National Health Service (England)

The National Health Service (NHS) is the publicly funded healthcare system in England, and one of the four National Health Service systems in the United Kingdom. It is the second largest single-payer healthcare system in the world after the Brazilian Sistema Único de Saúde. Primarily funded by the government from general taxation (plus a small amount from National Insurance contributions), and overseen by the Department of Health and Social Care, the NHS provides healthcare to all legal English residents and residents from other regions of the UK, with most services free at the point of use. Some services, such as emergency treatment and treatment of infectious diseases, are free for most people, including visitors. [2]

This article is about the health service in England. For its oversight body, see NHS England. For the UK as a whole, see National Health Service.

National Health Service
Publicly funded health service overview
FormedFounded on July 5th 1948 72 years ago
JurisdictionEngland
HeadquartersRichmond House, London, England
Employees1.4 million
Annual budget£134 billion (2019)[1]
Minister responsible
Publicly funded health service executive
  • Simon Stevens, Chief Executive of the National Health Service
Parent departmentDepartment of Health and Social Care
Websitewww.nhs.uk
Norfolk and Norwich University Hospital, which with 1237 beds is one of the largest NHS hospitals
Queen Elizabeth Hospital Birmingham, another large NHS hospital in England, which has 1213 beds

Free healthcare at the point of use comes from the core principles at the founding of the National Health Service. The 1942 Beveridge cross party report established the principles of the NHS which was implemented by the Labour government in 1948. In practice, "free at the point of use" normally means that anyone legitimately and fully registered with the system (i.e., in possession of an NHS number), available to legal UK residents regardless of nationality (but not non-resident British citizens), can access the full breadth of critical and non-critical medical care, without payment except for some specific NHS services, for example eye tests, dental care, prescriptions and aspects of long-term care. These charges are usually lower than equivalent services provided by a private provider and many are free to vulnerable or low-income patients.[3][4]

The NHS provides the majority of healthcare in England, including primary care, in-patient care, long-term healthcare, ophthalmology and dentistry. The National Health Service Act 1946 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.

The NHS is largely funded from general taxation, with a small amount being contributed by National Insurance payments[5] and from fees levied in accordance with recent changes in the Immigration Act 2014.[6] The UK government department responsible for the NHS is the Department of Health and Social Care, headed by the Secretary of State for Health and Social Care. On 9 January 2018, the Department of Health was renamed the Department of Health and Social Care. The Department of Health had a £110 billion budget in 2013–14, most of this being spent on the NHS.

Organisation

The NHS was established within the differing nations of the United Kingdom through differing legislation, and such there has never been a singular British healthcare system, instead there are 4 health services in the United Kingdom; NHS England, the NHS Scotland, HSC Northern Ireland and NHS Wales, which were run by the respective UK government ministries for each home nation before falling under the control of devolved governments in 1999.[7] In 2009, NHS England agreed to a formal NHS constitution, 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.[8]

The Health and Social Care Act 2012 came into effect in April 2013, giving GP-led groups responsibility for commissioning most local NHS services. Starting in April 2013, primary care trusts (PCTs) began to be replaced by general practitioner (GP)-led organisations called clinical commissioning groups (CCGs). Under the new system, a new NHS Commissioning Board, called NHS England, oversees the NHS from the Department of Health.[9] The Act has also become associated with the perception of increased private provision of NHS services. In reality, the provision of NHS services by private companies long precedes this legislation, but there are concerns that the new role of the healthcare regulator ('Monitor') could lead to increased use of private-sector competition, balancing care options between private companies, charities, and NHS organisations.[9] NHS trusts responded to the Nicholson challenge—which involved making £20 billion in savings across the service by 2015.

History
Main article: History of the National Health Service (England)
Aneurin Bevan. As health minister from 1945 to 1951, he spearheaded the establishment of the National Health Service
Leaflet concerning the launch of the NHS in England and Wales

A. J. Cronin's controversial novel The Citadel, published in 1937, had fomented extensive debate about the severe inadequacies of healthcare. The author's innovative ideas were not only essential to the conception of the NHS, but in fact, his best-selling novels are said to have greatly contributed to the Labour Party's victory in 1945.[10]

A national health service was one of the fundamental assumptions in the Beveridge Report. The Emergency Hospital Service established in 1939 gave a taste of what a National Health Service might look like.

