National Health Service
logo in England]] logo]] logo]] , the equivalent in Northern Ireland]] The National Health Service (NHS) is the public health services of England, Scotland and Wales, and is commonly used to refer to those of Northern Ireland. They were established together by the Labour Party as one of the major social reforms following the Second World War. The founding principles were being comprehensive, universal and free at the point of delivery. Today, each provides a comprehensive range of health services, the vast majority of which are free for people ordinarily resident in the United Kingdom. Charges are made for prescriptions (in England), dental treatment and optical care, but there is a range of exemptions from these charges. Taken together, the four National Health Services in 2015–16 employed around 1.6 million people with a combined budget of £136.7 billion. UK residents are not charged for medical treatment.
History, who spearheaded the establishment of the National Health Services]] The NHS began on the 'Appointed Day' of 5 July 1948. This put into practice Westminster legislation for England and Wales from 1946 and Scotland from 1947, and the Northern Ireland Parliament's 1947 Public Health Services Act.Ruth Barrington, Health, Medicine & Politics in Ireland 1900–1970 (Institute of Public Administration: Dublin, 1987) pp. 188–89. Calls for a "unified medical service" can be dated back to the Minority Report of the Royal Commission on the Poor Law in 1909,Brian Abel-Smith, The Hospitals 1800–1948 (London, 1964), p.229 but it was following the 1942 Beveridge Report's recommendation to create "comprehensive health and rehabilitation services for prevention and cure of disease" that cross-party consensus emerged on introducing a National Health Service of some description. When Clement Attlee's Labour Party won the 1945 election he appointed Aneurin Bevan as Health Minister. Bevan then embarked upon what the official historian of the NHS, Charles Webster, called an "audacious campaign" to take charge of the form the NHS finally took.Charles Webster, The Health Services since the War, Volume 1: Problems of Health Care, The National Health Service Before 1957 (London: HMSO, 1988), p. 399. The NHS was born out of a long-held British ideal that good healthcare should be available to all, regardless of wealth. At its launch by 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, and that it be based on clinical need, not ability to pay. Three years after the founding of the NHS, Bevan resigned from the Labour government in opposition to the introduction of charges for the provision of dentures and glasses.Kenneth O. Morgan, 'Aneurin Bevan' in Kevin Jeffreys (ed.), Labour Forces: From Ernie Bevin to Gordon Brown (I.B. Taurus: London & New York, 2002), pp. 91–92. The following year, Winston Churchill's Conservative government introduced prescription charges. These charges were the first of many controversies over reforms to the NHS throughout its history.Martin Powell and Robin Miller, 'Seventy Years of Privatizing the British National Health Service?', Social Policy & Administration, vol. 50, no. 1 (January 2016), pp. 99–118. Each of the UK's four nations has their own separate NHS, each with its own history. NHS Scotland and Health and Social Care in Northern Ireland (HSC) were separate from the foundation of the NHS, whereas the NHS in Wales was originally combined with England until devolved to the Secretary of State for Wales in 1969 and then to the Welsh Executive and Assembly under devolution in 1999, 1960's|last=Wales|first=NHS|website=www.wales.nhs.uk|access-date=2016-11-22}} the same year as responsibility for the Scottish NHS was transferred from the Secretary of State for Scotland to the new Scottish Government and Parliament. From its earliest days, the cultural history of the NHS has shown its place in British society reflected and debated in film, TV, cartoons and literature. The NHS had a prominent slot during the directed by Danny Boyle, being described as "the institution which more than any other unites our nation". 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. NHS 'not fit for 21st Century', says chief hospital inspector BBC
StructureEach of the UK's health service systems operates independently, and is politically accountable to the relevant government: the Scottish Government, Welsh Government, the Northern Ireland Executive, and the UK Government which is responsible for England's NHS. NHS Wales was originally part of the same structure as England until powers over the NHS in Wales were firstly transferred to the Secretary of State for Wales in 1969 and thereafter, in 1999, to the Welsh Assembly (now the Welsh Government) as part of Welsh devolution. However, some functions might be routinely performed by one health service on behalf of another. For example, Northern Ireland has no high-security psychiatric hospitals and thus depends on using hospitals in Great Britain, routinely at Carstairs hospital in Scotland for male patients and Rampton Secure Hospital in England for female patients. Similarly, patients in North Wales use specialist facilities in Manchester and Liverpool which are much closer than facilities in Cardiff, and more routine services at the Countess of Chester hospital. There have been issues about cross-border payments. Taken together, the four National Health Services in 2015-16 employed around 1.6 million people with a combined budget of £136.7 billion. In 2014 the total health sector workforce across the UK was 2,165,043. This broke down into 1,789,586 in England, 198,368 in Scotland, 110,292 in Wales and 66,797 in Northern Ireland.
