2Aneurin Bevan Minister of Health 1946 “No society can legitimately call itself civilized if a sick person is denied medical aid because of a lack of means.”Aneurin BevanMinister of Health1946
3“United Kingdom”The United Kingdom of Great Britain and Northern IrelandCommonly known as UK or BritainConstitutional monarchy and unitary state: England, Northern Ireland, Scotland and Wales
4Demographics Population (2010 est.): 62.2 M Annual population growth rate (2010 est.):0.56%Major ethnic groups: British, Irish, West Indian, South AsianInfant mortality rate (2009est.) – 4.69/1,000Life expectancy (2009 est.) – Males 77.8 yrs; Females 82.1 yrs; total 79.9 yrsWork force (2009, 31.5M): Services-80.4%; Industry-18.2%; agriculture-1.4%Average Total Fertility Rate (TFR) in children per woman
5THE BEVERIDGEan MODELNamed 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 paymentsMostly, hospitals and clinics are owned by the governmentGovernment and private doctors collect their fees from the governmentMany, but not all, hospitals and clinics are owned by the governmentIn Britain, you never get a doctor billCuba represents the extreme application of the Beveridge approach; it is probably the world's purest example of total government control.
6Beveridgean modellow 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
7Healthcare system in UK National Health Service (NHS)Shared name of three of the four publicly funded healthcare systems in UK:National Health Service-EnglandNHS ScotlandNHS WalesHealth and Social Care in Northern Ireland (HSC)-Northern IrelandEach system operates independentlyPolitically accountable to the relevant government: the Scottish Government, Welsh Assembly Government, the Northern Ireland Executive, or the UK government (for the English NHS)
8Brief history1834 – “Poor Law Amendment Act” – legal mandates for mandates for workhouses to provide health care for inmates and sick paupers1870s – evolving network of workhouses, isolation hospitals, asylums, volunteer hospitals1919 – Ministry of Health established1942 – Beveridge Report – first comprehensive system, including access to both community-based care and hospital treatment
9Brief historyNational Health Service Act 1948—based on Beverage Report and the belief in post-World War II solidarity1983 – Griffith report1989 – Caring for People by England, Scotland, Wales1990 – National Health Service and Community Care Act – shift resources to primary care1990s – Thatcher Revolution: public-private ownership
12NHS Act of 1948 establishing the National Health Service Central administrationRegional hospital boardsLocal health authoritiesExecutive councilsTripartite of providersHospital servicesCommunity servicesFamily practitioner services
13The National Health Service in 1948 Ministry of HealthCentral Health Services CouncilRegional Hospital BoardsLocal Health AuthoritiesExecutive CouncilsTeaching Hospital Boards of GovernorsHospital Management CommitteesFamily Practitioner ServicesCommunity ServicesHospital Services
14Minister of HealthResponsible 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.
15Tripartite 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.'
16Tripartite providers Community services Local authority health services were managed by a Medical Officer of Health.Community nursesSchool dentistsHealth centers
17Tripartite 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.
18Reforming the NHS in 197414 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.
19Area 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.
20Reforming the NHS in 1990 Griffith report in 1983 recommending That the NHS become more business-likeAddress the problem of growth of public expenditures, andInitiate internal market forces within the NHS.To create competition between hospitals and providers through a separation of purchaser and provider role.
21After 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).
22To 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.
23Self-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.
24The 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.
25The NHS after the 1990 National Health Service and Community Care Act Secretary of State for HealthDepartment of HealthRegional Health AuthoritiesDistrict Health AuthoritiesFamily Health Services AuthoritiesGP Fund HoldersNHS TrustsSpecial Health AuthoritiesGP’s, dentists, opticians, pharmacistsDirectly Managed Units
261990 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)
27The 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.
28Secretary 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.
29Department of Health- responsible for the overall planning, regulation and inspection of the health service- develops policies and decides the general direction of healthcare.
30Strategic health authorities - 28 strategic health authorities in England.- look after the healthcare of their region- link between the Department of Healthand the NHS.- make sure that national healthpriorities (such as cancer programmes)are integrated into local health plans.
