National Health Service (England)

The National Health Service (NHS) is the publicly funded healthcare system of England. It is the largest and the oldest single-payer healthcare system in the world. It is able to function in the way that it does because it is primarily funded through the general taxation system, in a similar fashion to the funding model for fire departments, police departments, and primary schools. The system provides high-quality healthcare to anyone normally legally resident in England, and also any other part of the United Kingdom (should a person from another UK area be travelling in England, for example), with almost all services free at the point of use for all such people.

The idea of the NHS being free at the point of use is contained in its core principles from the original NHS set-up, which are non-negotiable at their root but have variously been open to some interpretation over the years. In practice, "free at the point of use" normally means that anyone legitimately fully registered with the system (i.e. in possession of an NHS number), including UK citizens and legal immigrants, can access the full breadth of critical and non-critical medical care without any out-of-pocket payment of any kind. Some specific NHS services do however require a financial contribution from the patient. Since 1948, patients have been charged for some services such as eye tests, dental care, prescriptions, and aspects of long-term care. However, these charges are often far lower than equivalent services provided by a private health care provider.

In addition to the impressive range of medical services available to legal residents and citizens of the UK, the NHS also provides free emergency care to those within UK borders, regardless of their legal status or national origin. People of questionable legal status or a different national origin who do not have the legal right to be in the UK long-term — including legitimate travellers and tourists from abroad — are not entitled to the full NHS, but are entitled to emergency care in an accident and emergency department without having to pay.

The NHS has further agreed a formal constitution which sets out the legal rights and responsibilities of the NHS, its staff, and users of the service and makes additional non-binding pledges regarding many key aspects of its operations.

The current primary legislation is the National Health Service Act 2006, but the hated Health and Social Care Act 2012, whose provisions include allowing capitalist corporations to provide health care under the auspices of the NHS, will come into effect in April 2013. NHS Trusts are responding to the harsh "Nicholson challenge" which involves making £20 billion in cuts across the service by 2015.

The NHS provides the majority of healthcare in England, including primary care, in-patient care, long-term healthcare, ophthalmology and dentistry. The National Health Service Act 1946 came into effect on 5 July 1948. Private health care has continued parallel to the NHS, paid for largely by private insurance: it is used by about 8% of the population, generally as an add-on to NHS services. In the first decade of the 21st century, the private sector started to be increasingly used by the NHS to increase capacity. According to the BMA, a large proportion of the public opposed this move.

The NHS is largely funded from general taxation (including a proportion from National Insurance payments). The UK government department responsible for the NHS is the Department of Health, headed by the Secretary of State for Health. Most of the expenditure of The Department of Health (£98.7 billion in 2008-9 ) is spent on the NHS.

History
A national health service was one of the fundamental assumptions in the Beveridge Report which Arthur Greenwood, Labour's Deputy Leader and wartime Cabinet Minister with responsibility for post-war reconstruction had successfully pressed the cabinet to commission from economist and social reformer William Beveridge. The government accepted this assumption in February 1943, and after a White Paper in 1944 it fell to Clement Attlee's Labour government to create the NHS as part of the "cradle to grave" welfare-state reforms in the aftermath of World War II. Aneurin Bevan, the newly appointed Minister of Health, was given the task of introducing the National Health Service.

Healthcare prior to the war had been a patchwork quilt of private, municipal and charity schemes. Bevan now decided that the way forward was a national system rather than a system operated by regional authorities, to prevent inequalities between different regions. He proposed that each resident of the UK would be signed up to a specific General Practice (GP) as the point of entry into the system, and would have access to any kind of treatment they needed without having to raise the money to pay for it.

Doctors were initially opposed to Bevan's plan, primarily on the stated grounds that it reduced their level of independence. Bevan had to get them onside, as, without doctors, there would be no health service. Being a shrewd political operator, Bevan managed to push through the radical health care reform measure by dividing and cajoling the opposition, as well as by offering lucrative payment structures for consultants. On this subject he stated, "I stuffed their mouths with gold". On 5 July 1948, at the Park Hospital (now known as Trafford General Hospital) in Manchester, Bevan unveiled the National Health Service and stated, "We now have the moral leadership of the world".

After the publication by the British Medical Journal on 24 December 1949 of University of Cambridge paediatrician Douglas Gairdner's landmark paper detailing the lack of medical benefit and the risks attached to non-therapeutic (routine) circumcision, the National Health Service decided that circumcision would not be performed unless there was a clear and present medical indication.

The cost of the new NHS soon took its toll on government finances. On 21 April 1951 the Chancellor of the Exchequer, Hugh Gaitskell, proposed that there should be a one shilling (5p) prescription charge and new charges for half the cost of dentures and spectacles. Bevan resigned from the Cabinet in protest. This led to a split in the party that contributed to the electoral defeat of the Labour government in 1951. The one shilling prescription charge was introduced in 1952 together with a £1 flat rate fee for ordinary dental treatment. Prescription charges were abolished in 1965, but re-introduced in June 1968.

