National Health Service (England)

Organization

There is no unified British NHS; the National Health Service in Scotland and Northern Ireland were always separate, and NHS Wales passed to the control of the devolved Welsh Government in 1999. In 2009 NHS England agreed a formal NHS constitution which sets out the legal rights and responsibilities of the NHS, its staff, and users of the service and makes additional non-binding pledges regarding many key aspects of its operations.

The Health and Social Care Act 2012 came into effect in April 2013, giving GP-led groups responsibility for commissioning most local NHS services. Starting in April 2013 Primary Care Trusts (PCTs) are being replaced by General Practitioner (GP) -led organisations called Clinical Commissioning Groups (CCGs). Under the new system, a new NHS Commissioning Board, called NHS England, oversees the NHS from the Department of Health. The Act has also become associated with the perception of increased private provision of NHS services. In reality, the provision of NHS services by private companies long precedes this legislation, but there are concerns that the new role of the healthcare regulator ('Monitor') could lead to increased use of private sector competition, balancing care options between private companies, charities, and NHS organisations. NHS Trusts are responding to the "Nicholson challenge" which involved making £20 billion in savings across the service by 2015.

Some NHS organisations are using referral management centres to help reduce inappropriate referrals in an attempt to save the NHS money. Millions of pounds have been spent for these services, 32% of which are provided by private companies, since 2013. Of the 211 clinical commissioning groups (CCGs) surveyed by the British Medical Journal (BMJ) in 2016, 184 responded and 72 of those said they had used such schemes. Of those CCGs using these services, 14% could show savings, 12% showed no overall savings and 74% could not show whether money had been saved. Because these services can prevent GPs from referring patients to hospitals, there are some concerns they may delay diagnosis and compromise patient safety.

History

Dr A. J. Cronin's controversial novel The Citadel, published in 1937, had fomented extensive debate about the severe inadequacies of health care. The author's innovative ideas were not only essential to the conception of the NHS, but in fact, his best-selling novels are said to have greatly contributed to the Labour Party's victory in 1945.

A national health service was one of the fundamental assumptions in the Beveridge Report. The Emergency Hospital Service established in 1939 gave a taste of what a National Health Service might look like.

Healthcare prior to the war had been an unsatisfactory mix of private, municipal and charity schemes. Bevan decided that the way forward was a national system rather than a system operated by local authorities. He proposed that each resident of the UK would be signed up to a specific General Practice (GP) as the point of entry into the system, building on the foundations laid in 1912 by the introduction of National Insurance and the list system for general practice. Patients would have access to all medical, dental and nursing care they needed without having to pay for it at the time.

In the 1980s, Thatcherism represented a systematic, decisive rejection and reversal of the Post-war consensus, whereby the major political parties largely agreed on the central themes of Keynesianism, the welfare state, nationalised industry, public housing and close regulation of the economy. There was one major exception: the National Health Service, which was widely popular and had wide support inside the Conservative Party. Prime Minister Margaret Thatcher promised Britons in 1982, the NHS is "safe in our hands."

On 13 November 2011 the government signed off on the 10-year contract to manage the debt-laden Hinchingbrooke Hospital in Huntingdon, Cambridgeshire by Circle Healthcare. It was the first time that management of an NHS hospital was to be taken over by a stock-market listed company.

There have been documented failures of some parts of the National Health Service to provide adequate care at a basic level. These failures were associated with bureaucratic fumbling as local institutions attempted to meet conflicting demands with inadequate resources. This notwithstanding, the NHS has received consistently strong approval and support from citizens.

Core principles

The principal NHS website states the following as core principles:

The NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth. At its launch by the then minister of health, Aneurin Bevan, on 5 July 1948, it had at its heart three core principles:

These three principles have guided the development of the NHS over more than half a century and remain. However, in July 2000, a full-scale modernisation programme was launched and new principles added.

The main aims of the additional principles are that the NHS will:

Structure

The English NHS is controlled by the UK government through the Department of Health (DH), which takes political responsibility for the service. Resource allocation and oversight was delegated to NHS England, an arms-length body, by the Health and Social Care Act 2012. NHS England commissions primary care services (including GPs) and some specialist services, and allocates funding to 211 geographically-based Clinical Commissioning Groups (CCGs) across England. The CCGs commission most services in their areas, including hospital and community-based healthcare.

A number of types of organisation are commissioned to provide NHS services, including NHS trusts and private sector companies. Many NHS trusts have become NHS foundation trusts, giving them an independent legal status and greater financial freedoms. The following types of NHS trusts and foundation trusts provide NHS services in specific areas:

Some services are provided at a national level, including:

Staffing

Nearly all hospital doctors and nurses in England are employed by the NHS and work in NHS-run hospitals, with teams of more junior hospital doctors (most of whom are in training) being led by consultants, each of whom is trained to provide expert advice and treatment within a specific speciality. From 2017 NHS doctors will have to reveal how much money they make in private practise.

General Practitioners, dentists, optometrists (opticians) and other providers of local health care are almost all self-employed, and contract their services back to the NHS. They may operate in partnership with other professionals, own and operate their own surgeries and clinics, and employ their own staff, including other doctors etc. However, the NHS does sometimes provide centrally employed health care professionals and facilities in areas where there is insufficient provision by self-employed professionals.

Nurses who are nationals of other EU nations are leaving the NHS in large numbers because their ability to live and work in the UK after Brexit has not been guaranteed. The mass exodus is damaging the NHS.

Note that due to methodological changes, these figures are not directly comparable.

A 2012 analysis by the BBC estimated that the NHS across the whole UK has 1.7 million staff, which made it fifth on the list of the world's largest employers (well above Indian Railways). In 2015 the Health Service Journal reported that there were 587,647 non-clinical staff in the English NHS. 17% worked supporting clinical staff. 2% in cleaning and 14% administrative. 16,211 were finance staff.

The NHS plays a unique role in the training of new doctors in England, with approximately 8000 places for student doctors each year, all of which are attached to an NHS University Hospital trust. After completing medical school, these new doctors must go on to complete a two-year foundation training programme to become fully registered with the General Medical Council. Most go on to complete their foundation training years in an NHS hospital although some may opt for alternative employers such as the armed forces.

Most staff working for the NHS including non-clinical staff and GPs (most of whom [GP's] are self-employed) are eligible to join the NHS Pension Scheme which, from 1 April 2015, is an average-salary defined-benefit scheme.

2011 reforms

The coalition government's white paper on health reform, published in July 2010, sets out the most significant reorganisation of the NHS in its history. The white paper, Equity and excellence: liberating the NHS, has implications for all health organisations in the NHS and very significant changes for PCTs and strategic health authorities. It aims to shift power from the centre to GPs and patients, moving somewhere between £60 to £80 billion into the hands of groups of GPs to commission services. The new commissioning system was expected to be in place by April 2013, by which time SHAs and PCTs should have been abolished.

Following widespread criticism of the plans, in April 2011, the Government announced a "pause" in the progress of the Health and Social Care Bill to allow the government to 'listen, reflect and improve' the proposals.

The bill became law in March 2012 with a government majority of 88 and following more than 1,000 amendments in the House of Commons and the House of Lords.

Funding

The total budget of Department of Health in England in 2013/14 was £110 billion. £13.8 billion was spent on medicines. The National Audit Office reports annually on the summarised consolidated accounts of the NHS.

The commissioning system

From 2003 to 2013 the principal fundholders in the NHS system were the NHS Primary Care Trusts (PCTs), that commissioned healthcare from NHS trusts, GPs and private providers. PCTs disbursed funds to them on an agreed tariff or contract basis, on guidelines set out by the Department of Health. The PCTs budget from the Department of Health was calculated on a formula basis relating to population and specific local needs. They were supposed to "break even" - that is, not show a deficit on their budgets at the end of the financial year. Failure to meet financial objectives could result in the dismissal and replacement of a Trust's Board of Directors, although such dismissals are enormously expensive for the NHS.