Eligibility for treatmentUK residents are not charged for most medical treatment, with exceptions such as a fixed charge for prescriptions; dental treatment is administered differently, with standard charges for most procedures. The NHS is free at the time of use, for general practitioner (GP) and emergency treatment not including admission to hospital, to non-residents. People with the right to medical care in European Economic Area (EEA) nations are also entitled to free treatment by using the European Health Insurance Card. Those from other countries with which the UK has reciprocal arrangements also qualify for free treatment. Since 6 April 2015, non-EEA nationals who are subject to immigration control must have the immigration status of indefinite leave to remain at the time of treatment and be properly settled, to be considered ordinarily resident. People not ordinarily resident in the UK are in general not entitled to free hospital treatment, with some exceptions such as refugees. People not ordinarily resident may be subject to an interview to establish their eligibility, which must be resolved before non-emergency treatment can commence. Patients who do not qualify for free treatment are asked to pay in advance or to sign a written undertaking to pay, except for emergency treatment. The provision of free treatment to non-UK-residents, formerly interpreted liberally, has been increasingly restricted, with new overseas visitor hospital charging regulations introduced in 2015. Links to many relevant documents: Guidance on implementing the overseas visitor hospital charging regulations 2015; Ways in which people can be lawfully resident in the UK; Summary of changes made to the way the NHS charges overseas visitors for NHS hospital care; Biometric residence permits: overseas applicant and sponsor information; Information sharing with the Home Office: guidance for overseas patients; Overseas chargeable patients, NHS debt and immigration rules: guidance on administration and data sharing; Ordinary residence tool; and documents on Equality analysis. People from outside the EEA coming to the UK for a temporary stay of more than six months may be required to pay an immigration health surcharge at the time of visa application, and will then be entitled to NHS treatment on the same basis as a resident. the surcharge was £200 per year, with exemptions and reductions in some cases.
FundingThe systems are 98.8% funded from general taxation and National Insurance contributions, plus small amounts from patient charges for some services. About 10% of GDP is spent on health and most is spent in the public sector. The money to pay for the NHS comes directly from taxation. The 2008/9 budget roughly equates to a contribution of £1,980 per person in the UK. NHS Choices The NHS in England: The NHS: About the NHS: Overview. Retrieved 22 June 2010. When the NHS was launched in 1948 it had a budget of £437 million (roughly £9 billion at today’s prices). In 2008/9 it received over 10 times that amount (more than £100 billion). In 1955/6 health spending was 11.2% of the public services budget. In 2015/6 it was 29.7%. 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. Under the Blair government investment levels increased to around 6% a year on average. Since 2010 spending growth has been constrained to just over 1% a year. 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, training costs, medical equipment, catering and cleaning. Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas.https://portal.rcem.ac.uk/LIVE/docs/International/6.5.2%20Part-2---The-structure-and-funding-of-the-NHS.pdf Since 2010, there has been a cap of 1% on pay rises for staff continuing in the same role. Unions representing doctors, dentists, nurses and other health professionals have called on the government to end the cap on health service pay, claiming the cap is damaging the health service and damaging patient care. Health unions urge Theresa May to ditch NHS pay cap The Guardian The pay rise is likely to be below the level of inflation and to mean a real terms pay cut. NHS staff suffer pay cuts in real terms as salaries rise by one per cent The Independent
Paying for higher spending70% of people say they would willingly pay an extra penny in the pound in income tax if the money were ringfenced and guaranteed for the NHS. Two thirds of respondents to a King's Fund poll favour increased taxation to help finance the NHS. Two-thirds support higher taxes to maintain NHS funding The Obsrver The BMA has called for £10bn more annually for the NHS to get Britain in line with what other advanced European nations spend on health. The BMA argues this could pay for at least 35,000 more hospital beds daily and many thousand more GPs. Dr Mark Porter of the BMA, wrote, “Our members report that services are truly at breaking point, with unprecedented rising patient demand met only with financial restraint and directives for the NHS and social care to make huge, unachievable savings through sustainability and transformation plans (STPs) across England.” Porter emphasised he was not asking for more than comparable nations, merely for the spending of other leading European nations to be matched. The increase, Porter said was desperately needed.
