Overview of Healthcare in The UK

Received 2010 Sep 1; Accepted 2010 Sep 27; Issue date 2010 Dec.

. The National Health System in the UK has progressed to become one of the biggest healthcare systems on the planet. At the time of writing of this review (August 2010) the UK government in its 2010 White Paper «Equity and excellence: Liberating the NHS» has revealed a method on how it will «develop a more responsive, patient-centred NHS which attains results that are among the best worldwide». This review post presents an introduction of the UK health care system as it presently stands, with emphasis on Predictive, Preventive and Personalised Medicine aspects. It intends to function as the basis for future EPMA short articles to expand on and present the changes that will be carried out within the NHS in the forthcoming months.

Keywords: UK, Healthcare system, National health system, NHS

Introduction

The UK health care system, National Health Service (NHS), originated in the consequences of the Second World War and became operational on the fifth July 1948. It was first proposed to the Parliament in the 1942 Beveridge Report on Social Insurance and Allied Services and it is the legacy of Aneurin Bevan, a previous miner who ended up being a political leader and the then Minister of Health. He founded the NHS under the concepts of universality, free at the point of shipment, equity, and paid for by central financing [1] Despite various political and organisational changes the NHS remains to date a service offered universally that cares for individuals on the basis of need and not capability to pay, and which is moneyed by taxes and nationwide insurance coverage contributions.

Health care and health policy for England is the responsibility of the main government, whereas in Scotland, Wales and Northern Ireland it is the obligation of the respective devolved governments. In each of the UK nations the NHS has its own distinct structure and organisation, but in general, and not dissimilarly to other health systems, healthcare consists of 2 broad sections; one handling method, policy and management, and the other with actual medical/clinical care which remains in turn divided into main (community care, GPs, Dentists, Pharmacists and so on), secondary (hospital-based care accessed through GP referral) and tertiary care (professional hospitals). Increasingly differences between the two broad sections are becoming less clear. Particularly over the last years and guided by the «Shifting the Balance of Power: The Next Steps» (2002) and «Wanless» (2004) reports, steady modifications in the NHS have actually led to a greater shift towards local rather than main choice making, elimination of barriers between primary and secondary care and more powerful focus on client option [2, 3] In 2008 the previous federal government enhanced this direction in its health method «NHS Next Stage Review: High Quality Take Care Of All» (the Darzi Review), and in 2010 the present federal government’s health strategy, «Equity and excellence: Liberating the NHS», stays encouraging of the exact same concepts, albeit through perhaps different mechanisms [4, 5]

The UK federal government has just revealed strategies that according to some will produce the most transformation in the NHS given that its inception. In the 12th July 2010 White Paper «Equity and quality: Liberating the NHS», the present Conservative-Liberal Democrat union government detailed a method on how it will «produce a more responsive, patient-centred NHS which achieves outcomes that are amongst the finest on the planet» [5]

This review short article will therefore provide a summary of the UK health care system as it presently stands with the objective to work as the basis for future EPMA articles to broaden and provide the changes that will be implemented within the NHS in the upcoming months.

The NHS in 2010

The Health Act 2009 developed the «NHS Constitution» which formally unites the function and concepts of the NHS in England, its worths, as they have been established by patients, public and staff and the rights, pledges and responsibilities of patients, public and staff [6] Scotland, Northern Ireland and Wales have actually also concurred to a high level statement declaring the principles of the NHS throughout the UK, despite the fact that services may be provided in a different way in the 4 nations, reflecting their various health requirements and scenarios.

The NHS is the biggest employer in the UK with over 1.3 million staff and a budget of over ₤ 90 billion [7, 8] In 2008 the NHS in England alone utilized 132,662 doctors, a 4% increase on the previous year, and 408,160 nursing personnel (Table 1). Interestingly the Kings Fund approximates that, while the overall variety of NHS staff increased by around 35% between 1999 and 2009, over the same period the variety of managers increased by 82%. As a proportion of NHS personnel, the variety of supervisors increased from 2.7 per cent in 1999 to 3.6 per cent in 2009 (www.kingsfund.org.uk). In 2007/8, the UK health spending was 8.5% of Gross Domestic Product (GDP)-with 7.3% accounting for public and 1.2% for private spending. The net NHS expenditure per head across the UK was lowest in England (₤ 1,676) and greatest in Scotland (₤ 1,919) with Wales and Northern Ireland at approximately the very same level (₤ 1,758 and ₤ 1,770, respectively) [8]

Table 1.

