National Health Service in Great Britain

1 Description of the National Health Service

The National Health Service is under the control of the Minister of Health, who is advised by a central health services council made up of 41 persons, 35 of whom are appointed by the Minister himself, selected from the various groups dealing with the care of the sick. The NHS is administered by the civil servants of Whitehall-this is important to remember-and it is divided into three sections. The first one is the hospital services, the second is the medical practice services and the third is public health.

The hospital services control all the hospitals in Great Britain with the exception of a very few denominational hospitals. The whole country is divided into 14 regions arranged around one or more medical schools and administered by the regional hospital boards. These regional boards, 25% of whose membership are physicians, are responsible for all consultans' and registars' appointments in the hospital. Each hospital in turn is controlled by a hospital management committee. The 36 teaching hospitals are under the control of boards of governors which are independent of the regional hospital boards. Each hospital must submit in September its budget for the year commencing the following March and must return to the Treasury any unspent money. This makes planning extremely difficult and complicated and invariably results in the complete expenditure of all funds in order to avoid a smaller allocation the following year.

To the second section of the medical practices committee belong to the general practice of medicine which includes the general practitioner, the dentist, the oculist and the druggist. The section controlled by 163 local executive councils, which succeeded the national insurance committees, is responsible for personal medical services. There are at present in GB about 19,000 physicians for a population of 45 millions which is a proportion of one physician per 2,300 people.

In the third section of the public health service we find the health centres, the various clinics for pre-natal care, for school children, for vaccination, for immunization, for tuberculosis and for rehabilitation.

At the present time it should be pointed out that the medical services are not entirely free since the patient has to make a weekly contribution to the national insurance system and has to pay a certain fraction of the cost of the prescriptions, dentures, glasses, trusses and other medical accessories. About 95% of the medical profession receive their income through governments cheques. Almost all the hospitals and sanatoria belong to the government and the whole NHS is ultimately controlled by civil servants of the Ministry of Health. It is estimated that about 92-95% of the population in England is now under the NHS.

2 Cost of the National Health Service

The individual weekly contribution to the national insurance system varies between 35 cents for an unemployed person under 18 to $1.25 for a worker whose employer pays half of its amount. Less than 10% of the total contributions to the national insurance system or about $100 million went to the division of the NHS in the years 1950-1951. Since the total cost of the NHS in those years was 1.2 billion dollars, it means that 92% of the total cost oh NHS had to come from the general taxation moneys. This represents about 3.5% of the total government revenue, about 22% of the expenses of the national insurance system and about $27.00 per head of population.

One of the cornerstones of the NHS was intended to be the creation of health centres throughout the country. At the present time, because of the lack of money and the enormous cost of the other services, it has only been possible to build one or two. Each of these centres which would provide general medical, dental and public health services for a population of about 20,000 persons under the local health branch of the NHS would cost about $450,000. Such a centre would include six general practitioners, two dentists and one or two health officers. On this basis, greater London alone would need about 450 such centres.

3 Free services and contributory services

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 organization 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 organization, 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 penalized 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.

As of April 2009[update] the prescription charge for medicines was ?7.20(which contrasts with Scotland at ?4.00 and 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.

The good points of the NHS

a) The main part of medical research in England depends on the Medical Research Council which is a government body, free of political influence. The characteristics of medical research in England are that the greatest part of the funds available come from one central body which is the MRC, that most of the work done under its grants is of good to superior quality and there is a minimum of useless duplication.

b) Medical care costs very little to the individual and there is no question that the public is satisfied.

c) The previously full time physicians in the hospitals receive a better income than before and are given the importance they deserve. Many of them are happy about the change.

d) The out-patient departments are given greater importance and better organization.

e) The most competent section of the medical profession, professors, consultants, and top research workers are given more importance than formerly in the advisory committees, in the organization and the development of the service.

f) It appears that that the British doctors have a reasonable income and are much happier in comparison with the rest of English society.

Weak points of the NHS

a) One of the most important failures of the NHS lies in its artificial administrative division into the three branches of the hospital services, general medical services, and public health, without any integration at any level. There is very little relationship between the consultant in the hospitals, the general practitioner and the public health officer. This often leads to misunderstanding and mutual ignorance. In the end it is the patient who suffers in this artificial no man's land between the three divisions.

b) Animal experimentation is under the control of the civil servants of the Home Office, who sometimes has little or no knowledge of hospital problems, medical care or of medical research. Any experimentation involving the use of animal requires a written application to the Home Office. Permission is usually given without difficulty but still there are exceptions.

c) The private charitable and the voluntary welfare associations have been chocked and replaced by the cold, slow and impersonal machinery of the various government bodies.

d) Since the actual number of young physicians prepared for consultants' posts is too great there is strong competition for these, as well as competition between consultants for the special awards, with all the unwelcome features attendant on these struggles.

e) Because of the number of certificates required and the impersonal character of hospital care, professional secrecy and discretion are in many instances things of the past.

f) Surgeons are paid by operating sessions and receive the same payment whether they do one appendectomy per operating session or four gastrectomies.

g) In the care of the aged, tuberculous patients, the chronically sick, the infirm and the patients with infected tonsils the situation is so bad that there is a waiting period of non-urgent cases of 6 months to 2 years before admission to the hospital and during that time the patient becomes a burden on the general practitioner.

In summary, the main weaknesses of the NHS consist of:

1) The lack of unity between the three divisions of general practice, public health, hospital services and consultants;

2) The excessive demands for services of the general practitioners which render them unable to give the necessary time to cases which deserve close attention;

3) The isolation of the general practitioners from hospitals, the long waiting list in all hospitals for non-urgent cases, and the lack of facilities for the aged and chronically sick patients.

References

1) National Health Service Act, 1946, 9&10 Geo.6 Ch.81, H.M. Stat Off-

Amendment-1949,12,13,14, Geo.6 Ch.81

Amendment-1951,14,15, Geo.6 Ch.31

2) Beveridge Report on “Social Insurance and Allied Services”, H.M. Stat. Off.,1942, Cmd 6404

3) Green, F.H.K.:Science,116:99, 1952

4) Peterson, O.L.: “A study of the National Health Service of Great Britain”,1951