NHS England
The UK National Health Service was put in place by the post-war Labour government. Its purpose was to provide medical care and treatment free at the point of use for the entire population. It was originally run centrally but was decentralised substantially in the 1980s and 1990s. It now comprises various parts which interact between particular boards that purchase services and providers who provide them.
Greater patient choice has been introduced, and attempts have been made to introduce competition.
Local clinical commissioning groups led by general practitioners and other community-based professionals commission healthcare for patients from NHS Trusts, comprising hospitals and other facilities or groups of them. NHS England is a national umbrella body that commissions healthcare services to ensure that they are available.
The Health Services Act followed from the Beveridge Report. The National Insurance Act of 1911 provided insurance against sickness and unemployment. Switch this around #[01:39]. The Beveridge Report was commissioned by the wartime government to look into social insurance and services.
The NHS is funded by taxes and, to a much lesser extent, by an NHS element of national insurance. There are also elements of charges for prescriptions, treatment, as well as miscellaneous other sources.
Until the 1980s, all employees were employed directly by the government, the NHS itself. Since the reforms of the last 30 years, general practitioners are largely self-employed. Many hospital doctors are also self-employed and move between different hospitals.
Certain services are outsourced, including canteen, catering, cleaning, security. Treatment is increasingly outsourced to external providers.
In the 1980s, governments focused on reducing costs and increasing efficiency in the National Health Service. 1980s reports recommended that management should be devolved to district areas with the then Department of Health and Social Services doing the role of directing, funding to hospital and GP care. It emphasized community-based care with primary care providers having their own budgets and commissioning services on behalf of patients, independent of — without having to go through the HSA, without health authorities.
1988 legislation created the internal and internal market, separated the Department of Social Security from the Department of Health.
The National Health Service and Community Care Act made hospitals and other care providers into NHS trusts with their own managing boards with both clinical staff and managers. General practitioners could opt out of District Health Authority and control their own funding. Fund holders, District Health Authorities, and Family Health Service Authorities were effectively purchasers of patient care from the NHS.
GP practices were the first point of call. Family Health Service Authorities purchased community services, and District Health Authorities purchased hospital facilities. The treatment process was service providers to the purchasers.
Family practices with more than 5000 patients (4000 Northern Ireland) could opt into being fund holder statuses. Significant numbers of additional managers were employed, largely from the private sector. Less than half the GP practices opted to become funds holding. The effect of the changes was to create a disparity in treatments available due to demographic health needs in differing areas.
The Labour government attempted to establish national service frameworks to harmonize the level of health service. However, the position remained that different processes, treatments were available depending on the particular authority’s needs and perceptions of priorities. Systems were made, and certain types of treatment were rationed arbitrarily.
Waiting lists grew during relative financial austerity in the mid-90s, becoming a priority for the incoming 1997 Labour government.
Very significant public investment followed during the 1997 to 2008 period. The percentage GDP expenditure on health increased by more than a third by 2010.
The internal market was modified by local management and budgetary control with many of the similar characteristics of the internal market. The Health Act of 1999 followed a white paper on the NHS, emphasizing community-based care where possible to avoid congestion and unnecessary hospital treatment. GPs and other primary health care providers were given considerable freedom and autonomy to offer treatment in their practices.
Primary care groups sought to bring together general practitioners, community nurses, and other practitioners who used funds on a more coordinated basis. As with fund-holding practices, they retained control of their budgets and established trusts like boards to make financial decisions.
Primary care trusts were the local bodies, administrative bodies covering populations of more than 100,000 purchasing services on behalf of patients from NHS trusts, commissioning/purchasing. They assumed responsibility for 4/5 of the budget. The coalition government’s Health and Social Care Act effectively reversed primary healthcare trust, and gave commissioning/purchasing directly to general practitioners.
Under the Labour reforms, the District Health Authorities became a much smaller number of strategic health authorities, and HS trusts remained as providers who could gain by providing services on a competitive basis in accordance with lead tables. Some trusts became foundation trusts, giving greater autonomy. This was available to all trusts under coalition reforms.
Accordingly, the providers are the strategic health authorities and primary care trusts. Providers are the NHS trusts, including foundation trusts. In 2006, the number of primary care trusts was halved to 150, expanding to populations of up to half a million. They were ultimately abolished by the coalition government. But by the Labour tenure, there were 168 acute trusts and 73 mental health trusts, covering 1600 hospitals and specialist health units. In 2011, the strategic health authorities were merged into four clusters, regional clusters, effectively managing the NHS in those areas.
The Health Secretary was given power under Labour reforms to set standards and targets for strategic health authorities and primary care trusts.
