National Health Service (England)

The NHS Logo for England

NHS hospital in England.

Norfolk and Norwich University Hospital, an NHS hospital.

The National Health Service (NHS) is the publicly funded healthcare system in England. The NHS provides healthcare to anyone normally resident in the UK with most services free at the point of use for the patient though there are charges associated with eye tests, dental care, prescriptions, and many aspects of personal care.

The NHS provides the majority of healthcare in England, including primary care, in-patient care, long-term healthcare, ophthalmology and dentistry. The National Health Service Act 1946 came into effect on 5 July 1948. Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used by less than 8% of the population, and generally as a top-up to NHS services. Recently the private sector has been increasingly used to increase NHS capacity despite a large proportion of the public opposing such involvement according to one survey by the BMA.

The NHS is largely funded from general taxation (including a proportion from National Insurance payments). The UK government department responsible for the NHS is the Department of Health, headed by the Secretary of State for Health (Health Secretary), who sits in the British Cabinet. Most of the expenditure of The Department of Health (£98.6 billion in 2008-9) is spent on the NHS.

The NHS is the world's largest health service and the world's fourth-largest employer; only the Chinese People's Liberation Army, Indian Railways, and Wal-Mart employ more people directly.

History

Main article: History of the National Health Service

In the aftermath of World War II, Clement Attlee's Labour government created the NHS as part of the "cradle to grave" welfare-state reforms, based on the proposals of the Beveridge Report, prepared in 1942 by the economist and social reformer William Beveridge.

The idea was that if Britain could work towards full employment and spend huge sums of money during the wartime effort, then in a time of peace equitable measures of social solidarity and financial resources could be redirected towards fostering public goods. This sentiment was widely shared, as the wartime hero Winston Churchill was decisively voted out in a landslide defeat in the 1945 elections. Although most of the British felt that Churchill's leadership during the war was commendable, there were a number of reasons which led to the Conservative defeat in the 1945 general election. One reason was that the public favoured a push for sweeping social changes that Churchill's Conservative Party vehemently opposed. The driving force behind this reformist agenda was popular enough, that eventually it constituted a 'Post-war Consensus' which continued virtually unchallenged until the 1980s, no matter which party controlled the government.

The first problem for Labour's reform agenda began when the second world war ended and funding was scarce due to the cost of the war. At this point, Attlee realised that his plans for the rebuilding of postwar Britain and enacting widespread reform were in serious financial trouble. It wasn't until the Cold War began to escalate that the Americans initiated the Marshall Plan which helped rebuild Western Europe from physical and economic ruin. This allowed Attlee to continue moving forward with the "cradle to grave" reforms outlined in the Beveridge Report that his government had promised the British public.

Aneurin Bevan, the newly appointed Health Minister, was given the task of introducing the National Health Service. Healthcare in the UK prior to the war had been a patchwork quilt of private, municipal and charity schemes. Bevan now decided that the way forward was a national system primarily operated by the Department of Health. He preferred this option to a more devolved structure operated by regional authorities. The thinking behind Bevan's plan was that it would prevent inequalities between different regions. He proposed that each resident would be signed up to a specific General Practice (GP) as the point of entry into the system. From that point on, any resident of the UK would have access to any kind of treatment they needed without having to face the embarrassment of being unable to pay for it. Some historians have criticised this centralised structure. However opinion polls have shown that the majority of the British public have retained support for it.

Doctors were initially opposed to Bevan's plan, primarily on the grounds that it reduced their level of independence. Bevan had to get them onside, as, without doctors, there would be no health service. Being a shrewd political operator, Bevan managed to push through the radical health care reform measure by dividing and cajoling the opposition, as well as by offering lucrative payment structures for consultants. On this subject he stated, "I stuffed their mouths with gold." On July 5, 1948, at the Park Hospital in Manchester, Bevan unveiled the National Health Service and stated, "We now have the moral leadership of the world."