Healthcare prior to the war had been an unsatisfactory mix of private, municipal and charity schemes. Bevan decided that the way forward was a national system rather than a system operated by local authorities. He proposed that each resident of the UK would be signed up to a specific General Practice (GP) as the point of entry into the system, building on the foundations laid in 1912 by the introduction of National Insurance and the list system for general practice. Patients would have access to all medical, dental and nursing care they needed without having to pay for it at the time.

In the 1980s, Thatcherism represented a systematic, decisive rejection and reversal of the post-war consensus, wherein the major political parties largely agreed on the central themes of Keynesianism, the welfare state, the mixed economy, supplies both of public and private housing, and close regulation of the economy. There was one major exception: the National Health Service, which was widely popular and had wide support inside the Conservative Party. In 1982, Prime Minister Margaret Thatcher promised Britons that the NHS is "safe in our hands."[11]

Core principles

The principal NHS website states the following as core principles:[12]

The NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth. At its launch by the then minister of health, Aneurin Bevan, on 5 July 1948, it had at its heart three core principles:

  • That it meet the needs of everyone
  • That it be free at the point of delivery
  • That it be based on clinical need, not ability to pay

These three principles have guided the development of the NHS over more than half a century and remain. However, in July 2000, a full-scale modernisation programme was launched and new principles added.

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 minimise 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
Main article: Health and Social Care Act 2012

The English NHS is controlled by the UK government through the Department of Health and Social Care (DHSC), which takes political responsibility for the service. Resource allocation and oversight was delegated to NHS England, an arms-length body, by the Health and Social Care Act 2012. NHS England commissions primary care services (including GPs) and some specialist services, and allocates funding to 211[13] geographically-based clinical commissioning groups (CCGs) across England. The CCGs commission most services in their areas, including hospital and community-based healthcare.[14]

A number of types of organisation are commissioned to provide NHS services, including NHS trusts and private sector companies. Many NHS trusts have become NHS foundation trusts, giving them an independent legal status and greater financial freedoms. The following types of NHS trusts and foundation trusts provide NHS services in specific areas:[15]

Some services are provided at a national level, including:

  • 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 special health authorities provide various types of services

Staffing

In the year ending at March 2017, there were 1.187 million staff in England's NHS, 1.9% more than in March 2016.[16] There were 34,260 unfilled nursing and midwifery posts in England by September 2017, this was the highest level since records began.[17] 23% of women giving birth were left alone part of the time causing anxiety to the women and possible danger to them and their babies. This is because there are too few midwives.[18] Neonatal mortality rose from 2.6 deaths for every 1,000 births in 2015 to 2.7 deaths per 1,000 births in 2016. Infant mortality (deaths during the first year of life) rose from 3.7 to 3.8 per 1,000 live births during the same period.[19] Assaults on NHS staff have increased, there were 56,435 recorded physical assaults on staff in 2016–2017, 9.7% more than the 51,447 the year before. Low staffing levels and delays in patients being treated are blamed for this.[20]

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 consultants, each of whom is trained to provide expert advice and treatment within a specific speciality. From 2017, NHS doctors must reveal how much money they make from private practice.[21]

General practitioners, 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.

Staff in NHS England from 2010 - 2017.[22]
Year[23]NursesDoctorsOther qualified[24]ManagersTotal
1978339,65855,00026,000-1,003,000[25] (UK)
2010318,935102,422180,62140,0251,168,750[22]
2011317,157103,898184,86935,0141,158,920[22]
2012310,359105,019183,81833,0231,128,140[22]
2013308,782106,151184,57132,4291,123,529[22]
2014314,097107,896187,69928,4991,126,947[22]
2015316,117109,890189,32130,2211,143,102[22]
2016318,912110,732193,07331,5231,164,471[22]
2017319,845113,508198,78332,5881,187,125[22]

Note that due to methodological changes, the 1978 figure is not directly comparable with later figures.

