Healthcare in England
Healthcare in England is mainly provided by England's public health service, the National Health Service, that provides healthcare to all permanent residents of the United Kingdom that is free at the point of use and paid for from general taxation. Since health is a devolved matter, there are differences with the provisions for healthcare elsewhere in the United Kingdom. Though the public system dominates healthcare provision in England, private health care and a wide variety of alternative and complementary treatments are available for those willing to pay.
National Health Service (NHS)
The National Health Service (NHS) is free at the point of use for the patient though there are charges associated with eye tests, dental care, prescriptions, and many aspects of personal care.
The NHS provides the majority of healthcare in England, including primary care, in-patient care, long-term healthcare, ophthalmology and dentistry. The National Health Service Act 1946 came into effect on 5 July 1948. Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used by less than 8% of the population, and generally as a top-up to NHS services. Recently there have been some examples where unused private sector capacity has been used to increase NHS capacity and in some cases the NHS has commissioned the private sector to establish and run new facilities on a sub contracted basis. Some new capital programs have been financed through the private finance initiative. The involvement of the private sector remains relatively small yet, according to one survey by the BMA, a large proportion of the public oppose such involvement.
Funding and management
The NHS is divided conceptually into two parts covering primary and secondary care with trusts given the task of health care delivery. There are two main kinds of trusts in the NHS reflecting purchaser/provider roles: commissioning trusts are responsible for examining local needs and negotiating with providers to provide health care services to the local population, and provider trusts which are NHS bodies delivering health care service. Commissioning trusts negotiate service delivery with providers that may be NHS bodies or private entities. They will be involved in agreeing major capital and other health care spending projects in their region. By far the most known and most important purchases are services including 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. Because hospitals tend to provide more complex and specialized care, they receive the lion's share of NHS funding. The hospital trusts own assets (such as hospitals and the equipment in them) purchased for the nation and held in trust for them. 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.
The NHS has recently adopted a formal constitution which for the first time, in one document, lays down the objectives of the NHS, the rights and responsibilities of the various parties (patients, staff, trust boards) and the guiding principles which govern the service. In summary, these guiding principles are
- The NHS provides a comprehensive service, available to all irrespective of age, gender, disability, race, sexual orientation, religion or belief, respecting their human rights.
- Access to NHS services is based on clinical need, not an individual’s ability to pay (except in limited circumstances sanctioned by Parliament).
- The NHS aspires to the highest standards of excellence and professionalism to provide high quality care that is safe, effective and focused on the patient experience.
- NHS services must reflect the needs and preferences of patients, their families and their carers.
- The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population. The NHS is an integrated system of organisations and services bound together by the principles and values reflected in the Constitution.
The NHS grants patients rights which are intended to be legally enforceable and also makes other non-binding pledges. These are in the areas of access; quality of care and environment; access to treatments, medicines and screening programmes; Respect, consent and confidentiality; informed choice; patient involvement in healthcare and public involvement in the NHS; and complaints and redress. The constitution:-
defines rights regarding access to health care which will be
- free of charge
- never refused on unreasonable grounds
- obtainable from any UK NHS provider or with pre-approval from any EEA or Swiss public provider
- assessed by the local NHS to meet locally assessed needs
and pledges that access to health care will be convenient and easy to access within defined waiting times; based on decision making that will be clear and transparent, and that transfers from one provider to another will be as smooth as possible and that patients will be involved in all relevant discussions.
defines rights regarding quality of care and environment as follows
- treatment with a professional standard of care, by appropriately qualified and experienced staff, an organisation that meets required levels of safety and quality.
- Patients can expect NHS organisations to monitor, and make efforts to improve, the quality of healthcare they commission or provide
add pledges that services will be provided in a clean and safe environment that is fit for purpose, based on national best practice and that there will be a continuous improvement in the quality of services, identifying and sharing best practice.
The constitution defines rights regarding approved treatments, drugs and programmes. Patients have the right to
- drugs and treatments that have been recommended by NICE for use in the NHS, if their doctor says they are clinically appropriate for them.
- expect local decisions on funding of other drugs and treatments to be made rationally following a proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you and your doctor feel would be right for you, the local NHS must explain that decision.
