The Healthcare System of the United Kingdom Lecture 5 Tracey Lynn Koehlmoos, PhD, MHA HSCI 609 Comparative International Health Systems

Aneurin Bevan Minister of Health 1946 “No society can legitimately call itself civilized if a sick person is denied medical aid because of a lack of means.” Aneurin Bevan Minister of Health 1946

The United Kingdom Population: 59 million Capitol: London Includes: England, Northern Ireland, Scotland and Wales Government: Constitutional Monarchy

UK: Updated Information Population: >60 million in 2006 Life Expectancy: 76.1 male/ 81.1 female Infant Mortality: 5.06 per 1000 (2006) Population over 60: 20.8% GDP for healthcare: 7.7% (2002) Per capita health expenditure: $2,031 (US)

Talking about the UK… The United Kingdom consists of England, Scotland, Wales and Northern Ireland Great Britain consists of England, Scotland, and Wales Northern Ireland has its own National Health Service We will not include Northern Ireland in the remainder of our discussion.

Health System Overview National Health Service Act 1948—based on Beverage Report and the belief in post-World War II solidarity. British NHS: National Health Service, first comprehensive, nationalized healthcare program. Highly centralize management and finance Patients choose their provider Providers can have public & private practices

Structural Changes to NHS Secretary of State for Health Department of Health (NHS) Strategic Health Authorities (like RHA’s) Primary Care Trusts (like DHA’s) Hospitals: NHS Trust (semi-independent) This represents a strong move toward internal market competition—more like managed care

Strategic Health Authorities 28 Strategic Health Authorities since 2002 to manage the local NHS. Responsible for: Local health service planning Monitoring quality Increasing the capacity of local health services Priority service integration - for example, programs for improving cancer services Strategic Health Authorities manage the NHS locally and are a key link between the Department of Health and the NHS.

Primary Care Trusts The center of the NHS, control 80% of the total NHS budget PCTs are responsible for: Assessing the health needs of the local community. Commissioning the right services, for instance from GP practices, hospitals and dentists. Improving the overall health of their local communities. Ensuring access to services Monitor interaction of social and healthcare organizations. Annual assessment of GP practices in their area. Buy and monitor services There are more than 300 PCTs covering all parts of England since April 2002, which report directly to their local Strategic Health Authority.

Private Market 12% of Britons have Supplementary Insurance--an employment perk Doctors & hospitals treat both public and private patients Private insurance pays for dental, vision, some prescription drugs (although 80% of all prescription drug payments are waived due to age, pregnancy, youth, poverty)

Economic Factors Revenues Expenditures 83% NHS funding from taxes 13% from employer-employee contributions 4% User fees Expenditures NHS accounts for 88% of health expenditures Private Insurance (SI) 4% of expenditures ~3/4 of NHS budget goes to workforce salaries 1/10th of NHS budget goes for drugs

Management Central authority for national health planning, budgeting and legislation. Distribution of funds and delegation of planning to Strategic Health Authorities Administration (streamlined compared to previous set-ups) is vital to success of the new system—emphasis on strategic planning, evaluation, budgeting and internal market competition.

Health Services Workforce More than 1 million employees, largest single employer in Europe MD’s: 2.1 per 1000 pop (low #) (OECD 2002) General Practitioners (GPs): 60% GPs handle 90% of episodic care; gatekeepers GPs paid by mix of capitation, salary, fees Specialists are hospital based, called “Consultants.” Specialists/Hospitalists are salaried All MD’s can have public and private practices

Health Services Workforce Nurses largest group within NHS staff 40% of NHS budget Nurses are trained specialist (child, MH) Work closely with GPs in the community Hospital nurses, much dissatisfaction salaries, working conditions, work load. Nursing shortage NHS is actively recruiting Indian, Spanish and Philippine nurses to make up for shortages in the field.

Hospitals More than 2000 public or NHS trust hospitals About 300 private/surgical procedure facilities

NHS Trusts (Hospitals) Emergency and planned hospital treatment Hospitals in the NHS are managed by NHS Trusts . Their wide-ranging services are commissioned – or purchased - on behalf of patients by Primary Care Trusts (PCTs) and include treatments where patients are admitted to hospital, day surgery and out-patient services where patients attend consultations and clinics. NHS Trusts employ most of the NHS workforce: consultants, doctors, nurses, hospital dentists, pharmacists, midwives and health visitors, managers and IT specialists, physiotherapists, radiographers, podiatrists, speech and language therapists, dieticians, counselors, occupational therapists and psychologists. Hospital treatment is arranged through a GP, except emergencies. Appointments and treatment at NHS hospitals are free.

NHS Foundation Trusts New type of NHS hospital run by local managers, staff and members of the public. Only the highest performing hospitals can apply to become NHS Foundation Trusts – a status which gives them much more freedom in running their services than other NHS Trusts. The creation of Foundation Trusts illustrates the shift of decision-making power to frontline-staff and the local communities they serve. However, Foundation Trusts remain firmly within the NHS and its framework of standards.

Long Term Care Community Care Act of 1990 reduced government role to only covering nursing services (unless indigent) Most LTC takes place in private sector Private, supplemental LTC ins is available State Equity Release Scheme From October 1 2001 a permanent resident in a care home in England need not sell their own home to fund their long term care fees.

Current Issues in the UK Aging population High cost of advanced technology and its impact on tight budgets Increased incidence of serious and expensive to treat diseases (cancer, HIV/AIDS) On-going problems with long queues and rationing

Compared to US Single payer system Surgeries and new technologies underused New efforts to decrease UK waiting times All access system US, 44 million uninsured, no access Tremendous cost control and access but a definite lack of quality compared to US

Summary National Health Service Centralized, publicly financed system Cradle-to-Grave care (except LTC!) for all citizens Largest employer in Europe