Received 2010 Sep 1; Accepted 2010 Sep 27; Issue date 2010 Dec.

. The National Health System in the UK has actually developed to become one of the biggest health care systems in the world. At the time of writing of this evaluation (August 2010) the UK federal government in its 2010 White Paper "Equity and excellence: Liberating the NHS" has actually announced a strategy on how it will "create a more responsive, patient-centred NHS which attains outcomes that are amongst the finest worldwide". This evaluation article presents a summary of the UK health care system as it presently stands, with emphasis on Predictive, Preventive and Personalised Medicine components. It aims to act as the basis for future EPMA short articles to broaden on and provide the changes that will be implemented within the NHS in the forthcoming months.

Keywords: UK, Healthcare system, National health system, NHS

Introduction

The UK healthcare system, National Health Service (NHS), originated in the aftermath of the Second World War and became functional on the 5th July 1948. It was first proposed to the Parliament in the 1942 Beveridge Report on Social Insurance and Allied Services and it is the legacy of Aneurin Bevan, a former miner who became a political leader and the then Minister of Health. He founded the NHS under the concepts of universality, totally free at the point of delivery, equity, and paid for by central funding [1] Despite many political and organisational changes the NHS remains to date a service offered widely that looks after individuals on the basis of requirement and not ability to pay, and which is funded by taxes and national insurance coverage contributions.

Healthcare and health policy for England is the obligation of the main federal government, whereas in Scotland, Wales and Northern Ireland it is the duty of the respective devolved governments. In each of the UK nations the NHS has its own unique structure and organisation, however in general, and not dissimilarly to other health systems, healthcare consists of two broad sections; one handling strategy, policy and management, and the other with actual medical/clinical care which is in turn divided into primary (neighborhood care, GPs, Dentists, Pharmacists etc), secondary (hospital-based care accessed through GP recommendation) and tertiary care (expert health centers). Increasingly distinctions in between the 2 broad sections are ending up being less clear. Particularly over the last years and assisted by the "Shifting the Balance of Power: The Next Steps" (2002) and "Wanless" (2004) reports, gradual changes in the NHS have caused a higher shift towards regional rather than main decision making, removal of barriers in between main and secondary care and stronger emphasis on client option [2, 3] In 2008 the previous federal government strengthened this instructions in its health method "NHS Next Stage Review: High Quality Care for All" (the Darzi Review), and in 2010 the current federal government's health method, "Equity and excellence: Liberating the NHS", stays helpful of the same concepts, albeit through perhaps different systems [4, 5]

The UK government has actually just revealed plans that according to some will produce the most transformation in the NHS considering that its creation. In the 12th July 2010 White Paper "Equity and quality: Liberating the NHS", the current Conservative-Liberal Democrat coalition government detailed a method on how it will "produce a more responsive, patient-centred NHS which attains results that are among the very best worldwide" [5]

This evaluation article will therefore present a summary of the UK healthcare system as it presently stands with the aim to serve as the basis for future EPMA short articles to expand and present the changes that will be carried out within the NHS in the forthcoming months.

The NHS in 2010

The Health Act 2009 established the "NHS Constitution" which formally unites the function and concepts of the NHS in England, its worths, as they have been developed by patients, public and staff and the rights, pledges and duties of patients, public and staff [6] Scotland, Northern Ireland and Wales have actually likewise accepted a high level declaration declaring the principles of the NHS throughout the UK, even though services may be offered differently in the four countries, showing their various health requirements and situations.

