UNITED KINGDOMHEALTH CARE SYSTEM

Team UK

“No society can legitimately call itself civilized if a sick person is denied

medical aid because of a lack of means.”

Aneurin BevanMinister of Health

1946

“United Kingdom”

• The United Kingdom of Great Britain and Northern Ireland

• Commonly known as UK or Britain

• Constitutional monarchy and unitary state: England, Northern Ireland, Scotland and Wales

Demographics• Population (2010 est.): 62.2 M• Annual population growth rate (2010 est.):0.56%• Major ethnic groups: British, Irish, West Indian,

South Asian• Infant mortality rate (2009est.) – 4.69/1,000• Life expectancy (2009 est.) – Males 77.8 yrs;

Females 82.1 yrs; total 79.9 yrs• Work force (2009, 31.5M): Services-80.4%;

Industry-18.2%; agriculture-1.4%• Average Total Fertility Rate (TFR) in 2008-1.96

children per woman

THE BEVERIDGEAN MODEL• Named after William Beveridge, the social

reformer who designed Britain's National Health Service.

• In this system, health care is provided and financed by the government through tax payments

• Mostly, hospitals and clinics are owned by the government

• Government and private doctors collect their fees from the government

Beveridgean model

• low costs per capita (Government controls what doctors can do and what they can charge)

• Great Britain, Spain, most of Scandinavia and New Zealand, Hong Kong, Cuba

Healthcare system in UK• National Health Service (NHS) • Shared name of three of the four publicly funded

healthcare systems in UK:– National Health Service-England– NHS Scotland– NHS Wales– Health and Social Care in Northern Ireland (HSC)-Northern

Ireland• Each system operates independently• Politically accountable to the relevant government: the

Scottish Government, Welsh Assembly Government, the Northern Ireland Executive, or the UK government (for the English NHS)

Brief history• 1834 – “Poor Law Amendment Act” – legal mandates

for mandates for workhouses to provide health care for inmates and sick paupers

• 1870s – evolving network of workhouses, isolation hospitals, asylums, volunteer hospitals

• 1919 – Ministry of Health established• 1942 – Beveridge Report – first comprehensive

system, including access to both community-based care and hospital treatment

Brief history• National Health Service Act 1948—based on

Beverage Report and the belief in post-World War II solidarity

• 1983 – Griffith report• 1989 – Caring for People by England, Scotland,

Wales• 1990 – National Health Service and Community

Care Act – shift resources to primary care• 1990s – Thatcher Revolution: public-private

ownership

HEALTH SERVICE DELIVERY

ORGANIZATION AND ADMINISTRATION

NHS Act of 1948 establishing theNational Health Service

• Central administration• Regional hospital boards• Local health authorities• Executive councils• Tripartite of providers

– Hospital services– Community services– Family practitioner services

The National Health Service in 1948

Ministry of Health Central Health Services Council

Regional Hospital Boards

Teaching Hospital

Boards of Governors

Hospital Management Committees

Hospital Services

Local Health Authorities

Community Services

Executive Councils

Family Practitioner

Services

Minister of Health

• Responsible for provision of all hospital and specialist services, for the quality of laboratory and blood products, major capital projects, and health research, and reported directly to the Parliament.

Tripartite providers

• Hospital services– Organization was based upon 14 Regional Hospital

Boards that oversaw local hospital management committees.

– The teaching hospitals were directly responsible to the Ministry of Health 'for they served the nation, not the locality.'

Tripartite providers

• Community services– Local authority health services were managed by a

Medical Officer of Health.– Community nurses– School dentists– Health centers

Tripartite providers

• Family practitioner services– Family doctors, dentists, opticians, and

pharmacists were self-employed under a contract for services from an Executive Council.

– The family doctor acted as gate-keeper to the rest of the NHS, referring patients where appropriate to hospitals or specialist treatment and prescribing medicines and drugs.

Reforming the NHS in 1974

• 14 Regional Health Authorities, covering all three parts of the NHS and incorporating the teaching hospitals, replaced the previous authorities.

• A new tier of Area Health Authorities was established, with boundaries largely co-terminous with local authorities, between the regions and the district health authorities that managed the hospitals.

Area Health Authorities

• The advantages were that the Area Health Authorities could unite the tripartite service and plan all NHS services in cooperation with local authorities.

• The disadvantages were that the system was complex and managerially driven and it soon earned criticism.

