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National Health Service (England)

The National Health Service (NHS) is the publicly funded national healthcare system for England and one of the four National Health Services of the United Kingdom. It is the largest and the oldest single-payer healthcare system in the world. Primarily funded through the general taxation system and overseen by the Department of Health, NHS England provides healthcare to all legal English residents, with most services free at the point of use. Some services, such as emergency treatment and treatment of infectious diseases are free for everyone, including visitors.[1]

National Health Services
NHS-Logo.svg
Entrance to Richmond House, 79 Whitehall, London - geograph.org.uk - 306901.jpg
Entrance to Richmond House, Whitehall.
Publicly funded health service overview
Formed July 5, 1948; 69 years ago (1948-07-05)
Jurisdiction England
Headquarters Richmond House, 79 Whitehall, London, SW1A 2NS
Employees 1.4 million
Minister responsible
Publicly funded health service executive
Parent department Department of Health
Child Publicly funded health service
Norfolk and Norwich University Hospital, one of the largest NHS hospitals with 1237 beds.
Queen Elizabeth Hospital Birmingham, another large NHS hospital in England with 1213 beds.

Free healthcare at the point of use comes from the core principles at the founding of the National Health Service by the Labour government in 1948. In practice, "free at the point of use" normally means that anyone legitimately fully registered with the system (i.e. in possession of an NHS number), available to legal UK residents regardless of nationality (but not non-resident British citizens), can access the full breadth of critical and non-critical medical care, without payment except for some specific NHS services, for example eye tests, dental care, prescriptions, and aspects of long-term care. These charges are usually lower than equivalent services provided by a private provider, and many are free to vulnerable or low-income patients.[2][3]

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: it is used by about 8% of the population, generally as an add-on to NHS services.

The NHS is largely funded from general taxation with a small amount being contributed by National Insurance payments[4] and from fees levied in accordance with recent changes in the Immigration Act.[5] The UK government department responsible for the NHS is the Department of Health, headed by the Secretary of State for Health. The Department of Health had a £110 billion budget in 2013–14, most of this being spent on the NHS.

The Care Quality Commission (CQC) says the NHS is "straining at the seams" with a "precarious" future.[6]

Sources do not always make clear if they refer to the whole of the NHS or only to England.

Contents

OrganizationEdit

The National Health Service was originally established in 1948 for the entire United Kingdom, as its name implies, and was funded by HM Treasury in London through the various departments, such as the Scottish Office and the Welsh Office. The NHS Pension scheme for the entire UK continues to have its HQ at Fleetwood in Lancashire. Today there is no fully unified British NHS; the National Health Service in Scotland and Northern Ireland and NHS Wales all passed to the control of the devolved governments in 1999.[7] In 2009 NHS England agreed a formal NHS constitution which sets out the legal rights and responsibilities of the NHS, its staff, and users of the service and makes additional non-binding pledges regarding many key aspects of its operations.[8]

The Health and Social Care Act 2012 came into effect in April 2013, giving GP-led groups responsibility for commissioning most local NHS services. Starting in April 2013 Primary Care Trusts (PCTs) are being replaced by General Practitioner (GP) -led organisations called Clinical Commissioning Groups (CCGs). Under the new system, a new NHS Commissioning Board, called NHS England, oversees the NHS from the Department of Health.[9] The Act has also become associated with the perception of increased private provision of NHS services. In reality, the provision of NHS services by private companies long precedes this legislation, but there are concerns that the new role of the healthcare regulator ('Monitor') could lead to increased use of private sector competition, balancing care options between private companies, charities, and NHS organisations.[9] NHS Trusts are responding to the "Nicholson challenge" which involved making £20 billion in savings across the service by 2015.

Some NHS organisations are using referral management centres to help reduce inappropriate referrals in an attempt to save the NHS money. Millions of pounds have been spent for these services, 32% of which are provided by private companies, since 2013. Of the 211 clinical commissioning groups (CCGs) surveyed by the British Medical Journal (BMJ) in 2016, 184 responded and 72 of those said they had used such schemes. Of those CCGs using these services, 14% could show savings, 12% showed no overall savings and 74% could not show whether money had been saved. Because these services can prevent GPs from referring patients to hospitals, there are some concerns they may delay diagnosis and compromise patient safety.[10][11]

HistoryEdit

 
Aneurin Bevan. As health minister from 1946–1951 he spearheaded the establishment of the National Health Service
 
Leaflet concerning the launch of the NHS in England and Wales.

Dr A. J. Cronin's controversial novel The Citadel, published in 1937, had fomented extensive debate about the severe inadequacies of healthcare. The author's innovative ideas were not only essential to the conception of the NHS, but in fact, his best-selling novels are said to have greatly contributed to the Labour Party's victory in 1945.[12]

A national health service was one of the fundamental assumptions in the Beveridge Report. The Emergency Hospital Service established in 1939 gave a taste of what a National Health Service might look like.

