National Health Service (England) - AbsoluteAstronomy.com

The National Health Service or NHS is the publicly funded healthcare system in England

England

England is a country that is part of the United Kingdom. It shares land borders with Scotland to the north and Wales to the west; the Irish Sea is to the north west, the Celtic Sea to the south west, with the North Sea to the east and the English Channel to the south separating it from continental...

. It is both the largest and oldest single-payer healthcare system in the world. It is able to function in the way that it does because it is primarily funded through the general taxation system, similar to how the various fire departments, police departments, and primary schools are also funded. The system thus provides healthcare to anyone normally legally resident in England, and also any other part of the United Kingdom (should a person from another UK area be travelling in England, for example), with almost all services free at the point of use for all such people.

The idea of the NHS being free at the point of use is contained in its core principles from the original NHS set-up, which are non-negotiable at their root but have variously been open to some interpretation over the years. Broadly speaking, in practice, "free at the point of use" means that anyone legitimately fully registered with the system (i.e. in possession of an NHS number

NHS number

The NHS number is a unique number used by the National Health Service in England and Wales to identify patients. Scotland's equivilant is called a CHI Number...

), including not only UK citizens but also legal emigrants, can access the full breadth of both critical and non-critical medical care without any out-of-pocket payment of any kind. Only extremely specific NHS service types are fee-for-service

Fee-for-service

Fee-for-service is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care...

: since 1948, there have been certain charges for the patient, such as associated with eye tests, dental care, prescriptions, and many aspects of long-term care

Long-term care

Long-term care is a variety of services which help meet both the medical and non-medical need of people with a chronic illness or disability who cannot care for themselves for long periods of time....

. However, even these charges are often lower than the same services under a private health care company.

In addition to the full breadth of medical services to all legal residents and citizens of the UK, the NHS also provides free emergency-based care to all people within UK borders, regardless of their legal status or national origin. People of questionable legal status or a different national origin who do not have the legal right to be in the UK long-term — including legitimate travellers and tourists from abroad — are not entitled to the full NHS, but they are entitled to emergency care in an accident and emergency department without having to pay for it.

The NHS has further agreed a formal constitution

NHS Constitution for England

The NHS constitution for England is a formal constitution which, in one document, lays down the objectives of the National Health Service , the rights and responsibilities of the various parties involved in health care in England, and the guiding principles which govern the service...

which sets out the legal rights and responsibilities of the NHS, its staff, and users of the service and makes additional non-binding pledges regarding many key aspects of its operations.

The current primary legislation is the National Health Service Act 2006

National Health Service Act 2006

The National Health Service Act 2006 is an Act of the Parliament of the United Kingdom. It sets out the structure of the National Health Service in England.If the Health and Social Care Bill 2011 passes it will be significantly altered....

, but the pending Health and Social Care Bill 2011

Health and Social Care Bill 2011

The Health and Social Care Bill 2011 is proposed health care reform legislation introduced in the House of Commons on 19 January 2011. If passed, the Bill would be the most extensive reorganisation of the structure of the National Health Service in England to date. It proposes to abolish NHS...

would greatly alter the fundamentals of the NHS if it becomes law. Also, even before such a passage, should it occur, the NHS is already experiencing upheavals in its inner workings: entirely separate from the proposed bill is a "Nicholson challenge

Nicholson challenge

The term "Nicholson challenge" refers to a set of mandates that the 2011 leader of the National Health Service in England, Sir David Nicholson, has put forth to the entirety of the NHS in a drive to find "efficiency savings" amidst a UK economy in upheaval...

" to the NHS, which involves finding £20 billion in "efficiency savings" across the service by 2015. Doctors and nurses have widely panned the effects of this "challenge", alleging that front-line NHS services of many different types have had to be cut immediately, and very heavily, in order to achieve these "savings" and that these hurried and very deep cuts inherently add up to active risks to patients' health and well-being, especially in cases of life-or-death accidents, support for terminal illnesses, long-term follow-up for debilitating mental disorders such as severe clinical depression

Clinical depression

Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...

and psychosis

Psychosis

Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...

, and similar. The Health And Social Care Bill 2011 and the Nicholson Challenge are both extremely controversial political and social points within the country today.

The NHS provides the majority of healthcare in England, including primary care

Primary care

Primary care is the term for the health services by providers who act as the principal point of consultation for patients within a health care system...

, in-patient care

Hospital

A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....

, long-term healthcare

Long-term care

, ophthalmology

Ophthalmology

Ophthalmology is the branch of medicine that deals with the anatomy, physiology and diseases of the eye. An ophthalmologist is a specialist in medical and surgical eye problems...

and dentistry

Dentistry

Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...

. The National Health Service Act 1946

National Health Service Act 1946

The National Health Service Act 1946 came into effect on 5 July 1948 and created the National Health Service in England and Wales. Though the title 'National Health Service' implies one health service for the United Kingdom, in reality a separate NHS was created for England and Wales accountable to...

came into effect on 5 July 1948. Private health care has continued parallel to the NHS, paid for largely by private insurance: it is used by about 8% of the population, generally as an add-on to NHS services. In the first decade of the 21st century the private sector started to be increasingly used by the NHS to increase capacity. According to the BMA

British Medical Association

The British Medical Association is the professional association and registered trade union for doctors in the United Kingdom. The association does not regulate or certify doctors, a responsibility which lies with the General Medical Council. The association’s headquarters are located in BMA House,...

a large proportion of the public opposed this move.

The NHS is largely funded from general taxation (including a proportion from National Insurance

National Insurance

National Insurance in the United Kingdom was initially a contributory system of insurance against illness and unemployment, and later also provided retirement pensions and other benefits...

payments). The UK government department responsible for the NHS is the Department of Health

Department of Health (United Kingdom)

The Department of Health is a department of the United Kingdom government with responsibility for government policy for health and social care matters and for the National Health Service in England along with a few elements of the same matters which are not otherwise devolved to the Scottish,...

, headed by the Secretary of State for Health

Secretary of State for Health

Secretary of State for Health is a UK cabinet position responsible for the Department of Health.The first Boards of Health were created by Orders in Council dated 21 June, 14 November, and 21 November 1831. In 1848 a General Board of Health was created with the First Commissioner of Woods and...

. Most of the expenditure of The Department of Health (£98.7 billion in 2008-9) is spent on the NHS.

History

A national health service was one of the fundamental assumptions in the Beveridge Report

Beveridge Report

The Report of the Inter-Departmental Committee on Social Insurance and Allied Services, known commonly as the Beveridge Report was an influential document in the founding of the Welfare State in the United Kingdom...

which Arthur Greenwood

Arthur Greenwood

Arthur Greenwood CH was a prominent member of the Labour Party from the 1920s until the late 1940s. He rose to prominence within the party as secretary of its research department from 1920 and served as Parliamentary Secretary to the Ministry of Health in the short-lived Labour government of 1924...

, Labour's Deputy Leader and wartime Cabinet Minister with responsibility for post-war reconstruction had successfully pressed the cabinet to commission from economist and social reformer William Beveridge

William Beveridge

William Henry Beveridge, 1st Baron Beveridge KCB was a British economist and social reformer. He is best known for his 1942 report Social Insurance and Allied Services which served as the basis for the post-World War II welfare state put in place by the Labour government elected in 1945.Lord...