A 2012 analysis by the BBC estimated that the NHS across the whole UK has 1.7 million staff, which made it fifth on the list of the world's largest employers (well above Indian Railways).[26] In 2015 the Health Service Journal reported that there were 587,647 non-clinical staff in the English NHS. 17% worked supporting clinical staff. 2% in cleaning and 14% administrative. 16,211 were finance staff.[27]

The NHS plays a unique role in the training of new doctors in England, with approximately 8,000 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. 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.[28]

Most NHS staff, including non-clinical staff and GPs (although most GPs are self-employed), are eligible to join the NHS Pension Scheme—which, from 1 April 2015, is an average-salary defined-benefit scheme.

Among the current challenges with recruiting staff are pay, work pressure,[29][30][31] and difficulty recruiting and retaining staff from EU countries due to Brexit.[32] and there are fears that doctors could also leave.[33][34]

2012 reforms
Main article: Health and Social Care Act 2012

The coalition government's white paper on health reform, published in July 2010, set out a significant reorganisation of the NHS. The white paper, Equity and excellence: liberating the NHS,[35] with implications for all health organisations in the NHS abolishing primary care trusts and strategic health authorities. It claimed to shift power from the centre to GPs and patients, moving somewhere between £60 to £80 billion into the hands of clinical commissioning groups to commission services. The bill became law in March 2012 with a government majority of 88 and following more than 1,000 amendments in the House of Commons and the House of Lords.

Funding

The total budget of Department of Health in England in 2017/18 is £124.7 billion.[36] £13.8 billion was spent on medicines.[37] The National Audit Office reports annually on the summarised consolidated accounts of the NHS.[38]

The population of England is ageing, which has led to an increase in health demand and funding.From 2011 to 2018, the population of England increased by about 6%. The number of patients admitted to hospital in an emergency went up by 15%.[39]  There were 542,435 emergency hospital admissions in England in October 2018, 5.8% more than in October 2017.[40] Health spending in England is expected to rise from £112 billion in 2009/10 to £127 billion in 2019/20 (in real terms),[36] and spending per head will increase by 3.5%.[41]

However, according to the Institute for Fiscal Studies (IFS), compared to the increase necessary to keep up with a rising population that is also ageing, spending will fall by 1.3% from 2009–10 to 2019–20.[42][41] George Stoye, senior research economist of the IFS, and said the annual increases since 2009-10 were "the lowest rate of increase over any similar period since the mid-1950s, since when the long-run annual growth rate has been 4.1%".[42] This has led to cuts to some services, despite the overall increase in funding.[43] In 2017, funding increased by 1.3% while demand rose by 5%.[44] Ted Baker, Chief Inspector of Hospitals has said that the NHS is still running the model it had in the 1960s and 1970s and has not modernised due to lack of investment.[45] The British Medical Association (BMA) has called for £10bn more annually for the NHS to get in line with what other advanced European nations spend on health.[46]

The commissioning system

From 2003 to 2013 the principal fundholders in the NHS system were the primary care trusts (PCTs), that commissioned healthcare from NHS trusts, GPs and private providers. PCTs disbursed funds to them on an agreed tariff or contract basis, on guidelines set out by the Department of Health. The PCTs budget from the Department of Health was calculated on a formula basis relating to population and specific local needs. They were supposed to "break even" – that is, not show a deficit on their budgets at the end of the financial year. Failure to meet financial objectives could result in the dismissal and replacement of a trust's board of directors, although such dismissals are enormously expensive for the NHS.[47]

From April 2013 a new system was established as a result of the Health and Social Care Act 2012. The NHS budget is largely in the hands of a new body, NHS England. NHS England commission specialist services and primary care. Acute services and community care is commissioned by local clinical commissioning groups led by GPs.

Free services and contributory services

Services free at the point of use

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

This 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 or other diagnostic services. Hospital inpatient and outpatient services are free, both medical and mental health services. Funding for these services is provided through general taxation and not a specific tax.

