National Health Service (England)

The English NHS is controlled by the UK government through the Department of Health and Social Care (DHSC), which takes political responsibility for the service. Resource allocation and oversight was delegated to NHS England, an arms-length body, by the Health and Social Care Act 2012. NHS England commissions primary care services (including GPs) and some specialist services, and allocates funding to 211[19] geographically based clinical commissioning groups (CCGs) across England. The CCGs commission most services in their areas, including hospital and community-based healthcare.[20]

A number of types of organisation are commissioned to provide NHS services, including NHS trusts and private sector companies. Many NHS trusts have become NHS foundation trusts, giving them an independent legal status and greater financial freedoms. The following types of NHS trusts and foundation trusts provide NHS services in specific areas:[21]

• acute trusts administer hospitals, treatment centres and specialist care in around 1,600 NHS hospitals (some trusts run between 2 and 8 different hospital sites)
• ambulance services trusts
• Care trusts, providing both health and social care services
• mental health trusts, specialising in managing and treating mental illness, including by the use of involuntary commitment powers

Some services are provided at a national level, including:

• www.nhs.uk is the primary public-facing NHS website, providing comprehensive official information on services, treatments, conditions, healthy living and current health topics
• Special health authorities provide various types of services

In the year ending at March 2017, there were 1.187 million staff in England's NHS, 1.9% more than in March 2016.[22] There were 34,260 unfilled nursing and midwifery posts in England by September 2017, this was the highest level since records began.[23] 23% of women giving birth were left alone part of the time causing anxiety to the women and possible danger to them and their babies. This is because there are too few midwives.[24] Neonatal mortality rose from 2.6 deaths for every 1,000 births in 2015 to 2.7 deaths per 1,000 births in 2016. Infant mortality (deaths during the first year of life) rose from 3.7 to 3.8 per 1,000 live births during the same period.[25] Assaults on NHS staff have increased, there were 56,435 recorded physical assaults on staff in 2016–2017, 9.7% more than the 51,447 the year before. Low staffing levels and delays in patients being treated are blamed for this.[26]

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 speciality. From 2017, NHS doctors must reveal how much money they make from private practice.[27]

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.

Staff in NHS England from 2010 - 2017.[28]

Note that due to methodological changes, the 1978 figure is not directly comparable with later figures.

A 2012 analysis by the BBC estimated that the NHS across the whole UK has 1.7 million staff, which made it fifth on the list of the world's largest employers (well above Indian Railways).[32] In 2015 the Health Service Journal reported that there were 587,647 non-clinical staff in the English NHS. 17% worked supporting clinical staff. 2% in cleaning and 14% administrative. 16,211 were finance staff.[33]

The NHS plays a unique role in the training of new doctors in England, with approximately 8,000 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.[34] Most NHS staff, including non-clinical staff and GPs (although most GPs are self-employed), are eligible to join the NHS Pension Scheme—which, from 1 April 2015, is an average-salary defined-benefit scheme. Among the current challenges with recruiting staff are pay, work pressure,[35][36][37] and difficulty recruiting and retaining staff from EU countries due to Brexit.[38] and there are fears that doctors could also leave.[39][40]

In March 2021, the Department of Health and Social Care made a non-binding recommendation that NHS staff in England should receive a 1% pay rise for 2021–2022, citing the 'uncertain' financial situation and the current low inflation.[41][42] This is estimated to cost £500 million a year, as almost half of the NHS's budget goes on staffing costs (at £56.1 billion).[42] The Trades Union Congress estimated that nurses' pay would be £2,500 less than in 2010, paramedics' pay would be £3,330 less and porters' pay would be £850 less due to inflation.[43] The Royal College of Nursing has criticized the pay rise, calling it 'pitiful' and said that nurses should be getting 12.5% more; it has also agreed to set up a £35m fund to support members in the event of a strike.[43][44] Other unions have threatened strike actions and warned that the proposal could lead to staff quitting their jobs, worsening staffing issues.[44][45][46] The Labour Party similarly criticized the proposal as 'reprehensible' and claimed that it goes against a government 'promise' made in 2020 to give NHS workers a 2.1% pay rise, which was voted for in a long-term spending plan in January 2020 but the Department of Health considered to be not legally binding.[44][46][47] Prime Minister Boris Johnson has defended the 1% pay rise, stating that the government is giving workers "as much as we can" in light of the COVID-19 pandemic and that he was "massively grateful" to the health and social care workers.[46] Secretary of State for Health and Social Care Matt Hancock and Secretary of State for Education Gavin Williamson have similarly argued that the decision was due to an assessment of what was affordable due to the pandemic and that NHS staff was excluded from a wider public sector pay freeze.[47][43] The Review Body on Doctors' and Dentists' Remuneration, an independent review body, is expected to make its own recommendations on NHS salaries in May 2021, which may differ from the Department of Health's recommendation.[43][46] Shadow Secretary of State for Health and Social Care Jon Ashworth has clarified that Labour would "honour whatever the review body recommends".[46]

At the end of 2021 there were 99,000 vacancies in the English NHS. 39,000 more nurses were needed, together with 1,400 more anesthetists, 1,900 more radiologists and 2,500 more GPs.[48]

Miriam Deakin of NHS Providers stated there were 133,000 NHS vacancies in late 2022.[49]

The coalition government's white paper on health reform, published in July 2010, set out a significant reorganisation of the NHS. The white paper, Equity and excellence: liberating the NHS,[50] with implications for all health organisations in the NHS abolishing primary care trusts and strategic health authorities. It claimed to shift power from the centre to GPs and patients, moving somewhere between £60 and £80 billion into the hands of clinical commissioning groups to commission services. The bill became law in March 2012 with a government majority of 88 and following more than 1,000 amendments in the House of Commons and the House of Lords.

From 2003 to 2013 the principal fundholders in the NHS system were the primary care trusts (PCTs), that commissioned healthcare from NHS trusts, GPs and private providers. PCTs disbursed funds to them on an agreed tariff or contract basis, on guidelines set out by the Department of Health. The PCTs budget from the Department of Health was calculated on a formula basis relating to population and specific local needs. They were supposed to "break even" – that is, not show a deficit on their budgets at the end of the financial year. Failure to meet financial objectives could result in the dismissal and replacement of a trust's board of directors, although such dismissals are enormously expensive for the NHS.[64]

From April 2013 a new system was established as a result of the Health and Social Care Act 2012. The NHS budget is largely in the hands of a new body, NHS England. NHS England commissions specialist services and primary care. Acute services and community care are commissioned by local clinical commissioning groups (CCGs) led by GPs. From April 2021 all CCGs have become part of Integrated Care Systems.

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

This 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 or other diagnostic services. Hospital inpatient and outpatient services are free, both medical and mental health services. Funding for these services is provided through general taxation and not a specific tax.

Because the NHS is not funded by a 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 that might otherwise involve complex consumable tracking and usage procedures at the patient level and concomitant invoicing, reconciliation and bad debt processing.

Eligibility for NHS services is based on having ordinary resident status, regardless of nationality.

Prescriptions for medication in England and Wales are subject to a fixed charge per item for up to three months' supply, regardless of the actual cost of the medicine. Some people qualify for free prescriptions. Higher charges apply to medical appliances. Pharmacies or other dispensing contractors are reimbursed for the actual cost of the medicines through NHS Prescription Services, a division of the NHS Business Services Authority.

As of March 2023 the NHS prescription charge in England was £9.35 per item[65] (in Scotland, Wales and Northern Ireland[66] there is no charge for items prescribed on the NHS. 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 charges, subject to penalties for claiming exemption when not entitled. Those who require repeated prescriptions may purchase a single-charge pre-payment certificate that allows unlimited prescriptions during its period of validity.

The high and rising costs of some medicines, especially some types of cancer treatment, means that prescriptions can present a heavy burden to the primary care trusts, whose limited budgets include responsibility for the difference between medicine costs and the low, fixed prescription charge. This has led to disputes whether some expensive drugs (e.g., Herceptin) should be prescribed by the NHS.[67]

The position of dentistry within the NHS has been contested frequently. At the inception of the NHS, three branches of dental service were established: local health authority dental service; general practitioner service; and hospital dental service.[68] Dental treatment was initially free at the point of use; however charges were introduced in 1951 for dentures – leading to the resignation of the architect of the NHS and Minister for Labour, Aneurin Bevan in March 1951 [69] – and in 1952 for other treatments.[70]

Dentists are private contractors to the NHS, which means practitioners must purchase and maintain the practice premises, equip the surgery, and hire staff in order to provide an NHS dental service. The contract between the NHS and dentists determines what work is provided for under the NHS, payments to dentists, and charges to patients. The contract is regularly revised – in 2003, the Government announced major changes to NHS dentistry, giving primary care trusts (PCTs) responsibility for commissioning NHS dental services in response to local needs, and using NHS contracts to influence where dental practices were located, and in 2006 a new contract was introduced following Department of Health recommendations on how to cash limit NHS primary care dentistry.[71] Professional bodies such as the British Dental Association have complained that the 2006 contract changes introduced a remuneration system which fails to incentivise disease prevention, leading to declining patient outcomes, and that radical reform was needed.[72]

NHS dentistry charges as of April 2017 were: £20.60 for an examination; £56.30 for a filling or extraction; and £244.30 for more complex procedures such as crowns, dentures or bridges.[73] As of 2007, less than half of dentists' income came from treating patients under NHS coverage; about 52% of dentists' income was from treating private patients.[74]

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.

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 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 went to the driver rather than the insurer, even when a charge was imposed it was often not passed on to the liable insurer. It was common to take no further action 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.[75] In the last year of the scheme immediately preceding 2007, over £128 million was reclaimed.[76]

From April 2019 £725 is payable for outpatient treatment, £891 per day for inpatient treatment and £219 per ambulance journey.[77]

Car parking charges are a minor source of revenue for the NHS,[78] with most hospitals deriving about 0.25% of their budget from them.[79] The level of fees is controlled individually by each trust.[78] In 2006 car park fees contributed £78 million towards hospital budgets.[78][79] Patient groups are opposed to such charges.[78] This contrasts with Scotland where car park charges were mostly scrapped from the beginning of 2009[80] and with Wales where car park charges were scrapped at the end of 2011.[81]

There are over 300 official NHS charities in England and Wales. Collectively, they hold assets in excess of £2 billion and have an annual income in excess of £300 million.[82] 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 that increase patient comfort.

In addition to official NHS charities, many other charities raise funds that 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 illegal. The idea continued to become the National Lottery.[83]

In an independent review in 2016 by Robert Francis, it was concluded that some staff in England felt unable or unwilling to raise concerns about standards of care due to fear or low expectations, and that some staff who raised concerns had bad experiences and suffered unjustifiable consequences which the report described as "shocking".[96]^: 86 There is a culture of bullying towards those who raise concerns.[96]^: 87 This response may consist of placing the whistleblower on performance review, providing no assistance to them, starting a review process that can take months or years, possibly leading to mental health problems, and bullying and victimisation by other staff.[96]^: 56 This process rarely ended with being redeployed in an organisation, instead resulting in retirement, dismissal, or alternative employment.[96]^: 63

An issue identified by the report was the use of "gagging clauses" involved in settlements surrounding the termination of employment of those who whistleblow. While the report found that all the contracts were legal, it noted that the language used was often complicated and legalistic, a culture of fear deterred public interest disclosures even when they were not in breach of contract, and that the terms were often unnecessarily restrictive, for example by making the existence of the agreement confidential.[96]^: 187

Surgeon Peter Duffy wrote about his experiences of whistleblowing following an avoidable death in an independently published book, Whistle In the Wind.[97]

In research from BMA, 81% of respondents (NHS workers) believed they were only partly or not at all protected during the third wave.[98] BMA also stated that the British government were unprepared for the Covid-19 outbreak and that the underfunding of the NHS left the UK 'Brutally exposed' with 'too few staff and too few beds'.[99] One Doctor even claimed, regarding masks '"We made our own and bought our own when we could find any—we depended on friends sourcing FFP3 masks, my son’s school 3D printing visors,".[98] This research revealed that during the COVID-19 pandemic, NHS employees believed the government had treated them unjustly. The report they released was also believed to be the first of its kind to be ever done where researchers go to the doctors themselves in regard to policy-making during the COVID-19 pandemic.[100]

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.[101] 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.[102]

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. 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.

A number of factors drove these reforms; 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 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. Some new services were developed to help manage demand, including NHS Direct. The Agenda for Change agreement aimed to provide harmonised pay and career progression. These changes have given rise to controversy within the medical professions, the news media and the public. The British Medical Association in a 2009 document on Independent Sector Treatment Centres (ISTCs) urged the government to restore the NHS to a service based on public provision, not private ownership; co-operation, not competition; integration, not fragmentation; and public service, not private profits.[103]

The Blair government, whilst leaving services free at point of use, encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals were built (or rebuilt) by private sector consortia; hospitals may have both medical services such as ISTCs[104] and non-medical services such as catering provided under long-term contracts by the private sector. A study by a consultancy company 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.[105]

The NHS was also required to take on pro-active socially "directive" policies, for example, in respect of smoking and obesity.

In the 1980s and 90s, NHS IT spent money on several failed IT projects. The Wessex project, in the 1980s, attempted to standardise IT systems across a regional health authority. The London Ambulance Service was to be a computer-aided dispatch system. Read code was an attempt to develop a new electronic language of health,[106] later scheduled to be replaced by SNOMED CT.

The NHS Information Authority (NHSIA) was established by an Act of Parliament in 1999 with the goal to bring together four NHS IT and Information bodies (NHS Telecoms, Family Health Service (FHS), NHS Centre for Coding and Classification (CCC) and NHS Information Management Group (IMG)) to work together to deliver IT infrastructure and information solutions to the NHS in England. A 2002 plan was for NHSIA to implement four national IT projects: Basic infrastructure, Electronic records, Electronic prescribing, and Electronic booking, modelled after the large NHS Direct tele-nurse and healthcare website program.[106] The NHSIA functions were divided into other organisations by April 2005.

In 2002, the NHS National Programme for IT (NPfIT) was announced by the Department of Health. It was widely seen as a failure, and blamed for delaying the implementation of IT in the service. Even in 2020 it appeared most of the 1.38 million NHS computers were still using Windows 7, which was released in 2009, and additional support had to be arranged by Microsoft until 14 January 2021 before the migration to Windows 10 could be completed. NHSX, the organisation set up to manage NHS information technology was supervising the migration, and has the power to impose sanctions on laggards.[107]

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"[108] as a comprehensive health information service for the public now known simply as "The NHS Website".

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 enables users to compare hospitals for treatment via a "scorecard".[109] 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,[110] which critically appraises media stories and the science behind them, was declared Best Innovation in Medical Communication in the prestigious BMJ Group Awards 2009.[111] and in a 2015 case study was found to provide highly accurate and detailed information when compared to other sources[112] In 2012, NHS England launched the NHS Apps Library, listing apps that had been reviewed by clinicians.[113]

In 2018, the NHS announced they would abandon the name NHS Choices, and in future, call the site the NHS website. This coincided with the launch of the NHS app.[114]

Eleven of the NHS hospitals in the West London Cancer Network were linked using the IOCOM Grid System in 2009. This helped increase collaboration and meeting attendance and even improved clinical decisions.[115]