The circulation of NHS labor force according to primary staff groups in the UK in 2008 (NHS Information Centre: www.ic.nhs.uk)

The general organisational structure of the NHS in England, Scotland, Wales and Northern Ireland in 2010 is displayed in Fig. 1. In England the Department of Health is accountable for the instructions of the NHS, social care and public health and delivery of healthcare by establishing policies and techniques, protecting resources, keeping track of efficiency and setting nationwide standards [9] Currently, 10 Strategic Health Authorities handle the NHS at a local level, and Medical care Trusts (PCTs), which currently manage 80% of the NHS’ spending plan, offer governance and commission services, in addition to make sure the accessibility of services for public heath care, and provision of neighborhood services. Both, SHAs and PCTs will cease to exist when the strategies detailed in the 2010 White Paper end up being carried out (see section listed below). NHS Trusts run on a «payment by outcomes» basis and acquire the majority of their earnings by supplying health care that has been commissioned by the practice-based commissioners (GPs, and so on) and PCTs. The primary kinds of Trusts include Acute, Care, Mental Health, Ambulance, Children’s and Foundation Trusts. The latter were created as non-profit making entities, complimentary of government control but likewise increased financial obligations and are managed by an independent Monitor. The Care Quality Commission manages independently health and adult social care in England in general. Other specialist bodies offer financial (e.g. Audit Commission, National Audit Office), treatment/services (e.g. National Patient Safety Agency, Medicines and Healthcare Products Regulatory Agency) and professional (e.g. British Medical Association) policy. The National Institute for Health and Clinical Excellence (NICE) was developed in 1999 as the body responsible for establishing nationwide guidelines and standards associated with, health promotion and avoidance, evaluation of brand-new and existing innovation (consisting of medications and treatments) and treatment and care medical guidance, available throughout the NHS. The health research study method of the NHS is being implemented through National Institute of Health Research (NIHR), the total budget for which remained in 2009/10 near ₤ 1 billion (www.nihr.ac.uk) [10]

Fig. 1.

Organisation of the NHS in England, Scotland, Wales and Northern Ireland, in 2010

Section 242 of the NHS Act specifies that Trusts have a legal task to engage and include clients and the general public. Patient experience information/feedback is officially gathered nationally by annual survey (by the Picker Institute) and is part of the NHS Acute Trust efficiency structure. The Patient Advice Liaison Service (PALS) and Local Involvement Networks (LINks) support patient feedback and participation. Overall, inpatients and outpatients studies have revealed that clients rate the care they get in the NHS high and around three-quarters suggest that care has been great or excellent [11]

In Scotland, NHS Boards have actually changed Trusts and provide an integrated system for tactical instructions, efficiency management and medical governance, whereas in Wales, the National Delivery Group, with guidance from the National Board Of Advisers, is the body performing these functions (www.show.scot.nhs.uk; www.wales.nhs.uk). Scottish NHS and Special Boards deliver services, with look after particular conditions delivered through Managed Clinical Networks. Clinical guidelines are released by the Scottish Intercollegiate Guidelines Network (SIGN) and the Scottish Medicines Consortium (SMC) advices on making use of brand-new drugs in the Scottish NHS. In Wales, Local Heath Boards (LHBs) plan, protected and deliver healthcare services in their areas and there are 3 NHS Trusts providing emergency, cancer care and public health services nationally. In Northern Ireland, a single body, the Health and Care Board is supervising commissioning, performance and resource management and improvement of health care in the nation and six Health and Social Care Trusts deliver these services (www.hscni.net). A number of health companies support supplementary services and handle a large range of health and care concerns consisting of cancer screening, blood transfusion, public health etc. In Wales Community Health Councils are statutory ordinary bodies advocating the interests of the public in the health service in their district and in Northern Ireland the Patient and Client Council represent patients, clients and carers.

Predictive, Preventive and Personalised Medicine (PPPM) in the NHS

Like other nationwide healthcare systems, predictive, preventive and/or personalised medicine within the NHS have actually traditionally been provided and are part of illness diagnosis and treatment. Preventive medicine, unlike predictive or personalised medication, is its own established entity and pertinent services are directed by Public Health and used either via GP, community services or health centers. Patient-tailored treatment has always been typical practice for good clinicians in the UK and any other health care system. The terms predictive and customised medicine though are developing to describe a a lot more highly sophisticated method of identifying disease and forecasting response to the standard of care, in order to maximise the advantage for the patient, the general public and the health system.

References to predictive and personalised medication are increasingly being presented in NHS related info. The NHS Choices site explains how clients can acquire personalised guidance in relation to their condition, and provides info on predictive blood test for illness such as TB or diabetes. The NIHR through NHS-supported research and together with scholastic and business working together networks is investing a considerable percentage of its budget plan in validating predictive and preventive restorative interventions [10] The previous government thought about the advancement of preventive, people-centred and more productive healthcare services as the means for the NHS to react to the obstacles that all modern-day health care systems are dealing with in the 21st century, particularly, high client expectation, aging populations, harnessing of info and technological advancement, changing labor force and progressing nature of illness [12] Increased focus on quality (client security, client experience and clinical efficiency) has likewise supported innovation in early medical diagnosis and PPPM-enabling technologies such as telemedicine.