From April 2013 a new system was established as a result of the Health and Social Care Act 2012. The NHS budget is largely in the hands of a new body, NHS England. NHS England commission specialist services and primary care. Acute services and community care is commissioned by local Clinical Commissioning Groups which are led by GPs.

Services free at the point of use

The vast majority of NHS services are free at the point of use.

This 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 or other diagnostic services. Hospital inpatient and outpatient services are free, both medical and mental health services. Funding for these services is provided through general taxation and not a specific tax.

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

Eligibility for NHS services is based on having ordinary resident status. This will include overseas students with a visa to study at a recognised institution for 6 months or more, but not visitors on a tourist visa for example. From April 2015 onwards there is an immigration health surcharge applied to most visa applications, the proceeds of which will go directly to funding the NHS. The surcharge amount will either be £150 or £200 in respect of each year of the visa's duration, to be paid in full by the migrant when the visa application is submitted.

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 organisation 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 organisation, 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 penalised 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.

Prescription charges

As of April 2015 the NHS prescription charge in England was £8.20 for each quantity of medicine (which contrasts with Scotland, Wales and Northern Ireland where items prescribed on the NHS 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 charges.

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.

NHS dentistry

Where available, NHS dentistry charges as of April 2015 were: £18.80 for an examination; £50.30 for a filling or extraction; and £222.50 for more complex procedures such as crowns, dentures or bridges. As of 2007, less than half of dentists' income came from treating patients under NHS coverage; about 52% of dentists' income was from treating private patients.

NHS Optical Services

From 1 April 2007 the NHS Sight Test Fee (in England) was £19.32, and there were 13.1 million NHS sight tests carried out in the UK.

For those who qualify through need, the sight test is free, and a voucher system is employed to pay for or reduce the cost of lenses. There is a free spectacles frame and most opticians keep a selection of low-cost items. For those who already receive certain means-tested benefits, or who otherwise qualify, participating opticians use tables to find the amount of the subsidy.

Where vouchers do not cover the cost of the selected product, they reduce the cost at their face value. Although these voucher values are the maximum amounts that opticians can recover from the NHS, they might well make additional marketing offers of their own. See the external site Optical Voucher Values for a full NHS listing that includes varifocals, contact lenses, and essential coatings.

Injury cost recovery scheme

Under older legislation (mainly the Road Traffic Act 1930) a hospital treating the victims of a road traffic accident was entitled to limited compensation (under the 1930 Act before any amendment, up to £25 per person treated) from the insurers of driver(s) of the vehicle(s) involved, but were not compelled to do so and often did not do so; the charge was in turn covered by the then legally required element of those drivers' motor vehicle insurance (commonly known as Road Traffic Act insurance when a driver held only that amount of insurance). As the initial bill was sent to the driver rather than to his/her insurer, even when a charge was imposed it was often not passed on to the liable insurer; it was common for no further action to be taken in such cases as there was no practical financial incentive (and often a financial disincentive due to potential legal costs) for individual hospitals to do so.

The Road Traffic (NHS Charges) Act 1999 introduced a standard national scheme for recovery of costs using a tariff based on a single charge for out-patient treatment or a daily charge for in-patient treatment; these charges again ultimately fell upon insurers. This scheme did not however fully cover the costs of treatment in serious cases.

Since January 2007, the NHS has a duty to claim back the cost of treatment, and for ambulance services, for those who have been paid personal injury compensation. In the last year of the scheme immediately preceding 2007, over £128 million was reclaimed.

Car park charges

Car parking charges are a minor source of revenue for the NHS, with most hospitals deriving about 0.25% of their budget from them. The level of fees is controlled individually by each trust. In 2006 car park fees contributed £78 million towards hospital budgets. Patient groups are opposed to such charges. (This contrasts with Scotland where car park charges were mostly scrapped from the beginning of 2009 and with Wales where car park charges were scrapped at the end of 2011.)

Charitable funds

There are over 300 official NHS charities in England and Wales. Collectively, they hold assets in excess of £2bn and have an annual income in excess of £300m. Some NHS charities have their own independent board of trustees whilst in other cases the relevant NHS Trust acts as a corporate Trustee. Charitable funds are typically used for medical research, larger items of medical equipment, aesthetic and environmental improvements, or services which increase patient comfort.

In addition to official NHS charities, many other charities raise funds which are spent through the NHS, particularly in connection with medical research and capital appeals.

Regional lotteries were also common for fundraising, and in 1988, a National Health Service Lottery was approved by the government, before being found to be illegal. The idea continued to become the National Lottery.

Financial outlook

As each division of the NHS is required to break even at the end of each financial year, the service should in theory never be in deficit. However, in recent years overspends have meant that, on a 'going-concern' (normal trading) basis, these conditions have been consistently, and increasingly, breached. Former Secretary of State for Health Patricia Hewitt consistently asserted that the NHS would be in balance at the end of the financial year 2007-8; however, a study by Professor Nick Bosanquet for the Reform think tank predicted a true annual deficit of nearly £7bn in 2010.

Under the austerity programme of the Cameron governments expenditure on the NHS, which had risen fairly steadily since 1950, was restricted. According to the King's Fund the "unprecedented squeeze on public spending and rising demand for services" left it "facing the most significant financial challenge in its history". £20 billion in productivity improvements were called for. Jeremy Hunt, in February 2016, denied that austerity was affecting the NHS, saying that 2016-7 would see the sixth biggest increase in funding (£3.8 billion) for the NHS in its entire 70-year history. However expenditure as a percentage of Gross Domestic Product had fallen, and was predicted to fall further, as was the UK's place among OECD nations' health expenditure. 95% of NHS hospital trusts were in deficit at the end of 2015, and the collective deficit for NHS providers was expected to be at least £3 billion by the end of the financial year.

The NHS in England experienced record overspending of £2.45 billion in 2015 and the head of NHS providers, Chris Hopson claimed the NHS is asked to provide too much for too little money. According to Clare Marx, president of the Royal College of Surgeons, balancing the books requires "draconian policies" that frequently go against clinical guidelines including those from the National Institute for Health and Care Excellence (NICE).

Between 2008 and 2009, owing to a sharp drop in Gross Domestic Product (GDP), health spending rose as a proportion of GDP from 8.5% to 9.1%. Since 2009, GDP has steadily increased again, resulting in health spending falling back as a proportion of GDP There were complaints that the Chancellor's 2016 ] to 8.8% by 2013. 'NHS Providers' maintains that the NHS in England needs extra funding to cope with an ageing population. Performance has declined over the last few years [before 2016] by most measures and without extra funds, many argue that the service will deteriorate further. Funding increases will fall from 3.8% in 2016 to 1.4% in 2017 and to 0.3% in 2018 while NHS demand and costs rise by at least 4% annually. 80% of hospitals are in financial deficit, as opposed to 5% in 2013. Ambulance response targets were missed 14 months running. A Guardian article suggested there is a strong case for the 7 day service but without extra funding it is unachievable. Without extra funding the NHS in England will according to The Guardian be forced to make unpopular and unpalatable choices. Possibilities include draconian rationing, charging patients, reducing priorities, or limiting the workforce. Chris Ham of the King's Fund think tank said, "It is simply not realistic to expect hard-pressed staff to deliver new commitments like seven-day services while also meeting waiting time targets and reducing financial deficits." Dr David Wrigley of the BMA Council said, "It is good to hear about some new investment into general practice but I am concerned seven-day routine working is being rolled out when GPs struggle to provide a good five-day service, Monday to Friday, due to the years of under investment. We are short of thousands of GPs across the country and this new seven-day plan will seek to stretch my colleagues even more thinly across the week."