The NHS is the largest employer in the UK with over 1.3 million staff and a budget of over ₤ 90 billion [7, 8] In 2008 the NHS in England alone utilized 132,662 doctors, a 4% boost on the previous year, and 408,160 nursing staff (Table 1). Interestingly the Kings Fund estimates that, while the overall variety of NHS staff increased by around 35% in between 1999 and 2009, over the very same duration the variety of managers increased by 82%. As a proportion of NHS personnel, the number of managers rose from 2.7 percent in 1999 to 3.6 percent in 2009 (www.kingsfund.org.uk). In 2007/8, the UK health costs was 8.5% of Gross Domestic Product (GDP)-with 7.3% accounting for public and 1.2% for personal spending. The net NHS expense per head throughout the UK was least expensive in England (₤ 1,676) and highest in Scotland (₤ 1,919) with Wales and Northern Ireland at roughly the very same level (₤ 1,758 and ₤ 1,770, respectively) [8]

Table 1.

The distribution of NHS labor force according to primary staff groups in the UK in 2008 (NHS Information Centre: www.ic.nhs.uk)

The total organisational structure of the NHS in England, Scotland, Wales and Northern Ireland in 2010 is displayed in Fig. 1. In England the Department of Health is responsible for the direction of the NHS, social care and public health and shipment of health care by establishing policies and methods, protecting resources, monitoring performance and setting national requirements [9] Currently, 10 Strategic Health Authorities manage the NHS at a regional level, and Medical care Trusts (PCTs), which presently manage 80% of the NHS' budget plan, provide governance and commission services, along with make sure the accessibility of services for public heath care, and provision of social work. Both, SHAs and PCTs will disappear once the plans outlined in the 2010 White Paper become executed (see area listed below). NHS Trusts operate on a "payment by results" basis and acquire the majority of their income by supplying healthcare that has been commissioned by the practice-based commissioners (GPs, and so on) and PCTs. The main types of Trusts consist of Acute, Care, Mental Health, Ambulance, Children's and Foundation Trusts. The latter were created as non-profit making entities, complimentary of government control but also increased financial obligations and are controlled by an independent Monitor. The Care Quality Commission manages individually health and adult social care in England overall. Other professional bodies provide financial (e.g. Audit Commission, National Audit Office), treatment/services (e.g. National Patient Safety Agency, Medicines and Healthcare Products Regulatory Agency) and professional (e.g. British Medical Association) policy. The National Institute for Health and Clinical Excellence (NICE) was established in 1999 as the body responsible for establishing national standards and requirements connected to, health promo and avoidance, evaluation of brand-new and existing innovation (consisting of medications and procedures) and treatment and care scientific assistance, available throughout the NHS. The health research method of the NHS is being carried out through National Institute of Health Research (NIHR), the overall budget plan for which was in 2009/10 close to ₤ 1 billion (www.nihr.ac.uk) [10]

Fig. 1.

Organisation of the NHS in England, Scotland, Wales and Northern Ireland, in 2010

Section 242 of the NHS Act mentions that Trusts have a legal task to engage and involve clients and the general public. Patient experience information/feedback is officially gathered nationally by annual study (by the Picker Institute) and belongs to the NHS Acute Trust efficiency framework. The Patient Advice Liaison Service (PALS) and Local Involvement Networks (LINks) support client feedback and involvement. Overall, inpatients and outpatients surveys have exposed that patients rate the care they get in the NHS high and around three-quarters show that care has actually been great or outstanding [11]

In Scotland, NHS Boards have changed Trusts and offer an integrated system for strategic direction, efficiency management and scientific governance, whereas in Wales, the National Delivery Group, with advice from the National Board Of Advisers, is the body carrying out these functions (www.show.scot.nhs.uk; www.wales.nhs.uk). Scottish NHS and Special Boards provide services, with look after specific conditions delivered through Managed Clinical Networks. Clinical guidelines are published by the Scottish Intercollegiate Guidelines Network (SIGN) and the Scottish Medicines Consortium (SMC) recommendations on the use of brand-new drugs in the Scottish NHS. In Wales, Local Heath Boards (LHBs) plan, protected and provide healthcare services in their locations and there are 3 NHS Trusts supplying emergency, cancer care and public health services nationally. In Northern Ireland, a single body, the Health and Care Board is overseeing commissioning, performance and resource management and enhancement of health care in the country and six Health and Social Care Trusts deliver these services (www.hscni.net). A variety of health agencies support supplementary services and deal with a wide variety of health and care concerns including cancer screening, blood transfusion, public health etc. In Wales Community Health Councils are statutory ordinary bodies promoting the interests of the general public in the health service in their district and in Northern Ireland the Patient and Client Council represent clients, clients and carers.

