About the National Health Service (NHS) in England - NHS Choices Learn more about the structure of the NHS in England . In 2014, the Commonwealth Fund declared that in comparison with the healthcare systems of 10 other countries (Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland and the US) the NHS was the most impressive overall. The NHS was rated as the best system in terms of efficiency, effective care, safe care, co-ordinated care, patient-centred care and cost-related problems. It was also ranked second for equity. Scale The NHS employs more than 1.5 million people, putting it in the top five of the world’s largest workforces, together with the US Department of Defence, McDonalds, Walmart and the Chinese People’s Liberation Army. The NHS in England is the biggest part of the system by far, catering to a population of 54.3 million and employing around 1.2 million people.

Of those, the clinically qualified staff include 150,273 doctors, 40,584 general practitioners (GPs), 314,966 nurses and health visitors, 18,862 ambulance staff, and 111,127 hospital and community health service (HCHS) medical and dental staff. The NHS in Scotland, Wales and Northern Ireland employs 161,415; 84,000 and 66,000 people respectively. Funding Funding for the NHS comes directly from taxation. Since the NHS transformation in 2013, the NHS payment system has become underpinned by legislation. The Health & Social Care Act 2012 moves responsibility for pricing from the Department of Health , to a shared responsibility for NHS England and NHS Improvement . When the NHS was launched in 1948, it had a budget of £437 million (roughly £15 billion at today’s value). For 2015/16, the overall NHS budget was around £116.4 billion. NHS England is managing £101.3 billion of this.

You can also read The NHS budget and how it has changed – a study by the King’s Fund. Happy Birthday To Great Britain's Increasingly Scandalous National Health Service Happy Birthday To Great Britain's Increasingly Scandalous National Health Service {{article.article.images.featured.caption}} Opinions expressed by Forbes Contributors are their own. Full Bio The author is a Forbes contributor. The opinions expressed are those of the writer. Loading ... This story appears in the {{article.article.magazine.pretty_date}} issue of {{article.article.magazine.pubName}}. Subscribe English: NHS logo (Photo credit: Wikipedia) Britain’s National Health Service (NHS) turns 65 years old this week. It is no small irony that the United States simultaneously celebrates its independence from Great Britain. Emotionally feted by UK citizens and political leaders, the NHS is typically celebrated as a magnificent badge of honor and even as a symbol of national identity in Britain. In its most recent portrayal to the world, the NHS was featured at the opening of London’s 2012 Olympic Games in a spectacular display with dancing nurses, delighted children, and other fantasy-based imagery.

Before the ceremony, Danny Boyle, the ceremony’s creator, declared that he chose to showcase the NHS because “everyone is aware of how important the NHS is to everybody in this country” and that “one of the core values of our (British) society is that it doesn’t matter who you are, you will get treated the same in terms of health care.” Despite its much heralded presence in Britain’s health care, the problems of the NHS are severe, notorious, and increasingly scandalous in the most fundamental attributes of any health care system: access and quality. Waits for care are shocking in the NHS, frequently exposed by British media reports, and long proven by facts, yet they go virtually unreported in the U.S. For instance, in 2010, about one-third of England’s NHS patients deemed ill enough by their GP waited more than one additional month for a specialist appointment. In 2008-2009, the average wait for CABG (coronary artery bypass) in the UK was 57 days. And the impact of this delayed access was obvious.

For example, twice as many bypass procedures and four times as many angioplasties are performed in patients needing surgery for heart disease per capita in the U.S. as in the UK. Another study showed that more UK residents die (per capita) than Americans from heart attack despite the far higher burden of risk factors in Americans for these fatal events. In fact, the heart disease mortality rate in England was 36 percent higher than that in the U.S. Access to medical care is so poor in the NHS that the government was compelled to issue England’s 2010 “NHS Constitution” in which it was declared that no patient should wait beyond 18 weeks for treatment – four months - after GP referral. Defined as acceptable by bureaucrats who set them, such targets propagate the illusion of meeting quality standards despite seriously endangering their citizens, all of whom share an equally poor access to health care. Even given this extraordinarily long leash, the number of patients not being treated within that time soared by 43% to almost 30,000 last January. BBC subsequently discovered that many patients initially assessed as needing surgery were later re-categorized by the hospital so that they could be removed from waiting lists to distort the already unconscionable delays.

