National Health Service

History

The NHS began on the 'Appointed Day' of 5 July 1948. This put into practice Westminster legislation for England and Wales from 1946 and Scotland from 1947, and the Northern Ireland Parliament's 1947 Public Health Services Act. Calls for a "unified medical service" can be dated back to the Minority Report of the Royal Commission on the Poor Law in 1909, but it was following the 1942 Beveridge Report's recommendation to create "comprehensive health and rehabilitation services for prevention and cure of disease" that cross-party consensus emerged on introducing a National Health Service of some description. When Clement Attlee's Labour Party won the 1945 election he appointed Aneurin Bevan as Health Minister. Bevan then embarked upon what the official historian of the NHS, Charles Webster, called an "audacious campaign" to take charge of the form the NHS finally took.

Three years after the founding of the NHS, Bevan resigned from the Labour government in opposition to the introduction of charges for the provision of dentures and glasses. The following year, Winston Churchill's Conservative government introduced prescription charges. These charges were the first of many controversies over reforms to the NHS throughout its history.

Each of the UK's four nations have their own separate NHS, each with its own history. NHS Scotland and Health and Social Care in Northern Ireland (HSC) were separate from the foundation of the NHS, whereas the NHS in Wales was originally combined with England until devolved to the Secretary of State for Wales in 1969 and then to the Welsh Executive and Assembly under devolution in 1999, the same year as responsibility for the Scottish NHS was transferred from the Secretary of State for Scotland to the new Scottish Government and Parliament.

From its earliest days, the cultural history of the NHS has shown its place in British society reflected and debated in film, TV, cartoons and literature.

Structure

Each of the UK's health service systems operates independently, and is politically accountable to the relevant government: the Scottish Government, Welsh Government, the Northern Ireland Executive, and the UK Government which is responsible for England's NHS. NHS Wales was originally part of the same structure as England until powers over the NHS in Wales were firstly transferred to the Secretary of State for Wales in 1969 and thereafter, in 1999, to the Welsh Assembly (now the Welsh Government) as part of Welsh devolution. However, some functions might be routinely performed by one health service on behalf of another. For example, Northern Ireland has no high-security psychiatric hospitals and thus depends on using hospitals in Great Britain, routinely Carstairs State Mental Hospital in Scotland for male patients and Rampton Secure Hospital in England for female patients. Similarly, patients in North Wales use specialist facilities in Manchester and Liverpool which are much closer than facilities in Cardiff, and more routine services at the Countess of Chester Hospital NHS Foundation Trust. There have been issues about cross-border payments.

Taken together, the four National Health Services in 2015-16 employed around 1.6 million people with a combined budget of £136.7 billion. In 2014 the total health sector workforce across the UK was 2,165,043. This broke down into 1,789,586 in England, 198,368 in Scotland, 110,292 in Wales and 66,797 in Northern Ireland.

Eligibility for treatment

UK residents are not charged for most medical treatment, with exceptions such as a fixed charge for prescriptions; dental treatment is administered differently, with standard charges for most procedures. The NHS is free at the time of use, for general practitioner (GP) and emergency treatment not including admission to hospital, to non-residents. People with the right to medical care in European Economic Area (EEA) nations are also entitled to free treatment by using the European Health Insurance Card. Those from other countries with which the UK has reciprocal arrangements also qualify for free treatment. Since 6 April 2015, non-EEA nationals who are subject to immigration control must have the immigration status of indefinite leave to remain at the time of treatment and be properly settled, to be considered ordinarily resident. People not ordinarily resident in the UK are in general not entitled to free hospital treatment, with some exceptions such as refugees.

People not ordinarily resident may be subject to an interview to establish their eligibility, which must be resolved before non-emergency treatment can commence. Patients who do not qualify for free treatment are asked to pay in advance, or to sign a written undertaking to pay, except for emergency treatment.

