Senior Research Associate Judge Business School
University of Cambridge
Dr Kim Sutherland, co-author of “The Quest for Quality in the NHS: a chartbook on quality of care in the UK” (2005), describes the infrastructure of the NHS in England.
The National Health Service (NHS) was established in 1948 and since that time has played a central role in British life, providing a broadly comprehensive service that is based on clinical need rather than ability to pay. The NHS serves over 50 million people in England and in the financial year 2004-5, its total net expenditure was £69bn. Although the healthcare sector in the UK is dominated by the NHS, there is substantial private provision. OECD figures for 2002 show that the £67bn public expenditure on healthcare was supplemented by £13bn of private expenditure (OECD Health Data, 2005).
Each day there are:
• 836 000 consultations with general practitioners or nurses in primary care
• 124 000 outpatient attendances
• 36 000 patients in bed as elective admissions
• 94 000 patients in bed as emergency admissions
• 49 000 Accident and Emergency (A&E) attendances
• 18 000 calls to NHS Direct (telephone advice service)
(Chief Executive’s Report to the NHS, May 2005)
The NHS is mainly financed through taxation and has to account for its actions to Parliament via the Secretary of State for Health. The Secretary of State is a member of cabinet and has overall strategic responsibility for NHS delivery, improvement, finance and resources. The Department of Health (DH) supports the Government in improving the health and well-being of the population. It negotiates levels of funding with the Treasury, and allocates resources throughout the health service.
Structurally, the main features of the NHS in England are:
• 28 Strategic Health Authorities (SHAs) which manage the NHS locally on behalf of the DH. Each covers approximately 1.8 million people. Their key functions are:
- To create a strategic framework for capital investment, information management and workforce development;
- To agree and monitor performance levels in primary and secondary care;
- Build capacity and support performance improvement.
• 295 NHS Trusts, comprising 176 acute trusts (which provide medical and surgical care, usually centred on a hospital); 88 mental health trusts; and 31 ambulance trusts. Foundation trusts are a recent development that are designed to give greater freedom to NHS organisations (e.g. can retain operating surpluses; access to capital markets) whilst at the same time subjecting them to standards, performance ratings and inspections systems used throughout the
sector. There are currently 31 foundation trusts, with 32 (including eight mental health trusts) applying for 2006.
• 302 Primary Care Trusts (PCTs) which run primary and community services and commission care from a wide range of NHS and other providers. PCTs each serve around 170 000 people and control around 75% of the NHS budget.
The English public are deeply committed to the NHS and that commitment, together with the level of public expenditure that healthcare consumes, means that health policy is a subject of significant attention both inside and outside Government. The core principles that underpin the NHS were articulated by the Government in 2000 (see table 1).
Building on these principles, the Blair Labour Government has developed and implemented a plethora of policy initiatives, along a number of themes.
• Improving the quality of healthcare.
• Providing greater patient choice.
• Plurality of provision in healthcare services.