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The National Health Service
The National Health Service (NHS) is the publicly-funded healthcare system of the United Kingdom. The organisation provides the majority of healthcare in the UK, from general practitioners to Accident and Emergency Departments, long-term healthcare and dentistry.
A feature of the NHS compared to other public healthcare systems in Continental Europe is that not only does it pay directly for health expenses (with partial exceptions like prescriptions and dentistry it is free at the point of use), it also employs the doctors and nurses that provide them, and in most cases owns and runs its hospitals and clinics. However, under the Private Finance Initiative, an increasing number of hospitals have been built (or rebuilt) by private sector consortia, and have non-medical services (such as catering) provided under long-term contracts by the same consortia.
History
Before 1948, when the NHS was created, patients were generally required to pay for their own healthcare. Systems of health insurance were relatively undeveloped, with the exception of National Insurance. However due to cuts during the economic troubles of the '30s so many of the poor were simply unable to obtain treatment when they were ill. Many charities were established to operate local hospitals, such as the Royal Free Hospital, and some local authorities operated local hospitals for local ratepayers, but provision was patchy and quality of care varied greatly.
A "Panel" system was set up in 1911 under the aegis of David Lloyd George. (The name survives in the "Lloyd George envelopes" in which most primary care records in England are stored, although today most working records in primary care are at least partially computerised).
In the aftermath of the Second World War, with a new spirit of social provision, Clement Attlee's Labour government created the NHS. The structure of the NHS in England and Wales was established by the National Health Service Act 1946 (1946 Act) and the new arrangements were launched on 5 July 1948. This was under health and housing minister Aneurin Bevan, who based the NHS on a coal-miners co-operative that he had seen in operation in his home town of Tredegar.
The same services would henceforth be provided by the same doctors and the same hospitals, but:
- services were provided entirely free of charge at the point of use;
- instead, services were financed from central taxation;
- everyone was eligible for care (even people temporarily resident or visiting the country).
The original structure of the NHS had three arms:
- Hospital Services - 14 Regional Hospital Boards were created in England and Wales to administer the great majority of hospital services. Beneath these were 400 Hospital Management Committees which directly administered their own hospitals. Teaching hospitals had different arrangements and were organised under Boards of Governors.
- Primary Care - General Practitioners (GPs) were independent contractors (that is they were not salaried employees) and would be paid for each person on their list. Dentists, opticians and pharmacists also generally provided services as independent contractors. Executive Councils were formed and they administered contracts and payments to the contractor professions as well as maintaining lists of local practitioners and dealing with patient complaints.
- Community Services - Maternity and Child Welfare clinics, health visitors, midwives, health education, vaccination and immunisation and ambulance services together with environmental health services were the responsibility of local authorities. This was a continuation of the role local government had held prior to establishment of the NHS.
This was known as the tripartite system, which would continue until 1974. In addition, private healthcare continued in parallel to the NHS.
By the 1950s, spending on the NHS far exceeded what had been expected by Parliament and the Treasury. Spiralling costs led to the introduction of a 5-shilling charge for prescriptions, and a £1 charge for dental treatment, in 1952. With updated pricing, these remain the major exceptions to the NHS being free at the point of use. The 1950s also saw the more rational planning of hospital services, dealing in part with some of the gaps and duplications that existed across England and Wales. The period also saw the growth in the number of medical staff and a more even distribution of these staff together with the development of hospital outpatient services. The Mental Health Act of 1959 also significantly altered legislation in respect of mental illness and reduced the grounds on which someone could be compulsorily admitted and detained in a mental hospital.
The 1960s has been characterised as a period of growth for the NHS. In primary care a more equitable distribution of GPs was emerging as was the concept of the primary healthcare team. The period also saw a growth in health centres. More mental health patients were discharged back into the community and Enoch Powell, who was Minister of Health in the early 1960s, predicted that many of the large mental health institutions would close within ten years. Concern also continued to grow about the structure of the NHS and the difficulties of the tripartite system which separated hospital, community and primary care services. A number of papers were published and committees and commissions established in the late 1960s which put forward proposals for major changes in the structure and organisation of the NHS.