. The government accepted this assumption in February 1943, and after a White Paper

White paper

A white paper is an authoritative report or guide that helps solve a problem. White papers are used to educate readers and help people make decisions, and are often requested and used in politics, policy, business, and technical fields. In commercial use, the term has also come to refer to...

in 1944 it fell to Clement Attlee

Clement Attlee

Clement Richard Attlee, 1st Earl Attlee, KG, OM, CH, PC, FRS was a British Labour politician who served as the Prime Minister of the United Kingdom from 1945 to 1951, and as the Leader of the Labour Party from 1935 to 1955...

's Labour government

Labour Party (UK)

The Labour Party is a centre-left democratic socialist party in the United Kingdom. It surpassed the Liberal Party in general elections during the early 1920s, forming minority governments under Ramsay MacDonald in 1924 and 1929-1931. The party was in a wartime coalition from 1940 to 1945, after...

to create the NHS as part of the "cradle to grave" welfare-state reforms in the aftermath of World War II

World War II

World War II, or the Second World War , was a global conflict lasting from 1939 to 1945, involving most of the world's nations—including all of the great powers—eventually forming two opposing military alliances: the Allies and the Axis...

. Aneurin Bevan

Aneurin Bevan

Aneurin "Nye" Bevan was a British Labour Party politician who was the Deputy Leader of the Labour Party from 1959 until his death in 1960. The son of a coal miner, Bevan was a lifelong champion of social justice and the rights of working people...

, the newly appointed Secretary of State for Health

Secretary of State for Health

, was given the task of introducing the National Health Service.

Healthcare prior to the war had been a patchwork quilt of private, municipal and charity schemes. Bevan now decided that the way forward was a national system rather than a system operated by regional authorities, to prevent inequalities between different regions. He proposed that each resident of the UK would be signed up to a specific General Practice

General practitioner

A general practitioner is a medical practitioner who treats acute and chronic illnesses and provides preventive care and health education for all ages and both sexes. They have particular skills in treating people with multiple health issues and comorbidities...

(GP) as the point of entry into the system, and would have access to any kind of treatment they needed without having to raise the money to pay for it.

Doctors were initially opposed to Bevan's plan, primarily on the stated grounds that it reduced their level of independence. Bevan had to get them onside, as, without doctors, there would be no health service. Being a shrewd political operator, Bevan managed to push through the radical health care reform measure by dividing and cajoling the opposition, as well as by offering lucrative payment structures for consultants

Consultant (medicine)

In the United Kingdom, Republic of Ireland, and parts of the Commonwealth, consultant is the title of a senior doctor who has completed all of his or her specialist training and been placed on the specialist register in their chosen specialty...

. On this subject he stated, "I stuffed their mouths with gold". On July 5, 1948, at the Park Hospital (now known as Trafford General Hospital) in Manchester

Manchester

Manchester is a city and metropolitan borough in Greater Manchester, England. According to the Office for National Statistics, the 2010 mid-year population estimate for Manchester was 498,800. Manchester lies within one of the UK's largest metropolitan areas, the metropolitan county of Greater...

, Bevan unveiled the National Health Service and stated, "We now have the moral leadership of the world".

The cost of the new NHS soon took its toll on government finances. On 21 April 1951 the Chancellor of the Exchequer, Hugh Gaitskell

Hugh Gaitskell

Hugh Todd Naylor Gaitskell CBE was a British Labour politician, who held Cabinet office in Clement Attlee's governments, and was the Leader of the Labour Party and Leader of the Opposition from 1955, until his death in 1963.-Early life:He was born in Kensington, London, the third and youngest...

, proposed that there should be a one shilling (5p) prescription charge and new charges for half the cost of dentures and spectacles. Bevan resigned from the Cabinet in protest. This led to a split in the party that contributed to the electoral defeat of the Labour government in 1951. The one shilling prescription charge was introduced in 1952 together with a £1 flat rate fee for ordinary dental treatment. Prescription charges were abolished in 1965, but reintroduced in June 1968.

Dr A. J. Cronin

A. J. Cronin

Archibald Joseph Cronin was a Scottish physician and novelist. His best-known works are Hatter's Castle, The Stars Look Down, The Citadel, The Keys of the Kingdom and The Green Years, all of which were adapted to film. He also created the Dr...

's highly controversial novel The Citadel

The Citadel (novel)

The Citadel is a novel by A. J. Cronin, first published in 1937, which was groundbreaking with its treatment of the contentious theme of medical ethics. It is credited with laying the foundation in Great Britain for the introduction of the NHS a decade later...

, published in 1937, had fomented extensive dialogue about the severe inadequacies of health care. The author's innovative ideas were not only essential to the conception of the NHS, but in fact, his best-selling novels are even said to have greatly contributed to the Labour Party's victory in 1945.

On November 13, 2011 the government has signed off on the 10-year contract to manage the debt-laden Hinchingbrooke hospital in Huntingdon

Huntingdon

Huntingdon is a market town in Cambridgeshire, England. The town was chartered by King John in 1205. It is the traditional county town of Huntingdonshire, and is currently the seat of the Huntingdonshire district council. It is known as the birthplace in 1599 of Oliver Cromwell.-History:Huntingdon...

, Cambridgeshire

Cambridgeshire

Cambridgeshire is a county in England, bordering Lincolnshire to the north, Norfolk to the northeast, Suffolk to the east, Essex and Hertfordshire to the south, and Bedfordshire and Northamptonshire to the west...

by Circle Healthcare. It was the first time that an NHS hospital is to be taken over by a stock-market listed company.

Core Principles

The principal NHS website states the following as core principles:
The main aims of the additional principles are that the NHS will:

Provide a comprehensive range of services
Shape its services around the needs and preferences of individual patients, their families and their carers
Respond to the different needs of different populations
Work continuously to improve the quality of services and to minimize errors
Support and value its staff
Use public funds for healthcare devoted solely to NHS patients
Work with others to ensure a seamless service for patients
Help to keep people healthy and work to reduce health inequalities
Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance

Structure

The English NHS is controlled by the UK government through the Department of Health (DH), which takes political responsibility for the service. Parliament has devolved management locally to ten Strategic Health Authorities (SHAs), which oversee all NHS operations, particularly the Primary Care Trusts, in their areas. These are coterminous the nine Government Office Regions for the most part, with the South East region split into South East Coast and South Central SHAs.

There are a number of types of regional NHS trust

NHS Trust

A National Health Service trust provides services on behalf of the National Health Service in England and NHS Wales.The trusts are not trusts in the legal sense but are in effect public sector corporations. Each trust is headed by a board consisting of executive and non-executive directors, and is...

NHS primary care trust
NHS Primary Care Trust
An NHS primary care trust is a type of NHS trust, part of the National Health Service in England. PCTs commission primary, community and secondary care from providers. Until 31 may2011 they also provided community services directly. Collectively PCT are responsible for spending around 80% of the...

s (PCTs), administer primary care and public health. On 1 October 2006 the number of PCTs was reduced from 303 to 152 in an attempt to bring services closer together and cut costs. PCTs oversee 29,000 GPs
General practitioner
A general practitioner is a medical practitioner who treats acute and chronic illnesses and provides preventive care and health education for all ages and both sexes. They have particular skills in treating people with multiple health issues and comorbidities...

and 18,000 NHS dentist
Dentist
A dentist, also known as a 'dental surgeon', is a doctor that specializes in the diagnosis, prevention, and treatment of diseases and conditions of the oral cavity. The dentist's supporting team aides in providing oral health services...

s. In addition, they commission services from other NHS Trusts and from the private and voluntary sectors, provide primary care in their locations, and oversee such matters as primary and secondary prevention, vaccination administration and control of epidemics. PCTs control 80 per cent of the total NHS budget
NHS hospital trust
NHS Hospital Trust
An NHS hospital trust, also known as an acute trust is an NHS trust that provides secondary health services within the English National Health Service and in NHS Wales. Hospital trusts are commissioned to provide these services by NHS primary care trusts....

