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The National Health Service (NHS) was formed in 1948 by Clement Attlee's post-war Labour government. It effectively nationalised
healthcare, with financing provided by central taxation. The NHS is currently the 4th largest employer in the world, with 1.2
million full and part-time staff.
The NHS now provides the majority of healthcare in England and has become an integral part of British society, culture
and everyday life.
The Private Sector
Private health care continues in parallel to the NHS and is paid for mostly by private insurance. This is used only by
a small percentage of the population and as a top-up to NHS services.
Organisation and Funding
NHS services are largely "free at the point of use" and paid for by taxes. The estimated budget for the NHS in 2010 -
2011 was £110 billion. Responsibility for the NHS lies with the government - the Department of Health (DH).
The DH is currently led my Secretary of State (and cabinet minister) Andrew Lansley and includes ministers whose job
it is to provide strategic leadership to the NHS and social care organisations.
History and Development
The NHS was conceived in the aftermath of World War II (1948) by Clement Attlee's Labour government based on the
proposals of the Beveridge Report. It is based on the idea that good healthcare should be available to all regardless
of wealth.
The 1980s saw the introduction of modern management processes in the NHS to replace the previous system of consensus
management (i.e. general managers were appointed and clinicians became more involved in management).
The Introduction of the Internet Market
Margaret Thatcher ordered a review of the NHS in 1988 and this outlined the introduction of the "internal market" which
changed the structure and organisation of the health services.
In 1990 the National Health Service and Community Care Act defined this "internal market" as a system whereby local
Health Authorities ceased to run hospitals but commissioned care from their own or other authorities' hospitals for
the local population. Certain GPs became "fund holders" and were able to purchase care for their patients.
Hospitals as healthcare providers became independent Hospital Trusts that compete to provide care. The rationale is
that competition improves standards of care, however the system has increased regional differences in care; this is
often referred to as the "postcode lottery".
These changes were condemned by the Labour Party, which claimed the Conservative intention was to privatise the
Health Service. This was a major feature of the Labour Party election campaign in 1997.
The Blair Years
The incoming government of Tony Blair stated an intention to abandon the principles of competition and the "internal market"
and abolish fund holding, but this was actually re-introduced as part of Blair's ongoing reforms to modernise the NHS.
After the NHS struggled to cope with a winter hospital crisis in 2000, Labour responded with an ambitious "NHS Plan"
that included principles of competition and market, massively increased investment and expansion of the "private finance
initiative" or PFI.
The PFI is a way of building hospitals and obtaining some services through private enterprise. In an attempt to create
uniform standards of care a vast array of performance targets and national guidelines were drawn up, however the NHS
is so complex that it has been difficult to set these guidelines and targets in a way that promotes a fair service to
patients. It is argued that hospitals built through PFI are:-
- More expensive to build and operate than if they were publicly funded;
- Result in staff losses;
- Result in a reduction in the number of patient beds.
The healthcare services provided by the NHS are divided into primary, secondary, elective and emergency care.
The Advent of Primary Care Trusts
In 2000, Primary Care Trusts were created to purchase primary healthcare and public health in a specific geographical
area. They currently spend around 80% of the NHS budget however they will no longer provide services directly from 2011
and are set to change under new reforms.
The Creation of Foundation Trusts
In 2004, Foundation Trusts were created with the aim of giving certain Hospital Trusts freedom from the control of central
government and make them instead accountable to local people. In addition, "extended patient choice" was introduced in 2004
to further improve standards through competition.
Reforms during the time of the previous Labour government have included:-
- Laying down of detailed service standards;
- Strict financial budgeting;
- Revised job specifications;
- Closure of surplus facilities;
- Emphasis on rigorous clinical and corporate governance;
- Medical training restructuring (foundation training);
- New services to manage demand (e.g. NHS Direct);
- Staff reforms - harmonised pay and career progression;
- NICE.
IT Problems
The NHS encountered significant IT problems with innovations accompanying the Blair reforms. The NHS's National Programme
for IT (NPfIT) was scrapped in favour of a more modest programme in September 2009 as it had run behind schedule and above
budget with friction between the government and the programme contractors.
Patient information security remains a source of concern for medical practitioners and patients.
Socially Directive Policies
The NHS has also been required to take on socially "directive" policies (e.g. with respect to obesity and
smoking: www.smokefreeengland.co.uk).
A number of ongoing factors continue to drive reforms:-
- Rising costs of medical technology and medicines;
- A desire to increase standards and "patient choice";
- An aging population;
- A desire to contain Government expenditure.
Conservative Reforms
Prior to the most recent election in 2010 the Conservatives promised to avoid "massive structural reorganisation", however
the health secretary Andrew Lansley nonetheless drew up the radical Health and Social Care Bill which aimed to give spending
power back to GPs, sideline primary care trusts, give the private sector a bigger role and dismantle much of the architecture
of regulation and targets introduced by the previous Labour government.
In June 2011 the government published proposed amendments to the Health and Social Care Bill following a "listening exercise"
on it's NHS reforms during which they were widely criticised by the medical profession and unions such as UNISON.
Prime Minister David Cameron announced a "pause" in the passage of the Health and Social Care Bill through Parliament while
the NHS Future Forum is commissioned to examine concerns.
