1990s: The Introduction of the Internal Market

Abstract

AbstractThe National Health Service and Community Care Act 1990, set in motion by the publication of the 1989 White Papers—Working for Patients and Caring for People, saw an intense time of policy change which would profoundly impact community and district nursing services. These papers ushered in the introduction of the internal market with purchaser/provider split between commissioners and providers of services, aiming for better services, better patient choice and to reduce costs. This chapter focuses on how the NHS was re-structured to facilitate this quasi-market organisation with Health Authorities (HAs), once pivotal, replaced by Primary Care Groups (PCGs) at the end of the decade. We document here the impact of these changes on the district nursing service as well as bringing to the fore that it was a service in crisis and in need of attention. Heavy caseloads coupled with a diminishing workforce led to a review of the grading system and an increasing use of ‘skill-mix’. We also highlight that aligned with internal marketisation ideals, funding of community services was based on a crude count of average number of contacts rather than based on the complexities of the role. As ever, there was a need for district nurses to ‘deliver more for less’ (Audit Commission, 1999, p. 94) at the end of the era.