Royal College of Surgeons President Norman Williams, calling this “outrageous,” charged that hospitals are cutting their waiting lists by artificially raising thresholds. Beyond access, the quality of medical care in the NHS, based on data in the medical journals, is unacceptable. Comparing data for cancer, heart disease, and stroke, the most common sources of sickness and death in the U.S. and Europe, and the diseases that generate the highest medical expenditures, we see the overt failure of the NHS and its socialist relatives. · For cancer, American patients, both men and women, have superior survival rates for all major types. For some specifics, per Verdecchia in Lancet Oncology, the breast cancer mortality rate is 88 percent higher in the United Kingdom than in the U.S.; prostate cancer mortality rates are strikingly worse in the UK than in the U.S.; mortality rate for colorectal cancer among British men and women is about 40 percent higher than in the U.S. · Even given the lifestyle-related disadvantages inherent to American patients (physically inactive, obese, and with high blood pressure – all significantly higher than comparison countries), studies also prove better medical care for stroke in the U.S. than in Britain.

In 2010, the British scientific journal Lancet Neurology stated in its editorial about stroke treatment entitled “Time is Brain for Carotid Endarterectomy” that “early intervention is crucial for a good outcome,” yet “two- thirds of patients (in the UK) face an unacceptable delay.” · To assess the quality of care for high blood pressure, or hypertension, we must look at two sets of data. First, once hypertension is diagnosed, is it treated or does it go untreated? About two-thirds to three-fourths of patients with high blood pressure in England were left untreated, compared to less than half in the U.S. Second, hypertension treatment in the UK has been inferior and less successful in controlling blood pressure than the U.S. One comparison showed that blood pressure control was best in the U.S., outperforming Canada, England, Germany, Italy, Sweden, and Spain. In a separate analysis of over 21,000 patients already visiting doctors for hypertension, the best rate of success was in the U.S. (63 percent), compared with 31 percent to 46 percent of patients in England and the European countries.

· No disease has more far-reaching and more serious consequences than diabetes, with a risk for death about twice that without diabetes, and significantly worse disease outcomes. In 2011, the World Health Organization determined that of seven countries including England and Scotland, the U.S. had the highest proportion of adult diabetics who were actually receiving treatment for their known diabetes, as well as for their hypertension and high cholesterol. The U.S. also performed best by several different quality measures, approximately twice the success of England and Scotland. Add to those illustrious facts the heinous scandals about the quality of care in NHS hospitals that are repeatedly discovered, investigated, and catalogued with promises of change. These scandals, like the Staffordshire Trust debacle where between 400 and 1,200 neglected and abused patients died in squalid and degrading circumstances, are directly caused by the very culture of the NHS, as overtly admitted even by the UK government at its highest levels.

Although under the radar here in the U.S., the 2013 Staffordshire report issued by the public inquiry that began in 2010, containing more than one million pages and 64,000 documents, and costing British taxpayers about $20 million, Chairman Robert Francis made 290 recommendations. Above all, the report noted the insidious negative culture involving a tolerance of poor standards, a focus of working for the system and its bureaucratic measurements rather than for patients, and a lack of accountability to the patients who ultimately pay considerably for the services. Even though Health Secretary Jeremy Hunt said the report marked the start of a “fundamental change to the system,” the majority of recommendations simply add more regulation and more power to GP’s instead of more patient choice. Reality also prevents accepting the fantasy that the NHS-style socialized medicine as initiated in 1948 has actually lived up to the so-called “core value” of British society. For if true, it must seem odd that people of means in Britain consistently look elsewhere for medical care. About six million Brits now buy private health insurance, including almost two-thirds of Brits earning more than $78,700.

According to The Telegraph, the number of people paying for their own private care is up 20 percent year-to-year, with about 250,000 now choosing to pay for private treatment out-of-pocket each year. And does anyone wonder why Prince Philip recently chose to receive his medical care in the private London Clinic? Is it a mystery why Prince William and Kate Middleton have chosen to deliver their royal baby and receive birth care at the private St. Mary's Hospital? Isn’t it notable that more than 50,000 Britons travel out of the country per year and spend £161 million to receive medical care due to lack of access, even though they are hemorrhaging money for their national pride? When given the choice, Brits shun the NHS, and rightfully so. Sadly, just as in America, many in the media attempt to spin the facts and control public opinion.

As yet another crisis is revealed at an NHS hospital in Greater Manchester that is so chaotic that patients are being left in pain, wait up to four days to even see a doctor, embarrassingly apologetic statements by the UK media try to rationalize the disgraceful system and assert, albeit lamely, the NHS’s supposed virtues, such as “In the resulting 65 years it has, like any huge public body, been guilty of incompetence, cover-up and cavalier disregard of its patients” (Scotland’s The Herald, July 1, 2013). Even the hard-hitting 2013 Staffordshire report still insisted near the top of its list of summary points that “the NHS is a service of which the country can be justly proud, offering as it does universal access to free medical care, often of the highest order.” All of these statements, even though the UK government itself needs to issue report after report designing extraordinarily weak objectives for patient wait times and restating what should be inherently obvious goals, such as “We will put patients at the heart of the NHS” (Department of Health, 2010, Equity and excellence: Liberating the NHS, p.5).

