The National Health Service was established on 5th July 1948. The aim of the NHS was to provide a comprehensive health service to improve the physical and mental health of the people through the prevention, diagnosis and treatment of illness.
The NHS was intended to make all the health services available to every man, woman and child in the population, irrespective of their age or where they live, or how much money they have and to make the total cost of the Service a charge on the national income in the same way as the Defence Services and other national necessities. This has hardly changed since. The funding almost exclusively from national taxation is virtually unique in the western world. Family doctors have always been independent contractors, often owning their own premises. Hospital services have, until recent years, been provided in state owned facilities by staff receiving NHS salaries. Increasingly private sector organisations and charities are providing services under contract to the NHS.
The NHS Act 1946 provided the legislation for the NHS. The current framework in England and Wales set out in the National Health Service Act 1977 was modified substantially by the Health and Social Care Act 2012. The NHS Acts give no one any right to anything – the Acts are framed to lay on the Secretary of State the duty of providing services with aims – but not necessarily aims that must be achieved. Additional Acts are passed from time to time, for example when there is a major reorganization of the NHS structure and finance that needs parliamentary agreement. The Health and Social Care (Community Health and Standards) Act established NHS foundation trusts, the Commission for Health Audit and Inspection (later the Healthcare Commission) and the Commission for Social Care Inspection.
Under the 1977 Act, the NHS is essentially split into two parts.
The family health services, i.e. the services provided by family doctors, general dental practitioners, ophthalmic opticians and chemists. The provision of health care in hospitals and also community health services, e.g. services provided by midwives, health visitors and clinics.
Primary care services (Family Health Services)
In the UK primary care is crucial. The whole system is based on it, access to hospital services, save in an emergency, is through the GP. As far as possible care is delivered outside hospital, and clinical pathways are designed with this in mind. Primary care ensures that people will receive a good service wherever they live, provides a beneficial continuity of care, and is cost effective. Primary care physicians influence who is referred to hospital.
Primary care services are provided by general practitioner practices, dentists, pharmacists and opticians. The majority are independent contractor but an increasing number of GPs are salaried. There are something like 32,000 GPs in England. The work undertaken in primary care has changed steadily since the NHS began. GPs see far less serious acute illness such as TB and do little maternity work now, but undertake substantially more care of chronic diseases and health promotion. GPs have been working with progressively more help: nurses and others. The trend to larger practices or federations is continuing. Dental services under the NHS are less comprehensive and sometimes difficult to obtain. Similarly much optical work is now undertaken privately.
Most GP practices are paid to carry out specified duties under a national contract for General Medical Services. A contract introduced in 2004 allowed practices to transfer responsibility for providing some services – including out-of-hours care. A second contract is used by about half the GPs. The NHS (Primary Care) Act 1997 allowed for the establishment of Personal Medical Services (PMS). This provides more flexibility for practices to work in different ways and develop specific services for local needs.
Since 2013, legislation establishing Clinical Commissioning Groups has given GPs extensive influence on the placement of contracts for hospital services, and for their nature.
Secondary care - hospitals and NHS trusts
The NHS inherited a disparate collection of hospitals and over 60 years these have been brought into a system based on an early decision to aim for district general hospitals serving natural areas of population, supported by university and specialist hospitals at a greater distance. The Hospital Plan of 1962 was explicit about this, and subsequent plans have taken account of the changing distribution of the population, and developments in medical science. This is quite unlike the situation in countries such as the USA where hospital development is driven more by the market than by planning based on health care needs. Revenue money can be directed through the placement of contracts, and there is supervision of capital spending that can be either from public funds or from private finance.
Most people reach hospital by GP referral, though accident and emergency departments, or NHS Direct (a phone and web based helpline). Services are provided by NHS trusts, increasingly foundation trusts which have greater responsibilities, more freedom of action and local governors. They work within a legal framework that lays down certain financial, quality and partnership requirements. There may be more than one hospital in an NHS trust. Some trusts also act as regional or national centres of expertise for more specialised care, and many are attached to universities and help to train professionals. Trusts may also provide services in the community – for example through health centres, clinics or in peoples’ homes. Trusts may merge, either with others of the same nature or to expand services, for example an acute hospital trust may take on community health services. Over the last ten years the quality of care has become far more of an issue that it was previously. Trusts have obligations to provide quality care, as well as obligations to stay within their budgets and meet targets for the speed of treatment.
Hospitals and community services are run by some 300 Trusts, the number changing with mergers and restructuring. For ten years the aim has been for all trusts to achieve "foundation" status, however to so so they had to demonstrate good governance and the ability to work within their budget. A little over half trusts have achieved this. Many have not and will not and are now the responsibility fo the NHS Trust Development Authority. Many of these are in great financial difficulty.
NHS Foundation Trusts
NHS foundation trusts first established in 2004 are approved by an independent regulator, Monitor. Foundation Trusts differed from earlier trusts primarily by having a Council of Governors as well as a Board of Directors. The Council of Governors represent the interests of the community and of local partnership organizations, but they have no real power. Foundation Trusts have financial freedoms, earned by a record of financial probity and are legally independent organisations. They are not allowed to sell off or mortgage NHS property and resources needed to provide key NHS services. Each Foundation Trust has an individual constitution within national guidance designed to meet its own circumstances.
Foundation Trusts are accountable to an independent regulator, Monitor, which is accountable directly to Parliament. Monitor watches to ensure that each trust is keeping to its budget and providing the services that were agreed. NHS foundation trusts are more free from central government control than simple hospital Trusts. They manage their own budgets and shape the health care services they provide to reflect local needs and priorities. They are inspected by the Care Quality Commission and have freedom to develop new solutions to long-standing problems. They deliver care for their population, purchased by locally commissioners.