purposes, reports before NHS establishment; these were regarded as the exclusion criteria as reports werent looked at prior to 1948. Healthcare service within Britain was looked at in general but for the results of this report, the inclusion criteria was healthcare service in England as it just look ed at the healthcare service being provided within England. The exclusion criterion was healthcare service in Scotland, Wales and Northern Ireland. For the first part of the report, the introduction: where the report looked at the history of the NHS. The resources used included looking at general management books looking at management theories. The classical theories of Max Weber, Frederic Taylor and Henri Fayol were the backbone of the NHS and that is why these were used. Another source to produce this paper was the Department of health (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/index.htm) where the publications and reports about the NHS in general were looked at. This paper used a lot of publications produced by the Department of health and the NHS publications as these sources are reliable; these were seen as good foundation to work from. One of the main publications used was The NHS white paper: Equity and excellence: Liberating the NHS presented to Parliament by the Secretary of State for Health, this was a key entity in writing up this paper. As the paper didnt contract with experiments and clinical trials, it didnt look at a lot of statistics; the majority of its content was obtained from qualitative data. Results/ Discussion Having carried out the required literature searches and reading journals, reports and Department of Health Publications, results were gathered and have been shown below with the discussion of the key topics. The results look at each reform taken place in the NHS and then goes onto analyse the plans set by the new government. Having looked at the reforms and the new plans the paper than talks about efficiency, equity and quality related to each reform. Reforms in the healthcare service in England The healthcare service in the UK has undergone a number of reforms since its inception in 1948. Prior to 1948, healthcare service was provided in England but due to the increasing pressures for efficiency and quality in health services it lead to these developments and reforms in healthcare being provided. A more overtly management-oriented approach to the healthcare service delivery was adopted based on classical management theories to gain more control of the healthcare service in England. 16,17 Classical theories and Scientific Management: 1960s The NHS was based on the classical theories of Frederic Winslow Taylor, Henri Fayol and Max Weber. 16-19 Table 1: Frederic Winslow Taylors four main scientific management principles. Replacing rule-of-work thumb methods with methods based on a scientific of the tasks Scientifically train each individual rather than leave them to train themselves Cooperate with each worker to ensure that the scientific method is being followed Divide workload equally between managers and staff Table 2: Henri Fayols Modern Operational Management approach. Division of work- Specialization for efficiency Authority Responsibility- Both are related, the latter arising from the former. Discipline-Requires good superiors at all levels Unity of Command- Employee should receive orders from one superior only Unity of Direction- Each group of activities with the same objective must have one head and one plan Subordination of individual to general interest- When the two are found to differ, management must reconcile them Remuneration-Should be fair and satisfactory Centralization-Extent to which authority is concentrated or dispersed Scalar chain/line of authority-Needs to be sensible, clear and understood Order : Right thing/person in the right place Equity- Equal opportunity for everyone Stability of tenure- Unnecessary turnover is both the cause and effect of bad management Initiative- Thinking out and execution of a plan Thinking out and execution of a plan Table 3. Max Webers Bureaucratic approach. Power-Ability to get things done, often by the use of threats or sanctions Authority- Ability to get things done because of the position that justified someone in terms of legitimacy Formal approach Hierarchical authority Extensive roles and procedures- Uniformity of decisions and actions Job description- Clear-cut division of labour and High level of specialization Discipline These classical theories contributed a lot to the healthcare service in England and still do to this day.16-19 The classical writers thought of the NHS in terms of purpose and formal structure. They created a formal structure on which the NHS could run on. They also looked at job design, scientific selection and development of workers. The classical theories generally serve as a backbone to the present day NHS management. Although the classical theories made a big contribution to the healthcare service in England it had its limitations and wasnt the most effective way. One drawback was that it wasnt evidence based; it didnt look at the way staff did their tasks and didnt look at the well being of staff, the human and social aspects of work. It just treated them like machines. The theories didnt look at motivating the staff and developing them in their own interests, had