The Healthcare System of the United Kingdom

1. The Healthcare System of the United Kingdom Lecture 5 Tracey Lynn Koehlmoos, PhD, MHA HSCI 609 Comparative International Health Systems

2. “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

3. The United Kingdom • Population: 59 million • Capitol: London • Includes: England, Northern Ireland, Scotland and Wales • Government: Constitutional Monarchy

4. UK: Updated Information • Population: >60 million in 2006 • Life Expectancy: 76.1 male/ 81.1 female • Infant Mortality: 5.06 per 1000 (2006) • Population over 60: 20.8% • GDP for healthcare: 7.7% (2002) • Per capita health expenditure: $2,031 (US)

5. Talking about the UK… • The United Kingdom consists of England, Scotland, Wales and Northern Ireland • Great Britain consists of England, Scotland, and Wales • Northern Ireland has its own National Health Service • We will not include Northern Ireland in the remainder of our discussion.

6. Health System Overview • National Health Service Act 1948—based on Beverage Report and the belief in post-World War II solidarity. • British NHS: National Health Service, first comprehensive, nationalized healthcare program. • Highly centralize management and finance • Patients choose their provider • Providers can have public & private practices

7. Structural Changes to NHS • Secretary of State for Health • Department of Health (NHS) • Strategic Health Authorities (like RHA’s) • Primary Care Trusts (like DHA’s) • Hospitals: NHS Trust (semi-independent) • This represents a strong move toward internal market competition—more like managed care

8. Strategic Health Authorities • 28 Strategic Health Authorities since 2002 to manage the local NHS. • Responsible for: • Local health service planning • Monitoring quality • Increasing the capacity of local health services • Priority service integration - for example, programs for improving cancer services • Strategic Health Authorities manage the NHS locally and are a key link between the Department of Health and the NHS.

9. Primary Care Trusts The center of the NHS, control 80% of the total NHS budget • PCTs are responsible for: • Assessing the health needs of the local community. • Commissioning the right services, for instance from GP practices, hospitals and dentists. • Improving the overall health of their local communities. • Ensuring access to services • Monitor interaction of social and healthcare organizations. • Annual assessment of GP practices in their area. • Buy and monitor services There are more than 300 PCTs covering all parts of England since April 2002, which report directly to their local Strategic Health Authority.

10. Private Market • 12% of Britons have Supplementary Insurance--an employment perk • Doctors & hospitals treat both public and private patients • Private insurance pays for dental, vision, some prescription drugs (although 80% of all prescription drug payments are waived due to age, pregnancy, youth, poverty)

11. Economic Factors • Revenues • 83% NHS funding from taxes • 13% from employer-employee contributions • 4% User fees • Expenditures • NHS accounts for 88% of health expenditures • Private Insurance (SI) 4% of expenditures • ~3/4 of NHS budget goes to workforce salaries • 1/10th of NHS budget goes for drugs

12. Management • Central authority for national health planning, budgeting and legislation. • Distribution of funds and delegation of planning to Strategic Health Authorities • Administration (streamlined compared to previous set-ups) is vital to success of the new system—emphasis on strategic planning, evaluation, budgeting and internal market competition.

13. Health Services Workforce More than 1 million employees, largest single employer in Europe • MD’s: 2.1 per 1000 pop (low #) (OECD 2002) • General Practitioners (GPs): 60% • GPs handle 90% of episodic care; gatekeepers • GPs paid by mix of capitation, salary, fees • Specialists are hospital based, called “Consultants.” • Specialists/Hospitalists are salaried • All MD’s can have public and private practices

14. Health Services Workforce • Nurses largest group within NHS staff • 40% of NHS budget • Nurses are trained specialist (child, MH) • Work closely with GPs in the community • Hospital nurses, much dissatisfaction salaries, working conditions, work load. • Nursing shortage • NHS is actively recruiting Indian, Spanish and Philippine nurses to make up for shortages in the field.

15. Hospitals • More than 2000 public or NHS trust hospitals • About 300 private/surgical procedure facilities

16. NHS Trusts (Hospitals) Emergency and planned hospital treatment • Hospitals in the NHS are managed by NHS Trusts . • Their wide-ranging services are commissioned – or purchased - on behalf of patients by Primary Care Trusts (PCTs) and include treatments where patients are admitted to hospital, day surgery and out-patient services where patients attend consultations and clinics. • NHS Trusts employ most of the NHS workforce: consultants, doctors, nurses, hospital dentists, pharmacists, midwives and health visitors, managers and IT specialists, physiotherapists, radiographers, podiatrists, speech and language therapists, dieticians, counselors, occupational therapists and psychologists. • Hospital treatment is arranged through a GP, except emergencies. • Appointments and treatment at NHS hospitals are free.

17. NHS Foundation Trusts • New type of NHS hospital run by local managers, staff and members of the public. • Only the highest performing hospitals can apply to become NHS Foundation Trusts – a status which gives them much more freedom in running their services than other NHS Trusts. • The creation of Foundation Trusts illustrates the shift of decision-making power to frontline-staff and the local communities they serve. • However, Foundation Trusts remain firmly within the NHS and its framework of standards.

18. Long Term Care • Community Care Act of 1990 reduced government role to only covering nursing services (unless indigent) • Most LTC takes place in private sector • Private, supplemental LTC ins is available • State Equity Release Scheme • From October 1 2001 a permanent resident in a care home in England need not sell their own home to fund their long term care fees.

19. Current Issues in the UK • Aging population • High cost of advanced technology and its impact on tight budgets • Increased incidence of serious and expensive to treat diseases (cancer, HIV/AIDS) • On-going problems with long queues and rationing

20. Compared to US • Single payer system • Surgeries and new technologies underused • New efforts to decrease UK waiting times • All access system • US, 44 million uninsured, no access • Tremendous cost control and access but a definite lack of quality compared to US

21. Summary • National Health Service • Centralized, publicly financed system • Cradle-to-Grave care (except LTC!) for all citizens • Largest employer in Europe