A number of preventive services are delivered through the NHS either by means of GP surgeries, social work or medical facilities depending upon their nature and consist of:

The Cancer Screening programmes in England are nationally coordinated and consist of Breast, Cervical and Bowel Cancer Screening. There is also a notified choice Prostate Cancer Risk Management program (www.cancerscreening.nhs.uk).

The Child Health Promotion Programme is handling concerns from pregnancy and the first 5 years of life and is provided by neighborhood midwifery and health checking out groups [13]

Various immunisation programs from infancy to adulthood, provided to anyone in the UK totally free and usually provided in GP surgeries.

The Darzi evaluation set out six essential medical objectives in relation to improving preventive care in the UK consisting of, 1) taking on obesity, 2) decreasing alcohol harm, 3) dealing with drug addiction, 4) decreasing smoking cigarettes rates, 5) improving sexual health and 6) improving mental health. Preventive programs to address these issues have actually been in place over the last years in various kinds and through various efforts, and include:

Assessment of cardiovascular risk and recognition of people at higher threat of cardiovascular disease is usually preformed through GP surgical treatments.

Specific preventive programs (e.g. suicide, mishap) in regional schools and neighborhood

Family preparation services and prevention of sexually transmitted illness programs, often with an emphasis on young people

A variety of prevention and health promo programs related to lifestyle options are provided though GPs and neighborhood services consisting of, alcohol and cigarette smoking cessation programmes, promotion of healthy consuming and physical activity. Some of these have a particular focus such as health promo for older individuals (e.g. Falls Prevention).

White paper 2010 — Equity and excellence: liberating the NHS

The current government’s 2010 «Equity and excellence: Liberating the NHS» White Paper has actually set out the vision of the future of an NHS as an organisation that still remains real to its founding principle of, readily available to all, free at the point of use and based on need and not capability to pay. It also continues to maintain the concepts and values defined in the NHS Constitution. The future NHS becomes part of the Government’s Big Society which is construct on social uniformity and entails rights and duties in accessing cumulative healthcare and guaranteeing reliable use of resources therefore providing better health. It will deliver healthcare results that are amongst the very best in the world. This vision will be executed through care and organisation reforms focusing on 4 locations: a) putting patients and public initially, b) improving on quality and health outcomes, c) autonomy, responsibility and democratic authenticity, and d) cut bureaucracy and improve effectiveness [5] This technique makes referrals to problems that relate to PPPM which shows the increasing influence of PPPM principles within the NHS.

According to the White Paper the concept of «shared decision-making» (no choice about me without me) will be at the centre of the «putting focus on client and public very first» strategies. In truth this includes strategies emphasising the collection and capability to access by clinicians and patients all client- and treatment-related details. It likewise includes greater attention to Patient-Reported Outcome Measures, higher option of treatment and treatment-provider, and notably personalised care preparation (a «not one size fits all» method). A newly created Public Health Service will combine existing services and place increased emphasis on research study analysis and assessment. Health Watch England, a body within the Care Quality Commission, will supply a stronger client and public voice, through a network of local Health Watches (based upon the existing Local Involvement Networks — LINks).

The NHS Outcomes Framework sets out the top priorities for the NHS. Improving on quality and health results, according to the White Paper, will be accomplished through modifying goals and health care concerns and establishing targets that are based upon clinically reputable and evidence-based procedures. NICE have a central function in developing recommendations and requirements and will be anticipated to produce 150 new standards over the next 5 years. The government prepares to establish a value-based pricing system for paying pharmaceutical business for supplying drugs to the NHS. A Cancer Drug Fund will be created in the interim to cover patient treatment.

The abolition of SHAs and PCTs, are being proposed as means of offering greater autonomy and responsibility. GP Consortia supported by the NHS Commissioning Board will be accountable for commissioning healthcare services. The intro of this type of «health management organisations» has been rather questionable but potentially not completely unexpected [14, 15] The transfer of PCT health enhancement function to regional authorities intends to supply increased democratic authenticity.

