National Health Service
The National Health Service (NHS) is the name used for each of the public health services in the United Kingdom – the National Health Service in England, NHS Scotland, NHS Wales, and Health and Social Care in Northern Ireland – as well as a term to describe them collectively. They were established together in 1948 as one of the major social reforms following the Second World War. The founding principles were that services should be comprehensive, universal and free at the point of delivery. Each service provides a comprehensive range of health services, free at the point of use for people ordinarily resident in the United Kingdom, apart from dental treatment and optical care. (The English NHS also requires patients to pay prescription charges with a range of exemptions from these charges.)
Dr Somerville Hastings, President of the Socialist Medical Association, successfully proposed a resolution at the 1934 Labour Party Conference that the party should be committed to the establishment of a State Health Service.
Conservative MP and Health Minister, Henry Willink, first proposed the National Health Service in 1944 with the publication of a White Paper "A National Health Service" which was widely distributed in full and short versions as well as in newsreel by Henry Willink himself. (White Paper – A National Health Service) Henry Willink's National Health Service received cross party support and became Westminster legislation for England and Wales from 1946 and Scotland from 1947, and the Northern Ireland Parliament's 1947 Public Health Services Act. (NHS Wales was split from NHS (England) in 1969 when control was passed to the Secretary of State for Wales before transferring to the Welsh Executive and Assembly under devolution in 1999.)
Calls for a "unified medical service" can be dated back to the Minority Report of the Royal Commission on the Poor Law in 1909, but it was following the 1942 Beveridge Report's recommendation to create "comprehensive health and rehabilitation services for prevention and cure of disease" that cross-party consensus emerged on introducing a National Health Service of some description. When Clement Attlee's Labour Party won the 1945 election he appointed Aneurin Bevan as Health Minister. Bevan then embarked upon what the official historian of the NHS, Charles Webster, called an "audacious campaign" to take charge of the form the NHS finally took. The NHS was born out of the ideal that good healthcare should be available to all, regardless of wealth. Although being freely accessible regardless of wealth maintained Henry Willink's principle of free healthcare for all, Conservative MPs were in favour of maintaining local administration of the NHS through existing arrangements with local authorities fearing that an NHS which owned hospitals on a national scale would lose the personal relationship between doctor and patient. Conservative MPs voted in favour of their amendment to Bevan's Bill to maintain local control and ownership of hospitals and against Bevan's plan for national ownership of all hospitals. The Labour Government defeated Conservative amendments and went ahead with the NHS as it remains today; a single large national organisation (with devolved equivalents) which forces the transfer of ownership from local authority and voluntary hospitals to the new NHS. Bevan's principle of ownership with no private sector involvement has been diluted with future Labour Governments which implemented large scale financing arrangements with private builders in Private Finance Initiatives and joint ventures. (kingsfund, July 2013)
At its launch by Bevan on 5 July 1948 it had at its heart three core principles: That it meet the needs of everyone, that it be free at the point of delivery, and that it be based on clinical need, not ability to pay.
Three years after the founding of the NHS, Bevan resigned from the Labour government in opposition to the introduction of charges for the provision of dentures and glasses. The following year, Winston Churchill's Conservative government introduced prescription charges. These charges were the first of many controversies over reforms to the NHS throughout its history.
From its earliest days, the cultural history of the NHS has shown its place in British society reflected and debated in film, TV, cartoons and literature. The NHS had a prominent slot during the 2012 London Summer Olympics opening ceremony directed by Danny Boyle, being described as "the institution which more than any other unites our nation".
UK health services
Each of the UK's health service systems operates independently, and is politically accountable to the relevant government: the Scottish Government; Welsh Government; Northern Ireland Executive; and the UK Government, responsible for England's NHS. NHS Wales was originally part of the same structure as that of England until powers over the NHS in Wales were firstly transferred to the Secretary of State for Wales in 1969 and thereafter, in 1999, to the Welsh Assembly as part of Welsh devolution. Some functions may be routinely performed by one health service on behalf of another. For example, Northern Ireland has no high-security psychiatric hospitals and depends on hospitals in Great Britain, routinely at Carstairs hospital in Scotland for male patients and Rampton Secure Hospital in England for female patients. Similarly, patients in North Wales use specialist facilities in Manchester and Liverpool which are much closer than facilities in Cardiff, and more routine services at the Countess of Chester Hospital. There have been issues about cross-border payments.
