National Health Service

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NHS logo in England
NHS Wales logo
Logo of Health and Social Care in Northern Ireland, the equivalent in Northern Ireland

The National Health Service (NHS) is the collective name of the four public health services in the United Kingdom: the National Health Service in England, NHS Scotland, NHS Wales, and Health and Social Care in Northern Ireland. They were established together by the Labour Party as one of the major social reforms following the Second World War. The founding principles were being comprehensive, universal and free at the point of delivery.[1] Today, each provides a comprehensive range of health services, the vast majority of which are free for people ordinarily resident in the United Kingdom.[2] Charges are made for prescriptions (in England), dental treatment and optical care, but there is a range of exemptions from these charges.

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 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 at Carstairs 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. There have been issues about cross-border payments.[4]

Taken together, the four National Health Services in 2015-16 employed around 1.6 million people with a combined budget of £136.7 billion.[5] 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.[6]


Aneurin Bevan, who spearheaded the establishment of the National Health Services

The National Health Services began their work 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.[7] Calls for a "unified medical service" can be dated back to the Minority Report of the Royal Commission on the Poor Law in 1909,[8] 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.[9] 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.[10] The NHS was born out of a long-held British ideal that good healthcare should be available to all, regardless of wealth. At its launch by Bevan on 5 July 1948 it had at its heart three core principles: That it meet the needs of everyone, that it be free at the point of delivery, and that it be based on clinical need, not ability to pay.[11]

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 glasses.[12] 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.[13]

Each of the UK's four nations has 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,[14] 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. The NHS had a prominent slot during the 2012 London Summer Olympics opening ceremony directed by Danny Boyle, being described as "the institution which more than any other unites our nation".[15]

Eligibility for treatment[edit]

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 point of use, for general practitioner (GP) and emergency treatment not including admission to hospital, to non-residents.[16] 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.[17][18] 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.[2][19]

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.[20]

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.[21]


NHS Spending 1948/49-2014/15[22]

The systems are 98.8% funded from general taxation and National Insurance contributions, plus small amounts from patient charges for some services.[23][24] About 10% of GDP is spent on health and most is spent in the public sector.[25] The money to pay for the NHS comes directly from taxation. The 2008/9 budget roughly equates to a contribution of £1,980 per person in the UK.[26]

When the NHS was launched in 1948 it had a budget of £437 million (roughly £9 billion at today’s prices).[27] In 2008/9 it received over 10 times that amount (more than £100 billion). In 1955/6 health spending was 11.2% of the public services budget. In 2015/6 it was 29.7%.[28] 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. Under the Blair government investment levels increased to around 6% a year on average. Since 2010 spending growth has been constrained to just over 1% a year.[28]

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.[29] Since 2010, there has been a cap of 1% on pay rises for staff continuing in the same role. Unions representing doctors, dentists, nurses and other health professionals have called on the government to end the cap on health service pay, claiming the cap is damaging the health service and damaging patient care.[30] The pay rise is likely to be below the level of inflation and to mean a real-terms pay cut.[31] The House of Commons Library did research showing that real-terms NHS funding per head will fall in 2018-19, and stay the same for two years afterwards.[32]

Paying for higher spending[edit]

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.[33] Two thirds of respondents to a King's Fund poll favour increased taxation to help finance the NHS.[34] The BMA has called for £10bn more annually for the NHS to get Britain in line with what other advanced European nations spend on health. The BMA argues this could pay for at least 35,000 more hospital beds daily and many thousand more GPs. Dr Mark Porter of the BMA, wrote, “Our members report that services are truly at breaking point, with unprecedented rising patient demand met only with financial restraint and directives for the NHS and social care to make huge, unachievable savings through sustainability and transformation plans (STPs) across England.” Porter emphasised he was not asking for more than comparable nations, merely for the spending of other leading European nations to be matched. The increase, Porter said was desperately needed.[35]

Mental health services[edit]

The NHS provides mental health services free of charge, but normally requires a referral from a GP first. Services which don't need a referral include psychological therapies and treatment for those with drug and alcohol problems. The NHS also provides online services which can help patients find the resources which are most relevant to them.[36] Many psychiatric inpatients are being treated very far away from where they live when beds are not available locally, some even stay in police cells for up to six days.[37] The extent of the problem varies between trusts. Louise Rubin of Mind said: “It’s unacceptable that people who are at their most unwell and in desperate need of care find themselves travelling across the country to get help ... When you’re experiencing a mental health crisis, you’re likely to feel scared, vulnerable and alone, so your support network of family and friends are instrumental to recovery.”[38] The numbers of mental health staff needing sick leave due to work pressure is increasing. Dave Munday of Unite said, "Our members tell us workplace stress is increasing and that cuts to staff and services mean they're working longer hours with fewer resources. Staff themselves are feeling the impact of austerity."[39] The use of restraints in UK psychiatric facilities is increasing. Sridevi Kalidindi of the Royal College of Psychiatrists maintains that cuts to bed numbers and cuts to community care mean patients admitted to psychiatric units are now more ill. Also Kalidindi maintains increased use of agency staff means fewer permanent staff with training in de-escalating situations are available.[40]