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 that might otherwise involve complex consumable tracking and usage procedures at the patient level and concomitant invoicing, reconciliation and bad debt processing.

Eligibility

Eligibility for NHS services is based on having ordinary resident status. See National Health Service Eligibility for treatment.

Prescription charges

As of May 2019 the NHS prescription charge in England was £9 for each quantity of medicine[48] (which contrasts with Scotland, Wales and Northern Ireland[49] where items prescribed on the NHS 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 that 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. Pharmacies or other dispensing contractors are reimbursed for the cost of the medicines through NHS Prescription Services, a division of the NHS Business Services Authority. For more details of prescription charges, see Prescription charges.

The high and rising costs of some medicines, especially some types of cancer treatment, means that prescriptions can present a heavy burden to the primary care trusts, 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.[50]

NHS dentistry
Main article: NHS dentistry

Where available, NHS dentistry charges as of April 2017 were: £20.60 for an examination; £56.30 for a filling or extraction; and £244.30 for more complex procedures such as crowns, dentures or bridges.[51] As of 2007, less than half of dentists' income came from treating patients under NHS coverage; about 52% of dentists' income was from treating private patients.[52] Some people needing NHS dental care are unable to get it.[53]

NHS Optical Services
Main article: Eye care in the United Kingdom

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.

Injury cost recovery scheme

Under older legislation (mainly the Road Traffic Act 1930) 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 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 went to the driver rather than the insurer, even when a charge was imposed it was often not passed on to the liable insurer. It was common to take no further action 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.[54] In the last year of the scheme immediately preceding 2007, over £128 million was reclaimed.[55]

From April 2019 £725 is payable for outpatient treatment, £891 per day for inpatient treatment and £219 per ambulance journey.[56]

Car park charges

Car parking charges are a minor source of revenue for the NHS,[57] with most hospitals deriving about 0.25% of their budget from them.[58] The level of fees is controlled individually by each trust.[57] In 2006 car park fees contributed £78 million towards hospital budgets.[57][58] Patient groups are opposed to such charges.[57] (This contrasts with Scotland where car park charges were mostly scrapped from the beginning of 2009[59] and with Wales where car park charges were scrapped at the end of 2011.)[60]

Charitable funds

There are over 300 official NHS charities in England and Wales. Collectively, they hold assets in excess of £2 billion and have an annual income in excess of £300 million.[61] 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 that increase patient comfort.

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

Regional lotteries were also common for fundraising, and in 1988, a National Health Service Lottery was approved by the government, before being found illegal. The idea continued to become the National Lottery.[62]

Outsourcing and privatisation

Although the NHS routinely outsources the equipment and products that it uses and dentistry, eye care, pharmacy and most GP practices are provided by the private sector, the outsourcing of hospital health care has always been controversial.[63] The involvement of private companies regularly draws the suspicion of NHS staff,[64] the media and the public.[65][66]

Outsourcing and privatisation has increased in recent years, with NHS spending to the private sector rose from £4.1 billion in 2009–10 to £8.7 billion in 2015–16.[67] The King's Fund's January 2015 report on the Coalition Government's 2012 reforms concluded that while marketisation had increased, claims of mass privatisation were exaggerated.[68] Private firms provide services in areas such as community service, general practise and mental health care. An article in The Independent suggested that the private sector tends to choose to deliver the services that are the most profitable, additionally because the private sector does not have intensive care facilities if things go wrong.[69]

Sustainability and transformation plans

Sustainability and transformation plans were produced during 2016 as a method of dealing with the service's financial problems. These plans appear to involve loss of services and are highly controversial. The plans are possibly the most far reaching change to health services for decades and the plans should contribute to redesigning care to manage increased patient demand. Some A&E units will close, concentrating hospital care in fewer places.[70] Nearly two thirds of senior doctors fear the plans will worsen patient care.[71]