Taken together, the four National Health Services in 2015–16 employed around 1.6 million people with a combined budget of £136.7 billion. In 2014 the total health sector workforce across the UK was 2,165,043. This broke down into 1,789,586 in England, 198,368 in Scotland, 110,292 in Wales and 66,797 in Northern Ireland. In 2017, there were 691,000 nurses registered in the UK, down 1,783 from the previous year. However, this is the first time nursing numbers have fallen since 2008.
Although there has been increasing policy divergence between the four National Health Services in the UK, it can be difficult to find evidence of the effect of this on performance since, as Nick Timmins says: "Some of the key data needed to compare performance – including data on waiting times – is defined and collected differently in the four countries." Statistics released in December 2017 showed that, compared with 2012/3, 9% fewer patients in Scotland were waiting more than four hours in accident and emergency, whereas in England the number had increased by 155%.
Eligibility for treatment
UK residents are not charged for most medical treatment though NHS dentistry does have standard charges in each of the four national health services in the UK. In addition, most patients in England have to pay charges for prescriptions though some are exempted.
Aneurin Bevan in considering the provision of NHS services to overseas visitors wrote, in 1952, that it would be "unwise as well as mean to withhold the free service from the visitor to Britain. How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? For if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody." 
The provision of free treatment to non-UK-residents, formerly interpreted liberally, has been increasingly restricted, with new overseas visitor hospital charging regulations introduced in 2015.
Citizens of the EU holding a valid European Health Insurance Card and persons from certain other countries with which the UK has reciprocal arrangements concerning health care can get emergency treatment without charge.
The NHS is free at the point of use, for general practitioner (GP) and emergency treatment not including admission to hospital, to non-residents. People with the right to medical care in European Economic Area (EEA) nations are also entitled to free treatment by using the European Health Insurance Card. Those from other countries with which the UK has reciprocal arrangements also qualify for free treatment. Since 6 April 2015, non-EEA nationals who are subject to immigration control must have the immigration status of indefinite leave to remain at the time of treatment and be properly settled, to be considered ordinarily resident. People not ordinarily resident in the UK are in general not entitled to free hospital treatment, with some exceptions such as refugees.
People not ordinarily resident may be subject to an interview to establish their eligibility, which must be resolved before non-emergency treatment can commence. Patients who do not qualify for free treatment are asked to pay in advance or to sign a written undertaking to pay, except for emergency treatment.
People from outside the EEA coming to the UK for a temporary stay of more than six months are required to pay an immigration health surcharge at the time of visa application, and will then be entitled to NHS treatment on the same basis as a resident. This includes overseas students with a visa to study at a recognised institution for 6 months or more, but not visitors on a tourist visa. In 2016 the surcharge was £200 per year, with exemptions and reductions in some cases. It is to increase to £400 in 2018. The discounted rate for students and those on the Youth Mobility Scheme will increase from £150 to £300.
From 15 January 2007, anyone who is working outside the UK as a missionary for an organisation with its principal place of business in the UK is fully exempt from NHS charges for services that would normally be provided free of charge to those resident in the UK. This is regardless of whether they derive a salary or wage from the organisation, or receive any type of funding or assistance from the organisation for the purposes of working overseas. This is in recognition of the fact that most missionaries would be unable to afford private health care and those working in developing countries should not effectively be penalised for their contribution to development and other work.
There are some other categories of people who are exempt from the residence requirements such as specific government workers and those in the armed forces stationed overseas.
See also Immigration health surcharge.
The systems are 98.8% funded from general taxation and National Insurance contributions, plus small amounts from patient charges for some services. About 10% of GDP is spent on health and most is spent in the public sector. The money to pay for the NHS comes directly from taxation. The 2008/9 budget roughly equates to a contribution of £1,980 per person in the UK.
When the NHS was launched in 1948 it had a budget of £437 million (roughly £9 billion at today’s prices). In 2008/9 it received over 10 times that amount (more than £100 billion). In 1955/6 health spending was 11.2% of the public services budget. In 2015/6 it was 29.7%. This equates to an average rise in spending over the full 60-year period of about 4% a year once inflation has been taken into account. Under the Blair government spending levels increased by around 6% a year on average. Since 2010 spending growth has been constrained to just over 1% a year. Many minor procedures may no longer be available from 2019 and the real reason may be to cut costs.
