Healthcare in the UK

• • funding model for NHS is largely tax-based (with national insurance contributions)
  • spending on health at national level is measured as proportion of gross domestic product (10%)
• The NHS provides comprehensive care, free at the point of service, irrespective of contributions made or ability to pay.
• Globally universal health coverage is a major goal for healthcare reform and priority for WHO - ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation and palliation) of sufficient quality to be effective while ensuring that does not expose the user to financial hardship
• Beveridge model - healthcare financed by government through tax payments. Most hospitals government owned, some doctors government employees. (UK, Spain, Scandinavia)
• Bismarck model - uses an insurance system - usually jointly financed by employers and employees to pay for health system. Has to provide for everyone. (Germany (social insurance), France, Belgium, Japan etc.)
• National Health Insurance Model - uses private-sector providers but payment from government-run insurance system that everyone pays into. (Canada, Taiwan)
• Out of Pocket Model - where not system of coverage and citizens pay pre-dominantly out of pocket (USA etc)
• The UK uses the Beveridge model of health systems.
• recent changes in NHS

  • Long Term Plan launched to shape NHS in light of additional funding announced
  • continued move away from competition to collaboration
  • NHS England and NHS Improvement have joined up
  • more integration - new Health and Care Bill (give more power to centre)
  • GPS work as primary care networks promoting collaboration and working with community services
• Public health has lacked stability and value in the system particularly in ENgland for the last two decades. Funding has reduced in real terms in the same period.
• Adult social care

  • means tested in England
  • greater role for private provision
  • informal carers play a huge part
  • can often result in significant out of pocket expenses for individuals and families
• Northern Ireland is the only country where health and social care are organisationally integrated.
• Legislation in Scotland introduced Integrated Joint Boards to bring NHS and local authorities together to plan and deliver services for population
• In England integrated care organisations have been evolving - now integrated care systems which are going to coincide with reduced number of clinical commissioning groups
• Integration remains challenging - historic ways of working, budgetary flows etc. take time to overcome even when intent is ther
• Different levels of integration

  • clinical
  • organisational
  • systems
• What benefits can be brought from different parts of the system (health, social care, public health) working better together?

  For patients and carers fragmented systems can lead to dissatisfaction - not seeing patient as a whole. Can lead to inefficiencies, repeated tests/investigations etc. Particularly problematic with multimorbidity and longterm conditions
• Transitions in care can be particularly important

  • mental and physical health
  • hospital to home care
  • children to adult services
• COVID-19 has highlighted fragmentation in the system - in England in early stages of pandemic, patients were discharged to care homes without knowing covid-19 status
• Triple Aim developed by Institute of Healthcare Improvement

  • improving patient experience of care (quality and satisfaction)
  • improving health of populations
  • reducing cost per capita of health care
• One of the strengths of the NHS is financial protection - there are user charges in place particularly in England (e.g. prescriptions) but many exemptions apply. Dental and social care are reminders of the impact when this is not in place - large inequalities in dental care use and outcomes.
• Catastrophic health spending - out of pocket health expenditure that is large relative to income
• A strength of the NHS is management of chronic conditions, particularly diabetes, kidney disease, suicide and patient experience, likely due to primary health networks.
• Response to public health emergency

  • workforce mobilisation
  • increasing critical care capacity
  • rapid increase in uptake of remote consultations
  • identification of groups to shield
  • vaccination programme
• Health Technology Assessment - robust and established system for evaluation of new technologies (pharmaceuticals)
• Research and Innovation is a strength of the NHS, demonstrated through COVID-19 in establishing world leading trials on vaccines and treatment
• Health outcomes and inequalities are weaknesses of the NHS

  • significant and widening inequalities in life expectancy and healthy life expectancy
  • in comparison to other high income countries perform worse in relation to outcomes including survival from common cancers, cardiovascular disease and infant mortality
• spending on healthcare has been relatively protected in the UK but over the last three decades the UK has had consistently lower public spending on health than most other high income countries
• The UK has fewer nurses and physicians per head of population than many other high-income countries. Have some areas of innovation in staffing but failures at planning level and significant shortages
• The NHS has been pushed to make significant efficiency drives over the last 10+ years. We run the service at very high capacity (making more vulnerable) and have under invested in areas such as capital spend
• The NHS response to COVID-19 has been highly commendable but limited excess capacity has impacted ability to respond. Initial stages saw poor supply of personal protective equipment and poor response to addressing shortages. Initially low testing capacity and erosion of public health capacity were highlighted.
• Wales and Scotland rejected the purchaser-provider split and competition. Northern Ireland has the split in theory but does not use it.
• Scotland is the only constituent country with entitlement for free personal care for over 65s.
• England is the only constituent country with prescription charges.
• Organ donation

  • wales has 'deemed consent'
  • scotland and england have 'opt-out'
  • northern ireland has 'opt-in'
• Basis of consent affects the willingness of individuals to donate their own organs and those of their relatives. Presumed consent increases willingness.
• Professional regulation and standards for education remain on UK-wide basis (GMC)
• Challenges faced across constituent countries are similar

  • workforce - recruitment and retention challenges
  • Data/IT - from frontline care, sharing information, taking advantage of 'big data'
  • integrated care - how to do it well
  • meeting needs of ageing population and needs of patients with multiple conditions