John Appleby, chief economist of the King's Fund claims NHS spending could certainly increase. He argues that it needs a political choice to raise taxes, cut spending elsewhere or to reduce the deficit more slowly, and that blaming the NHS in England for choices they have to make through lack of funds is considered unreasonable.

Frail patients are staying in hospital longer than would otherwise be necessary because the care they need in the community is not available. This can prevent new patients being admitted and operations have been cancelled due to beds being taken up by patients who could leave hospital with proper care elsewhere. Long hospital stays reduce the chances elderly patients can be rehabilitated. Age UK blamed cuts to social care for creating a situation where elderly patients end up in A & E and also blamed lack of social care for requiring patients to stay unnecessarily long in hospital. The situation has worsened due to cuts in government financial support for local authorities which caused social care for elderly people to fall 17% between 2009/10 and 2013/14. Frail patients turn up at A&E who with better social care could cope at home. In July 2016 the time patients spent in hospital waiting for care in the community reached 61,000 days which was up from 33,000 days In July 2014. This adds to the costs and pressure on the NHS. In January 2017 record numbers spent longer than 4 hours waiting in A&E and record numbers waited over 12 hours for a hospital bed after being seen at A&E. Over 60,000 people waited from four to 12 hours for a hospital bed. And over 780 waited more than 12 hours. Dr Tajek Hassan of the Royal College of Emergency Medicine said: “The [four-hour] target is a very sophisticated metric of the overall system and the thermostat is set red hot in the emergency department. (...) The international evidence shows that the more crowded your emergency departments are the higher the risk of dying. Delays to assessment will compromise your care.” Chris Hopson of NHS Providers said, “NHS staff have responded magnificently to increased winter pressures, but the situation has become unsustainable. The rise in long trolley waits is particularly worrying, as there is clear evidence they can lead to worse outcomes for patients.”

In the Vale of York clinical commissioning group in North Yorkshire, obese patients will be barred from most routine operations, notably hip and knee operations for a year (or if they lose 10% of their body weight), while smokers will face a six-month delay unless they quit. The move was described by the head of NHS Providers as an effort by the group "to balance their books". There are fears similar measures will be introduced elsewhere and rationing will become the NHS norm. A critic felt leaving patients waiting in pain longer than clinically necessary should be unacceptable. Denying obese patients life changing surgery without offering help losing weight was compared to racial or religious discrimination by Shaw Somers, a bariatric surgeon from Portsmouth. Limits are being imposed throughout the NHS for cataracts, knee and hip operations, overweight people and smokers are denied some treatments in most NHS authorities. A spokesman for NHS England said: “Major surgery poses much higher risks for severely overweight patients who smoke. So local GP-led clinical commissioning groups are entirely right to ensure these patients first get support to lose weight and try and stop smoking before their hip or knee operation. Reducing obesity and cutting smoking not only benefits patients but saves the NHS and taxpayers millions of pounds. This does not and cannot mean blanket bans on particular patients such as smokers getting operations, which would be inconsistent with the NHS constitution." Patients in several West Midlands areas, Bromsgrove, Reddish, South Worcestershire and Wyre Forest will be denied NHS knee and hip replacements unless pain prevents them sleeping at night or they are unable to do ordinary daily activities. Severely obese patients will have to lose 10% of their body mass before surgery unless their clinical condition is severe. The Royal College of Surgeons maintains there is no clinical justification for this but it should reduce operations by about 350 a year and cut costs. Stephen Cannon of the Royal College of Surgeons says the scoring system used, "should not be used to create barriers to care". Cannon also said, “There’s going to be a postcode lottery. It is absolutely iniquitous that you have this sort of system.” Cannon wants to see extra funding rather than rationing, he said further, “While the CCGs have stated they hope this policy will save them £2m a year, it is unclear whether they have considered the costs of not treating a patient. This could include the cost of pain relief medication and a later operation when the patient does meet the required pain and weight thresholds. Delaying access to surgery also adversely affects a patient’s quality of life and surgical outcomes, meaning the operation may not be as beneficial as if it had been carried out earlier.” Philippa Roxby, BBC health reporter fears rationing hip and knee replacements will become increasingly common. Harrogate, Shropshire and the south coast of Kent are making similar restrictions.

At a British Medical Association (BMA) conference (the doctors' union), a conference at which some of the contributions may have been politically motived according to the BBC, the NHS in England has been described by some senior medical professionals as overstretched, underfunded and understaffed. Nigel Edwards of Nuffield Trust stated, "the NHS has never experienced this level of austerity for this long a period". Edwards questioned whether planned £22 billion of efficiency savings were fully achievable. UK health spending is a lower proportion of UK economic output than the European average. The BMA argue that overworked and underfunded general practitioners have insufficient time to assess and properly treat patients with complex needs.

The Guardian health policy editor suggests that understaffing forces hospitals to rely on agency staff who are much more expensive and this expense is the main reason the NHS overspent. He believes that experts argue the NHS has insufficient funds to care for the ageing population and the increased numbers of patients with chronic health trouble like diabetes, depression, heart and respiratory issues which leads to steady increases in demand for NHS services. In April 2016 he reported that NHS staffing levels had been overestimated and without increases in staff the pressure on the NHS will continue. In response to this report, Labour's shadow health secretary argued that "Hospital wards are already dangerously understaffed and morale in the NHS is at rock bottom. This is impacting on patient care and leaving some staff so overstretched they are unable to complete basic tasks, such as changing dressings or checking patients have finished their meals."

Before the 2015 General election, the government promised £8.4 billion extra for the NHS in England by 2020-21. This promise was repeated by David Cameron and George Osborne many times while they were still in office. Despite this, a report by the House of Commons Health Select Committee showed that some of the extra £8.4 billion will be found from taking money from elsewhere in the health budget. For example, money for staff recruitment and training has been moved to a different fund. Staff training has been cut and the money saved will go towards the £8.4 billion. Since staff training is now in a different fund the cut may be overlooked. The report found the transfer of funds that were cut misleading as these other funds finance services that matter for patient care, for preventing sickness and for training the future workforce. According to the report, there will only be a £4.5bn increase in total health spending in England by 2020-21. The committee expressed concern that the transfer of resources from capital budgets, health education, public health and other areas will make ambitions stated in the Forward View, (the NHS blueprint for its modernisation by 2020) much harder to achieve and fails to meet the government's stated commitments. Anita Charlesworth of the Health Foundation agreed with the report and argued that cuts to health education and public health are shortsighted. There are fears of a return to the way the NHS was in the 1990s when hospitals were overcrowded and some patients had to wait years for treatment.

Autumn Statement

There were complaints that the Chancellor's 2016 Autumn Statement did not include extra funding for the NHS and did not even mention the NHS despite a looming funding crisis. Luciana Berger said in the Commons “There is actually not one single mention in the 72-page Autumn Statement document of the words NHS, social care, mental health, and public health. The Chancellor cannot ignore the fact that our health and social care services are in crisis, facing massive, massive deficits, and surely the many economists in his department will have told him that it’s economically illiterate to ignore the massive decrease in people receiving social care in the community and the cuts to public health and NHS staff training.” There was no boost to funding for social care in England and the number of patients fit to leave hospital who stay because social care cannot be arranged for them rose markedly. Many health think tanks and leaders of the medical profession described the Autumn Statement as a missed opportunity. The Royal College of Emergency Medicine fears government inaction on the NHS could risk lives. A National Audit Office report emphasised financial pressure on the NHS suggesting problems were, "endemic and not sustainable". The NAO confirmed highest level tensions in Whitehall. John McDonnell claimed NHS spending per head is falling for the first time in NHS history. The government claim of adequate funding was contradicted by requests from NHS England and Health Servicer leaders. The NAO concluded, "Confronted as NHS England is by the pressures of rising demand for services, these signs of differences do not help build a confident feel about the future of the NHS."