In the year ending at March 2017, there were 1.187 million staff in the NHS, 1.9% more than in March 2016.[41]

In the same year, there were 691,000 nurses registered in the UK, down 1,783 from the previous year. However, this is the first time nursing numbers have fallen since 2008 and there are 13,000 more nurses in the NHS than in 2010. Poor working conditions, staffing levels and workload also dissatisfaction with the quality of patient care were given as reasons as were poor pay and benefits. Saffron Cordery of NHS Providers said, "These figures provide further evidence of the severe workforce problems NHS trusts face. Burseries to nursing students are to be stopped forcing nurses to pay for their training, it is expected this will also be a discouragement.[42] Commentators are increasingly arguing that staffing shortages are endangering the sustinability of the NHS. There are too few health workers, nurses and midwives, doctors are also in short supply. Hospitals, Community Trusts and Mental Health Trusts all face shortages.[43] Some General practitioners are losing sleep because they worry work pressure may have lead them to miss something that puts a patient at risk.[44] In hospitals junior doctors are sometimes forced to do work beyond what they have been trained for. This is stressful for doctors and puts patients at risk. Overworked consultants do not have the time to carry out proper supervision of less qualified doctors.[45]

Effect of Brexit[edit]

The plan to exit the European Union will affect physicians from EU countries, about 11% of the physician workforce.[46] Many of these physicians feel unwelcome and are considering leaving the UK if Brexit happens, as they have doubts that they and their families can live in the country.[46] A survey suggests 60% are considering leaving.[47] Record numbers of EU nationals (17,197 EU staff working in the NHS which include nurses and doctors) left last year. The figures, put together by NHS Digital, lead to calls to reassure European workers over their future in the UK.[48] EU nurses registering to work in the UK are down 96% since the Brexit vote aggravating shortages of nurses. Janet Davies of the Royal College of Nursing, said, “We rely on the contributions of EU staff and this drop in numbers could have severe consequences for patients and their families. Our nursing workforce is in a state of crisis. Across our health service, from A&E to elderly care, this puts patients at serious risk.”[49]

Rising social care costs[edit]

Social care will cost more in future according to research by Liverpool University, University College London, and others and higher investment are needed. Professor Helen Stokes-Lampard of the Royal College of GPs said, “It’s a great testament to medical research, and the NHS, that we are living longer – but we need to ensure that our patients are living longer with a good quality of life. For this to happen we need a properly funded, properly staffed health and social care sector with general practice, hospitals and social care all working together – and all communicating well with each other, in the best interests of delivering safe care to all our patients.”[50]

Outsourcing and privatisation[edit]

Although the NHS routinely outsources the equipment and products that it uses and dentistry, eye care, pharmacy and most GP practices have always been provided by the private sector, the outsourcing of hospital health care has always been controversial.[51]

According to a BMA survey over two-thirds of doctors are fairly uncomfortable or very uncomfortable about the independent sector providing NHS services. The BMA believes it is important the independent sector is held to the same standards as the NHS when giving NHS care. The BMA recommends: data collection, through impact analysis before independent providers are accepted to ensure existing NHS services are not disrupted, risk assessment to find out likely results if NHS staff are unwilling to transfer to the private sector, transparent reporting by the private sector of patient safety and performance, independent providers should be regulated like NHS providers, patients should be protected if independent providers terminate a contract early, transfers from independent providers to the NHS should be regularly reviewed to establish how much this costs the NHS, private sector contracts should be amended so private sector providers contribute to the cost of staff training financially or by providing training opportunities.[52] There were renewed calls for transparent reporting in the private sector following Ian Patterson's criminal conviction for wounding private sector patients by carrying out unnecessary operations.[53]

Vulnerability of information systems[edit]

Proprietary operating system[edit]

