Health care in the United Kingdom

Health care in the United Kingdom is a devolved matter, with England, Northern Ireland, Scotland and Wales each having their own systems of publicly funded healthcare, funded by and accountable to separate governments and parliaments, together with smaller private sector and voluntary provision. As a result of each country having different policies and priorities, a variety of differences now exist between these systems.[1][2]

Despite there being separate health services for each country, the performance of the National Health Service (NHS) across the UK can be measured for the purpose of making international comparisons. In a 2017 report by the Commonwealth Fund ranking developed-country healthcare systems, the United Kingdom was ranked the best healthcare system in the world overall and was ranked the best in the following categories: Care Process (i.e. effective, safe, coordinated, patient-oriented) and Equity.[3] The UK system was ranked the best in the world overall in the previous three reports by the Commonwealth Fund in 2007, 2010 and 2014.[4][5][6] The UK's palliative care has also been ranked as the best in the world by the Economist Intelligence Unit.[7] On the other hand, in 2005-09 cancer survival rates lagged ten years behind the rest of Europe,[8] although survival rates continue to increase.[9][10]

In 2015, the UK was 14th (out of 35) in the annual Euro health consumer index. It was criticised for its poor accessibility and "an autocratic top-down management culture".[11] The index has in turn been criticized by academics, however.[12]

The total expenditure on healthcare as a proportion of GDP in 2013 was 8.5%, below the OECD average of 8.9% and considerably less than comparable economies such as France (10.9%), Germany (11.0%), Netherlands (11.1%), Switzerland (11.1%) and the USA (16.4%).[13] The percentage of healthcare provided directly by the state is higher than most European countries, which have insurance-based healthcare with the state providing for those who cannot afford insurance.[14][15] In 2017 the UK spent £2,989 per person on healthcare, the second lowest of the Group of Seven, but around the median for members of the Organisation for Economic Co-operation and Development. [16] The NHS has a reasonable claim to be the most efficient healthcare system in the world. The 2018 OECD data, which incorporates in health a chunk of what in the UK is classified as social care, has the UK spending £3121 per head, France £3471, Australia £3892, Germany £4057 and Sweden £4877.[17]

The exit of the United Kingdom from the European Union could make an impact on the healthcare industry if there is a "no deal" Brexit. There are speculations that the supply of medicines to the UK will be hit. As a precautionary measure, the government has asked the drug companies to stock up a six-week supply of medicines and make arrangements for their storage.[18]

Common features

Each NHS system uses General Practitioners (GPs) to provide primary healthcare and to make referrals to further services as necessary. Hospitals then provide more specialist services, including care for patients with psychiatric illnesses, as well as direct access to Accident and Emergency (A&E) departments. Community pharmacies are privately owned but have contracts with the relevant health service to supply prescription drugs.

The public healthcare system also provides free (at the point of service) ambulance services for emergencies, when patients need the specialist transport only available from ambulance crews or when patients are not fit to travel home by public transport. These services are generally supplemented when necessary by the voluntary ambulance services (British Red Cross, St Andrews Ambulance Association and St John Ambulance). In addition, patient transport services by air are provided by the Scottish Ambulance Service in Scotland and elsewhere by county or regional air ambulance trusts (sometimes operated jointly with local police helicopter services[19]) throughout England and Wales.[20]

In specific emergencies, emergency air transport is also provided by naval, military and air force aircraft of whatever type might be appropriate or available on each occasion,[21] and dentists can only charge NHS patients at the set rates for each country. Patients opting to be treated privately do not receive any NHS funding for the treatment. About half of the income of dentists in England comes from work sub-contracted from the NHS,[22] however not all dentists choose to do NHS work.

When purchasing drugs, the NHS has significant market power that, based on its own assessment of the fair value of the drugs, influences the global price, typically keeping prices lower.[23] Several other countries either copy the U.K.'s model or directly rely on Britain’s assessments for their own decisions on state-financed drug reimbursements.[24]

Private medicine

Private medicine, where patients, or their insurers, pay for treatment in the UK is a niche market. Some is provided by NHS hospitals. Private providers also contract with the NHS, especially in England, to provide treatment for NHS patients, particularly in mental health and planned surgery.

Patients also go abroad for treatment. In 2014 about 48,000 went abroad for treatment and about 144,000 in 2016. This may be driven by increasing waiting times for NHS treatment, but will also include migrants who may return to their home country for treatment, especially childbirth. It also includes fertility services, dentistry and cosmetic surgery which may not be available on the NHS.[25] See Medical tourism.