Investment, funding and efficiency

Between 2008 and 2009, due to a sharp drop in Gross Domestic Product (GDP), health spending rose as a proportion of GDP from 8.5% to 9.1%. Since 2009, GDP has steadily increased again, resulting in health spending falling back as a proportion of GDP to 8.8% by 2013. 'NHS Providers' maintains that the NHS in England needs extra funding to cope with an ageing population. Performance has declined over the last few years [before 2016] by most measures and without extra funds, many argue that the service will deteriorate further. Funding increases will fall from 3.8% in 2016 to 1.4% in 2017 and to 0.3% in 2018 while NHS demand and costs rise by at least 4% annually. 80% of hospitals are in financial deficit, as opposed to 5% in 2013. Dr Chaand Nagpaul of the British Medical Association GP's committee accused the government of scapegoating GP's over the Health Service crisis. Nagpaul said: “The UK spends less on health and has fewer doctors and beds per head than other leading countries (...) the government should take responsibility for a crisis of its own making and outline an emergency plan to get to grips with the underlying cause [of pressure on hospitals], which is the chronic under-resourcing of the NHS and social care.” Nagpaul, also spoke of a “major alert”, with eight out of 10 practices complaining they could not ensure safe care, and one out of three havinging unfilled vacancies. “We have got a very serious problem that we don’t have the capacity in general practice. The crisis in the NHS won’t be solved by scapegoating or deflecting blame on to GPs,”

Four out of five English hospital trusts compromise patient safety and standards vary widely between hospitals and even between deepartments in the same hospital. There are pockets of poor care in otherwise good hospitals. Part of the reason is that hospitals are understaffed and overcrowded with staff under unprecedented pressure. There are delays in getting tests and life-threatening conditions like sepsis are poorly managed. 70% of hospitals needed improvement. Too many beds are routinely occupied meaning oveercrowding. Waits for operations like knee and hip replacement are too long. There are too few nurses in medical and geriatric wards, too few midwives in maternity wards and too few doctors in A&E. Temporary escalation wards operating during busy periods are mainly staffed by agency nurses unfamiliar with the hospital system. Infections are poorly controlled. Equipment is badly maintained and out of date medicines are used. Hospital chief inspector Prof Sir Mike Richards said "The scale of the challenge that hospitals are now facing is unprecedented - rising demand coupled with economic pressures are creating difficult-to-manage situations that are putting patient care at risk. During winter 2016-17, hospitals have faced ever-increasing demand for urgent and emergency services and the continuing challenges of delays in discharging patients to community and social care services.” The Care Quality Commission reported 81% of non-specialist trusts were considered inadequate or needed better safety standards and 11% got the lowest safety rating, none were rated outstanding. More emergency services were rated inadequate than were rated good or outstanding because A&E services were struggling with increased demand. Alan Taman, of Keep Our NHS Public and Doctors for the NHS asked, “How many years of cuts, cloaked in the coy term ‘efficiency savings’ did the government think it would take to put lives at serious risk? And how many lives will be taken before the truth is faced?”

Ambulance response targets were missed 14 months running. When ambulances reach hospital the patients too often have to wait with the ambulance staff for over an hour because overstretched A&E staff cannot take over. This decreases the number of ambulance crews available to deal with new calls as well as delaying patients getting the care they need from trained hospital staff. Waiting times in A&E were worse in 2017 than any time since 2014. Ambulance paramedics are leaving the profession because they find the work too stressful, shifts can overrun by two hours and meal breaks can be missed. There is further a national shortage of trained paramedics. This adds to pressure on remaining staff and adds to delays in ambulance response times which can be problematic for patients whose lives are in danger. In many hospitals patients regularly must wait in corridors. Medical examinations happen in corridors without sufficient privacy. Doctors and other medical staff are overworked, risk burnout and patients' lives are at risk. Pressure of work can damage the health of NHS staff. Also staff feel bad because they cannot give patients the care NHS staff feel patients should get due to lack of resources. Sick children need attention quickly because they can deteriorate fast. At one point there was not an intensive care paediatric bed free in the whole of London which was worrying. In the first week of January 2017 485 patients had to wait on trolleys for over 12 hours and that is more than 3 times the number over the whole of January 2016. During the same period there were over 18,000 trolley waits of 4 hours or more. During the first week of January 2017 overcrowding became dangerously high in many hospitals, 95% of hospital beds were occupied, many patients were in corridors and 40% of hospitals needed to issue an alert. Targets for the numbers of A&E patients seen within 4 hours were widely missed. The second week in January 2017 was even busier with 95.8% of beds occupied while 85% is considered safe. With more than 85% bed occupancy hospitals cannot so easily prevent potentially deadly infections and cannot so easily deal with emergencies. During the winter 2016-2017 BBC research showed 9 in 10 English Hospital Trusts were overcrowded above the 85% level leading to risk of infection and delays in patients being treated. Frail patients stayed in hospital longer than necessary due to lack of care for them in the community.

Dr Chris Moulton, of the Royal College of Emergency Medicine, stated to the BBC: “Patients who are delayed like this are still being monitored by staff. But we know that the overcrowding we are seeing is dangerous. It leads to worse outcomes for patients – higher infection rates, patients ending up on the wrong wards, and generally a negative experience. (...) We simply don’t have enough [beds]. If you compare us to other European countries we are really short and the demands being placed on the health service means we are now struggling to cope.” Chris Moulton also said, "While increasing numbers of doctors is vital, the more pressing problem is a lack of beds. We simply do not have any more room to put patients - we have the lowest number of acute beds per capita in Europe. As a result, bed occupancy is at dangerous levels and exit block is putting lives at risk."

South East Coast Ambulance Service is under severe financial pressure and faces a £7.1 million deficit. Ambulance crews in the area will no longer be paid to interrupt meal breaks and attend to some types of emergencies. Patients with breathing problems, car crash victims, patients with chest pains, seizures strokes among others face delayed response times. Critics fear this will put lives at risk and worsen outcomes for some surviving patients. Jon Ashworth blamed government financial pressure on the Health Service. Critics complain money is prioritised over patient care.

There is increasing reliance on private ambulance firms to deal with emergencies despite concern that their staff may be less well trained than NHS ambulance crews. Private ambulances are expensive and it is argued money would be better spent making the work of NHS ambulance crews more attractive so fewer leave the profession.

Help and counseling for smokers wanting to stop is being discontinued for the majority in many areas of England. Smokers wanting to stop are subject to a postcode lottery. This is considered a false economy as the NHS will later have to pay to treat diseases and complications that smoking brings on.

A Guardian article suggested there is a strong case for the 7 day service but without extra funding it is unachievable. Without extra funding the NHS in England will according to The Guardian be forced to make unpopular and unpalatable choices. Possibilities include draconian rationing, charging patients, reducing priorities, or limiting the workforce. Chris Ham of the King's Fund think tank said, "It is simply not realistic to expect hard-pressed staff to deliver new commitments like seven-day services while also meeting waiting time targets and reducing financial deficits." John Appleby, chief economist of the King's Fund claims NHS spending could certainly increase. He argues that it needs a political choice to raise taxes, cut spending elsewhere or to reduce the deficit more slowly, and that blaming the NHS in England for choices they have to make through lack of funds is unreasonable.

