National Health Service
The National Health Service (NHS) is the name of the public health services of England, Scotland and Wales, and is commonly used to refer to those of Northern Ireland. They were established together as one of the major social reforms following the Second World War on the founding principles of being comprehensive, universal and free at the point of delivery. Today, each provides a comprehensive range of health services, the vast majority of which are free for people ordinarily resident in the United Kingdom.
Taken together, the four National Health Services in 2015-16 employed around 1.6 million people with a combined budget of £136.7 billion. UK residents are not charged for most medical treatment, with exceptions such as a fixed charge for prescriptions; dental treatment is administered differently, with standard charges for most procedures. The NHS is free at the time of use, for general practitioner (GP) and emergency treatment not including admission to hospital, to non-residents.
The NHS began on the 'Appointed Day' of 5 July 1948. This put into practice Westminster legislation for England and Wales from 1946 and Scotland from 1947, and the Northern Ireland Parliament's 1947 Public Health Services Act. Calls for a "unified medical service" can be dated back to the Minority Report of the Royal Commission on the Poor Law in 1909, but it was following the 1942 Beveridge Report's recommendation to create "comprehensive health and rehabilitation services for prevention and cure of disease" that cross-party consensus emerged on introducing a National Health Service of some description. When Clement Attlee's Labour Party won the 1945 election he appointed Aneurin Bevan as Health Minister. Bevan then embarked upon what the official historian of the NHS, Charles Webster, called an "audacious campaign" to take charge of the form the NHS finally took.
Three years after the founding of the NHS, Bevan resigned from the Labour government in opposition to the introduction of charges for the provision of dentures and spectacles. The following year, Winston Churchill's Conservative government introduced prescription charges. These charges were the first of many controversies over reforms to the NHS throughout its history.
Each of the UK's four nations have their own separate NHS, each with its own history. NHS Scotland and Health and Social Care in Northern Ireland (HSC) were separate from the foundation of the NHS, whereas the NHS in Wales was originally combined with England until devolved to the Secretary of State for Wales in 1969 and then to the Welsh Executive and Assembly under devolution in 1999, the same year as responsibility for the Scottish NHS was transferred from the Secretary of State for Scotland to the new Scottish Government and Parliament.
From its earliest days, the cultural history of the NHS has shown its place in British society reflected and debated in film, TV, cartoons and literature.
Each of the UK's health service systems operates independently, and is politically accountable to the relevant government: the Scottish Government, Welsh Government, the Northern Ireland Executive, and the UK Government which is responsible for England's NHS. NHS Wales was originally part of the same structure as England until powers over the NHS in Wales were firstly transferred to the Secretary of State for Wales in 1969 and thereafter, in 1999, to the Welsh Assembly (now the Welsh Government) as part of Welsh devolution. However, some functions might be routinely performed by one health service on behalf of another. For example, Northern Ireland has no high-security psychiatric hospitals and thus depends on using hospitals in Great Britain, routinely Carstairs State Mental Hospital in Scotland for male patients and Rampton Secure Hospital in England for female patients. Similarly, patients in North Wales use specialist facilities in Manchester and Liverpool which are much closer than facilities in Cardiff, and more routine services at the Countess of Chester Hospital NHS Foundation Trust. There have been issues about cross-border payments.
Taken together, the four National Health Services in 2015-16 employed around 1.6 million people with a combined budget of £136.7 billion. In 2014 the total health sector workforce across the UK was 2,165,043. This broke down into 1,789,586 in England, 198,368 in Scotland, 110,292 in Wales and 66,797 in Northern Ireland.
Eligibility for treatment
UK residents are not charged for most medical treatment, with exceptions such as a fixed charge for prescriptions; dental treatment is administered differently, with standard charges for most procedures. The NHS is free at the time of use, for general practitioner (GP) and emergency treatment not including admission to hospital, to non-residents. People with the right to medical care in European Economic Area (EEA) nations are also entitled to free treatment by using the European Health Insurance Card. Those from other countries with which the UK has reciprocal arrangements also qualify for free treatment. Since 6 April 2015, non-EEA nationals who are subject to immigration control must have the immigration status of indefinite leave to remain at the time of treatment and be properly settled, to be considered ordinarily resident. People not ordinarily resident in the UK are in general not entitled to free hospital treatment, with some exceptions such as refugees.