Healthcare prior to the war had been an unsatisfactory mix of private, municipal and charity schemes. Bevan decided that the way forward was a national system rather than a system operated by local authorities. He proposed that each resident of the UK would be signed up to a specific General Practice (GP) as the point of entry into the system, building on the foundations laid in 1912 by the introduction of National Insurance and the list system for general practice. Patients would have access to all medical, dental and nursing care they needed without having to pay for it at the time.

In the 1980s, Thatcherism represented a systematic, decisive rejection and reversal of the Post-war consensus, whereby the major political parties largely agreed on the central themes of Keynesianism, the welfare state, nationalised industry, public housing and close regulation of the economy. There was one major exception: the National Health Service, which was widely popular and had wide support inside the Conservative Party. Prime Minister Margaret Thatcher promised Britons in 1982, the NHS is "safe in our hands."[13]

In 2011 the government signed off on the 10-year contract to manage the debt-laden Hinchingbrooke Hospital in Huntingdon, Cambridgeshire by Circle Healthcare. It was the first time that management of an NHS hospital was to be taken over by a stock-market listed company.[14]

There have been documented failures of some parts of the National Health Service to provide adequate care at a basic level. These failures were associated with bureaucratic fumbling as local institutions attempted to meet conflicting demands with inadequate resources.[15] This notwithstanding, the NHS has received consistently strong approval and support from citizens.[16][citation needed]

Core principlesEdit

The principal NHS website states the following as core principles:[17]

The NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth. At its launch by the then minister of health, Aneurin Bevan, on 5 July 1948, it had at its heart three core principles:

  • That it meet the needs of everyone
  • That it be free at the point of delivery
  • That it be based on clinical need, not ability to pay

These three principles have guided the development of the NHS over more than half a century and remain. However, in July 2000, a full-scale modernisation programme was launched and new principles added.

The main aims of the additional principles are that the NHS will:

  • Provide a comprehensive range of services
  • Shape its services around the needs and preferences of individual patients, their families and their carers
  • Respond to the different needs of different populations
  • Work continuously to improve the quality of services and to minimise errors
  • Support and value its staff
  • Use public funds for healthcare devoted solely to NHS patients
  • Work with others to ensure a seamless service for patients
  • Help to keep people healthy and work to reduce health inequalities
  • Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance

StructureEdit

The English NHS is controlled by the UK government through the Department of Health (DH), which takes political responsibility for the service. Resource allocation and oversight was delegated to NHS England, an arms-length body, by the Health and Social Care Act 2012. NHS England commissions primary care services (including GPs) and some specialist services, and allocates funding to 211[18] geographically-based Clinical Commissioning Groups (CCGs) across England. The CCGs commission most services in their areas, including hospital and community-based healthcare.[19]

A number of types of organisation are commissioned to provide NHS services, including NHS trusts and private sector companies. Many NHS trusts have become NHS foundation trusts, giving them an independent legal status and greater financial freedoms. The following types of NHS trusts and foundation trusts provide NHS services in specific areas:[20]

Some services are provided at a national level, including:

  • www.nhs.uk is the primary public-facing NHS website, providing comprehensive official information on services, treatments, conditions, healthy living and current health topics
  • NHS special health authorities provide various types of services

StaffingEdit

Nearly all hospital doctors and nurses in England are employed by the NHS and work in NHS-run hospitals, with teams of more junior hospital doctors (most of whom are in training) being led by consultants, each of whom is trained to provide expert advice and treatment within a specific speciality. From 2017 NHS doctors will have to reveal how much money they make from private practice.[21]

General Practitioners, dentists, optometrists (opticians) and other providers of local health care 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 health care professionals and facilities in areas where there is insufficient provision by self-employed professionals.

 
Staff in NHS England from 2010 - 2017.[22]
Year[23] Nurses Doctors Other qualified[24] Managers Total
1978 339,658 55,000 26,000 - 1,003,000[25] (UK)
2010 318,935 102,422 180,621 40,025 1,168,750[22]
2011 317,157 103,898 184,869 35,014 1,158,920[22]
2012 310,359 105,019 183,818 33,023 1,128,140[22]
2013 308,782 106,151 184,571 32,429 1,123,529[22]
2014 314,097 107,896 187,699 28,499 1,126,947[22]
2015 316,117 109,890 189,321 30,221 1,143,102[22]
2016 318,912 110,732 193,073 31,523 1,164,471[22]
2017 319,845 113,508 198,783 32,588 1,187,125[22]

Note that due to methodological changes, the 1978 figure is not directly comparable with later figures.