Improved mental health funding makes economic sense as it enables people with mental health problems to become more productive workers. The King's Fund found that 40% of English Mental Health Trusts experienced budget cuts in 2015-16. Money promised for children's mental health services is not reaching frontline services and instead is being used to offset cuts elsewhere. According to the Education Policy Institute 'Independent Commission on Children and Young People's Mental Health', young people still struggle to get psychiatric help. 23% of children and young people referred to mental health services are turned away due to "high thresholds" to access services. A report claimed, "something has to go drastically wrong before some services will intervene". Young English people with eating disorders are sent hundreds of miles away to Scotland because the services they need are not available locally. Being away from friends and family compromises their recovery. There are concerns that not enough is being done to support people at risk of taking their own lives. The numbers attending A&E due to psychiatric problems rose by 50% between 2011 and 2016 and reached 165,000 in that year. Patients are suffering psychiatric crises due to lack of earlier intervention. It is suspected that yet more psychiatric cases are recorded as something else like self-harm or attempted suicide. Some trusts claim 10% of A&E cases are psychiatric. Patients attending A&E due to psychiatric problems have not benefited from early intervention due to years of underfunding. Young people do not get early help and problems escalate. There are calls for increased provision of in patient psychiatric services and community psychiatric services because otherwise patients will be failed, sometimes with tragic results. A&E is stressful and far from ideal for people in a mental health crisis but many patients in mental distress, some suicidal have nowhere else to go.

Frail patients are staying in hospital longer than would otherwise be necessary because the care they need in the community is not available. This can prevent new patients being admitted and operations have been cancelled due to beds being taken up by patients who could leave hospital with proper care elsewhere. Targets for improving care outside hospital to prevent bedblocking are in most cases missed. 193,680 days were lost in November 2016 through bedblocking according to official figures and official figures underestimate the real problem. Nigel Edwards of the Nuffield Trust said: “Our audits show that up to two-thirds of the patients stuck unnecessarily in hospital beds aren’t actually being counted in the official figures.” Discharge from hospital can be delayed for months, even for over a year due to lack of appropriate care in the community. Long hospital stays reduce the chances elderly patients can be rehabilitated. Patients who stay too long in hospital can become more ill as a result and care at home is better tailored to their needs. Age UK blamed cuts to social care for creating a situation where elderly patients end up in A & E and also blamed lack of social care for requiring patients to stay unnecessarily long in hospital. The situation has worsened due to cuts in government financial support for local authorities which caused social care for elderly people to fall 17% between 2009/10 and 2013/14. In July 2016 the time patients spent in hospital waiting for care in the community reached 61,000 days which was up from 33,000 days In July 2014. This adds to the costs and pressure on the NHS. Patients staying longer than needed in hospital due to problems with the next stage of health or social care rose by more than a quarter in 2016. The Health Foundation, the King's Fund and the Nuffield Trust published a warning that cuts in social care funding cause "significant human and financial costs on older people, their families and carers" and keeps people "stranded in hospital". The British Medical Association claims bedblocking in A&E in 2017 is the worst ever. Delay in social care assessments strand patients in hospital without care packages for when they leave.

Sending patients home early is also problematic. Janet Davies of the Royal College of Nursing (RCN), complained frontline nurses want to give the best care to patients but had to discharge them before they were fit to free up beds. Mike Adamson of the Red Cross said: "The British Red Cross is on the front line, responding to the humanitarian crisis in our hospital and ambulance services across the country. We have been called in to support the NHS and help get people home from hospital and free up much needed beds. We've seen people sent home without clothes, some suffer falls and are not found for days, while others are not washed because there is no carer there to help them." Patients who ideally should stay a few days longer for observation or rehabilitation are discharged to free beds for patients with greater need. Pressure on beds is delaying patients getting treatment and it is suspected this may have caused deaths. Dr Taj Hassan of the Royal College of Emergency Medicine, spoke of an "absolute and urgent need" to help emergency departments. Hassan added, "We entered this winter [2016-2017] in the worst state of affairs possible, staff are working at the very limit of their capabilities." The Nuffield Trust said 50 hospital trusts had announced they were under severe pressures, compromising patient flow and in 7 cases pressure prevented hospitals giving comprehensive care. Mary Muldowney, 57, died of a brain haemorrhage. She needed fairly urgent surgery but several neurosurgical units contacted had no free beds. When a neurosurgical unit eventually agreed to admit her she could not be saved. A coroner found earlier surgery would probably have saved Muldowney.

Dr Mark Holland of the Society for Acute Medicine, said: “For a long time we have been saying that the NHS is on the edge. But people dying after long spells in hospital corridors shows that the NHS is now broken. We have got to the point where the efforts of staff to prop up the system are no longer enough to keep the system afloat. We are asking NHS staff to provide a world-class service, but with third world levels of staffing and third world levels of beds. Holland fears avoidable deaths may have occurred and may occur in the future due to pressure on hospitals. Lack of beds in wards suited to a patient's needs lead to that patient being admitted to less suitable wards where the staff lack the ideal skills for that patient. Hassan and Holland blamed government under-funding of the NHS and social care for contributing to hospitals becoming excessively full.

Cuts to contraceptive services risk increasing unplanned pregnancies and abortions. Former Chancellor, George Osborne cut the public health budgets which fund contraception by £200 million. Roughly a third of women in England live in places with restricted contraceptive services. The Family Planning Association (FPA) found that only 2% of GP's supply all contraceptive methods. 53% have insufficient time during standard contraceptive appointments to give all information women need. Natika Halil of the FPA claimed local authorities are, "between a rock and a hard place when faced with cuts. It's a false economy to restrict women's access to contraception. Every £1 spent on contraception saves £11 in averted health costs."

In the Vale of York clinical commissioning group in North Yorkshire, obese patients will be barred from most routine operations, notably hip and knee operations for a year (or if they lose 10% of their body weight), while smokers will face a six-month delay unless they quit. The move was described by the head of NHS Providers as an effort by the group to "to balance their books". There are fears similar measures will be introduced elsewhere and rationing will become the NHS norm. A critic felt leaving patients waiting in pain longer than clinically necessary should be unacceptable. Denying obese patients life changing surgery without offering help losing weight was compared to racial or religious discrimination by Shaw Somers, a bariatric surgeon from Portsmouth. Limits are being imposed throughout the NHS for cataracts, knee and hip operations, overweight people and smokers are denied some treatments in most NHS authorities. A spokesman for NHS England said: “Major surgery poses much higher risks for severely overweight patients who smoke. So local GP-led clinical commissioning groups are entirely right to ensure these patients first get support to lose weight and try and stop smoking before their hip or knee operation. Reducing obesity and cutting smoking not only benefits patients but saves the NHS and taxpayers millions of pounds. This does not and cannot mean blanket bans on particular patients such as smokers getting operations, which would be inconsistent with the NHS constitution."

There have been some improvements in cancer care but too many patients are waiting too long for diagnosis and treatment. Radiologists, specialist nurses and other key staff are in short supply. Increased investment is insufficient to meet the rise in the number of cancer patients.

English hospitals cancelled 4,093 urgent procedures in 2016, 8% above the 3,777 cancelled in 2015 and 27% above the 3,216 such operations cancelled in 2014. The vast majority of cancellations were through lack of beds for example because a more urgent case had arrived. 38,129 non-urgent operations were cancelled from April to October, the biggest recorded figure for those six months. Jonathan Ashworth said: “NHS crisis continues, and the problems are worse and more widespread than in previous years. By underfunding and overstretching the NHS, the [government] have pushed health services to the brink.” Cancelled operations cause serious psychological stress and also sometimes financial loss for the patient. In England cancelled operations are not always recorded if the cancellation happens a few days prior to the scheduled day of the operation. Cancelled operations have been increasing over time. Clare Marx of the Royal College of Surgeons said, lack of beds, pressure on A&E facilities and staff shortages worsened the problem. Saffron Cordery of NHS Providers said: "Some of these may be due to poor scheduling and a lack of effective planning, but this is very often not the case. Increasingly, we are hearing from NHS trusts that it is often down to a more general lack of availability of critical care beds and a lack of anaesthetists and surgeons. It is also often down to ever increasing emergency cases requiring theatre time that exceeds level of demand that has been expected." In early 2017 some adults were treated in what are usually children's wards due to alleged unprecedented demand. 82,730 planned operations were cancelled at a very late stage without clinical reasons in 2016. Sometimes surgeons are left with no work to do because there are no beds available where their patients could be treated after the planned operation. Clare Marx described this "shocking waste" as due to NHS underfunding.

