British used to have a TOTALLY FREE National Healthcare system but it
suffered huge wastages and could not deliver the needed services under
complete government ownership. Here is what has happened since:
Guide: How the
healthcare system works in England
Health Service (NHS) was set up in 1948 to provide free healthcare
for all the residents of the UK.
For its founders, the most important feature was that it was free at the
point of need. This means that every time you go to the doctor or
receive treatment at hospital, it is provided free of charge. The NHS is
funded through general taxation and is run by the Department of Health.
There is also a private healthcare sector in the UK. People pay for
private healthcare either through insurance or when they use its services.
Over the last few years the structure of the NHS has undergone considerable
change. The private sector now has a role in supplying and funding some
buildings and services within the NHS. The power to make important decisions
about local healthcare is also being devolved to local communities in some
There are now significant differences in how the NHS works between the
countries. This guide deals with England. You can also read our guide to
healthcare system works in
healthcare system works in
Northern Ireland and
healthcare system works in
1. How the NHS
Secretary of state for health
This is the government minister responsible for the NHS in England and is
answerable to Parliament for its work.
Department of Health
The Department of Health is responsible for the overall planning, regulation
and inspection of the health service. It develops policies and decides the
general direction of healthcare.
Strategic health authorities
There are 28 strategic health authorities in England. They look after the
healthcare of their region. They are the link between the Department of
Health and the NHS. They make sure that national health priorities (such as
cancer programmes) are integrated into local health plans.
Primary and secondary health services
Health services in the UK are divided into ‘primary’ and ‘secondary’ and are
provided by local NHS organisations called ‘trusts’.
- Primary care covers everyday health services such
as GP’s surgeries, dentists and opticians and these are delivered by
‘primary care trusts.’
- Secondary care refers to specialised services such
as hospitals, ambulances and mental health provision and these are
delivered by a range of other NHS trusts, all accountable to the strategic
2. The different types of trusts
Primary care trusts
There are about 300 primary care trusts in England.
They decide what health services their area needs and make sure these are
delivered efficiently. For example, they are responsible for making sure
there are enough GPs. Primary care trusts are responsible for services you
access directly such as:
- NHS Direct
- NHS walk-in centres
Primary care trusts are responsible for secondary
planning: they decide on the amount and quality of services provided by
hospitals, dentists, patient transport and population screening. They are
also responsible for generally improving local health and making sure that
NHS organisations work effectively with councils.
Primary care trusts are a crucial part of the NHS and they receive about 75
% of the NHS budget. They also 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. The trusts make sure that
hospitals provide high quality health care and spend their money
efficiently. They employ most of the NHS workforce from hospital doctors and
radiographers to security staff.
- Acute trusts: These look after hospitals
that provide short-term care, such as Accidents and Emergencies,
maternity, surgery, x-ray etc
- Care trusts: These work in both health and
social care and they can carry out a variety of services such as mental
health services and primary care provision. They are generally set up when
the NHS and a local authority decide to work closely together
- Mental health trusts: There are a number of
specialist mental health trusts in England. Specialist care that a mental
health trust might provide includes psychological therapy and specialist
medical and training services for people with severe mental health
- Ambulance trusts: There are over 30
ambulance services for England and these provide access to emergency
healthcare. Ambulance trusts are responsible for providing transport to
get patients to hospital for treatment
From April 2004 certain NHS trusts will be allowed to receive foundation
status, paving the way for a new kind of hospital. Although they remain part
of the NHS and people will continue to receive free healthcare, foundation
trusts will have much more freedom and financial flexibility and less
central control and monitoring.
Foundation trusts won’t be run by central government. They will be owned by
their community, local residents, employees and patients and they will have
the power to manage their own budgets and shape their healthcare provision
according to local needs and priorities, for example by having the freedom
to address long waits for certain treatments. The trusts will also have more
access to funds for investment and this can come from the public or the
They will be held accountable by an elected board of governors and an
independent regulator will monitor their performance. Like all healthcare
organisations, they will be inspected by the Healthcare Commission
(currently called the Commission for Healthcare Audit and Inspection).