s and NHS foundation trust
NHS Foundation Trust
An NHS foundation trust is part of the National Health Service in England and has gained a degree of independence from the Department of Health and local NHS strategic health authority.Foundation Trusts are represented by the , .-Function:...

s administer hospitals, treatment centre
Treatment centre
Treatment centres are medical institutions in the United Kingdom which provide routine diagnostic and surgery procedures to day-case and short-stay patients. By diverting these patients away from hospitals, they aim to reduce waiting lists by allowing hospitals to concentrate on emergency and more...

s and specialist care in around 1,600 NHS hospitals (some trusts run between 2 and 8 different hospital sites)
NHS ambulance services trusts
NHS care trust
NHS Care Trust
An NHS care trust, is a type of NHS trust in the English National Health Service and NHS Wales that provides both health and social care. They may carry out a range of services, including social care, mental health services or primary care services...

s, providing both health and social care services
NHS mental health services trust
NHS Mental Health Services Trust
An NHS Mental Health Trust provides health and social care services for people with mental health problems in England. They are one kind of NHS trust, the regional organisations that together form the National Health Service....

s, specialising in managing and treating mental illness
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...

, including by the use of involuntary commitment
Involuntary commitment
Involuntary commitment or civil commitment is a legal process through which an individual with symptoms of severe mental illness is court-ordered into treatment in a hospital or in the community ....

powers

Some services are provided at a national level:

www.nhs.uk is the primary public-facing NHS website, providing comprehensive official information on services, treatments, conditions, healthy living and current health topics
NHS Direct
NHS Direct
NHS Direct is the health advice and information service provided by the National Health Service for residents and visitors in England, with advice offered 24 hours a day, every day of the year through telephone contact on the national 0845 46 47 number, web based symptom checkers at and via...

provides telephone and email support services
NHS special health authorities
NHS Special Health Authority
A special health authority is a type of NHS trust which provide services on behalf of the National Health Service in England. Unlike other types of Trust, they operate nationally rather than serve a specific geographical area....

provide various types of services

Nearly all hospital doctors and nurses in England are employed by the NHS and work in NHS-run hospitals, with teams of more junior hospital doctors (most of whom are in training) being led by consultant

Consultant

A consultant is a professional who provides professional or expert advice in a particular area such as management, accountancy, the environment, entertainment, technology, law , human resources, marketing, emergency management, food production, medicine, finance, life management, economics, public...

s, each of whom is trained to provide expert advice and treatment within a specific specialty. But most General Practitioner

General practitioner

s, dentists, optometrists (opticians) and other providers of local health care 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 health care professionals and facilities in areas where there is insufficient provision by self-employed professionals.

In 2009, the NHS Hospital & Community Health Service plus the General Practice service had a total workforce of a little under 1.18 million full-time equivalent of which 0.61 m were qualified clinical staff such as doctors (0.13 million), nurses (0.34 m), scientists, therapists and technical staff (0.13 m), and ambulance staff (0.02 m).
It has been claimed that the NHS is the third or fifth largest workforce in the world, after the Chinese Army

People's Liberation Army

The People's Liberation Army is the unified military organization of all land, sea, strategic missile and air forces of the People's Republic of China. The PLA was established on August 1, 1927 — celebrated annually as "PLA Day" — as the military arm of the Communist Party of China...

, Indian Railways

Indian Railways

Indian Railways , abbreviated as IR , is a departmental undertaking of Government of India, which owns and operates most of India's rail transport. It is overseen by the Ministry of Railways of the Government of India....

and (as argued by Jon Hibbs, the NHS's head of news, in a press release from March 22, 2005) Wal-Mart

Wal-Mart

Wal-Mart Stores, Inc. , branded as Walmart since 2008 and Wal-Mart before then, is an American public multinational corporation that runs chains of large discount department stores and warehouse stores. The company is the world's 18th largest public corporation, according to the Forbes Global 2000...

and the United States Department of Defense

United States Department of Defense

The United States Department of Defense is the U.S...

.

The NHS also plays a unique role in the training of new doctors in England, with approximately 8000 places for student doctors each year, all of which are attached to an NHS University Hospital trust. After completing medical school, these new doctors must go on to complete a two-year foundation training programme to become fully registered with the General Medical Council

General Medical Council

The General Medical Council registers and regulates doctors practising in the United Kingdom. It has the power to revoke or restrict a doctor's registration if it deems them unfit to practise...

. Most go on to complete their foundation training years in an NHS hospital although some may opt for alternative employers such as the armed forces.

Most staff working for the NHS including non-clinical staff and GPs (most of whom [GP's] are self-employed) are eligible to join the NHS Pension Scheme

NHS Pension Scheme

The NHS Pension Scheme is a large pension scheme for people who work for the English NHS and NHS Wales. It is administered by the NHS Business Services Authority, a special health authority of the Department of Health of the United Kingdom....

which, from 1 April 2008, is an average-salary defined-benefit scheme.

In July 2010 it was announced that Britain planned to do a major decentralization of the National Health Service. This plan entails shifting control of England’s $160 billion annual health budget from a centralized bureaucracy to doctors at the local level, as well as shrinking the bureaucratic apparatus.

Current reform proposals

The coalition government's

Cameron Ministry

David Cameron is Prime Minister of the United Kingdom, after being invited by Queen Elizabeth II to form a new government after the resignation as Prime Minister of Gordon Brown on 11 May 2010. Leading a coalition government formed by the Conservative Party and the Liberal Democrats, the coalition...

white paper

White paper

on health reform, published on 12 July 2010, sets out the most significant reorganisation of the NHS in its history.
The white paper, Equity and excellence: liberating the NHS, has implications for all health organisations in the NHS and very significant changes for PCT

NHS Primary Care Trust

An NHS primary care trust is a type of NHS trust, part of the National Health Service in England. PCTs commission primary, community and secondary care from providers. Until 31 may2011 they also provided community services directly. Collectively PCT are responsible for spending around 80% of the...

s and strategic health authorities. It focuses on the Government’s wish to reduce bureaucracy by shifting power from the centre to GPs and patients, moving somewhere between £60 to £80 billion into the hands of groups of GPs to commission services.

Announcing the paper, the Secretary of State for Health

Secretary of State for Health

Andrew Lansley

Andrew David Lansley, CBE, MP is the UK Secretary of State for Health, who has been the Conservative Member of Parliament for South Cambridgeshire since the 1997 general election, and was Shadow Secretary of State for Health from June 2004 until becoming Secretary of State for Health in May 2010...

told parliamentarians of plans for all NHS trusts to become or be part of a foundation trust and used the white paper to reiterate three key principles:

patients at the centre of the NHS
changing the emphasis of measurement to clinical outcomes
empowering health professionals, in particular GPs.

The white paper sets out an ambitious timetable. By April 2012 it proposes:

establishing the Independent NHS Commissioning Board
establishing new local authority health and well-being boards
developing Monitor as an economic regulator.

The new commissioning system is expected to be in place by April 2013, by which time SHAs and PCTs will be abolished.

Following widespread criticism of the plans, on April 4, 2011, the Government announced a "pause" in the progress of the Health and Social Care Bill

Health and Social Care Bill 2011

to allow the government to 'listen, reflect and improve' the proposals.

Funding

The money to pay for the NHS comes directly from taxation. The 2008/9 budget roughly equates to a contribution of £1,980 for every man, woman and child in the UK.