Consultation will start over cost saving, streamlining and some service reduction in the National Health Service. The streamlining will lead to ward closures including psychiatric ward closures and reduction in the number of beds in many areas among other changes. There is concern that hospital beds are being closed without increased community provision.[72]

Sally Gainsbury of the Nuffield Trust think tank said many current transformation plans involve shifting or closing services. Gainsbury added, "Our research finds that, in a lot of these kinds of reconfigurations, you don't save very much money – all that happens is the patient has to go to the next hospital down the road. They're more inconvenienced... but it rarely saves the money that's needed."[73] By contrast, NHS England claims that the plans bring joined-up care closer to home. Senior Liberal Democrat MP Norman Lamb accepted that the review made sense in principle but stated: "It would be scandalous if the government simply hoped to use these plans as an excuse to cut services and starve the NHS of the funding it desperately needs. While it is important that the NHS becomes more efficient and sustainable for future generations, redesign of care models will only get us so far – and no experts believe the Conservative doctrine that an extra £8bn funding by 2020 will be anywhere near enough."[74]

NHS policies and programmes

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.[75] 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 Margaret Thatcher announced a review of the NHS. From this review in 1989 two white papers Working for Patients and Caring for People were produced. These outlined the introduction of what was termed the internal market, which was to shape the structure and organisation of health services for most of the next decade.

In England, the National Health Service and Community Care Act 1990 defined this "internal market", whereby health authorities ceased to run hospitals but "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients. The "providers" became independent trusts, which encouraged competition but also increased local differences. Increasing competition may have been statistically associated with poor patient outcomes.[76]

Changes under the Blair government

These innovations, especially the "fund holder" option, were condemned at the time by the Labour Party. Opposition to what was claimed to be the Conservative intention to privatise the NHS became a major feature of Labour's election campaigns.

Labour came to power in 1997 with the promise to remove the "internal market" and abolish fundholding. 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.

A number of factors drove these reforms; 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 for descriptions of their developments).

Reforms included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous clinical and corporate governance. Some new services were developed to help manage demand, including NHS Direct. The Agenda for Change agreement aimed to provide harmonised pay and career progression. These changes have given rise to controversy within the medical professions, the news media and the public. The British Medical Association in a 2009 document on Independent Sector Treatment Centres (ISTCs) urged the government to restore the NHS to a service based on public provision, not private ownership; co-operation, not competition; integration, not fragmentation; and public service, not private profits.[77]

The Blair government, whilst leaving services free at point of use, encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals were built (or rebuilt) by private sector consortia; hospitals may have both medical services such as ISTCs[78] and non-medical services such as catering provided under long-term contracts by the private sector. A study by a consultancy company 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.[79]

The NHS was also required to take on pro-active socially "directive" policies, for example, in respect of smoking and obesity.

Information technology

In the 1980s and 90s, NHS IT spent money on several failed IT projects. The Wessex project, in the 1980s, attempted to standardise IT systems across a regional health authority. The London Ambulance Service was to be a computer-aided dispatch system. Read code was an attempt to develop a new electronic language of health,[80] later scheduled to be replaced by SNOMED CT.

The NHS Information Authority (NHSIA) was established by an Act of Parliament in 1999 with the goal to bring together four NHS IT and Information bodies (NHS Telecoms, Family Health Service (FHS), NHS Centre for Coding and Classification (CCC) and NHS Information Management Group (IMG)) to work together to deliver IT infrastructure and information solutions to the NHS in England. A 2002 plan was for NHSIA to implement four national IT projects: Basic infrastructure, Electronic records, Electronic prescribing, and Electronic booking, modelled after the large NHS Direct tele-nurse and healthcare website program.[80] The NHSIA functions were divided into other organisations by April 2005.

