Healthcare in the United Kingdom

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A map of the United Kingdom, in which responsibility of healthcare lies with four executives:

Healthcare in the United Kingdom is a devolved matter, meaning England, Northern Ireland, Scotland and Wales each have their own systems of private and publicly funded healthcare. Each region having different policies and priorities has resulted in a variety of differences existing between the systems.[1][2] That said, each country provides public healthcare to all UK permanent residents that is free at the point of need, being paid for from general taxation. In addition, each also has a private healthcare sector which is considerably smaller than its public equivalent, with provision of private healthcare acquired by means of private health insurance, funded as part of an employer funded healthcare scheme or paid directly by the customer, though provision can be restricted for those with conditions such as AIDS/HIV.[3]

Taken together, the World Health Organization, in 2000, ranked the provision of healthcare in the United Kingdom as fifteenth best in Europe and eighteenth in the world.[4][5] A more recent report, the Commonwealth Fund Mirror, Mirror on the Wall survey of seven first world healthcare systems, ranked the United Kingdom as second overall, taking first place in subcategories including effective care and efficiency.[6] Overall, around 8.4 per cent of the United Kingdom's gross domestic product is spent on healthcare, which is 0.5% below the Organisation for Economic Co-operation and Development average and about one percent below the average of the European Union.[7]

Healthcare in England[edit]

Most healthcare in England is provided by the National Health Service (NHS), England's publicly funded healthcare system, which accounts for most of the Department of Health's budget (£98.6 billion in 2008-9[8]). The actual delivery of health care services is managed by ten Strategic Health Authorities and, below this, locally accountable trusts and other bodies.[9] Social care services are a shared responsibility with the local NHS and the local government Directors of Social Services under the guidance of the DH. From the birth of the NHS in 1948, private healthcare has continued to exist, paid for largely by private insurance. In recent years, despite some evidence that a large proportion of the public oppose such involvement,[10] the private sector has been used to increase NHS capacity. In addition, there is some relatively minor sector crossover between public and private provision with it possible for some NHS patients to be treated in private healthcare facilities[11] and some NHS facilities let out to the private sector for privately funded treatments or for pre- and post-operative care.[12] However, since private hospitals tend to manage only routine operations and lack a level 3 critical care unit (or intensive therapy unit), unexpected emergencies may lead to the patient being transferred to an NHS hospital[13] as very few private hospitals have a level 3 critical care unit (or intensive therapy unit), putting the patients at greater risk and costing the NHS money.

The two main kinds of trusts in the NHS, reflecting purchaser/provider roles, are commissioning trusts such as Primary Care Trusts which examine local needs and negotiate with providers (that may be public or private entities) to provide health care services to the local population, and provider trusts which are NHS bodies delivering health care service. They will be involved in agreeing major capital and other health care spending projects in their region.[9] Services commissioned include general practice physician services (most of whom are private businesses working under exclusive contract to the NHS), community nursing, local clinics and mental health service. For most people, the majority of health care is delivered in a primary health care setting. Provider trusts are care deliverers, the main examples being the hospital trusts and the ambulance trusts which spend the money allocated to them by the commissioning trusts. Hospitals, as they tend to provide more complex and specialized care, receive the lion's share of NHS funding.[14] The hospital trusts own assets (such as hospitals and the equipment in them) purchased for the nation and held in trust for them.[9] Commissioning has also been extended to the very lowest level enabling ordinary doctors who identify a need in their community to commission services to meet that need. Primary care is delivered by a wide range of independent contractors such as GPs, dentists, pharmacists and optometrists and is the first point of contact for most people. Secondary care (sometimes termed acute health care) can be either elective care or emergency care and providers may be in the public or private sector, though the majority of secondary care happens in NHS owned facilities.[15] There are also (as of 2009) 246 Memory clinics in the United Kingdom.[16]