Reforming the NHS in 1990

• Griffith report in 1983 recommending– That the NHS become more business-like– Address the problem of growth of public

expenditures, and– Initiate internal market forces within the NHS.– To create competition between hospitals and

providers through a separation of purchaser and provider role.

• After the establishment of the internal market and the purchaser-provider split, – 'purchasers' (health authorities and some family

doctors) were given budgets to buy health care from 'providers' (acute hospitals, organizations providing care for the mentally ill, people with learning disabilities and the elderly, and ambulance services).

• To become a 'provider' in the internal market, health organizations became NHS trusts, independent organizations with their own management, competing with each other.

• The first wave of 57 NHS Trusts came into being in 1991.

• By 1995 all health care was provided by trusts.

• Self-governing trusts would be created to run hospitals and other services, and

• DHAs would be transformed into purchasers for their local constituencies.

• GP practices would become fundholders, become purchasers of some hospital services, and establish contracts for other services.

• The fundamental idea was to assure that funding would follow the patient and this competition for patients would stimulate increased efficiency and greater response to patient needs.

The NHS after the 1990 National Health Service and Community Care Act

Secretary of State for Health

Department of Health

Regional Health Authorities

Family Health Services Authorities

GP’s, dentists, opticians, pharmacists

District Health Authorities

GP Fund Holders

Directly Managed Units

NHS Trusts

Special Health

Authorities

1990 National Health Service and Community Care Act

• Overall mission was to shift resources to primary care by introducing fundamental change in the management of hospital and family practitioner services.

• The 1990 Act represents a major shift to community-based care, privatization, accountability, quality assurance, and cost containment that was envisioned over 30 years ago. (Gillie, 1963)

The NHS in the recent decade (1998-2007)

• A new type of body that encouraged public participation as members appeared, the NHS Foundation Trust.

• Ultimately there were 10 strategic health authorities controlling some 200 primary care trusts that contracted with both public and private providers, trusts, hospitals, community, mental illness and ambulance, as well as managing GPs and primary health care.

• Secretary of state for health – This is the government minister responsible for

the NHS in England, and he or she is answerable to Parliament for the work of the NHS.

• Department of Health - responsible for the overall planning,

regulation and inspection of the health service- develops policies and decides the

general direction of healthcare.

• Strategic health authorities - 28 strategic health authorities in

England. - look after the healthcare of their region- link between the Department of Health and the NHS.- make sure that national health priorities (such as cancer programmes)

are integrated into local health plans.

Primary and secondary health services

• Primary care – covers everyday health services such as GPs’

surgeries, dentists and opticians – delivered by “primary care trusts”

• Secondary care – specialized services such as hospitals, ambulances

and mental health provision – delivered by a range of other NHS trusts.

NHS “trusts”

- distinct legal entities w/n the NHS- run by a board of directors and a chairman appointed by the Secretary of Health- rationale: stimulate a managed care system, with incentive to reward efficiency, quality and cost effectiveness and provide citizens with choices.

The different types of Trusts • Primary care trusts

• about 300 primary care trusts in England.– decide what health services their area needs and

have responsibility for making sure these are delivered efficiently

– 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• decide on the amount and quality of services

provided by hospitals, dentists, patient transport and population screening.

• responsible for generally improving local health • make sure that NHS organizations work

effectively with councils. • Receive about 75% of the NHS budget. • control funding for hospitals, which are managed

by NHS trusts called "acute trusts".

NHS Trusts• run most hospitals and are responsible for

specialised patient care and services, such as mental health care.

• make sure that hospitals provide high quality health care and spend their money efficiently and some pay for private treatment to clear backlogs and waiting lists.

• employ most of the NHS workforce from hospital doctors and radiographers to security staff.

• NHS trusts which oversee 1,600 NHS hospitals and specialist care centers

Types of NHS Trust• Acute trusts:

– look after hospitals that provide short-term care, such as Accidents and Emergencies, maternity, surgery, x-ray

– 175 acute NHS trusts • Care trusts:

– work in both health and social care and they can carry out a variety of services, such as mental health services.