At a British Medical Association (BMA) conference (the doctors' union), a conference at which some of the contributions may have been politically motived according to the BBC, the NHS in England has been described by some senior medical professionals as overstretched, underfunded and understaffed. Nigel Edwards of Nuffield Trust stated, "the NHS has never experienced this level of austerity for this long a period". Edwards questioned whether planned £22 billion of efficiency savings were fully achievable. UK health spending is a lower proportion of UK economic output than the European average. The BMA argue that overworked and underfunded general practitioners have insufficient time to assess and properly treat patients with complex needs.

The Guardian health policy editor suggests that understaffing forces hospitals to rely on agency staff who are much more expensive and this expense is the main reason the NHS overspent. He believes that experts argue the NHS has insufficient funds to care for the ageing population and the increased numbers of patients with chronic health trouble like diabetes, depression, heart and respiratory issues which leads to steady increases in demand for NHS services. In April 2016 he reported that NHS staffing levels had been overestimated and without increases in staff the pressure on the NHS will continue. In response to this report, Labour's shadow health secretary argued that "Hospital wards are already dangerously understaffed and morale in the NHS is at rock bottom. This is impacting on patient care and leaving some staff so overstretched they are unable to complete basic tasks, such as changing dressings or checking patients have finished their meals."

Before the 2015 General election, the government promised £8.4 billion extra for the NHS in England by 2020-21. This promise was repeated by David Cameron and George Osborne many times while they were still in office. Despite this, a report by the House of Commons Health Select Committee showed that some of the extra £8.4 billion will be found from taking money from elsewhere in the health budget. For example, money for staff recruitment and training has been moved to a different fund. Staff training has been cut and the money saved will go towards the £8.4 billion. Since staff training is now in a different fund the cut may be overlooked. The report found the transfer of funds that were cut misleading as these other funds finance services that matter for patient care, for preventing sickness and for training the future workforce. According to the report, there will only be a £4.5bn increase in total health spending in England by 2020-21. The committee expressed concern that the transfer of resources from capital budgets, health education, public health and other areas will make ambitions stated in the Forward View, (the NHS blueprint for its modernisation by 2020) much harder to achieve and fails to meet the government's stated commitments. Anita Charlesworth of the Health Foundation agreed with the report and argued that cuts to health education and public health are shortsighted.

Acutely ill children are having to wait up to nine hours for an intensive care bed or to be transported over a hundred miles to a hospital with a free bed. Intensive care units are stretched beyond capacity and further stresses on the system could compromise safety.

Serious medical and surgical errors in hospital care, some with possibly life-threatening consequences are increasing in NHS England. Critics attribute this to the pressure on staff due to rising demand for services coupled with continual pressure to save money. Patients in England will suffer cuts in staff numbers, increased waiting time and rationing if the NHS does not get increased funding according to health bosses.Robert Francis of the Care Quality Commission stated there was an “increasing disconnect” between national statements on the NHS and “what people on the ground feel or see is going on.” Francis continued, “Let’s make no bones about it, the NHS is facing an existential crisis. The service is running faster and faster to try and keep up and is failing, manifestly failing. The danger is that we reach a tipping point; we haven’t reached it yet, but there will come a point where public confidence in the service dissipates.”

Roughly 30 health charities that include the Motor Neurone Disease Association, National AIDS Trust and Teenage Cancer Trust, expressed serious concern over NHS England “restricting and rationing treatment” due to underfunding, particularly for patients with rare and complex conditions. The groups from the Specialised Healthcare Alliance said this rationing is taking place with inadequate public oversight. They wrote a letter to the prime minister, stating, NHS England is “choosing to restrict and ration treatments that patients with rare and complex conditions need – often without proper consultation with patients. (...) We hope that you will take action to ensure full patient involvement in these decisions, and to ensure that any decision to ration treatment is overseen by democratically elected politicians,” This follows after the King's Fund health think tank claimed politicians would avoid blame for rationing when after April 2017 patients could be deniued even cost effective treatments (asthma, cancer and diabetes patients could all be affected). King's Fund policy adviser, Nicholas Timmins wrote, “If the NHS can no longer fund new and cost-effective treatments, ministers should announce that decision case by case, and be held accountable for so doing”. The warning from the charities comes before the Lords debate the Medical supplies bill which Lord Philip Hunt called a missed opportunity.

John Appleby, chief economist at the Nuffield Trust said, “The number of patients stuck on a trolley waiting for a hospital bed has gone through the roof, with more than 80,000 patients waiting for four hours or more in January, [2017] and a staggering 988 of them waiting longer than 12 hours. These are vulnerable people with acute medical needs. Corridors, it seems, have become the new emergency wards.”

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."

NHS England may delay introduction of life saving new drugs for up to three years even after the National Institute for Health and Care Excellence (Nice) has decided the treatment is cost effective. During the three years lives may be lost. Patients with conditions like cancer, diabetes and heart disease could be affected.

NHS Providers maintains NHS England faces 'mission impossible' meeting statutory requirements due to insufficient funding. Funding is estimated to increase by 2.6% in 2017-2018 but demand is expected to rise by 5.2%. Problems like long waits for hip and knee replacements and long waits in A&E are expected to worsen. Chris Hopson said the government needed to “sit up and listen NHS trusts will strain every sinew to deliver the commitments made for the health service. But we now have a body of evidence showing that, with resources available, the NHS can no longer deliver what the NHS constitution requires of it. We fear that patient safety is increasingly at risk.”

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.

Outsourcing and privatisation is steadily increasing in NHS England, and NHS England spending going to the private sector rose from £4.1 billion in 2009-10 to £8.7 billion in 2015-16. Private firms provide services in areas such as community service, general practise and mental health care. Denis Campbell, Guardian health policy editor states there is concern the quality of private sector care may be below what the NHS provides. Dr Louise Irvine, of the National Health Action Party, which campaigns against the use of private firms in the NHS, maintains that private firms tend to do the easier work leaving complicated medicine to the NHS. An article in The Independent also suggests the private sector cherry picks the easier cases because those are more profitable, additionally because the private sector does not have intensive care facilities if things go wrong. Professor Allyson Pollock argued privatisation should be monitored to ensure the poor, the old and the sick do not lose out.

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.

Sustainability and transformation plans

Sustainability and transformation plans were produced during 2016 as a method of dealing with the services's financial problems. These plans appear to involve loss of services and are highly controversial. The plans are possibly the most far reaching change to health services for decades and the plans should contribute to redesigning care to manage increased patient demand. Some A&E units will be closed and hospital care concentrated in fewer places.

Consultation will start over cost saving, streamlining and some service reduction 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. Dr Brian Fisher wrote, "STPs are driven by the Treasury. They are focused on reducing NHS spend. (...) Unless STPs meet the funding demands of the Treasury, the plans will not be approved and areas will not receive any transformation money." An article by the King's Fund states, "Allocations from the fund for sustainability and transformation must be agreed in advance with HM Treasury and DH’." The same article states that the spending review, "is both ring-fenced and needs HM Treasury agreement to unlock."

