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NATIONAL HEALTH SERVICE
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The National Health Service (NHS) is the "public face" of the three publicly funded health care systems of Great Britain (Northern Ireland does not use the title). It currently employs 1.33 million people, making it the world's fourth largest employer after the Chinese Army, Indian Railways and Wal-mart.
The NHS provides the majority of healthcare in the UK, from general practitioners to hospitals, long-term healthcare, dentistry and opthalmology. It was founded in 1948 and has become an integral part of British society, culture and everyday life: the NHS was once described by Nigel Lawson, former Chancellor of the Exchequer, as "the national religion". Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used only by a small percentage of the population, and generally as a top-up to NHS services.
NHS services are largely "free at the point of delivery", paid for by taxes; the NHS's budget for 2006–07 is £96 billion.[1] Employing over 1.3 million people, the NHS is the largest employer in Europe and one of the largest employers in the world, (believed to be third or fifth, according to different commentators). The government department responsible for the NHS is the Department of Health, headed by the Secretary of State for Health, (presently Patricia Hewitt), who sits in the British Cabinet. As of January 2007, the Ministers of State under Ms. Hewitt are:
The department also has one Parliamentary Under Secretary of State who is Ivan Lewis (Care Services). History
In the aftermath of World War II, Clement Attlee's Labour government created the NHS, based on the proposals of the Beveridge Report, prepared in 1942. The structure of the NHS in England and Wales was established by the National Health Service Act 1946 (1946 Act); the Welsh NHS is now the responsibility of the Welsh Assembly. The introduction of the service was carried out by Aneurin Bevan as Secretary of State for Health, the "Appointed Day" for its launch being July 5, 1948.
NHS policies and programmes
Reforms under the Thatcher government
The 1980s saw the introduction of modern management processes (General Management) in the NHS to replace the previous system of consensus management. This was outlined in the Griffiths Report of 1983. This recommended the appointment of general managers in the NHS with whom responsibility should lie. The report also recommended that clinicians be better involved in management. Financial pressures continued to place 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 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 (in England) defined this "internal market", whereby Health Authorities ceased to run hospitals but "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients. The "providers" became independent trusts, which encouraged competition but also increased local differences.
The Blair government
These innovations, especially the "fund holder" option were condemned at the time by the Labour Party; opposition to what was claimed to be the Conservative intention to privatise the NHS became a major feature of Labour campaigning in the 1997 and subsequent British elections. Although the incoming government of Tony Blair (1997) stated its intention to remove the "internal market" and abolished fundholding, in effect the market was strengthened and fundholding reintroduced as part of Blair's ongoing reforms to modernise the NHS.
Driving these reforms has been a number of factors. They include the rising costs of medical technology and medicines, the desire to increase standards and "patient choice", an ageing population, and a desire to contain government expenditure. The National Health Services in Wales, Scotland and Northern Ireland are not directly controlled by the UK government and these reforms have not all been copied uniformly. (See NHS Wales and NHS Scotland for descriptions of their developments).
Reforms have included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous clinical and corporate governance. In addition medical training has been restructured. Some new services have been developed to help manage demand, including NHS Direct. A new emphasis has been given to staff reforms, with the Agenda for Change agreement providing harmonised pay and career progression. These changes have, however, given rise to controversy within the medical professions, the media and the public. During 2005 and 2006 hospitals began to lay off staff as a consequence of these reforms and the financial stringency accompanying them, further adding to controversy.
The Blair Government, whilst leaving services free at point of use, has encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals have been built (or rebuilt) by private sector consortia; hospitals may have both medical services (such as "surgicentres"), and non-medical services (such as catering) provided under long-term contracts by the private sector. These are more expensive than if the new build was simply funded from the public purse. A study by a consultancy company which works for the Department of Health shows that every £200 million spent on privately financed hospitals will result in the loss of 1000 doctors and nurses. The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced.
In 2005, surgicentres (ISTCs) treated around 3% of NHS patients (in England) having routine surgery. By 2008 this is expected to be around 10%. NHS Primary Care Trusts have been given the target of sourcing at least 15% of primary care from the private or voluntary sectors over the medium term.
Given ongoing redundancies within the NHS, accusations of staff cuts and "privatisation" are now made against the Blair government, often by NHS staff unions such as UNISON.
As a corollary to these intitiatives, the NHS has been required to take on pro-active socially "directive" policies, for example, in respect of smoking and obesity.
The NHS has also encountered significant problems with the IT innovations accompanying the Blair reforms. The NHS's National Programme for IT (NPfIT), believed to be the largest IT project in the world, is running significantly behind schedule and above budget, with friction between the Government and the programme contractors. Originally budgeted at £2.3 billion, present estimates are £20-30 billion and rising. There has also been criticism of a lack of patient information security. The ability to deliver integrated high quality services will require care professionals to use sensitive medical data. This must be controlled and in the NPfIT model it is, sometimes too tightly to allow the best care to be delivered. One concern is that GPs and hospital doctors have given the project a lukewarm reception, citing a lack of consultation and complexity. Key "front-end" parts of the programme include Choose and Book, intended to assist patient choice of location for treatment, which has missed numerous deadlines for going "live", substantially overrun its original budget, and is still (May 2006) available in only a few locations. The programme to computerise all NHS patient records is also experiencing great difficulties. Furthermore there are unresolved financial and managerial issues on training NHS staff to introduce and maintain these systems once they are operative.
Structure
Organization
The NHS is controlled by the UK government. Some NHS agencies (e.g. NICE and SIGN) have influence in other parts of the United Kingdom. The service is generally known simply as NHS. Its structure is discussed in this article.