– generally set up when the NHS and a local authority decide to work closely together

• Mental health trusts: – number of specialist mental health trusts in

England, providing care, such as psychological therapy and specialist medical and training services for people with severe mental health problems

– 60 mental health trust

• Ambulance trusts: – There are over 30 ambulance services for England,

each run by its own trust.– responsible for providing transport to get patients

to hospital for treatment– 12 ambulance trust

Foundation trusts

• High-achieving NHS trusts can opt out of NHS control and receive foundation status

• more freedom and financial flexibility and less central control and monitoring.

• owned by their community, local residents, employees and patients

• have the power to manage their own budgets and shape their healthcare provision according to local needs and priorities

• more access to funds for investment (public or private sector)

• currently 115 available

Private Health Care• smaller than the NHS and does not have the same

structures of accountability. • 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.

• Private health insurance• Secondary care in the private sector: specialized health

treatment• 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 and treatment for addiction or rehabilitation

Private hospitals

• over 300 private hospitals in the UK. • provided by private hospital groups and the

NHS also provides a number of private patient units within its hospitals.

• licensed by the local healthcare authority, which conducts two inspections a year.

• not regulated by the national inspection bodies that monitor NHS organizations.

HEALTH HUMAN RESOURCES

HUMAN HEALTH RESOURCES• 90,000 doctors (2.1 per 1000 pop) (OECD 2002)

3 Categories:1. Hospital consultant2. General Practitioner

-gatekeepers :all citizen register with a GP-1: 1800 approval for practice; >2,500 financial incentives- group practice- additional reimbursement opportunities “rural practice payments”-Augment income through dispensing of drugs

3. Public Health Doctor in Community Medicine-smallest-can advance to senior appointments as District or Regional Public Health Director

• 300,000 nurses– 40% of the NHS budget– Initial core course then select a branches of

nursing for specialization (adult, children etc..)

• 150,000 healthcare assistants• 22,000 midwives• 13,500 radiographers• 15,000 occupational therapists

• 7,500 opticians• 10,000 health visitors• 6,500 paramedics• 90,000 porters, cleaners and other support staff• 11,000 pharmacists• 19,000 physiotherapists• 24,000 managers• 105,000 practice staff in GP surgeries

Health Care Administration

• Expertise in the planning and evaluation of services in the NHS.

• Present at all level (regional, district )

NHS HOSPITALS

Capacity: 400,000 bedsAbsorbs over half of the NHS budgetSizes ranges from the small community facility

to the large District HospitalAverage length of stay 8.8days (1991), 12.5

(1981)

HEALTH FINANCING

Health Finance

• NHS principle on health finance: financed almost 100% from central taxation

* The rich paid more than the poor for comparable benefits

• Public funding through taxation– Efficient (lower administrative costs)

• Services are free to patients at the point of use.

Financing Scheme

• Small co-payment on few services (e.g. prescription drugs, optician and dental services)– 80% of patients are exempted from these co-

payments namely pregnant women, mothers, children, most elderly persons & patients with chronic diseases

• Small but growing private sector (10-20%)

Financing Scheme

It pays general practitioners on a capitation basis and hospital physicians largely on a salaried basis.

Financing Scheme

• Before the 1990: monolithic bureaucracy• Prior to the reforms, each health district authority

was provided a fixed budget with no incentive for good performance.

• Greater efficiency and shorter waiting lists meant more referrals from other districts without an offsetting transfer of resources. Increase productivity added to workloads but not revenues.

Financing Scheme

• The reforms replaced the centralized hierarchical NHS bureaucracy with a quasi-market mechanism.

• Establishment of the internal market and the purchaser-provider split

• A provider/purchaser split: “purchasers” of health care, regional health authorities and general practice fund holders are allocated budgets to purchase services for their populations

Financing Scheme

• These purchasers are distinct from providers (mainly hospitals)• The incentives for efficiency and a responsive

system come as providers compete for contracts with purchasers

• The Thatcher reforms of 1993, created an internal market and GP fundholders, adding choice and competition to a system where little or either existed

Financing Scheme

• To become a “provider” health organizations became NHS trusts, independent with their own management and competing with each other

• NHS Trust hospitals served as primary providers of specialty services to GPFHs

Financing Scheme

GP fund holding• Family doctors were given budgets with which

to buy health care from NHS trusts (and also from the private sector)

• Two tier system: Patients of GP fund holders were often able to obtain treatment more quickly than patients of non-fund holders

• Supporters said fundholding saved money and was more efficient.