The Nuffield Trust think tank claims many suggestions would fail to implement government financial targets and involve a "dauntingly large implementation task". Sally Gainsbury of the Nuffield Trust said many current plans involve shifting or closing services. Gainsbury added, "Our research finds that, in a lot of these kinds of reconfigurations, you don't save very much money - all that happens is the patient has to go to the next hospital down the road. They're more inconvenienced... but it rarely saves the money that's needed." There will be a shift from inpatient to outpatient care but critics fear cuts that could put lives at risk, that the plans dismantle the health service rather than protecting it, further that untested plans put less mobile, vulnerable patients at risk. By contrast, NHS England claims that the plans bring joined-up care closer to home. John Lister of Keep Our NHS Public said there are too many assumptions, and managers desperate to cut deficits were resorting to untried plans. NHS managers are already hard pressed struggling to keep the service running, handling increased volume and juggling for hospital beds. Finding the extra time to develop a workable sustainability and transformation plan is itself problematic.

The review is about more than reducing costs. An article in The Guardian suggests possible substantial benefits from the review. The system as a whole lacks money and an ageing English population has growing complex requirements which add to pressure on the NHS. Health and social services need to be coordinated, STP's got people working enthusiastically together. The Guardian article suggests NHS England 'made up the policy on the hoof' and managers were under pressure to produce plans fast. NHS England gave fragmented guidance, coming in bursts with frequently insufficient time for responding to requests. There are fears secrecy within the NHS is hindering effective public discussion and without public discussion there is a risk of later delays, protests, judicial reviews. The Guardian article argues that full-time leaders are needed who will not put the interests of their own department before the needs of the whole and will send money where it is needed. Another Guardian article questions whether the plan might be to prepare for greater privatisation after 2020. Transferring services from hospitals to the community will only work if there is spare capacity in the community and GP's are already overstretched. There are too few NHS staff generally to enable the reorganisation.

Critics are concerned that the plan will involve cuts but supporters insist some services will be cut while others will be enhanced. Senior Liberal Democrat MP Norman Lamb accepted that the review made sense in principle but stated: "It would be scandalous if the government simply hoped to use these plans as an excuse to cut services and starve the NHS of the funding it desperately needs. While it is important that the NHS becomes more efficient and sustainable for future generations, redesign of care models will only get us so far – and no experts believe the Conservative doctrine that an extra £8bn funding by 2020 will be anywhere near enough." Norman Lamb also said the NHS was hurtling towards a “catastrophe (...) With demand rising so rapidly, more funding is needed. It would be unforgivable for the government not to act in light of these warnings.” NHS bosses have kept plans for cuts secret, also prevented NHS staff and the public from having an input. This led to accusations of cover-ups and stealth cuts. Plans kept secret include closures of A&Es and of one hospital though full details remain under wraps. One local manager described keeping plans confidential as 'ludicrous' and another said the 'wrong judgement call' had been made. Another person spoke about being in meetings where, 'real people' like patients and the public were not involved. The King's Fund reported the public and patients were mostly absent from plans which could involve large scale service closing. Chris Ham of the King's Fund described suggesting out-of-hospital services and GP's could take over work now done by hospitals as a “heroic assumption” since both out-of-hospital services and GP's are under too much pressure. Some councils that disagree with the secrecy have published plans on their websites. Funds that should have gone to helping with moving services after closures instead went to plugging other NHS deficits.

As of late February 2017 the BBC reported hospital services are to be cut and some hospitals closed in two thirds of England. It is planned to transfer patients to care in the community. This may lead to improved care in some cases but the King's Fund claims not all community care plans are credible because there are insufficient services outside hospitals and there is insufficient money to provide more. The King's Fund fears reducing hospital beds will increase the strain on hospital services which were overstretched during the 2016-2017 winter. Professor Chris Ham of King's Fund maintains transferring services to the community is a potential improvement in many cases and planshttp://www.bbc.co.uk/news/uk-39167350 should be considered on their merits. Ham maintains further transfer to the community cannot be done without extra funding and urges the government to invest in community services.

Organisers of a protest march in London where tens of thousands of people took part fear the Sustainability Transformation Plans are a "smokescreen for further cuts". Hospital services could be cut in nearly two thirds of England and some hospitals will be completely closed. During the march Jeremy Corbyn said, “There are those waiting on trolleys and those who are desperate to get into an A&E department waiting hours for treatment. It is not the fault of the staff. It is the fault of a government who have made a political choice.” Corbyn also said, "The Tories and the coalition before them managed to cut taxes on big business. Don't let them tell you there's no money for the NHS. There's no excuse for it... the money is there if you collect the taxes properly to fund it and pay for it." Len McCluskey of Unite stated, hospitals, GPs, mental health, ambulance and community services are on their knees". Dr David Wrigley of the BMA said, "As a doctor I see day to day the serious pressures in the NHS due to the funding cuts from the government."

Changes under the Thatcher government

The 1980s saw the introduction of modern management processes (General Management) in the NHS to replace the previous system of consensus management. This was outlined in the Griffiths Report of 1983. This recommended the appointment of general managers in the NHS with whom responsibility should lie. The report also recommended that clinicians be better involved in management. Financial pressures continued to place strain on the NHS. In 1987, an additional £101 million was provided by the government to the NHS. In 1988 Prime Minister Margaret Thatcher announced a review of the NHS. From this review in 1989 two white papers Working for Patients and Caring for People were produced. These outlined the introduction of what was termed the "internal market", which was to shape the structure and organisation of health services for most of the next decade.

In England, the National Health Service and Community Care Act 1990 defined this "internal market", whereby health authorities ceased to run hospitals but "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients. The "providers" became independent trusts, which encouraged competition but also increased local differences. Increasing competition may have been statistically associated with poor patient outcomes.

Changes under the Blair government

These innovations, especially the "fund holder" option, were condemned at the time by the Labour Party. Opposition to what was claimed to be the Conservative intention to privatise the NHS became a major feature of Labour's election campaigns.

Labour came to power in 1997 with the promise to remove the "internal market" and abolish fundholding. However, in his second term Blair renounced this direction. He pursued measures to strengthen the internal market as part of his plan to "modernise" the NHS.

A number of factors drove these reforms; they include the rising costs of medical technology and medicines, the desire to improve standards and "patient choice", an ageing population, and a desire to contain government expenditure. (Since the National Health Services in Wales, Scotland and Northern Ireland are not controlled by the UK government, these reforms have increased the differences between the National Health Services in different parts of the United Kingdom. See NHS Wales and NHS Scotland for descriptions of their developments).

Reforms included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous clinical and corporate governance. Some new services were developed to help manage demand, including NHS Direct. The Agenda for Change agreement aimed to provide harmonised pay and career progression. These changes have given rise to controversy within the medical professions, the news media and the public. The British Medical Association in a 2009 document on Independent Sector Treatment Centres (ISTCs) urged the government to restore the NHS to a service based on public provision, not private ownership; co-operation, not competition; integration, not fragmentation; and public service, not private profits.

The Blair government, whilst leaving services free at point of use, encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals were built (or rebuilt) by private sector consortia; hospitals may have both medical services such as ISTCs and non-medical services such as catering provided under long-term contracts by the private sector. A study by a consultancy company which works for the Department of Health shows that every £200 million spent on privately financed hospitals will result in the loss of 1000 doctors and nurses. The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced.

The NHS was also required to take on pro-active socially "directive" policies, for example, in respect of smoking and obesity.

Internet information service

In the 1980s and 90s, NHS IT spent money on several failed IT projects. The Wessex project, in the 1980s, attempted to standardise IT systems across a regional health authority. The London Ambulance Service was to be a computer-aided dispatch system. Read code was an attempt to develop a new electronic language of health, later scheduled to be replaced by SNOMED CT.