Healthcare in England

The Norfolk and Norwich University Hospital, a National Health Service hospital.

Most healthcare in England is provided by the NHS England, England's publicly funded healthcare system, which accounts for most of the Department of Health and Social Care's budget (£122.5 billion[26] in 2017-18).

Commissioning

In April 2013, under the terms of the Health and Social Care Act 2012, a reorganisation of the NHS took place regarding the administration of the NHS. Primary care trusts (PCTs) and strategic health authorities (SHAs) were abolished, and replaced by clinical commissioning groups (CCGs).[27] CCGs now commission most of the hospital and community NHS services in the local areas for which they are responsible.[28] Commissioning involves deciding what services a population is likely to need, and ensuring that there is provision of these services.[29]

The CCGs are overseen by NHS England, formally known as the NHS Commissioning Board (NHS CB) which was established on 1 October 2012 as an executive non-departmental public body.[29] NHS England also has the responsibility for commissioning primary care services - General Practitioners, opticians and NHS dentistry, as well as some specialised hospital services. Services commissioned include general practice physician services (most of whom are private businesses working under contract to the NHS), community nursing, local clinics and mental health services.

Provider trusts are NHS bodies delivering health care service. They are involved in agreeing major capital and other health care spending projects in their region.[27] NHS trusts are care deliverers which spend money allocated to them by CCG's.[30] Secondary care (sometimes termed acute health care) can be either elective care or emergency care and providers may be in the public or private sector.[31]

Healthcare in Northern Ireland

The biggest part of healthcare in Northern Ireland is provided by Health and Social Care in Northern Ireland. Though this organization does not use the term 'National Health Service', it is still sometimes referred to as the 'NHS'.[32]

Healthcare in Scotland

The majority of healthcare in Scotland is provided by NHS Scotland; Scotland's current national system of publicly funded healthcare was created in 1948 at the same time as those in Northern Ireland and in England and Wales, incorporating and expanding upon services already provided by local and national authorities as well as private and charitable institutions. It remains a separate body from the other public health systems in the United Kingdom although this is often not realised by patients when "cross-border" or emergency care is involved due to the level of co-operation and co-ordination, occasionally becoming apparent in cases where patients are repatriated by the Scottish Ambulance Service to a hospital in their country of residence once essential treatment has been given but they are not yet fit to travel by non-ambulance transport.

Healthcare in Wales

The majority of healthcare in Wales is provided by NHS Wales. This body was originally formed as part of the same NHS structure for England and Wales created by the National Health Service Act 1946 but powers over the NHS in Wales came under the Secretary of State for Wales in 1969[33] and, in turn, responsibility for NHS Wales was passed to the Welsh Government under devolution in 1999.

Comparisons between the healthcare systems in the United Kingdom

Differences

Telephone advisory services

Each NHS system has developed ways of offering access to non-emergency medical advice. People in England[34] and Scotland can access these services by dialling the free-to-call 111 number. Scotland's service is run by NHS24.[35] The telephone number for NHS Direct Wales/Galw Iechyd Cymru[36] is 0845 4647, but this service intends to offer access through the 111 number from some point in 2015.[37]

Best practice and cost effectiveness

In England and Wales, the National Institute for Health and Clinical Excellence (NICE) sets guidelines for medical practitioners as to how various conditions should be treated and whether or not a particular treatment should be funded. These guidelines are established by panels of medical experts who specialise in the area being reviewed.

In Scotland, the Scottish Medicines Consortium advises NHS Boards there about all newly licensed medicines and formulations of existing medicines as well as the use of antimicrobiotics but does not assess vaccines, branded generics, non-prescription-only medicines (POMs), blood products and substitutes or diagnostic drugs. Some new drugs are available for prescription more quickly than in the rest of the United Kingdom. At times this has led to complaints.[38]

Cost control

The National Audit Office reports annually on the summarised consolidated accounts of the NHS, and Audit Scotland performs the same function for NHS Scotland.[39]

Since January 2007, the NHS have been able to claim back the cost of treatment, and for ambulance services, for those who have been paid personal injury compensation.[40]

Parking charges

Parking charges at hospitals have been abolished in Scotland (except for 3 PFI hospitals)[41] and have also been abolished in Wales.[42] Parking charges continue to be in place at many hospitals in England,[43] however, since April 2020, disabled people, frequent outpatient attenders, parents of sick children staying overnight and staff working night shifts have had access to free parking.[44]