People not ordinarily resident may be subject to an interview to establish their eligibility, which must be resolved before non-emergency treatment can commence. Patients who do not qualify for free treatment are asked to pay in advance, or to sign a written undertaking to pay, except for emergency treatment.
The provision of free treatment to non-UK-residents, formerly interpreted liberally, has been increasingly restricted, with new overseas visitor hospital charging regulations introduced in 2015.
People from outside the EEA coming to the UK for a temporary stay of more than six months may be required to pay an immigration health surcharge at the time of visa application, and will then be entitled to NHS treatment on the same basis as a resident. As of 2016[update] the surcharge was £200 per year, with exemptions and reductions in some cases.
The systems are 98.8% funded from general taxation and National Insurance contributions, plus small amounts from patient charges for some services. About 10% of GDP is spent on health and most is spent in the public sector.
The money to pay for the NHS comes directly from taxation. The 2008/9 budget roughly equates to a contribution of £1,980 for every man, woman and child in the UK.
When the NHS was launched in 1948 it had a budget of £437million (roughly £9billion at today’s value). In 2008/9 it received over 10 times that amount (more than £100billion).
This equates to an average rise in spending over the full 60-year period of about 4% a year once inflation has been taken into account. However, in recent years investment levels have been double that to fund a major modernisation programme.
Some 60% of the NHS budget is used to pay staff. A further 20% pays for drugs and other supplies, with the remaining 20% split between buildings, equipment, training costs, medical equipment, catering and cleaning. Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas.
70% of people say they would willingly pay an extra penny in the pound in income tax if the money were ringfenced and guaranteed for the NHS.
Investment and efficiency
The Organisation for Economic Cooperation and Development (OECD) state in a 2015 study that the UK had one of the worst healthcare systems among the nations looked at and that people were dying needlessly due to lack of investment in the NHS. A wide range of medical professionals consider hospital conditions in winter 2017 the worst ever. Hospitals are overcrowded with patients on trolleys in corridors due to lack of beds in wards. The Royal College of Nursing reported nurses claiming current conditions are the worst they have experienced. The Royal College of Physicians (RCP) asked for urgent investment to deal with "over-full hospitals with too few qualified staff". Prof Jane Dacre of the RCP, said: "Our members tell me it is the worst it has ever been in terms of patients coming in during a 24-hour period and numbers of patients coming in when there are no beds to put them in. And there are patients within the hospital who can no longer get home because of the difficulties there are in placing people in social care. Our members fear that patients' lives are at risk because they can't get round to see patients who aren't in the emergency and accident department or are waiting for results to come back." The Royal College of Radiologists also calls for increased investment. Trusts are told to make a surplus when that is not feasible, then lose funds for being in deficit.
Pathology laboratories that diagnose cancer are struggling to cope with rising demand. Many of the staff are nearing retiring age and young graduates are not joining the profession to replace them. Cancer Research UK claims similar problems exist with other diagnostic services like scans and endoscopies. Because the UK population is growing and aging more people need cancer diagnosis. Still services are not growing to meet rising demand. The 'Cancer Research UK' report also advises the Royal College of Pathologists to update guidance and study how to attract staff to train for pathology. UK cancer survival rates are below those of other European nations and earlier diagnosis would help deal with this. If nothing is done the problem will worsen. In winter 2017 cancer operations are being cancelled,sometimes at short notice due to insufficient beds. This is stressful for patients and leads to fears that a cancer will get worse.
An editorial in The Independent stated "The National Health Service is in trouble. Statistics on ambulance response times, accident and emergency waiting times and delayed discharges, published [in 2016], are all markedly worse than over the previous year. Ambulances reached critically ill patients within the target of eight minutes less than 70% of the time in the year to June, down from 75% the previous year. The proportion of patients at accident and emergency seen within four hours fell from 92 per cent to 86 per cent. The number of days lost to delayed discharges rose by a quarter from 91,000 to 115,000." The editorial argued further that if the efficiency of the NHS does not improve, this could affect the popularity of the current government. Further almost half of hospital authorities are reducing the number of beds while a third of A&E's are due to close because of increasing hospital deficits. Total NHS deficits reached £2.4bn in 2015, the largest recorded deficit in NHS history.