Some 60% of the NHS budget is used to pay staff. A further 20% pays for drugs and other supplies, with the remaining 20% split between buildings, equipment, training costs, medical equipment, catering and cleaning. Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas. Since 2010, there has been a cap of 1% on pay rises for staff continuing in the same role. Unions representing doctors, dentists, nurses and other health professionals have called on the government to end the cap on health service pay, claiming the cap is damaging the health service and damaging patient care. The pay rise is likely to be below the level of inflation and to mean a real-terms pay cut. The House of Commons Library did research showing that real-terms NHS funding per head will fall in 2018–19, and stay the same for two years afterwards.
There appears to be support for higher taxation to pay for extra spending on the NHS as an opinion poll in 2016 showed that 70% of people were willing to pay an extra penny in the pound in income tax if the money were ringfenced and guaranteed for the NHS. Two thirds of respondents to a King's Fund poll favour increased taxation to help finance the NHS.
The Guardian has said that GPs face excessive workloads throughout Britain, and that this puts the GP's health and that of their patients at risk. The Royal College of Physicians did a survey of doctors in England, Wales, Scotland and Northern Ireland. Two thirds of doctors surveyed maintained patient safety had deteriorated during the year to 2018, 80% feared they would be unable to provide safe patient care in the coming year while 84% felt increased pressure on the NHS was demoralising the workforce. Jane Dacre said, “We simply cannot go through this [a winter when the NHS is badly overstretched] again. It is not as if the situation was either new or unexpected. As the NHS reaches 70, our patients deserve better. Somehow, we need to move faster towards a better resourced, adequately staffed NHS during 2018 or it will happen again.” At a time when the NHS is short of doctors foreign doctors are forced to leave the UK due to visa restrictions.
The NHS is underresourced compared to health provision in other developed nations. A King’s Fund study of OECD data from 21 nations, revealed that the NHS has among the lowest numbers of doctors, nurses and hospital beds per capita in the western world. Nurses within the NHS maintain that patient care is compromised by the shortage of nurses and the lack of experienced nurses with the necessary quailfications. According to a YouGov poll, 74 percent of the UK public believes there are too few nurses. The NHS performs below average in preventing deaths from cancer, strokes and heart disease. Staff shortages at histoloy departments are delaying diagnosis and start of treatment for cancer patients. Some cancer patients stop getting follow up treatment when they are still at risk of dying from cancer. Joyce Robins of 'Patient Concern' said, it was “terrifying that cancer patients are being abandoned like this. This is such a life-changing disease and to think that after recovering you’re on your own is very scary. People should be getting the full follow-up they deserve at the time when they are still at high-risk.” Death rates for babies at birth and during the month following birth were also higher.
62% of Intensive Care Units function below normal because there are not enough nurses, a survey of ICU consultants by the Faculty of Intensive Care Medicine (FICM) stated. The survey found the 210 intensive care units throughout the UK were short of 12 nurses each on average and nurses are vital caring for critically ill patients.
Prescriptions for drugs to help patients stop smoking fell by 75% in England by 40% in Scotland and by two thirds in Wales over ten years to 2018. Combining medication with support has been found to help smokers quit most effectively and is three times more effective than leaving smokers to try on their own. The combination is recommended by the National Institute for Health and Care Excellence (Nice). Lack of funding is blamed.
Theresa May is under pressure from MP's of both the main political parties to increase funding for the NHS and for social care, also to consider tax rises to achieve this. 98 signatories to a letter maintain the NHS, public health and social care are “overstretched, poorly integrated and no longer able to keep pace with rising demand and the cost pressures of new drugs and technologies”. Without action, patients will experience a serious further decline in services.” One possibility is a NHS tax where the money would be earmarked for the NHS. 61% of voters favour higher taxes to pay for improvements to the NHS. The NHS is a major concern for voters and consensus for finding more money exists.