The provision of free treatment to non-UK-residents, formerly interpreted liberally, has been increasingly restricted, with new overseas visitor hospital charging regulations introduced in 2015.

People from outside the EEA coming to the UK for a temporary stay of more than six months may be required to pay an immigration health surcharge at the time of visa application, and will then be entitled to NHS treatment on the same basis as a resident. As of 2016 the surcharge was £200 per year, with exemptions and reductions in some cases.

Funding

The systems are 98.8% funded from general taxation and National Insurance contributions, plus small amounts from patient charges for some services. About 10% of GDP is spent on health and most is spent in the public sector.

The money to pay for the NHS comes directly from taxation. The 2008/9 budget roughly equates to a contribution of £1,980 for every man, woman and child in the UK.

When the NHS was launched in 1948 it had a budget of £437million (roughly £9billion at today’s value). In 2008/9 it received over 10 times that amount (more than £100billion). In 1955/6 health spending was 11.2% of the public services budget. In 2015/6 it was 29.7%.

This equates to an average rise in spending over the full 60-year period of about 4% a year once inflation has been taken into account. Under the Blair government investment levels increased to around 6% a year on average. Since 2010 spending growth has been constrained to just over 1% a year.

Some 60% of the NHS budget is used to pay staff. A further 20% pays for drugs and other supplies, with the remaining 20% split between buildings, equipment, training costs, medical equipment, catering and cleaning. Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas.

70% of people say they would willingly pay an extra penny in the pound in income tax if the money were ringfenced and guaranteed for the NHS. The BMA has called for £10bn more annually for the NHS to get Britain in line with what other advanced European nations spend on health. The BMA argues this could pay for at least 35,000 more hospital beds daily and many thousand more GPs. Dr Mark Porter of the BMA, wrote, “Our members report that services are truly at breaking point, with unprecedented rising patient demand met only with financial restraint and directives for the NHS and social care to make huge, unachievable savings through sustainability and transformation plans (STPs) across England.” Porter emphasised he was not asking for more than comparable nations, merely for spending of other leading European nations to be matched. The increase, Porter said was desperately needed.

Investment and efficiency

The Organisation for Economic Cooperation and Development (OECD) stated in a 2015 study that the UK had one of the worst healthcare systems among the nations looked at and that people were dying needlessly due to lack of investment in the NHS. It has been suggested that while the UK government and people are focused on Brexit, problems with the NHS are being neglected. A wide range of medical professionals consider hospital conditions in winter 2017 to have been the worst ever and worse than during corresponding periods in 2016. Hospitals are overcrowded with patients on trolleys in corridors due to lack of beds in wards. The Royal College of Nursing reported nurses claiming current conditions are the worst they have experienced. The Royal College of Physicians (RCP) asked for urgent investment to deal with "over-full hospitals with too few qualified staff". Prof Jane Dacre of the RCP, said: "Our members tell me it is the worst it has ever been in terms of patients coming in during a 24-hour period and numbers of patients coming in when there are no beds to put them in. And there are patients within the hospital who can no longer get home because of the difficulties there are in placing people in social care. Our members fear that patients' lives are at risk because they can't get round to see patients who aren't in the emergency and accident department or are waiting for results to come back." The Royal College of Radiologists also calls for increased investment. Trusts are told to make a surplus when that is not feasible, then lose funds for being in deficit.