Mental health services
The Public Accounts Committee claims that plans to improve mental health services have a doubtful future due to uncertainties over funding. Only a quarter of patients needing mental health services get them. Mental health services were found hard to navigate and with quality varying. Meg Hillier said, "Many people can make a full recovery from mental health problems if they receive appropriate treatment at an early stage. This is good for them and has wider benefits for the economy and society in general. It is therefore crucial that mental health is given equal priority to physical health and that service provision reflects this. (...) If [the government] is serious about achieving its aims it must also plan to secure skilled staff in sufficient numbers." Nine former health secretaries claim the government broke promises on mental health. A Guardian article cited widespread distrust that government promises to increase mental health funding were being met. Mental health services for young people are inadequate according to a poll of nurses working in that area. Shortage of resources and staff are seen as a problem and nurses have insufficient time to talk to young patients or to show patients they matter. Sarah Brennan of YoungMinds said new money promised by the government will only reach a third of those who need it. Nurses fear the need to ration care puts young people at risk of self harm or even suicide. Numbers of young people admitted to hospital for self-harm are increasing. The NSPCC claims children needing help following abuse are not getting it and children need to reach rock bottom regularly self harming or feeling suicidal before getting desperately needed help. A leaked government report showed sick children were taken, “almost anywhere in the country” to be treated. Suicide is increasing. Polling suggests the British public overwhelmingly support increased funding for mental health care.
According to the General Medical Council, many doctors experience low morale which can put patients at risk. The GMC criticised the amount of funding that the NHS receives, saying that years of constraint coupled with social care pressures were leaving services struggling to cope with rising demand. According to MP Dr Dan Poulter, pressure to deal with patients prevents doctors getting necessary training and there are too few middle grade doctors in paediatrics, obstetrics and gynaecology. 38% of GP's plan to leave within five years. According to the Royal College of Physicians (RCP), the Health Service budget has not kept pace with rising demand for services and either funding must increase or care must be cut. GP's are overstretched and some patients must wait three weeks for problems which do not appear urgent like lumps or bleeding. There is concern over this because such problems can be life-threatening. There is also concern that chronic disease management may get insufficient attention because overstretched GP's are too busy dealing with acute illnesses. Maintaining GP services is important because if GP's fail patients will overwhelm the hospitals instead.
There is apprehension that the numbers of medical students fell since 2010 despite patient numbers increasing. The RCP wants NHS efficiency targets overhauled, wants government goals to be realistic and wants investment in 'long-term sustainability' of the NHS. The RCP warns further that government's promise of 5,000 more GP's should not come 'at the expense of other specialties'. Prompt action is needed to counter funding and staff shortages and staff feel like 'collateral damage' when struggling over rising demand and budget shortages. Efficiency improvements can help but it is unclear for how long. Dr Andrew Goddard of the RCP said that providing more expensive treatments for increasing numbers of patients would fail. “As doctors, we see the problems this creates on a daily basis, be it at the front door of the hospital, in A&E or in out-patients. Patients can see it too and realise that the NHS is no longer the envy of the world and isn’t fit for our changing world. There are some big decisions that society has to make and the political parties have to stop blaming each other for where we are and work together to build a health and social care system that is fit for the UK in the 21st century.” The RCP maintains the NHS is living beyond its means which cannot be sustained long term. More 'training places' are needed from medical school onwards to counter staff shortages. 2 in 5 NHS doctors are from overseas, the RCP fears uncertainties over Brexit and immigration regulations render their position unpredictable.
The RCP reports 70% of doctors in training have a permanent gap in their work rota and 96% reported gaps in nursing rotas. Hospitals record 40% of consultant posts remain vacant. Close to 50% of consultants state they were asked to do more junior work and over 10% of junior doctors said patients were not guaranteed treatment with appropriately experienced doctors. The RCP maintains this makes the government's goal of a 7-day week unachievable.
Nurses' pay has not kept pace with inflation and their real pay has fallen while people wanting to become nurses lack training bursaries. Unfilled nursing vacancies rose sixfold since 2010. In 2013 over half of the 600 nurses responding to an online poll by the Nursing Times believed their ward or unit is sometimes or always dangerously understaffed. Three-quarters had witnessed poor patient care and thirty percent said poor patient care happened regularly. A spokesperson for the Royal College of Nursing commented that in the worst cases this can cause unnecessary deaths and called for clear national guidelines for safe staffing levels and said one registered nurse to eight patients was considered risky while there should be one nurse to five patients. A spokesperson for Patient Concern, a patient campaigning group, commented that the work expected of nurses was rising continually while staffing levels did not rise. The Royal College of Nursing (RCN) said nurses from Scotland to London were seriously concerned about the quality of care they could provide. 43% of A&E staff have suffered physical assaults and lack of staff increases the risk that patients will be violent.