According to a BMA poll 4 out of 5 doctors think quality and safety of patient care is threatened by underfunding. 3 in 4 doctors polled believe financial targets have higher priority than patient care, doctors maintain more staff and better IT systems could improve their working environment. Chaand Nagpaul of the BMA said, 'We know the NHS has been systematically and scandalously starved of resources for years. It lacks doctors, it lacks nurses, it lacks beds. It’s not just the channel that separates us from our European neighbours, but a vast funding gap equating to 35,000 hospital beds or 10,000 doctors. (...) A health service of gaps and stopgaps where two out of three juniors report holes in their rota and one third of GP practices have long-term vacancies. It’s the new norm. It’s a new low. (...) All this is inevitably affecting patient safety, with bed occupancy in some trusts running up to 100% – well above recommended safe limits of 85%. Is it safe for patients who should be admitted in an emergency to suffer ambulance delays of several hours with some not surviving the wait as reported last winter? Is it safe to work in an understaffed environment of perpetual rota gaps? Is it safe to manage patients in car parks because the hospital has no space, or to treat patients on trolleys in corridors rather than the facilities of a ward? Is it safe for GPs to spend just 10 minutes with patients with four or more complex problems? The prime minister’s belated and desperately needed announcement of increased NHS funding after years of denial is a positive step. But the investment is still well short of what’s needed and we need it now. We will continue to campaign to be at parity with our European neighbours. Meanwhile it’s crucial that this money is delivered to treat patients and attract and retain staff.' In the worst cases patients waited over 24 hours for an ambulance.
Amyas Morse of the National Audit Office also maintains spending on the NHS should provide substantially more than has been promised. Morse would like the NHS’s to expand into a “bigger and better” and “fully developed” healthcare provider that would be able to give better care to Britain’s ageing and growing population and the 15 million patients with at least one chronic health problem like diabetes, cancer, heart or lung issues, dementia or depression. The 2018 British Isles heat wave also created a situation where patients are treated in corridors because there is no room for them in wards, patients were sent away from the hospital where they first arrived because that hospital was too busy. Chris Hopson of NHS Providers said, “The increased pressure we’ve seen in many places over the summer is a symptom of the health and care system running at boiling point all year round. The NHS is struggling to cope and that shows just how important it will be to invest the right amount of extra NHS funding in frontline services like A&E capacity”.
The plan to exit the European Union will affect physicians from EU countries, about 11% of the physician workforce. Many of these physicians are considering leaving the UK if Brexit happens, as they have doubts that they and their families can live in the country. A survey suggests 60% are considering leaving. Record numbers of EU nationals (17,197 EU staff working in the NHS which include nurses and doctors) left in 2016. The figures, put together by NHS Digital, led to calls to reassure European workers over their future in the UK. EU nurses registering to work in the UK are down 96% since the Brexit vote aggravating shortages of nurses. Janet Davies of the Royal College of Nursing, said, “We rely on the contributions of EU staff and this drop in numbers could have severe consequences for patients and their families. Our nursing workforce is in a state of crisis. Across our health service, from A&E to elderly care, this puts patients at serious risk.” 3,962 nurses and midwives from the European Economic Area (EEA) left in 2017 and 2018. With reduced numbers of nurses patient mortality increases, in 2018 there are 40,000 unfilled nursing vacancies just in England EU nurses are badly needed to prevent the nursing situation getting worse.
In June 2018 the Royal College of Physicians calculated that medical training places need to be increased from 7,500 to 15,000 by 2030 to take account of part-time working among other factors. At that time there were 47,800 consultants working in the UK of which 15,700 were physicians. About 20% of consultants work less than full time.
Since bursaries for students studying to become nurses have stopped apprenticeships have decreased by over a third in the three years to 2018 leading to fears over how the NHS will be staffed after BREXIT. European Economic Area workers comprise 15% of dentists, 9.1% of doctors and 5.5% of nurses and midwives. There have been efforts to increase the number of British nurses and doctors, however this takes time. Therefore “continued migration across the NHS is vital to maintain service levels”.
A study by the King's Fund, Health Foundation, Nuffield Trust and the Institute for Fiscal Studies to mark the NHS 70th anniversary concluded that the main weakness of the NHS was health care outcomes. Mortality for cancer, heart attacks and stroke, was higher than average among comparable countries. The NHS does well at protecting people from heavy financial costs when they are ill. Waiting times are about the same and the management of longterm illness is better than in other comparable countries. Efficiency is good, with low administrative costs and high use of cheaper generic medicines.
There is also concern that a disorderly Brexit may compromise patients' access to vital medicines. Many medical organisations are diverting resources from patient care to managing a possible worst case Brexit scenario. Doctors' and nurses' organisations both say Brexit is bad for the nation's health. Paul Willims said, “Instead of the £350m a week for the NHS we were promised by the Brexiters, we have had cuts and closures as the NHS loses staff and struggles with budgets that are limited by the Brexit economic squeeze. If Brexit actually happens, it seems certain it will only make things worse – with new drug treatments, investment in research and sustainable funding all under threat.”