The cost of the new NHS soon took its toll on government finances. On 21st April 1951 the Chancellor of the Exchequer, Hugh Gaitskell, proposed that there should be a one shilling (5p) prescription charge together with new charges for half the cost of dentures and spectacles. Bevan resigned from the Cabinet in protest. This led to a split in the party that contributed to the electoral defeat of the Labour government in 1951. The one shilling prescription charge was introduced in 1952 together with a £1 flat rate fee for ordinary dental treatment. Prescription charges were abolished in 1965. Prescriptions remained free until June 1968 when the charges were reintroduced.

Dr. A. J. Cronin's highly controversial novel, The Citadel, published in 1937, had fomented extensive dialogue about the severe inadequacies of health care. The author's innovative ideas were not only essential to the conception of the NHS, but in fact, his best-selling novels are even said to have greatly contributed to the Labour Party's victory in 1945. Millions of citizens had been unable to afford the privatized system and were disenfranchised from access to health care before the NHS. Now, every single person has access to quality health care that is financed through progressive taxation, that is, from each according to his ability to pay, to each according to his needs as a patient.

Core Principles

According to the NHS website

'The NHS is committed to providing quality care that meets the needs of everyone, is free at the point of need, and is based on a patient's clinical need, not their ability to pay. The NHS will not exclude people because of their health status or ability to pay.'

The main aims are

• To provide a universal service for all based on clinical need, not ability to pay
• To provide a comprehensive range of services
• To shape its services around the needs and preferences of individual patients, their families and their carers
• To respond to the different needs of different populations
• To work continuously to improve the quality of services and to minimize errors
• To support and value its staff
• To use public funds for healthcare devoted solely to NHS patients
• To work with others to ensure a seamless service for patients
• To help to keep people healthy and work to reduce health inequalities
• To respect the confidentiality of individual patients and provide open access to information about services, treatment and performance

Structure

Main article: NHS Institutions and Organisations

Organisation

The NHS in England is controlled by the UK government through the Department of Health, which takes political responsibility for the service. The DH controls ten Strategic Health Authorities (SHAs), which oversee all NHS operations, particularly the Primary Care Trusts, in their area. These are coterminous the nine Government Office Regions for the most part, with the South East region split into South East Coast and South Central SHAs.

There are several types of NHS trust:

• Primary Care Trusts (PCTs), which administer primary care and public health. On 1 October 2006 the number of PCTs was reduced from 303 to 152 in an attempt to bring services closer together and cut costs. These oversee 29,000 GPs and 18,000 NHS dentists. In addition, they commission acute services from other NHS Trusts and the private sector, provide primary care in their locations, and oversee such matters as primary and secondary prevention, vaccination administration and control of epidemics. PCTs control 80 per cent of the total NHS budget.
• NHS Hospital Trusts. 290 organisations administer hospitals, treatment centres and specialist care in about 1,600 NHS hospitals (many trusts maintain between 2 and 8 different hospital sites).
• NHS Ambulance Services Trusts
• NHS Care Trusts
• NHS Mental Health Services Trusts
• NHS Direct Trust provides telephone and online support services

Staff

A feature of the NHS, distinguishing it from other public healthcare systems in Continental Europe, is that not only does it pay directly for health expenses, it also employs a large number of staff that provide them. In particular, nearly all hospital doctors and nurses in England are employed by the NHS and work in NHS-run hospitals.

In contrast General Practitioners, dentists, optometrists (opticians) and other providers of local healthcare, are almost all self-employed, and contract their services back to the NHS. They may operate in partnership with other professionals, own and operate their own surgeries and clinics,and employ their own staff, including other doctors etc. However, the NHS does sometimes provide centrally employed healthcare professionals and facilities in areas where there is insufficient provision by self-employed professionals.

As of March 2005, the NHS has 1.3 million workers, and is variously the third or fifth largest workforce in the world, after the Chinese Army, Indian Railways and (as argued by Jon Hibbs, the NHS's head of news, in a press release from March 22, 2005) Wal-Mart and the United States Department of Defense. The BBC quotes an alternative workforce of 1.33 million people in 2004.

It should be noted that NHS workforce figures provided by the Department of Health include not only employees of NHS divisions but also local authority social services workers. The full-time equivalent figure for 2005 was about 980,000 staff.