Mental health servicesThe NHS provides mental health services free of charge, but normally requires a referral from a GP first. Services which don't need a referral include psychological therapies and treatment for those with drug and alcohol problems. The NHS also provides online services which can help patients find the resources which are most relevant to them.http://www.nhs.uk/NHSEngland/AboutNHSservices/mental-health-services-explained/Pages/accessing%20services.aspx Many psychiatric inpatients are being treated very far away from where they live when beds are not available locally, some even stay in police cells. The extent of the problem varies between trusts. Louise Rubin of Mind said: “It’s unacceptable that people who are at their most unwell and in desperate need of care find themselves travelling across the country to get help ... When you’re experiencing a mental health crisis, you’re likely to feel scared, vulnerable and alone, so your support network of family and friends are instrumental to recovery.” Almost 6,000 mental health patients sent out of area for care last year The Guardian The numbers of mental health staff needing sick leave due to work pressure is increasing. Dave Munday of Unite said, "Our members tell us workplace stress is increasing and that cuts to staff and services mean they're working longer hours with fewer resources. Staff themselves are feeling the impact of austerity." Mental health staff on long-term stress leave up 22% BBC The use of restraints in UK psychiatric facilities is increasing. Sridevi Kalidindi of the Royal College of Psychiatrists maintains that cuts to bed numbers and cuts to community care mean patients admitted to psychiatric units are now more ill. Also Kalidindi maintains increased use of agency staff means fewer permanent staff with training in de-escalating situations are available. Mental health trusts restrain patients 'every 10 minutes' BBC
Sexual healthFunding for sexual health services has been cut despite an increase in demand for treatment of sexually transmitted infection. Demand rose 25% in the five years to 2017 while funding was cut by 10%. This leads to a risk that STD will spread while patients are waiting for treatment. Nearly 2.5 million new people attended sexual health clinics in 2016 compared to 1.9 million in 2012. Debbie Laycock of the Terrence Higgins Trust said, “There is still much to do to address the nation’s poor sexual health and the inequalities that are faced by those most at risk. In this climate of cuts to local authorities’ public health budgets, it is inevitable that the progress that has been made against STIs will be reversed. We are already witnessing the closure of busy sexual health clinics and, without proper funding, this will only continue and have a negative impact on people’s sexual health. Cutting sexual health services is considered shortsighted because every £1 spent on sexual health saves £11 later through, for example preventing unwanted pregnancy. Government cuts 'leave sexual health services at tipping point' The Guardian Sexual health clinics 'at tipping point' after Government cuts and huge rise in demand, councils warn The Independent
StaffingIn the year ending at March 2017, there were 1.187 million staff in the NHS, 1.9% more than in March 2016.http://www.content.digital.nhs.uk/catalogue/PUB24214/nhs-work-stat-mar-2017-pdf.pdf In the same year, there were 691,000 nurses registered in the UK, down 1,783 from the previous year. However, this is the first time nursing numbers have fallen since 2008 and there are 13,000 more nurses in the NHS than in 2010. Poor working conditions, staffing levels and workload also dissatisfaction with the quality of patient care were given as reasons as were poor pay and benefits. Saffron Cordery of NHS Providers said, "These figures provide further evidence of the severe workforce problems NHS trusts face. Burseries to nursing students are to be stopped forcing nurses to pay for their training, it is expected this will also be a discouragement. More UK nurses and midwives leaving than joining profession BBC Commentators are increasingly arguing that staffing shortages are endangering the sustinability of the NHS. There are too few health workers, nurses and midwives, doctors are also in short supply. Hospitals, Community Trusts and Mental Health Trusts all face shortages. The NHS's sustainability is under threat if more isn't done to look after its staff New Statesman Some General practitioners are losing sleep because they worry work pressure may have lead them to miss something that puts a patient at risk. GPs losing sleep over patient safety fears, says head of profession The Guardian