Predictive, Preventive and Personalised Medicine (PPPM) in the NHS

Like other national health care systems, predictive, preventive and/or personalised medicine services within the NHS have typically been offered and are part of disease diagnosis and treatment. Preventive medicine, unlike predictive or personalised medicine, is its own recognized entity and appropriate services are directed by Public Health and provided either via GP, neighborhood services or hospitals. Patient-tailored treatment has actually constantly prevailed practice for great clinicians in the UK and any other health care system. The terms predictive and personalised medicine though are developing to describe a far more technologically innovative way of detecting disease and anticipating response to the standard of care, in order to increase the benefit for the patient, the general public and the health system.

References to predictive and personalised medicine are significantly being presented in NHS related information. The NHS Choices website explains how patients can get customised recommendations in relation to their condition, and uses details on predictive blood test for illness such as TB or diabetes. The NIHR through NHS-supported research and together with scholastic and commercial collaborating networks is investing a considerable proportion of its budget plan in confirming predictive and preventive restorative interventions [10] The previous government thought about the development of preventive, people-centred and more efficient healthcare services as the methods for the NHS to react to the obstacles that all modern-day health care systems are dealing with in the 21st century, namely, high patient expectation, ageing populations, harnessing of information and technological advancement, altering labor force and progressing nature of disease [12] Increased focus on quality (client security, patient experience and scientific efficiency) has also supported innovation in early medical diagnosis and PPPM-enabling innovations such as telemedicine.

A number of preventive services are provided through the NHS either by means of GP surgeries, social work or hospitals depending upon their nature and consist of:

The Cancer Screening programs in England are nationally collaborated and include Breast, Cervical and Bowel Cancer Screening. There is likewise an informed choice Prostate Cancer Risk Management program (www.cancerscreening.nhs.uk).

The Child Health Promotion Programme is dealing with concerns from pregnancy and the very first 5 years of life and is provided by neighborhood midwifery and health visiting groups [13]

Various immunisation programs from infancy to their adult years, provided to anybody in the of charge and normally provided in GP surgical treatments.

The Darzi review set out six essential medical goals in relation to enhancing preventive care in the UK consisting of, 1) dealing with weight problems, 2) lowering alcohol damage, 3) treating drug dependency, 4) minimizing smoking rates, 5) improving sexual health and 6) improving mental health. Preventive programs to attend to these concerns have been in location over the last years in different kinds and through various efforts, and include:

Assessment of cardiovascular danger and recognition of people at higher danger of cardiovascular disease is generally preformed through GP surgeries.

Specific preventive programs (e.g. suicide, accident) in regional schools and community

Family planning services and prevention of sexually transmitted illness programs, typically with an emphasis on young people

A variety of prevention and health promo programmes associated with way of life options are delivered though GPs and social work consisting of, alcohol and smoking cigarettes cessation programmes, promotion of healthy eating and physical activity. Some of these have a particular focus such as health promotion for older people (e.g. Falls Prevention).

White paper 2010 - Equity and excellence: liberating the NHS

The current government's 2010 "Equity and excellence: Liberating the NHS" White Paper has set out the vision of the future of an NHS as an organisation that still remains true to its founding concept of, readily available to all, free at the point of use and based on need and not capability to pay. It likewise continues to uphold the principles and values specified in the NHS Constitution. The future NHS becomes part of the Government's Big Society which is develop on social solidarity and entails rights and responsibilities in accessing cumulative health care and ensuring reliable usage of resources thus providing better health. It will provide healthcare results that are amongst the very best on the planet. This vision will be implemented through care and organisation reforms concentrating on 4 areas: a) putting clients and public first, b) enhancing on quality and health results, c) autonomy, responsibility and democratic authenticity, and d) cut bureaucracy and improve performance [5] This strategy makes recommendations to issues that pertain to PPPM which indicates the increasing influence of PPPM principles within the NHS.