31Primary and secondary health services Primary carecovers everyday health services such as GPs’ surgeries, dentists and opticiansdelivered by “primary care trusts”Secondary carespecialized services such as hospitals, ambulances and mental health provisiondelivered by a range of other NHS trusts.
32NHS “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.
33The different types of Trusts Primary care trustsabout 300 primary care trusts in England.decide what health services their area needs and have responsibility for making sure these are delivered efficientlyPrimary care trusts are responsible for services you access directly such as:GPsDentistsPharmacistsOpticiansNHS DirectNHS walk-in centres
34Primary Care Trustsdecide on the amount and quality of services provided by hospitals, dentists, patient transport and population screening.responsible for generally improving local healthmake 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".
35NHS Trustsrun 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
36Types of NHS Trust Acute trusts: Care trusts: look after hospitals that provide short-term care, such as Accidents and Emergencies, maternity, surgery, x-ray175 acute NHS trustsCare 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
37Mental health trusts: 60 mental health trust 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 problems60 mental health trust
38Ambulance 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 treatment12 ambulance trust
39Foundation trustsHigh-achieving NHS trusts can opt out of NHS control and receive foundation statusmore freedom and financial flexibility and less central control and monitoring.owned by their community, local residents, employees and patientshave the power to manage their own budgets and shape their healthcare provision according to local needs and prioritiesmore access to funds for investment (public or private sector)currently 115 available
40Private Health Caresmaller 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 insuranceSecondary care in the private sector: specialized health treatmentDiagnostic 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
41Private 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.
43HUMAN HEALTH RESOURCES 90,000 doctors (2.1 per 1000 pop) (OECD 2002)3 Categories:Hospital consultantGeneral 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
443. Public Health Doctor in Community Medicine -smallest-can advance to senior appointments as District or Regional Public Health Director
45150,000 healthcare assistants 22,000 midwives 13,500 radiographers 300,000 nurses40% of the NHS budgetInitial core course then select a branches of nursing for specialization (adult, children etc..)150,000 healthcare assistants22,000 midwives13,500 radiographers15,000 occupational therapists
46• 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
47Health Care Administration Expertise in the planning and evaluation of services in the NHS.Present at all level (regional, district )
48NHS HOSPITALSCapacity: 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)
50Health FinanceNHS principle on health finance: financed almost 100% from central taxation* The rich paid more than the poor for comparable benefitsPublic funding through taxationEfficient (lower administrative costs)Services are free to patients at the point of use.
51Financing SchemeSmall co-payment on few services (e.g. prescription drugs, optician and dental services)80% of patients are exempted from these co-payments namely pregnant women, mothers, children, most elderly persons & patients with chronic diseasesSmall but growing private sector (10-20%)
52Financing SchemeIt pays general practitioners on a capitation basis and hospital physicians largely on a salaried basis.Every citizen is registered with a general practitioner and receives all primary and preventative care in this setting.Persons not subject to copays on dental and prescriptions:-those receiving means tested benefits-those on retirement benefitsOver 2/3 of those with private health insurance have risk rated group policies provided through their employers.Private insurance is concentrated among those in the professional and managerial occupations, high income earners, and those living in London and the south east.
53Financing Scheme Before the 1990: monolithic bureaucracy Prior to the reforms, each health district authority was provided a fixed budget with no incentive for good performance.Greater efficiency and shorter waiting lists meant more referrals from other districts without an offsetting transfer of resources. Increase productivity added to workloads but not revenues.