The NHS Information Authority (NHSIA) was established by an Act of Parliament in 1999 with the goal to bring together four NHS IT and Information bodies (NHS Telecoms, Family Health Service (FHS), NHS Centre for Coding and Classification (CCC) and NHS Information Management Group (IMG)) to work together to deliver IT infrastructure and information solutions to the NHS in England. A 2002 plan was for NHSIA to implement four national IT projects: Basic infrastructure, Electronic records, Electronic prescribing, and Electronic booking, modelled after the large NHS Direct tele-nurse and healthcare website program. The NHSIA functions were divided into other organisations by April 2005.

In 2002, the NHS National Programme for IT (NPfIT) was announced by the Department of Health.

Despite problems with internal IT programmes, the NHS has broken new ground in providing health information to the public via the internet. In June 2007 www.nhs.uk was relaunched under the banner "NHS Choices" as a comprehensive health information service for the public.

In a break with the norm for government sites, www.nhs.uk allows users to add public comments giving their views on individual hospitals and to add comments to the articles it carries. It also enables users to compare hospitals for treatment via a "scorecard". In April 2009 it became the first official site to publish hospital death rates (Hospital Standardised Mortality Rates) for the whole of England. Its Behind the Headlines daily health news analysis service, which critically appraises media stories and the science behind them, was declared Best Innovation in Medical Communication in the prestigious BMJ Group Awards 2009. and in a 2015 case study was found to provide highly accurate and detailed information when compared to other sources In 2012, NHS England launched an NHS library of mobile apps that had been reviewed by clinicians.

Eleven of the NHS hospitals in the West London Cancer Network have been linked using the IOCOM Grid System. The NHS has reported that the Grid has helped increase collaboration and meeting attendance and even improved clinical decisions.

Health screening for people aged 40 to 74

Since 1 April 2008, everyone aged 40 to 74 years old has been able to get a health check for heart disease, stroke, diabetes and kidney disease. In recent years, it has included dementia checks. However, doctors have expressed doubts about the effectiveness of the policy.

Smoking cessation

One in four hospital patients smoke and that is higher than the proportion in the general population (just under one in five). Public Health England (PHE) wants all hospitals to help smokers quit. One in thirteen smoking patients was referred to a hospital or community based cessation programme. Over a quarter of patients were not asked if they smoke and nearly three quarters of smokers were not asked if they wanted to stop. Half of frontline hospital staff were offered no training in smoking cessation. Smoking patients should be offered specialized help to stop and nicotine replacement. There should be dedicated staff helping patients to quit. Seven tenths of smokers say they want to stop and those offered help are four times more likely to stop permanently. PHE claims smoking causes 96,000 deaths per year in England and twenty times the number of smoking related illnesses. Dr Frank Ryan, psychologist said, "It's really about refocusing our efforts and motivating our service users and staff to quit. And of course, whatever investment we make in smoking cessation programmes, there's a payback many times more in terms of the health benefits and even factors such as attendance at work, because it's workers who smoke [who] tend to have more absent spells from work."

Public satisfaction and criticism

A 2016 survey by Ipsos MORI found that the NHS tops the list of "things that makes us most proud to be British" at 48%. 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. 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. 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." The reason for this disparity between personal experience and overall perceptions is not clear, however researchers at King's College London found high-profile media spectacles may function as part a wider 'blame business', in which the media, lawyers and regulators have vested interests. It is also apparent from the satisfaction survey that most people believe 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) . 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).

In the first decade of the 21st century, the private sector started to be increasingly used by the NHS to increase capacity. According to the BMA, a large proportion of the public opposed this move.

Some examples of criticism include:

1. Some extremely expensive treatments may be available in some areas but not in others, the so-called postcode lottery.
2. The National Programme for IT which was designed to provide the infrastructure for electronic prescribing, booking appointments and elective surgery, and a national care records service. The programme ran into delays and overspends before it was finally abandoned.
3. In 2008 there was a decreasing availability of NHS dentistry following a new government contract and a trend towards dentists accepting private patients only, with 1 in 10 dentists having left the NHS totally. However, in 2014 the number of NHS dental patients was reported to be increasing.
4. There have been a number of high-profile scandals within the NHS. Most recently there have been scandals at acute hospitals such as at Alder Hey and at the Bristol Royal Infirmary. Stafford Hospital is currently under investigation for poor conditions and inadequacies that statistical analysis has shown caused excess deaths.
5. A 14 October 2008 article in The Daily Telegraph stated, "An NHS trust has spent more than £12,000 on private treatment for hospital staff because its own waiting times are too long."
6. In January 2010, the NHS was accused of allocating £4 million annually on homoeopathic medicines, which are unsupported by scientific research.
7. The absence of identity/residence checks on patients at clinics and hospitals allows people who ordinarily reside overseas to travel to the UK for the purpose of obtaining free treatment, at the expense of the UK taxpayer. A report published in 2007 estimates that the NHS bill for treatment of so-called ‘health tourists’ was £30m, 0.03% of the total cost.

NHS mental health services is one area that tends to receive regular criticism from service users and the public, for sometimes opposing reasons. Women do not get gender specific help and in most trusts are not routinely asked if they have suffered domestic abuse though NICE recommends asking this.

Quality of healthcare, and accreditation

There are many regulatory bodies with a role in the NHS, both government-based (e.g. Department of Health, General Medical Council, Nursing and Midwifery Council),and non-governmental-based (e.g. Royal Colleges). Independent accreditation groups exist within the UK, such as the public sector Trent Accreditation Scheme and the private sector CHKS.

With respect to assessing, maintaining and improving the quality of healthcare, in common with many other developed countries, the UK government has separated the roles of suppliers of healthcare and assessors of the quality of its delivery. Quality is assessed by independent bodies such as the Healthcare Commission according to standards set by the Department of Health and the National Institute for Health and Clinical Excellence (NICE). Responsibility for assessing quality transferred to the Care Quality Commission in April 2009.

A comparative analysis of health care systems in 2010 put the NHS second in a study of seven rich countries. The report put the UK health systems above those of Germany, Canada and the US; the NHS was deemed the most efficient among those health systems studied.

Cancer treatment

Treatment of cancer has been a recurring issue. Official guidelines state that no one should have to wait more than 62 days for cancer treatment after a referral from their general practitioner. However, press reports in 2015 indicated that some patients had to wait longer. On 4 September 2015, the NHS announced it would no longer pay for 17 different cancer medications. The Telegraph reported that over 5,000 patients with breast, bowel, skin, and pancreatic cancers would be affected.

National cancer waiting times standards were established by NHS England in 2009 (and the same targets have been set by NHS Scotland). In 2017 the targets are

The targets are monitored monthly and in the period from 2014 to 2016 were only met in 4 months out of 36.

Performance

In 2014 the Nuffield Trust and the Health Foundation produced a report comparing the performance of the NHS in the four countries of the UK since devolution in 1999. They included data for the North East of England as an area more similar to the devolved areas than the rest of England. They found that there was little evidence that any one country was moving ahead of the others consistently across the available indicators of performance. There had been improvements in all four countries in life expectancy and in rates of mortality amenable to health care. Despite the hotly contested policy differences between the four countries there was little evidence, where there was comparable data, of any significant differences in outcomes. The authors also complained about the increasingly limited set of comparable data on the four health systems of the UK. Medical school places are set to increase by 25% from 2018.

A report from Public Health England’s Neurology Intelligence Network based on hospital outpatient data for 2012-13 showed that there was significant variation in access to services by Clinical Commissioning Group. In some places there was no access at all to consultant neurologists or nurses. The number of new consultant adult neurology outpatient appointments varied between 2,531 per 100,000 resident population in Camden to 165 per 100,000 in Doncaster.