The NHS Constitution covers the rights and obligations of patients and staff, many of which are legally enforceable.[17] The NHS has a high level of popular public support within the country: an independent survey conducted in 2004 found that users of the NHS often expressed very high levels satisfaction about their personal experience of the medical services they received: 92% of hospital in-patients, 87% of GP users, 87% of hospital outpatients, and 70% of Accident and Emergency department users.[18] However, only 67% of those surveyed agreed with the statement "My local NHS is providing me with a good service”, and only 51% agreed with the statement “The NHS is providing a good service.[18] Satisfaction in successive surveys has noted high satisfaction across all patient groups, especially recent inpatients, and user satisfaction is notably higher than that of the general public. The report found that most highly recalled sources of information on the NHS are perceived to be the most critical. The national press was seen to be the most critical (64%), followed by local press (54%) and TV or radio (51%) compared to just 13% saying the national press is favourable). The national press was reported as being 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).[18] 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).[18]

Healthcare in Northern Ireland[edit]

The biggest part of healthcare in Northern Ireland is provided by Health and Social Care in Northern Ireland. Though this organization does not use the term 'National Health Service', it is still sometimes referred to as the 'NHS'.[19]

Healthcare in Scotland[edit]

The majority of healthcare in Scotland is provided by NHS Scotland; Scotland's current national system of publicly funded healthcare was created in 1948 at the same time as those in Northern Ireland and in England and Wales, incorporating and expanding upon services already provided by local and national authorities as well as private and charitable institutions. It remains a separate body from the other public health systems in the United Kingdom although this is often not realised by patients when "cross-border" or emergency care is involved due to the level of co-operation and co-ordination, occasionally becoming apparent in cases where patients are repatriated by the Scottish Ambulance Service to a hospital in their country of residence once essential treatment has been given but they are not yet fit to travel by non-ambulance transport.

Healthcare in Wales[edit]

The majority of healthcare in Wales is provided by NHS Wales. This body was originally formed as part of the same NHS structure for England and Wales created by the National Health Service Act 1946 but powers over the NHS in Wales came under the Secretary of State for Wales in 1969[20] and, in turn, responsibility for NHS Wales was passed to the Welsh Assembly and the Welsh Assembly Government under devolution in 1999.

Comparisons between the public health systems in the United Kingdom[edit]

The reduction in infant mortality between 1960 to 2008 for the United Kingdom in comparison with France, Ireland, Sweden, Switzerland, and the United States. The overall trend has meant a large improvement in health inside the United Kingdom.

Common features[edit]

Each NHS system uses General Practitioners (GPs) to provide primary healthcare and to make referrals to further services as necessary. Hospitals then provide more specialist services, including care for patients with psychiatric illnesses, as well as direct access to Accident and Emergency (A&E) departments. Pharmacies (other than those within hospitals) are privately owned but have contracts with the relevant health service to supply prescription drugs.

Each public healthcare system also provides free[21] ambulance services for emergencies, when patients need the specialist transport only available from ambulance crews or when patients are not fit to travel home by public transport. These services are generally supplemented when necessary by the voluntary ambulance services (British Red Cross, St Andrews Ambulance Association and St John Ambulance). In addition, patient transport services by air are provided by the Scottish Ambulance Service in Scotland and elsewhere by county or regional air ambulance trusts (sometimes operated jointly with local police helicopter services[22]) throughout England and Wales.[23] In specific emergencies, emergency air transport is also provided by naval, military and air force aircraft of whatever type might be appropriate or available on each occasion.[24]

Each NHS system also provides dental services through private dental practices and dentists can only charge NHS patients at the set rates for each country. Patients opting to be treated privately do not receive any NHS funding for the treatment. About half of the income of dentists in England comes from work sub-contracted from the NHS,[25] however not all dentists choose to do NHS work.

Differences[edit]

Advice services[edit]

Each NHS system has its own 24-hour telephone advisory service: England has NHS Direct,[26] Wales has NHS Direct Wales/Galw Iechyd Cymru[27] while Scotland has NHS24.[28]

Best practice and cost effectiveness[edit]

In England and Wales, the National Institute for Health and Clinical Excellence (NICE) sets guidelines for medical practitioners as to how various conditions should be treated and whether or not a particular treatment should be funded. These guidelines are established by panels of medical experts who specialize in the area being reviewed.