A 2012 analysis by the BBC estimated that the NHS across the whole UK has 1.7 million staff, which made it fifth on the list of the world's largest employers (well above Indian Railways).[26] In 2015 the Health Service Journal reported that there were 587,647 non-clinical staff in the English NHS. 17% worked supporting clinical staff. 2% in cleaning and 14% administrative. 16,211 were finance staff.[27]

The NHS plays a unique role in the training of new doctors in England, with approximately 8000 places for student doctors each year, all of which are attached to an NHS University Hospital trust. After completing medical school, these new doctors must go on to complete a two-year foundation training programme to become fully registered with the General Medical Council. Most go on to complete their foundation training years in an NHS hospital although some may opt for alternative employers such as the armed forces.[28]

Most staff working for the NHS including non-clinical staff and GPs (most of whom [GP's] are self-employed) are eligible to join the NHS Pension Scheme which, from 1 April 2015, is an average-salary defined-benefit scheme.

Nurses who are nationals of other EU nations are leaving the NHS in large numbers because their ability to live and work in the UK after Brexit has not been guaranteed[29] and there are fears that doctors could also leave.[30]

Pay increases have been capped at 1% per year though inflation is higher than that. NHS Providers claims this makes recruiting and retaining staff difficult and puts patient safety at risk. Chris Hopson of NHS Providers said, "Growing problems of recruitment and retention are making it harder for trusts to ensure patient safety. Unsustainable staffing gaps are quickly opening up." Seven years of pay restraint together with stressful work had a bad effect on the workforce. Hopson said further, "Pay is becoming uncompetitive. Significant numbers of trusts say lower paid staff are leaving to stack shelves in supermarkets rather than carry on working in the NHS." Uncertainty over Brexit signified that "vital recruitment from EU countries is dropping rapidly. Pay restraint must end and politicians must therefore be clear about when during the lifetime of the next parliament it will happen and how.” Hopson repeated NHS Providers request for £25bn in additional funds and warned staff are also leaving through exhaustion because of constant work to meet unprecedented demands for care.[31][32] Trainee doctors are 'propping 'hospitals due to lack of consultants. Shortages of family doctors are feared in areas like Kent, Medway and Somerset where many doctors are over 55 years old and therefore likely to retire.[30] Unfilled vacancies have reached record levels and rose by 12% in the year to 2017. There is particular shortage of nurses and midwives.[33][34] More GP's are leaving the profession than are entering despite a government drive to recruit GP's.[35] The numbers of both doctors and nurses in the NHS are both falling despite more being needed and despite government efforts to recruit more. The Guardian stated. "Health Foundation finds fall in number of nurses and GPs, and casts doubt on ability of government to meet staffing targets" High staff turnover is damaging the NHS financially and damaging continuity of care. The 1% pay cap on NHS salaries is blamed for this.[36] In the year 2016-17 the number of GP's working in the NHS in England fell by 1,190.[37]

2012 reformsEdit

The coalition government's white paper on health reform, published in July 2010, set out a significant reorganisation of the NHS. The white paper, Equity and excellence: liberating the NHS,[38] with implications for all health organisations in the NHS abolishing PCTs and strategic health authorities. It claimed to shift power from the centre to GPs and patients, moving somewhere between £60 to £80 billion into the hands of Clinical Commissioning Groups to commission services. The bill became law in March 2012 with a government majority of 88 and following more than 1,000 amendments in the House of Commons and the House of Lords.

FundingEdit

The total budget of Department of Health in England in 2013/14 was £110 billion.[39] £13.8 billion was spent on medicines.[40] The National Audit Office reports annually on the summarised consolidated accounts of the NHS.[41] Health spending per head is projected to fall by 1.3% from 2009-10 to 2019–20 despite the population aging. George Stoye, senior research economist of the Institute for Fiscal Studies did the analysis and said the annual increases since 2009-10 were “the lowest rate of increase over any similar period since the mid-1950s, since when the long-run annual growth rate has been 4.1%”.[42] The NHS has been accused of making drastic cuts to some services while keeping the public in the dark over what is happening.[43] In 2017 funding increased by 1.3% while demand rose by 5% and there are fears for how the NHS will manage in winter 2017-2018.[44]

The commissioning systemEdit

From 2003 to 2013 the principal fundholders in the NHS system were the NHS Primary Care Trusts (PCTs), that commissioned healthcare from NHS trusts, GPs and private providers. PCTs disbursed funds to them on an agreed tariff or contract basis, on guidelines set out by the Department of Health. The PCTs budget from the Department of Health was calculated on a formula basis relating to population and specific local needs. They were supposed to "break even" - that is, not show a deficit on their budgets at the end of the financial year. Failure to meet financial objectives could result in the dismissal and replacement of a Trust's Board of Directors, although such dismissals are enormously expensive for the NHS.[45]

From April 2013 a new system was established as a result of the Health and Social Care Act 2012. The NHS budget is largely in the hands of a new body, NHS England. NHS England commission specialist services and primary care. Acute services and community care is commissioned by local Clinical Commissioning Groups which are led by GPs.