When the NHS was launched in 1948 it had a budget of £437million (roughly £9billion at today’s value). In 2008/9 it received over 10 times that amount (more than £100billion).

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. However, in recent years investment levels have been double that to fund a major modernisation programme.

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 and training costs on the one hand and medical equipment, catering and cleaning on the other. Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas.

The total budget of Department of Health in England in 2008/9 was £94bn of which NHS England accounted for £92.5bn. The National Audit Office

National Audit Office (United Kingdom)

The National Audit Office is an independent Parliamentary body in the United Kingdom which is responsible for auditing central government departments, government agencies and non-departmental public bodies...

reports annually on the summarised consolidated accounts of the NHS.

The commissioning system

The principal fundholders in the NHS system are the NHS Primary Care Trust

NHS Primary Care Trust

s (PCTs), that commission healthcare from hospitals, GPs and others. PCTs disburse funds to 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 financial objectives can result in the dismissal and replacement of a Trust's Board of Directors, although such dismissals are enormously expensive for the NHS.

Services free at the point of use

The vast majority of NHS services are free at the point of use.

This term, which is commonly used, means that people generally do not pay anything for their doctor visits, nursing services, surgical procedures or appliances, consumables such as medications and bandages, plasters, medical tests, and investigations, x-rays, CT or MRI scans etc. Hospital inpatient and outpatient services are free, both medical and mental health services. This is because these services are all pre-paid from taxation.

Because the NHS is not funded by contributory insurance scheme in the ordinary sense and most patients pay nothing for their treatment there is thus no billing to the treated person nor to any insurer or sickness fund as is common in many other countries. This saves hugely on administration costs which might otherwise involve complex consumable tracking and usage procedures at the patient level and concomitant invoicing, reconciliation and bad debt processing.

Eligibility for free NHS services is based on having "permanent residence status" (a birthright for some or granted by the Home Office for those who have immigrated). The person must be registered with a general practitioner and have an NHS card and number. This will include overseas students with a visa to study at a recognized institution for 6 months or more, but not visitors on a tourist visa for example.

Citizens of the EU holding a valid European Health Insurance Card

European Health Insurance Card

The European Health Insurance Card is issued free of charge and allows anyone who is insured by or covered by a statutory social security scheme of the EEA countries and Switzerland to receive medical treatment in another member state for free or at a reduced cost, if that treatment becomes...

and persons from certain other countries with which the UK has reciprocal arrangements concerning health care can likewise get emergency treatment without charge.

In England, from 15 January 2007, anyone who is working outside the UK as a missionary

Missionary

A missionary is a member of a religious group sent into an area to do evangelism or ministries of service, such as education, literacy, social justice, health care and economic development. The word "mission" originates from 1598 when the Jesuits sent members abroad, derived from the Latin...

for an organisation with its principal place of business in the UK is 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 and other work.

Those who are not "ordinarily resident" who do not fall into the above category (including British citizens

British nationality law

British nationality law is the law of the United Kingdom that concerns citizenship and other categories of British nationality. The law is complex because of the United Kingdom's former status as an imperial power.-History:...

who may have paid National Insurance contributions in the past) are liable to charges for services.

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

the prescription charge for medicines was £7.40 (which contrasts with Scotland, Wales and Northern Ireland where they are free). People over sixty, children under sixteen (or under nineteen if 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 its 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 Prescription drugs.

The high and rising costs of some medicines, especially some types of cancer treatment, means that prescriptions can present a heavy burden to the PCT

NHS Primary Care Trust

s, whose limited budgets include responsibility for the difference between medicine costs and the fixed prescription charge. This has led to disputes whether some expensive drugs (e.g. Herceptin) should be prescribed by the NHS.

NHS dentistry

Following the government's introduction of a new contract in April 2006, NHS dentistry is not as widely available as it once was, with 900,000 fewer patients seeing an NHS dentist in 2008 and 300,000 losing their NHS dentist in a single month. This has forced many patients to pay much higher sums for private treatment, and has been criticised by the British Dental Association

British Dental Association

The British Dental Association is the largest voluntary membership organisation for dentists in the UK.-Structure:The majority of the BDA’s 22,000 members are family dentists, working in general practice providing both National Health Service and private care...

as having "failed to improve access to care for patients and failed to allow dentists to provide the modern, preventive care they want to deliver".

Where available, NHS dentistry charges were: £17 for an examination; £47 for a filling or extraction; and £204 for more complex procedures such as crowns, dentures or bridges. Less than 50% of the turnover of dentists comes from work sub-contracted from the NHS.

NHS Optical Services

From 1 April 2007 the NHS Sight Test Fee (in England) was £19.32, and there were 13.1 million NHS sight tests carried out in the UK.

For those who qualify through need, the sight test is free, and a voucher system is employed to pay for or reduce the cost of lenses. There is a free spectacles frame and most opticians keep a selection of low-cost items. For those who already receive certain means-tested benefits, or who otherwise qualify, participating opticians use tables to find the amount of the subsidy. An extract of the NHS benefits profile for spectacles is given in the table below, and a more detailed discussion of optical vouchers can be found at NHS Optical Benefits in the UK.

NHS Voucher Values for Single Vision Spectacles
Prescription Details	2008	2009
A. Single vision lenses of a spherical power not more than 6 dioptres but with cylindrical power not more than 2 dioptres.	£35.50	£36.20
B. Single vision lenses: 1. Spherical power more than 6 dioptres but less than 10 dioptres with cylindrical power not more than 6 dioptres; 2. Spherical power less than 10 dioptres and a cylindrical power more than 2 dioptres but not more than 6 dioptres.	£54.00	£55.10
C. Spherical power 10 or more dioptres but not more than 14 dioptres with cylindrical power not more than 6 dioptres.	£79.00	£80.60
D. Single vision lenses: 1. Spherical power of more than 14 dioptres with any cylindrical power; 2. Cylindrical power of more than 6 dioptres with any spherical power.	£178.40	£182.00

Notes on the table:

The term 'single-vision' means simple glasses for one purpose, as opposed to multifocals.
The table intends the use of the highest powers for sphere and cylinder in the glasses, assuming that the prescription is written in the cylinder format that yields the highest spherical power.

Where vouchers do not cover the cost of the selected product, they reduce the cost at their face value. Although these voucher values are the maximum amounts that opticians can recover from the NHS, they might well make additional marketing offers of their own. See the external site Optical Voucher Values for a full NHS listing that includes varifocals, contact lenses, and essential coatings.

Injury cost recovery scheme

Under older legislation (mainly the Road Traffic Act 1930

Road Traffic Act 1930

The Road Traffic Act 1930 was an Act of the Parliament of the United Kingdom introduced by the then Minister of Transport Herbert Morrison following the 1929 election which resulted in a hung parliament in which the Labour party won the most seats for the first time and Ramsay MacDonald became...

) a hospital treating the victims of a road traffic accident was entitled to limited compensation (under the 1930 Act before any amendment, up to 25 pounds per person treated) from the insurers of driver(s) of the vehicle(s) involved but were not compelled to do so and often did not do so; the charge was in turn covered by the then legally required element of those drivers' motor vehicle insurance (commonly known as Road Traffic Act insurance when a driver held only that amount of insurance). As the initial bill was sent to the driver rather than to his/her insurer, even when a charge was imposed it was often not passed on to the liable insurer; it was common for no further action to be taken in such cases as there was no practical financial incentive (and often a financial disincentive due to potential legal costs) for individual hospitals to do so.

