National Health Service

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For the individual national healthcare services of England, Scotland, Wales and Northern Ireland, see National Health Service (England), NHS Scotland, NHS Wales, and Health and Social Care in Northern Ireland.
Logo of the NHS in England
Aneurin Bevan, who spearheaded the establishment of the National Health Services

Each of the four countries of the United Kingdom has a publicly funded health care system referred to as the National Health Service (NHS). The terms "National Health Service" or "NHS" are also used to refer to the four systems collectively. All of the services were founded in 1948, based on legislation passed in 1946, 1947 and 1948, by the Labour Government that had been elected in 1945 with a manifesto commitment[1] to implement the Beveridge Report recommendation to create "comprehensive health and rehabilitation services for prevention and cure of disease".[2] 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.

Each system 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. 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.[3] 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.[4]

The systems are 98.8% funded from general taxation and National Insurance contributions, plus small amounts from patient charges for some services.[5] Each provides a comprehensive range of health services, the vast majority of which are free for people ordinarily resident in the United Kingdom[6] and free at the time of use, for general practitioner (GP) and emergency treatment not including admission to hospital,[7] 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.[8][9] Some detailed regulations may vary to some extent in different countries of the UK; others are UK-wide. About 10% of GDP is spent on health and most is spent in the public sector.[10]

People not ordinarily resident in the UK are in general not entitled to free hospital treatment, with some exceptions such as refugees.[6][11]

Taken together, the four National Health Services in 2015-16 employed around 1.6 million people with a combined budget of £136.7 billion.[12] 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.[13]

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.

According to a 2015 survey, the majority of British people are satisfied with the NHS, often citing quality of care and that it is free at the point of delivery. However, in the survey many people complained about long waiting times and underfunding. Satisfaction with the Health Service fell in 2015.[14]

Investment, funding and efficiency[edit]

The Organisation for Economic Cooperation and Development (OECD) state in a 2015 study that the UK has one of the worst healthcare systems among the nations looked at and that people are dying needlessly through lack of investment in the NHS.[15] By contrast, a 2014 study by an international panel of experts for the US-based Commonwealth Fund declared the NHS as the best healthcare system amongst those of the eleven countries it looked at.[16] The NHS in England experienced record overspending of £2.45 billion in 2015 and the head of NHS providers, Chris Hopson claimed the NHS is asked to provide too much for too little money. According to Clare Marx, president of the Royal College of Surgeons, balancing the books requires "draconian policies" that frequently go against clinical guidelines including those from the National Institute for Health and Care Excellence (NICE).[17]

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.[18]

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 per cent of the time in the year to June, down from 75 per cent 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.[19]

The Public Accounts Committee claims 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."[20]

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.[21] There is concern that 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 specialities'. 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 sustaineed 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.[22] [23]

In England[edit]

Between 2008 and 2009, due to a sharp drop in Gross Domestic Product (GDP), health spending rose as a proportion of GDP from 8.5% to 9.1%. Since 2009, GDP has steadily increased again, resulting in health spending falling back as a proportion of GDP to 8.8% by 2013.[24][25] 'NHS Providers' maintains that the NHS in England needs extra funding to cope with an aging population. Performance has declined over the last few years [before 2016] by most measures and without extra funds, many argue that the service will deteriorate further. Funding increases will fall from 3.8% in 2016 to 1.4% in 2017 and to 0.3% in 2018 while NHS demand and costs rise by at least 4% annually. 80% of hospitals are in financial deficit, as opposed to 5% in 2013. Ambulance response targets were missed 14 months running. A Guardian article suggested there is a strong case for the 7 day service but without extra funding it is unachievable. Without extra funding the NHS in England will according to The Guardian be forced to make unpopular and unpalatable choices. Possibilities include draconian rationing, charging patients, reducing priorities, or limiting the workforce. Chris Ham of the King's Fund think tank said, "It is simply not realistic to expect hard-pressed staff to deliver new commitments like seven-day services while also meeting waiting time targets and reducing financial deficits." John Appleby, chief economist of the King's Fund claims NHS spending could certainly increase. He argues that it needs a political choice to raise taxes, cut spending elsewhere or to reduce the deficit more slowly, and that blaming the NHS in England for choices they have to make through lack of funds is considered unreasonable.[26][27][28][25]

