National Health Service

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The logo of the NHS for England. The colour, "NHS Blue" (Pantone 300, coincidentally the same as the blue of the Flag of Scotland), is used on signs and leaflets throughout the NHS in England.

Norfolk and Norwich University Hospital.

NHS hospital in the UK.

The National Health Service (NHS) is the publicly funded health care system in the United Kingdom. Each of the four constituent countries of the UK (England, Scotland, Wales, Northern Ireland) have their own NHS, each of which are run along the same lines but are managed separately and operate without general discrimination toward citizens from each others' areas. This article predominantly covers the NHS in England.

The NHS provides the majority of healthcare in England, including primary care (such as general practitioners), in-patient care, long-term healthcare, ophthalmology and dentistry (NHS dentistry is done by dentists in private practice doing sub-contracted work for the NHS). The National Health Service Act 1946 came into effect on 5 July 1948; subsequently it has become an integral part of British society, culture and everyday life. The NHS was once described by Nigel Lawson, former Chancellor of the Exchequer, as "the national religion". Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used only by a small percentage of the population, and generally as a top-up to NHS services.

The large majority of NHS services are provided free of charge to the patient. The costs of running the NHS (est. £104 billion in 2007-8 ) are met directly from general taxation.

The government department responsible for the NHS is the Department of Health, headed by a Secretary of State for Health (Health Secretary), who sits in the British Cabinet.

The NHS is the world's largest, centralised health service, and the world's third largest employer after the Chinese army and the Indian railways.

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 Conservative defeat in the elections following the war. 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 'Postwar Consensus' which continued virtually unchallenged until the early 1970's, no matter which party controlled the government.

The first problem for Labour's reform agenda began when the U.S. war with Japan ended, and the United States subsequently withdrew the funding that had sustained Britain during 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. Bevan based his plan for the NHS on the Tredegar Medical Aid Society which was set up in his place of birth, and in fact, had been a member and later chairman of the Cottage Hospital Management Committee in the late 1920s. Doctors were initially opposed to the reform measure and even organized to try to fight against it. 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 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."

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. To this day, the Labour Party still considers the creation of the publicly-funded National Health Service its proudest achievement.

Structure

Main article: NHS Institutions and Organisations

Organisation

There are several types of NHS trust:

• Primary Care Trusts (PCTs), which administer primary care and public health. In 1 October 2006 the number of PCTs were 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 directly primary care in their locations, and oversee such matters as primary and secondary prevention, vaccination administration and control of epidemics. PCTs are at the centre of the NHS and 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

The NHS in England is controlled by the UK government through the Department of Health. Some NHS agencies (e.g. NICE and SIGN) have influence in other parts of the United Kingdom. The service is generally known simply as NHS. Its structure is discussed in this article.

The NHS is managed at the top by the Department of Health, which takes political responsibility for the service. It controls Strategic Health Authorities (SHAs), which oversee all NHS operations in an area of England. There are 10 SHAs, coterminous the nine Government Office Regions in most part, with the South East region split into South East Coast and South Central SHAs.

The SHAs are responsible for strategic supervision of the trusts in their area.

In addition, several Special Health Authorities provide services and, in some cases, to the devolved NHS administrations. These include The Information Centre for health and social care, NHS Blood and Transplant, NHS Direct, NHS Professionals, NHS Business Services Authority, National Patient Safety Agency, National Treatment Agency and the National Institute for Health and Clinical Excellence (NICE).

Telephone support services are provided by the NHS:-

NHS Direct 0845 46 47

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 the doctors and nurses 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, 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 commissioning system

The principal fundholders in the NHS system are the NHS Primary Care Trusts (PCTs), who commission healthcare from hospitals, GPs and others and pay 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 the financial objective can result in the dismissal and replacement of a Trust's Board of Directors.

Patient charges and prescriptions

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. This includes British citizens who work for a UK-based charity outside the UK (except in certain countries) for more than five years, regardless of their intention to return to the UK or payment of National Insurance contributions. These people are treated as overseas visitors even if they own property, return regularly or have family in the UK and regard their home country as the UK.

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 2007 the prescription charge for medicines in England is £6.85; 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

NHS dentistry is not as widely available as it once was, and the private sector has expanded to fill the gap. 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 per cent of the income of dentists comes from work sub-contracted from the NHS.

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.

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 campaigning in the 1997 and subsequent British elections. Although the incoming government of Tony Blair (1997) stated its intention to remove the "internal market" and abolished fundholding, in effect the market was strengthened and fundholding reintroduced as part of Blair's ongoing reforms 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. The National Health Services in Wales, Scotland and Northern Ireland are not directly controlled by the UK government and these reforms have not all been copied uniformly. (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 been restructured. 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. During 2005 and 2006 hospitals began to lay off staff as a consequence of these reforms and the financial stringency accompanying them, further adding to controversy.

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.

Given ongoing redundancies within the NHS, accusations of staff cuts and "privatisation" are now made against the Blair government, often by NHS staff unions such as UNISON.

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.

