Healthcare in England

The NHS uses General Practitioners (GPs) to provide primary healthcare and to make referrals to further services as necessary. Hospitals then provide more specialist services, including care for patients with psychiatric illnesses, as well as direct access to Accident and Emergency (A&E) departments. Pharmacists are able prescribe medication. Community pharmacies are privately owned but have contracts with the national health service to supply prescription drugs.

The public healthcare system also provides free (at the point of service) ambulance services for emergencies, when patients need the specialist transport only available from ambulance crews or when patients are not fit to travel home by public transport. These services are generally supplemented when necessary by the voluntary ambulance services (British Red Cross, St Andrews Ambulance Association and St John Ambulance). In specific emergencies, emergency air transport is also provided by naval, military and air force aircraft of whatever type might be appropriate or available on each occasion.[4]

Dentists can only charge NHS patients at the set rates.[5] Dental care is free for patients under 18 years old (19 if still in full-time education), with certain medical conditions, on low incomes or in receipt of welfare benefits.[5] About half of the income of dentists in England comes from work sub-contracted from the NHS,[6] however not all dentists choose to do NHS work.[5]

In England, a fixed NHS prescription charge is payable for up to a three-month supply of each item (£9.35 as of April 2022), regardless of actual cost.[7] There are many exemptions from the charge, including patients under 16 years old (18 if still in full-time education), over 60, with certain medical conditions, on low incomes or in receipt of welfare benefits.[7] Permanent residents in England who are liable to pay prescription charges can purchase a Prescription Prepayment Certificate (PPC) covering all prescriptions in a specified period.[7]

When purchasing drugs, the NHS has significant market power that, based on its own assessment of the fair value of the drugs, influences the global price, typically keeping prices lower.[8] Several other countries either copy the U.K.'s model or directly rely on the country's assessments for their own decisions on state-financed drug reimbursements.[9]

The NHS is divided conceptually into two parts covering primary and secondary care with trusts given the task of health care delivery. There are two main kinds of trusts in the NHS reflecting purchaser/provider roles: commissioning trusts are responsible for examining local needs and negotiating with providers to provide health care services to the local population, and provider trusts which are NHS bodies delivering health care service. Commissioning trusts negotiate service delivery with providers that may be NHS bodies or private entities. They will be involved in agreeing major capital and other health care spending projects in their region.[10]

By far the most known and most important purchases are services including general practice physician services (most of whom are private businesses working under exclusive contract to the NHS), community nursing, local clinics and mental health service. For most people, the majority of health care is delivered in a primary health care setting. Provider trusts are care deliverers, the main examples being the hospital trusts and the ambulance trusts which spend the money allocated to them by the commissioning trusts. Because hospitals tend to provide more complex and specialised care, they receive the lion's share of NHS funding.[11]

The hospital trusts own assets (such as hospitals and the equipment in them) purchased for the nation and held in trust for them.[10] Some hospitals and trusts are affiliated with universities, like the Queen Alexandra Hospital in Portsmouth, affiliated with the University of Portsmouth.[12] University hospitals are specialty trusts with involvement in research and education.[12] Commissioning has also been extended to the very lowest level enabling GPs who identify a need in their community to commission services to meet that need. Primary care is delivered by a wide range of independent contractors such as GPs, dentists, pharmacists and optometrists and is the first point of contact for most people. Secondary care (sometimes termed acute health care) can be either elective care or emergency care and providers may be in the public or private sector, but the majority of secondary care happens in NHS owned facilities.[13]

The Care Quality Commission is an executive non-departmental public body of the Department of Health and Social Care. It was established in 2009 to regulate and inspect health and social care services in England. The CQC's stated role is to make sure that hospitals, care homes, dental and general practices and other care services in England provide people with safe, effective and high-quality care, and to encourage those providers to improve. It carries out this role through checks during the registration process which all new care services must complete, as well as through inspections and monitoring of a range of data sources that can indicate problems with services.

The Department of Health and Social Care (DHSC) is the government department responsible for government policy on health and adult social care matters in England. The department develops policies and guidelines to improve the quality of care and to meet patient expectations. It carries out some of its work through arms-length bodies (ALBs),[14] including executive non-departmental public bodies such as NHS England and the NHS Digital, and executive agencies such as Public Health England, the Office for Health Improvement and Disparities (OHID), the UK Health Security Agency and the Medicines and Healthcare products Regulatory Agency (MHRA). Health Education England is responsible for ensuring enough high-quality training is available to develop the healthcare workforce.