There were 30,000 more deaths than expected in England and Wales in 2015. Peer reviewed research by the London School of Hygiene & Tropical Medicine, Oxford University and Blackburn with Darwen council was published in the Journal of the Royal Society of Medicine. The research claims the increase happened during “severe cuts” to the NHS and social care, which compromised their performance. Relevant NHS performance data was studied showing almost all targets were missed. Researchers concluded: “The evidence points to a major failure of the health system, possibly exacerbated by failings in social care.” The percentage rise in mortality was the largest in nearly 50 years and the excess was the largest in the post war period. The increase was mainly due to older people dying and older people depend more on medical and social care. There was a spike in January which it is feared could become normal. Prof Martin McKee of the London School of Hygiene & Tropical Medicine, said, "The impact of cuts resulting from the imposition of austerity on the NHS has been profound. Expenditure has failed to keep pace with demand and the situation has been exacerbated by dramatic reductions in the welfare budget of £16.7 billion and in social care spending. (...) The possibility that the cuts to health and social care are implicated in almost 30,000 excess deaths is one that needs further exploration. Given the relentless nature of the cuts, and potential link to rising mortality, we ask why is the search for a cause not being pursued with more urgency?" Prof Danny Dorling of Oxford University said, “It may sound obvious that more elderly people will have died earlier as a result of government cutbacks, but to date the number of deaths has not been estimated and the government have not admitted responsibility.” Researchers noted that the rise in deaths coincided with a rise in waiting times in A&E departments, though there were not exceptional numbers of patients in A&E. Ambulances also took longer to respond and more operations were cancelled for non-clinical reasons. More staff were absent and more posts remained unfilled. £16.7bn was cut from welfare spending and 17% was cut from spending on older people since 2009 though the numbers of old people rose nearly 9%. Both factors compounded the problems that health service austerity caused. Report co-author, Dominic Harrison of Blackburn with Darwen council, warned the research “raises a red flag that is telling us that the health and care system may have reached the limits of its capacity to safely and effectively care for the population that funds it. Our analysis suggests that the most likely cause of that failure, when all other possible explanations have been excluded, is insufficient resources and capacity”.

Intensive care beds are sometimes 100% occupied despite 85% occupancy being considered the maximum safe occupancy rate. There is a shortage of intensive care beds and of qualified staff to deal with patients in intensive care. Dr Carl Waldmann of the Faculty of Intensive Care Medicine (FICM) said, “Intensive care is at its limits in terms of capacity and struggles to maintain adequate staffing levels.” Life saving operations are being postponed due to a lack of available post-operative intensive care. Patients who need intensive care do not always get it because beds or skilled staff are not available. Patients who should be in intensive care have to wait in A&E, sometimes for many hours. Hospitals struggle to manage and patients are put at risk. Jonathan Ashworth said, “The truth is problems are getting worse and more widespread than in previous years with even life-saving cardiac, abdominal or neurosurgery operations being cancelled. Theresa May needs to get a grip of the crisis and explain what action she’s going to take to make sure that hospitals can get in place the number of staff they need to keep patients safe.”

Pathology laboratories that diagnose cancer are struggling to cope with rising demand. Many of the staff are nearing retiring age and young graduates are not joining the profession to replace them. Cancer Research UK claims similar problems exist with other diagnostic services like scans and endoscopies. Because the UK population is growing and aging more people need cancer diagnosis. Still services are not growing to meet rising demand. The 'Cancer Research UK' report also advises the Royal College of Pathologists to update guidance and study how to attract staff to train for pathology. UK cancer survival rates are below those of other European nations and earlier diagnosis would help deal with this. If nothing is done the problem will worsen. In winter 2017 cancer operations are being cancelled, sometimes at short notice due to insufficient beds. This is stressful for patients and leads to fears that a cancer will get worse.

Waiting times for routine knee and hip operations are excessively long and long waits lead to a worse outcome. Waiting times also increased for other routine operations. Waiting times more than doubled in England between 2012 and 2016 and rose significantly in Scotland, Wales and Northern Ireland. Richard Murray of the King's Fund think tank, expects numbers on waiting lists to continue rising and exceed 4 million by spring. Hospital leaders and experts in health say increased waiting times result inevitably from NHS budgets increasing less than patient demand. Emergency admissions are rising, delayed transfer of care further reduces bed availability, something must give, patients waiting for routine surgery lose out.