The Road Traffic (NHS Charges) Act 1999 introduced a standard national scheme for recovery of costs using a tariff based on a single charge for out-patient treatment or a daily charge for in-patient treatment; these charges again ultimately fell upon insurers. This scheme did not however fully cover the costs of treatment in serious cases.

Since January 2007, the NHS has a duty to claim back the cost of treatment, and for ambulance services, for those who have been paid personal injury compensation. In the last year of the scheme immediately preceding 2007, over £128 million was reclaimed.

Car park charges

Car parking charges are a minor source of additional revenue for the NHS, with most hospitals deriving about 0.25% of their budget from them. The level of fees is controlled individually by each trust. In 2006 car park fees contributed £78 million towards hospital budgets. Patient groups are opposed to such charges. (This contrasts with Scotland where car park charges were mostly scrapped from the beginning of 2009 and with Wales where car park charges are due to be scrapped by the end of 2011.)

Charitable funds

There are over 300 official NHS charities in England and Wales. Collectively, they hold assets in excess of £2bn and have an annual income in excess of £300m. Some NHS charities have their own independent board of trustees whilst in other cases the relevant NHS Trust acts as a corporate Trustee. Charitable funds are typically used for medical research, larger items of medical equipment, aesthetic and environmental improvements, or services which increase patient comfort.

In addition to official NHS charities, many other charities raise funds which are spent through the NHS, particularly in connection with medical research and capital appeals.

Regional lotteries

Lottery

A lottery is a form of gambling which involves the drawing of lots for a prize.Lottery is outlawed by some governments, while others endorse it to the extent of organizing a national or state lottery. It is common to find some degree of regulation of lottery by governments...

were also common for fundraising, and in 1988, a National Health Service Lottery

National Health Service Lottery

The National Health Service Lottery was a failed lottery scheme designed to provide funding for the National Health Service in the United Kingdom...

was approved by the government, before being found to be illegal. The idea continued to become the National Lottery

National Lottery (United Kingdom)

The National Lottery is the state-franchised national lottery in the United Kingdom and the Isle of Man.It is operated by Camelot Group, to whom the licence was granted in 1994, 2001 and again in 2007. The lottery is regulated by the National Lottery Commission, and was established by the then...

Financial outlook

As each division of the NHS is required to break even at the end of each financial year, 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. Former Secretary of State for Health

Secretary of State for Health

Patricia Hewitt

Patricia Hope Hewitt is an Australian-born British Labour Party politician, who was the Member of Parliament for Leicester West from 1997 until 2010. She served in the Cabinet until 2007, most recently as Health Secretary....

consistently asserted that the NHS would 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.

Changes 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 Prime Minister

Prime minister

A prime minister is the most senior minister of cabinet in the executive branch of government in a parliamentary system. In many systems, the prime minister selects and may dismiss other members of the cabinet, and allocates posts to members within the government. In most systems, the prime...

Margaret Thatcher

Margaret Hilda Thatcher, Baroness Thatcher, was Prime Minister of the United Kingdom from 1979 to 1990...

announced a review of the NHS. From this review in 1989 two white paper

White paper

s 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 England, the National Health Service and Community Care Act 1990

National Health Service and Community Care Act 1990

The National Health Service and Community Care Act 1990 is a piece of legislation which governs health care and social care in the United Kingdom...

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

NHS Trust

, which encouraged competition but also increased local differences. Increasing competition may have been statistically associated with poor patient outcomes.

Changes under the Blair government

These innovations, especially the "fund holder" option, were condemned at the time by the Labour Party

Labour Party (UK)

. Opposition to what was claimed to be the Conservative

Conservative Party (UK)

The Conservative Party, formally the Conservative and Unionist Party, is a centre-right political party in the United Kingdom that adheres to the philosophies of conservatism and British unionism. It is the largest political party in the UK, and is currently the largest single party in the House...

intention to privatise the NHS became a major feature of Labour's election campaigns.

Labour came to power in 1997 with the promise to remove the "internal market" and abolish fundholding. In a speech given by the new Prime Minister, Tony Blair

Tony Blair

Anthony Charles Lynton Blair is a former British Labour Party politician who served as the Prime Minister of the United Kingdom from 2 May 1997 to 27 June 2007. He was the Member of Parliament for Sedgefield from 1983 to 2007 and Leader of the Labour Party from 1994 to 2007...

, at the Lonsdale Medical Centre on 9 December 1997, he stated that:

"The White Paper we are publishing today marks a turning point for the NHS. It replaces the internal market with "integrated care
Integrated Care
Integrated care – also known as coordinated care, comprehensive care, seamless care and transmural care – is a worldwide trend in health care reforms and new organizational arrangements focusing on more coordinated and integrated forms of care provision...

". We will put doctors and nurses in the driving seat. The result will be that £1 billion of unnecessary red tape will be saved and the money put into frontline patient care. For the first time the need to ensure that high quality care is spread throughout the service will be taken seriously. National standards of care will be guaranteed. There will be easier and swifter access to the NHS when you need it. Our approach combines efficiency and quality with a belief in fairness and partnership. Comparing not competing will drive efficiency."

However in his second term Blair renounced this direction. He pursued measures to strengthen the internal market as part of his plan to "modernise" the NHS.

Driving these reforms have been a number of factors. They include the rising costs of medical technology and medicines, the desire to improve standards and "patient choice", an ageing population, and a desire to contain government expenditure. (Since the National Health Services in Wales, Scotland and Northern Ireland are not controlled by the UK government, these reforms have increased the differences between the National Health Services in different parts of the United Kingdom. See NHS Wales and NHS Scotland

NHS Scotland

NHS Scotland is the publicly funded healthcare system of Scotland. Although they are separate bodies the organisational separation between NHS Scotland and the other three healthcare organisations each commonly called the National Health Service in the United Kingdom tends to be hidden from its...

for descriptions of their developments).

Reforms have included (amongst other actions) the laying down of detailed service standards

Standards for Better Health

Standards for Better Health are a set of standards that the National Health Service in England must meet. The standards were set out by the Department of Health of the United Kingdom in a document of the same name published in 2004...

, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous clinical

Clinical governance

Clinical governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. The term became widely used in health care following the Bristol heart scandal in 1995, during which anaesthetist Dr Stephen Bolsin exposed the...

and corporate governance

Corporate governance

Corporate governance is a number of processes, customs, policies, laws, and institutions which have impact on the way a company is controlled...

. In addition Modernising Medical Careers

Modernising Medical Careers

Modernising Medical Careers is a programme for postgraduate medical training introduced in the UK from 2005 onwards. The programme replaced the traditional grades of medical career before the level of Consultant. The different stages of the programme contribute towards a "Certificate of...

(MMC) medical training has undergone an unsuccessful restructuring which was so badly managed that the Secretary of State for Health was forced to apologise publicly. MMC is now being revised but its flawed implementation has left the NHS with significant medical staffing problems which are unlikely to be resolved before 2010. Some new services have been developed to help manage demand, including NHS Direct

NHS Direct

NHS Direct is the health advice and information service provided by the National Health Service for residents and visitors in England, with advice offered 24 hours a day, every day of the year through telephone contact on the national 0845 46 47 number, web based symptom checkers at and via...