Funding

The total budget Health in England in 2008/9 is £94bn of which NHS England accounts for £91.7bn. The National Audit Office reports annually on the summarised consolidated accounts of the NHS .

The commissioning system

The principal fundholders in the NHS system are the NHS Primary Care Trusts (PCTs), who commission healthcare from hospitals, GPs and others. PCTs disburse funds to them on an agreed tariff or contract basis, on guidelines set out by the Department of Health. The PCTs receive a budget from the Department of Health on a formula basis relating to population and specific local needs. They are required to "break even" - that is, they must not show a deficit on their budgets at the end of the financial year, although in recent years cost and demand pressures have made this objective impossible for some Trusts. Failure to meet financial objectives can result in the dismissal and replacement of a Trust's Board of Directors, although such dismissals are enormously expensive for the NHS.

Other revenue sources

Access to the NHS and patient charges

Except for set charges applying to most adults for prescriptions, optician services and dentistry, the NHS is free for all patients "ordinarily resident" in the UK at the point of use irrespective of whether any National Insurance contributions have been paid.

Those who are not "ordinarily resident" (including British citizens who have paid National Insurance contributions in the past) are liable to charges for services other than that given in Accident and Emergency departments or "walk-in" centres.

NHS costs are met, via the PCTs, from UK government taxation, thus all UK taxpayers contribute to its funding.

Exemption for missionaries who work abroad for a UK based organisation

In England, from 15 January 2007, anyone who is working outside the UK as a missionary for an organisation with its principal place of business in the UK will be fully exempt from NHS charges for services that would normally be provided free of charge to those resident in the UK. This is regardless of whether they derive a salary or wage from the organisation, or receive any type of funding or assistance from the organisation for the purposes of working overseas. This is in recognition of the fact that most missionaries would be unable to afford private health care and those working in developing countries should not effectively be penalised for their contribution to development/other work.

Exemption for others

There are some other categories of people who are exempt from the residence requirements such as specific government workers and those in the armed forces stationed overseas.

Prescription charges

As of April 2008 the prescription charge for medicines is set at £7.10 (which contrasts with Scotland at £5 and Wales where they are free.) People over sixty, children under sixteen (or under nineteen if the child is still in full time education), patients with certain medical conditions, and those with low incomes, are exempt from paying. Those who require repeated prescriptions may purchase a single-charge pre-payment certificate which allows unlimited prescriptions during the period of validity. The charge is the same regardless of the actual cost of the medicine but higher charges apply to medical appliances. For more details of prescription charges, see Prescription drugs.

However, the rising costs of some medicines, especially some types of cancer treatment, means that prescriptions can present a heavy burden to the PCTs whose limited budgets include responsibility for the difference between medicine costs and the fixed prescription charge. This has led to disputes in certain cases (e.g. over Herceptin), as to whether such drugs should be prescribed.

NHS dentistry

Following the government's introduction of a new contract in April 2006, NHS dentistry is not as widely available as it once was, forcing many patients to pay much higher sums for private treatment. Where available, NHS dentistry charges from 1 April 2007 are: £15.90 for an examination; £43.60 if a filling is needed; and £194 for more complex procedures such as crowns, dentures or bridges.. About 50% of the income of dentists comes from work sub-contracted from the NHS.

NHS Optical Services

(needs expanding) From 1 April 2007 the NHS Sight Test Fee (in England) is £19.32; in 2006-7 there were 13.1 million NHS sight tests carried out in the UK. A voucher system is employed to offset private commitments towards eyeware appliances. Currently £34.60 for the most common 'A' voucher.

Injury cost recovery scheme

Since January 2007, the NHS have been able to claim back the cost of treatment, and for ambulance services, for those who have been paid personal injury compensation. Prior to 2007, the NHS were only able to claim back their costs for those who received personal injury compensation as a result of a motor vehicle crash. In the last year of the old scheme, over £128 million was reclaimed.

Car park charges

Car parking charges are an important source of revenue for the NHS, with some hospitals deriving more than 1 per cent of their budget from them. The level of fees is controlled individually by each trust. In 2006, car park fees contributed £78 million towards hospital budgets, with individual hospitals netting up to £1.5 million. Patient groups are opposed to such charges. (This contrasts with Wales where car park charges in Welsh hospitals are due to be scrapped by the end of 2011.)