Free services and contributory servicesEdit

Services free at the point of useEdit

The vast majority of NHS services are free at the point of use.

This means that people generally do not pay anything for their doctor visits, nursing services, surgical procedures or appliances, consumables such as medications and bandages, plasters, medical tests, and investigations, x-rays, CT or MRI scans or other diagnostic services. Hospital inpatient and outpatient services are free, both medical and mental health services. Funding for these services is provided through general taxation and not a specific tax.

Because the NHS is not funded by contributory insurance scheme in the ordinary sense and most patients pay nothing for their treatment there is thus no billing to the treated person nor to any insurer or sickness fund as is common in many other countries. This saves hugely on administration costs which might otherwise involve complex consumable tracking and usage procedures at the patient level and concomitant invoicing, reconciliation and bad debt processing.

EligibilityEdit

Eligibility for NHS services is based on having ordinary resident status. This will include overseas students with a visa to study at a recognised institution for 6 months or more, but not visitors on a tourist visa for example. From April 2015 onwards there is an immigration health surcharge applied to most visa applications, the proceeds of which will go directly to funding the NHS. The surcharge amount will either be £150 or £200 in respect of each year of the visa's duration, to be paid in full by the migrant when the visa application is submitted.[46]

Citizens of the EU holding a valid European Health Insurance Card and persons from certain other countries with which the UK has reciprocal arrangements concerning health care can likewise get emergency treatment without charge.[47]

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 is 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.[48] 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 and other work.

Those who are not "ordinarily resident" who do not fall into the above category (including British citizens who may have paid National Insurance contributions in the past) are liable to charges for services.

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 chargesEdit

As of April 2015 the NHS prescription charge in England was £8.20 for each quantity of medicine[49] (which contrasts with Scotland, Wales and Northern Ireland[50] where items prescribed on the NHS are free). People over sixty, children under sixteen (or under nineteen if 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 its 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 charges.

The high and 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 whether some expensive drugs (e.g. Herceptin) should be prescribed by the NHS.[51]

NHS dentistryEdit

Where available, NHS dentistry charges as of April 2017 were: £20.60 for an examination; £56.30 for a filling or extraction; and £244.30 for more complex procedures such as crowns, dentures or bridges.[52] As of 2007, less than half of dentists' income came from treating patients under NHS coverage; about 52% of dentists' income was from treating private patients.[53] Some people needing NHS dental care are unable to get it.[54]

NHS Optical ServicesEdit

From 1 April 2007 the NHS Sight Test Fee (in England) was £19.32, and there were 13.1 million NHS sight tests carried out in the UK.

For those who qualify through need, the sight test is free, and a voucher system is employed to pay for or reduce the cost of lenses. There is a free spectacles frame and most opticians keep a selection of low-cost items. For those who already receive certain means-tested benefits, or who otherwise qualify, participating opticians use tables to find the amount of the subsidy.

Injury cost recovery schemeEdit

Under older legislation (mainly the Road Traffic Act 1930) a hospital treating the victims of a road traffic accident was entitled to limited compensation (under the 1930 Act before any amendment, up to £25 per person treated) from the insurers of driver(s) of the vehicle(s) involved, but were not compelled to do so and often did not do so; the charge was in turn covered by the then legally required element of those drivers' motor vehicle insurance (commonly known as Road Traffic Act insurance when a driver held only that amount of insurance). As the initial bill was sent to the driver rather than to his/her insurer, even when a charge was imposed it was often not passed on to the liable insurer; it was common for no further action to be taken in such cases as there was no practical financial incentive (and often a financial disincentive due to potential legal costs) for individual hospitals to do so.

The Road Traffic (NHS Charges) Act 1999 introduced a standard national scheme for recovery of costs using a tariff based on a single charge for out-patient treatment or a daily charge for in-patient treatment; these charges again ultimately fell upon insurers. This scheme did not however fully cover the costs of treatment in serious cases.[citation needed]

Since January 2007, the NHS has a duty to claim back the cost of treatment, and for ambulance services, for those who have been paid personal injury compensation.[55] In the last year of the scheme immediately preceding 2007, over £128 million was reclaimed.[56]

Car park chargesEdit

Car parking charges are a minor source of revenue for the NHS,[57] with most hospitals deriving about 0.25% of their budget from them.[58] The level of fees is controlled individually by each trust.[57] In 2006 car park fees contributed £78 million towards hospital budgets.[57][58] Patient groups are opposed to such charges.[57] (This contrasts with Scotland where car park charges were mostly scrapped from the beginning of 2009[59] and with Wales where car park charges were scrapped at the end of 2011.)[60]

Charitable fundsEdit

There are over 300 official NHS charities in England and Wales. Collectively, they hold assets in excess of £2bn and have an annual income in excess of £300m.[61] Some NHS charities have their own independent board of trustees whilst in other cases the relevant NHS Trust acts as a corporate Trustee. Charitable funds are typically used for medical research, larger items of medical equipment, aesthetic and environmental improvements, or services which increase patient comfort.