In 2002, the NHS National Programme for IT (NPfIT) was announced by the Department of Health. It was widely seen as a failure, and blamed for delaying the implementation of IT in the service. Even in 2020 it appeared most of the 1.38 million NHS computers were still using Windows 7, which was released in 2009, and additional support had to be arranged by Microsoft until 14 January 2021 before the migration to Windows 10 could be completed. NHSX, the organisation set up to manage NHS information technology was supervising the migration, and has the power to impose sanctions on laggards.[81]

Despite problems with internal IT programmes, the NHS has broken new ground in providing health information to the public via the internet. In June 2007 www.nhs.uk was relaunched under the banner "NHS Choices"[82] as a comprehensive health information service for the public now known simply as "The NHS Website".

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 enables users to compare hospitals for treatment via a "scorecard".[83] 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,[84] which critically appraises media stories and the science behind them, was declared Best Innovation in Medical Communication in the prestigious BMJ Group Awards 2009.[85] and in a 2015 case study was found to provide highly accurate and detailed information when compared to other sources[86] In 2012, NHS England launched the NHS Apps Library, listing apps that had been reviewed by clinicians.[87]

In 2018, the NHS announced they would abandon the name NHS Choices, and in future, call the site the NHS website. This coincided with the launch of the NHS app.[88]

Eleven of the NHS hospitals in the West London Cancer Network were linked using the IOCOM Grid System in 2009. This helped increase collaboration and meeting attendance and even improved clinical decisions.[89]

Smoking cessation
Further information: Smoking in the United Kingdom

One in four hospital patients smoke and that is higher than the proportion in the general population (just under one in five). Public Health England (PHE) wants all hospitals to help smokers quit. One in thirteen smoking patients was referred to a hospital or community based cessation programme. Over a quarter of patients were not asked if they smoke and nearly three quarters of smokers were not asked if they wanted to stop. Half of frontline hospital staff were offered no training in smoking cessation. Smoking patients should be offered specialised help to stop and nicotine replacement. There should be dedicated staff helping patients to quit. Seven tenths of smokers say they want to stop and those offered help are four times more likely to stop permanently. PHE claims smoking causes 96,000 deaths per year in England and twenty times the number of smoking related illnesses. Frank Ryan, psychologist said, "It's really about refocusing our efforts and motivating our service users and staff to quit. And of course, whatever investment we make in smoking cessation programmes, there's a payback many times more in terms of the health benefits and even factors such as attendance at work, because it's workers who smoke [who] tend to have more absent spells from work."[90] The numbers of smokers getting help to quit has fallen due to cuts in funding for smoking cessation care though the National Institute for Health and Care Excellence recommends such help. Smoking is the greatest cause of avoidable illness and death in England, costs the NHS £2.5bn a year and the economy £11bn.[91]

Public satisfaction and criticism
Main article: Criticism of the National Health Service (England)

A 2016 survey by Ipsos MORI found that the NHS tops the list of "things that makes us most proud to be British" at 48%.[92] 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.[93] Despite this some patients complain about being unable to see a GP at once when they feel their condition requires prompt attention.[94] 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."[93] The reason for this disparity between personal experience and overall perceptions is not clear; however, researchers at King's College London found high-profile media spectacles may function as part of a wider 'blame business', in which the media, lawyers and regulators have vested interests.[95][96] The survey found 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% rating it not very or not at all reliable, compared to 36% believing the press was reliable) .[93] Newspapers were reported as being less favourable and also less reliable than the broadcast media. The most reliable sources of information were considered leaflets from GPs and information from friends (both 77% reported as reliable) and medical professionals (75% considered reliable).[93]

Some examples of criticism include:

  1. Some extremely expensive treatments may be available in some areas but not in others, the so-called postcode lottery.[97]
  2. The National Programme for IT, which was designed to provide infrastructure for electronic prescribing, booking appointments and elective surgery, and a national care records service. The programme ran into delays and overspends before it was finally abandoned.
  3. In 2008 there was a decreasing availability of NHS dentistry following a new government contract[98] and a trend towards dentists accepting private patients only,[99] with 1 in 10 dentists having left the NHS totally. However, in 2014 the number of NHS dental patients increased.[100]
  4. There have been a number of high-profile scandals within the NHS. Most recently there have been scandals at acute hospitals such as Alder Hey and the Bristol Royal Infirmary. Stafford Hospital is currently under investigation for poor conditions and inadequacies that statistical analysis has shown caused excess deaths.
  5. A 14 October 2008 article in The Daily Telegraph stated, "An NHS trust has spent more than £12,000 on private treatment for hospital staff because its own waiting times are too long."[101]
  6. The NHS has been criticised in the past for funding homeopathic medicines, which are not supported by scientific research. £4 million of funding was given in 2010.[102] The NHS ceased funding homeopathy in 2017.[103]
  7. The absence 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.[104]
  8. Negative media coverage about the NHS commonly focuses on staff shortages and the consequences on patients' health and care.[105][106][107]

