Healthcare in England


Healthcare in Britain is mainly provided by the National Health Service, a public body that provides healthcare to all permanent residents of the United Kingdom that is free at the point of use and paid for from general taxation. Since health is a devolved matter, there are differences with the provisions for healthcare elsewhere in the United Kingdom. Though the public system dominates healthcare provision in Britain, private health care and a wide variety of alternative and complementary treatments are available for those willing to pay.

National Health Service (NHS)

The National Health Service is free at the point of use for the patient though there are charges associated with eye tests, dental care, prescriptions, and many aspects of personal care.
The NHS provides the majority of healthcare in England, including primary care, in-patient care, long-term healthcare, ophthalmology and dentistry. The National Health Service Act 1946 came into effect on 5 July 1948. Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used by less than 8% of the population, and generally as a top-up to NHS services. Recently there have been some examples where unused private sector capacity has been used to increase NHS capacity and in some cases the NHS has commissioned the private sector to establish and run new facilities on a sub contracted basis. Some new capital programs have been financed through the private finance initiative. The involvement of the private sector remains relatively small and according to one survey by the BMA, a large proportion of the public oppose such involvement.

Funding and management

The NHS is divided conceptually into two parts covering primary and secondary care with trusts given the task of health care delivery. There are two main kinds of trusts in the NHS reflecting purchaser/provider roles: commissioning trusts are responsible for examining local needs and negotiating with providers to provide health care services to the local population, and provider trusts which are NHS bodies delivering health care service. Commissioning trusts negotiate service delivery with providers that may be NHS bodies or private entities. They will be involved in agreeing major capital and other health care spending projects in their region.
By far the most known and most important purchases are services including general practice physician services, community nursing, local clinics and mental health service. For most people, the majority of health care is delivered in a primary health care setting. Provider trusts are care deliverers, the main examples being the hospital trusts and the ambulance trusts which spend the money allocated to them by the commissioning trusts. Because hospitals tend to provide more complex and specialised care, they receive the lion's share of NHS funding.
The hospital trusts own assets purchased for the nation and held in trust for them. Commissioning has also been extended to the very lowest level enabling GPs who identify a need in their community to commission services to meet that need. Primary care is delivered by a wide range of independent contractors such as GPs, dentists, pharmacists and optometrists and is the first point of contact for most people. Secondary care can be either elective care or emergency care and providers may be in the public or private sector, but the majority of secondary care happens in NHS owned facilities.
The NHS is the world's largest health service and the world's fourth-largest employer; only the Chinese People's Liberation Army, Indian Railways, and Wal-Mart employ more people directly.

NHS Constitution

The NHS has recently adopted a formal constitution which for the first time, in one document, lays down the objectives of the NHS, the rights and responsibilities of the various parties and the guiding principles which govern the service.

Patient experience

A patient needing specialist care at a hospital or clinic, will be informed by the GP of the hospitals where they can get their treatment. This choice usually includes public and private hospitals. The NHS will pay for treatment in a private setting if the hospital meets the cost and service criteria that NHS hospitals adhere to. Otherwise opting for a private hospital makes the patient liable for private hospital fees. Because the private sector often has higher costs, most people choose to be treated for free in an NHS hospital. If the GP judges the case to be extremely urgent, the doctor may by-pass the normal booking system and arrange an emergency admission. The median wait time for a consultant led first appointment in English hospitals is a little over 3 weeks.
Patients can be seen by the hospital as out-patients or in-patients, with the latter involving overnight stay. The speed of in-patient admission is based on medical need and time waiting with more urgent cases faster though all cases will be dealt with eventually. Only about one third of hospital admissions are from a waiting list. For those not admitted immediately, the median wait time for in-patient treatment in English hospitals is a little under 6 weeks.
Trusts are working towards an 18-week guarantee that means that the hospital must complete all tests and start treatment within 18 weeks of the date of the referral from the GP. Some hospitals are introducing just in time workflow analysis borrowed from manufacturing industry to speed up the processes within the system and improve efficiencies.
Almost all NHS hospital treatment is free of charge along with drugs administered in hospital, surgical consumables and appliances issued or loaned. However, if a patient has chosen to be treated in an NHS hospital as a private fee paying patient by arrangement with his consultant, the patient will be billed. This can happen because at the inception of the NHS, hospital consultants were allowed to continue doing private work in NHS hospitals and can enable private patients to "jump the NHS queue". This arrangement is nowadays quite rare as most consultants and patients choose to have private work done in private hospitals.
Emergency Department treatment is also free of charge. A triage nurse prioritises all patients on arrival. Waiting times can be up to 4 hours if a patient goes to the Emergency Department with a minor problem or may be referred to other agencies. Emergency Departments try to treat patients within 4 hours as part of NHS targets for emergency care. The Emergency Department is always attached to an NHS general hospital. Private hospitals do not provide emergency care services.
The NHS also provides end of life palliative care in the form of Palliative Care Specialist Nurses. The NHS can also commission the expertise of organisations in the voluntary sector to complement palliative care. Such organisations include Marie Curie Cancer Care, Sue Ryder Care and Macmillan Cancer Support. Despite their names, these services are designed for all palliative conditions, not exclusively cancer. All palliative care services provide support for both the patient and their relatives during and after the dying process. Again, these are all free of charge to the patient.