In addition to official NHS charities, many other charities raise funds which are spent through the NHS, particularly in connection with medical research and capital appeals.

Regional lotteries were also common for fundraising, and in 1988, a National Health Service Lottery was approved by the government, before being found to be illegal. The idea continued to become the National Lottery.[62]

Outsourcing and privatisationEdit

Although the NHS routinely outsources the equipment and products that it uses and dentistry, eye care, pharmacy and most GP practices are provided by the private sector, the outsourcing of hospital health care has always been controversial.[63]

Outsourcing and privatisation is steadily increasing in NHS England, and NHS England spending going to the private sector rose from £4.1 billion in 2009-10 to £8.7 billion in 2015–16.[64] Private firms provide services in areas such as community service, general practise and mental health care. Denis Campbell, Guardian health policy editor states there is concern the quality of private sector care may be below what the NHS provides. Dr Louise Irvine, of the National Health Action Party, which campaigns against the use of private firms in the NHS, maintains that private firms tend to do the easier work leaving complicated medicine to the NHS.[65] An article in the Independent stated the private sector cherry picks the easier cases because those are more profitable, additionally because the private sector does not have intensive care facilities if things go wrong. Professor Allyson Pollock argued privatisation should be monitored to ensure the poor, the old and the sick do not lose out.[66]

According to a BMA survey over two thirds of doctors are fairly uncomfortable or very uncomfortable about the independent sector providing NHS services. The BMA believes it is important the independent sector is held to the same standards as the NHS when giving NHS care. The BMA recommends: data collection, thorough impact analysis before independent providers are accepted to ensure existing NHS services are not disrupted, risk assessment to find out likely results if NHS staff are unwilling to transfer to the private sector, transparent reporting by the private sector of patient safety and performance, independent providers should be regulated like NHS providers, patients should be protected if independent providers terminate a contract early, transfers from independent providers to the NHS should be regularly reviewed to establish how much this costs the NHS, private sector contracts should be amended so private sector providers contribute to the cost of staff training financially or by providing training opportunities.[67] According to the BMA, a large proportion of the public opposed increasing privatisation.[68]

Sustainability and transformation plansEdit

Sustainability and transformation plans were produced during 2016 as a method of dealing with the services's financial problems. These plans appear to involve loss of services and are highly controversial. The plans are possibly the most far reaching change to health services for decades and the plans should contribute to redesigning care to manage increased patient demand. Some A&E units will be closed and hospital care concentrated in fewer places.[69] Nearly two thirds of senior doctors fear the plans will worsen patient care.[70]

Consultation will start over cost saving, streamlining and some service reduction in the National Health Service. The streamlining will lead to ward closures including psychiatric ward closures and reduction in the number of beds in many areas among other changes. There is concern that hospital beds are being closed without increased community provision.[71]

The Nuffield Trust think tank claims many suggestions would fail to implement government financial targets and involve a "dauntingly large implementation task". Sally Gainsbury of the Nuffield Trust said many current plans involve shifting or closing services. Gainsbury added, "Our research finds that, in a lot of these kinds of reconfigurations, you don't save very much money – all that happens is the patient has to go to the next hospital down the road. They're more inconvenienced... but it rarely saves the money that's needed."[72] There will be a shift from inpatient to outpatient care but critics fear cuts that could put lives at risk, that the plans dismantle the health service rather than protecting it, further that untested plans put less mobile, vulnerable patients at risk. By contrast, NHS England claims that the plans bring joined-up care closer to home. John Lister of Keep Our NHS Public said there are too many assumptions, and managers desperate to cut deficits were resorting to untried plans.[73] NHS managers are already hard pressed struggling to keep the service running, handling increased volume and juggling for hospital beds. Finding the extra time to develop a workable sustainability and transformation plan is itself problematic.[69]

