The United Kingdom has a publicly financed, publicly provided health care system called the National Health Service (NHS). The NHS is funded through general taxation and provides universal coverage to the population for most treatment free of charge. Care is delivered through primary care physicians and hospitals, with patients entering through their general practitioner (GP). While most services are free, some individuals pay user fees for services like dental care and prescriptions. The government centrally determines the NHS budget which is allocated based on population need. Overall costs are kept relatively low through tight expenditure control and a "gatekeeping" system where GPs manage most patient care.
2. I. Overview
● Publicly financed
● Largely publicly provided
● Universal coverage for the population with a
zero price at the point of consumption for the
majority of treatment
● Dominated by the public sector
● Relatively small private sector → specializes in
non-emergency surgical procedures .
3. II. Health Care System ( = HCS )
A. Historical Development
● Comprehensive national health insurance
● NHS = National Health Service
=> Publicly financed and provided, largely from general
taxation
● Clinicians did not challenge the government's funding
decisions .
● In exchange → maintained discretion in the use of
ressources within the fixed global budget .
4. B . Financing the UK NHS
● Funded largely from general taxation that covers
approximately 86% of the total cost
● National insurance contributions = proportional payroll
taxes to individuals and employers
→ 12% of expenditure and user charges
→ for dental care and prescribed pharmaceuticals
→ finances the remaining 2%
5. ● Dentists now provide only private dental care
● Ophthalmic « privatized » over time
● NHS ressources : fell from 5,3% in 1949 to 0,6% in 1999.
● 1999 , UK spent :
- £61 billion on health care
- £52 billion on the NHS
- £4,4 billion on pharmaceuticals an other products without
NHS prescriptions
6. C. What is purchased with the expenditures ?
● majority of services by the NHS are free at the point of
delivery → includes access to all hospital and primary
care services
● patients’ access to the health care system tends to be
through the general practitioner ( GP )
● patients can also enter the hospital sector through
accident and emergency departments .
=> GPs provide the majority of primary care services ,
including practice nurses and sometimes other health
professionals such as physiotherapists and counselors
7. ● Individuals pay for some NHS-provided
services ( dentistry and prescriptions )
● Prescription charges = £6.10 / item
Exemption = only 14% of prescriptions are
chargeable and so user charges cover only a
small proportion of overall NHS costs .
● Exempt people : children , the elderly , people
with certain chronic diseases, and people with
low incomes receiving state benefits
● Some prescribed items are exempt : oral
contraceptives .
8. D. How do these expenditures reach the
providers
● Government decides the total size of the UK
NHS budget for each of the four countries .
HCHS = Hospital and Community Health Service.
● Population is weighted by age and other
determinants of the “ need” for health care
resources .
● Primary care budget has demand determined
and cash-limited components : it is a function of
the number of general practitioners and their
prescribing behavior .
9. ● Relatively low cost of the NHS = result of tight
control of expenditure by central government ,
in comparison to other HCS .
● Salary systems for remuneration of hospital
doctors reduce the incentives for overtreatment
and supplier-induces demand , which may exist
in fee-for-service systems .
● “ gatekeeper ” system = patients enter the
HCS via their family General Practitioners
(GP) , who care for approximately 90% of all
patient episodes in the community → may keep
overall costs down .
10. Remuneration of GPs :
- combines a capitation element , a basic practice
allowance and some fee-for-service elements .
- 60% is paid on a capitation basis and additional
payments are also made for individual services .
These additional payments include :
- Target payments for childhood immunizations
- Target payments for cervical cytology
- Additional payments for holding health promotion clinics
- Fee-for-service elements such as payments for minor
surgery and payments for provision of contraceptive
services .
11. Remuneration of hospital doctors :
- paid on a salary basis , with fixed salary scales .
- majority of consultant also undertake some
private practice , with varying levels of
remuneration .
=> payments for medical examinations or other
requests from individuals , insurance companies ,
employers , which are thought to be outside
normal duties .
- consultants may receive a distinction award ,
paid in addition to their basic NHS salary .
12. III. The demand for health care : scarcity and
rationing
HC demands of individuals , groups, and society
axceed the available resources to fund these
services .
Private HCS → rationing takes place on the basis
of ability to pay => price of health care determines
its allocation .
13. Waiting list :
- introduced in 1987
- Around 1 million people are on , waiting for
hospital therapy → but priority setting must take
place .
- “urgent” , “soon” , and “routine” indicate priorities
within the waiting list .
=> The numbers of patients on waiting lists in the
UK do , however , attract a great deal of political
and media attention .
14. In general , doctors feel happier making clinical
rather than economic decisions .
Constraints on public funding in the NHS and the
gap between demand for HC and supply of HC
resources in the UK during 1980s created a public
perception of “underfunding” in the H service and
were the precursors to the radical NHS reforms of
1991.
