Transcript Guide to the NHS

NHS 101 – A
Primer for
Americans on
England’s
National Health
Service
Pre-reading for: Whole System Presentation – 18 March 2010
Care Oregon, Portland, USA
1
NHS 101
The purpose of this document is to provide US-based health care leaders
with a high-level overview of the highly complex English healthcare
system. We have concentrated on just the “headline facts”.
Overview
•
The English NHS is the largest single national health system in the
world. It provides care to all of England’s population (54 million people)
and employs 1.4 million individuals. This makes it one of the five
largest employers in the world (the Chinese Military is the largest). It
has a $160 billion annual budget
•
Whilst it has evolved greatly in its 62-year history, the NHS has
remained faithful to its initial set of funding and access principles
•
The NHS is funded from general taxation, and provides more than 90%
of all healthcare in England. The proportion of English healthcare
provided outside of the NHS (eg, through insurance systems, by the
private sector) is falling
2
NHS 101
•
The NHS provides comprehensive care to the entire population literally “from
cradle to grave”. No user pays (except for minimal “co-pays” in very limited
situations)
•
“Co-pays” represent only about 2% of the income of the NHS:
– the working population pay a subsidised amount for any drugs from their
family physician (maximum individual payment of $10 for any prescribed
drug)
– there is a subsidised charge for dental and eye checks and for further
dental treatment.
– children and young people in education, over 65s and pregnant women do
not have to make ANY co-payments - everything is free for them
– anyone who is a cancer survivor gets all drugs free for the rest of their life
•
Public support for the NHS remains consistent and strong. In regular polls,
85% of the population agree that England should have a National Health
Service free at the point of need, paid for out of national taxation and with
equal access for all. Every political party supports these basic principles
3
Percentage of national funding spent on
government
4
Percentage of Gross Domestic Product spent
on healthcare
5
Launch of the NHS, July 1948
“It will provide you with all medical,
dental and nursing care.
Everyone - rich or poor, man, woman or
child – can use it.
There are no charges… There are no
insurance qualifications.
But it is not a “charity”. You are all paying
for it, mainly as taxpayers, and it will
relieve your money worries in time of
illness.”
6
Why was the NHS established?
• Cataclysmic effects of WWII made it possible to have a
massive change of system, rather than incremental
modification
• View that healthcare is a fundamental right, not
something bestowed erratically by charity
• Creation of an emergency medical service as part of
the war effort – a precursor to the NHS
• Bipartisan agreement that the existing services were in
a mess overall and had to be sorted out
• Financial difficulties for the voluntary (primarily charitybased) hospitals
• Increasing view among younger members of the
medical profession that there was a better – and more
equitable – way of doing things
7
Some spending comparisons……
Health spending as a share of GDP
16%
8.4%
Public spending on healthcare
(% of total spending on healthcare)
45%
82%
Health spending per head
Key:
$2,992
UK
USA
$7,290
8
MRI scanners per million population
8.2
25.9
Nurses
(per 1,000 people)
Practising physicians
(per 1,000 people)
2.5
10.0
10.6
2.4
Acute care hospital beds
(per 1,000 people)
2.6
Key:
UK
2.7
USA
9
The English NHS today: a complex system
•
•
•
1.4 million employees
54 million patients (population)
1 million patients every 24 hours
•
10 Strategic Health Authorities (each
covering a population 2.5-7 million)
•
Primary, secondary AND tertiary care
– Ambulance services
– Mental health
– Dentists, Opticians, Pharmacies
– Preventative health
– School health
– Sexual health
– etc
10
NHS Finance 1
Total budget: $160 billion
• Most money comes from
General Taxation. This is paid
by the whole population A
very small proportion comes
from other sources such as:
– prescription charges
– dental charges
– overseas visitors
– capital receipts
– charges for road traffic
– personal injury victims
(from insurers)
0.2%
2.6% 2.6%
General taxation
Capital receipts
Charges and misc
94.6%
Trust interest receipts
and loan repayments
NHS Finance 2
Translation: “A&E ”= Accident & Emergency=Emergency Room
Structure of the NHS
NHS Commissioning
Commissioning is the process of determining:
• the health needs of the population
• the resources available
• how to organise service provision for this
• buying the resources from local providers
Commissioning occurs:
• mainly by Primary Care Trusts (PCTs)
• for rarer conditions, at PCT group, Strategic Health
Authority or national level
Commissioners of Health Care
152 NHS Primary Care Trusts
•
PCTs ensure a comprehensive range of
health services and deliver population health
outcomes for the local population. They
receive all their resources per capitation from
central Government and are responsible for
the whole population in their locality. They
buy health improvement and healthcare
services for the local population through:
NHS Hospital Trusts, Mental Health
Trusts, Ambulance Trusts, GP practices,
dental practices, community pharmacies,
optical practices, and some third sector
and private providers, etc
Governance
Public Health
PCTs are government organisations
• PCTs assess needs and work with local
That hold service providers to
partners
account via contracts. They can ask
• (eg, local government) to provide services to regulators to intervene if the
• meet identified health needs
providers are not meeting expected
standards.
Since last year, the NHS has even
had its own Constitution
• Establishes the principles and values
of the NHS in England
• Sets out in law:
– rights to which patients, public
and staff are entitled
– pledges which the NHS is
committed to achieve
– responsibilities which the public,
patients and staff owe to one
another
to ensure that the NHS operates
fairly and effectively
16
Under the NHS Constitution,
patients have a legal right to:
• Access to health services
• Nationally approved treatments, drugs and
programmes
• Respect, consent and confidentiality
• Informed choice
• Involvement in their healthcare and in the
NHS
• Complain and to have that complaint
redressed
17
How is the NHS performing?