Dr A. J. Cronin's highly controversial novel The Citadel, published in 1937, had fomented extensive dialogue about the severe inadequacies of health care. The author's innovative ideas were not only essential to the conception of the NHS, but in fact, his best-selling novels are even said to have greatly contributed to the Labour Party's victory in 1945.

On 13 November 2011 the government signed off on the 10-year contract to manage the debt-laden Hinchingbrooke Hospital in Huntingdon, Cambridgeshire by Circle Healthcare. It was the first time that an NHS hospital was to be taken over by a stock-market listed company, symbolising the gradual deonstruction of one of Britain's most valued institutions.

Stafford Hospital scandal
There have been documented failures of some parts of the National Health Service to provide adequate care at a basic level. These failures were associated with bureaucratic fumbling as local institutions attempted to meet conflicting demands with inadequate resources.

Core Principles
The principal NHS website states the following as core principles:

"The NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth. At its launch by the then minister of health, Aneurin 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
 * That it be based on clinical need, not ability to pay

These three principles have guided the development of the NHS over more than half a century and remain. However, in July 2000, a full-scale modernisation programme was launched and new principles added."

The main aims of the additional principles are that the NHS will:


 * Provide a comprehensive range of services
 * Shape its services around the needs and preferences of individual patients, their families and their carers
 * Respond to the different needs of different populations
 * Work continuously to improve the quality of services and to minimize errors
 * Support and value its staff
 * Use public funds for healthcare devoted solely to NHS patients
 * Work with others to ensure a seamless service for patients
 * Help to keep people healthy and work to reduce health inequalities
 * Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance

Structure
The English NHS is controlled by the UK government through the Department of Health (DH), which takes political responsibility for the service. Parliament has devolved management locally to ten Strategic Health Authorities (SHAs), which oversee all NHS operations, particularly the Primary Care Trusts, in their areas. These are coterminous with the nine Government Office Regions for the most part, with the South East region split into South East Coast and South Central SHAs.

There are a number of types of regional NHS trust:
 * NHS primary care trusts (PCTs), administer primary care and public health. On 1 October 2006 the number of PCTs was reduced from 303 to 152 in an attempt to bring services closer together and cut costs. PCTs oversee 29,000 GPs and 18,000 NHS dentists. In addition, they commission services from other NHS Trusts and from the private and voluntary sectors, provide primary care in their locations, and oversee such matters as primary and secondary prevention, vaccination administration and control of epidemics. PCTs control 80 per cent of the total NHS budget
 * NHS hospital trusts and NHS foundation trusts administer hospitals, treatment centres and specialist care in around 1,600 NHS hospitals (some trusts run between 2 and 8 different hospital sites)
 * NHS ambulance services trusts
 * NHS care trusts, providing both health and social care services
 * NHS mental health services trusts, specialising in managing and treating mental illness, including by the use of involuntary commitment powers

Some services are provided at a national level:
 * www.nhs.uk is the primary public-facing NHS website, providing comprehensive official information on services, treatments, conditions, healthy living and current health topics
 * NHS Direct and new service "111" provide telephone and email support services
 * NHS special health authorities provide various types of services

Nearly all hospital doctors and nurses in England are employed by the NHS and work in NHS-run hospitals, with teams of more junior hospital doctors (most of whom are in training) being led by consultants, each of whom is trained to provide expert advice and treatment within a specific specialty. But most General Practitioners, dentists, optometrists (opticians) and other providers of local health care are almost all self-employed, and contract their services back to the NHS. They may operate in partnership with other professionals, own and operate their own surgeries and clinics, and employ their own staff, including other doctors etc. However, the NHS does sometimes provide centrally employed health care professionals and facilities in areas where there is insufficient provision by self-employed professionals.

In 2009, the NHS Hospital & Community Health Service plus the General Practice service had a total workforce of a little under 1.18 million full-time equivalent of which 0.61 m were qualified clinical staff such as doctors (0.13 million), nurses (0.34 m), scientists, therapists and technical staff (0.13 m), and ambulance staff (0.02 m). It has been claimed that the NHS is the third or fifth largest workforce in the world, after the Chinese Army, Indian Railways and (as argued by Jon Hibbs, the NHS's head of news, in a press release from 22 March 2005) Wal-Mart and the United States Department of Defense. A recent analysis by the BBC placed the NHS fifth on the list of the world's largest employers (well above Indian Railways).

The NHS also plays a unique role in the training of new doctors in England, with approximately 8000 places for student doctors each year, all of which are attached to an NHS University Hospital trust. After completing medical school, these new doctors must go on to complete a two-year foundation training programme to become fully registered with the General Medical Council. Most go on to complete their foundation training years in an NHS hospital although some may opt for alternative employers such as the armed forces.

Most staff working for the NHS including non-clinical staff and GPs (most of whom [GP's] are self-employed) are eligible to join the NHS Pension Scheme which, from 1 April 2008, is an average-salary defined-benefit scheme.

