UNITED KINGDOM | Summary
OVERVIEW
HISTORY
The end of World War II created opportunities for new reforms in health care. According to History Extra, the BBC World Histories Magazine, the National Health Service (NHS) was launched in July 1948 to provide health care that was free at the point of delivery. Before the establishment of this formal health system, health care relied heavily on lady almoners. They were around 1,000 women in hospitals across the country that worked medical charity, public and private health care, and mangaged the bounardy by interviewing patients and deciding an appropriate rate for service.4
During Victorian era (1837 - 1901), hospitals were founded and funded by the middle and upper classes to serve the medical welfare needs of the working-class population. Higher income individuals sought private health care. Due to the fear of abusing the system, the hospital began to assess patients. If they were too well off they were either told to find private care or make a donation to the hospital. Instead of financial clerks, the lady almoners were tasked with the job to screen patients.4
With payment systems developing, hospitals taking on private services, and doctors using public hospitals to build credentials and open private practices, some hospital fees became beyond reach for working-class patients. There were two schemes that provided alternative payment for this population4:
- Compulsory insurance scheme for certain workers that covered local doctors but not hospital treatment. Also, it did not cover family members.
- Membership to community-owned mutual aid funds and medical clubs. This gave members access to a doctor, medicine, and some hospital treatment.
NHS is defined as a free health service, private wards were a part of payment until they were phased out completely in 1979. It is thought that the NHS was a post-war consensus in British politics but the consensus was not reached in 1948 but rather in 1951 with the resignation of former prime minister, Aneurin Bevan. Click this link5 to see a timeline of health events in the 1970s and 80s.
According to Nuffield Trust, an independent health think tank, when the NHS reached its 30 year anniversary in 1978, British medical staff were disappointed because it measured poorly against other alternative methods of providing health care. However, just 10 years ago, medical staff praised the system even though there had been little fundamental change. The reason for the initial doubt in the system is the delays in decision making and the fear of the economic implications.5
- 1979 Suggestions from Royal Commission to the NHS (This was during the election of the Conservative party with Prime Minister Margaret Thatcher)
- Strengthening local management with greater delegation
- Simplification of the structure by removing
- Simplification of professional advisory machinery
- Simplification of the planning system
- 1984 NHS Restructuring
- 14 Regional Health Authorities (RHAs)
- 192 District Health Authorities (DHAs) replaced 90 area health authorities (AHAs)
- 7 special health authorities replaced the boards of governors of postgraduate teaching hospitals
- 90 family practitioner committees (FPCs)
- 1987 White Paper: Promoting Better Health
- Instead of good practice allowance, financial incentives would be used to encourage specific services such as immunization, cervical cytology, comprehensive care for elderly people, postgraduate education and practice in the inner cities.
- Freedom of GPs to advertise their services and increase in the proportion of GP pay related to list size. This would provide a greater incentive to doctors to practice in ways that will encourage patients to join their lists.
In the 1990s, the UK government put into effect one of the most significant changes for the NHS in recent times by creating the internal market. These markets were independent organizations that were individually managed and and created a competitive and efficient system.6 The system had many issues; it lacked an effective implementation strategy; has operational flaw, and was poorly designed and politically motivated.6 In 2019, the NHS Long-term Plan established integrated care systems across England by 2021, effectively ending the internal market.7
Most recently, on January 31, 2020, the United Kingdom formally left the European Union. This changes many dynamics within the country, including health care. Here are a couple short videos explaining Brexit and its implications:
- Brexit Day: What is Brexit and What Does it Mean for Britain?8
- Brexit: What happens After the UK leaves the EU?9
HEALTH & HEALTH SYSTEM
The NHS consists of multiple publicly funded health care systems in the United Kingdom including the NHS England, NHS Scotland, NHS Wales and Health and Social Care in Northern Ireland. Although all systems are collectively known as the NHS.10 According to The Commonwealth Fund, the public sector is generally paid for by taxation.11
All citizens are eligible for these services offered by the NHS, but also have the option to buy private health insurance as well. This is typically funded as part of an employer funded health care scheme or is paid directly by the customer. Approximately 10.5% of the United Kingdom’s population carries voluntary supplemental insurance to gain more rapid access to elective care.11
