The National Health Service (NHS) is the umbrella term for the publicly-funded healthcare systems of the United Kingdom. Since 1948 it has been funded out of general taxation. It is made up of the four separate systems of the four countries of the UK: The National Health Service in England, NHS Scotland, NHS Wales, and Health and Social Care in Northern Ireland. They were established together in 1948 as one of the major social reforms following the Second World War. The founding principles were that services should be comprehensive, universal and free at the point of delivery.Each service provides a comprehensive range of health services, free at the point of use for people ordinarily resident in the United Kingdom, apart from dental treatment and optical care. In England, NHS patients have to pay prescription charges with a range of exemptions from these charges.
Each of the UK's health service systems operates independently, and is politically accountable to the relevant government: the Scottish Government, Welsh Government, Northern Ireland Executive, and the UK Government, responsible for England's NHS. Since 2013 operational responsibility for the NHS in England has been passed to NHS England. NHS Wales was originally part of the same structure as that of England until powers over the NHS in Wales were first transferred to the Secretary of State for Wales in 1969 and thereafter, in 1999, to the Welsh Assembly as part of Welsh devolution. Some functions may be routinely performed by one health service on behalf of another. For example, Northern Ireland has no high-security psychiatric hospitals and depends on 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 2015–2016 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. In 2017, 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. Every 24 hours it sees one million patients, and with 1.7 million staff it is the fifth biggest employer in the world.
Although there has been increasing policy divergence between the four National Health Services in the UK, it can be difficult to find evidence of the effect of this on performance since, as Nick Timmins says: "Some of the key data needed to compare performance – including data on waiting times – is defined and collected differently in the four countries." Statistics released in December 2017 showed that, compared with 2012-2013, the number of patients in Scotland waiting more than four hours in accident and emergency dropped by 9% (from about 8% of all A&E patients to about 6%), whereas in England that proportion had increased by 155% (from less than 5% of all A&E patients to about 11%). However, since then, Scotland in common with the other three UK nations has experienced increasing pressure in Accident and Emergency departments with lengthening waiting times.
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. Several other countries either copy the UK's model or directly rely on Britain’s assessments for their own decisions on state-financed drug reimbursements.
History
Dr Somerville Hastings, President of the Socialist Medical Association, successfully proposed a resolution at the 1934 Labour Party Conference that the party should be committed to the establishment of a State Health Service.
Calls for a "unified medical service" can be dated back to the Minority Report of the Royal Commission on the Poor Law in 1909, 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. Conservative MP and Health Minister, Henry Willink
later advanced this notion of a National Health Service in 1944 with
his consultative White Paper "A National Health Service" which was
circulated in full and short versions to colleagues, as well as in
newsreel.
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. Bevan's National Health Service was proposed in Westminster legislation for England and Wales from 1946 and Scotland from 1947, and the Northern Ireland Parliament's Public Health Services Act 1947. NHS Wales was split from NHS (England) in 1969 when control was passed to the Secretary of State for Wales before transferring to the Welsh Executive and Assembly under devolution in 1999.
The NHS was born out of the ideal that good healthcare should be
available to all, regardless of wealth. Although being freely accessible
regardless of wealth maintained Henry Willink's principle of free
healthcare for all, Conservative MPs were in favour of maintaining local
administration of the NHS through existing arrangements with local
authorities fearing that an NHS which owned hospitals on a national
scale would lose the personal relationship between doctor and patient.
Conservative MPs voted in favour of their amendment to Bevan's
Bill to maintain local control and ownership of hospitals and against
Bevan's plan for national ownership of all hospitals. The Labour
government defeated Conservative amendments and went ahead with the NHS
as it remains today; a single large national organisation (with
devolved equivalents) which forced the transfer of ownership of
hospitals from local authorities and charities to the new NHS. Bevan's
principle of ownership with no private sector involvement has since been
diluted, with later Labour governments implementing large scale
financing arrangements with private builders in private finance initiatives and joint ventures.