In Scotland, the Scottish Medicines Consortium advises NHS Boards there about all newly licensed medicines and formulations of existing medicines as well as the use of antimicrobiotics but does not assess vaccines, branded generics, non-prescription-only medicines (POMs), blood products and substitutes or diagnostic drugs. Some new drugs are available for prescription more quickly than in the rest of the United Kingdom. At times this has led to complaints.[29]

Cost control[edit]

The National Audit Office reports annually on the summarised consolidated accounts of the NHS, and Audit Scotland performs the same function for NHS Scotland.[30]

Parking charges[edit]

Parking charges at hospitals have been abolished in Scotland (except for 3 PFI hospitals)[31] but continue to be in place at many hospitals in England, Parking charges have also been abolished in Wales[32]

Prescription charges[edit]

Northern Ireland, Scotland and Wales no longer have prescription charges. However, in England, a prescription charge of £7.85 is payable per item, (due to increase to £8.05 1st April 2014, and to £8.25 1st April 2015) though patients under 16 years old (16-18 years if still in full-time education) or over 60 years get prescribed drugs are exempt from paying as are people with certain medical conditions, those on low incomes or in receipt of certain benefits, and those prescribed drugs for contraception.

Policlinics[edit]

Policlinics are being trialled in England alone, in London and other suburban areas.

Role of private sector in public healthcare[edit]

Whereas the United Kingdom Government is expanding the role of the private sector within the NHS in England,[33][34] the current Scottish government is actively reducing the role of the private sector within public healthcare in Scotland[35] and planning legislation to prevent the possibility of private companies running GP practices in future.[36]

Funding and performance of healthcare since devolution[edit]

In January 2010 the Nuffield Trust published a comparative study of NHS performance in England and the devolved administrations since devolution, concluding that while Scotland, Wales and Northern Ireland have had higher levels of funding per capita than England, with the latter having fewer doctors, nurses and managers per head of population, the English NHS is making better use of the resources by delivering relatively higher levels of activity, crude productivity of its staff, and lower waiting times.[37] However, the Nuffield Trust quickly issued a clarifying statement in which they admitted that the figures they used to make comparisons between Scotland and the rest of the United Kingdom were inaccurate due to the figure for medical staff in Scotland being overestimated by 27 per cent.[38] Using revised figures for medical staffing, Scotland's ranking relative to the other devolved nations on crude productivity for medical staff changes, but there is no change relative to England.[39] The Nuffield Trust study was comprehensively criticised by the BMA which concluded "whilst the paper raises issues which are genuinely worth debating in the context of devolution, these issues do not tell the full story, nor are they unambiguously to the disadvantage of the devolved countries. The emphasis on policies which have been prioritised in England such as maximum waiting times will tend to reflect badly on countries which have prioritised spending increases in other areas including non-health ones.[40]

See also[edit]

References[edit]