The government hopes that by 2008 all NHS trusts will be able to become
foundation trusts. You can read the
hospitals: an iCan briefing for more information on the issue.
3. How the private sector and the NHS work
The government is keen to encourage the use of private healthcare within the
NHS. They argue that as it is free at the point of need and the service is
good, it is not important who provides the service to patients but that it
is. The private sector now works with the NHS in a number of ways.
Outsourcing treatments: Parts of the NHS use private healthcare
companies to help them provide more treatment to more people and to help
reduce waiting lists:
- Many primary care trusts outsource work to private
companies. Out-of-hours healthcare is often provided by private companies
- Some NHS hospitals pay for private treatment to
clear backlogs and waiting lists
- Treatment centres, which offer pre-booked
short-term surgery and diagnosis in areas with long waiting lists such as
ophthalmology have been set up across the UK. Some of these are NHS run
and others are managed by private companies although they deliver a free
Private finance initiatives (PFI): The
government is building more hospitals using private money. PFI is a way of
funding major public building projects and involves private companies
contracted for about 30 years to design, build and manage these large new
projects. The building is leased by a health trust from the private company
for this period while the government pays back the building cost with
interest. The developer maintains the building during this period. Because
the payment can be spread over time the government has been able to start an
extensive building programme.
4. The private healthcare sector
There are a number of ways that people access private healthcare.
Private health insurance: Membership of health insurance schemes such
as BUPA accounts for a large proportion of private health treatment and more
employers are offering membership of such schemes.
Secondary care in the private sector: Secondary care, which refers to
more specialised health treatment such as hospitals, mental health provision
and care for the elderly, is especially well served by the private sector.
While people may be registered with an NHS GP the private sector is often
used for secondary care such as:
- Diagnostic tests for certain conditions
- One-off specialist treatment, such as visiting a
- Specific operations in a private hospital
- Non-essential treatment such as cosmetic surgery
- Treatment for addiction or rehabilitation
Private hospitals:There are over 300 private
hospitals in the UK. Private hospitals are provided by six organisations:
the NHS, which runs a number of private patient units within its hospitals
and five private hospital groups: BMI Healthcare, BUPA, Nuffield Hospitals,
Capio Healthcare UK and HCA International.
The private healthcare sector is much smaller than the NHS and does not have
the same structures of accountability. It mirrors the NHS by providing GPs
(many doctors in the NHS also have private practices), nursing homes,
ambulances, hospitals and medical specialists, but it 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, only for its
paying clients. Private hospitals are licensed by the local healthcare
authority and they conduct two inspection visits a year. Private hospitals
are not regulated by the national inspection bodies that inspect NHS
5.The regulation and inspection of healthcare
A number of bodies have been set up to check that people are getting good
healthcare services. These ‘special healthcare authorities’ primarily
regulate and inspect important aspects of healthcare such as clinical
guidelines on medical conditions and patient safety.
Providing guidance on medical treatment
The National Institute for Clinical Excellence (Nice) publishes guidelines
and advice for the public and for healthcare professionals in England and
Wales on specific diseases, drugs, medical devices and technologies and the
management or treatment of certain conditions. The NHS is expected to take
these guidelines into account. Private hospitals do not have to follow them,
although they are issued as ‘best practice’ guides.
Monitoring healthcare standards
The Healthcare Commission (currently known as the Commission for Healthcare
Audit and Inspection) is responsible for monitoring healthcare standards and
efficiency in the UK.