they done this staffs work quality wouldve enhanced thus providing an efficient service to patients and overall improve the quality of healthcare service in England. Overall the classical theories were too concrete and fully based on rules and procedures. In terms of efficiency the theories bought a set way of running the healthcare service in England. Once the NHS was established it introduced equity as well as healthcare service was now available to anyone. The NHS was just established and with these set in place in the 1960s the qua lity of service would improve from now with further reforms to come. Salmon Report: 1960s One of the first reforms took place since the NHS was established was in the 1960s. The Salmon Report bought findings and changes which included that workload should be equally distributed between managers and practitioners.20 The NHS would also get rid of matrons and replace them with a hierarchy of nurse managers. The introduction of several additional layers to the management hierarchy; in order to improve efficiency in operating the NHS. This lead to responsibility being equally distributed and the service met its aims and objectives more efficiently. Another change was that nurse managers would contribute to the overall management of the service through the medium of consensus management teams and thus improve efficiency and quality within the NHS. Having nurse managers lead to them taking control of set responsibilities and helped in general running of tasks at ward level leading to an improvement in general quality in the healthcare service being provided. 1974 Reorganization: 1970s The aim of this reform was to attain greater integration of the healthcare service in order to provide more stability and increase efficiency. The reorganisation also introduced more central control in order to: 21 ensure policies were implemented improve accountability encourage delegation develop democratic decision-making process These changes lead to a more structured way for managers to follow and enhance the quality of the healthcare service. By the mid 1970s quality was improving but there were still concerns of equity in the NHS. There were still clear differences of health sufferers in terms of social class; figures showed that people in lower social classes more likely suffered from diseases. There were several possible explanations for these inequalities. Natural and social selection. This would depend on the view that people who are fittest are most likely to succeed in society, and classes reflect this degree of selection. Poverty leads to ill health, through nutrition, housing and environment. Cultural and behavioural explanations. There are differences in the diet and fitness of different social classes, and in certain habits like smoking. 22,23 Overall in the 1970s the quality of healthcare service was still improving, equity issues were still a concern and in terms of efficiency they were recuperating the NHS. The Griffiths Report: 1980s This reform was a major point in NHS history, the Griffiths Report identified problems such as the healthcare service was institutionally inactive and that the local health authorities were filled with directives without being given any clear procedures to follow.24 The Griffiths report stated that changes were difficult to achieve but gave recommendations to improve the NHS. It introduced a more formal and modern way of management. It gave increased participation for managers in setting and controlling budgets. The report also gave greater emphasis on cost awareness in order to improve efficiency. A Clear and quick decision-making process was introduced to improve quality of service provided to patients. The managers in local authorities were given a more clearly defined direction and the overall staffs were better informed.24 The Internal Market Working For Patients: 1990s Another reform in the 1990s took place, this bought a new dimension to the NHS; large publicly-owned hospitals could opt to become self-managed trusts. This meant that health services could be bought by private investors i.e. patients themselves thus allowing them to take control of the way they want the service. Even large GPs could become fund holders and be both purchasers and providers of care.25 This reform lead to introduction of greater flexibility thus allowing more effective matching of patients needs and care. Money followed the patients through the system of purchasing and providing of healthcare service, this led to equity being improved as patients had more selection of services. This reform led to higher competition in providing quality healthcare service, the costs decreased and the general quality increased. The NHS Plan 2000 The NHS Plan 2000 made key findings : the NHS is a 1940s system operating in the 21st century and that it lacked of national standards. It also said that there were barriers between staff and providing services. There were a lack of clear guidelines and the NHS structure has over-centralization.14 Plans to diminish problems and propose new plans such as introducing Modern Matrons to improve the management of services, a strong leader with clinical experience and with clear authority at ward level, improve efficiency by setting standards and controlling resources these were there aims.14,26 The figure below shows the comparison