54Financing SchemeThe reforms replaced the centralized hierarchical NHS bureaucracy with a quasi-market mechanism.Establishment of the internal market and the purchaser-provider splitA provider/purchaser split: “purchasers” of health care, regional health authorities and general practice fund holders are allocated budgets to purchase services for their populations“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)
55Financing Scheme These purchasers are distinct from providers (mainly hospitals)The incentives for efficiency and a responsive system come as providers compete for contracts with purchasersThe Thatcher reforms of 1993, created an internal market and GP fundholders, adding choice and competition to a system where little or either existed
56Financing SchemeTo become a “provider” health organizations became NHS trusts, independent with their own management and competing with each otherNHS Trust hospitals served as primary providers of specialty services to GPFHs
57Financing Scheme GP fund holding Family doctors were given budgets with which to buy health care from NHS trusts (and also from the private sector)Two tier system: Patients of GP fund holders were often able to obtain treatment more quickly than patients of non-fund holdersSupporters said fundholding saved money and was more efficient. -, contrary to the founding principles of the NHS of fair and equal access for all to health care
58Financing SchemeEstablishment of NHS Trust and General Practitioner Fund Holders (GPFH) organizationsProvide care and purchase services for their patients including hospital services, pharmaceutical care, health visiting, district nursing, dietetic and chiropody servicesQuicker access to hospital care and consultants
59Financing SchemeA patient-focused service (patient choice, an expanding independent sector and providing extra capacity)Competitive providers, giving hospitals and GPs incentives to change (Payment by results, money following patients)Active purchasers - giving PCTs purchasing power and practice-based commissioning)Cost effectiveness and affordability, (tariffs and commissioning)
60Financing SchemeThe NHS had become a service provided to all without payment, but the provision was no longer necessarily by a publicly owned infrastructurePrivate sector organizations came to build and operate hospitals under the public/private partnerships, and to run clinical services such as Independent Treatment Centers and some NHS Walk-in Centers"Contestability" - the introduction of competition between providers - became significant. Private practice was now an important part of a new and more sophisticated market.
61Private Market12% of Britons have Supplementary Insurance--an employment perkDoctors & hospitals treat both public and private patientsPrivate insurance pays for dental, vision, some prescription drugs (although 80% of all prescription drug payments are waived due to age, pregnancy, youth, poverty)
62Economic Factors Revenues Expenditures 83% NHS funding from taxes 13% from employer-employee contributions4% User feesExpendituresNHS accounts for 88% of health expendituresPrivate Insurance (SI) 4% of expenditures~3/4 of NHS budget goes to workforce salaries1/10th of NHS budget goes for drugs
63Health Care Expenditures Expenditure on healthcare in the UK was £136.4 billion in 2009The graph on the next slide shows the current price expenditure on healthcare within the UK for the years 1997–2009.
64Current price expenditure on healthcare from year 1997–2009 Source: Office for National Statistics
65Expenditure on healthcare as a percentage of GDP (1997–2009) Source: Office for National Statistics
66Public and private health expenditure as a percentage of GDP 1997–2009 Source: Office for National Statistics
67Breakdown of Budget for NHS Approximately sixty-percent of the budget for the NHS is spent on payments to staff members. Twenty-percent of the budget pays for pharmaceuticals and additional supplies, while the remaining twenty-percent is spent between buildings, equipment, training costs, medical equipment, catering, and cleaning. Almost eighty-percent of the NHS' total budget is distributed through local trusts in line with the particular health priorities in their particular areas.
68Breakdown of Health Spending Given that we spend over 5 per cent of our GDP on the NHS – or about £54 billion this year – it is interesting to see where the money goes. Roughly 75 per cent of the budget is spent on Hospital and Community Health Services, over 20 per cent on Family Health Services with the rest being distributed between Central Health and Miscellaneous Services and Departmental Administration.
69NHS expenditure, by ageNHS spending goes disproportionately on births and those aged over 65. This means that changes in demographics could place additional demands on the NHS budget.
70Health Care Expenditures in Comparison to Other Countries (Spending per capita ($2,160) in the United Kingdom in 2002 was just 41 percent of the United States level ($5,267) and a little more than half when expressed as a ratio to GDP (7.7 percent as opposed to about 15 percent)
73The US is also the worst performer in terms of infant mortality while Japan is again the best. This does not measure what healthcare systems do directly. Perhaps a better measure of the quality of healthcare is provided by the success rates of certain treatments.
76CQC Care Quality Commission Regulates all health and adult social care services in England, including those provided by the NHS, local authorities, private companies or voluntary organisationAlso protects the interests of people detained under the Mental Health Act
77CQCMakes sure that essential common quality standards are being met where care is provided, from hospitals to private care homesHas a wide range of enforcement powers to take action on behalf of people who use services if services are unacceptably poor.Brings together independent regulation of health, mental health and adult social care for the first timeAims to make sure better care is provided for everyone, whether that’s in hospital, in care homes, in people’s own homes or elsewhere.