The NHS also conducts research through the National Institute for Health and Care Research (NIHR). The National Institute for Health and Care Excellence (NICE) is an executive body of the Department of Health and Social Care in England that publishes guidelines in the use of health technologies, the use of new and existing medicines, treatments and procedures, clinical practice (guidance on the appropriate treatment and care of people with specific diseases and conditions), guidance for public sector workers on health promotion, and ill-health avoidance guidance for social care services. These appraisals are based primarily on evidence-based evaluations of efficacy, safety and cost-effectiveness in various circumstance.[15]

The NHS is the world's largest health service and the world's fourth-largest employer.[16]

The NHS Constitution for England establishes the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with responsibilities, which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively. The Secretary of State for Health and Social Care, all NHS bodies, private and voluntary sector providers supplying NHS services, and local authorities in the exercise of their public health functions are required by law to take account of the constitution in their decisions and actions.

The NHS is founded on a common set of principles and values that bind together the communities and people it serves – patients and public – and the staff who work for it. Seven key principles guide the NHS.[17][18]

• The NHS provides a comprehensive service, available to all
• Access to NHS services is based on clinical need, not an individual’s ability to pay
• The NHS aspires to the highest standards of excellence and professionalism
• The patient will be at the heart of everything the NHS does
• The NHS works across organisational boundaries
• The NHS is committed to providing best value for taxpayers’ money
• The NHS is accountable to the public, communities and patients that it serves

A patient needing specialist care at a hospital or clinic, will be informed by the GP of the hospitals where they can get their treatment.[19] This choice usually includes public and private hospitals. The NHS will pay for treatment in a private setting if the hospital meets the cost and service criteria that NHS hospitals adhere to. Otherwise opting for a private hospital makes the patient liable for private hospital fees. Because the private sector often has higher costs, most people choose to be treated for free in an NHS hospital. If the GP judges the case to be extremely urgent, the doctor may by-pass the normal booking system and arrange an emergency admission. The median wait time for a consultant led first appointment in English hospitals is a little over 3 weeks.[20]

Patients can be seen by the hospital as out-patients or in-patients, with the latter involving overnight stay. The speed of in-patient admission is based on medical need and time waiting with more urgent cases faster though all cases will be dealt with eventually. Only about one third of hospital admissions are from a waiting list. For those not admitted immediately, the median wait time for in-patient treatment in English hospitals is a little under 6 weeks.[20]

Trusts are working towards an 18-week guarantee that means that the hospital must complete all tests and start treatment within 18 weeks of the date of the referral from the GP. Some hospitals are introducing just in time workflow analysis borrowed from manufacturing industry to speed up the processes within the system and improve efficiencies.[21]

Almost all NHS hospital treatment is free of charge along with drugs administered in hospital, surgical consumables and appliances issued or loaned. However, if a patient has chosen to be treated in an NHS hospital as a private fee paying patient by arrangement with his consultant, the patient (or the insurance company) will be billed. This can happen because at the inception of the NHS, hospital consultants were allowed to continue doing private work in NHS hospitals and can enable private patients to "jump the NHS queue". This arrangement is nowadays quite rare as most consultants and patients choose to have private work done in private hospitals.

Emergency Department (traditionally known as Accident and Emergency) treatment is also free of charge. A triage nurse prioritises all patients on arrival. Waiting times can be up to 4 hours if a patient goes to the Emergency Department with a minor problem or may be referred to other agencies (e.g. pharmacy, GP, Walk in clinic). Emergency Departments try to treat patients within 4 hours as part of NHS targets for emergency care. The Emergency Department is always attached to an NHS general hospital. Private hospitals do not provide emergency care services.

The NHS also provides end of life palliative care in the form of Palliative Care Specialist Nurses. The NHS can also commission the expertise of organisations in the voluntary sector to complement palliative care. Such organisations include Marie Curie Cancer Care, Sue Ryder Care and Macmillan Cancer Support. Despite their names, these services are designed for all palliative conditions, not exclusively cancer. All palliative care services provide support for both the patient and their relatives during and after the dying process, free of charge to the patient.

Although the NHS has a high level of popular public support within the country, the national press is often highly critical of it and 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 they received. 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.[22]

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''.[22] The reason for this disparity between personal experience and overall perceptions is clear. The wait times for specialty service are rising.[23] The survey also showed that net satisfaction with NHS services (the number reporting satisfied less those reporting dissatisfied) was generally higher amongst NHS services users than for all respondents (users as well as non-users). Where more people had no recent experience of that service, the difference in net positive perception reported by users compared to non-users was more likely to diverge.[22]

For example, the least used service surveyed was walk-in centres (only 15% of all persons surveyed had actually used an NHS Walk in clinic in the last year) but 85% of walk in clinic users were satisfied with the service they received. Users' net positive satisfaction was 80%. However, for all respondents (including non-recent users) the overall net positive satisfaction was just 25%. The service with the highest rate of use was the GP service (77% having seen their GP in the last year) and the difference in net satisfaction between users and all users was the smallest (76% and 74% net satisfied respectively).[22]

It is also apparent from the survey that most people realise 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).[22] 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).[22]

Most people think that the NHS is well run, with 73% of people reporting that they are satisfied with the running of the service and only a little over 10% reporting themselves as dissatisfied.[24]