Challenges facing the UK healthcare system

Overall the health, along with ideological and organisational difficulties that the UK Healthcare system is dealing with are not dissimilar to those faced by numerous national healthcare systems across the world. Life span has actually been steadily increasing throughout the world with taking place increases in persistent illness such as cancer and neurological disorders. Negative environment and way of life influences have actually produced a pandemic in weight problems and associated conditions such as diabetes and heart disease. In the UK, coronary heart illness, cancer, renal illness, psychological health services for grownups and diabetes cover around 16% of total National Health Service (NHS) expense, 12% of morbidity and between 40% and 70% of death [3] Across Western societies, health inequalities are disturbingly increasing, with minority and ethnic groups experiencing most severe illnesses, sudden death and disability. Your House of Commons Health Committee cautions that whilst the health of all groups in England is enhancing, over the last 10 years health inequalities in between the social classes have widened-the gap has increased by 4% for guys, and by 11% for women-due to the fact that the health of the rich is enhancing much quicker than that of the bad [16] The focus and practice of health care services is being transformed from typically providing treatment and encouraging or palliative care to increasingly dealing with the management of persistent illness and rehabilitation routines, and using disease prevention and health promotion interventions. Pay-for-performance, changes in guideline together with cost-effectiveness and spend for medications problems are becoming a vital consider brand-new interventions reaching medical practice [17, 18]

Preventive medication is solidly established within the UK Healthcare System, and predictive and personalised methods are significantly ending up being so. Implementation of PPPM interventions may be the service but likewise the reason for the health and healthcare challenges and issues that health systems such as the NHS are dealing with [19] The efficient intro of PPPM needs scientific understanding of disease and health, and technological development, together with detailed methods, evidence-based health policies and proper guideline. Critically, education of healthcare experts, patients and the public is likewise critical. There is little doubt nevertheless that harnessing PPPM properly can help the NHS accomplish its vision of providing health care results that will be among the very best worldwide.

— 1. Delamothe T. NHS at 60: establishing principles. BMJ. 2008; 336:1216 -8. doi: 10.1136/ bmj.39582.501192.94. [DOI] [PMC totally free article] [PubMed] [Google Scholar]- 2. Shifting the Balance of Power: The Next Steps. Department of Health publications. 2002. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4008424
— 3. Wanless D. Securing health for the entire population: Final report-February 2004. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4074426
— 4. Professor the Lord Darzi of Denham KBE High quality take care of all: NHS Next Stage Review final report. Department of Health publications. 2008. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825
— 5. White paper Equity and quality: Liberating the NHS. Department of Health publications. 2010. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
— 6. The NHS Constitution for England. Department of Health publications. 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093419
— 7. NHS Hospital and Community Health Services: Medical and Dental staff England 1998-2008. The NHS Information Centre. 2009. www.ic.nhs.uk/webfiles/publications/nhsstaff2008/medandden/Medical%20and%20Dental%20bulletin%201998-2008.pdf
— 8. House of Commons Health Committee: Public Expenditure on Health and Personal Social Services. Your Home of Commons. 2008. www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/cmhealth.htm
— 9. The DH Guide A guide to what we do and how we do it. Department of Health publications. 2007. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/index.htm
— 10. NIHR Annual Report 2009/10: Embedding Health Research. National Institute for Health Research. 2010. www.nihr.ac.uk/Pages/default.aspx
— 11. Leatherman S. and Sutherland K. Patient and Public Experience in the NHS. The Health Foundation. 2007. www.health.org.uk/publications/research_reports/patient_and_public.html
— 12. NHS 2010-2015: from excellent to excellent. Preventative, people-centred, productive. Department of Health publications. 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_109876
— 13. Updated Child Health Promotion Programme. Department of Health publications. 2009. webarchive.nationalarchives.gov.uk/+/ www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_083645.
— 14. Klein R. What does the future hold for the NHS at 60? BMJ. 2008; 337: a549. doi: 10.1136/ bmj.a549. [DOI] [PMC free post] [PubMed] [Google Scholar]- 15. Ham C (2007) Clinically incorporated systems: the next step in English health reform? Briefing paper. London Nuffield Trust.
— 16. Health Inequalities Third Report of Session 2008-09. House of Commons Health Committee. 2009; Volume I. www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/286/28602.htm.
— 17. Clinicians, services and commissioning in persistent illness management in the NHS The need for collaborated management programmes. Report of a joint working celebration of the Royal College of Physicians of London, the Royal College of General Practitioners and the NHS Alliance. 2004. www.rcgp.org.uk/PDF/Corp_chronic_disease_nhs.pdf.
— 18. Hughes DA. From NCE to NICE: the function of pharmacoeconomics. Br J Clin Pharmacol. 2010; 70( 3 ):317 -9. doi: 10.1111/ j.1365-2125.2010.03708. x. [DOI] [PMC free article] [PubMed] [Google Scholar]- 19. Griggs JJ. Personalized medicine: a perk of privilege? Clin Pharmacol Ther.