Effect of BrexitThe plan to exit the European Union will affect physicians from EU countries, about 11% of the physician workforce. Many of these physicians feel unwelcome and are considering leaving the UK if Brexit happens, as they have doubts that they and their families can live in the country. A survey suggests 60% are considering leaving. Record numbers of EU nationals (17,197 EU staff working in the NHS which include nurses and doctors) left last year. The figures, put together by NHS Digital, lead to calls to reassure European workers over their future in the UK. EU nurses registering to work in the UK are down 96% since the Brexit vote aggravating shortages of nurses. Janet Davies of the Royal College of Nursing, said, “We rely on the contributions of EU staff and this drop in numbers could have severe consequences for patients and their families. Our nursing workforce is in a state of crisis. Across our health service, from A&E to elderly care, this puts patients at serious risk.” 96% drop in EU nurses registering to work in Britain since Brexit vote The Guardian
CapacityThe NHS was severely stretched in winter 2016-17 and there are fears the situation could be worse in 2017-18. Chris Hopson of NHS Providers wrote in summer 2017, "Worryingly, 92% of trusts reported a lack of capacity in primary care to manage next winter; 91% a lack of capacity in social care; 80% a lack of capacity in mental health services; 76% a lack of community service capacity; 71% a lack of acute hospital capacity and 64% a lack of ambulance capacity. Only 57% of trusts were confident they could provide safe and high quality care this winter." Give the NHS more money – or it will face trouble this winter The Guardian England, Wales and Northern Ireland missed every one of their three key targets (cancer care, operations and A&E) over 18 months. Patients are waiting longer for treatment. NHS waits for cancer care, A&E and ops worsen across UK BBC 6,932 patients waited more than 3 hours in A&E in October 2010, but this rose to 45,532 patients in October 2017. Long waits in A&E have increased by 557% in seven years, NHS data reveals The Observer NHS Improvement also fears the NHS will be more severely overstretched in 2017-18 than it was the previous winter though the British Red Cross declared the state of UK hospitals in 2016-17 a humanitarian crisis. NHS faces even worse winter crisis than last year, watchdog warns The Guardian
Rising social care costsSocial care will cost more in future according to research by Liverpool University, University College London, and others and higher investment are needed. Professor Helen Stokes-Lampard of the Royal College of GPs said, “It’s a great testament to medical research, and the NHS, that we are living longer – but we need to ensure that our patients are living longer with a good quality of life. For this to happen we need a properly funded, properly staffed health and social care sector with general practice, hospitals and social care all working together – and all communicating well with each other, in the best interests of delivering safe care to all our patients.” NHS faces staggering increase in cost of elderly care, academics warn The Guardian Rising social costs have led to a significant increase in the time between patients being declared "medically fit" and finding social care placements in many cases.
Outsourcing and privatisationAlthough the NHS routinely outsources the equipment and products that it uses and dentistry, eye care, pharmacy and most GP practices have always been provided by the private sector, the outsourcing of hospital health care has always been controversial. According to a BMA survey over two-thirds of doctors are fairly uncomfortable or very uncomfortable about the independent sector providing NHS services. The BMA believes it is important the independent sector is held to the same standards as the NHS when giving NHS care. The BMA recommends: data collection, through impact analysis before independent providers are accepted to ensure existing NHS services are not disrupted, risk assessment to find out likely results if NHS staff are unwilling to transfer to the private sector, transparent reporting by the private sector of patient safety and performance, independent providers should be regulated like NHS providers, patients should be protected if independent providers terminate a contract early, transfers from independent providers to the NHS should be regularly reviewed to establish how much this costs the NHS, private sector contracts should be amended so private sector providers contribute to the cost of staff training financially or by providing training opportunities. There were renewed calls for transparent reporting in the private sector following Ian Patterson's criminal conviction for wounding private sector patients by carrying out unnecessary operations. Surgeons call for review of safety standards in private hospitals The Guardian
Vulnerability of information systems