Critics are concerned that the plan will involve cuts but supporters insist some services will be cut while others will be enhanced. Senior Liberal Democrat MP Norman Lamb accepted that the review made sense in principle but stated: "It would be scandalous if the government simply hoped to use these plans as an excuse to cut services and starve the NHS of the funding it desperately needs. While it is important that the NHS becomes more efficient and sustainable for future generations, redesign of care models will only get us so far – and no experts believe the Conservative doctrine that an extra £8bn funding by 2020 will be anywhere near enough."[74] Norman Lamb also said the NHS was hurtling towards a “catastrophe (...) With demand rising so rapidly, more funding is needed. It would be unforgivable for the government not to act in light of these warnings.”[75] NHS bosses have kept plans for cuts secret, also prevented NHS staff and the public from having an input. This led to accusations of cover-ups and stealth cuts.[69] Plans kept secret include closures of A&Es and of one hospital though full details remain under wraps. One local manager described keeping plans confidential as 'ludicrous' and another said the 'wrong judgement call' had been made. Another person spoke about being in meetings where, 'real people' like patients and the public were not involved. Complex jargon may confuse people who try and follow what happens.[76] The King's Fund reported the public and patients were mostly absent from plans which could involve large scale service closing. Chris Ham of the King's Fund described suggesting out-of-hospital services and GP's could take over work now done by hospitals as a “heroic assumption” since both out-of-hospital services and GP's are under too much pressure. Some councils that disagree with the secrecy have published plans on their websites.[77][78] Funds that should have gone to helping with moving services after closures instead went to plugging other NHS deficits.[79]

NHS policies and programmesEdit

Changes under the Thatcher governmentEdit

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.[80] 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 Prime Minister Margaret Thatcher announced a review of the NHS. From this review 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 England, the National Health Service and Community Care Act 1990 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. Increasing competition may have been statistically associated with poor patient outcomes.[81]

Changes under the Blair governmentEdit

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.[citation needed]

Labour came to power in 1997 with the promise to remove the "internal market" and abolish fundholding. 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.[citation needed]

A number of factors drove these reforms; they include the rising costs of medical technology and medicines, the desire to improve 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 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. Some new services were developed to help manage demand, including NHS Direct. The Agenda for Change agreement aimed to provide harmonised pay and career progression. These changes have given rise to controversy within the medical professions, the news media and the public. The British Medical Association in a 2009 document on Independent Sector Treatment Centres (ISTCs) urged the government to restore the NHS to a service based on public provision, not private ownership; co-operation, not competition; integration, not fragmentation; and public service, not private profits.[82]

The Blair government, whilst leaving services free at point of use, encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals were built (or rebuilt) by private sector consortia; hospitals may have both medical services such as ISTCs[83] 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.[citation needed] The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced.[84]

The NHS was also required to take on pro-active socially "directive" policies, for example, in respect of smoking and obesity.

Internet information serviceEdit

In the 1980s and 90s, NHS IT spent money on several failed IT projects. The Wessex project, in the 1980s, attempted to standardise IT systems across a regional health authority. The London Ambulance Service was to be a computer-aided dispatch system. Read code was an attempt to develop a new electronic language of health,[85] later scheduled to be replaced by SNOMED CT.

The NHS Information Authority (NHSIA) was established by an Act of Parliament in 1999 with the goal to bring together four NHS IT and Information bodies (NHS Telecoms, Family Health Service (FHS), NHS Centre for Coding and Classification (CCC) and NHS Information Management Group (IMG)) to work together to deliver IT infrastructure and information solutions to the NHS in England. A 2002 plan was for NHSIA to implement four national IT projects: Basic infrastructure, Electronic records, Electronic prescribing, and Electronic booking, modelled after the large NHS Direct tele-nurse and healthcare website program.[85] The NHSIA functions were divided into other organisations by April 2005.

In 2002, the NHS National Programme for IT (NPfIT) was announced by the Department of Health.

Despite problems with internal IT programmes, the NHS has broken new ground in providing health information to the public via the internet. In June 2007 www.nhs.uk was relaunched under the banner "NHS Choices"[86] as a comprehensive health information service for the public.

In a break with the norm for government sites, www.nhs.uk allows users to add public comments giving their views on individual hospitals and to add comments to the articles it carries. It also enables users to compare hospitals for treatment via a "scorecard".[87] In April 2009 it became the first official site to publish hospital death rates (Hospital Standardised Mortality Rates) for the whole of England. Its Behind the Headlines daily health news analysis service,[88] which critically appraises media stories and the science behind them, was declared Best Innovation in Medical Communication in the prestigious BMJ Group Awards 2009.[89] and in a 2015 case study was found to provide highly accurate and detailed information when compared to other sources[90] In 2012, NHS England launched an NHS library of mobile apps [91] that had been reviewed by clinicians.