In July 2010 it was announced that the UK government planned to do a major decentralization of the English National Health Service. This plan entails shifting control of England’s $160 billion annual health budget from a centralized bureaucracy to doctors at the local level, as well as shrinking the bureaucratic apparatus.

Current reform proposals
The coalition government's white paper on health reform, published on 12 July 2010, sets out the most significant reorganisation of the NHS in its history. The white paper, Equity and excellence: liberating the NHS, has implications for all health organisations in the NHS and very significant changes for PCTs and strategic health authorities. It focuses on the Government’s wish to reduce bureaucracy by shifting power from the centre to GPs and patients, moving somewhere between £60 to £80 billion into the hands of groups of GPs to commission services.

Announcing the paper, the Secretary of State for Health Andrew Lansley told parliamentarians of plans for all NHS trusts to become or be part of a foundation trust and used the white paper to reiterate three key principles:
 * patients at the centre of the NHS
 * changing the emphasis of measurement to clinical outcomes
 * empowering health professionals, in particular GPs.

The white paper sets out the timetable for implementation. By April 2012 it proposes:
 * establishing the Independent NHS Commissioning Board
 * establishing new local authority health and well-being boards
 * developing Monitor as an economic regulator.

The new commissioning system is expected to be in place by April 2013, by which time SHAs and PCTs will be abolished.

Following widespread criticism of the plans, on 4 April 2011, the Government announced a "pause" in the progress of the Health and Social Care Bill to allow the government to 'listen, reflect and improve' the proposals.

The bill became law on Tuesday 20 March 2012. After more than 1,000 amendments in the House of Commons and the House of Lords, MPs cast their final vote for the bill, with a government majority of 88.

Funding
The money to pay for the NHS comes directly from taxation. The 2008/9 budget roughly equates to a contribution of £1,980 for every man, woman and child in the UK.

When the NHS was launched in 1948 it had a budget of £437million (roughly £9billion at today’s value). In 2008/9 it received over 10 times that amount (more than £100billion).

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. However, in recent years investment levels have been double that to fund a major modernisation programme.

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 and training costs on the one hand and medical equipment, catering and cleaning on the other. Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas.

The total budget of Department of Health in England in 2008/9 was £94bn of which NHS England accounted for £92.5bn. The National Audit Office reports annually on the summarised consolidated accounts of the NHS. In 2012 the NHS budget was set at £104 Billion, or £3000 per second.

The commissioning system
The principal fundholders in the NHS system are the NHS Primary Care Trusts (PCTs), that commission healthcare from hospitals, GPs and others. PCTs disburse funds to them on an agreed tariff or contract basis, on guidelines set out by the Department of Health. The PCTs receive a budget from the Department of Health on a formula basis relating to population and specific local needs. They are required to "break even" - that is, they must not show a deficit on their budgets at the end of the financial year, although in recent years cost and demand pressures have made this objective impossible for some Trusts. Failure to meet financial objectives can result in the dismissal and replacement of a Trust's Board of Directors, although such dismissals are enormously expensive for the NHS.

Services free at the point of use
The vast majority of NHS services are free at the point of use.

This term, which is commonly used, means that people generally do not pay anything for their doctor visits, nursing services, surgical procedures or appliances, consumables such as medications and bandages, plasters, medical tests, and investigations, x-rays, CT or MRI scans etc. Hospital inpatient and outpatient services are free, both medical and mental health services. This is because these services are all pre-paid from taxation.

Because the NHS is not funded by contributory insurance scheme in the ordinary sense and most patients pay nothing for their treatment there is thus no billing to the treated person nor to any insurer or sickness fund as is common in many other countries. This saves hugely on administration costs which might otherwise involve complex consumable tracking and usage procedures at the patient level and concomitant invoicing, reconciliation and bad debt processing.

Eligibility for free NHS services is based on having "permanent residence status" (a birthright for some or granted by the Home Office for those who have immigrated). The person must be registered with a general practitioner and have an NHS card and number. This will include overseas students with a visa to study at a recognized institution for 6 months or more, but not visitors on a tourist visa for example.

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 likewise get emergency treatment without charge.

In England, 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.

Those who are not "ordinarily resident" who do not fall into the above category (including British citizens who may have paid National Insurance contributions in the past) are liable to charges for services.

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.

Prescription charges
the prescription charge for medicines was £7.40 (which contrasts with Scotland, Wales and Northern Ireland where they are free). People over sixty, children under sixteen (or under nineteen if in full-time education), patients with certain medical conditions, and those with low incomes, are exempt from paying. Those who require repeated prescriptions may purchase a single-charge pre-payment certificate which allows unlimited prescriptions during its period of validity. The charge is the same regardless of the actual cost of the medicine, but higher charges apply to medical appliances. For more details of prescription charges, see Prescription drugs.

The high and rising costs of some medicines, especially some types of cancer treatment, means that prescriptions can present a heavy burden to the PCTs, whose limited budgets include responsibility for the difference between medicine costs and the fixed prescription charge. This has led to disputes whether some expensive drugs (e.g. Herceptin) should be prescribed by the NHS.