Brexit could cause a wide range of problems. Radioisotopes for treating cancer patients could be harder to obtain. Skilled medical professional could find it harder to emigrate to the UK. Collaborating with the rest of Europe on medical research could become harder. A separate regulatory system for medicines in the UK could lead to delays of up to two years before UK patients can receive new life saving drugs. In the opinion of the BMA a continued relationship between the UK and the EU is highly desirable. A no-deal Brexit could be catastrophic for patients, health workers and health services and UK health. Among other problems reciprocal arrangements for health care in the UK and the EU would be unclear.
Social care will cost more in future according to research by Liverpool University, University College London, and others and higher investment are needed. Professor Helen Stokes-Lampard of the Royal College of GPs said, “It’s a great testament to medical research, and the NHS, that we are living longer – but we need to ensure that our patients are living longer with a good quality of life. For this to happen we need a properly funded, properly staffed health and social care sector with general practice, hospitals and social care all working together – and all communicating well with each other, in the best interests of delivering safe care to all our patients.”
Patients needing a wheelchair for less than 6 months are subject to a postcode lottery and frequently do not get one. This is shortsighted from the economic point of view as it forces patients to stay in hospital longer. It also leaves patients isolated, trapped in their homes, unable to get to work. Affected patients include those reovering from an operation, those with broken bones and patients receiving end of life care. Jon Ashworth said, “Restricting access to wheelchairs or mobility aids has proven negative mental and physical impacts on patients’ health, wellbeing and sense of independence. The new health secretary should therefore make every effort to end this unacceptable postcode lottery in provision.” The Red Cross surveyed 139 NHS wheelchair services and 114 said they could not provide short-term wheelchairs. Most public services say they have insufficient funding to supply needed wheelchairs. Some patients who got home without mobility needed expensive home visits and the health of others deteriorated due to lack of mobility. Mike Adamson of the Red Cross said statutory provision of short-term wheelchairs "should be a no-brainer. They reduce recovery time, boost independence and would ultimately save money for both the NHS and social care."
Children suspected of having ADHD are subject to a postcode lottery. In some areas diagnosis is prompt. In more areas there is a wait of months or even up to two years while children's school performance and life chances suffer.
One out of seven NHS hospital operations are cancelled just before they should happen, often due to insufficient beds, staff or operating theatres. Delays cause patients pain and distress when they wait longer than expected for surgery and the NHS is short of the resources it needs to function properly. Research published in the British Journal of Anaesthesia also revealed patients were often refused surgery at a late stage because patients who came to the hospital through A&E were considered in more urgent need. Too few beds in high-dependency and intensive care units cause cancellations. Patients who will need either type of facility after surgery are three times more likely to face cancellation than other groups waiting for surgery. 31% of cancellations were through lack of beds, 12.7% through lack of available operating theatres, 2.3% through equipment difficulties and 2.2% due to staff not being available.
2018 funding increase
In 2018, British Prime Minister Theresa May announced that NHS in England would receive a 3.4% increase in funding which would allow it to receive an extra £20bn a year in real terms funding by 2024. Some expressed doubt over whether May could carry out this proposed increase in funding. The next day, Health Secretary Jeremy Hunt backed the extra £20bn annual increase in NHS funding and responded to criticism by stating that taxation would be used to carry out the funding and that details would be revealed when the next budget is unveiled in November. The Institute for Fiscal Studies has stated a 5% real-terms increase was needed for real change. Paul Johnson of the IFS pointed out the 3.4% was greater than recent increases, but less than the long-term average. Health experts maintain the money will “help stem further decline in the health service, but it’s simply not enough to address the fundamental challenges facing the NHS, or fund essential improvements to services that are flagging.”
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- History of NHS Scotland
- History of NHS Wales
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- NHS cancels 14% of operations at last minute, research finds The Guardian
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- Spending on the NHS in England
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- NHS Choices official website for England's NHS
- Health and Social Care in Northern Ireland official website for Health & Personal Social Services in Northern Ireland
- NHS Scotland official website for NHS Scotland
- Health in Wales official website for NHS Wales
- Birth of the national Health Service archive collection of programmes and documents