. A new emphasis has been given to staff reforms, with the Agenda for Change

Agenda for Change

Agenda for Change is the current National Health Service grading and pay system for all NHS staff, with the exception of doctors, dentists and some senior managers...

agreement providing harmonised pay and career progression. These changes have, however, given rise to controversy within the medical professions, the news media and the public. The British Medical Association

British Medical Association

in 2009 in a document on Independent Sector Treatment Centre

Independent Sector Treatment Centre

Independent sector treatment centres are private-sector owned treatment centres contracted within the English National Health Service to treat NHS patients free at the point of use, like any other NHS hospital. They are sometimes referred to as 'surgicentres' or ‘specialist hospitals’.ISTCs are...

s urged the Government to restore the NHS to a service based on public provision, not private ownership; co-operation, not competition; integration, not fragmentation; public service, not private profits, saying "The BMA is committed to an NHS funded from general taxation providing care free at the point of delivery and advancing the social goal of providing healthcare fairly and transparently. The BMA wishes to reverse the current government’s policy, and that of the main opposition parties, which actively promotes a market approach in the NHS, with its emphasis on competition and private sector involvement at the expense of co-operation and a public sector ethos."

The Blair

Tony 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

Private Finance Initiative

The private finance initiative is a way of creating "public–private partnerships" by funding public infrastructure projects with private capital...

, an increasing number of hospitals have been built (or rebuilt) by private sector consortia; hospitals may have both medical services such as independent Sector Treatment Centre

Independent Sector Treatment Centre

s (ISTCs) and non-medical services such as catering provided under long-term contracts by the private sector. 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.

Secretary of State for Health Patricia Hewitt

Patricia Hewitt

said in 2005 that ISTCs would treat around 3% of NHS patients in England having routine surgery that year, and that by 2008 this was expected to be around 10%. NHS Primary Care Trust

NHS Primary Care Trust

s were given the target of sourcing at least 15% of primary care from the private or voluntary sectors over the medium term. However, a generally favourable February 2008 CBI

Confederation of British Industry

The Confederation of British Industry is a British not for profit organisation incorporated by Royal charter which promotes the interests of its members, some 200,000 British businesses, a figure which includes some 80% of FTSE 100 companies and around 50% of FTSE 350 companies.-Role:The CBI works...

document on "ISTCs and the NHS" reported that "of the
27 schemes originally intended, only nine are going ahead. Five schemes were cancelled in 2006 and a further six in
November 2007. The remaining seven contracts are under review until March 2008" and that "the ISTC programme was originally designed to provide 15% of the NHS’s elective care capacity ... but the original programme is being scaled back and ... ISTCs are likely to make up only 5% of the NHS’s elective care capacity."

As a corollary to these initiatives, the NHS has been required to take on pro-active socially "directive" policies, for example, in respect of smoking

Tobacco smoking

Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...

and obesity

Obesity

Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...

.

The NHS has encountered significant problems with the IT

Information technology

Information technology is the acquisition, processing, storage and dissemination of vocal, pictorial, textual and numerical information by a microelectronics-based combination of computing and telecommunications...

innovations accompanying the Blair reforms. The NHS National Programme for IT (NPfIT), believed to be the largest IT project in the world, has been 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 complexity and a lack of consultation. Key "front-end" parts of the programme include Choose and Book

Choose and Book

Choose and Book , is an E-Booking software application which has been introduced to the National Health Service in England...

, intended to assist patient choice of location for treatment, which has missed numerous deadlines for going live, substantially overrun its original budget, and was still available in only a few locations. The programme to computerise all NHS patient records has also had great difficulties. Furthermore there were unresolved financial and managerial issues on training NHS staff to introduce and maintain these systems once operative. Due to the aforementioned difficulties, the Conservative-Liberal coalition government announced in September 2010 that the programme would be dismantled, and that individual hospital trusts would be assigned responsibility for their own IT infrastructures.

Internet information service

Despite problems with internal IT programmes, the NHS has broken new ground in providing health information to the publc via the internet. In June 2007 www.nhs.uk was relaunched under the banner "NHS Choices" as a comprehensive health information service for the public.

Ben Bradshaw, Minister of State for Health Services, told the House of Commons in a written answer on March 25, 2008:

"NHS Choices (www.nhs.uk) is the National Health Service's online service for the public - the digital wing of the NHS. It is a response to the 21st century challenges of achieving better health and delivering high quality personalised services for all, amid ever-increasing demands on a resource-constrained NHS.

As the online service for all communication with citizens on health, it has been designed specifically with the consumer in mind. The information on NHS Choices is all NHS accredited and written in plain English. It is accompanied by videos,
user comments and a growing range of interactive tools which allow users to test and monitor their health and well-being. The information held on NHS Choices is designed so that general practitioners and others can print it off for people who don't have internet access.

There are in the region of 100,000 pages of content available on NHS Choices."

In a break with the norm for government sites, www.nhs.uk allows users to add public comments giving their views on individual hospitals and to add comments to the articles it carries. It also publishes blog

Blog

A blog is a type of website or part of a website supposed to be updated with new content from time to time. Blogs are usually maintained by an individual with regular entries of commentary, descriptions of events, or other material such as graphics or video. Entries are commonly displayed in...

s on a range of health topics written by patients, carers and clinicians and enables users to compare hospitals for treatment via a "scorecard". In April 2009 it became the first official site to publish hospital death rates (Hospital Standardised Mortality Rates) for the whole of England. Its Behind the Headlines daily health news analysis service, which critically appraises media stories and the science behind them, was declared Best Innovation in Medical Communication in the prestigious BMJ Group Awards 2009.

In April 2009, Mr. Bradshaw told the House of Commons in a written answer:

"Where digital services are offered to citizens, the Department is working to ensure no citizens are disadvantaged due to access to relevant technology ... In October 2008, NHS Choices launched a new Carers Direct hub on its site aimed at carers of people with disabilities and long-term conditions. NHS Choices is also developing an online training programme aimed at health information intermediaries, who can work with those who lack access to the internet. From April 2009, NHS Choices takes over the NHS Direct digital TV service on Freeview and will be developing this further as an access channel for non-internet users. "

11 of the NHS hospitals in the West London Cancer Network have been linked using the IOCOM Grid System

IOCOM

IOCOM, formerly known as InSORS, is an American technology corporation that develops and markets visual communication software. Founded in 1998 by Kevin Gleason and Michael Galich, and has an advisory board which includes Edward Zander, former Sprint Nextel executive John Garcia and Ian Foster...

. The NHS has reported that the Grid has helped increase collaboration and meeting attendance and even improved clinical decisions.

Health screening for over 40s

From 1 April 2008, everyone over 40 in England has been offered health checks for heart disease, stroke, diabetes and kidney disease under new government plans. However, doctors currently reserve judgment on the effectiveness of the policy.

Criticism

Although the NHS has a high level of popular public support within the country, the national press is perceived to be highly critical of it. This may have affected perceptions of the service within the country as a whole and outside. An independent survey conducted in 2004 found that users of the NHS often expressed very high levels of satisfaction about their personal experience of the medical services. Of hospital inpatients, 92% said they were satisfied with their treatment; 87% of GP users were satisfied with their GP; 87% of hospital outpatients were satisfied with the service they received; and 70% of Accident and Emergency department users reported being satisfied. When asked whether they agreed with the question "My local NHS is providing me with a good service” 67% of those surveyed agreed with it, and 51% agreed with the statement “The NHS is providing a good service." The reason for this disparity between personal experience and overall perceptions is not clear. It is also apparent from the survey that most people believe that the national press is generally critical of the service (64% reporting it as being critical compared to just 13% saying the national press is favourable), and also that the national press is the least reliable source of information (50% reporting it to be not very or not at all reliable, compared to 36% believing the press was reliable) . Newspapers were reported as being less favourable and also less reliable than the broadcast media. The most reliable sources of information were considered to be leaflets from GPs and information from friends (both 77% reported as reliable) and medical professionals (75% considered reliable). On many occasions, however, the uncovering of a scandal leads to changes which improve the service in many ways, and sometimes unexpectedly.