In 2001 the NHS entered into a licensing deal with Microsoft, ignoring the advice of some of its own IT specialists that had recommended investing in Linux instead.[54] Concerns about the vulnerability of NHS computer systems to cyber-attack have been expressed since at least 2016.[55] NHS computer systems have been subject to cyber attacks of which one in May 2017 was notable.[56] The May 2017 attack lead to the cancellation of at least 6912 appointments including operations, 139 suspected cancer patients had urgent referrals cancelled. The number of GP appointments cancelled, the number of ambulances diverted from A&E departments unable to treat some patients, the number of delays in receiving information like test results are unknown. North Korea is strongly suspected of starting the attack. The attack happened on a Friday in May. A cyberattack on a Monday in winter would be even more damaging.[57] NHS computers have been vulnerable because a minority still use or used Windows XP, an outdated system that originated in 2001, and one which Microsoft stopped supporting with security patches. Complacency among NHS staff and among government departments that pay for computer security are blamed. Unless systems are upgraded, more cyber attacks are feared.[58] Dr David Wrigley of the British Medical Association said, “It’s been known about for years, that the software isn’t up to date across the NHS, so it’s not unpredictable that this situation should have arisen. But it’s disappointing that funding hasn’t been given to upgrade the system. It needs urgent action by politicians.”[59]

Internal mail lost by part-privatised subsidiary[edit]

In 2017, it was reported that NHS Shared Business Services, a part state-owned, part-privately owned company tasked with internal mail delivery for NHS England, had lost 864,000 documents relating to patient healthcare.[60]

Comparative performance[edit]

Although there has been increasing policy divergence between the four National Health Services in the UK, it can be difficult to find evidence of the effect of this on performance since, as Nick Timmins notes: "Some of the key data needed to compare performance – including data on waiting times – is defined and collected differently in the four countries."[61][62] However, statistics released in December 2017 showed that, compared to 2012/3, 9% fewer patients in Scotland were waiting longer than four hours in A&E whereas in England the number had increased by 155%.[63]

See also[edit]