It is also responsible for publishing the NHS performance ratings and
indicators. Star rating affects how much independence trusts have and the
ability to become a foundation trust. NHS organisations in England are
allocated 0-3 stars based on their performance in areas such as:
- Waiting times and waiting lists
- The number of operations cancelled
- Hospital cleanliness
- Death rates
- Financial position
- Emergency re-admission rates
Monitoring social care standards
The Commission for Social Care Inspection is the body responsible for
inspecting and regulating social care services and will work in parallel to
the Healthcare Commission (currently known as the Commission for Healthcare
Audit and Inspection). Its commissioners will be appointed by an independent
process and its role includes:
- Carrying out inspections of all social care
organisations, public, private and voluntary
- Carrying out inspections of local social service
- Reporting to Parliament on the performance of
- Publishing the star ratings for social services
Monitoring patient safety
The National Patient Safety Agency was set up to improve standards of safety
throughout the NHS by learning from adverse incidents involving patient care
and safety. It encourages staff to report incidents and by collecting
reports, hopes to initiate preventative measures in hospitals in England and
The Health Service Ombudsman is completely independent of the NHS and the
government. It investigates complaints about the NHS and private healthcare
providers if the treatment was funded by the NHS. For more on complaining
about medical treatment you can read our iCan guides,
complain about private healthcare and
complain about NHS medical treatment in England.
Regulating medical professionals
The Council for the Regulation of Healthcare Professionals is the umbrella
body answerable to Parliament, which represents the regulatory councils for
nurses, doctors, pharmacists, opticians, osteopaths and chiropractors. It
promotes good practice in the regulation of healthcare professions.
You can visit
their website to find out more about the individual regulatory councils.
The General Medical Council has a role in protecting public health and can
take action against doctors where there has been a serious professional
See also the iCan guide, How you can get involved in improving NHS services in England.
California's SA BILL810
Single Payer Healthcare
Achieving Universal Coverage Without Turning to a Single Payer Lessons From 3 Other Countries
measurement, ICT, and clinical practice guidelines,
the US Veterans Administration Health System
reduced surgical mortality by 9% over 4 years, increased
compliance with practice standards from 34% to 81%, and
reduced patient care costs by 25% over
In countries where Private health
plays a prominent role, it can be credited with having injected
resources into health systems, added to consumer choice, and helped make
the systems more responsive.
However, it has also given rise to considerable equity challenges in
many cases and has added to total health care expenditure ( in some
cases to public expenditure).
A system based on competing primary private insurers can improve
responsiveness and consumer choice, but this will come at increased
While it can help reduce some of the capacity pressures faced by public
health systems, it does not significantly reduce public health
Decisions to de-list services need to balance the desire to reduce
public sector cost with the equity implications of no longer covering
certain services publicly.
Sweden and Israel are the world's
healthiest countries and possibly have the world’s
top healthcare systems, according to an assessment of 19 leading
industrial nations published in the latest issue of the
British Medical Journal.
Taiwan coming out above the
UK and Mexico
above the United States !
Included is maternal and infant death rates, deaths from cancer,
infection, and heart and respiratory disease, HIV infection rate, and
Taiwan has a low death rate–less than
10% of the population is aged over 65. It also has a low incidence of
maternal mortality–lower than the US–and a low incidence of AIDS.
Mexico benefits from better immunisation
coverage than the US and lower death rates from cancer and from
respiratory and circulatory diseases. However, the report in
Healthcare International acknowledges that, as the figures are
mostly derived from government, politicians an be reluctant to divulge
the true incidence of local disease in case this affects investment and
tourism. Britain does badly mainly because
of the high rate of cancer and circulatory diseases, which may be due to
the country's poor diet.
Totals for childhood and maternal mortality:
Japan, Sweden, and
Singapore, which have the lowest figures.
The report also found no correlation between the numbers of doctors
and quality of medical care. Italy has a large number of doctors–478 per
100000 population–but is still middle of the table. Alexandra Wyke,
editor of Healthcare International, said: "The conclusion must be
that the amount spent on
healthcare and the quality of doctors and hospitals have little to do
with the quality of medicine."