The NHS in England was reorganised in 1974 to bring together services provided by hospitals and services provided by local authorities under the umbrella of Regional Health Authorities, with a further restructuring in 1982. The 1970s also saw the end of the economic optimism which had characterised the 1960s and increasing pressures coming to bear to reduce the amount of money spent on public services and to ensure increased efficiency for the money spent. Through the 1970s and 1980s, it became increasingly clear that the NHS would never have the resources necessary to provide unlimited access to the latest medical treatments, especially in the context of an ageing population.
The 1980s also saw the introduction of General Management to replace the previous system of consensus management. This was outlined in the Griffiths Report of 1983. This report recommended the appointment of general managers with whom individual responsibility and accountability lay at all levels of the NHS. The report also recommended that clinicians be better involved in management processes. Financial pressures continued to place significant strain on the NHS. In 1987, an additional £101 million was provided by the government to the NHS. In 1988 the then Prime Minister, Margaret Thatcher, announced a review of the NHS. From this review and in 1989, two white papers Working for Patients and Caring for People were produced. These papers outlined the introduction of what was termed the "internal market", which was to shape the structure and organisation of health services for most of the next decade.
In 1990, the National Health Service & Community Care Act 1990 (in England) introduced an "internal market" into the NHS, whereby Health Authorities ceased to run hospitals directly but instead "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients directly. The "providers" became independent trusts, which encouraged competition but also increased differences.
Structure
Responsibility for the NHS has been devolved to the component parts of the UK.
England
The NHS in England is managed at the top level by the Department of Health, which takes political responsibility for the service. It controls 28 Strategic Health Authorities (SHAs), which oversee all NHS operations in a particular area.
The SHAs supervise:
- Primary Care Trusts (PCTs), which administer primary care and public health. There are 302 PCTs, which oversee England's 29,000 GPs and 18,000 NHS dentists. In addition, they oversee such matters as primary and secondary prevention, vaccination administration and control of epidemics.
- NHS Hospital Trusts. These 290 organisations administer hospitals, treatment centres and specialist care in the about 1,600 NHS hospitals (many trusts maintain between 2 and 8 different hospital sites).
- Ambulance Trusts
- Care Trusts
- Mental Health Trusts
In addition, several Special Health Authorities provide a health service to the whole of England. These include NHS Blood and Transplants, the NHS Direct and the National Institute for Health and Clinical Excellence (NICE).
Wales
NHS Wales is operated and managed by the Health and Social Care Department of the Welsh Assembly Government. Strategic Health Authorities in Wales are known as Local Health Boards (LHBs). A Welsh Trust will typically administer all hospitals in a region, as well as all care and mental health functions. Most people in Wales will have access to a District General Hospital which provides a range of services on an outpatient, inpatient and day case basis. Some of these hospitals also provide specialist services such as burns and plastics and cardiac surgery. Wales has one main teaching hospital, the University Hospital of Wales, based in Cardiff. The NHS also provides community services which includes district nurses, health visitors, midwives and community based speech therapists, physiotherapists and occupational therapists.
Another important organisation in the structure is Health Commission Wales. This is an executive agency of the Welsh Assembly Government whose primary role is to centrally organise and fund all Tertiary care and other highly specialist services. It also provides advise and guidance about specialist services to other parts of NHS Wales.
Scotland
The NHS in Scotland has always been a separate and distinct body from the NHS in other parts of the United Kingdom. Healthcare policy and funding is the responsibility of the Scottish Executive. The chief civil servant in the Scottish Executive Health Department is also chief executive of NHS Scotland.
Provision of healthcare is the responsibility of 15 geographically-based NHS Boards. There are no NHS Trusts in Scotland; instead, hospitals are owned by and GPs contracted in by the local NHS Board. Provision of community and mental health care is also the responsibility of each local Board.
They are supported in this task by NHS National Services Scotland and several other special health boards, including NHS Health Scotland (Public health and health education), Health Protection Scotland, NHS Education for Scotland (training and e-library), NHS Quality Improvement Scotland, and the Scottish Ambulance Service.
The State Hospital for Scotland and Northern Ireland at Carstairs, which provides high security services for mentally disordered offenders and others who pose a high risk to themselves or others, is the responsibility of the State Hospitals Board for Scotland.
Northern Ireland
In Northern Ireland, the NHS is administered by the Department of Health, Social Services and Public Safety.