Some examples of criticism heard inside the UK and outside include the following.

Coverage and access

In the NHS, GP referrals are needed to access specialist care and one of the original roles of general practitioner

General practitioner

was to act as 'the gatekeeper'. This role as gatekeeper has become more prominent in the 1990s with the introduction of the 'internal market' with GPs managing funds to buy clinical services. 'Referral management centres' are also another recent innovation to divert referrals from GPs to cheaper nursing or therapy-led alternatives.

It has been argued that a nominal charge for an appointment with a GP could be introduced to prevent patients consulting their GP for frivolous reasons. To date, this has never been introduced to avoid the danger of patients avoiding consultations (for financial reasons) for conditions which might be potentially serious.

Although nominally a national service, the precise limits of coverage are rarely discussed and are determined not nationally but locally by each regional authority or trust. This means that some extremely expensive treatments may be available in some areas but not in others, the so-called postcode lottery. The exception to this are a few treatments which have been determined by NICE

NICE

NICE may refer to:* National Independent Cadres and Elites in Iraq* National Institute for Coordinated Experiments, a fictional organisation in C.S...

to be ineffective or relatively cost-ineffective (i.e. drugs that have only minor effect at great cost) are simply not offered by the NHS though may be available privately. Most NICE determinations are positive and not restrictive, and the grounds are usually clinical effectiveness and not cost effectiveness. Nevertheless the rare cases of non-recommendation on cost grounds have been called by some "rationing" and by others a sensible mechanism to control costs by funding only cost-effective evidence-based medicine

Evidence-based medicine

Evidence-based medicine or evidence-based practice aims to apply the best available evidence gained from the scientific method to clinical decision making. It seeks to assess the strength of evidence of the risks and benefits of treatments and diagnostic tests...

. On the first occasion that a NICE ruling went to judicial review

Judicial review

Judicial review is the doctrine under which legislative and executive actions are subject to review by the judiciary. Specific courts with judicial review power must annul the acts of the state when it finds them incompatible with a higher authority...

a claim submitted by the drug company Eisai (with support from Pfizer and Shire) regarding assessment for certain drugs at the onset of Alzheimer's Disease

Alzheimer's disease

Alzheimer's disease also known in medical literature as Alzheimer disease is the most common form of dementia. There is no cure for the disease, which worsens as it progresses, and eventually leads to death...

), the court upheld NICE's decision that the drugs are only cost-effective in later-stage disease. Claims that NICE did not properly evaluate the impact of the drugs on the quality of life of carers, that the figures on the cost of long-term care used in their analysis were too low were not upheld by the court and two further claims against NICE on grounds of "irrationality" and "procedural fairness" were also dismissed.

Politicisation

Over time, increased demand leads to continual political pressures to increase spending and widen the range of treatments available.

Supporters of the NHS would point out that the NHS has wide public support and the English population has as good a health outcome as many other similar countries, and often at much lower cost. Political pressure could work both ways, but the Blair government was elected in 1997 largely on a promise to invest more taxpayers' money in health to bring spending closer to the European average. Most people would prefer to see gradual improvements within the current framework and be able to hold politicians to account for the service. This is the position of all the major political parties, none of which has an agenda to replace the system. The Conservative Party says its policies are aimed at "Protecting and improving our health service by putting patients back at the heart of the NHS, and trusting the professionals to ensure that they are able to use their skills to make the fullest possible contribution to patient care.".

In 2009, arguments about reform of the United States

United States

The United States of America is a federal constitutional republic comprising fifty states and a federal district...

' $2.4 trillion healthcare system have led to the NHS being represented among critics as "evil", and "Orwellian". This has led to a vigorous defence of the NHS in the UK. One source said "people such as scientist Stephen Hawking

Stephen Hawking

Stephen William Hawking, CH, CBE, FRS, FRSA is an English theoretical physicist and cosmologist, whose scientific books and public appearances have made him an academic celebrity...

[who suffers from the crippling motor neurone disease

Motor neurone disease

The motor neurone diseases are a group of neurological disorders that selectively affect motor neurones, the cells that control voluntary muscle activity including speaking, walking, breathing, swallowing and general movement of the body. They are generally progressive in nature, and can cause...

] wouldn't have a chance in the UK, where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless"; Professor Hawking, who is a British citizen and resident, remarked "I wouldn't be here today if it were not for the NHS; I have received a large amount of high-quality treatment without which I would not have survived".

Waiting lists and the 18 week target

In the NHS, which aims to give a broad coverage of care to all without charging, health care is given on the grounds of clinical need, meaning that emergency cases (e.g. heart attacks

Myocardial infarction

Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...

) get instant access where those with less urgent needs (e.g. cataract

Cataract

A cataract is a clouding that develops in the crystalline lens of the eye or in its envelope, varying in degree from slight to complete opacity and obstructing the passage of light...

surgery) are given lower priority and so wait longer.

Although there are obvious arguments in favour of prioritising by clinical need rather than ability to pay, it can mean that waiting lists vary widely between regions. Patients waiting can choose to have a procedure done outside their local NHS district in order to be seen more quickly, and if the waiting time is long can often get private treatment at public expense, either in the UK or abroad. A major programme is underway in the NHS to reduce all wait times to 18 weeks by December 2008. This new target starts when the patient's own doctor writes to the hospital specialist and ends when treatment begins. It therefore includes the time to make the first appointment, and the time for all diagnostic tests to be completed, evaluated, and discussed with the patient, which were not in the previous target. It has been widely criticised by doctors, healthcare professionals, and think-tanks as diverting resources from more serious conditions to achieve politically motivated goals, and doubts persist over its achievability.

One aspect of patient care beyond the hospital's direct control has been delayed discharges which refers to patients who have been declared fit for discharge, but for some reason or other they are not able to return to their normal home. Often they are awaiting placement in some nursing home or other form of residential care. This strains hospital resources, through both increased costs and longer waiting times for other patients. Fines for social services departments did succeed in reducing bed-blocking, but the numbers are creeping up again.

"Superbugs"

Antibiotic-resistant

Antibiotic resistance

Antibiotic resistance is a type of drug resistance where a microorganism is able to survive exposure to an antibiotic. While a spontaneous or induced genetic mutation in bacteria may confer resistance to antimicrobial drugs, genes that confer resistance can be transferred between bacteria in a...

bacteria

Bacteria

Bacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...

("superbugs"), such as Methicillin-resistant Staphylococcus aureus

Methicillin-resistant Staphylococcus aureus

Methicillin-resistant Staphylococcus aureus is a bacterium responsible for several difficult-to-treat infections in humans. It is also called multidrug-resistant Staphylococcus aureus and oxacillin-resistant Staphylococcus aureus...

(MRSA) and Clostridium difficile

Clostridium difficile

Clostridium difficile , also known as "CDF/cdf", or "C...

, are found in NHS hospitals but recent attempts to reduce the problem have been quite successful. Both C. difficile and MRSA are, however, not exclusive to the NHS, existing in British private hospitals and throughout other western healthcare systems. The UK's record is good internationally. For instance, cases doubled in the USA's private healthcare system between 1999 and 2005, and the UK's death rate is half that of the USA's. The introduction of Private Finance Initiative

Private Finance Initiative

The private finance initiative is a way of creating "public–private partnerships" by funding public infrastructure projects with private capital...

cleaning contractors into the NHS and the associated "cutting corners on cleaning" have been blamed for the problem, as has increased drug resistance due to inappropriate prescribing of antibiotics and patients failing to complete courses of antibiotics.