World Health Report 2004
Health systems by country
Statistics by Country
National health accounts indicators: measured levels of
per capita expenditure on health, 1997–2001 [pdf 49kb]
Selected national health accounts indicators: measured
levels of expenditure on health, 1997–2001 [pdf 71kb]
Pakistan needs British healthcare systemhttp://www.dailytimes.com.pk/default.asp?date=08/31/2004
Minister for Health, is impressed by the British
healthcare system in which
100 percent of the population has health insurance and he
wants to bring healthcare to the doorsteps of the people by adapting the
world’s best healthcare systems to Pakistan. The minister was convinced
the government must have control on basic healthcare services. In the
National Healthcare System of Britain, he said, the first thing
doctors do is treat patients rather inquire about their healthcare
insurance, as is the practice in the US.”
Commenting on the local situation he said government healthcare service
providers had to cater to the needs of a large number of people who
cannot afford expensive medicine. He said Pakistan
had excellent healthcare infrastructure such as
Basic Health Units, Rural Health Centers, DHQs and
hospitals. “We can provide descent
healthcare to our people. One cannot have an
appendix operation for $2 in the USA.
This is only possible in Pakistan. Of course, we cannot offer the
five-star facilities, but we can give descent healthcare to our people.
The only thing required is better organization and motivation.”
To a question about private practice by doctors, he said he had floated
the idea of private practice by the medical specialists within the
hospitals in 1988, when he was Punjab’s health minister. “In Britain the
doctors have private clinics within the premises of the hospitals. We
want to implement the same here in Pakistan. They would be required to
give a certain percentage to the hospital against the services like
electricity, gas, rent, staff, etc being provided by the hospital.”
He was against the privatization of the government hospitals and other
institutions- a change in the approach he had since his tenure as
provincial heath minister. He had then stopped the privatization of
public hospitals in Lahore which led to a conflict between him and the
chief minister at the time.
“I believe the government must
give a descent, skeleton healthcare system to the people while I also
believe the government must have a hold on the basic healthcare system.
Therefore, I resisted the privatization of Services Hospital in Lahore
at that time.” But he ardently supported involving the private sector in
healthcare, believing the involvement of more and more private concerns
would generate competition and improve healthcare services. He also
hinted at regulating the cost of treatment at private clinics and
hospitals. Asked about the sky-high prices of lifesaving and other
drugs, he said, “I have told the multinationals to give me complete
lists of their products and their prices and I will compare them with
the prices of similar drugs in India,
Nepal and Burma. We have to regulate the price and also maintain
the quality of the medicine at the same time.”
He said the government might be implementing new laws to check the
quality of medicine, but confessed “the gigantic task of regulating
prices and checking quality needs more time and resources”.
many countries have adopted targets of around 3-6 months for maximum
Countries with the worst waiting times depends on the procedure,
but patients in Finland and the
UK often had the longest waits in 2000.
Q: why do around half of
OECD countries have no waiting lists?
A: differences in capacity explain much of the international variation
in waiting times. For example, countries without lists have about 70%
more acute beds and 25% more specialists, per capita, than countries
a) There are waiting time problems in about half of
b) Some countries (such as
Denmark, in the case of coronary re-vascularisation in the
1990s) have brought down waiting times dramatically after significant
increases in capacity.
c) It seems to cost roughly an extra 1% of GDP devoted
to health expenditure to go from high waiting to average waiting and
another 1% to go from average waiting to low waiting.
Canada, where waiting times
can be long, spends the same share of its GDP on health as
France where there are no waiting times.
watchful waiting’ by the general practitioner is often the most
appropriate thing to do for mild cases. The trick is to get the
prioritisation of patients right.
New Zealand has been able to introduce a booking system for all patients
and limit waiting times to under 6 months by introducing a careful
Prioritisation system and demand management.
Q: Why have not more countries opted for a social-insurance
solution for nursing home care?
A: Some countries provide comprehensive services that are tax
funded (Scandinavia); others stick to
means-tested programmes to contain costs.
German long-term care insurance has managed
to keep spending increases under control. The number of countries with
social insurance type programmes has been growing (Germany, Japan, and