Sustainability and transformation plans
Consultation will start over cost saving, streamlining and reduction of some services 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. See Sustainability and transformation plans in England for more.
Although there have been increasing policy divergence between the four systems there is very little evidence linking these policy differences to a matching divergence of performance. It has been suggested that this is because of the uniform professional culture. There are national terms and conditions of employment across the UK, regulation of clinicians is performed on a UK basis and the health trades unions operate across the UK. However, it does not help that, as Nick Timmins noted "Some of the key data needed to compare performance – including data on waiting times – is defined and collected differently in the four countries."
For details see:
- History of the National Health Service (England)
- History of NHS Scotland
- History of NHS Wales
- Healthcare in the United Kingdom
- Scottish Government Health and Social Care Directorates
- British Medical Association
- Royal College of General Practitioners
- Gibraltar Health Authority
- Health Service Executive (Republic of Ireland)
- Choices, NHS. "The principles and values of the NHS in England - NHS Choices". www.nhs.uk. Retrieved 2016-11-23.
- "NHS entitlements: migrant health guide - Detailed guidance". UK Government. Retrieved 6 June 2016.
- Ruth Barrington, Health, Medicine & Politics in Ireland 1900-1970 (Institute of Public Administration: Dublin, 1987) pp. 188-189
- Brian Abel-Smith, The Hospitals 1800-1948 (London, 1964), p.229
- Beveridge, William (November 1942). "Social Insurance and Allied Services" (PDF). HM Stationery Office. Retrieved 3 March 2013.
- Charles Webster, The Health Services since the War, Volume 1: Problems of Health Care, The National Health Service Before 1957 (London: HMSO, 1988), p.399
- Kenneth O. Morgan, 'Aneurin Bevan' in Kevin Jeffreys (ed.), Labour Forces: From Ernie Bevin to Gordon Brown (I.B. Taurus: London & New York, 2002), pp. 91-92.
- Martin Powell and Robin Miller, 'Seventy Years of Privatizing the British National Health Service?', Social Policy & Administration, vol. 50, no. 1 (January 2016), pp. 99-118.
- Wales, NHS. "NHS Wales | 1960's". www.wales.nhs.uk. Retrieved 2016-11-22.
- The Transfer of Mentally Disordered Patients – Guidance on the transfer of mentally disordered patients detained under the Mental Health (NI) Order 1986 to and from Hospitals in Great Britain – August 2011
- "Breakdown of cross-border agreements is costing English trusts millions". Health Service Journal. 14 February 2008. Retrieved 19 January 2016.
- "10 truths about Britain's health service". Guardian. 18 January 2016. Retrieved 19 January 2016.
- Cowper, Andy (23 May 2016). "Visible and valued: the way forward for the NHS's hidden army". Health Service Journal. Retrieved 28 July 2016.
- "Visiting or moving to England? - How to access NHS services (see "Hospital Services" section)". NHS Choices. 26 June 2015. Retrieved 6 June 2016.
- "NHS charges for people from abroad". Citizens Advice. Retrieved 2010-11-16.
- "Non-EEA country-by-country guide - Healthcare abroad". NHS Choices. 1 January 2016. Retrieved 6 June 2016.
- "Categories of exemption - Healthcare in England for visitors - NHS Choices". NHS England. 18 August 2015. Retrieved 6 June 2016.
- "Guidance on overseas visitors hospital charging regulations - Publications - GOV.UK". UK Government. 6 April 2016. Retrieved 6 June 2016. Links to many relevant documents: Guidance on implementing the overseas visitor hospital charging regulations 2015; Ways in which people can be lawfully resident in the UK; Summary of changes made to the way the NHS charges overseas visitors for NHS hospital care; Biometric residence permits: overseas applicant and sponsor information; Information sharing with the Home Office: guidance for overseas patients; Overseas chargeable patients, NHS debt and immigration rules: guidance on administration and data sharing; Ordinary residence tool; and documents on Equality analysis.
- "Moving from outside the EEA - Access to healthcare in England - NHS Choices". Nhs.uk. 18 August 2015. Retrieved 6 June 2016.
- "How the NHS is funded". TheKing'sFund. 15 January 2016. Retrieved 6 June 2016.
- "Health care spending compared to other countries".