Financing Scheme

• Establishment of NHS Trust and General Practitioner Fund Holders (GPFH) organizations

• Provide care and purchase services for their patients including hospital services, pharmaceutical care, health visiting, district nursing, dietetic and chiropody services

• Quicker access to hospital care and consultants

Financing Scheme

• A patient-focused service (patient choice, an expanding independent sector and providing extra capacity)

• Competitive providers, giving hospitals and GPs incentives to change (Payment by results, money following patients)

• Active purchasers - giving PCTs purchasing power and practice-based commissioning)

• Cost effectiveness and affordability, (tariffs and commissioning)

Financing Scheme

• The NHS had become a service provided to all without payment, but the provision was no longer necessarily by a publicly owned infrastructure

• Private sector organizations came to build and operate hospitals under the public/private partnerships, and to run clinical services such as Independent Treatment Centers and some NHS Walk-in Centers

• "Contestability" - the introduction of competition between providers - became significant.

• Private practice was now an important part of a new and more sophisticated market.

Private Market

• 12% of Britons have Supplementary Insurance--an employment perk

• Doctors & hospitals treat both public and private patients

• Private insurance pays for dental, vision, some prescription drugs (although 80% of all prescription drug payments are waived due to age, pregnancy, youth, poverty)

Economic Factors

• Revenues– 83% NHS funding from taxes– 13% from employer-employee contributions– 4% User fees

• Expenditures– NHS accounts for 88% of health expenditures– Private Insurance (SI) 4% of expenditures– ~3/4 of NHS budget goes to workforce salaries– 1/10th of NHS budget goes for drugs

Health Care Expenditures

• Expenditure on healthcare in the UK was £136.4 billion in 2009

• The graph on the next slide shows the current price expenditure on healthcare within the UK for the years 1997–2009.

Current price expenditure on healthcare from year 1997–2009

Source: Office for National Statistics

Expenditure on healthcare as a percentage of GDP (1997–2009)

Source: Office for National Statistics

Public and private health expenditure as a percentage of GDP 1997–2009

Source: Office for National Statistics

Breakdown of Budget for NHS

Breakdown of Health Spending

NHS expenditure, by age

£2,011

£461

£183£295

£410

£785

£1,391

£2,256

0

500

1,000

1,500

2,000

2,500

All livebirths

Age 0-4 Age 5-15 Age 16-44 Age 45-64 Age 65-74 Age 75-84 Age 85+

Age group

£ p

er

he

ad

Health Care Expenditures in Comparison to Other Countries

• (Spending per capita ($2,160) in the United Kingdom in 2002 was just 41 percent of the United States level ($5,267) and a little more than half when expressed as a ratio to GDP (7.7 percent as opposed to about 15 percent)

Total health spending in G7 countries

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

US

Germany

France

Canada

Italy

Japan

UK

Percentage of GDP

Public spending

Private spending

http://scienceblogs.com/denialism/2009/05/what_is_health_care_like_in_th.php

Total Life expectancy Infant

spending Female Male mortality

US 1 7 7 7

Germany 2 5 6 3

France 3 2 5 2

Canada 4 3 2 4=

Italy 5 4 3 6

Japan 6 1 1 1

UK 7 6 4 4=

HEALTH REGULATION

Health Regulation

• CQC• HPA• NICE

CQC

• Care Quality Commission • Regulates all health and adult social care

services in England, including those provided by the NHS, local authorities, private companies or voluntary organisation

• Also protects the interests of people detained under the Mental Health Act

CQC• Makes sure that essential common quality

standards are being met where care is provided, from hospitals to private care homes

• Has a wide range of enforcement powers to take action on behalf of people who use services if services are unacceptably poor.

• Brings together independent regulation of health, mental health and adult social care for the first time

• Aims to make sure better care is provided for everyone, whether that’s in hospital, in care homes, in people’s own homes or elsewhere.

HPA

• Health Protection Agencys • A non-departmental public body• Role is to help protect UK public health by

giving support and advice to the NHS, local authorities, emergency services, the Department of Health and any other organisations that play a part in protecting health

HPA• Operates from three major centres:

– The Centre for Infections at Colindale – The Centre for Radiation, Chemical and

Environmental Hazards at Chilton – The Centre for Emergency Preparedness and

Response at Porton • HPA Act requires the agency to be accountable

for the standards of the healthcare services it provides as if it were an NHS authority

• Is subject to the Care Quality Commission's Annual Health Check and measured against the Department of Health's Standards for Better Health

NICE

• National Institute for Health and Clinical Excellence

• An independent organisation that provides national guidance on the promotion of good health and the prevention of ill health.