There is no cost-sharing with physician visits or hospital inpatient care with the NHS and prescription drugs are GBP 8.80 (USD 12.5). Drug cost-sharing exemptions do exist for low-income, elderly, children, pregnant women, new mothers, and some with disability or chronic illness. Primary care is delivered mainly through general practitioners (GPs), who act as gatekeepers for secondary care. General practices are normally patients’ first point of contact, and people are required to register with a local practice of their choice; however, choice is effectively limited because many practices are full and do not accept new patients. Most GPs work under a national contract with the government. Unlike most other countries, GPs work for the government paid mostly through capitation, some fee-for-service, and sometimes bonuses for good performance. Specialists are salaried at hospitals run by the NHS. Patients have the ability to choose which specialists they'd like to see in those hospitals. About half of specialists do see private patients in private hospitals.11
NHS dentistry services are subject to copayments of up to GBP 256.50 (USD 365.00) per course of treatment. No dental care copays: children/youth, students, pregnant women, recent mothers, prisoners, people with low income. Publicly owned hospitals are organized either as NHS trusts (currently 64) directly accountable to the Department of Health or as foundation trusts (currently 142) regulated by NHS Improvement. Foundation trusts have more freedom to borrow and invest and have local people and staff involved in governance. Mental health care is an integral part of the NHS and covers a full range of services. The 2012 Health and Social Care Act charged NHS England and CCGs (Clinical Commissioning Groups, which are local GPs groups who plan, commission, and pay for much of the hospital and community care service in their areas11) with promoting integrated care, which is defined as closer links between hospital and community-based health services, including primary and social care. For long term care, the NHS used to cover more but the policy now is for those who make less than 23,350, they are entitled to receive state-funded residential care. Residential care is paid by for mostly by the private sector and out-of-pocket.11
Costs in the NHS are constrained by a national health care budget that cannot be exceeded, rather than through patient cost-sharing or direct constraints on supply. NHS budgets are set at the national level, usually on a three-year cycle. Cost-containment strategies to date include freezing staff pay increases, supporting the increased use of generic drugs, reducing DRG payments for hospital activity, managing demand, and reducing administration costs.11
HEALTH INDICATORS & DEMOGRAPHICS
The country’s health indicators align with those of high income countries:
- Fertility Rate: 1.8 live births per woman
- Life Expectancy: 80 Male, 83 Female
- Infant Mortality Rate: 3.3 Deaths per 1000 live births
- Child Mortality Rate: 4.3 Deaths per 1000 live births
- Prevalence of obesity: 28.7% of population
- White: 86%
- Asian: 7.5%
- Black: 3.3%
- Arab: 0.4%
- Other: 0.6%
- 0-14 group: 17.6%
- 15-24 group: 11.7%
- 25-54 group: 40.3%
- 55-64 group: 12.2%
- 65+ group: 18.2%
References
1 United Kingdom . Data. (2020). https://data.worldbank.org/country/united-kingdom.
2 The World Bank. (2017). Current health expenditure (% of GDP). Data. https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS.
3 U.K. Population (LIVE). Worldometer. (2020). https://www.worldometers.info/world-population/uk-population/.
4 Gosling, G. C. (2018, August 9). Paying for healthcare: life in Britain before the ‘free’ Nhs. History Extra. https://www.historyextra.com/period/20th-century/nhs-history-pay-healthc....
5 Rivett, G. (2020, May 19). 1978–1987: Clinical advance and financial crisis. The Nuffield Trust. https://www.nuffieldtrust.org.uk/chapter/1978-1987-clinical-advance-and-....
6 Dragoonis, P. (2009). Have new NHS market reforms learned from failings of old? London Journal of Primary Care, 2(2), 153–157. https://doi.org/10.1080/17571472.2009.11493272
7 House of Commons, NHS Long-term Plan: legislative proposals (2019).
8 The Heritage Foundation. (2020). Brexit Day: What is Brexit and What Does it Mean for Britain? YouTube. https://www.youtube.com/watch?v=-Yho7QCC1hA.
9 Sky News. (2020). Brexit: What happens after the Uk leaves the Eu? YouTube. https://www.youtube.com/watch?v=_Ak7VWi-6Us.
10 What is the NHS? Full Fact. (2017, June 1). https://fullfact.org/health/what-is-the-nhs/.
11 Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., & Wharton, G. A. (2020, June 5). England. The Commonwealth Fund. https://www.commonwealthfund.org/international-health-policy-center/coun....
12 Office for National Statistics. (2020, August 7). Population of England and Wales. GOV.UK Ethnicity facts and figures. https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethn....
13 United Kingdom Age structure. United Kingdom Age structure - Demographics. (2020). https://www.indexmundi.com/united_kingdom/age_structure.html.
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