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. 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.
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 2012 London Summer Olympics opening ceremony directed by Danny Boyle, being described as "the institution which more than any other unites our nation".
The Luftwaffe achieved in months what had defeated politicians and planners for at least two decades.
— NHS’s official historian, Charles Webster
Eligibility for treatment
UK residents are not charged for most medical treatment, though NHS dentistry
does have standard charges in each of the four national health services
in the UK. In addition, most patients in England have to pay charges
for prescriptions though some are exempted.
Aneurin Bevan,
in considering the provision of NHS services to overseas visitors
wrote, in 1952, that it would be "unwise as well as mean to withhold the
free service from the visitor to Britain. How do we distinguish a
visitor from anybody else? Are British citizens to carry means of
identification everywhere to prove that they are not visitors? For if
the sheep are to be separated from the goats both must be classified.
What began as an attempt to keep the Health Service for ourselves would
end by being a nuisance to everybody."
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.
Citizens of the EU holding a valid European Health Insurance Card
and persons from certain other countries with which the UK has
reciprocal arrangements concerning health care can get emergency
treatment without charge.
The NHS is free at the point 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.
People from outside the EEA coming to the UK for a temporary stay
of more than six months are 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. This includes overseas students with a visa to
study at a recognised institution for 6 months or more, but not visitors
on a tourist visa. In 2016 the surcharge was £200 per year, with exemptions and reductions in some cases.
It is to increase to £400 in 2018. The discounted rate for students
and those on the Youth Mobility Scheme will increase from £150 to £300.
From 15 January 2007, anyone who is working outside the UK as a missionary
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 (including British citizens 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.
Current issues
Under pressure in recent years as a result of economic austerity according to Unite, public satisfaction with the NHS has fallen from 70% in 2010 to 53% in 2018.
Public satisfaction with NHS care is more than twice as high as for
local authority-funded social care, which stands at 26%. Furthermore,
the NHS is consistently ranked as the institution that makes people
proudest to be British, beating the Royal family, Armed Forces and the
BBC. NHS staff – particularly nurses and doctors – are the most trusted professions in Britain.
Funding
The 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.
When the NHS was launched in 1948 it had a budget of £437 million (equivalent to £16.01 billion in 2019). In 2016–2017, the budget was £122.5 billion. In 1955/6 health spending was 11.2% of the public services budget. In 2015/16 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
spending levels increased by around 6% a year on average. Since 2010
spending growth has been constrained to just over 1% a year. Many minor procedures may no longer be available from 2019 and the real reason may be to cut costs.
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.
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. The pay rise is likely to be below the level of inflation and to mean a real-terms pay cut.
The House of Commons Library did research showing that real-terms NHS funding per head will fall in 2018–19, and stay the same for two years afterwards.
There appears to be support for higher taxation to pay for extra
spending on the NHS as an opinion poll in 2016 showed that 70% of people
were willing to 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.
The Guardian has said that GPs face excessive workloads
throughout Britain and that this puts the GP's health and that of their
patients at risk. The Royal College of Physicians
surveyed doctors across the UK, with two-thirds maintaining patient
safety had deteriorated during the year to 2018: 80% feared they would
be unable to provide safe patient care in the coming year while 84% felt
increased pressure on the NHS was demoralising the workforce. Jane Dacre
said, “We simply cannot go through this [a winter when the NHS is badly
overstretched] again. It is not as if the situation was either new or
unexpected. As the NHS reaches 70, our patients deserve better. Somehow,
we need to move faster towards a better resourced, adequately staffed
NHS during 2018 or it will happen again.” At a time when the NHS is short of doctors foreign doctors are forced to leave the UK due to visa restrictions. A study found that a fifth of doctors had faced bullying from seniors in the previous year due to pressure at work.
The NHS is under-resourced compared to health provisions in other developed nations. A King’s Fund study of OECD
data from 21 nations, revealed that the NHS has among the lowest
numbers of doctors, nurses and hospital beds per capita in the western
world.