• Set out in a 2004 white paper, Choosing health: making healthier choices easier and is intended to help people to make well informed choices about their health

NICE

• NICE guidance is produced by healthcare professionals, NHS staff, patients and carers, members of the academic world and other members of the wider healthcare community

NICE Guidance

Guidance is developed for the following areas:• Public health: guidance on the promotion of good

health and the prevention of ill health for those working in the NHS, local authorities and the voluntary sector, and the wider public

• Health technologies: guidance on the use of new and existing medicines, treatments and procedures within the NHS

• Clinical practice: guidance on the appropriate treatment and care within the NHS of people with specific diseases and conditions

CHALLENGES AND REFORM

Reforms

• Increase in demand at zero pricing• Growing public expectations• Advances in costly medical technologies• Ageing population

A. 1990 National Health service and Community Act2 objectives:• To improve ability to control the NHS financially

by separating ‘health’ from ‘social’ care. Free but controlled NHS in practice meant making doctors more accountable to government. This required restricting the clinical autonomy of doctors

• To increase the efficiency of the NHS by improving both productive efficiency and allocative efficiency .

• Introduction of the internal market by separating “purchasing” and “providing” functions– purchasers' (health authorities and some family

doctors) were given budgets to buy health care from 'providers' (acute hospitals, organizations providing care for the mentally ill, people with learning disabilities and the elderly, and ambulance services)

• Creation of NHS trusts with greater freedom to set pay levels and to borrow for capital projects

• Fund holding for larger GP practices allowing them to purchase certain patient services direct from providers– Elevation of GP status– Many family doctors were given budgets in a scheme

called GP fund holding. – Fund holding saved money and was more efficient.

• GPFH must have a minimum of 7000 patients enrolled and can purchase a number of provider services directly on behalf of their patient

CHALLENGES

• Concerns that GPs might engage in practices to maximize their budgets such as excluding high risk, high cost patients or under referring patients to hospitals

• Waiting lists are an epidemic problem– UK only spent 6.8% of GDP on health care hence

the numbers of doctors4, nurses, therapists and hospital beds were insufficient to match the increasing demand and, therefore, the waiting times for treatment lengthened

• Equity in access issue is unsolved• Health workers are paid considerably less

than their counterparts in other countries

B. NHS Plan of 2000

4 principles• A patient-focused service (patient choice, an

expanding independent sector and providing extra capacity)

• Competitive providers, giving hospitals and GPs incentives to change

• Active purchasers • Cost effectiveness and affordability, (tariffs, legal

contracts and commissioning)

• Health care system based on cooperation not competition– Private sector organizations came to build and

operate hospitals under the public/private partnerships, and to run clinical services such as Independent Treatment Centres and some NHS Walk-in Centers

• Emphasis on efficiency and quality through creation of NICE (National Institute of Clinical Excellence) and CHI (Commission for Health Improvement)

• Consumer choice– Means to address problem on “waiting list”– This innovation meant that spare capacity in one

hospital can be used to shorten queues at another, speeding treatment for patients and making more efficient use of resources.

– Hospitals that fail to deliver lose money

CHALLENGES

• Tax revenue for financing NHS will depend on the rate of economic growth hence there is a continuing debate as to whether NHS should be exclusively funded by general taxes and national insurance contributions or instead adopt some form of social health insurance

• How to cope up with advances in technology in tax-funded system

• How to address the rising alcohol misuse and obesity

• Prime minister needs for greater integration and efficiency, with more emphasis on prevention

• Those In poorer communities are still those with poorer health

CHALLENGES

Sources• http://www.dh.gov.uk/en/Aboutus/MinistersandDepartme

ntLeaders/index.htm• http://www.nhshistory.com/nhsplan.pdf• http://en.wikipedia.org/wiki/Healthcare_in_the_United_Ki

ngdom• http://www.nhs.uk/NHSEngland/thenhs/Pages/thenhshom

e.aspx• http://mighealth.net/uk/index.php/The_Health_Care_Syste

m_in_the_UK• http://www.disabled-world.com/medical/healthcare/uk-he

althcare/• http://www.statistics.gov.uk/articles/nojournal/healthcare-

expenditure-may2011.pdf