Healthcare in England

Healthcare in England is mainly provided by the National Health

Service (NHS), a public body that provides healthcare to all
permanent residents in England, that is free at the point of use. The
body is one of four forming the UK National Health Service as
health is a devolved matter; there are differences with the provisions The Royal Hospital Chelsea is a
for healthcare elsewhere in the United Kingdom, and in England it retirement home and nursing home,
is overseen by NHS England.[1] Though the public system founded by King Charles II in 1682
dominates healthcare provision in England, private health care and as a retreat for veterans.
a wide variety of alternative and complementary treatments are
available for those willing and able to pay.

The Secretary of State for Health and Social Care is a senior minister of the Crown within the Government
of the United Kingdom, and leads the Department of Health and Social Care with responsibility for
England's NHS. The Secretary serves as the principal adviser to the Prime Minister of the United Kingdom
on all health matters.[2]

National Health Service

The NHS is free at the point of use for the patient though there are charges associated with eye tests, dental
care, prescriptions, and many aspects of personal care.

The NHS provides the majority of healthcare in England, including primary care, in-patient care, long-term
healthcare, ophthalmology and dentistry. The National Health Service Act 1946 came into effect on 5 July
1948. Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is
used by less than 8% of the population, and generally as a top-up to NHS services. Recently there have
been some examples where unused private sector capacity has been used to increase NHS capacity and in
some cases the NHS has commissioned the private sector to establish and run new facilities on a sub
contracted basis. The involvement of the private sector remains relatively small and according to one survey
by the BMA , a large proportion of the public oppose such involvement.[3]

Common features

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 to 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. 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.[8]

Funding and management

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
Royal London Hospital, a large
agreeing major capital and other health care spending projects in
teaching hospital. The hospital's roof-
their region.[9] top helipad is the London's Air
Ambulance operating base.
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.[10]

The hospital trusts own assets (such as hospitals and the equipment in them) purchased for the nation and
held in trust for them.[9] Some hospitals and trusts are affiliated with universities, like the Queen Alexandra
Hospital in Portsmouth, affiliated with the University of Portsmouth.[11] University hospitals are specialty
trusts with involvement in research and education.[11] 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.[12]
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),[13] 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.[14]

The NHS is the world's largest health service and the world's fourth-largest employer.[15]

NHS Constitution

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.[16][17]

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

Patient experience
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.[18] 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.[19]

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.[19]

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.[20]

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.

Experiences, perceptions and reporting of the NHS

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.[21]
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''.[21] The reason for this disparity between personal experience and overall perceptions is clear. The
wait times for specialty service are rising.[22] 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.[21]

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).[21]

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).[21] 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).[21]

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.[23]

Royal colleges
Medical royal colleges are professional bodies in the form of a royal college responsible for the
development of and training in one or more medical specialities. They are generally charged with setting
standards within their field and for supervising the training of doctors within that speciality, although the
responsibility for the application of those standards. Most medical royal colleges are members of the
Academy of Medical Royal Colleges (AoMRC).[24]

The royal colleges are involved with international activities to improve health through education and
training.[25] The Royal College of General Practitioners has been actively involved on an international level
to help family medicine doctors have access to "contextually relevant training and development
programmes".[26] Medical colleges can seek royal patronage and permission to use the prefix royal, usually
also having a royal charter.[27]

Professional bodies in England include:

Royal College of Anaesthetists

Royal College of Emergency Medicine
Royal College of General Practitioners
Royal College of Nursing
Royal College of Obstetricians and Gynaecologists
Royal College of Ophthalmologists
Royal College of Paediatrics and Child Health
 Royal College of Pathologists
Royal College of Physicians
Royal College of Podiatry
Royal College of Psychiatrists
Royal College of Radiologists
Royal College of Surgeons of England
Royal College of Veterinary Surgeons

Medical associations
The British Medical Association (BMA) is a registered trade union for doctors in England.[28] The BMA
has a range of representative and scientific committees and is recognised by National Health Service
employers as the sole contract negotiator for doctors. The BMA's stated aim is "to promote the medical and
allied sciences, and to maintain the honour and interests of the medical profession".[29]