Financial outlook

As each division of the NHS is required to break even at the financial year-end, the service should in theory never be in deficit. However in recent years overspends have meant that, on a 'going-concern' (normal trading) basis, these conditions have been consistently, and increasingly, breached. Former Secretary of State for Health Patricia Hewitt consistently asserted that the NHS will be in balance at the end of the financial year 2007-8; however, a study by Professor Nick Bosanquet for the Reform think tank predicts a true annual deficit of nearly £7bn in 2010.

NHS policies and programmes

Reforms under the Thatcher government

The 1980s saw the introduction of modern management processes (General Management) in the NHS to replace the previous system of consensus management. This was outlined in the Griffiths Report of 1983. This recommended the appointment of general managers in the NHS with whom responsibility should lie. The report also recommended that clinicians be better involved in management. Financial pressures continued to place strain on the NHS. In 1987, an additional £101 million was provided by the government to the NHS. In 1988 the then Prime Minister, Margaret Thatcher, announced a review of the NHS. From this review and in 1989, two white papers Working for Patients and Caring for People were produced. These outlined the introduction of what was termed the "internal market", which was to shape the structure and organisation of health services for most of the next decade.

In 1990, the National Health Service & Community Care Act (in England) defined this "internal market", whereby Health Authorities ceased to run hospitals but "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients. The "providers" became independent trusts, which encouraged competition but also increased local differences. There is also evidence that increasing competition decreased the quality of patient care, with death rates highest in those areas forced to compete for patients

The Blair government

These innovations, especially the "fund holder" option, were condemned at the time by the Labour Party. Opposition to what was claimed to be the Conservative intention to privatise the NHS became a major feature of Labour's election campaigns.

Labour came to power in 1997 with the promise to remove the "internal market" and abolish fundholding. In a speech given by the new Prime Minister, Tony Blair, at the Lonsdale Medical Centre on 9th December 1997, he stated that:

"The White Paper we are publishing today marks a turning point for the NHS. It replaces the internal market with "integrated care". We will put doctors and nurses in the driving seat. The result will be that £1 billion of unnecessary red tape will be saved and the money put into frontline patient care. For the first time the need to ensure that high quality care is spread throughout the service will be taken seriously. National standards of care will be guaranteed. There will be easier and swifter access to the NHS when you need it. Our approach combines efficiency and quality with a belief in fairness and partnership. Comparing not competing will drive efficiency."

However in his second term Blair renounced this direction. He pursued measures to strengthen the internal market as part of his plan to "modernise" the NHS.

Driving these reforms have been a number of factors. They include the rising costs of medical technology and medicines, the desire to increase standards and "patient choice", an ageing population, and a desire to contain government expenditure. Since the National Health Services in Wales, Scotland and Northern Ireland are not controlled by the UK government, these reforms have increased the differences between the National Health Services in different parts of the United Kingdom. (See NHS Wales and NHS Scotland for descriptions of their developments).

Reforms have included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous clinical and corporate governance. In addition medical training has undergone an unsuccessful restructuring which was so badly managed that the Secretary of State for Health was forced to apologise publicly. MMC is now being revised but its flawed implementation has left the NHS with significant medical staffing problems which are unlikely to be resolved before 2009. Some new services have been developed to help manage demand, including NHS Direct. A new emphasis has been given to staff reforms, with the Agenda for Change agreement providing harmonised pay and career progression. These changes have, however, given rise to controversy within the medical professions, the media and the public.

The Blair Government, whilst leaving services free at point of use, has encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals have been built (or rebuilt) by private sector consortia; hospitals may have both medical services (such as "surgicentres"), and non-medical services (such as catering) provided under long-term contracts by the private sector. A study by a consultancy company which works for the Department of Health shows that every £200 million spent on privately financed hospitals will result in the loss of 1000 doctors and nurses. The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced.

In 2005, surgicentres (ISTCs) treated around 3% of NHS patients (in England) having routine surgery. By 2008 this is expected to be around 10%. NHS Primary Care Trusts have been given the target of sourcing at least 15% of primary care from the private or voluntary sectors over the medium term.