Quality of healthcare, and accreditation

There are many regulatory bodies with a role in the NHS, both government-based (e.g., Department of Health and Social Care, General Medical Council, Nursing and Midwifery Council),and non-governmental-based (e.g., Royal Colleges). Independent accreditation groups exist within the UK, such as the public sector Trent Accreditation Scheme and the private sector CHKS.

With respect to assessing, maintaining and improving the quality of healthcare, in common with 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 according to standards set by the Department of Health and the National Institute for Health and Clinical Excellence (NICE). Responsibility for assessing quality transferred to the Care Quality Commission in April 2009.

A comparative analysis of health care systems in 2010 put the NHS second in a study of seven rich countries.[108][109] 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.

700 hospital patients suffered harm in serious incidents due to treatment delays in part of 2015–16, 1,027 hospital patients suffered similar harm in 2016-17 and this rose to 1,515 in 2017–18. Norman Lamb blames understaffing. NHS Improvement stated during 2017-18 the NHS was short of 93,000 staff, which included 10,000 doctors and 37,000 nurses.[110]

Performance
See also: NHS targets

In 2014 the Nuffield Trust and the Health Foundation produced a report comparing the performance of the NHS in the four countries of the UK since devolution in 1999. They included data for the North East of England as an area more similar to the devolved areas than the rest of England. They found that there was little evidence that any one country was moving ahead of the others consistently across the available indicators of performance. There had been improvements in all four countries in life expectancy and in rates of mortality amenable to health care. Despite the hotly contested policy differences between the four countries there was little evidence, where there was comparable data, of any significant differences in outcomes. The authors also complained about the increasingly limited set of comparable data on the four health systems of the UK.[111] Medical school places are set to increase by 25% from 2018.[112]

A report from Public Health England’s Neurology Intelligence Network based on hospital outpatient data for 2012–13 showed that there was significant variation in access to services by clinical commissioning group. In some places there was no access at all to consultant neurologists or nurses. The number of new consultant adult neurology outpatient appointments varied between 2,531 per 100,000 resident population in Camden to 165 per 100,000 in Doncaster.[113]

Mental health services

The NHS provides mental health services free of charge, but normally requires a referral from a GP first. Services that don't need a referral include psychological therapies through the Improving Access to Psychological Therapies initiative, and treatment for those with drug and alcohol problems. The NHS also provides online services that help patients find the resources most relevant to their needs.[114]

gollark: Not all food, just bread and pasta - carbohydratey things I guess.
gollark: Here we seem to be lacking food *and* toilet paper!
gollark: The reaction certainly doesn't *help*, though.
gollark: It's not *just* that.
gollark: I don't think people will react very well to being told to basically not have any social interaction for large parts of a year, honestly.

See also

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Further reading
  • Allyson M Pollock (2004), NHS plc: the privatisation of our healthcare. Verso. ISBN 1-84467-539-4 (Polemic against PFI and other new finance initiatives in the NHS)
  • Rudolf Klein (2010), The New Politics of the NHS: From creation to reinvention. Radcliffe Publishing ISBN 978-1-84619-409-2 ( Authoritative analysis of policy making (political not clinical)in the NHS from its birth to the end of 2009)
  • Geoffrey Rivett (1998) From Cradle to Grave, 50 years of the NHS. Kings Fund, 1998, Covers both clinical developments in the 50 years and financial/political/organisational ones. kept up to date at www.nhshistory.net

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