Experiences, perceptions and reporting of the NHS

Although the NHS has a high level of popular public support within the country, the national press is often highly critical of it and this may have affected perceptions of the service within the country as a whole and outside. An independent survey conducted in 2004 found that users of the NHS often expressed very high levels satisfaction about their personal experience of the medical services they received. Of hospital inpatients, 92% said they were satisfied with their treatment; 87% of GP users were satisfied with their GP, 87% of hospital outpatients were satisfied with the service they received, and 70% of Accident and Emergency department users reported being satisfied.
When asked whether they agreed with the question "My local NHS is providing me with a good service" 67% of those surveyed agreed with it, and 51% agreed with the statement "The NHS is providing a good service. The reason for this disparity between personal experience and overall perceptions is clear. The wait times for specialty service is too long. The survey also showed that net satisfaction with NHS services was generally higher amongst NHS services users than for all respondents. Where more people had no recent experience of that service, the difference in net positive perception reported by users compared to non-users was more likely to diverge.
For example, the least used service surveyed was walk-in centres but 85% of walk in clinic users were satisfied with the service they received. Users' net positive satisfaction was 80%. However, for all respondents the overall net positive satisfaction was just 25%. The service with the highest rate of use was the GP service and the difference in net satisfaction between users and all users was the smallest
It is also apparent from the survey that most people realise that the national press is generally critical of the service, and also that the national press is the least reliable source of information. Newspapers were reported as being less favourable and also less reliable than the broadcast media. The most reliable sources of information were considered to be leaflets from GPs and information from friends and medical professionals.
Most people think that the NHS is well run, with 73% of people reporting that they are satisfied with the running of the service and only a little over 10% reporting themselves as dissatisfied.
England's healthcare is ranked 16th in Europe in the Euro Health Consumer Index.

Private-sector medical care

England also has a private health care sector. Private health care is sometimes funded by employers through medical insurance as part of a benefits package to employees though it is mostly the larger companies that do. Insurers also market policies directly to the public. Most private care is for specialist referrals with most people retaining their NHS GP as point of first contact.
The private sector now does some subcontracting work for the NHS. Thus an NHS patient can be treated in the private sector as an NHS patient if the Health Services has subcontracted work to the hospital.
Some private hospitals are business enterprises and some are non-profit-making trusts. Some hospital groups provide insurance plans, and some insurance companies have deals with particular private hospital groups. Some private sector patients can be treated in NHS hospitals in which case the patient or his/her insurance company is billed.
The Care Quality Commission, after inspecting more than 200 private sector hospitals, warned in April 2018 that informality in processes meant that systematic and robust safety procedures were not in place. Hospital consultants are generally not employed by the private hospitals where they have admitting rights and the commission said private companies could be reluctant to challenge them. Safety was viewed as the responsibility of individual clinicians, rather than a corporate responsibility supported by formal governance processes. Furthermore, private hospitals “were not set up to anticipate and handle emergency situations”. There were only 15 critical care services across 206 hospital sites so in an emergency they had to rely on the 999 service.