Frail patients are staying in hospital longer than would otherwise be necessary because the care they need in the community is not available. This can prevent new patients being admitted and operations have been cancelled due to beds being taken up by patients who could leave hospital with proper care elsewhere. Long hospital stays reduce the chances elderly patients can be rehabilitated. Age UK blamed cuts to social care for creating a situation where elderly patients end up in A & E and also blamed lack of social care for requiring patients to stay unnecessarily long in hospital.[29] The situation has worsened due to cuts in government financial support for local authorities which caused social care for elderly people to fall 17% between 2009/10 and 2013/14.[30] In July 2016 the time patients spent in hospital waiting for care in the community reached 61,000 days which was up from 33,000 days In July 2014. This adds to the costs and pressure on the NHS.[31]

In the Vale of York clinical commissioning group in North Yorkshire, obese patients will be barred from most routine operations, notably hip and knee operations for a year (or if they lose 10% of their body weight), while smokers will face a six-month delay unless they quit. The move was described by the head of NHS Providers as an effort by the group to "to balance their books". There are fears similar measures will be introduced elsewhere and rationing will become the NHS norm. A critic felt leaving patients waiting in pain longer than clinically necessary should be unacceptable.[32] Denying obese patients life changing surgery without offering help losing weight was compared to racial or religious discrimination by Shaw Somers, a bariatric surgeon from Portsmouth.[17] Limits are being imposed throughout the NHS for cataracts, knee and hip operations, overweight people and smokers are denied some treatments in most NHS authorities. A spokesman for NHS England said: “Major surgery poses much higher risks for severely overweight patients who smoke. So local GP-led clinical commissioning groups are entirely right to ensure these patients first get support to lose weight and try and stop smoking before their hip or knee operation. Reducing obesity and cutting smoking not only benefits patients but saves the NHS and taxpayers millions of pounds. This does not and cannot mean blanket bans on particular patients such as smokers getting operations, which would be inconsistent with the NHS constitution."[32][17]

At a British Medical Association (BMA) conference (the doctors' union), a conference at which some of the contributions may have been politically motived according to the BBC, the NHS in England has been described by some senior medical professionals as overstretched, underfunded and understaffed. Nigel Edwards of Nuffield Trust stated, "the NHS has never experienced this level of austerity for this long a period". Edwards questioned whether planned £22 billion of efficiency savings were fully achievable. UK health spending is a lower proportion of UK economic output than the European average.[33] The BMA argue that overworked and underfunded general practitioners have insufficient time to assess and properly treat patients with complex needs.[34]

The Guardian health policy editor suggests that understaffing forces hospitals to rely on agency staff who are much more expensive and this expense is the main reason the NHS overspent. He believes that experts argue the NHS has insufficient funds to care for the ageing population and the increased numbers of patients with chronic health trouble like diabetes, depression, heart and respiratory issues which leads to steady increases in demand for NHS services.[35] In April 2016 he reported that NHS staffing levels had been overestimated and without increases in staff the pressure on the NHS will continue. In response to this report, Labour's shadow health secretary argued that "Hospital wards are already dangerously understaffed and morale in the NHS is at rock bottom. This is impacting on patient care and leaving some staff so overstretched they are unable to complete basic tasks, such as changing dressings or checking patients have finished their meals."[36]