Eleven of the NHS hospitals in the West London Cancer Network have been linked using the IOCOM Grid System. The NHS has reported that the Grid has helped increase collaboration and meeting attendance and even improved clinical decisions.[92]

Smoking cessationEdit

One in four hospital patients smoke and that is higher than the proportion in the general population (just under one in five). Public Health England (PHE) wants all hospitals to help smokers quit. One in thirteen smoking patients was referred to a hospital or community based cessation programme. Over a quarter of patients were not asked if they smoke and nearly three quarters of smokers were not asked if they wanted to stop. Half of frontline hospital staff were offered no training in smoking cessation. Smoking patients should be offered specialized help to stop and nicotine replacement. There should be dedicated staff helping patients to quit. Seven tenths of smokers say they want to stop and those offered help are four times more likely to stop permanently. PHE claims smoking causes 96,000 deaths per year in England and twenty times the number of smoking related illnesses. Dr Frank Ryan, psychologist said, "It's really about refocusing our efforts and motivating our service users and staff to quit. And of course, whatever investment we make in smoking cessation programmes, there's a payback many times more in terms of the health benefits and even factors such as attendance at work, because it's workers who smoke [who] tend to have more absent spells from work."[93]

See Smoking in the United Kingdom

Public satisfaction and criticismEdit

A 2016 survey by Ipsos MORI found that the NHS tops the list of "things that makes us most proud to be British" at 48%.[94] An independent survey conducted in 2004 found that users of the NHS often expressed very high levels of satisfaction about their personal experience of the medical services. Of hospital inpatients, 92% said they were satisfied with their treatment; 87% of GP users were satisfied with their GP; 87% of hospital outpatients were satisfied with the service they received; and 70% of Accident and Emergency department users reported being satisfied.[95] When asked whether they agreed with the question "My local NHS is providing me with a good service” 67% of those surveyed agreed with it, and 51% agreed with the statement “The NHS is providing a good service."[95] The reason for this disparity between personal experience and overall perceptions is not clear; however, researchers at King's College London found high-profile media spectacles may function as part of a wider 'blame business', in which the media, lawyers and regulators have vested interests.[96][97] It is also apparent from the satisfaction survey that most people believe that the national press is generally critical of the service (64% reporting it as being critical compared to just 13% saying the national press is favourable), and also that the national press is the least reliable source of information (50% reporting it to be not very or not at all reliable, compared to 36% believing the press was reliable) .[95] Newspapers were reported as being less favourable and also less reliable than the broadcast media. The most reliable sources of information were considered to be leaflets from GPs and information from friends (both 77% reported as reliable) and medical professionals (75% considered reliable).[95]

Professor Sir Michael Adrian Richards said more money needs to be spent on the NHS. Richards maintains nurses need a pay rise to encourage them to stay. Richards also said the NHS needs to spend money more effectively and that some hospitals have improved by focusing on providing what patients need.[98]

Some examples of criticism include:

  1. Some extremely expensive treatments may be available in some areas but not in others, the so-called postcode lottery.[99]
  2. The National Programme for IT which was designed to provide the infrastructure for electronic prescribing, booking appointments and elective surgery, and a national care records service. The programme ran into delays and overspends before it was finally abandoned.
  3. In 2008 there was a decreasing availability of NHS dentistry following a new government contract[100] and a trend towards dentists accepting private patients only,[101] with 1 in 10 dentists having left the NHS totally. However, in 2014 the number of NHS dental patients was reported to be increasing.[102]
  4. There have been a number of high-profile scandals within the NHS. Most recently there have been scandals at acute hospitals such as Alder Hey and the Bristol Royal Infirmary. Stafford Hospital is currently under investigation for poor conditions and inadequacies that statistical analysis has shown caused excess deaths.
  5. A 14 October 2008 article in The Daily Telegraph stated, "An NHS trust has spent more than £12,000 on private treatment for hospital staff because its own waiting times are too long."[103]
  6. In January 2010, the NHS was accused of allocating £4 million annually on homoeopathic medicines, which are unsupported by scientific research.[104]
  7. The absence of identity/residence checks on patients at clinics and hospitals allows people who ordinarily reside overseas to travel to the UK for the purpose of obtaining free treatment, at the expense of the UK taxpayer. A report published in 2007 estimates that the NHS bill for treatment of so-called ‘health tourists’ was £30m, 0.03% of the total cost.[105]
  8. Long waits for treatment like cancer care, cataracts, knee and hip replacement lead vulnerable people to pay for these treatments privately. Patients use up savings or take out loans. It is widely felt the NHS should provide free health care for those who need it and patients shoud not be under pressure to pay.[106]

NHS mental health services is one area that tends to receive regular criticism from service users and the public, for sometimes opposing reasons.[107][108][109][110][111] Women do not get gender specific help and in most trusts are not routinely asked if they have suffered domestic abuse though NICE recommends asking this.[112] Some psychiatric patients are hard to manage.[113] Police are increasingly called to deal with mental health crises due to insufficient trained mental health staff in the NHS. Police are poorly suited for this role.[114] The number of psychiatrists working with children and teenagers fell from 1,015 full-time equivalent posts in 2013 to 948 in 2017 despite rising psychiatric need among youngsters. Many troubled youngsters must wait a long time before treatment starts or are denied treatment altogether.[115] There is also a shortage of psychiatrists treating elderley patients.[116] Due to a bed shortage patients are more sick when entering units and there are fewer staff to manage them. Assaults on staff have risen from 33,620 in 2012-3 to 42692 in 2016-7. There were also over 17,000 assaults by patients on other patients.[117] Patients with eating disorders are sometimes denied treatment or made to wait too long for treatment which reduced their chances of making a good recovery.[118]

