Healthcare in the United Kingdom
Healthcare in the United Kingdom is a devolved matter, meaning England, Northern Ireland, Scotland and Wales each have their own systems of publicly funded healthcare. A variety of differences exist between these systems, as a result of each region having different policies and priorities. However, 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.
The most recent comparison from the World Health Organization is now significantly out of date: in 2000, it ranked the provision of healthcare in the United Kingdom as fifteenth best in Europe and eighteenth in the world. In their 2014 edition, the Commonwealth Fund's Mirror, Mirror on the Wall report, which ranks the top eleven first world healthcare systems, placed the United Kingdom as first overall taking first place in the following categories: Quality of Care (i.e. effective, safe, coordinated, & patient-oriented subcategories), Access to care, Efficiency, & Equity. The UK system had placed 2nd just four years previous in the 2010 report. The UK's palliative care has been ranked as the best in the world "due to comprehensive national policies, the extensive integration of palliative care into the National Health Service, a strong hospice movement, and deep community engagement on the issue.". On the other hand, in 2005-09 cancer survival rates lagged 10 years behind the rest of Europe, although survival rates continue to increase.
In 2011 public expenditure on healthcare was around 7.8 per cent of the United Kingdom's gross domestic product, which was 1.1% above the Organisation for Economic Co-operation and Development average and about 1.4% above the average of the European Union. The total spending of GDP on healthcare, including private, in the UK is 9.4%, considerably less than comparable economies such as France (11.6%), Germany (11.3%), Netherlands (11.9%), Canada (11.2%) and the USA (17.7%).
- 1 Common features
- 2 Healthcare in England
- 3 NHS Constitution
- 4 Healthcare in Northern Ireland
- 5 Healthcare in Scotland
- 6 Healthcare in Wales
- 7 Comparisons between the healthcare systems in the United Kingdom
- 8 See also
- 9 References
- 10 Further reading
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. Community pharmacies are privately owned but have contracts with the relevant health service to supply prescription drugs.
Each public healthcare system also provides free (at the point of service) 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) throughout England and Wales. 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, 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, however not all dentists choose to do NHS work.
Healthcare in England
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 (£110 billion in 2013-14).
In April 2013, under the terms of the Health and Social Care Act 2012, a huge top-down reorganisation of the NHS took place, resulting in a much more complex web of organisations to administer it. Primary care trusts (PCTs) and strategic health authorities (SHAs) were abolished, with new organisations such as clinical commissioning groups (CCGs) taking their place. CCGs now commission most of the hospital and community NHS services in the local areas for which they are responsible. Commissioning involves deciding what services a population is likely to need, and ensuring that there is provision of these services. The CCGs are overseen by NHS England, formally known as the NHS Commissioning Board (NHS CB) which was established on 1 October 2012 as an executive non-departmental public body. NHS England also has the responsibility for commissioning primary care services - General Practitioners, opticians and NHS dentistry, as well as some specialised hospital services. Services commissioned include general practice physician services (most of whom are private businesses working under 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. 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.
Provider trusts are NHS bodies delivering health care service. They are involved in agreeing major capital and other health care spending projects in their region. NHS trusts are care deliverers which spend money allocated to them by the Clinical commissioning groups. Hospitals, as they tend to provide more complex and specialised care, 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. 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 most secondary care happens in NHS owned facilities. There are also (as of 2009) 246 Memory clinics in the United Kingdom.
The NHS Constitution covers the rights and obligations of patients and staff, many of which are legally enforceable. 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. 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. 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). 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).
Healthcare in Northern Ireland
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'.
Healthcare in Scotland
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
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 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 healthcare systems in the United Kingdom
Telephone advisory services
Each NHS system has developed ways of offering access to non-emergency medical advice. People in England and Scotland can access these services by dialling the free-to-call 111 number. Scotland's service is run by NHS24. The telephone number for NHS Direct Wales/Galw Iechyd Cymru is 0845 4647, but this service intends to offer access through the 111 number from some point in 2015.
Best practice and cost effectiveness
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 specialise 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.
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.
Parking charges at hospitals have been abolished in Scotland (except for 3 PFI hospitals) and have also been abolished in Wales. Parking charges continue to be in place at many hospitals in England.
In a sample of 13 developed countries the UK was 9th in its population weighted usage of medication in 14 classes in both 2009 and 2013. The drugs studied were selected on the basis that the conditions treated had high incidence, prevalence and/or mortality, caused significant long-term morbidity and incurred high levels of expenditure and significant developments in prevention or treatment had been made in the last 10 years. The study noted considerable difficulties in cross border comparison of medication use.
Northern Ireland, Scotland and Wales no longer have Prescription charges. However, in England, a prescription charge of £8.20 is payable per item, though patients under 16 years old (16–18 years if still in full-time education) or over 60 years getting 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. UK permanent residents in England do not pay the real cost of the medicines and so for some prescribed medicines that can be bought over the counter without a prescription, for example aspirin, it can be much cheaper to purchase these without a prescription. UK permanent residents in England who must pay can (instead of paying for each medical item individually) purchase a three month Prescription Prepayment Certificate (PPC) costing £29.10. This saves the patient money where the patient needs four or more items in three months. There is also a 12-month PPC certificate costing £104.00 which saves patient's money if 13 or more items are needed in 12 months. Unlike for individual items there will not be an increase in PPC costs on 1 April 2015. There are no prescription charges anywhere in the UK for medicines administered at a hospital, by a doctor or at an NHS walk-in centre.
Role of private sector in public healthcare
From the birth of the NHS in 1948, private medicine has continued to exist, paid for partly by private insurance. 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. In recent years, despite some evidence that a large proportion of the public oppose such involvement, 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 and some NHS facilities let out to the private sector for privately funded treatments or for pre- and post-operative care. 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 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.
When the Blair government expanded the role of the private sector within the NHS in England, the Scottish government reduced the role of the private sector within public healthcare in Scotland and planned legislation to prevent the possibility of private companies running GP practices in future. Later, however in an attempt to comply with the Scottish Treatment Time Guarantee, a 12 week target for inpatient or day-case patients waiting for treatment, NHS Lothian spent £11.3 million on private hospital treatment for NHS patients in 2013-14.
Funding and performance of healthcare since devolution
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. 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. 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. 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.
In April 2014 the Nuffield Trust produced a further comparative report "The four health systems of the UK: How do they compare?" which concluded that despite the widely publicised policy differences there was little sign that any one country was moving ahead of the others consistently across the available indicators of performance. It also complained that there was an increasingly limited set of comparable data on the four health systems of the UK which made comparison difficult.
In 2015, the medical journal, Pulse reported that doctors in some English areas, notably South Birmingham are paid to limit hospital referrals. The payments include limiting referrals for cancer patients. The scheme is controversial and some members of the British Medical Association fear it could affect patient care adversely. GMC guidelines forbid doctors to receive, "inducement, gift or hospitality" which influences or can be seen as influencing the way patients are treated or referred. There is concern the payments could affect doctor patient trust.
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