- receive the approved vaccinations under an NHS-provided national immunisation programme.
and pledges to provide screening programmes as recommended by the UK National Screening Committee.
With regard to rights regarding Respect, consent and confidentiality the NHS gives patients the right to
- be treated with dignity and respect.
- accept or refuse treatment that is offered, and not to be given any examination or treatment without valid consent.
- be given information about your proposed treatment in advance, including any significant risks and any alternative treatments which may be available, and the risks involved in doing nothing.
- privacy and confidentiality and to expect the NHS to keep their confidential information safe and secure.
- access to their own health records. which will always be used to manage treatment in the patient's best interests.
and pledges that it will share with patients any letters sent between clinicians about their care.
Patients are given rights in relation to informed choice including the right to
- choose their own GP practice, and to be accepted by that practice unless there are reasonable grounds to refuse
- express a preference for using a particular doctor within your GP practice, and for the practice to try to comply.
- make choices about their NHS care and to information to support these choices.
The NHS also pledges to inform patients about the healthcare services available locally and nationally and will offer easily accessible, reliable and relevant information to enable patients to participate fully in their own healthcare decisions and to support them in making choices. This includes information on the quality of clinical services where there is robust and accurate information available.
The population has rights regarding Involvement in their own healthcare and in the NHS. There are rights to
- be involved in discussions and decisions about one's own health care, and to be given information to enable you to do this
- be involved, directly or through representatives, in the planning of health care services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services.
The NHS also pledges to provide the information you need to influence and scrutinise the planning and delivery of NHS services and to work in partnership with patients, their family, carers and their representatives. It also pledges continuous improvement in the quality of services provided, identifying and sharing best practice in quality of care and treatments.
When complaining or seeking redress, patients are given rights to
- have any complaint made about NHS services dealt with efficiently and to have it properly investigated.
- know the outcome of any investigation into a complaint.
- take a complaint to the independent Health Service Ombudsman, if they are not satisfied with the way your complaint was dealt with by the NHS.
- make a claim for judicial review if they think they have been directly affected by an unlawful act or decision of an NHS body.
- compensation where they have been harmed by negligent treatment.
The NHS also pledges to ensure patients are treated with courtesy and receive appropriate support throughout the handling of a complaint, and the fact that they have made a complaint will not adversely affect their future treatment. When mistakes happen, the NHS promises to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively. It primises that the organisation will learn lessons from complaints and will use them to improve NHS services.
A patient needing specialist care at a hospital or clinic, will be informed by the GP of the hospitals where they can get their treatment. available and helped to decide. This choice usually includes public and private hospitals. The NHS will pay for treatment in a private setting if the hospital meets the cost and service criteria that NHS hospitals adhere to. Otherwise opting for a private hospital makes the patient liable for private hospital fees. Because the private sector often has higher costs, most people choose to be treated for free in an NHS hospital. If the GP judges the case to be extremely urgent, the doctor may by-pass the normal booking system and arrange an emergency admission. The median wait time for a consultant led first appointment in English hospitals is a little over 3 weeks. Patients can be seen by the hospital as out-patients or in-patients, with the latter involving overnight stay. The speed of in-patient admission is based on medical need and time waiting with more urgent cases faster though all cases will be dealt with eventually. Only about one third of hospital admissions are from a waiting list. For those not admitted immediately, the median wait time for in-patient treatment in English hospitals is a little under 6 weeks Ibid. Trusts are working towards an 18 week guarantee that means that the hospital must complete all tests and start treatment within 18 weeks of the date of the referral from the GP. Some hospitals are introducing just in time workflow analysis borrowed from manufacturing industry to speed up the processes within the system and improve efficiencies.
Almost all NHS hospital treatment is free of charge along with drugs administered in hospital, surgical consumables and appliances issued or loaned. However, if a patient has chosen to be treated in an NHS hospital as a private fee paying patient by arrangement with his consultant, the patient (or the insurance company) will be billed. This can happen because at the inception of the NHS, hospital consultants were allowed to continue doing private work in NHS hospitals and can enable private patients to "jump the NHS queue". This arrangement is nowadays quite rare as most consultants and patients choose to have private work done in private hospitals.
