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 Bevan Minister 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 BEVERIDGEanMODEL • 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
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 Local Health Authorities Executive Councils Teaching Hospital Boards of Governors Hospital Management Committees Family Practitioner Services Community Services Hospital 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 District Health Authorities Family Health Services Authorities GP Fund Holders NHS Trusts Special Health Authorities GP’s, dentists, opticians, pharmacists Directly Managed Units
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.
HUMAN HEALTH RESOURCES • 90,000 doctors (2.1 per 1000 pop) (OECD 2002) 3 Categories: • Hospital consultant • 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 beds Absorbs over half of the NHS budget Sizes ranges from the small community facility to the large District Hospital Average length of stay 8.8days (1991), 12.5 (1981)
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.