An editorial in The Independent stated "The National Health Service is in trouble. Statistics on ambulance response times, accident and emergency waiting times and delayed discharges, published [in 2016], are all markedly worse than over the previous year. Ambulances reached critically ill patients within the target of eight minutes less than 70% of the time in the year to June, down from 75% the previous year. The proportion of patients at accident and emergency seen within four hours fell from 92 per cent to 86 per cent. The number of days lost to delayed discharges rose by a quarter from 91,000 to 115,000." The editorial argued further that if the efficiency of the NHS does not improve, this could affect the popularity of the current government. Further almost half of hospital authorities are reducing the number of beds while a third of A&E's are due to close because of increasing hospital deficits. Total NHS deficits reached £2.4bn in 2015, the largest recorded deficit in NHS history. BMA chairman, Mark Porter, said: “The UK already has the second lowest number of hospital beds per head in Europe and these figures paint an even bleaker picture of an NHS that is at breaking point. (...) The delays that vulnerable patients are facing, particularly those with mental health issues, have almost become the norm and this is unacceptable. Failures within the social care system are also having a considerable knock-on effect on an already stretched and underfunded NHS. (...) In the short term we need to see bed plans that are workable and focused on the quality of care and patient experiences, rather than financial targets. But in the long term we need politicians to take their heads out of the sand and provide a sustainable solution to the funding and capacity challenges that are overwhelming the health service.”

Chris Hopson of NHS Providers said, “Despite doing everything they possibly can, NHS trusts are £300m behind the target of reducing the provider sector deficit to £580m by the end of March. This is largely because of winter pressures. Trusts spent more than they planned and they lost income from cancelled operations – both were needed to create the extra bed capacity to meet record emergency winter demand. This shows the danger of planning with no margin for unexpected extra demand. We can’t expect to run NHS finances on wafer thin margins year after year and keep getting away with it.”

Bob Kerslake maintains that the NHS is struggling from day to day to maintain services despite inadequate funding. Kerslake maintains the NHS needs increased funding of at least 4% per year to deal with medical advances and an aging population, he wrote "The hardest thing for governments to do is to listen and act on inconvenient advice. It is also the most important."

There are calls for an extra 10bn annually to be spent on the Health Service to match health spending in other advanced European nations. Dr Mark Porter of the BMA wrote, “Our members report that services are truly at breaking point, with unprecedented rising patient demand met only with financial restraint and directives for the NHS and social care to make huge, unachievable savings through sustainability and transformation plans (STPs) across England. We are not calling for more than other comparable nations, we are simply calling for you to match the average spending of other leading European economies. Based on our analysis of the figures available, this would, in 2015, have equated to an increase of £10.3bn for NHS funding; an increase which is desperately needed.” Porter also wrote, “The crisis currently facing the NHS and social care is well known and becoming increasingly severe – the government cannot remain a bystander any longer. An entire system under such strain is not due to frontline financial mismanagement, or individual chief executives’ poor decision making, it is due to the conscious underinvestment in our health service.”

Denis Campbell wrote in, The Guardian "A poll of 96 MPs of all parties by the Royal College of Emergency Medicine, which represents A&E doctors, has found that only 33% of them believe A&E departments have enough money and staff to provide safe care. More than six in 10 MPs believe A&E departments need more money, said the college."

Dying patients are having to wait up to 8 hours for pain relief because overworked district nurses cannot get to them promptly. A hospice manager described it as 'a frightening time for patients.' Research by the King’s Fund found district nursing and sexual health services are included in types of care most restricted through six years of the NHS getting annual budget increases of 1.2%, while its historic average was 3.7% rises. There are fewer hip replacement operations though the numbers of patients needing them is increasing due to an aging population, The operations are rationed by requiring patients to lose weight or give up smoking before having the operation. One in seven district nursing posts was lost during the two years up to 2017, the number of district nurses and resources do not match demand for services. Due to heavy work loads there are 20% vacancies for district nurses in some areas. Need to cut costs and reduced district nurses got some NHS bodies to tighten eligibility criteria for patients and refuse it for patients with serious mobility issues who are not completely housebound.