  1. ^ 'Huge contrasts' in devolved NHS BBC News, 28 August 2008
  2. ^ NHS now four different systems BBC 2 January 2008
  3. ^ BUPA exclusions bupa.co.uk, accessed 23 February 2009
  4. ^ World Health Organisation, World Health Staff, (2000). Haden, Angela; Campanini, Barbara, eds. The world health report 2000 - Health systems: improving performance. Geneva, Switzerland: World Health Organisation. ISBN 92-4-156198-X. 
  5. ^ World Health Organization. "Measuring overall health system performance for 191 countries" (PDF). pages.stern.nyu.edu. 
  6. ^ http://www.commonwealthfund.org/Publications/Fund-Reports/2010/Jun/Mirror-Mirror-Update.aspx?page=all
  7. ^ "OECD Health Data 2009- How Does the United Kingdom Compare" (PDF). Retrieved 2011-04-28. 
  8. ^ HM Treasury (2008-03-24). "Budget 2008, Chapter C". p. 23. Retrieved 2008-03-24. 
  9. ^ a b c THE STRUCTURE OF THE NHS Royal College of General Practitioners
  10. ^ "Survey of the general public's views on NHS system reform in England". BMA. 2007-06-01. 
  11. ^ Private hospital serving NHS patients http://www.spirehealthcare.com/Washington/NHS-Services-at-Spire-Washington-Hospital/
  12. ^ NHS units offering services to paying private patients http://www.privatehealth.co.uk/private-hospitals/nhs/
  13. ^ What if surgery goes wrong? Private Health Advice - A reference point on how private healthcare works in the uk.
  14. ^ Seconday care consumes more costs than any other part of the spending of PCTS. See Figure A.15: Primary care trust expenditure Appendix A Financial Data Tables taken from DH Annual Report at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_100667
  15. ^ "NHS structure". Nhs.uk. 2010-05-26. Retrieved 2011-04-28. 
  16. ^ "Number of memory clinics UK". Dementiaweb.org. 
  17. ^ "NHS Constitution - interactive version" (PDF). Retrieved 2011-04-28. 
  18. ^ a b c d IPSOS-Mori. "NHS 2004 survey". UK Department of Health. Retrieved 2009-06-29. 
  19. ^ Hospital warns of 'Third World' NHS BBC News, 30 August 2000
  20. ^ Introduction to NHS Wales 1960's www.wales.nhs.uk
  21. ^ 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. "NHS Injury Cost Recovery scheme". NHS. Retrieved 2008-03-10. 
  22. ^ "Wiltshire Air Ambulance". Wiltshire Air Ambulance. Retrieved 2011-04-28. 
  23. ^ "Air Ambulance Association". Air Ambulance Association. Retrieved 2011-04-28. 
  24. ^ "RAF flight 'saved couple's baby'". BBC News. 2006-11-21. Retrieved 2011-04-28. 
  25. ^ "Call for dentists' NHS-work quota". BBC News (London). 3 June 2007. Retrieved 5 January 2010. 
  26. ^ NHS Direct (England)[dead link]
  27. ^ "NHS Direct Wales/Galw Iechyd Cymru". Nhsdirect.wales.nhs.uk. Retrieved 2011-04-28. 
  28. ^ "Scotland". NHS 24. Retrieved 2011-04-28. 
  29. ^ Call for quicker drug decisions BBC News, 10 January 2008
  30. ^ "NAO report (HC 129-I 2007-08): Report on the NHS Summarised Accounts 2006-07: Achieving Financial Balance". Nao.org.uk. 2007-12-11. Retrieved 2011-04-28. 
  31. ^ NHS car parking charges abolished BBC News, 2 September 2008
  32. ^ http://news.bbc.co.uk/1/hi/wales/7323027.stm
  33. ^ Private firm to carry out surgery BBC News, 5 August 2007
  34. ^ £64bn NHS privatisation plan revealed guardian.co.uk, 30 June 2006
  35. ^ Plans to end private cash for NHS BBC News, 21 June 2007
  36. ^ Sturgeon to end privatisation of GP practices Sunday Herald, 8 June 2008
  37. ^ Sheelah Connolly, Gwyn Bevan and Nicholas Mays (20 January 2010). "Funding and Performance of Healthcare Systems in the Four Countries of the UK Before and After Devolution". Nuffield Trust. Retrieved 26 January 2010. 
  38. ^ Nuffield Trust statement scotland.gov.uk, 20 January 2010
  39. ^ "Nuffield Trust statement on NHS Scotland figures included in study of UK health performance". Nuffield Trust. Retrieved 27 January 2010. 
  40. ^ Briefing Note, March 2010 bma.org.uk, accessed 20 March 2010

Further reading[edit]

  • Alcock, P. (2003) Social Policy in Britain. Houndmills: McMillan
  • Allsop, J. (1995) Health Policy and the NHS towards 2000. London: Longman
  • Ham, C. (2004) Health Policy in Britain. London: McMillan
  • Klein, R. (2006) The New Politics of the NHS: from creation to reinvention. Oxford: Radcliff Publishing
  • Thane, P. (1982) The Foundations of the Welfare State. Harlow: Longman.
  • Webster, C. (2002) The National Health Service: a political history. Oxford: Oxford University Press.