Prescribed drugs

In a sample of 13 developed countries the UK was 9th in its population weighted usage of medication in 14 classes in both 2009 and 2013. The drugs studied were selected on the basis that the conditions treated had high incidence, prevalence and/or mortality, caused significant long-term morbidity and incurred high levels of expenditure and significant developments in prevention or treatment had been made in the last 10 years. The study noted considerable difficulties in cross border comparison of medication use.[45]

Northern Ireland, Scotland and Wales no longer have Prescription charges. However, in England, a prescription charge of £9.00 is payable per item as of April 2019,[46] though patients under 16 years old (16–18 years if still in full-time education) or over 60 years getting prescribed drugs are exempt from paying as are people with certain medical conditions, those on low incomes or in receipt of certain benefits, and those prescribed drugs for contraception.[47]

UK permanent residents in England do not pay the real cost of the medicines and so for some prescribed medicines that can be bought over the counter without a prescription, for example aspirin, it can be much cheaper to purchase these without a prescription. UK permanent residents in England who must pay can (instead of paying for each medical item individually) purchase a three-month Prescription Prepayment Certificate (PPC) costing £29.10. This saves the patient money where the patient needs three or more items in three months. There is also a 12-month PPC certificate costing £104.00 which saves patient's money if 12 or more items are needed in 12 months. There are no prescription charges anywhere in the UK for medicines administered at a hospital, by a doctor or at an NHS walk-in centre.[47]

Role of private sector in public healthcare

From the birth of the NHS in 1948, private medicine has continued to exist, paid for partly by private insurance. Provision of private healthcare acquired by means of private health insurance, funded as part of an employer funded healthcare scheme or paid directly by the customer, though provision can be restricted for those with conditions such as AIDS/HIV.[48] In recent years, despite some evidence that a large proportion of the public oppose such involvement,[49] the private sector has been used to increase NHS capacity. In addition, there is some relatively minor sector crossover between public and private provision with it possible for some NHS patients to be treated in private healthcare facilities[50] and some NHS facilities let out to the private sector for privately funded treatments or for pre- and post-operative care.[51] However, since private hospitals tend to manage only routine operations and lack a level 3 critical care unit (or intensive therapy unit), unexpected emergencies may lead to the patient being transferred to an NHS hospital.[52]

When the Blair government expanded the role of the private sector within the NHS in England,[53][54] the Scottish government reduced the role of the private sector within public healthcare in Scotland[55] and planned legislation to prevent the possibility of private companies running GP practices in future.[56] Later, however in an attempt to comply with the Scottish Treatment Time Guarantee, a 12-week target for inpatient or day-case patients waiting for treatment, NHS Lothian spent £11.3 million on private hospital treatment for NHS patients in 2013-14.[57]

Funding and performance of healthcare since devolution

In January 2010 the Nuffield Trust published a comparative study of NHS performance in England and the devolved administrations since devolution, concluding that while Scotland, Wales and Northern Ireland have had higher levels of funding per capita than England, with the latter having fewer doctors, nurses and managers per head of population, the English NHS is making better use of the resources by delivering relatively higher levels of activity, crude productivity of its staff, and lower waiting times.[58] However, the Nuffield Trust quickly issued a clarifying statement in which they admitted that the figures they used to make comparisons between Scotland and the rest of the United Kingdom were inaccurate due to the figure for medical staff in Scotland being overestimated by 27 per cent.[59]

Using revised figures for medical staffing, Scotland's ranking relative to the other devolved nations on crude productivity for medical staff changes, but there is no change relative to England.[60] The Nuffield Trust study was comprehensively criticised by the BMA which concluded "whilst the paper raises issues which are genuinely worth debating in the context of devolution, these issues do not tell the full story, nor are they unambiguously to the disadvantage of the devolved countries. The emphasis on policies which have been prioritised in England such as maximum waiting times will tend to reflect badly on countries which have prioritised spending increases in other areas including non-health ones."[61]

In April 2014 the Nuffield Trust produced a further comparative report "The four health systems of the UK: How do they compare?" which concluded that despite the widely publicised policy differences there was little sign that any one country was moving ahead of the others consistently across the available indicators of performance. It also complained that there was an increasingly limited set of comparable data on the four health systems of the UK which made comparison difficult.

In February 2016 the Organisation for Economic Co-operation and Development published a review which concluded that performance of the NHS in Wales was little different from that in the rest of the UK. They described performance across the UK as "fairly mediocre" saying that great policies were not being translated into great practices. They suggested that GPs should be more involved in health boards and that resources should be shifted out of hospitals.[62]

History

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