As a corollary to these intitiatives, the NHS has been required to take on pro-active socially "directive" policies, for example, in respect of smoking and obesity.

The NHS has also encountered significant problems with the IT innovations accompanying the Blair reforms. The NHS's National Programme for IT (NPfIT), believed to be the largest IT project in the world, is running significantly behind schedule and above budget, with friction between the Government and the programme contractors. Originally budgeted at £2.3 billion, present estimates are £20-30 billion and rising. There has also been criticism of a lack of patient information security. The ability to deliver integrated high quality services will require care professionals to use sensitive medical data. This must be controlled and in the NPfIT model it is, sometimes too tightly to allow the best care to be delivered. One concern is that GPs and hospital doctors have given the project a lukewarm reception, citing a lack of consultation and complexity. Key "front-end" parts of the programme include Choose and Book, intended to assist patient choice of location for treatment, which has missed numerous deadlines for going "live", substantially overrun its original budget, and is still (May 2006) available in only a few locations. The programme to computerise all NHS patient records is also experiencing great difficulties. Furthermore there are unresolved financial and managerial issues on training NHS staff to introduce and maintain these systems once they are operative.

Health Screening for over 40's

From 1st April, 2008, everyone over 40 in England will be offered health checks for heart disease, stroke, diabetes and kidney disease under new government plans. However, doctors are not convinced that the policy will be effective.

Criticism

The NHS has frequently been the target of criticism over the years. Examples of such criticism include:

Access controls

Treatments determined by NICE to be ineffective (e.g. homeopathy) or relatively cost-ineffective (i.e. drugs that have only minor effect at great cost) are simply not offered by the NHS though may be available privately. The media are apt to label these controls as "rationing" though they are seen more as being a sensible cost control mechanism, and a means to support modern evidence-based medicine by the medical profession and the public generally.

GP referrals are needed to access specialist care. It has been argued that a nominal charge for an appointment with a GP could be introduced to prevent patients consulting their GP with minor real or imaginary complaints. To date this has never been introduced to avoid the danger of patients avoiding consultations (for financial reasons) for conditions which might be potentially serious.

Politicisation

Over time, increased demand leads to continual political pressures to increase spending and widen the range of treatments available.

Supporters of the NHS would point out that the NHS has wide public support and the English population has as good a health outcome as many other similar countries, and often at much lower cost. Political pressure could work both ways, but the Blair government was elected in 1997 largely on a promise to invest more taxpayers money in health to bring spending closer to the European average. Most people would prefer to see gradual improvements within the current framework and be able to hold politicians to account for the service. This is the position of all the political parties, none of which has an agenda to replace or make a wholesale reform to the system. The Conservative Party says its policies are aimed at "Protecting and improving our health service by putting patients back at the heart of the NHS, and trusting the professionals to ensure that they are able to use their skills to make the fullest possible contribution to patient care.".

"Paying twice"

Taxpayers who choose to pay for private healthcare must nonetheless still contribute to the NHS via taxation, and in effect "pay twice", although the vast majority of emergency medical treatment is carried out by the NHS. This is not an effect specific to the NHS, and occurs whenever a choice between a publicly-funded and privately-funded service exists - for instance in private education.

Some patients with complex illnesses pay for some medical services privately, while turning to the NHS for the rest of their care. In one recent case a cancer patient was told that if she paid privately for a drug that was not covered by the NHS she would have to pay for the rest of her care. NHS officials argue that allowing the practice would give wealthy patients an unfair advantage and undermine the philosophy of the system.

Waiting lists and the 18 week target

Rationing is a part of all health care systems because resources are necessarily finite. In purely private systems, health care is rationed via the price mechanism, with those being able to pay for care getting it immediately and those not able waiting indefinitely (until they can afford it, which may be never). In the NHS, which aims to give a broad coverage of care to all without charging, health care is rationed on the grounds of clinical need, meaning that emergency cases (e.g. heart attacks) get instant access where those with less urgent needs (e.g. cataract surgery) are given lower priority and so wait longer.

