The National Health Service and the health system in England

The NHS – Great Britain’s public health service – was born in 1948, as a pillar of the Welfare State, set up by the post-war Labour government. It was during the Second World War that the national coalition government asked a commission under the responsibility of economist and academic William Beveridge to review the country’s health and social security coverage systems. The Beveridge Report recommended the establishment of national systems providing social and medical coverage for all citizens “from the cradle to the grave”.

At first, the new National Health Service (NHS) offered completely free medical coverage for all, without selection criteria or contribution requirements. The flat-rate contributions paid by all those who worked (called National Insurance contributions) were supposed to contribute mainly to the financing of social benefits, and very little to the financing of health.

As the health service was financed directly from the general state budget, and not from a specific budget, it could not go at a loss, nor could it have a “hole”.  Britain was the first country in the world to offer its citizens this kind of public health service, which is completely free and open to all.

However, even if directly funded by the state, the system cost more than expected from the outset, and it only took the Labour government three years to challenge the principle of total free access. In 1952, the new Conservative government introduced the first prescription charge, or lump sum per prescription drug. Medical consultation and hospital care remained free, but other services such as dental or ophthalmic care have become partially paid for: on the whole, this remains the situation today. Hospitalisation and consultations with the general practitioner were free of charge, drugs, dental or ophthalmic care paid – in varying proportions – by the patient.

Like all public health systems, the National Health Service (with Scottish NHS and Welsh NHS) has seen its costs explode over the years, due to the ageing of the British population and the development of new drugs and forms of treatment much more expensive than those available in 1948. All governments, Labour or Conservative, have tried to control the costs of the system, while maintaining or improving the quality of service; but the problem of financing the system still remains.

The first major restructuring of the system took place under Margaret Thatcher. Considering that the high cost of the national service was at least partly due to its poor organisation and the lack of commercial sense of the civil servants managing the system, it promoted reforms setting up a decentralised administration of the hospital service, and an internal market that put service providers in competition with each other. Forced to respect financial limits, NHS trusts or regional hospital services have often limited their activities no longer according to patient demand, but according to budgetary constraints.

The results were predictable; on the one hand, the tragedy of “hospital waiting lists”, the lengthening of waiting lists for treatment in hospitals, on the other hand the reduction of certain treatments, and finally the development of private health insurance systems. The private sector had never ceased to exist, even in the early years of the NHS; but during the 1980s it experienced a new boom, with private insurance offering, for a contribution, state-of-the-art treatment without a waiting list. Many employers have begun to add additional private medical coverage to the premiums offered to their employees, including BUPA, a non-profit company that was already, before the establishment of the NHS, one of the country’s major health insurance providers.

From 1997 onwards, the Labour Party made the consolidation of the NHS one of the main axes of its policy, promising to return to the commodification of the service. An increase in the budget made possible by the sound public finances has made it possible to continue to reduce waiting lists; new, more efficient hospitals have been built. But the operating costs of the service remained very high, and the government could not turn back; the competition of medical service providers had reduced the costs of the service, and Labour governments do not want to increase them again.

Latest changes

Since 2010, the Conservative-Lib-Dem and Conservative coalition governments have been committed to further improving the system and increasing its budget.  The Health and Social Care Act of 2012 set in motion the abolition of NHS Trusts and regional authorities, and the transfer of the management of regional hospital resources to doctors themselves. The new system should result in significant savings in terms of administrative staff. The new proposals are highly controversial, with some seeing them as a fundamental transformation of the nature of the service, or even a partial privatization of it.

How it works

Anyone wishing to use NHS services must be registered with a general practitioner (GP). The vast majority of GPs operate in practices that include several general practitioners. To access the services of a specialist, or hospitalization (except emergency) a patient must be referred by his GP. Consultations are free, but GPs make few home visits, except for patients who cannot travel or are very ill.

Except in rural areas, general practitioners’ practices currently tend to evolve into health centres, bringing together several general practitioners, nurses and sometimes other medical or para-medical staff.

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