Long waits for surgery increased by a factor of three in four years.[119]

Due to shortage of nurses in hospitals, drugs for sepsis, Parkinson and diabetes are given late, pain is untreated since nurses are too busy, children go without food since treatment must be prioritized, patients are not moved risking bed sores, patients remain in corridors because there ar no empty beds, community staff complain they cannot do all the work asked of them.[120] The number of hospital beds has fallen despite the demand for beds rising.[121]

Record numbers of GP practises are closing, The Royal College of GPs said doctors could no longer manage rising patient demand unless there is higher funding.[122]

Quality of healthcare, and accreditationEdit

There are many regulatory bodies with a role in the NHS, both government-based (e.g. Department of Health, General Medical Council, Nursing and Midwifery Council),and non-governmental-based (e.g. Royal Colleges). Independent accreditation groups exist within the UK, such as the public sector Trent Accreditation Scheme and the private sector CHKS.

With respect to assessing, maintaining and improving the quality of healthcare, in common with many other developed countries, the UK government has separated the roles of suppliers of healthcare and assessors of the quality of its delivery. Quality is assessed by independent bodies such as the Healthcare Commission according to standards set by the Department of Health and the National Institute for Health and Clinical Excellence (NICE). Responsibility for assessing quality transferred to the Care Quality Commission in April 2009.

A comparative analysis of health care systems in 2010 put the NHS second in a study of seven rich countries.[123][124] The report put the UK health systems above those of Germany, Canada and the US; the NHS was deemed the most efficient among those health systems studied.

PerformanceEdit

In 2014 the Nuffield Trust and the Health Foundation produced a report comparing the performance of the NHS in the four countries of the UK since devolution in 1999. They included data for the North East of England as an area more similar to the devolved areas than the rest of England. They found that there was little evidence that any one country was moving ahead of the others consistently across the available indicators of performance. There had been improvements in all four countries in life expectancy and in rates of mortality amenable to health care. Despite the hotly contested policy differences between the four countries there was little evidence, where there was comparable data, of any significant differences in outcomes. The authors also complained about the increasingly limited set of comparable data on the four health systems of the UK.[125] Medical school places are set to increase by 25% from 2018.[126]

A report from Public Health England’s Neurology Intelligence Network based on hospital outpatient data for 2012–13 showed that there was significant variation in access to services by Clinical Commissioning Group. In some places there was no access at all to consultant neurologists or nurses. The number of new consultant adult neurology outpatient appointments varied between 2,531 per 100,000 resident population in Camden to 165 per 100,000 in Doncaster.[127]

Funding shortfall is forcing NHS England to make cuts.[when?] The BMA is concerned that the public are not being told what will be cut and how cuts will affect their health care.[128][when?]

Access to IVF treatment is being limited in many parts of England.[129][when?] English maternity wards were compelled to close 382 times in 2016, there has been a 70% increase in closures over two years. 42 hospital trusts closed at some time, 44% of those which responded, many blamed shortages of staff or of bed and cot capacity in 2016. 14 closed over ten times and some remained closed over 24 hours in 2016. Elizabeth Duff of the NCT said when the figures were released in 2017, “It’s appalling that a shortage of midwives and equipment means that so many units have been closed time and again so that pregnant women are pushed from pillar to post in the throes of labour. (...) [women in advanced labour could be made to travel to another hospital] leaving them anxious and frightened about having their baby in a car or by the roadside”.[130]

Over four million patients were waiting for non urgent hospital care as of July 2017. The Royal College of Surgeons together with other medical groups fear patients are waiting longer in anxiety and pain for hospital procedures.[131]

Security breachesEdit

On May 12, 2017, a major cyber-attack occurred within a large number of NHS computer systems causing disruption among NHS institutions across England and Scotland. It was reported that 25 NHS Trusts were affected, most located in London, Nottingham, Blackpool, York, Carlisle, Dumfries and Glasgow.[132] See Vulnerability of NHS computer systems.

See alsoEdit

ReferencesEdit

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Further readingEdit

  • 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 (2010), The New Politics of the NHS: From creation to reinvention. Radcliffe Publishing ISBN 978-1-84619-409-2 ( Authoritative analysis of policy making (political not clinical)in the NHS from its birth to the end of 2009)
  • 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

External linksEdit