Twenty-one different electronic systems were used in the NHS in England to record data on patients in 2019. These systems do not communicate well with each other so there is a risk doctors treating a patient will not know everything they need to know to treat the patient effectively. There were 11 million patient interactions out of 121 million where information from a previous visit could not be accessed. Half the Trusts using Electronic Medical Records used one of three systems and at least those three should be able to share information. A tenth of Trusts used multiple systems in the same hospital. Leigh Warren who participated in the research said, "Hospitals and GPs often don't have the right information about the right patient in the right place at the right time. This can lead to errors and accidents that can threaten patients' lives."[116]

In February 2022 Sajid Javid declared that at least 90% of NHS trusts should have electronic patient record systems by the end of 2023 and that the remaining 10% of trusts without them must be in the implementation phase by December 2023. He wants 80% of social care providers to have a digital record in place by March 2024. He also said he wanted 75% of adults in England to have downloaded the NHS App by March 2024.[117]

Information on millions of NHS patients in England was sold to international pharmaceutical companies, in the US and other nations for research, adding to concerns over USA ambitions to access remunerative parts of the NHS after Brexit. There is concern over lack of transparency and clarity over the data and how it is used. Phil Booth of medConfidential , campaigning for privacy of health data, said: "Patients should know how their data is used. There should be no surprises. While legitimate research for public health benefit is to be encouraged, it must always be consensual, safe and properly transparent. Do patients know – have they even been told by the one in seven GP practices across England that pass on their clinical details – that their medical histories are being sold to multinational pharma companies in the US and around the world?"[118]

Waiting times for routine surgery have fallen substantially since 2000. As of July 2019, the median wait for planned care in England is under 8 weeks. The number of people waiting over 12 months has fallen from over 200,000 in the 1980s to under 2000 in 2019.[119] However the number of patients on the waiting list has risen recently as constrained funding, hospital beds and staffing growth has not kept up with increasing patient need.[120]

Smoking is the greatest cause of avoidable illness and death in England, and costs the NHS £2.5 billion a year and the economy £11bn.[121] Public Health England (PHE) states that one in four hospital patients smoke tobacco products, higher than the proportion in the general population, and smoking causes 96,000 deaths per year in England and twenty times the number of smoking related illnesses. PHE wants hospitals to help smokers quit. Few patients who smoke are referred to a hospital or community based cessation programme. During their hospital stay, over a quarter of patients were not asked if they smoke and nearly three quarters of smokers were not asked if they wanted to stop. PHE states smoking patients should be offered specialised help to stop and nicotine replacement therapy. Frank Ryan, a psychologist said, "It's really about refocusing our efforts and motivating our service users and staff to quit. And of course, whatever investment we make in smoking cessation programmes, there's a payback many times more in terms of the health benefits and even factors such as attendance at work, because it's workers who smoke [who] tend to have more absent spells from work."[122] The numbers of smokers getting help to quit has fallen due to cuts in funding for smoking cessation care, though the National Institute for Health and Care Excellence recommends such help.[121]

There are many regulatory bodies with a role in the NHS, both government-based (e.g., Department of Health and Social Care, General Medical Council, Nursing and Midwifery Council),and non-governmental-based (e.g., Royal Colleges). Independent accreditation groups exist within the UK, such as the public sector Trent Accreditation Scheme and the private sector CHKS.

With respect to assessing, maintaining and improving the quality of healthcare, in common with 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 (NICE). Responsibility for assessing quality transferred to the Care Quality Commission in April 2009.

700 hospital patients suffered harm in serious incidents due to treatment delays in part of 2015–16, 1,027 hospital patients suffered similar harm in 2016-17 and this rose to 1,515 in 2017–18. Norman Lamb blames understaffing. NHS Improvement stated during 2017-18 the NHS was short of 93,000 staff, which included 10,000 doctors and 37,000 nurses.[140]