of the 1948 and the new NHS model outlining the key differences. Figure.4 the key difference between the 1948 model and The NHS Plan 2000 model 14 The NHS Plan 2000: Achievements This reform set out specific targets which were achieved in order to improve efficiency, equity and quality of healthcare service in England: Over 100 new hospitals by 2010 and 500 new one-stop primary care centres Clean wards and better hospital food 7,000 extra beds in hospitals Over 3,000 GP premises modernized Modern IT systems in every hospital and GP surgery 7,500 more consultants and 2,000 more GPs 20,000 extra nurses and 6,500 extra therapists Childcare support for NHS staff with 100 on-site nurseries.26 These targets were achieved in 2008 and it led to the improvement of efficiency as the number of GPs and consultants employed were increased. The modernisation of technology and IT systems led to quality of service being improved as high investment in high quality equipment made the NHS one of the worlds top quality service. Since 2000 NHS has improved the overall service and met its objectives. NHS Implications: Equity and excellence: Liberating the NHS With the new coalition government coming into election another set of reforms have been proposed as they hope to improve the overall healthcare service in England. The main aims and objectives to improve the healthcare service are varied and very detailed but to summarise it these are the points covered:15 Increase health spending in real terms in each year of this Parliament 15and also that there goal is an NHS which achieves results that are amongst the best in the world 15. However the government will uphold the foundation that the NHS was formed on; a comprehensive service, available to all, free at the point of use and based on clinical need, not the ability to pay 15. The government than goes into detail of what they arrange to initiate to make an efficient healthcare service: acknowledge the fact that patients come first and therefore will give them greater choice and control. An example of this is that a patient will be able to choose any GP practice, consultant, and choice of treatment consequently improving equity of the service. The government endeavours to develop the healthcare outcomes: set objectives such as reduce mortality and morbidity, increase safety, and improve patient experience and outcomes for all 15. By doing this they are ensuring they are driving efficiency and improving the service. In order to achieve the objectives that the government sets, the ability for service providers to have more autonomy, responsibility and accountability will be a means to achieving efficient results. A big change will be the establishment of a NHS Commissioning Board. The board will be accountable for making sure health outcomes are achieved, allocate resources and have the lead on quality improvement and to tackle inequalities that exist in the NHS. Overall the reforms in the NHS Paper 2010 will provide the NHS with greater incentives to increase efficiency, equity and quality. Efficiency The healthcare system in England has on the whole perceived a huge improvement in terms of efficiency since its inception in 1948. A system has been established where it endows with one of the best services in the world but there are still room for improvements. An analysis of the services gives evidence such as the NHS building 100 new hospitals since 2000, therefore improving the efficiency and allowing better access for patients. 27 Even though there continue to be a lack of quality and accessibility to services across the country. The patients havent been able to impose enough pressure to force improvements. The NHS need to give patients more control over the health services they have access to improve efficiency. In 2008 investment in the NHS as a whole rose from ÂÂ £43.9bn per year in 2000, when the NHS Plan was launched, to ÂÂ £92.6bn. another measurement of efficiency is looking at numbers of early deaths from cancer, coronary heart disease and suicide; they continue to fall as services improve; over 98% of patients at Accident and Emergency (AE) Departments are seen within 4 hours; and hospital waiting lists are lower than ever, with half a million fewer patients waiting since lists were at their peak.28 One key way to achieve the set objectives is to cut down NHS managements costs by 45% over the next four years enabling them to free up investment for further improvements.28 Much has been achieved during the last five years of investment and reforms. For example, the significant investment in NHS staff, along with more flexible working, is facilitating healthcare professionals to take advantage of the freedom thus improving their commitment to the NHS. NHS staff working flexibly and using improved technology are better able to respond to patients needs and changing expectations and are achieving improvements in quality and productivity across the system.27 Since 1948, the NHS budget on average has risen over 4% in real terms each year; this is something they hope to resolve as the NHS will face a sustained and substantial financial constraint if it continues. They hope to avoid the financial crisis that happened in the NHS in the 1970s. The NHS hopes to release up to ÂÂ £20 billion of efficiency savings by 2014, which will be reinvested to suppor