NHS dentistry
Following the government's introduction of a new contract in April 2006, NHS dentistry is not as widely available as it once was, with 900,000 fewer patients seeing an NHS dentist in 2008 and 300,000 losing their NHS dentist in a single month. This has forced many patients to pay much higher sums for private treatment, and has been criticised by the British Dental Association as having "failed to improve access to care for patients and failed to allow dentists to provide the modern, preventive care they want to deliver".

Where available, NHS dentistry charges were: £17 for an examination; £47 for a filling or extraction; and £204 for more complex procedures such as crowns, dentures or bridges. Less than 50% of the turnover of dentists comes from work sub-contracted from the NHS.

NHS Optical Services
From 1 April 2007 the NHS Sight Test Fee (in England) was £19.32, and there were 13.1 million NHS sight tests carried out in the UK.

For those who qualify through need, the sight test is free, and a voucher system is employed to pay for or reduce the cost of lenses. There is a free spectacles frame and most opticians keep a selection of low-cost items. For those who already receive certain means-tested benefits, or who otherwise qualify, participating opticians use tables to find the amount of the subsidy. An extract of the NHS benefits profile for spectacles is given in the table below, and a more detailed discussion of optical vouchers can be found at NHS Optical Benefits in the UK.

Notes on the table:
 * The term 'single-vision' means simple glasses for one purpose, as opposed to multifocals.
 * The table intends the use of the highest powers for sphere and cylinder in the glasses, assuming that the prescription is written in the cylinder format that yields the highest spherical power''.

Where vouchers do not cover the cost of the selected product, they reduce the cost at their face value. Although these voucher values are the maximum amounts that opticians can recover from the NHS, they might well make additional marketing offers of their own. See the external site Optical Voucher Values for a full NHS listing that includes varifocals, contact lenses, and essential coatings.

Injury cost recovery scheme
Under older legislation (mainly the Road Traffic Act 1930) a hospital treating the victims of a road traffic accident was entitled to limited compensation (under the 1930 Act before any amendment, up to 25 pounds per person treated) from the insurers of driver(s) of the vehicle(s) involved but were not compelled to do so and often did not do so; the charge was in turn covered by the then legally required element of those drivers' motor vehicle insurance (commonly known as Road Traffic Act insurance when a driver held only that amount of insurance). As the initial bill was sent to the driver rather than to his/her insurer, even when a charge was imposed it was often not passed on to the liable insurer; it was common for no further action to be taken in such cases as there was no practical financial incentive (and often a financial disincentive due to potential legal costs) for individual hospitals to do so.

The Road Traffic (NHS Charges) Act 1999 introduced a standard national scheme for recovery of costs using a tariff based on a single charge for out-patient treatment or a daily charge for in-patient treatment; these charges again ultimately fell upon insurers. This scheme did not however fully cover the costs of treatment in serious cases.

Since January 2007, the NHS has a duty to claim back the cost of treatment, and for ambulance services, for those who have been paid personal injury compensation. In the last year of the scheme immediately preceding 2007, over £128 million was reclaimed.

Car park charges
Car parking charges are a minor source of additional revenue for the NHS, with most hospitals deriving about 0.25% of their budget from them. The level of fees is controlled individually by each trust. In 2006 car park fees contributed £78 million towards hospital budgets. Patient groups are opposed to such charges. (This contrasts with Scotland where car park charges were mostly scrapped from the beginning of 2009 and with Wales where car park charges were scrapped at the end of 2011.)

Charitable funds
There are over 300 official NHS charities in England and Wales. Collectively, they hold assets in excess of £2bn and have an annual income in excess of £300m. Some NHS charities have their own independent board of trustees whilst in other cases the relevant NHS Trust acts as a corporate Trustee. Charitable funds are typically used for medical research, larger items of medical equipment, aesthetic and environmental improvements, or services which increase patient comfort.

In addition to official NHS charities, many other charities raise funds which are spent through the NHS, particularly in connection with medical research and capital appeals.

Regional lotteries were also common for fundraising, and in 1988, a National Health Service Lottery was approved by the government, before being found to be illegal. The idea continued to become the National Lottery.

Financial outlook
As each division of the NHS is required to break even at the end of each financial year, the service should in theory never be in deficit. However in recent years overspends have meant that, on a 'going-concern' (normal trading) basis, these conditions have been consistently, and increasingly, breached. Former Secretary of State for Health Patricia Hewitt consistently asserted that the NHS would be in balance at the end of the financial year 2007-8; however, a study by Professor Nick Bosanquet for the Reform think tank predicts a true annual deficit of nearly £7bn in 2010.

Changes under the Thatcher government
The 1980s saw the introduction of modern management processes (General Management) in the NHS to replace the previous system of consensus management. This was outlined in the Griffiths Report of 1983. This recommended the appointment of general managers in the NHS with whom responsibility should lie. The report also recommended that clinicians be better involved in management. Financial pressures continued to place strain on the NHS. In 1987, an additional £101 million was provided by the government to the NHS. In 1988 Prime Minister Margaret Thatcher announced a review of the NHS. From this review in 1989 two white papers Working for Patients and Caring for People were produced. These outlined the introduction of what was termed the "internal market", which was to shape the structure and organisation of health services for most of the next decade.

In England, the National Health Service and Community Care Act 1990 defined this "internal market", whereby health authorities ceased to run hospitals but "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients. The "providers" became independent trusts, which encouraged competition but also increased local differences. Increasing competition may have been statistically associated with poor patient outcomes.

Changes under the Blair government
These innovations, especially the "fund holder" option, were condemned at the time by the Labour Party. Opposition to what was claimed to be the Conservative intention to privatise the NHS became a major feature of Labour's election campaigns.

Labour came to power in 1997 with the promise to remove the "internal market" and abolish fundholding. In a speech given by the new Prime Minister, Tony Blair, at the Lonsdale Medical Centre (North-West London) on 9 December 1997, he stated that:

"The White Paper we are publishing today marks a turning point for the NHS. It replaces the internal market with "integrated care". We will put doctors and nurses in the driving seat. The result will be that £1 billion of unnecessary red tape will be saved and the money put into frontline patient care. For the first time the need to ensure that high quality care is spread throughout the service will be taken seriously. National standards of care will be guaranteed. There will be easier and swifter access to the NHS when you need it. Our approach combines efficiency and quality with a belief in fairness and partnership. Comparing not competing will drive efficiency."

However in his second term Blair renounced this direction. He pursued measures to strengthen the internal market as part of his plan to "modernise" the NHS.

Driving these reforms have been a number of factors. They include the rising costs of medical technology and medicines, the desire to improve standards and "patient choice", an ageing population, and a desire to contain government expenditure. (Since the National Health Services in Wales, Scotland and Northern Ireland are not controlled by the UK government, these reforms have increased the differences between the National Health Services in different parts of the United Kingdom. See NHS Wales and NHS Scotland for descriptions of their developments).

Reforms have included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous clinical and corporate governance. In addition Modernising Medical Careers (MMC) medical training has undergone an unsuccessful restructuring which was so badly managed that the Secretary of State for Health was forced to apologise publicly. MMC is now being revised but its flawed implementation has left the NHS with significant medical staffing problems which are unlikely to be resolved before 2010. Some new services have been developed to help manage demand, including NHS Direct. A new emphasis has been given to staff reforms, with the Agenda for Change agreement providing harmonised pay and career progression. These changes have, however, given rise to controversy within the medical professions, the news media and the public. The British Medical Association in 2009 in a document on Independent Sector Treatment Centres urged the Government to restore the NHS to a service based on public provision, not private ownership; co-operation, not competition; integration, not fragmentation; public service, not private profits, saying "The BMA is committed to an NHS funded from general taxation providing care free at the point of delivery and advancing the social goal of providing healthcare fairly and transparently. The BMA wishes to reverse the current government’s policy, and that of the main opposition parties, which actively promotes a market approach in the NHS, with its emphasis on competition and private sector involvement at the expense of co-operation and a public sector ethos."

The Blair Government, whilst leaving services free at point of use, has encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals have been built (or rebuilt) by private sector consortia; hospitals may have both medical services such as independent Sector Treatment Centres (ISTCs) and non-medical services such as catering provided under long-term contracts by the private sector. A study by a consultancy company which works for the Department of Health shows that every £200 million spent on privately financed hospitals will result in the loss of 1000 doctors and nurses. The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced.

Secretary of State for Health Patricia Hewitt said in 2005 that ISTCs would treat around 3% of NHS patients in England having routine surgery that year, and that by 2008 this was expected to be around 10%. NHS Primary Care Trusts were given the target of sourcing at least 15% of primary care from the private or voluntary sectors over the medium term. However, a generally favourable February 2008 CBI document on "ISTCs and the NHS" reported that "of the 27 schemes originally intended, only nine are going ahead. Five schemes were cancelled in 2006 and a further six in November 2007. The remaining seven contracts are under review until March 2008" and that "the ISTC programme was originally designed to provide 15% of the NHS’s elective care capacity ... but the original programme is being scaled back and ... ISTCs are likely to make up only 5% of the NHS’s elective care capacity."

As a corollary to these initiatives, the NHS has been required to take on pro-active socially "directive" policies, for example, in respect of smoking and obesity.

The NHS has encountered significant problems with the IT innovations accompanying the Blair reforms. The NHS National Programme for IT (NPfIT), believed to be the largest IT project in the world, has been running significantly behind schedule and above budget, with friction between the Government and the programme contractors. Originally budgeted at £2.3 billion, present estimates are £20-30 billion and rising. There has also been criticism of a lack of patient information security. The ability to deliver integrated high quality services will require care professionals to use sensitive medical data. This must be controlled and in the NPfIT model it is, sometimes too tightly to allow the best care to be delivered. One concern is that GPs and hospital doctors have given the project a lukewarm reception, citing complexity and a lack of consultation. Key "front-end" parts of the programme include Choose and Book, intended to assist patient choice of location for treatment, which has missed numerous deadlines for going live, substantially overrun its original budget, and was still available in only a few locations. The programme to computerise all NHS patient records has also had great difficulties. Furthermore there were unresolved financial and managerial issues on training NHS staff to introduce and maintain these systems once operative. Due to the aforementioned difficulties, the Conservative-Liberal coalition government announced in September 2010 that the programme would be dismantled, and that individual hospital trusts would be assigned responsibility for their own IT infrastructures.

Internet information service
Despite problems with internal IT programmes, the NHS has broken new ground in providing health information to the public via the internet. In June 2007 www.nhs.uk was relaunched under the banner "NHS Choices" as a comprehensive health information service for the public.

Ben Bradshaw, Minister of State for Health Services, told the House of Commons in a written answer on 25 March 2008:

"NHS Choices (www.nhs.uk) is the National Health Service's online service for the public - the digital wing of the NHS. It is a response to the 21st century challenges of achieving better health and delivering high quality personalised services for all, amid ever-increasing demands on a resource-constrained NHS.

As the online service for all communication with citizens on health, it has been designed specifically with the consumer in mind. The information on NHS Choices is all NHS accredited and written in plain English. It is accompanied by videos, user comments and a growing range of interactive tools which allow users to test and monitor their health and well-being. The information held on NHS Choices is designed so that general practitioners and others can print it off for people who don't have internet access.

There are in the region of 100,000 pages of content available on NHS Choices."

In a break with the norm for government sites, www.nhs.uk allows users to add public comments giving their views on individual hospitals and to add comments to the articles it carries. It also publishes blogs on a range of health topics written by patients, carers and clinicians and enables users to compare hospitals for treatment via a "scorecard". In April 2009 it became the first official site to publish hospital death rates (Hospital Standardised Mortality Rates) for the whole of England. Its Behind the Headlines daily health news analysis service, which critically appraises media stories and the science behind them, was declared Best Innovation in Medical Communication in the prestigious BMJ Group Awards 2009.

In April 2009, Mr. Bradshaw told the House of Commons in a written answer:

"'Where digital services are offered to citizens, the Department is working to ensure no citizens are disadvantaged due to access to relevant technology ... In October 2008, NHS Choices launched a new Carers Direct hub on its site aimed at carers of people with disabilities and long-term conditions. NHS Choices is also developing an online training programme aimed at health information intermediaries, who can work with those who lack access to the internet. From April 2009, NHS Choices takes over the NHS Direct digital TV service on Freeview and will be developing this further as an access channel for non-internet users. '"

11 of the NHS hospitals in the West London Cancer Network have been linked using the IOCOM Grid System. The NHS has reported that the Grid has helped increase collaboration and meeting attendance and even improved clinical decisions.

Health screening for over 40s
From 1 April 2008, everyone over 40 years old will be offered health checks for heart disease, stroke, diabetes and kidney disease under new government plans. However, doctors currently reserve judgment on the effectiveness of the policy.

Criticism
Although the NHS has a high level of popular public support within the country, the capitalist national press is perceived to be critical of it. This may have affected perceptions of the service within the country as a whole and outside. An independent survey conducted in 2004 found that users of the NHS often expressed very high levels of satisfaction about their personal experience of the medical services. Of hospital inpatients, 92% said they were satisfied with their treatment; 87% of GP users were satisfied with their GP; 87% of hospital outpatients were satisfied with the service they received; and 70% of Accident and Emergency department users reported being satisfied. When asked whether they agreed with the question "My local NHS is providing me with a good service” 67% of those surveyed agreed with it, and 51% agreed with the statement “The NHS is providing a good service." The reason for this disparity between personal experience and overall perceptions is not clear. It is also apparent from the survey that most people believe that the national press is generally critical of the service (64% reporting it as being critical compared to just 13% saying the national press is favourable), and also that the national press is the least reliable source of information (50% reporting it to be not very or not at all reliable, compared to 36% believing the press was reliable). Newspapers were reported as being less favourable and also less reliable than the broadcast media. The most reliable sources of information were considered to be leaflets from GPs and information from friends (both 77% reported as reliable) and medical professionals (75% considered reliable). On many occasions, however, the uncovering of a scandal leads to changes which improve the service in many ways, and sometimes unexpectedly.

Some examples of criticism heard inside the UK and outside include the following.

Coverage and access
In the NHS, GP referrals are needed to access specialist care and one of the original roles of general practitioner was to act as 'the gatekeeper'. This role as gatekeeper has become more prominent in the 1990s with the introduction of the 'internal market' with GPs managing funds to buy clinical services. 'Referral management centres' are also another recent innovation to divert referrals from GPs to cheaper nursing or therapy-led alternatives.

It has been argued that a nominal charge for an appointment with a GP could be introduced to prevent patients consulting their GP for frivolous reasons. To date, this has never been introduced to avoid the danger of patients avoiding consultations (for financial reasons) for conditions which might be potentially serious.

Although nominally a national service, the precise limits of coverage are rarely discussed and are determined not nationally but locally by each regional authority or trust. This means that some extremely expensive treatments may be available in some areas but not in others, the so-called postcode lottery. The exception to this are a few treatments which have been determined by NICE to be ineffective or relatively cost-ineffective (i.e. drugs that have only minor effect at great cost) are simply not offered by the NHS though may be available privately. Most NICE determinations are positive and not restrictive, and the grounds are usually clinical effectiveness and not cost effectiveness. Nevertheless the rare cases of non-recommendation on cost grounds have been called by some "rationing" and by others a sensible mechanism to control costs by funding only cost-effective evidence-based medicine. On the first occasion that a NICE ruling went to judicial review a claim submitted by the drug company Eisai (with support from Pfizer and Shire) regarding assessment for certain drugs at the onset of Alzheimer's Disease), the court upheld NICE's decision that the drugs are only cost-effective in later-stage disease. Claims that NICE did not properly evaluate the impact of the drugs on the quality of life of carers, that the figures on the cost of long-term care used in their analysis were too low were not upheld by the court and two further claims against NICE on grounds of "irrationality" and "procedural fairness" were also dismissed.

Politicisation
Over time, increased demand leads to continual political pressures to increase spending and widen the range of treatments available.

Supporters of the NHS would point out that the NHS has wide public support and the English population has as good a health outcome as many other similar countries, and often at much lower cost. Political pressure could work both ways, but the Blair government was elected in 1997 largely on a promise to invest more taxpayers' money in health to bring spending closer to the European average. The position of all the major political parties is to make gradual improvements within the current framework; none have an agenda to replace the system. The Conservative Party says its policies are aimed at "Protecting and improving our health service by putting patients back at the heart of the NHS, and trusting the professionals to ensure that they are able to use their skills to make the fullest possible contribution to patient care.".

In 2009, arguments about reform of the United States' $2.4 trillion healthcare system have led to the NHS being represented among critics as "evil", and "Orwellian". This has led to a vigorous defence of the NHS in the UK. One source said "people such as scientist Stephen Hawking [who suffers from the crippling motor neurone disease] wouldn't have a chance in the UK, where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless"; Professor Hawking, who is a British citizen and resident, remarked "I wouldn't be here today if it were not for the NHS; I have received a large amount of high-quality treatment without which I would not have survived".

Waiting lists and the 18 week target
In the NHS, which aims to give a broad coverage of care to all without charging, health care is given on the grounds of clinical need, meaning that emergency cases (e.g. heart attacks) get instant access where those with less urgent needs (e.g. cataract surgery) are given lower priority and so wait longer.

Although there are obvious arguments in favour of prioritising by clinical need rather than ability to pay, it can mean that waiting lists vary widely between regions. Patients waiting can choose to have a procedure done outside their local NHS district in order to be seen more quickly, and if the waiting time is long can often get private treatment at public expense, either in the UK or abroad. A major programme is underway in the NHS to reduce all wait times to 18 weeks by December 2008. This new target starts when the patient's own doctor writes to the hospital specialist and ends when treatment begins. It therefore includes the time to make the first appointment, and the time for all diagnostic tests to be completed, evaluated, and discussed with the patient, which were not in the previous target. It has been widely criticised by doctors, healthcare professionals, and think-tanks as diverting resources from more serious conditions to achieve politically motivated goals, and doubts persist over its achievability.

One aspect of patient care beyond the hospital's direct control has been delayed discharges (sometimes called "bed blockers") which refers to patients who have been declared fit for discharge, but for some reason are not able to return to their normal homes. Often they are awaiting placement in some nursing home or other form of residential care. This strains hospital resources, through both increased costs and longer waiting times for other patients. Fines for social services departments did succeed in reducing bed-blocking, but the numbers are creeping up again.

"Superbugs"
Antibiotic-resistant bacteria ("superbugs"), such as Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile, are found in NHS hospitals but recent attempts to reduce the problem have been quite successful. Both C. difficile and MRSA are, however, not exclusive to the NHS, existing in British private hospitals and throughout other Western healthcare systems. The UK's record is good internationally. For instance, cases doubled in the USA's private healthcare system between 1999 and 2005, and the UK's death rate is half that of the USA's. The introduction of Private Finance Initiative cleaning contractors into the NHS and the associated "cutting corners on cleaning" have been blamed for the problem, as has increased drug resistance due to inappropriate prescribing of antibiotics and patients failing to complete courses of antibiotics.

Another viewpoint is that the spread of communicable diseases in hospitals is facilitated by the overcrowding in NHS hospitals with high bed occupancy rates (as the NHS has a low bed:population ratio produced by hospital bed closures and the increasing emphasis on increasing bed "turnaround time").