National Service Frameworks were established in 1998 as strategic agreements to provide for consistency of care. There are national service frameworks and strategy covering 10 key priority conditions, including cancer, heart disease, diabetes.
The number of framework agreements was reduced to nine by the coalition government and is subject to further review. The agreements have increased elements of patient choice, which is argued to undermine the harmonization approach. Strategic health authorities were abolished in 2013.
The national Institute of Health and Care Excellence, formed in 1999, approves treatments and drugs for NHSEs, promotes public health, and ensures higher-quality healthcare. It advises on priority in terms of new types of treatment procedures, drugs, etc.
In Scotland and Wales, the internal market has been largely abandoned with a more centralized NHS funding, Health Boards.
Foundation trusts were overseen by an independent regulator, monitor. It regulates competition between foundation trusts.
The Health and Social Care Act 2012
The Health and Social Care Act 2012 acquired GPs, abolished primary care trusts, and passed their commissioning roles to GPs. GP clinical commissioning groups were to purchase services. The GPs could not opt out. The legislation incentivized foundation trusts to form not-for-profit companies independent of the NHS. They could generate their own revenue by charging customers, in addition to providing traditional free healthcare.
The coalition government required 20 billion in savings and administration while pledging the key, maintain real increases in expenditure.
In 2012, a healthcare authority was put into administration, largely due to accumulated debt arising from private fund-financed initiative contracts. It was argued that the new regulator Healthwatch would have power to scrutinize for business judgments.
NHS England was established to act at the center of the healthcare market.
The coalition government has sought to move towards an insurance-based system under which trusts would seek business from willing providers, and the private or voluntary sectors can argue that this could lead to cherry-picking by international providers, which would then lead to more difficult or simple procedures leaving more complex and costly cases to the NHS. It was argued that these CCGs needed to replace the private care trust by hiring managers and consultants. The legislation (the more extreme of the above proposals were modified in accordance with legislation in 2011), and the legislation provided for a duty to provide a comprehensive National Health Service, following was the structure that has emerged from the 2012 Act.
Clinical commissioning groups have replaced private care trusts which are led by GPs and others. They involve collaborations between healthcare professionals at the community level.
NHS England was responsible for commissioning primary care and ensuring the maintenance of appropriate services at the national and regional level. It uses clinical senates to provide advice on commission plans and networks to advise on integration of local services.
Councils have replaced the strategic health authorities as the main entity in promoting health improvement and overall health service provisions in their areas. Their quality assurance role now covers all healthcare providers whether in the voluntary or private sectors. County Councils may scrutinize the provision of healthcare through committees or other arrangements approved by the department.
Health and well-being boards have been formed by the upper tier of councils in England and binding commissioners of health and social care, representatives of Healthwatch. Boards include elected members of Councils.
The Quality Care Commission regulates standards of health and social care through all providers. The monetary issues and licenses registered health providers. It looks for efficiency and seeks to ensure and set prices for treatment and competition works in the patient’s interest. Care must be based on quality and not price.
Public Health England is an agency of the Department of Health and funds public health initiatives across England. Councils receive ring-fence budgets for public health service.
NHS Trust Development Authority established to convert remaining trusts to foundation status.
Health Education England is responsible for overseeing the training of health professionals.
Commissioning Boards and the NHS Commissioning Board and Clinical Commissioning Board, the Commissioner purchases services from the NHS trusts, foundation trusts, and any qualified third-party provider. This encompasses public-private partnership, and wholly private provision.
A Chief Inspector of Hospitals has been established in 2013/14 following reporting high-profile incidents in hospitals. They sought to hold the hospitals accountable by making finance and unannounced inspections and requiring measures to deal with failures in health provision. The CQC promotes improvement in health service and reviews complaints. It is necessary to make complaints in the first instance is to the NHS body, subject of the complaint. It may impose fines, enforcement notices, and withdraw registrations. Function is performed in Northern Ireland by the Regulation and Quality Improvement Authority.
The Council’s health service scrutiny committees scrutinize the provision of local NHS services. They are operated by the top-level local authority. It includes local and district Council representatives as well as representatives of prominent national bodies in the area of childcare, mental health, and age.
The Care Act 2014 allows the health secretary and trust special administrators appointed powers to downgrade and close facilities if [neighboring] trusts are in financial difficulties.
A formal complaint may be made internally to the Ombudsman in relation to unsatisfactory NHS care. There is one Ombudsman in each of England, Scotland, Wales, and Northern Ireland. The Northern Ireland Ombudsman acts in Northern Ireland.
Each Ombudsman produces an annual report to the Assembly or Parliament regarding standards and failures of performance, maladministration, failures in the exercise of clinical judgment.
Management of the NHS is devolved to the national assemblies, including the Northern Ireland Assembly. The annual budget of NHS is €100 billion.