Proprietary operating systemIn 2001 the NHS entered into a licensing deal with Microsoft, ignoring the advice of some of its own IT specialists that had recommended investing in Linux instead. Concerns about the vulnerability of NHS computer systems to cyber-attack have been expressed since at least 2016. NHS computer systems have been subject to cyber attacks of which one in May 2017 was notable. The May 2017 attack lead to the cancellation of at least 6912 appointments including operations, 139 suspected cancer patients had urgent referrals cancelled. The number of GP appointments cancelled, the number of ambulances diverted from A&E departments unable to treat some patients, the number of delays in receiving information like test results are unknown. North Korea is strongly suspected of starting the attack. The attack happened on a Friday in May. A cyberattack on a Monday in winter would be even more damaging. NHS 'could have prevented' WannaCry ransomware attack BBC NHS computers have been vulnerable because a minority still use or used Windows XP, an outdated system that originated in 2001, and one which Microsoft stopped supporting with security patches. Complacency among NHS staff and among government departments that pay for computer security are blamed. Unless systems are upgraded, more cyber attacks are feared. Dr David Wrigley of the British Medical Association said, “It’s been known about for years, that the software isn’t up to date across the NHS, so it’s not unpredictable that this situation should have arisen. But it’s disappointing that funding hasn’t been given to upgrade the system. It needs urgent action by politicians.” Warning of NHS cyber-attack risk was not acted on, says cybersecurity adviser The Guardian
Internal mail lost by part-privatised subsidiaryIn 2017, it was reported that NHS Shared Business Services, a part state-owned, part-privately owned company tasked with internal mail delivery for NHS England, had lost 864,000 documents relating to patient healthcare.
Comparative performanceAlthough there has been increasing policy divergence between the four national NHS services (listed below), there is very little evidence linking these policy differences to a matching divergence of performance. It has been suggested that this is because of the uniform professional culture. There are national terms and conditions of employment across the UK, regulation of clinicians is performed on a UK basis and the health trades unions operate across the UK. However, it does not help that, as Nick Timmins noted: "Some of the key data needed to compare performance – including data on waiting times – is defined and collected differently in the four countries." For details see:
- History of the National Health Service (England)
- History of NHS Scotland
- History of NHS Wales
- Healthcare in the United Kingdom
- Scottish Government Health and Social Care Directorates
- Brady, Robert A. Crisis in Britain. Plans and Achievements of the Labour Government (1950) pp. 352–41 excerpt
- Gorsky, Martin. "The British National Health Service 1948–2008: A Review of the Historiography," Social History of Medicine, Dec 2008, Vol. 21 Issue 3, pp. 437–60
- Hacker, Jacob S. "The Historical Logic of National Health Insurance: Structure and Sequence in the Development of British, Canadian, and U.S. Medical Policy," Studies in American Political Development, April 1998, Vol. 12 Issue 1, pp. 57–130.
- Hilton, Claire. (26 August 2016). Whistle-blowing in the National Health Service since the 1960s History and Policy. Retrieved 11 May 2017.
- Loudon, Irvine, John Horder and Charles Webster. General Practice under the National Health Service 1948–1997 (1998) online
- Rintala, Marvin. Creating the National Health Service: Aneurin Bevan and the Medical Lords (2003) online.
- Rivett G C From Cradle to Grave – the first 50 (65) years of the NHS. King's Fund, London, 1998 now updated to 2014 and available at www.nhshistory.co.uk
- Stewart, John. "The Political Economy of the British National Health Service, 1945–1975: Opportunities and Constraints," Medical History, Oct 2008, Vol. 52 Issue 4, pp. 453–70
- Valier, Helen K. "The Manchester Royal Infirmary, 1945–97: a microcosm of the National Health Service," Bulletin of the John Rylands University Library of Manchester, 2005, Vol. 87 Issue 1, pp. 167–92
- Webster, Charles. "Conflict and Consensus: Explaining the British Health Service," Twentieth Century British History, April 1990, Vol. 1 Issue 2, pp. 115–51
- Webster, Charles. Health Services since the War. 'Vol. 1:' Problems of Health Care. The National Health Service before 1957 (1988) 479pp online
- NHS Choices official website for England's NHS
- Health and Social Care in Northern Ireland official website for Health & Personal Social Services in Northern Ireland
- NHS Scotland official website for NHS Scotland
- Health in Wales official website for NHS Wales
- Birth of the national Health Service archive collection of programmes and documents