• 98% patients can get a routine appointment with their
primary care physician/General Practitioner (GP) within 48
hours or with another primary care professional within 24
hours
• 97% people with cancer start treatment within 32 days of
referral by their GP
• 92% patients get surgery in <18 weeks of GP referral
• 98% patients get through the emergency room in <4 hours
(either treated/discharged or admitted to a bed)
• Cancer mortality rates fallen by 19.3% since 95-7
• Biggest reductions in recorded hospital infection rates in
the world
• (Currently) highest recorded improvements in public
satisfaction with NHS since surveys started
Everyone (54 million) gets this. No-one pays!
18
2009 Commonwealth Fund International Health
Policy Survey of Primary Care Physicians
AUS Australia
NOR Norway
CAN Canada
NZ New Zealand
FR France
SWE Sweden
GER Germany
UK United Kingdom
ITA Italy
US United States
NET Netherlands
19
Doctors use electronic patient
medical records
100
98 99
2006
92
97
96
2009
95
89
79
72
75
50
46
42
37
28
25
23
0
NET
NZ
UK
AUS
GER
US
CAN
2006: “Do you currently use electronic patient medical records in your practice?”
2009: “Do you use electronic patient medical records in your practice (excluding billing systems)?”
Source: 2006 and 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
20
Patients are routinely sent reminders
for preventive or follow-up care
%
100
97
97
Yes, using a manual system
89
4
21
7
Yes, using a computerized system
80
75
31
60
51
50
92
76
35
82
47
33
25
29
25
48
24
24
26
18
0
NZ
UK
AUS
NET
FR
SWE
US
32
15
9
17
ITA
GER
31
21
15
10
12
3
CAN
NOR
Percentages may not sum to totals because of rounding.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
21
Arrangements in place so patients can
see doctor/nurse outside of “normal”
office hours
%
100
97
89
89
78
77
75
54
54
50
43
50
38
29
25
0
NET
NZ
UK
FR
ITA
GER
SWE
AUS
CAN
NOR
US
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
22
Extent to which restrictions on medication or
treatment for patients pose major time concerns
for doctors
50
% saying amount of time physician or staff
spend getting patients needed medications or
treatment due to coverage restrictions is a
MAJOR PROBLEM
48
42
34
25
10
10
NET
SWE
13
16
16
17
FR
NZ
NOR
19
6
0
UK
AUS
CAN
GER
ITA
US
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
23
Six Nation Summary Ranks on Health
System Performance
AUS
CAN
GER
NZ
UK
US
Overall ranking
3.5
5
2
3.5
1
6
Quality Care
4
6
2.5
2.5
1
5
Right Care
5
6
3
4
2
1
Safe Care
4
5
1
3
2
6
Coordinated Care
3
6
4
2
1
5
Patient-Centred Care
3
6
2
1
4
5
Access
3
5
1
2
4
6
Efficiency
4
5
3
2
1
6
Equity
2
5
4
3
1
6
Healthy Lives
1
3
2
4.5
4.5
6
Source: Commonwealth Fund (2007)
The Challenges for the
future of the NHS
25
Short-term reasons for the
challenging resource climate
• There will be significant cuts in English public
expenditure because of the world financial crisis
• For the last 8 years, resources have increased at 7%
per annum. Average since World War Two is 4%.
Resources will not grow above inflation for the next few
years
• Demand for health care will go on increasing
• If NHS spending stays at the current level, all other
public spending has to be cut by 3.5%
• In every recession since WWII, during the recession
NHS expenditure increases, afterwards it stands still.
The length of this recession and depth will mean a long
standstill (GDP has gone down 7% in a year when NHS
spend has gone up by 7%)
26
Long-term reasons for a challenging
resource climate
• In developed countries since 1960s healthcare
expenditure has gone up by 1.7% more than GDP per
annum (in the US 2%)
• Healthcare is a unique industry. Our experience as an
industry is that as demand for healthcare has risen so
have available resources
• Now all health care systems globally face bankruptcy
because of a) an aging population and, therefore, more
patients with complex health needs and b) new
technology
• We can no longer assume that resource will rise in line
with demand. We now need to do what other industries
do: transform the system
27
What should our response be?
• Since in the past financial resource has risen
with demand, if that does not happen now, how
do we realise (bring into reality) other sources
of value?
• Other industries use new technology to wipe
out old technology. Health services are bad at
doing that as the old technology makes sense
in the hands of very powerful professionals
• How do we transform by finding new value
relationships and stopping old value
relationships?
28
£ and/or demand
A transformational response
The “Hospital Care” area is likely to
reduce, with the other care models
fundamentally shifting upward to
enable resources to be redeployed
more effectively.
Community Individual
Public
Prevention
Health
Long-term
Avoiding
Condition
Hospital
Management Admissions
Hospital
Care
Rehabilitation
End-ofLife care
29
Primary goal –
Higher Quality and Productivity at
Lower Cost
Quality
+
Recent
decade
Space of
current
transformation
efforts
+
–
Do not go here!
Productivity
(but we might if we do
not align our efforts)
Source: Mark Jennings, NHS Institute
–
NHS
pre-2000
30