According to the White Paper the concept of "shared decision-making" (no decision about me without me) will be at the centre of the "putting emphasis on client and public very first" plans. In truth this includes strategies emphasising the collection and capability to gain access to by clinicians and patients all client- and treatment-related information. It also consists of greater attention to Patient-Reported Outcome Measures, greater option of treatment and treatment-provider, and importantly customised care preparation (a "not one size fits all" method). A newly produced Public Health Service will bring together existing services and location increased focus on research study analysis and evaluation. Health Watch England, a body within the Care Quality Commission, will supply a stronger client and public voice, through a network of local Health Watches (based upon the existing Local Involvement Networks - LINks).

The NHS Outcomes Framework sets out the priorities for the NHS. Improving on quality and health results, according to the White Paper, will be accomplished through modifying objectives and health care priorities and establishing targets that are based on medically reputable and evidence-based procedures. NICE have a main role in establishing recommendations and standards and will be expected to produce 150 brand-new requirements over the next 5 years. The government plans to establish a value-based pricing system for paying pharmaceutical business for offering drugs to the NHS. A Cancer Drug Fund will be produced in the interim to cover patient treatment.

The abolition of SHAs and PCTs, are being proposed as ways of offering greater autonomy and responsibility. GP Consortia supported by the NHS Commissioning Board will be accountable for commissioning health care services. The intro of this type of "health management organisations" has been rather controversial however potentially not absolutely unforeseen [14, 15] The transfer of PCT health improvement function to local authorities intends to offer increased democratic legitimacy.

Challenges facing the UK health care system

Overall the health, in addition to ideological and organisational obstacles that the UK Healthcare system is dealing with are not dissimilar to those faced by lots of national health care systems throughout the world. Life span has actually been gradually increasing across the world with ensuing increases in persistent diseases such as cancer and neurological conditions. Negative environment and way of life influences have produced a pandemic in obesity and associated conditions such as diabetes and heart disease. In the UK, coronary heart problem, cancer, kidney disease, mental health services for adults and diabetes cover around 16% of total National Health Service (NHS) expenditure, 12% of morbidity and in between 40% and 70% of death [3] Across Western societies, health inequalities are disturbingly increasing, with minority and ethnic groups experiencing most serious health problems, early death and impairment. The House of Commons Health Committee warns that whilst the health of all groups in England is enhancing, over the last 10 years health inequalities between the social classes have widened-the gap has increased by 4% for men, and by 11% for women-due to the truth that the health of the rich is enhancing much quicker than that of the bad [16] The focus and practice of health care services is being transformed from traditionally offering treatment and helpful or palliative care to significantly handling the management of persistent illness and rehab programs, and using disease prevention and health promotion interventions. Pay-for-performance, changes in regulation together with cost-effectiveness and pay for medications problems are becoming a critical element in brand-new interventions reaching clinical practice [17, 18]

Preventive medicine is sturdily developed within the UK Healthcare System, and predictive and customised techniques are increasingly ending up being so. Implementation of PPPM interventions might be the solution however also the cause of the health and health care obstacles and problems that health systems such as the NHS are dealing with [19] The efficient intro of PPPM requires clinical understanding of illness and health, and technological advancement, together with extensive strategies, evidence-based health policies and proper policy. Critically, education of healthcare specialists, patients and the public is also vital. There is little doubt nevertheless that harnessing PPPM properly can assist the NHS attain its vision of delivering health care outcomes that will be among the best on the planet.

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