  1. ^ Choices, NHS. "The principles and values of the NHS in England". Retrieved 2016-11-23. 
  2. ^ a b "NHS entitlements: migrant health guide - Detailed guidance". UK Government. Retrieved 6 June 2016. 
  3. ^ "Guidance on the Transfer of Mentally Disordered Patients August 2011". 
  4. ^ "Breakdown of cross-border agreements is costing English trusts millions". Health Service Journal. 14 February 2008. Retrieved 19 January 2016. 
  5. ^ "10 truths about Britain's health service". Guardian. 18 January 2016. Retrieved 19 January 2016. 
  6. ^ Cowper, Andy (23 May 2016). "Visible and valued: the way forward for the NHS's hidden army". Health Service Journal. Retrieved 28 July 2016. 
  7. ^ Ruth Barrington, Health, Medicine & Politics in Ireland 1900–1970 (Institute of Public Administration: Dublin, 1987) pp. 188–89.
  8. ^ Brian Abel-Smith, The Hospitals 1800–1948 (London, 1964), p.229
  9. ^ Beveridge, William (November 1942). "Social Insurance and Allied Services" (PDF). HM Stationery Office. Retrieved 3 March 2013. 
  10. ^ 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.
  11. ^ "The NHS in England - About the NHS - NHS core principles". 23 March 2009. Retrieved 27 June 2017. 
  12. ^ 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.
  13. ^ 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.
  14. ^ Wales, NHS. "NHS Wales | 1960's". Retrieved 2016-11-22. 
  15. ^ Adams, Ryan (27 July 2012). "Danny Boyle's intro on Olympics programme". Awards Daily. Retrieved 27 November 2016. 
  16. ^ "Visiting or moving to England? - How to access NHS services (see "Hospital Services" section)". NHS Choices. 26 June 2015. Retrieved 6 June 2016. 
  17. ^ "NHS charges for people from abroad". Citizens Advice. Retrieved 2010-11-16. 
  18. ^ "Non-EEA country-by-country guide – Healthcare abroad". NHS Choices. 1 January 2016. Retrieved 6 June 2016. 
  19. ^ "Categories of exemption - Healthcare in England for visitors - NHS Choices". NHS England. 18 August 2015. Retrieved 6 June 2016. 
  20. ^ "Guidance on overseas visitors hospital charging regulations". 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.
  21. ^ NHS Choices (18 August 2015). "Moving from outside the EEA – Access to healthcare in England". Retrieved 6 June 2016. 
  22. ^ "Health spending". 
  23. ^ "How the NHS is funded". TheKing'sFund. 15 January 2016. Retrieved 6 June 2016. 
  24. ^ "Underfunded, underdoctored, overstretched: The NHS in 2016". 21 September 2016. 
  25. ^ "Health care spending compared to other countries". 
  26. ^ NHS Choices The NHS in England: The NHS: About the NHS: Overview. Retrieved 22 June 2010.
  27. ^ "The NHS in England". NHS choices. 28 January 2013. Retrieved 27 July 2014. 
  28. ^ a b "10 charts that show why the NHS is in trouble". BBC News. 8 February 2017. Retrieved 10 February 2017. 
  29. ^
  30. ^ Health unions urge Theresa May to ditch NHS pay cap The Guardian
  31. ^ NHS staff suffer pay cuts in real terms as salaries rise by one per cent The Independent
  32. ^ Conservatives will break NHS funding pledge, Labour claims The Guardian
  33. ^ editor, Rowena Mason Deputy political (30 December 2016). "People may be ready to pay extra penny on tax for NHS, Tim Farron says" – via The Guardian. 
  34. ^ Two-thirds support higher taxes to maintain NHS funding The Obsrver
  35. ^ Siddique, Haroon (5 March 2017). "BMA calls for extra £10bn a year for NHS in Hammond's budget" – via The Guardian. 
  36. ^
  37. ^ Police reveal 'unlawful' mental health detentions BBC
  38. ^ Almost 6,000 mental health patients sent out of area for care last year The Guardian
  39. ^ Mental health staff on long-term stress leave up 22% BBC
  40. ^ Mental health trusts restrain patients 'every 10 minutes' BBC
  41. ^
  42. ^ More UK nurses and midwives leaving than joining profession BBC
  43. ^ The NHS's sustainability is under threat if more isn't done to look after its staff New Statesman
  44. ^ GPs losing sleep over patient safety fears, says head of profession The Guardian
  45. ^ Safety fears as junior doctors left to run A&Es and other hospital units The Guardian
  46. ^ a b mamk (February 23, 2017). "Brexit gelungenn, Patient tot" (in German). Der Spiegel. Retrieved February 23, 2017. 
  47. ^ O'Carroll, Lisa; Campbell, Denis (28 February 2017). "Poll shows 60% of European doctors are considering leaving UK" – via The Guardian. 
  48. ^ Marsh, Sarah; Duncan, Pamela (30 March 2017). "Record number of EU citizens quit working in NHS last year" – via The Guardian. 
  49. ^ 96% drop in EU nurses registering to work in Britain since Brexit vote The Guardian
  50. ^ NHS faces staggering increase in cost of elderly care, academics warn The Guardian
  51. ^ "Is the NHS being privatised?". The King's Fund. 19 March 2015. Retrieved 11 October 2016. 
  52. ^ "Privatisation and independent sector providers". BMA. 
  53. ^ Surgeons call for review of safety standards in private hospitals The Guardian
  54. ^ Rogers, James (October 2001). "Is Microsoft deal best medicine for NHS?". Computer Weekly. UK. Retrieved 16 June 2017. 
  55. ^ Murdock, Jason (23 March 2016). "NHS hospitals are 'ripe and vulnerable targets' for ransomware cyberattacks". 
  56. ^ "NHS hospitals in England hit by massive crippling cyber-attack". NursingNotes. 2017-05-12. Retrieved 2017-06-01. 
  57. ^ NHS 'could have prevented' WannaCry ransomware attack BBC
  58. ^ "The ransomware attack is all about the insufficient funding of the NHS". 13 May 2017 – via The Guardian. 
  59. ^ Warning of NHS cyber-attack risk was not acted on, says cybersecurity adviser The Guardian
  60. ^ Syal, Rajeev; Campbell, Denis (16 October 2017). "NHS data loss scandal deepens with further 162,000 files missing". The Guardian. Retrieved 17 October 2017. 
  61. ^ "Outcomes in EHCI 2015" (PDF). Health Consumer Powerhouse. 26 January 2016. Retrieved 27 January 2016. 
  62. ^ Timmins, Nick. "The four UK health systems: Learning from each other,". Kings Fund. Retrieved 2 February 2016. 
  63. ^ "Scottish A&E bucks trend on long waits". BBC. 7 December 2017. Retrieved 10 December 2017. 

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. 437–60
  • 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.
  • Hilton, Claire. (26 August 2016). Whistle-blowing in the National Health Service since the 1960s History and Policy. Retrieved 11 May 2017.
  • 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. 453–70
  • 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. 167–92
  • Webster, Charles. "Conflict and Consensus: Explaining the British Health Service," Twentieth Century British History, April 1990, Vol. 1 Issue 2, pp. 115–51
  • 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]