Another viewpoint is that the spread of communicable diseases in hospitals is facilitated by the overcrowding in NHS hospitals with high bed occupancy rates (as the NHS has a low bed:population ratio produced by hospital bed closures and the increasing emphasis on increasing bed 'turnaround time').

Computerisation

The NHS has been criticised over the implementation of its National Programme for IT which is designed to provide the infrastructure for electronic prescribing

Electronic prescribing

Electronic prescribing or e-prescribing is the ability to send error-free, accurate, and understandable prescriptions electronically from the healthcare provider to the pharmacy. E-prescribing is meant to reduce the risks associated with traditional prescription script writing. It is also one of...

, booking appointments and elective surgery, and a national care records service. The programme has run into delays and overspends, with the initial budget of £2.3 billion over three years officially revised to £12.4bn over 10 years and some sources putting it as high as £20bn. Critics including the House of Commons Public Accounts Committee and the National Audit Office

National Audit Office (United Kingdom)

claim the project is falling behind schedule. In addition, 93% of doctors within the NHS are not confident their patients' data will be secure, some GP practices have begun to advise all their patients to opt-out of the scheme, and privacy campaigners have claimed the national care records system breaches patients' privacy rights.

The Government and NHS national leadership have consistently argued that major capital investment in IT is necessary to transform services. Fragmented information systems, as in the US, prevent health services providing consistent data and can damage patient care where doctors may not have an overview of patients records held by another NHS body.

Dentistry

There has been a decreasing availability of NHS dentistry following the new government contract and a trend towards dentists accepting private patients only, with 1 in 10 dentists having left the NHS totally. Many more continue to offer treatment for children under NHS regs but are disputing the imposed NHS contract.

Scandals

There have been a number of high-profile scandals within the NHS. The first to cause significant political disquiet was at Ely Hospital, a long stay institution for the mentally ill, in 1969. More recently there have been scandals at acute hospitals such as at Alder Hey

Alder Hey organs scandal

The Alder Hey organs scandal involved the unauthorised removal, retention, and disposal of human tissue, including children’s organs, during the period 1988 to 1995...

and at the Bristol Royal Infirmary

Bristol heart scandal

The Bristol heart scandal occurred in England during the 1990s. At the Bristol Royal Infirmary, babies died at high rates after cardiac surgery. An inquiry found "staff shortages, a lack of leadership, [a] ... unit ... 'simply not up to the task' ... 'an old boy's culture' among doctors, a lax...

. Stafford Hospital

Stafford Hospital scandal

The Stafford Hospital scandal came to light because of an investigation by the Healthcare Commission into the operation of Stafford Hospital in Stafford, England. The commission was first alerted by the "apparently high mortality rates in patients admitted as emergencies"...

is currently under investigation for poor conditions and inadequacies that statistical analysis has shown caused excess deaths.

Supporters would argue that there is nothing endemic about such issues which might equally have occurred in other types of health care establishments. The detection of such issues leads to better controls being established throughout the NHS for the benefit of all. For instance the inquiry into the Bristol babies scandal led to the publication of mortality statistics which has led to much lower mortalities and greatly improved services for people, with surgeons now taking on and treating higher risk patients which previously they may have been reluctant to treat.

An October 14, 2008 article in The Daily Telegraph

The Daily Telegraph

The Daily Telegraph is a daily morning broadsheet newspaper distributed throughout the United Kingdom and internationally. The newspaper was founded by Arthur B...

stated, "An NHS trust has spent more than £12,000 on private treatment for hospital staff because its own waiting times are too long."

In January 2010, the NHS has been accused of allocating £4 million annually on homeopathic medicines, which are unsupported by scientific research.

The "World Health Service"

People are eligible for NHS treatment, like any UK citizen, if they are “ordinarily resident” in the UK.
A lack of identity/residence checks on patients at clinics and hospitals allows people who ordinarily reside overseas to travel to the UK for the purpose of obtaining free treatment, at the expense of the UK taxpayer. A report published in 2007 estimates that the NHS bill for treatment of so-called ‘health tourists’ was £30m, 0.03% of the total cost. A Conservative Party MP has said that health checks on immigrants are vital to stop the NHS becoming a "world health service".

Quality of healthcare, and accreditation

There are various regulatory bodies in the UK, both government-based (e.g. Department of Health, General Medical Council

General Medical Council

The General Medical Council registers and regulates doctors practising in the United Kingdom. It has the power to revoke or restrict a doctor's registration if it deems them unfit to practise...

, Nursing and Midwifery Council

Nursing and Midwifery Council

Established in 2002, the Nursing and Midwifery Council is a statutory body set up by the Parliament of the United Kingdom through the . The NMC is the UK regulator for nursing and midwifery professions with a stated aim to safeguard the health and wellbeing of the public...

) and non-governmental-based (e.g. Royal College

Royal College

A Royal College in some Commonwealth countries is technically a college which has received permission to use the prefix Royal. Permission is usually granted through a Royal Charter. The charter normally confers a constitution with perpetual succession and the right to sue or be sued independently...

s). Some of these organisations have a high worldwide standing.

With respect to assessing, maintaining and improving the quality of healthcare, in common with the United States and many other developed countries, the UK government has separated the roles of suppliers of healthcare and assessors of the quality of its delivery. Quality is assessed by independent bodies such as the Healthcare Commission

Healthcare Commission

The Healthcare Commission was a non-departmental public body sponsored by the Department of Health of the United Kingdom. It was set up to promote and drive improvement in the quality of health care and public health in England and Wales...

according to standards

Standards for Better Health

set by the Department of Health and the National Institute for Health and Clinical Excellence

National Institute for Health and Clinical Excellence

The National Institute for Health and Clinical Excellence is a special health authority of the English National Health Service , serving both English NHS and the Welsh NHS...

. Responsibility for assessing quality will transfer to the Care Quality Commission

Care Quality Commission

The Care Quality Commission is a non-departmental public body of the United Kingdom government established in 2009 to regulate and inspect health and social care services in England. This includes services provided by the NHS, local authorities, private companies and voluntary organisations -...

from April 2009.

Independent accreditation groups exist within the UK, such as the public sector Trent Accreditation Scheme

Trent Accreditation Scheme

The Trent Accreditation Scheme , , was a British accreditation scheme formed with a mission to maintain and continually evaluate standards of quality, especially in health care delivery, through the surveying and accreditation of health care organisations, especially...

and the private sector CHKS.

The National Institute for Health Research

National Institute for Health Research

The National Institute for Health Research is a UK government body that coordinates and funds research for the National Health Service . Its tagline is "Improving the health and wealth of the nation through research". It supports individuals, facilities and research projects, in order to help...

is a government body that coordinates and funds research for the NHS in England.

A recent comparative analysis of health care systems put the NHS second in a study of seven rich countries. The report put the UK health systems above those of Germany, Canada and the US; the NHS was deemed the most efficient among those health systems studied.

History

Core Principles

Structure

Current reform proposals

Funding

The commissioning system

Services free at the point of use

Prescription charges

NHS dentistry

NHS Optical Services

Injury cost recovery scheme

Car park charges

Charitable funds

Financial outlook

Changes under the Thatcher government

Changes under the Blair government

Internet information service

Health screening for over 40s

Criticism

Coverage and access

Politicisation

Waiting lists and the 18 week target

"Superbugs"

Computerisation

Dentistry

Scandals

The "World Health Service"

Quality of healthcare, and accreditation

See also

English NHS and related government sites

Shared with other UK health services

Other sites

Further reading