Although there are obvious arguments in favour of prioritising by clinical need rather than ability to pay, it can mean that waiting lists vary widely between regions. Patients waiting can choose to have a procedure done outside their local NHS district in order to be seen more quickly, and if the waiting time is long can often get private treatment at public expense, either in the UK or abroad. A major programme is underway in the NHS to reduce all wait times to 18 weeks by December 2008. This new target starts at the point the time the patient's own doctor writes to the hospital specialist and ends when treatment begins. It therefore includes the time to make the first appointment, and the time for all diagnostic tests to be completed, evaluated, and discussed with the patient, which were not in the previous target. It has been widely criticised by doctors, healthcare professionals, and think-tanks as diverting resources from more serious conditions to achieve politically-motivated goals, and doubts persist over its achievability.

"Superbugs"

Fatal outbreaks of antibiotic-resistant bacteria ("superbugs"), such as Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile, in NHS hospitals has led to criticism of standards of hygiene across the NHS.

Both C. difficile and MRSA are, however, not exclusive to the NHS, existing in British private hospitals and throughout other western healthcare systems; for instance, cases doubled in the USA's private healthcare system between 1999 and 2005, and the UK's death rate is half that of the USA's. The introduction of Private Finance Initiative cleaning contractors into the NHS and the associated "cutting corners on cleaning" have been blamed for the problem, as has increased drug resistance due to inappropriate prescribing of antibiotics and patients failing to complete courses of antibiotics.

There has been a move to fight the "superbugs" in the Hospitals by wearing special anti-germ proof clothing which kills germs when they make contact with the clothing. They have also put up many more soap dispensers in the Hospitals to help fight germs, there is also a campaign to scrub out germs and adverts on the t.v stating "lets spread the word not the infection".

Computerisation

The NHS has been criticised over the implementation of its National Programme for IT which is designed to provide the infrastructure for electronic prescribing, booking appointments and elective surgery, and a national care records service. The programme has run into delays and overspends, with the initial budget of £2.3 billion over three years officially revised to £12.4bn over 10 years and some sources putting it as high as £20bn. Critics including the House of Commons Public Accounts Committee and the National Audit Office claim the project is falling behind schedule. In addition, 93% of doctors within the NHS are not confident their patients' data will be secure, some GP practices have begun to advise all their patients to opt-out of the scheme, and privacy campaigners have claimed the national care records system breaches patients' privacy rights.

The Government and NHS national leadership have consistently argued that major capital investment in IT is necessary to transform services. Fragmented information systems, as in the US, prevent health services providing consistent data and can damage patient care where doctors may not have an overview of patients records held by another NHS body.

Dentistry

There has been a decreasing availability of NHS dentistry following the new government contract and a trend towards dentists accepting private patients only, with 10% of dentists having rejected the contract offered.

Coverage

The lack of availability of some treatments due to their perceived poor cost-effectiveness sometimes leads to what some call a "postcode lottery".

NHS supporters would argue that the NHS has a duty to ensure that taxpayers money is used wisely and such denials are effective controls. People can always choose to go private, if they can afford it, if the treatment is legally available in the UK or elsewhere.

Deficits

Some hospitals and trusts were running a financial deficit and getting into debt.

Supporters would argue that this problem has been controlled without the taxpayer having to fund the shortfall.

Scandals

Several high-profile scandals have occurred within the NHS over the years such as the Alder Hey organs scandal, Harold Shipman and the Bristol heart scandal.

Supporters would argue that there is nothing endemic about such issues which might equally have occurred in other types of health care establishments. They might also point out that the detection of such issues leads to better controls being established throughout the NHS for the benefit of all.

Quality of Healthcare, and Accreditation

There are various regulatory bodies in the UK, both government-based (e.g. Department of Health, General Medical Council, Nursing and Midwifery Council) and non-governmental-based (e.g. Royal Colleges). Some of these organisations have a high world-wide standing.

With respect to assessing, maintaining and improving the quality of healthcare, unlike in the USA and many other developed countries where hospital accreditation groups independent of central government are utilised, the UK government take on both the role of suppliers of healthcare and assessors of the quality of its delivery through groups organised directly by government departments, such as NICE and CHI.