Criticism

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

• Access controls. Simple economics states that the cheaper a good or service is, the greater the demand for it. By making health care a largely invisible cost to the patient (there is no special NHS tax or levy) health care seems to be effectively free to its consumers. To prevent gratuitous demand NHS treatments are available only according to preset rules which doctors must adhere to. Denial of service can cause distress to both patient and doctor. Those falling just outside the rules must then seek and pay for private treatment or go without.

Supporters of the NHS would argue that the rules are there to ensure that everyone gets treated by the same rules, and that in any case, health is not a consumable commodity like ice-cream. People do not get more sprained ankles or heart attacks just because health care is free at the point of use.

• Politicisation. Over time, increased demand leads to continual political pressures to increase spending and widen the range of treatments available. The politicisation of health care which it is centrally funded and free at the point of use may be one reason why so few countries have adopted this model.

Supporters of the NHS would point out that the NHS has wide public support and the UK 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 mainstream right wing 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.". Even the ultra-right wing British National Party says that "socialised medicine is not just a hallmark of a decent society, but economically rational as well. If one leaves behind capitalist-romantic theories about private-sector efficiency and looks at real-world privatised medicine, which may be observed in America, it is an obvious disaster. It is vastly more expensive and delivers mediocre results outside of luxury care. Britain spends about 1/3 (!) the money per person and we have public health statistics roughly equivalent to America. Except for the fact that the bottom 1/4 of our population is vastly healthier."

• Paying Twice. Those who can afford it sometimes opt for private health care, usually to get treated more quickly. When this occurs, these patients are opting to pay twice for their health care, once for the NHS through taxes, which they are not using, and again for the private care they are using.

Supporters of the NHS would argue that these people usually do get value from the NHS because almost everyone uses their NHS GP and other health services such as screening, vaccinations etc. and that their opting out from time-to-time is effectively queue jumping because they are utilizing a resource ahead of someone in greater need and that their double payment is the penalty for queue jumping. The concept is well recognized and accepted in the field of public services such as libraries and state-funded schools -- that it is a civic responsibility for every citizen capable of paying legally applicable levels of tax, to do so, regardless of service use. Therefore, the public services can be subsidised for those who wish to use them -- economically, the more people who pay taxes, the less cost to each individual concerned.

• Waiting lists.Because NHS access is controlled by medical priority rather than a price mechanism, there are sometimes waiting lists for certain consultations and surgical procedures. These can be months long. If when a patient finally has a consultation the consultation is in any way unsatisfactory and the patient wishes to see another consultant, they must again pass through a waiting list. If two or three consultations occur, the wait can easily be a year.

NHS supporters would counter that the access to services is fair to everyone and if the need is urgent it will bring that patient to the front of the queue. Those in the queue are those with less acute need. Patients dissatisfied with the queue can always choose to seek care in the private sector, albeit at their expense. Supporters might also point out that even in free market medicine paid for out-of-pocket or from insurance, there are also many people who are waiting or go untreated because they have to save for their care because their insurance is insufficient or they cannot afford to pay it. They would argue that in the NHS everyone needing treatment will get it eventually, but not everyone in a free market health care system will get what they need.

• Superbugs. The high levels of antibiotic-resistant bacteria ("superbugs"), such as Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile, in hospitals. which some believe are a result of poor hygiene standards in many NHS hospitals.

Supporters would point out that there is not much evidence to support the argument that this is a problem peculiar to the NHS. Both C. Diff and MRSA are problems in British private hospitals, as well as other western healthcare systems. It is theorised that the increased use of strong antibiotics and disinfectants in modern society may account for the resistance of such a "superbug". Some in the UK argue that the introduction of private cleaning contractors into the NHS has been partly to blame as contractors try to cut costs and hygiene levels may have suffered because of this. There is not much evidence to prove the case either way.

• Computerization There have been issues with the ongoing NHS IT upgrade.

Supporters would point out that all new systems will have teething troubles and that these can be overcome. In private health care in the USA, there is even less computerisation and therefore little use of computerization to provide consistent data about patients and to check things such as potential drug interactions. A large organization such as the NHS can easily afford the overhead costs of developing and maintaining such systems whereas a fragmented system just could not contemplate doing so.

• Dentistry There has been a decreasing availability of NHS dentistry in some areas and a trend towards dentists accepting private patients only.

NHS supporters would argue that the failings in dentistry are primarily because the NHS opts not to get heavily involved and would argue that this implies more NHS investment in dentistry is required not less, and that this would pay dividends in the longer run. Dentistry outside the NHS is effectively piece work and private dentists are incentivized to do unnecessary and expensive treatments.

• Coverage. The lack of availability of some treatments due to their perceived poor cost-effectiveness.

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 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 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.

See also

• Healthcare in the United Kingdom
• Emergency Medical Services in the United Kingdom
• Publicly-funded health care
• Health Forecasting
• Health policy analysis
• School health services
• List of NHS Trusts
• NHS Scotland
• NHS Wales
• Health and Care NI
• Private hospital

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 Executive - 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

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

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