Before the 2015 General election, the government promised £8.4 billion extra for the NHS in England by 2020-21. This promise was repeated by David Cameron and George Osborne many times while they were still in office. Despite this, a report by the House of Commons Health Select Committee showed that some of the extra £8.4 billion will be found from taking money from elsewhere in the health budget. For example, money for staff recruitment and training has been moved to a different fund. Staff training has been cut and the money saved will go towards the £8.4 billion. Since staff training is now in a different fund the cut may be overlooked. The report found the transfer of funds that were cut misleading as these other funds finance services that matter for patient care, for preventing sickness and for training the future workforce. According to the report, there will only be a £4.5bn increase in total health spending in England by 2020-21. The committee expressed concern that the transfer of resources from capital budgets, health education, public health and other areas will make ambitions stated in the Forward View, (the NHS blueprint for its modernisation by 2020) much harder to achieve and fails to meet the government's stated commitments. Anita Charlesworth of the Health Foundation agreed with the report and argued that cuts to health education and public health are shortsighted.[37]

Sustainability and transformation plans in England[edit]

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.[38] Dr Brian Fisher wrote, "STPs are driven by the Treasury. They are focused on reducing NHS spend. (...) Unless STPs meet the funding demands of the Treasury, the plans will not be approved and areas will not receive any transformation money."[39] An article by the King's Fund states, "Allocations from the fund for sustainability and transformation must be agreed in advance with HM Treasury and DH’." The same article states that the spending review, "is both ring-fenced and needs HM Treasury agreement to unlock."[40]

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."[41] 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 people 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.[42]

The review is about more than reducing costs. An article in The Guardian suggests possible substantial benefits from the review. The system as a whole lacks money and an aging English population has growing complex requirements. Health and social services need to be coordinated, STP's got people working enthusiastically together. The Guardian article suggests NHS England 'made up the policy on the hoof' and managers were under pressure to produce plans fast. NHS England gave fragmented guidance, coming in bursts with frequently insufficient time for responding to requests. There are fears secrecy within the NHS is hindering effective public discussion and without public discussion there is a risk of later delays, protests, judicial reviews. The Guardian article argues that full-time leaders are needed who will not put the interests of their own department before the needs of the whole and will send money where it is needed.[43] Another Guardian article questions whether the plan might be to prepare for greater privatisation after 2020. Transfering services from hospitals to the community will only work if there is spare capacity in the community and GP's are already overstretched. There are too few NHS staff generally to enable the reorganisation.[44] 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."[45]

Outsourcing and privatisation[edit]

Outsourcing and privatisation is steadily increasing, in areas affected include community service, general practise and mental health care. NHS money spent the private sector rose from £4.1 billion in 2009-10 to £8.7 billion in 2015-16.[46]

People not eligible for free treatment[edit]

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.[47]

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 the surcharge was £200 per year, with exemptions and reductions in some cases.[48]

Comparative performance[edit]

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.[49] 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."[50][51]

For details see:

See also[edit]