This lack of separation of government from healthcare delivery is often seen as weakness and has the potential to over-politicise healthcare, especially over issues of funding and geographical distribution of services. The fact that the body who are underwriting the bills (ie. the government) have a political stake in how the NHS runs is potentially divisive. Scandals and other difficulties, such as hospital "superbugs", often become political issues simply as a result of media coverage, and the response is often driven by political considerations rather than by science and by evidence-based medicine. In addition, the problems of ensuring quality and improvement in the growing private sector in British healthcare have not yet been solved.

To try to solve this problem, an independent hospital accreditation group, or groups, responsible for surveying hospitals and other healthcare facilities, similar to the role of the Joint Commission in the USA and the Trent Accreditation Scheme in Hong Kong, may be a viable alternative for solving some of these problems and concerns.

File:London Ambulance on Hamilton Terrace .jpg

The traditional ambulance, as pictured in London and the one which is sometimes referred to as "The Big White Taxi"

File:Bwts.JPG

The BWTS logo, a drawing used on the Big White Taxi Service website to denote the jovial nature of the site

Big White Taxi Service

The ambulances used by the NHS are sometimes referred to by their staff as the "Big White Taxi Service". This slang term is used to express the frustration felt when members of the public dial 999 for minor ailments and injuries. The term is becoming obsolete as ambulances are no longer painted white and the term "Blue Light Taxi" is now more widely used.

"The Big White Taxi Service" is also the name of an online community established by ambulance staff from the London Ambulance Service during 1999. The forum provided peer support in the aftermath of the 7 July 2005 London bombings.

See also

• Emergency medical services in the United Kingdom
• Evidence-based medicine
• Health
• Health and Care NI
• Health and Social Care in Northern Ireland
• Health forecasting
• Health policy analysis
• Healthcare in the United Kingdom
• Hospital accreditation
• List of NHS Trusts
• NHS Scotland
• NHS Wales
• Private hospital
• Publicly-funded health care
• School health services
• Socialized medicine
• Trent Accreditation Scheme

External links

English NHS and related government sites

• NHS in England - Gateway to various departments and services
• NHS Direct Telephone advice service which uses the same telephone number as the Welsh service but deals with calls made in England
• NHS Professionals Special Health Authority
• Department of Health

Shared and other UK health services and related government sites

Shared by two or more countries

• The NHS Confederation
• National Library for Health previously called the National Electronic Library for Health

Northern Ireland

• Department of Health, Social Services and Public Safety (Northern Ireland)
• Health and Care Northern Ireland

Scotland/Alba

• Scottish Government - Health and Community Care
• NHS Scotland

Wales/Cymru

• Welsh Assembly Government - NHS Wales
• Llywodraeth Cynulliad Cymru - GIG Cymru
• NHS Wales
• NHS Direct Wales Telephone advice service - this uses the same telephone number as the English service but deals with calls made in Wales
• Galw Iechyd Cymru

Other sites

• NHS guide from the BBC - includes charts and statistics
• BBC coverage of NHS 50th anniversary
• History of the Tredegar Medical Aid Society
• From Cradle to Grave - the first 50 years of the NHS 1998 - 2007 the contemporary chapter dealing with the NHS in England
• Map of Every Uk Hospital Also Shows Nearby Accommodation for patients and visitors
• 'The Origins of the NHS', by Professor Berridge, Gresham College, 14th April 2008 (available for video, audio and text download).

Further reading

• Allyson M Pollock (2004), NHS plc: the privatisation of our healthcare. Verso. ISBN 1-84467-539-4 (Polemic against PFI and other new finance initiatives in the NHS)
• Rudolf Klein (2006), The New Politics of the NHS: From creation to reinvention. Radcliffe Publishing ISBN 1 84619 066 5 ( Authoritative analysis of policy making (political not clinical)in the NHS from its birth to the end of 2006)
• Geoffrey Rivett (1998) From Cradle to Grave, 50 years of the NHS. Kings Fund, 1998, Covers both clinical developments in the 50 years and financial/political/organisational ones. kept up to date at www.nhshistory.net