National Health Service

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The logo of the NHS for England. The colour, "NHS Blue" (Pantone 300), is used on signs and leaflets throughout the NHS in England.

The National Health Service (NHS) is the "public face" of the four publicly funded health care systems of the United Kingdom. The organisations provide the majority of healthcare in the UK, from general practitioners to Accident and Emergency Departments, long-term healthcare and dentistry. They were founded in 1948 and have 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.<ref>Template:Cite web</ref> Employing well over 1 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). A study by Professor Nick Bosanquet for the Reform think tank predicts an annual deficit of nearly £7bn in 2010.<ref>Template:Cite web</ref>

The government department responsible for the NHS in England is the Department of Health, headed by the Secretary of State for Health, (presently Patricia Hewitt), who sits in the British Cabinet. As of May 2006, the Ministers of State under Ms. Hewitt are:

The department also has one Parliamentary Under Secretary of State who is Ivan Lewis (Care Services).

The devolved administrations of Wales, Scotland and Northern Ireland are each responsible for their own NHS.


[edit] 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.<ref></ref> The structure of the NHS in England and Wales was established by the National Health Service Act 1946 (1946 Act). 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.

[edit] NHS Policies and programmes

[edit] 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.<ref>Manfred Davidmann (1985). Reorganising the National Health Service: An Evaluation of the Griffiths Report, Second edition. ISBN 0-85192-046-2.</ref> 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.

[edit] 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"),<ref>Template:Cite web</ref> 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.<ref>Template:Cite web</ref>

In 2005, surgicentres (ISTCs) treated around 3% of NHS patients (in England) having routine surgery. By 2008 this is expected to be around 10%.<ref>Template:Cite web</ref> 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.<ref>Template:Cite web</ref>

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.<ref>Template:Cite web</ref> There has also been criticism of a lack of patient information security.<ref>Template:Cite web</ref> 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.<ref>Template:Cite web</ref> 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.

[edit] Structure

[edit] Organisation

Responsibility for the National Health Services in Scotland, Wales and Northern Ireland belongs to the relevant devolved administration; the NHS for England is controlled by the UK government. Similar principles of service and management are common to all four services, and some NHS agencies (e.g. NICE) have influence in all four. The English service is generally known simply as NHS. Its structure is discussed in this article. Links are provided to NHS Wales, NHS Scotland and Health and Care NI, the three sister organisations.

The NHS in England 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 supervison of:

  • Primary Care Trusts (PCTs), which administer primary care and public health. There are 302 PCTs (these are also being reduced in number, by about half, to provide savings), which oversee England's 29,000 GPs and 18,000 NHS dentists. In addition, they commission acute services from other NHS Trusts and the private sector, provide directly primary care in their locations, and oversee such matters as primary and secondary prevention, vaccination administration and control of epidemics. PCTs are at the centre of the NHS and control 80 per cent of the total NHS budget.
  • NHS Hospital Trusts. 290 organisations administer hospitals, treatment centres and specialist care in about 1,600 NHS hospitals (many trusts maintain between 2 and 8 different hospital sites).
  • NHS Ambulance Services Trusts
  • NHS Care Trusts
  • NHS Mental Health Services Trusts

In addition, several Special Health Authorities provide services in England 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 health services:-

England - NHS Direct 0845 46 47
Scotland - NHS 24 0845 42 42 42 4
Wales - NHS Direct Wales / Galw Iechyd Cymru 0845 46 47
Northern Ireland - Health&CareNI currently (20 Jul 2006) refers to NHS Direct

[edit] Funding

[edit] The commissioning system

The principal fundholders in the English 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.

[edit] Patient charges and prescriptions

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. The costs are met, via the PCTs, from UK government taxation - thus all UK taxpayers contribute to its funding.

As of April 2006 the prescription charge for medicines in England, Scotland and Northern Ireland is £6.65. In Wales the charge is £3.00 per item however the intention has been announced to abolish charges from 2007.<ref name="welshcharges">Template:Cite web</ref>

In England people over 60, under 16, patients with certain medical conditions, and those with low incomes, are exempt from paying, the lower age limit in Wales is 25 years.<ref name="welshcharges"></ref> 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.<ref>Template:Cite web</ref>

Where NHS dentistry is available 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. <ref>Template:Cite web</ref>.

[edit] 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 the doctors and nurses that provide them and in most cases owns and runs its hospitals and clinics. (UK General Practitioners, in contrast, are almost all self-employed, and contract their services back to the NHS, usually in group practices. Recently however, a number of salaried GP posts have been created, often in poorer areas where health care provision has been harder for locals to access)

As of March 2005, the English 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.<ref>Template:Cite web</ref><ref>Template:Cite web</ref>

[edit] Wales

For the structure of the NHS in Wales see separate article NHS Wales.

[edit] Scotland

For the structure of NHS services in Scotland, see separate article NHS Scotland

[edit] Northern Ireland

For the structure of NHS services in Northern Ireland, see separate article Health and Care NI.

[edit] Criticism

The NHS has had some criticism at times. For example, levels of the MRSA "superbug" in UK hospitals have been the subject of scrutiny in recent years.<ref></ref> The ongoing NHS IT upgrade has also been subject to recent scrutiny.<ref></ref> Availability of NHS dentistry is poor, with by March 2006 two million people in the UK trying but failing to register with an NHS dentist and overall figures of 55% of adults and 36% of children not registered with an NHS dentist.<ref></ref><ref></ref> Following the Private Finance Initiative (PFI) hospital building programme, many hospitals have found themselves in debt.<ref>,11381,1169102,00.html</ref>

[edit] See also

This is a partial list of Wikipedia articles relating to health care policy.

[edit] Wikipedia project

[edit] References


[edit] External links

[edit] NHS sites

[edit] UK and Devolved Government sites

[edit] Other sites

[edit] Further reading

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National Health Service

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