Continual policy changes and restructuring demoralise NHS staff and add to pressure on staff to leave the NHS.

Mental health services

The Public Accounts Committee claims that plans to improve mental health services have a doubtful future due to uncertainties over funding. Only a quarter of patients needing mental health services get them. Mental health services were found hard to navigate and with quality varying. Meg Hillier said, "Many people can make a full recovery from mental health problems if they receive appropriate treatment at an early stage. This is good for them and has wider benefits for the economy and society in general. It is therefore crucial that mental health is given equal priority to physical health and that service provision reflects this. (...) If [the government] is serious about achieving its aims it must also plan to secure skilled staff in sufficient numbers." Nine former health secretaries claim the government broke promises on mental health. A Guardian article cited widespread distrust that government promises to increase mental health funding were being met. Polling suggests the British public overwhelmingly support increased funding for mental health care.

Mental health services for young people are inadequate according to a poll of nurses working in that area. Shortage of resources and staff are seen as a problem and nurses have insufficient time to talk to young patients or to show patients they matter. Sarah Brennan of YoungMinds said new money promised by the government will only reach a third of those who need it. Nurses fear the need to ration care puts young people at risk of self harm and suicide. Numbers of young people admitted to hospital for self-harm are increasing. The NSPCC claims children needing help following abuse are not getting it and children need to reach rock bottom, regularly self-harming or feeling suicidal before getting help. A leaked government report showed sick children were taken “almost anywhere in the country” to be treated. Suicides are increasing. 54% of parents with children in psychiatric hospitals claim they did not improve and 24% say they got worse. Parents cannot visit as often as they would like because children are too far away. Parents are frequently not consulted over children's medication and frequently feel unable to challenge decisions over their child's treatment. Just over half parents were not confident their child was getting appropriate treatment. In the worst cases children deteriorated in inappropriate places while parents tried desperately to get the child home. Sarah Brennan finds it alarming that so many parents are dissatisfied. There are calls for a charter of rights for young patients. Patients and their families should be involved in treatment decisions. Patients should be treated with dignity and respect, restraints and seclusion should not be over used. Patients should be treated as near home as possible. Mark Lever of the National Autistic Society wants families fully involved in decisions about care decisions for their loved ones. He said, “Our joint survey with YoungMinds suggests that many parents of children and young people in mental health inpatient units feel powerless.”

When patients with mental health issues are in hospital with physical illness, hospital staff do not know how to treat them, leading to worse outcomes.

Staffing

According to the General Medical Council, many doctors experience low morale which can put patients at risk. The GMC criticised the amount of funding that the NHS receives, saying that years of constraint coupled with social care pressures were leaving services struggling to cope with rising demand. GP consultations average 10 minutes and are the shortest in Europe. Many patients need more complex care than can be delivered in 10 minutes and the aging population means the numbers of patients needing longer consultations is increasing. Plans to transfer some work now done in hospitals to GP's will increase the numbers of patients needing complex care that GP's cannot deliver under the present system and patient care may suffer. Extra funding for GP's is in the pipeline but will not become available till after hospital work has been transferred to GP's and patient care may be compromised during the time between transferring services from hospitals and providing extra funding.