  1. ^ "Let Us Face the Future: A Declaration of Labour Policy for the Consideration of the Nation". Labour Party. 1945. Retrieved 3 March 2013. 
  2. ^ Beveridge, William (November 1942). "Social Insurance and Allied Services" (PDF). HM Stationery Office. Retrieved 3 March 2013. 
  3. ^ 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
  4. ^ "Breakdown of cross-border agreements is costing English trusts millions". Health Service Journal. 14 February 2008. Retrieved 19 January 2016. 
  5. ^ "How the NHS is funded". TheKing'sFund. 15 January 2016. Retrieved 6 June 2016. 
  6. ^ a b "NHS entitlements: migrant health guide - Detailed guidance". UK Government. Retrieved 6 June 2016.  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.
  7. ^ "Visiting or moving to England? - How to access NHS services (see "Hospital Services" section)". NHS Choices. 26 June 2015. Retrieved 6 June 2016. 
  8. ^ "NHS charges for people from abroad". Citizens Advice. Retrieved 2010-11-16. 
  9. ^ "Non-EEA country-by-country guide - Healthcare abroad". NHS Choices. 1 January 2016. Retrieved 6 June 2016. 
  10. ^ Health care spending compared to other countries
  11. ^ "Categories of exemption - Healthcare in England for visitors - NHS Choices". NHS England. 18 August 2015. Retrieved 6 June 2016. 
  12. ^ "10 truths about Britain's health service". Guardian. 18 January 2016. Retrieved 19 January 2016. 
  13. ^ Cowper, Andy (23 May 2016). "Visible and valued: the way forward for the NHS's hidden army". Health Service Journal. Retrieved 28 July 2016. 
  14. ^ Public satisfaction with the NHS
  15. ^ Four charts showing the NHS is underfunded and understaffed The Independent
  16. ^ Campbell, Denis; Watt, Nicholas (17 June 2014). "NHS comes top in healthcare survey". theguardian. Guardian News and Media. Retrieved 29 August 2016. 
  17. ^ a b c Decision to deny surgery to obese patients is like 'racial discrimination' The Guardian
  18. ^ Wards dangerously understaffed, say nurses in survey BBC
  19. ^ After Brexit, turning around the NHS is Theresa May’s most urgent task The Independent
  20. ^ NHS budget pressures will leave mental health services underfunded, spending watchdog warns The Independent
  21. ^ Underfunded, underdoctored, overstretched: The NHS in 2016
  22. ^ NHS is underfunded, underdoctored and in crisis, doctors warn
  23. ^ Starved NHS ‘at point of no return’ and ‘no longer envy of the world’
  24. ^ "Expenditure on Healthcare in the UK: 2013". UK Office for National Statistics. 26 March 2015. Retrieved 18 September 2016. 
  25. ^ a b Is enough being spent on the NHS? BBC
  26. ^ NHS in England at 'tipping point' - hospital bosses BBC
  27. ^ Cash-strapped hospitals face 'unpalatable' choices over care levels, warns NHS chief ITV
  28. ^ The gap between funds and delivery is a chasm in the NHS: something has to give The Guardian
  29. ^ ‘Bedblockers’: the fit-to-leave patients deepening hospital crisis The Guardian
  30. ^ Spending on social care for older people
  31. ^ Sharp rise in care delays 'piles pressure on hospitals' BBC
  32. ^ a b Obese patients and smokers banned from routine surgery in 'most severe ever' rationing in the NHS The Daily Telegraph
  33. ^ Is the NHS underdoctored, underfunded and overstretched? BBC
  34. ^ 'Patients at risk' from length of GP consultations BBC
  35. ^ Why has the NHS deficit ballooned? One word: understaffing The Guardian
  36. ^ Campbell, Denis (3 April 2016). "NHS has 70,000 fewer staff, new figures reveal". theguardian. Guardian News and Media. Retrieved 31 August 2016. 
  37. ^ Jeremy Hunt has broken NHS funding pledges, report finds The Guardian
  38. ^ NHS plans closures and radical cuts to combat growing deficit in health budget The Guardian
  39. ^ NHS reform: Why sustainability and transformation plans could be dangerous
  40. ^ How will services access the new Sustainability and Transformation Fund?
  41. ^ NHS cuts 'planned across England' BBC
  42. ^ Plan to 'transform' NHS could lead to downgrade of major London hospitals The Guardian
  43. ^ NHS plans could bring benefits but we're barred from telling the public The Guardian
  44. ^ The NHS secret is out. And local communities won't like it The Guardian
  45. ^ NHS plans 'not just about closures', bosses insist The Guardian
  46. ^ How much is the government really privatising the NHS? The Guardian
  47. ^ "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.
  48. ^ "Moving from outside the EEA - Access to healthcare in England - NHS Choices". 18 August 2015. Retrieved 6 June 2016. 
  49. ^ Bevan, Gwyn; Mays, Nicholas (11 April 2014). "The four health systems of the UK: How do they compare?". Nuffield Trust. Retrieved 2 February 2016. 
  50. ^ "Outcomes in EHCI 2015" (PDF). Health Consumer Powerhouse. 26 January 2016. Retrieved 27 January 2016. 
  51. ^ Timmins, Nick. "The four UK health systems: Learning from each other,". Kings Fund. Retrieved 2 February 2016. 

Further reading[edit]

  • 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
  • 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

External links[edit]