The Royal Society of Medicine (RSM) is one of the major providers of accredited postgraduate medical
education in England. Each year, the RSM organises over 400 academic and public events.[30] The RSM is
home to one of the largest medical libraries in Europe,[31] with an extensive collection of journal and online
medical databases. As well as providing medical education, the Society aims to promote an exchange of
information and ideas on the science, practice and organisation of medicine, both within the health
professions and with responsible and informed public opinion.[32]

The Royal College of Physicians (RCP) is a professional membership body dedicated to improving the
practice of medicine, chiefly through the accreditation of physicians by examination. Founded by royal
charter from King Henry VIII in 1518, the RCP is the oldest medical college in England. It set the first
international standard in the classification of diseases, and its library contains medical texts of great
historical interest.[33] There are many medical associations and national specialist societies in England,
promoting knowledge, science, and healthcare research.[34]

Medical schools
Medical schools generally refer to departments within a universities
which are involved in the education of future medical practitioners.
All leading medical schools in England are state-funded and their
core purpose is to train doctors on behalf of the National Health
Service. In England students generally begin medical school after
secondary education. Medical schools can also carry out medical
research and operate teaching hospitals.[35][36]

There are thirty four medical schools in the United Kingdom that
are recognised by the General Medical Council and where students
can study for a medical degree.[35] Applications for entry into
GKT School of Medical Education is
medical school (in common with other university courses) are made
the medical school of King's College
through the Universities and Colleges Admissions Service
London.
(UCAS).[36] Such medical degrees include the Bachelor of
Medicine, Bachelor of Surgery (MBBS, MBChB, MBBCh,
BMBS).[36]
Most medical schools in England also require applicants to sit additional entrance tests such as the
Universities Clinical Aptitude Test (UCAT) (required by 26 universities) and the BioMedical Admissions
Test (BMAT) (required by 5 universities). The number of available medical school places had risen by
3,500 since 1998.[37]

Examples of medical schools include Barts and The London School of Medicine and Dentistry, Brunel
Medical School, UCLan School of Medicine, University of Exeter Medical School, Edge Hill University
Faculty of Health, Social Care & Medicine, Plymouth University Peninsula Schools of Medicine and
Dentistry, Imperial College School of Medicine, Sheffield Medical School and King's College London
School of Medicine and Dentistry.

Private provision
England has a small private health care sector. Private health care is sometimes funded by employers
through medical insurance as part of a benefits package to employees though it is mostly the larger
companies that do. Insurers also market policies directly to the public. Most private care is for specialist
referrals with most people retaining their NHS GP as point of first contact.

The private sector does some subcontracting work for the NHS. Thus an NHS patient can be treated in the
private sector as an NHS patient if the health services has subcontracted work to the hospital. Some private
hospitals are business enterprises and some are non-profit-making trusts. Some hospital groups provide
insurance plans (e.g. Bupa, Benenden), and some insurance companies have deals with particular private
hospital groups. Some private sector patients can be treated in NHS hospitals in which case the patient or
his/her insurance company is billed.

The Care Quality Commission, after inspecting more than 200 private sector hospitals, warned in April
2018 that informality in processes meant that systematic and robust safety procedures were not in place.
Hospital consultants are generally not employed by the private hospitals where they have admitting rights
and the commission said private companies could be reluctant to challenge them. Safety was viewed as the
responsibility of individual clinicians, rather than a corporate responsibility supported by formal governance
processes. Furthermore, private hospitals "were not set up to anticipate and handle emergency situations".
There were only 15 critical care services across 206 hospital sites so in an emergency they had to rely on
the 999 service.[38]

See also
England portal

Medicine portal

Healthcare in the United Kingdom

History of the National Health Service
List of NHS trusts
List of hospitals in England
NHS app

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0319024417/http://www.gmc-uk.org/education/medical_school_reports_full_list.asp).
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