According to MP Dr Dan Poulter, pressure to deal with patients prevents doctors getting necessary training and there are too few middle grade doctors in paediatrics, obstetrics and gynaecology. 38% of GP's plan to leave within five years. Junior hospital doctors reportedly face burnout and exhaustion, often work unpaid beyond their shift, and skip meals or fail to get adequate hydration during shifts. Their physical and mental health frequently suffers. “We are exhausted, frustrated and burned out. I see lapses in safety daily and, even if somebody cared, there is no money or staff to do anything about it,” a trainee anaesthetist stated. Another stated, “I have reached a point where my physical and mental health have been seriously adversely affected, and I wonder whether I’m suffering from burnout.” Unpaid overtime is common. Due to understaffing junior doctors must work extra shifts to cover for gaps in rotas. The family life of doctors suffers. Many doctors are considering leaving the profession to do alternative work with a better work-life balance, while others are considering emigrating to countries where doctors' work is less demanding. Doctors reportedly have insufficient time to train and improve skills, which will cause problems for them and for patients in the future. According to the Royal College of Physicians (RCP), the Health Service budget has not kept pace with rising demand for services and either funding must increase or care must be cut. GP's are overstretched and some patients must wait three weeks for problems which do not appear urgent like lumps or bleeding. There is concern over this because such problems can be life-threatening. There is also concern that chronic disease management may get insufficient attention because overstretched GP's are too busy dealing with acute illnesses. Maintaining GP services is considered important because if GP's fail patients are likely to overwhelm hospitals instead. Pressuring doctors to remain open 7 days a week will add to the difficulties of recruiting and retaining GP's.

4 million people were left without emergency cover during 2016 due to a shortage of doctors. Some patients needing emergency treatment were sent to A&E which is also under pressure, others were seen by less qualified staff. Many doctors have expressed concern for patient safety due to this. The Royal College of GPs wants the government to make out-of-hours work more attractive for family doctors.

There is apprehension that the numbers of medical students fell since 2010 despite patient numbers increasing. The RCP wants NHS efficiency targets overhauled, wants government goals to be realistic and wants investment in 'long-term sustainability' of the NHS. The RCP warns further that government's promise of 5,000 more GP's should not come 'at the expense of other specialties'. Prompt action is needed to counter funding and staff shortages and staff feel like 'collateral damage' when struggling over rising demand and budget shortages. Efficiency improvements can help but it is unclear for how long. Dr Andrew Goddard of the RCP said that providing more expensive treatments for increasing numbers of patients would fail. “As doctors, we see the problems this creates on a daily basis, be it at the front door of the hospital, in A&E or in out-patients. Patients can see it too and realise that the NHS is no longer the envy of the world and isn’t fit for our changing world. There are some big decisions that society has to make and the political parties have to stop blaming each other for where we are and work together to build a health and social care system that is fit for the UK in the 21st century.” The RCP maintains the NHS is living beyond its means which cannot be sustained long term. More 'training places' are needed from medical school onwards to counter staff shortages. 2 in 5 NHS doctors are from overseas, the RCP fears uncertainties over Brexit and immigration regulations render their position unpredictable. Many doctors from other nations in the EEA have said that they feel unwelcome after Brexit and are considering leaving.

The RCP reports 70% of doctors in training have a permanent gap in their work rota and 96% reported gaps in nursing rotas. Hospitals record 40% of consultant posts remain vacant. Close to 50% of consultants state they were asked to do more junior work and over 10% of junior doctors said patients were not guaranteed treatment with appropriately experienced doctors. The RCP maintains this makes the government's goal of a 7-day week unachievable.

Staff pay

Nurses' pay has not kept pace with inflation and their real pay has fallen while people wanting to become nurses lack training bursaries. Unfilled nursing vacancies rose sixfold since 2010. In 2013 over half of the 600 nurses responding to an online poll by the Nursing Times believed their ward or unit is sometimes or always dangerously understaffed. Three-quarters had witnessed poor patient care and thirty percent said poor patient care happened regularly. A spokesperson for the Royal College of Nursing commented that in the worst cases this can cause unnecessary deaths and called for clear national guidelines for safe staffing levels and said one registered nurse to eight patients was considered risky while there should be one nurse to five patients. A spokesperson for Patient Concern, a patient campaigning group, commented that the work expected of nurses was rising continually while staffing levels did not rise. The Royal College of Nursing (RCN) said nurses from Scotland to London were seriously concerned about the quality of care they could provide. 43% of A&E staff have suffered physical assaults and lack of staff increases the risk that patients will be violent.