Nurses within the NHS maintain that patient care is compromised by the
shortage of nurses and the lack of experienced nurses with the necessary
qualifications. According to a YouGov poll, 74 percent of the UK public believes there are too few nurses. The NHS performs below average in preventing deaths from cancer, strokes and heart disease. Staff shortages at histology departments are delaying diagnosis and start of treatment for cancer patients.
In England and Scotland cancer wards and children's wards have to
close because the hospital cannot attract sufficient qualified doctors
and nurses to run the wards safely. Cancer patients and child patients
are having to travel very long distances to get treatment and their
relatives must travel far to visit the patients. In wards which have not
closed staff sometimes work under stress due to staff shortages.
Brexit is likely to aggravate these problems. Due to the shortage of nurses the NHS is relying on less qualified staff like healthcare assistants and nursing associates.
Cancer survival rates in the UK have been rising fast but
probably still lag behind the best results internationally, mainly
because of late diagnosis.
However death rates from breast cancer are falling faster in Britain
than in any other of the six largest countries in Europe, and are
estimated now to have improved beyond the European average. According to Breast Cancer Care 72% of NHS trusts across the UK do not provide dedicated specialist nurses for patients with incurable breast cancer." Cancer Research UK
maintains more NHS cancer personnel are needed to enable the UK to
catch up The NHS in England is expanding early diagnosis services with
the goal of increasing the proportion of cancers diagnosed early (at
stages 1 and 2) from 53% to 75% in the decade to 2028.
The NHS was the first health service in Europe to negotiate coverage
for novel CAR-T cancer therapy, with agreement reached within 10 days of
its European marketing authorisation.
Staffing
The plan to exit the European Union will affect physicians from EU countries, about 11% of the physician workforce.
Many of these physicians 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 in 2016. The figures, put
together by NHS Digital, led to calls to reassure European workers over their future in the UK.
In June 2018 the Royal College of Physicians
calculated that medical training places need to be increased from 7,500
to 15,000 by 2030 to take account of part-time working among other
factors. At that time there were 47,800 consultants working in the UK of
which 15,700 were physicians. About 20% of consultants work less than
full-time.
A study by the Centre for Progressive Policy called for NHS trusts
to become “exemplar employers” by improving social mobility and pay
especially for those "trusts in poorer places where they can play a
particularly large role in determining the economic wellbeing of the
local population.” They found the NHS to be " a middle ranking employer
in comparison to other large organisations and falls short on social
mobility and the real Living Wage", and ranked trusts using a ‘good
employer index’. Ambulance trusts were ranked worst.
Performance
A study by the King's Fund, Health Foundation, Nuffield Trust and the Institute for Fiscal Studies
to mark the NHS 70th anniversary concluded that the main weakness of
the NHS was health care outcomes. Mortality for cancer, heart attacks
and stroke, was higher than average among comparable countries. The NHS
does well at protecting people from heavy financial costs when they are
ill. Waiting times are about the same and the management of longterm
illness is better than in other comparable countries. Efficiency is
good, with low administrative costs and high use of cheaper generic
medicines. Twenty-nine hospital trusts and boards out of 157 have not hit any waiting time target in the year 2017–2018.
The Office for National Statistics reported in January 2019 that
productivity in the English NHS had been growing at 3%, considerably
faster than across the rest of the UK economy.
Over 130,000 deaths since 2012 in the UK could have been prevented if progress in public health policy had not stopped due to austerity, analysis by the Institute for Public Policy Research found. Dean Hochlaf of the IPPR said, “We have seen progress in reducing preventable disease flatline since 2012."
British exit from the European Union
There is also concern that a disorderly Brexit
may compromise patients' access to vital medicines. Many medical
organisations are diverting resources from patient care to managing a
possible worst-case Brexit scenario.
Pharmaceutical organisations working with the Civil Service to keep
medicine supplies available if there is a no-deal Brexit have signed 26
Non-Disclosure Agreements (NDA's) or, “gagging orders” to prevent them
giving the public information. The figures were given on 21 December
2018 after Rushanara Ali
asked a parliamentary question. Ali said, “It is utterly unacceptable
for the government to use non-disclosure agreements with pharmaceutical
businesses and trade associations. By effectively ‘gagging’ these
organisations, these secretive agreements are preventing essential
information from being shared, are undermining transparency and are
hampering businesses’ ability to speak out.”
Rising social care costs
Social
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.”
Mental health
Some patients have to wait excessively long for mental health care. The Royal College of Psychiatrists
found some must wait up to thirteen months for the right care. Wendy
Burn of the Royal College of Psychiatrists said, “It is a scandal that
patients are waiting so long for treatment. The failure to give people
with mental illnesses the prompt help they need is ruining their lives.”
Even patients who are suicidal or who have attempted suicide are
sometimes denied treatment; patients are told they are not ill enough or
waiting lists are too long. During very long waits for treatment, one
in three patients deteriorate, and they may become unemployed or get
divorced. One in four patients throughout the UK wait over three months
to see an NHS mental health professional, with 6% waiting at least a
year.
The National Audit Office
found mental health provisions for children and young people will not
meet growing demand, despite promises of increased funding. Even if
promises to provide £1.4bn more for the sector are kept, there will be
“significant unmet need” due to staff shortages, inadequate data and
failure to control spending by NHS clinical commissioning groups.
Currently one-quarter of young people needing mental health services can
get NHS help. The Department of Health and Social Care hopes to raise the ratio to 35%. Efforts to improve mental health provisions could reveal previously unmet demand.
Meg Hillier
of the select committee on public accounts said, “The government
currently estimates that less than a third of children and young people
with a diagnosable mental health condition are receiving treatment. But
the government doesn’t understand how many children and young people
are in need of treatment or how funding is being spent locally. The
government urgently needs to set out how departments, and national and
local bodies, are going to work together to achieve its long-term
ambition.” Amyas Morse
said, “Current targets to improve care are modest and even if met would
still mean two-thirds of those who need help are not seen. Rising
estimates of demand may indicate that the government is even further
away than it thought.”
In response, NHS England has embarked on a major programme to expand mental health services, whose budgets are now growing faster than the NHS overall.
MIND the mental health charity responded saying: "We are pleased that
the plan includes a commitment of £2.3bn a year towards mental health,
to help redress the balance. The plan promises that this money will see
around two million more people with anxiety, depression and other mental
health problems receive help, including new parents, and 24 hour access
to crisis care. The plan also includes a guarantee that investment in
primary, community and mental health care will grow faster than the
growing overall NHS budget so that different parts of the NHS come
together to provide better, joined-up care in partnership with local
government. Since the funding announcement in the summer, Mind has been
working with the NHS, Government and voluntary sector to help shape the
long term plan. This longer-term strategy was developed in consultation
with people with mental health problems to ensure their views are
reflected."
Surgery
Waiting
times for routine surgery have fallen substantially since 2000. As of
July 2019, the median wait for planned care in England is under 8 weeks.
The number of people waiting over 12 months has fallen from over
200,000 in the 1980s to under 2000 in 2019.
However the number of patients on the waiting list has risen recently
as constrained funding, hospital beds and staffing growth has not kept
up with increasing patient need.
2018 funding increase
In 2018, British Prime Minister Theresa May
announced that NHS in England would receive a 3.4% increase in funding
every year to 2024, which would allow it to receive an extra £20bn a
year in real terms funding.
There is concern that a high proportion of this money will go to
service NHS debts rather than for improved patient care. There are
calls for the government to write off the NHS debt. Saffron Cordery of NHS Providers said that hospitals needed help to do their work without being up in deficit, as two-thirds were in the year to 2018. Some expressed doubt over whether May could carry out this proposed increase in funding.
The next day, Health Secretary Jeremy Hunt backed the extra £20bn
annual increase in NHS funding and responded to criticism by stating
that taxation would be used to carry out the funding and that details
would be revealed when the next budget is unveiled in November.
The Institute for Fiscal Studies has stated a 5% real-terms increase was needed for real change. Paul Johnson of the IFS said the 3.4% was greater than recent increases, but less than the long-term average.
Health experts maintain the money will "help stem further decline in
the health service, but it's simply not enough to address the
fundamental challenges facing the NHS, or fund essential improvements to
services that are flagging." Inflation may erode the real value of this funding increase.
As part of the 2018 funding increase the government asked the NHS
to produce a 10-year plan as to how this funding would be used. On 7
January 2019, the NHS England published the NHS Long Term Plan.
Electronic systems
21
different electronic systems are used in the NHS to record data on
patients. These systems do not communicate well with each other so
there is a risk doctors treating a patient will not know everything they
need to know to treat the patient effectively. There were 11 million
patient interactions out of 121 million where information from a
previous visit could not be accessed. Half the Trusts using Electronic
Medical Records used one of three systems and at least those three
should be able to share information. A tenth of Trusts used multiple
systems in the same hospital. Dr Leigh Warren who participated in the
research said, "Hospitals and GPs often don't have the right information
about the right patient in the right place at the right time. This can
lead to errors and accidents that can threaten patients' lives."
Sale of data
Information
on millions of NHS patients was sold to international pharmaceutical
companies, in the US and other nations for research, adding to concerns
over USA ambitions to access remunerative parts of the NHS after Brexit.
There is concern over lack of transparency and clarity over the data
and how it is used. Phil Booth of medConfidential,
campaigning for privacy of health data said, “Patients should know how
their data is used. There should be no surprises. While legitimate
research for public health benefit is to be encouraged, it must always
be consensual, safe and properly transparent. Do patients know – have
they even been told by the one in seven GP practices across England that
pass on their clinical details – that their medical histories are being
sold to multinational pharma companies in the US and around the world?”
Medicines
In
November 2019 unprecedented shortages of medicines patients need
developed. Drugs to treat cancer, heart disease, Parkinson's disease,
mental health conditions, some eye conditions, antibiotics for
tuberculosis and drugs to control epilepsy are among those in short
supply. Life saving drugs will have to be rationed and not all patients
who need them will get them. Some patients can be switched onto other
drugs, though this may increase the workload of hard-pressed medical
staff; other patients cannot be switched to alternative drugs. Many
problems can impact the supply chain, like IT failure, speculators
stockpiling drugs, alterations in regulation and sudden disease
outbreaks. Dr Tony O’Sullivan of Keep Our NHS Public
said, “The Health Department’s guidance includes an unprecedented list
of drugs unavailable or in short supply. Patients and clinicians alike
should be on high alert when the advice includes how to ‘share stocks’
to make them last, to ‘prioritise’ patients already on specific
treatments including cancer rather than a new patient and effectively
how to ration so many vital drugs. Drug companies’ behaviour must be
controlled. We must urgently protect the NHS from further risks of loss
of control of drug prices and supplies from trade deals with the US and
that requires returning it to a wholly public service.”
In
2020, the NHS issued medical advice in combating COVID-19 and partnered
with tech companies to create computer dashboards to help combat the nation's coronavirus pandemic. During the pandemic, the NHS also established integrated COVID into its 1-1-1 service line as well. Following his discharge from the St. Thomas' Hospital in London on 13 April 2020 after being diagnosed with COVID-19, British Prime Minister Boris Johnson described NHS medical care as "astonishing" and that "NHS saved my life. No question."
Numbers
In 2015, the UK had 2.6 hospital beds per 1,000 people. In September 2017, the King's Fund
documented the number of NHS hospital beds in England as 142,000,
describing this as less than 50% of the number 30 years previously.