The Department is organised under a Permanent Secretary into several groups and one agency. These are the Planning and Resources Group, Strategic Planning and Modernisation Group and Primary, Secondary and Community Care Group and the 5 Professional Groups. The Department’s Executive Agency is the Northern Ireland Health and Social Services Estates Agency (known as Health Estates).
The five professional groups are
- Medical and Allied Services
- Social Services Inspectorate
- Nursing and Midwifery Advisory Group
- Dental Services
- Pharmaceutical Advice and Services
Other
In addition to this hierarchy there are various internal bodies which have authority over particular matters. For example, the National Institute for Clinical Excellence (NICE) is an NHS body which produces guidelines and standards for healthcare.
Funding
The NHS was, and largely remains, a system of healthcare intended to be "free at the point of delivery" and paid for by taxes. Nigel Lawson, former Chancellor of the Exchequer once said that it was the national religion. Private medical care remained, and remains, available in the UK, but it largely used as a "top up" service to obtain speedy operations. The NHS's budget for 2005-06 is over £80 billion.
Contrary to popular misconception, the founding principles of the NHS called for its funding out of general taxation, not through national insurance. As of March 2005, the NHS has 1.3 million employees, and is variously the third or fifth largest employer in the world, after the Chinese army, Indian Railways and (as argued by Jon Hibbs, the NHS's head of news, in a press release from March 22, 2005) Wal-Mart and the US Department of Defense.
Political Issues in England
The long-term future of the NHS and its day to day organisation are major issues in British politics, and the Secretary of State for Health is one of the senior positions in the British Cabinet. Though the Secretary of State and Department of Health (UK) deal with a much wider range of issues, the NHS dominates the department's remit and many government policies, such as anti-smoking and obesity campaigns are implemented by the NHS.
In recent times, UK politicians have been trying to reduce waiting times for surgery and medical procedures. Although they have sometimes failed to meet some of the targets they have set, many contend that the NHS is respected worldwide,as a role model for the welfare state.
The NHS National Programme for IT (NPfIT)— a large-scale project to renovate the use of Information Technology in the NHS in England (the Welsh equivalent is called Informing Healthcare) — has been criticised for substantial budget over-runs, from £6 billion to a potential £30 billion. However this arises from confusion over the hardware and software procurement costs (the £6 billion) and the total costs of changing practices to use the new way of doing things that the IT investment is intended to support (the £30 billion). There has also been criticism of a perceived lack of adequate patient information security, but some of this has been poorly informed. The ability to deliver integrated high quality services will require care professionals to access sensitive medical data. This access must however be tightly controlled and in the NPfIT model it is, sometimes too tightly to allow the best care to be delivered. One of the main concerns is that GPs and hospital doctors have given the project a lukewarm reception, citing a lack of consultation and excessive complexity.
In 2005, Independent Sector Treatment Centres (ISTCs) will treat around 3% of NHS patients (in England) having routine elective surgery. By 2008 this is expected to be around 10%.
Overseas Doctors and the NHS:
Staff shortages in the NHS during 50s and 60s led to recruitment drives for qualified doctors from overseas, particularly the Indian subcontinent.This is a trend which continues to this day, and Overseas Doctors continue to contribute significantly to the NHS, especially in areas and posts which appear less glamorous or desirable to the local doctors.In recent years,several overseas doctors won race disrimination claims against the NHS, highlighting the absence of career progression and other difficulties faced by doctors from overseas.
Private Healthcare in the UK
Of course private healthcare also exists in the UK. However health insurance only provides a supplemental level of health care as the National Health Service already provides a comprehensive health service. Because of the NHS, only 12% of people bother to have their own health insurance (compared with 85% in the US) and the majority of these (9%) have their insurance paid by their employer. When a UK employer pays for health insurance, the cost of the insurance is treated by the Inland Revenue as a benefit in kind and is subject to income tax.
In the UK Health insurance only provides cover for curable, short-term health problems. It is designed to enable policyholders to jump the NHS queues to see consultants, be diagnosed, receive surgery or be treated. It does not cover medical care for emergencies or accidents and nor does it provide preventative medical treatment.
The largest providers are BUPA, BHP, BMI healthcare and Nuffield hospitals.
Interesting Links
National Institute for Healthcare and Excellence
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