Sustainability and transformation plans

Consultation will start over cost saving, streamlining and reduction of some services in the National Health Service. The streamlining will lead to ward closures including psychiatric ward closures and reduction in the number of beds in many areas among other changes. There is concern that hospital beds are being closed without increased community provision. See Sustainability and transformation plans in England for more.

Effect of Brexit

The plan to exit the European Community will affect physicians from EU countries, about 11% of the physician workforce. In this scenario many of these feel unwelcome and are considering leaving the UK if the Brexit would be enacted, as they have doubts that they and their families can live in the country. A survey suggests 60% are considering leaving.

Outsourcing and privatisation

Although the NHS routinely outsources the equipment and products that it uses and dentistry, eye care, pharmacy and most GP practices are provided by the private sector, the outsourcing of hospital health care has always been controversial.

According to a BMA survey over two thirds of doctors are fairly uncomfortable or very uncomfortable about the independent sector providing NHS services. The BMA believes it is important the independent sector is held to the same standards as the NHS when giving NHS care. The BMA recommends: data collection, thorough impact analysis before independent providers are accepted to ensure existing NHS services are not disrupted, risk assessment to find out likely results if NHS staff are unwilling to transfer to the private sector, transparent reporting by the private sector of patient safety and performance, independent providers should be regulated like NHS providers, patients should be protected if independent providers terminate a contract early, transfers from independent providers to the NHS should be regularly reviewed to establish how much this costs the NHS, private sector contracts should be amended so private sector providers contribute to the cost of staff training financially or by providing training opportunities.

Restraints and mental health

Face down restraints are used more often on women and girls than on men. 51 out of 58 mental health trusts use restraints unnecessarily when other techniques would work. Organisations opposed to restraints include Mind and Rethink Mental Illness. YoungMinds and Agenda claim restraints are “frightening and humiliating” and “re-traumatises” patients especially women and girls who have previously been victims of physical and/or sexual abuse. The charities sent an open letter to health secretary, Jeremy Hunt showing evidence from 'Agenda, the alliance for women and girls at risk', revealing that patients are routinely restrained in some mental health units while others use non-physical ways to calm patients or stop self-harm. According to the letter over half of women with psychiatric problems have suffered abuse, restraint can cause physical harm, can frighten and humiliate the victim. Restraint, specially face down restraint can re-traumatise patients who previously suffered violence and abuse. “Mental health units are meant to be caring, therapeutic environments, for people feeling at their most vulnerable, not places where physical force is routine.”

Government guidelines state that face down restraint should not be used at all and other types of physical restraint are only for last resort. Research by Agenda found one fifth of women and girl patients in mental health units had suffered physical restraint. Some trusts averaged over twelve face down restraints per female patient. Over 6% of women, close to 2,000 were restrained face-down in total more than 4,000 times. The figures vary widely between regions.

Some trusts hardly use restraints, others use them routinely. A woman patient was in several hospitals and units at times for a decade with mental health issues, she said in some units she suffered restraints two or three times daily. Katharine Sacks-Jones director of Agenda, maintains trusts use restraint when alternatives would work. Sacks-Jones maintains women her group speak to repeatedly describe face down restraint as a traumatic experience. On occasions male nurses have used it when a woman did not want her medication. “If you are a woman who has been sexually or physically abused, and mental health problems in women often have close links to violence and abuse, then a safer environment has to be just that: safe and not a re-traumatising experience. (...) Face-down restraint hurts, it is dangerous, and there are some big questions around why it is used more on women than men.”

Comparative performance

Although there have been increasing policy divergence between the four systems there is very little evidence linking these policy differences to a matching divergence of performance. It has been suggested that this is because of the uniform professional culture. There are national terms and conditions of employment across the UK, regulation of clinicians is performed on a UK basis and the health trades unions operate across the UK. However, it does not help that, as Nick Timmins noted "Some of the key data needed to compare performance – including data on waiting times – is defined and collected differently in the four countries."

For details see: