The British used to have a TOTALLY FREE National Healthcare system but it suffered huge wastages and could not deliver the needed services under complete government ownership. Here is what has happened since:

Guide: How the healthcare system works in England http://www.bbc.co.uk/dna/ican/A2454978

The National Health Service (NHS) was set up in 1948 to provide free healthcare for all the residents of the UK.

For its founders, the most important feature was that it was free at the point of need. This means that every time you go to the doctor or receive treatment at hospital, it is provided free of charge. The NHS is funded through general taxation and is run by the Department of Health.

There is also a private healthcare sector in the UK. People pay for private healthcare either through insurance or when they use its services.

Over the last few years the structure of the NHS has undergone considerable change. The private sector now has a role in supplying and funding some buildings and services within the NHS. The power to make important decisions about local healthcare is also being devolved to local communities in some areas.

There are now significant differences in how the NHS works between the countries. This guide deals with England. You can also read our guide to How the healthcare system works in Wales, How the healthcare system works in Northern Ireland and How the healthcare system works in Scotland.

1. How the NHS works

Secretary of state for health
This is the government minister responsible for the NHS in England and is answerable to Parliament for its work.

Department of Health
The Department of Health is responsible for the overall planning, regulation and inspection of the health service. It develops policies and decides the general direction of healthcare.

Strategic health authorities
There are 28 strategic health authorities in England. They look after the healthcare of their region. They are the link between the Department of Health and the NHS. They make sure that national health priorities (such as cancer programmes) are integrated into local health plans.

Primary and secondary health services
Health services in the UK are divided into ‘primary’ and ‘secondary’ and are provided by local NHS organisations called ‘trusts’.

  • Primary care covers everyday health services such as GP’s surgeries, dentists and opticians and these are delivered by ‘primary care trusts.’
  • Secondary care refers to specialised services such as hospitals, ambulances and mental health provision and these are delivered by a range of other NHS trusts, all accountable to the strategic health authorities

2. The different types of trusts

Primary care trusts
There are about 300 primary care trusts in England. They decide what health services their area needs and make sure these are delivered efficiently. For example, they are responsible for making sure there are enough GPs. Primary care trusts are responsible for services you access directly such as:

  • GPs
  • Dentists
  • Pharmacists
  • Opticians
  • NHS Direct
  • NHS walk-in centres

Primary care trusts are responsible for secondary planning: they decide on the amount and quality of services provided by hospitals, dentists, patient transport and population screening. They are also responsible for generally improving local health and making sure that NHS organisations work effectively with councils.

Primary care trusts are a crucial part of the NHS and they receive about 75 % of the NHS budget. They also control funding for hospitals, which are managed by NHS trusts called ‘acute trusts’.

NHS trusts
NHS Trusts run most hospitals and are responsible for specialised patient care and services such as mental health care. The trusts make sure that hospitals provide high quality health care and spend their money efficiently. They employ most of the NHS workforce from hospital doctors and radiographers to security staff.

  • Acute trusts: These look after hospitals that provide short-term care, such as Accidents and Emergencies, maternity, surgery, x-ray etc
  • Care trusts: These work in both health and social care and they can carry out a variety of services such as mental health services and primary care provision. They are generally set up when the NHS and a local authority decide to work closely together
  • Mental health trusts: There are a number of specialist mental health trusts in England. Specialist care that a mental health trust might provide includes psychological therapy and specialist medical and training services for people with severe mental health problems
  • Ambulance trusts: There are over 30 ambulance services for England and these provide access to emergency healthcare. Ambulance trusts are responsible for providing transport to get patients to hospital for treatment

Foundation trusts
From April 2004 certain NHS trusts will be allowed to receive foundation status, paving the way for a new kind of hospital. Although they remain part of the NHS and people will continue to receive free healthcare, foundation trusts will have much more freedom and financial flexibility and less central control and monitoring.

Foundation trusts won’t be run by central government. They will be owned by their community, local residents, employees and patients and they will have the power to manage their own budgets and shape their healthcare provision according to local needs and priorities, for example by having the freedom to address long waits for certain treatments. The trusts will also have more access to funds for investment and this can come from the public or the private sector.

They will be held accountable by an elected board of governors and an independent regulator will monitor their performance. Like all healthcare organisations, they will be inspected by the Healthcare Commission (currently called the Commission for Healthcare Audit and Inspection).

The government hopes that by 2008 all NHS trusts will be able to become foundation trusts. You can read the Foundation hospitals: an iCan briefing for more information on the issue.

3. How the private sector and the NHS work together

The government is keen to encourage the use of private healthcare within the NHS. They argue that as it is free at the point of need and the service is good, it is not important who provides the service to patients but that it is. The private sector now works with the NHS in a number of ways.

Outsourcing treatments: Parts of the NHS use private healthcare companies to help them provide more treatment to more people and to help reduce waiting lists:

  • Many primary care trusts outsource work to private companies. Out-of-hours healthcare is often provided by private companies
  • Some NHS hospitals pay for private treatment to clear backlogs and waiting lists
  • Treatment centres, which offer pre-booked short-term surgery and diagnosis in areas with long waiting lists such as ophthalmology have been set up across the UK. Some of these are NHS run and others are managed by private companies although they deliver a free NHS service

Private finance initiatives (PFI): The government is building more hospitals using private money. PFI is a way of funding major public building projects and involves private companies contracted for about 30 years to design, build and manage these large new projects. The building is leased by a health trust from the private company for this period while the government pays back the building cost with interest. The developer maintains the building during this period. Because the payment can be spread over time the government has been able to start an extensive building programme.

4. The private healthcare sector

There are a number of ways that people access private healthcare.

Private health insurance: Membership of health insurance schemes such as BUPA accounts for a large proportion of private health treatment and more employers are offering membership of such schemes.

Secondary care in the private sector: Secondary care, which refers to more specialised health treatment such as hospitals, mental health provision and care for the elderly, is especially well served by the private sector. While people may be registered with an NHS GP the private sector is often used for secondary care such as:

  • Diagnostic tests for certain conditions
  • One-off specialist treatment, such as visiting a dermatologist
  • Specific operations in a private hospital
  • Non-essential treatment such as cosmetic surgery
  • Treatment for addiction or rehabilitation

Private hospitals:There are over 300 private hospitals in the UK. Private hospitals are provided by six organisations: the NHS, which runs a number of private patient units within its hospitals and five private hospital groups: BMI Healthcare, BUPA, Nuffield Hospitals, Capio Healthcare UK and HCA International.

The private healthcare sector is much smaller than the NHS and does not have the same structures of accountability. It mirrors the NHS by providing GPs (many doctors in the NHS also have private practices), nursing homes, ambulances, hospitals and medical specialists, but it does not have to follow national treatment guidelines and health plans and it does not have responsibility for the health of the wider local community, only for its paying clients. Private hospitals are licensed by the local healthcare authority and they conduct two inspection visits a year. Private hospitals are not regulated by the national inspection bodies that inspect NHS organisations.

5.The regulation and inspection of healthcare

A number of bodies have been set up to check that people are getting good healthcare services. These ‘special healthcare authorities’ primarily regulate and inspect important aspects of healthcare such as clinical guidelines on medical conditions and patient safety.

Providing guidance on medical treatment
The National Institute for Clinical Excellence (Nice) publishes guidelines and advice for the public and for healthcare professionals in England and Wales on specific diseases, drugs, medical devices and technologies and the management or treatment of certain conditions. The NHS is expected to take these guidelines into account. Private hospitals do not have to follow them, although they are issued as ‘best practice’ guides.

Monitoring healthcare standards
The Healthcare Commission (currently known as the Commission for Healthcare Audit and Inspection) is responsible for monitoring healthcare standards and efficiency in the UK.

It is also responsible for publishing the NHS performance ratings and indicators. Star rating affects how much independence trusts have and the ability to become a foundation trust. NHS organisations in England are allocated 0-3 stars based on their performance in areas such as:

  • Waiting times and waiting lists
  • The number of operations cancelled
  • Hospital cleanliness
  • Death rates
  • Financial position
  • Emergency re-admission rates

Monitoring social care standards
The Commission for Social Care Inspection is the body responsible for inspecting and regulating social care services and will work in parallel to the Healthcare Commission (currently known as the Commission for Healthcare Audit and Inspection). Its commissioners will be appointed by an independent process and its role includes:

  • Carrying out inspections of all social care organisations, public, private and voluntary
  • Carrying out inspections of local social service authorities
  • Reporting to Parliament on the performance of social services
  • Publishing the star ratings for social services authorities

Monitoring patient safety
The National Patient Safety Agency was set up to improve standards of safety throughout the NHS by learning from adverse incidents involving patient care and safety. It encourages staff to report incidents and by collecting reports, hopes to initiate preventative measures in hospitals in England and Wales.

Investigating complaints
The Health Service Ombudsman is completely independent of the NHS and the government. It investigates complaints about the NHS and private healthcare providers if the treatment was funded by the NHS. For more on complaining about medical treatment you can read our iCan guides, How to complain about private healthcare and How to complain about NHS medical treatment in England.

Regulating medical professionals
The Council for the Regulation of Healthcare Professionals is the umbrella body answerable to Parliament, which represents the regulatory councils for nurses, doctors, pharmacists, opticians, osteopaths and chiropractors. It promotes good practice in the regulation of healthcare professions.

You can visit their website to find out more about the individual regulatory councils. The General Medical Council has a role in protecting public health and can take action against doctors where there has been a serious professional misconduct.

See also the iCan guide, How you can get involved in improving NHS services in England.

 California's SA BILL810 Single Payer Healthcare
 
Using performance measurement, ICT, and clinical practice guidelines, the US Veterans Administration Health System reduced surgical mortality by 9% over 4 years, increased compliance with practice standards from 34% to 81%, and reduced patient care costs by 25% over 5 years.
 
mixed public-private insurance systems
In countries where Private health insurance plays a prominent role, it can be credited with having injected resources into health systems, added to consumer choice, and helped make the systems more responsive.
However, it has also given rise to considerable equity challenges in many cases and has added to total health care expenditure ( in some cases to public expenditure).

A system based on competing primary private insurers can improve responsiveness and consumer choice, but this will come at increased cost.
While it can help reduce some of the capacity pressures faced by public health systems, it does not significantly reduce public health expenditure.
Decisions to de-list services need to balance the desire to reduce public sector cost with the equity implications of no longer covering certain services publicly.

Sweden and Israel are the world's healthiest countries and possibly have the world’s top healthcare systems, according to an assessment of 19 leading industrial nations published in the latest issue of the British Medical Journal. Taiwan coming out above the UK and Mexico above the United States !

Included is maternal and infant death rates, deaths from cancer, infection, and heart and respiratory disease, HIV infection rate, and immunisation rates.

Taiwan has a low death rate–less than 10% of the population is aged over 65. It also has a low incidence of maternal mortality–lower than the US–and a low incidence of AIDS.

Mexico benefits from better immunisation coverage than the US and lower death rates from cancer and from respiratory and circulatory diseases. However, the report in Healthcare International acknowledges that, as the figures are mostly derived from government, politicians an be reluctant to divulge the true incidence of local disease in case this affects investment and tourism. Britain does badly mainly because of the high rate of cancer and circulatory diseases, which may be due to the country's poor diet.

Totals for childhood and maternal mortality: Japan, Sweden, and Singapore, which have the lowest figures.

The report also found no correlation between the numbers of doctors and quality of medical care. Italy has a large number of doctors–478 per 100000 population–but is still middle of the table. Alexandra Wyke, editor of Healthcare International, said: "The conclusion must be that the amount spent on healthcare and the quality of doctors and hospitals have little to do with the quality of medicine."

World Health Report 2004
Health systems by country

Statistics by Country http://www.who.int/whr/2004/annex/country/en/

National health accounts indicators: measured levels of per capita expenditure on health, 1997–2001 [pdf 49kb]

- Selected national health accounts indicators: measured levels of expenditure on health, 1997–2001 [pdf 71kb]

 

Pakistan needs British healthcare systemhttp://www.dailytimes.com.pk/default.asp?date=08/31/2004 7:37:08 AM

ISLAMABAD: Federal Minister for Health, is impressed by the British healthcare system in which 100 percent of the population has health insurance and he wants to bring healthcare to the doorsteps of the people by adapting the world’s best healthcare systems to Pakistan. The minister was convinced the government must have control on basic healthcare services. In the National Healthcare System of Britain, he said, the first thing doctors do is treat patients rather inquire about their healthcare insurance, as is the practice in the US.”

Commenting on the local situation he said government healthcare service providers had to cater to the needs of a large number of people who cannot afford expensive medicine. He said Pakistan had excellent healthcare infrastructure such as Basic Health Units, Rural Health Centers, DHQs and hospitals. “We can provide descent healthcare to our people. One cannot have an appendix operation for $2 in the USA. This is only possible in Pakistan. Of course, we cannot offer the five-star facilities, but we can give descent healthcare to our people. The only thing required is better organization and motivation.”

To a question about private practice by doctors, he said he had floated the idea of private practice by the medical specialists within the hospitals in 1988, when he was Punjab’s health minister. “In Britain the doctors have private clinics within the premises of the hospitals. We want to implement the same here in Pakistan. They would be required to give a certain percentage to the hospital against the services like electricity, gas, rent, staff, etc being provided by the hospital.”

He was against the privatization of the government hospitals and other institutions- a change in the approach he had since his tenure as provincial heath minister. He had then stopped the privatization of public hospitals in Lahore which led to a conflict between him and the chief minister at the time.

“I believe the government must give a descent, skeleton healthcare system to the people while I also believe the government must have a hold on the basic healthcare system. Therefore, I resisted the privatization of Services Hospital in Lahore at that time.” But he ardently supported involving the private sector in healthcare, believing the involvement of more and more private concerns would generate competition and improve healthcare services. He also hinted at regulating the cost of treatment at private clinics and hospitals. Asked about the sky-high prices of lifesaving and other drugs, he said, “I have told the multinationals to give me complete lists of their products and their prices and I will compare them with the prices of similar drugs in India, Bangladesh, Iran, Nepal and Burma. We have to regulate the price and also maintain the quality of the medicine at the same time.”

He said the government might be implementing new laws to check the quality of medicine, but confessed “the gigantic task of regulating prices and checking quality needs more time and resources”.

 

Waiting Times
many countries have adopted targets of around 3-6 months for maximum waiting.
Countries with the worst waiting times depends on the procedure,
but patients in Finland and the UK often had the longest waits in 2000.
Q: why do around half of OECD countries have no waiting lists?
A: differences in capacity explain much of the international variation in waiting times. For example, countries without lists have about 70% more acute beds and 25% more specialists, per capita, than countries with lists.

a) There are waiting time problems in about half of OECD countries.
b) Some countries (such as Denmark, in the case of coronary re-vascularisation in the 1990s) have brought down waiting times dramatically after significant increases in capacity.
c) It seems to cost roughly an extra 1% of GDP devoted to health expenditure to go from high waiting to average waiting and another 1% to go from average waiting to low waiting.
Canada, where waiting times can be long, spends the same share of its
GDP on health as France where there are no waiting times.
Waiting Prioritisation
watchful waiting’ by the general practitioner is often the most appropriate thing to do for mild cases. The trick is to get the prioritisation of patients right.
New Zealand has been able to introduce a booking system for all patients and limit waiting times to under 6 months by introducing a careful Prioritisation system and demand management.
Home Care
Q: Why have not more countries opted for a social-insurance solution for nursing home care?
A: Some countries provide comprehensive services that are tax funded (Scandinavia); others stick to means-tested programmes to contain costs.
German long-term care insurance has managed to keep spending increases under control. The number of countries with social insurance type programmes
has been growing (Germany, Japan, and Luxembourg).