- NHS Choices The NHS in England: The NHS: About the NHS: Overview. Retrieved 22 June 2010.
- "The NHS in England". NHS choices. 28 January 2013. Retrieved 27 July 2014.
- People may be ready to pay extra penny on tax for NHS, Tim Farron says The Guardian
- Four charts showing the NHS is underfunded and understaffed The Independent
- NHS conditions worst ever, say leading nurses BBC
- NHS crisis: the one act of self-sacrifice that could rescue our health service The Guardian
- UK’s pathology services at tipping point
- NHS cancer testing service 'at breaking point' BBC
- NHS in crisis as cancer operations cancelled due to lack of beds The Guardian
- "After Brexit, turning around the NHS is Theresa May's most urgent task". The Independent. 11 August 2016. Retrieved 8 October 2016.
- NHS completely absent from 72-page Autumn Statement document The Independent
- Stone, Jon (20 September 2016). "NHS budget pressures will leave mental health services underfunded, spending watchdog warns". The Independent. Retrieved 8 October 2016.
- 2016 was the worst year in NHS history – we must fight for its survival The Guardian
- NHS mental health funding is still lagging behind, says report The Guardian
- Young people's mental health care is 'inadequate' according to specialist nurses BBC
- Self-harm hospital admissions of children show 'frightening rise' BBC
- ‘This isn’t acceptable’: outcry at state of NHS mental health care funding The Guardian
- Doctors' low morale 'puts patients at risk' BBC
- Proposals for seven-day NHS are immoral, says leading GP The Guardian
- "Underfunded, underdoctored, overstretched: The NHS in 2016". 21 September 2016.
- Senior GP Helen Stokes-Lampard voices fears for services BBC
- "NHS is underfunded, underdoctored and in crisis, doctors warn - GPonline".
- "Starved NHS 'at point of no return' and 'no longer envy of the world'".
- Wards dangerously understaffed, say nurses in survey BBC
- The hidden crisis in the National Health Service New Statesman
- NHS plans closures and radical cuts to combat growing deficit in health budget The Guardian
- Bevan, Gwyn; Mays, Nicholas (11 April 2014). "The four health systems of the UK: How do they compare?". Nuffield Trust. Retrieved 2 February 2016.
- "Outcomes in EHCI 2015" (PDF). Health Consumer Powerhouse. 26 January 2016. Retrieved 27 January 2016.
- Timmins, Nick. "The four UK health systems: Learning from each other,". Kings Fund. Retrieved 2 February 2016.
- Brady, Robert A. Crisis in Britain. Plans and Achievements of the Labour Government (1950) pp 352–41 excerpt
- Gorsky, Martin. "The British National Health Service 1948–2008: A Review of the Historiography," Social History of Medicine, Dec 2008, Vol. 21 Issue 3, pp 437–460
- Hacker, Jacob S. "The Historical Logic of National Health Insurance: Structure and Sequence in the Development of British, Canadian, and U.S. Medical Policy," Studies in American Political Development, April 1998, Vol. 12 Issue 1, pp 57–130.
- Loudon, Irvine, John Horder and Charles Webster. General Practice under the National Health Service 1948-1997 (1998) online
- Rintala, Marvin. Creating the National Health Service: Aneurin Bevan and the Medical Lords (2003) online.
- Rivett G C From Cradle to Grave – the first 50 (65) years of the NHS. King's Fund, London, 1998 now updated to 2014 and available at www.nhshistory.co.uk
- Stewart, John. "The Political Economy of the British National Health Service, 1945–1975: Opportunities and Constraints," Medical History, Oct 2008, Vol. 52 Issue 4, pp 453–470
- Valier, Helen K. "The Manchester Royal Infirmary, 1945–97: a microcosm of the National Health Service," Bulletin of the John Rylands University Library of Manchester, 2005, Vol. 87 Issue 1, pp 167–192
- Webster, Charles. "Conflict and Consensus: Explaining the British Health Service," Twentieth Century British History, April 1990, Vol. 1 Issue 2, pp 115–151
- Webster, Charles. Health Services since the War. 'Vol. 1:' Problems of Health Care. The National Health Service before 1957 (1988) 479pp online
- NHS Choices official website for England's NHS
- Health and Social Care in Northern Ireland official website for Health & Personal Social Services in Northern Ireland
- NHS Scotland official website for NHS Scotland
- Health in Wales official website for NHS Wales
- Birth of the national Health Service BBC archive collection of programmes and documents