78HPA Health Protection Agencys A non-departmental public body Role is to help protect UK public health by giving support and advice to the NHS, local authorities, emergency services, the Department of Health and any other organisations that play a part in protecting health
79HPA Operates from three major centres: The Centre for Infections at ColindaleThe Centre for Radiation, Chemical and Environmental Hazards at ChiltonThe Centre for Emergency Preparedness and Response at PortonHPA Act requires the agency to be accountable for the standards of the healthcare services it provides as if it were an NHS authorityIs subject to the Care Quality Commission's Annual Health Check and measured against the Department of Health's Standards for Better Health
80NICE National Institute for Health and Clinical Excellence An independent organisation that provides national guidance on the promotion of good health and the prevention of ill health.Set out in a 2004 white paper, Choosing health: making healthier choices easier and is intended to help people to make well informed choices about their health
81NICENICE guidance is produced by healthcare professionals, NHS staff, patients and carers, members of the academic world and other members of the wider healthcare community
82NICE Guidance Guidance is developed for the following areas: Public health: guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the voluntary sector, and the wider publicHealth technologies: guidance on the use of new and existing medicines, treatments and procedures within the NHS Clinical practice: guidance on the appropriate treatment and care within the NHS of people with specific diseases and conditions
84Reforms Increase in demand at zero pricing Growing public expectations Advances in costly medical technologiesAgeing population
85A. 1990 National Health service and Community Act 2 objectives:To improve ability to control the NHS financially by separating ‘health’ from ‘social’ care. Free but controlled NHS in practice meant making doctors more accountable to government. This required restricting the clinical autonomy of doctorsTo increase the efficiency of the NHS by improving both productive efficiency and allocative efficiency .
86Introduction of the internal market by separating “purchasing” and “providing” functions 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)Creation of NHS trusts with greater freedom to set pay levels and to borrow for capital projects
87Fund holding for larger GP practices allowing them to purchase certain patient services direct from providersElevation of GP statusMany family doctors were given budgets in a scheme called GP fund holding.Fund holding saved money and was more efficient.GPFH must have a minimum of 7000 patients enrolled and can purchase a number of provider services directly on behalf of their patient
88CHALLENGESConcerns that GPs might engage in practices to maximize their budgets such as excluding high risk, high cost patients or under referring patients to hospitalsWaiting lists are an epidemic problemUK only spent 6.8% of GDP on health care hence the numbers of doctors4, nurses, therapists and hospital beds were insufficient to match the increasing demand and, therefore, the waiting times for treatment lengthened
89Equity in access issue is unsolved Health workers are paid considerably less than their counterparts in other countries
90B. NHS Plan of 2000 4 principles A patient-focused service (patient choice, an expanding independent sector and providing extra capacity)Competitive providers, giving hospitals and GPs incentives to changeActive purchasersCost effectiveness and affordability, (tariffs, legal contracts and commissioning)
91Health care system based on cooperation not competition Private sector organizations came to build and operate hospitals under the public/private partnerships, and to run clinical services such as Independent Treatment Centres and some NHS Walk-in CentersEmphasis on efficiency and quality through creation of NICE (National Institute of Clinical Excellence) and CHI (Commission for Health Improvement)
92Consumer choice Means to address problem on “waiting list” This innovation meant that spare capacity in one hospital can be used to shorten queues at another, speeding treatment for patients and making more efficient use of resources.Hospitals that fail to deliver lose money
93CHALLENGESTax revenue for financing NHS will depend on the rate of economic growth hence there is a continuing debate as to whether NHS should be exclusively funded by general taxes and national insurance contributions or instead adopt some form of social health insuranceHow to cope up with advances in technology in tax-funded system
94CHALLENGES How to address the rising alcohol misuse and obesity Prime minister needs for greater integration and efficiency, with more emphasis on preventionThose In poorer communities are still those with poorer health