Computerisation
The NHS has been criticised over the implementation of its National Programme for IT which is designed to provide the infrastructure for electronic prescribing, booking appointments and elective surgery, and a national care records service. The programme has run into delays and overspends, with the initial budget of £2.3 billion over three years officially revised to £12.4bn over 10 years and some sources putting it as high as £20bn. Critics including the House of Commons Public Accounts Committee and the National Audit Office claim the project is falling behind schedule. In addition, 93% of doctors within the NHS are not confident their patients' data will be secure, some GP practices have begun to advise all their patients to opt-out of the scheme, and privacy campaigners have claimed the national care records system breaches patients' privacy rights.

The Government and NHS national leadership have consistently argued that major capital investment in IT is necessary to transform services. Fragmented information systems, as in the US, prevent health services providing consistent data and can damage patient care where doctors may not have an overview of patients records held by another NHS body.

Dentistry
There has been a decreasing availability of NHS dentistry following the new government contract and a trend towards dentists accepting private patients only, with 1 in 10 dentists having left the NHS totally. Many more continue to offer treatment for children under NHS regs but are disputing the imposed NHS contract.

Scandals
There have been a few high-profile scandals within the NHS. The first to cause significant political disquiet was at Ely Hospital, a long stay institution for the mentally ill, in 1969. More recently there have been scandals at acute hospitals such as at Alder Hey and at the Bristol Royal Infirmary. Stafford Hospital is currently under investigation for poor conditions and inadequacies that statistical analysis has shown caused excess deaths.

Generally, there is nothing endemic about such issues which might equally have occurred in other types of health care establishments. The detection of such issues leads to better controls being established throughout the NHS for the benefit of all. For instance the inquiry into the Bristol babies scandal led to the publication of mortality statistics which has led to much lower mortalities and greatly improved services for people, with surgeons now taking on and treating higher risk patients which previously they may have been reluctant to treat.

A 14 October 2008 article in The Daily Telegraph stated, "An NHS trust has spent more than £12,000 on private treatment for hospital staff because its own waiting times are too long."

In January 2010, the NHS was accused of allocating £4 million annually on homeopathic medicines, which are unsupported by scientific research.

The "World Health Service"
People are eligible for NHS treatment, like any UK citizen, if they are “ordinarily resident” in the UK. A lack of identity/residence checks on patients at clinics and hospitals allows people who ordinarily reside overseas to travel to the UK for the purpose of obtaining free treatment, at the expense of the UK taxpayer. A report published in 2007 estimates that the NHS bill for treatment of so-called ‘health tourists’ was £30m, 0.03% of the total cost. A Conservative Party MP has said that health checks on immigrants are vital to stop the NHS becoming a "world health service".

Quality of healthcare, and accreditation
There are various regulatory bodies in the UK, both government-based (e.g. Department of Health, General Medical Council, Nursing and Midwifery Council) and non-governmental-based (e.g. Royal Colleges). Some of these organisations have a high worldwide standing.

With respect to assessing, maintaining and improving the quality of healthcare, in common with the United States and many other developed countries, the UK government has separated the roles of suppliers of healthcare and assessors of the quality of its delivery. Quality is assessed by independent bodies such as the Healthcare Commission according to standards set by the Department of Health and the National Institute for Health and Clinical Excellence. Responsibility for assessing quality transferred to the Care Quality Commission in April 2009.

Independent accreditation groups exist within the UK, such as the public sector Trent Accreditation Scheme and the private sector CHKS.

The National Institute for Health Research is a government body that coordinates and funds research for the NHS in England.

A recent comparative analysis of health care systems put the NHS second in a study of seven rich countries. The report put the UK health systems above those of Germany, Canada and the US; the NHS was deemed the most efficient among those health systems studied.

English NHS and related government sites

 * NHS Choices - The UK's biggest health website and online 'front door' to the NHS
 * NHS Bristol launches iPhone mobile app NHS Bristol's appointment reminder app
 * NHS Direct - The NHS telephone advice service
 * About the NHS: Overview - NHS Choices
 * The NHS in England - NHS Choices
 * NHS Services - NHS Choices
 * NHS: Rights and pledges - NHS Choices
 * NHS Professionals Special Health Authority
 * Department of Health
 * NHS Direct jobs and careers
 * NHS local a range of digital services for NHS staff and the public in the West Midlands.

Shared with other UK health services

 * NHS Confederation
 * NHS Employers
 * National Library for Health previously called the National Electronic Library for Health

Other sites

 * NHS guide from the BBC - includes charts and statistics
 * BBC coverage of NHS 50th anniversary
 * Guardian Special Report - National Health Service
 * History of the Tredegar Medical Aid Society
 * From Cradle to Grave - the first 50 years of the NHS 1998 - 2007 the contemporary chapter dealing with the NHS in England
 * NHS Optical Benefits in the UK A WikiBooks page
 * 'The Origins of the NHS', by Professor Berridge, Gresham College, 14 April 2008 (available for video, audio and text download).
 * Birth of the National Health Service - how the state of the nation's health became a political ideal, a BBC archive collection of programmes and documents.
 * NHS Constitution(PDF)
 * Text reminders could save NHS millions every year