Emergency Department (traditionally known as Accident and Emergency) treatment is also free of charge. A triage nurse prioritises all patients on arrival. Waiting times can be up to 4 hours if a patient goes to the Emergency Department with a minor problem or may be referred to other agencies (e.g. pharmacy, GP, Walk in clinic). Emergency Departments try to treat patients within 4 hours as part of NHS targets for emergency care. The Emergency Department is always attached to an NHS general hospital. Private hospitals do not provide emergency care services.
The NHS also provides end of life palliative care in the form of Palliative Care Specialist Nurses. The NHS can also commission the expertise of organisations in the voluntary sector to compliment palliative care. Such organisations include Marie Curie Cancer Care, Sue Ryder Care and Macmillan Cancer Support. Despite their names, these services are designed for all palliative conditions, not exclusively cancer. All palliative care services provide support for both the patient and their relatives during and after the dying process. Again, these are all free of charge to the patient.
Experiences, perceptions and reporting of the NHS
Although the NHS has a high level of popular public support within the country, the national press is often highly critical of it and this may have affected perceptions of the service within the country as a whole and outside. 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. 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. But when asked whether they agreed with the question "My local NHS is providing me with a good service” only 67% of those surveyed agreed with it, and only 51% agreed with the statement “The NHS is providing a good service. The reason for this disparity between personal experience and overall perceptions is not clear. Similarly the survey also showed that net satisfaction with NHS services (the number reporting satisfied less those reporting dissatisfied) was generally higher amongst NHS services users than for all respondents (users as well as non-users). Where more people had no recent experience of that service, the difference in net positive perception reported by users compared to non users was more likely to diverge. For example, the least used service surveyed was walk in centres (only 15% of all persons surveyed had actually used an NHS Walk in clinic in the last year) but 85% of walk in clinic users were satisfied with the service they received. Users' net positive satisfaction was 80%. However, for all respondents (including non recent users) the overall net positive satisfaction was just 25%. The service with the highest rate of use was the GP service (77% having seen their GP in the last year) and the difference in net satisfaction between users and all users was the smallest (76% and 74% net satisfied respectively)  It is also apparent from the survey that most people realize 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). 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).
Most people think that the NHS is well run, with 73% of people reporting that they are satisfied with the running of the service and only a little over 10% reporting themselves as dissatisfied.
Private-sector medical care
England has a private sector in health care providing a lesser set of treatments than those obtainable from the NHS. Private health care is sometimes funded by employers through medical insurance as part of a benefits package to employees though it is mostly the larger companies that do. Insurers also market policies directly to the public. Most private care is for specialist referrals with most people retaining their NHS GP as point of first contact.
The private sector now does some subcontracting work for the NHS. Thus an NHS patient can be treated in the private sector as an NHS patient if the Health Services has subcontracted work to the hospital. This development is still in its infancy and quite rare.
Some private hospitals are business enterprises and some are non-profit-making trusts. Some hospital groups provide insurance plans (e.g. Bupa) and some insurance companies have deals with particular private hospital groups. Some private sector patients can be treated in NHS hospitals in which case the patient or his/her insurance company is billed.
- Polyclinics in England
- History of the National Health Service (England)
- List of NHS trusts
- List of hospitals in England
- NHS now four different systems BBC January 2, 2008
- "Survey of the general public's views on NHS system reform in England". BMA. 2007-06-01.
- THE STRUCTURE OF THE NHS Royal College of General Practitioners
- Secondary 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
- http://www.nhs.uk/NHSEngland/aboutnhs/Pages/NHSstructure.aspx NHS structure
- About the NHS
- http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093419 NHS Constitution for England
- More about choosing your hospital
- Patients can compare hospitals and average waiting times here
- http://www.nodelaysachiever.nhs.uk/Essentials/ The NHS No Delays performance improvement programme
- IPSOS-Mori. "NHS 2004 survey". UK Department of Health. Retrieved 2009-06-29.
- See Figure 4.2: Responses to the Question "overall, how satisfied or dissatisfied are you with the running of the NHS nowadays?" taken from latest IPSOS/Mori survey (see Page 43 of DH Annual report to parliament)
- Search for your local hospitals providing NHS treatment