The NHS is managed at the top by the Department of Health, which takes political responsibility for the service. It controls Strategic Health Authorities (SHAs), which oversee all NHS operations in an area. Originally 28 in number, these have been reduced in 2006 to 10 SHAs with the intention of reducing costs, reducing central control and fostering greater responsibility for decisions closer to the delivery of services.
The SHAs are responsible for strategic supervision of:
In addition, several Special Health Authorities provide services and, in some cases, to the devolved NHS administrations. These include The Information Centre for health and social care,NHS Blood and Transplant, NHS Direct, NHS Professionals, NHS Business Services Authority, National Patient Safety Agency, National Treatment Agency and the National Institute for Health and Clinical Excellence (NICE).
Telephone support services are provided by the NHS:-
Funding
The commissioning system
The principal fundholders in the NHS system are the NHS Primary Care Trusts (PCTs), who commission healthcare from hospitals, GPs and others and pay them on an agreed tariff or contract basis, on guidelines set out by the Department of Health. The PCTs receive a budget from the Department of Health on a formula basis relating to population and specific local needs. They are required to "break even" - that is, they must not show a deficit on their budgets at the end of the financial year, although in recent years cost and demand pressures have made this objective impossible for some Trusts. Failure to meet the financial objective can result in the dismissal and replacement of a Trust's Board of Directors.
Patient charges and prescriptions
Access to the NHS and Patient Charges
Except for set charges applying to most adults for prescriptions, optician services and dentistry, the NHS is free for all patients "ordinarily resident" in the UK at the point of use irrespective of whether any National Insurance contributions have been paid; those who are not "ordinarily resident" (including British Nationals who have paid NI contributions in the past) are liable to charges for services other than that given in Accident and Emergency departments or "walk-in" centres. This includes UK citizens who work for a UK based charity outside the UK (except in certain countries) for more than 5 years, regardless of their intention to return to the UK or payment of NI contributions. These people are treated as overseas visitors even if they own property, return regularly or have family in the UK and regard their home country as the UK. NHS costs are met, via the PCTs, from UK government taxation, - thus all UK taxpayers contribute to its funding.
Exemption for Missionaries who work abroad for a UK based organisation
In England, from 15 January 2007, anyone who is working outside the UK as a missionary for an organisation with its principal place of business in the UK will be fully exempt from NHS charges for services that would normally be provided free of charge to those resident in the UK. This is regardless of whether they derive a salary or wage from the organisation, or receive any type of funding or assistance from the organisation for the purposes of working overseas. This is in recognition of the fact that most missionaries would be unable to afford private health care and those working in developing countries should not effectively be penalised for their contribution to development/other work.
Exemption for others
There are some other categories of people who are exempt from the residence requirements such as specific government workers and those in the armed forces stationed overseas.
Prescription Charges in England, Scotland, Northern Ireland
As of April 2007 there the prescription charge for medicines in England, Scotland and Northern Ireland is £6.85; people over sixty, children under sixteen (or under eighteen, if the child is still in full time education), patients with certain medical conditions, and those with low incomes, are exempt from paying. Those who require repeated prescriptions may purchase a single-charge pre-payment certificate which allows unlimited prescriptions during the period of validity. The charge is the same regardless of the actual cost of the medicine but higher charges apply to medical appliances. For more details of prescription charges, see the United Kingdom section of the article Prescription drug.
However, the rising costs of some medicines, especially some types of cancer treatment, means that prescriptions can present a heavy burden to the PCTs whose limited budgets include responsibility for the difference between medicine costs and the fixed prescription charge. This has led to disputes in certain cases (e.g. over Herceptin), as to whether such drugs should be prescribed.
Prescription Charges in Wales
As of April 2007, there is NO prescription charge for those who are registered with a Welsh GP and Welsh people living outside Wales with an exemption card.
NHS dentistry is not as widely available as it once was, and the private sector has expanded to fill the gap. Where available, NHS dentistry charges as at August 2006 are: £15.50 for an examination; £42.40 if a filling is needed; and £189 for more complex procedures such as crowns, dentures or bridges.
Financial outlook
As each division of the NHS is required to break even at the financial year-end, the service should in theory never be in deficit. However in recent years overspends have meant that, on a 'going-concern' (normal trading) basis, these conditions have been consistently, and increasingly, breached. Patricia Hewitt has consistently asserted that the NHS will be in balance at the end of the financial year 2007-8; however, a study by Professor Nick Bosanquet for the Reform think tank predicts a true annual deficit of nearly £7bn in 2010.
Staff
A feature of the NHS, distinguishing it from other public healthcare systems in Continental Europe, is that not only does it pay directly for health expenses, it also employs a large number of the doctors and nurses that provide them. In particular, nearly all hospital doctors and nurses are employed by the NHS and work in NHS-run hospitals.
In contrast General Practitioners, dentists, opticians and other providers of local healthcare, are almost all self-employed, and contract their services back to the NHS. They may operate in partnership with other professionals, own and operate their own surgeries and clinics, and employ their own staff, including other doctors etc. However, the NHS does sometimes provide centrally employed healthcare professionals and facilities in areas where there is insufficient provision by self-employed professionals.
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 United States Department of Defense.
Criticism
The NHS has frequently been the target of criticism over the years. Examples of such criticism includes:
Several high profile scandals have also been attributed to the NHS over the years such as the Alder Hey organs scandal and the Bristol heart scandal.
ROW OVER 'FAT CAT' SALARIES - FRIDAY 19 March 2004 - EASTBOURNE HERALD
FAT CAT health chiefs were under fire this week after the boss of the DGH admitted to a 19 per cent increase in her six-figure pay cheque. The massive hike pushed up the annual salary of Annette Sergeant, chief executive of the East Sussex Hospital NHS Trust, to between £125,000 and £130,000 a year.
Annette Sergeant Gina Brocklehurst
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