Organisation of the NHS
People can't plan for emergency events and there are various first ports of call:-
- Primary care out-of-hours services - telephone or face-to-face advice;
- NHS Walk-in Centres - treatment for minor conditions with no appointment;
- Ambulance Services - trained paramedics with advanced emergency care skills;
- Hospital A&E - emergency medical care.
GP Practices
General practitioners (GPs) diagnose and treat a wide range of health problems in the local community. They and their teams also:-
- Provide health education and advice on things like smoking and diet;
- Run clinics;
- Give vaccinations;
- Carry out simple surgical operations.
Doctors usually work in a team with nurses, health visitors and midwives, as well as a range of other health professionals such as
physiotherapists and occupational therapists.
If a GP cannot deal with your problem, they will refer you to a hospital for tests, treatment or to see a consultant with specialist
knowledge.
Social Care Services
These look after the health and welfare of the population. The main groups include:-
- Children of families under stress;
- People with disabilities;
- People with emotional or psychological difficulties;
- People with financial or housing problems;
- Older people who need help with daily living activities.
Social care services may be offered in hospitals or health centres, in educational settings,
community groups, residential homes, advice centres or even in people's own homes.
These services are normally run by local councils, and are sometimes run in conjunction with
local NHS providers and organisations.
Summary of NHS Structure
The overall structure of the NHS is illustrated below.
The Structure of the NHS
Click Image to Enlarge
Administration is divided into:-
- Strategic Health Authorities (SHAs) - oversee all NHS operations in an area;
- Special Health Authorities - provide services such as: National Institute for Health and Clinical Excellence (NICE), NHS Direct (24hr telephone/online health service) and NHS Business Services Authority (pension scheme).
Direct healthcare providers are organised into:-
- Primary Care Trusts (PCTs) - administer primary care and public health in a specific geographical area - have their own board of directors and CEO;
- NHS Acute Trusts - administer hospitals, treatment centres and specialist care. There is often more than one hospital per trust;
- NHS Foundation Trusts ("foundation hospitals") - are a new type of NHS hospital with significantly increased managerial and financial freedom;
- NHS Ambulance Services Trusts - emergency medical services;
- NHS Care Trusts - health and social care;
- Mental Health Trusts.
NHS Funding
The principal fund holders in the NHS are the PCTs who commission healthcare from hospitals, GPs and others and pay them on an agreed tariff or
contract basis.
The PCTs receive a budget from the Department of Health depending on their population and specific local needs. They are required to "break even",
although this is often impossible to do.
Except for set charges applying to most adults for prescriptions, optician services and dentistry, the NHS is free for patients at the point of
use. As of April 2007, the prescription charge for medicines in England is £7.20 (certain groups are exempt).
The rising costs of some medicines, especially cancer treatments, mean that prescriptions can present a heavy burden to the PCTs. This has led
to disputes in certain cases (e.g. Herceptin) as to whether drugs should be prescribed.
The role of NICE (established in May 2008) is to assess new treatments, drugs and technology to develop clinical guidelines that balance the
costs to the taxpayer and the benefits to patients.
NHS Dentistry is not as widely available as it used to be and the private sector has expanded to fill the gap. Dental charges, even for routine
procedures, can be very high.
The NHS employs nearly all hospital doctors and nurses in England and they work in NHS-run hospitals. In contrast, GPs, dentists and opticians
are almost all self-employed and contract their services back to the NHS. They may own and operate their own clinics and employ their own staff.
The NHS does provide some facilities and centrally employed healthcare professionals in areas where there is inadequate provision by self-employed
professionals.
Common Criticisms
The NHS has frequently been a target of criticism over the years regarding:-
- Length of waiting lists for consultations diagnostics and treatment;
- Levels of antibiotic-resistant bacteria in hospitals (e.g. MRSA and Clostridium difficile);
- Problems with the NHS IT update;
- Decreasing availability of NHS dentistry;
- Lack of availability of some treatments due to their cost ineffectiveness;
- Hospitals and trusts running into debt.
Some of these have resulted in people seeking medical care overseas ("health tourists").
There have also been a number of high-profile scandals [e.g. Alder Hey organs scandal (Redfern Report), Bristol Heart Scandal (Samantha Rickard)
and the Harold Shipman murders.
Further Reading on the NHS
Other Organisations
The General Medical Council (GMC) - www.gmc-uk.org
The GMC registers doctors to practise medicine in the UK. Their purpose is to protect, promote and maintain the health and safety of the
public by ensuring proper standards in the practice of medicine.
The British Medical Association (BMA) - www.bma.org
The BMA is a voluntary professional association of doctors and is an independent trade union. It keeps doctors informed of medical issues
and publishes the BMJ - British Medical Journal.
Medical Research Council (MRC) - www.mrc.ac.uk
Distributes taxpayers' money to medical researchers. Promotes research in all areas of medicine and medicine-related technologies.
Sets out standards and rights which UK citizens can expect from the NHS. This includes complaints procedures for substandard and
non-professional treatment.
The Medical Defence Unit (MDU) - www.the-mdu.com
The MDU is a mutual, non-profit organisation that defends the professional reputation of its members when their clinical performance
is called into question. The MDU may pay legal costs for its members and it may also pay compensation to patients who have been harmed
by medical negligence during their treatment.
This is a not-for-profit organisation offering support to health professionals with the legal and ethical problems that arise from their
professional practice.
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