The start of the NHS Many people come to this site for a short account of the health service The history of the NHS is that of an organisation established after a century's discussion on the provision of health services to meet a long recognised need. It appeared at a time when Britain saw health care as crucial to one of the "five giants" that Beveridge declared should be slain during post-war reconstruction. (want, disease, squalor, ignorance, idleness) The cataclysm of war provided an opportunity that might not have been taken in quieter times. The NHS was noble in conception and has been faced on the one side with ever increasing costs as a result of advances in medical knowledge, medicines and technology, and on the other with the financial restrictions inevitable in a centrally funded service with changing management dogmas and political beliefs. Whether knowing what we know now Britain would follow the same pathway towards a universal health care system is anyone's guess. Below you will find a quick and simplified over-view. You may find the link to the inheritance of the NHS is useful for this provides the text of the book's introductory chapter.

The links to 1948-1957 , 1958-1967 , 1968-1977 , 1978-1987 , 1988-1997 , 1998-2007 , 2008-2117 provide the text of the book and more recent decades. Two links give financial information over the years, earlier and later periods . More information on the factors that led to the creation of the NHS is to be found in Geoffrey Rivett's earlier book on the Development of the London Hospital System, This short account of the chronological time line, for simplicity’s sake, is mainly about England , though more detailed texts are available on this site and in hard copy [1] The Nuffield Trust has produced a historical timeline (to which I contributed). How we came to have a health service. Others have written extensively on the reasons for a health service.

These included The emergence of a view that health care was a right, not something bestowed erratically by charity Bipartisan agreement that the existing services were in a mess and had to be sorted out Financial difficulties for the voluntary hospitals The second world war that ensured the creation of an emergency medical service as part of the war effort The cataclysmic effects of the war that made it possible to have a massive change of system, rather than incremental modification An increasing view among the younger members of the medical profession that there was a better way of doing things The genesis of the NHS stretched back into the 19th Century. Even then some believed that access to health care was part of the structure of a civilized society. Some municipalities, such as the London County Council, had the ambition to run hospitals as well as utilities. Hospital charities had been supported by the benevolent while socialists such as the Webbs argued for a state system or the insurance principle - pay in advance when well to provide for the care needed when sick. In the First World War the army medical services had shown the benefits of organisation and transport. At the government's request in 1920 Lord Dawson produced a forward thinking report on how a health service might be organised.

[2] Under the Local Government Act (1929) local authorities had taken over poor law hospitals that now became municipal hospitals serving ratepayers, not paupers.. They needed much upgrading. In general the services that existed were in a mess. The quality varied widely from town to town, and country areas were in general poorly served. The London County Council and Middlesex were doing an excellent job - but many councils did not. There might be duplication or an almost total absence of specialist services. During the 1930s a series of reports were produced by the BMA [3] (1930), think tanks such as Political and Economic Planning (1937) [4] and the Hospitals Association. The King's Fund and the Nuffield Provincial Hospitals Trust as protectors of hospitals were also deeply involved for they appreciated that the future of the voluntary movement depended upon its efficiency. Working together and regionalisation were they key to this. The experience of the Second World War, when in 1939 an emergency medical service was instantly created as the country came under command and control, provided an example of what could be done.

In his report on social welfare systems Beveridge had little to say about the precise nature or funding of a health service, though seeing one as essential to a satisfactory system of social security (1942). [5] A major issue that later split the Labour Party was whether a future NHS should be run by local authorities, or quite separately on a regional basis. During the war the Conservatives produced the first White Paper on a future service in which local authorities would lead. (1944) [6] . But after Labour's election victory in 1945 Bevan presented to the Cabinet a radically different plan favouring nationalisation of all hospitals, voluntary or council, and a regional framework. After much tough negotiation this plan went through, with modest concessions. The National Health Service started in 1948 in a society weary but disciplined by war, and accustomed to austerity. There remained resilience, humour and a sense of fun. People who had become accustomed to little were content with simple things. Cinema, sport and radio, combined with “holidays at home” or the British seaside and Butlin’s camps, were the entertainment, there being little travel abroad.

We take the National Health Service for granted now, but it is only 60 years ago that health care was a luxury not everyone could afford. It is difficult for us to imagine what life was like without ‘free’ health care and the difference that the NHS made to people's lives. The same services were available the day after the creation of the NHS as the day before, no new hospitals were built nor hundreds of new doctors employed. But poor people who often previously went without medical treatment now had access to services, instead of relying instead on dubious and sometimes dangerous home remedies or the charity of doctors who gave their services free to their poorest patients. The services on which the NHS was based were General practitioners Access to a GP had been free to workers who were on low pay, but this didn't cover their wives or children, workers with a better standard of living or the retired. It worked through a "panel" often operated by Friendly Societies that paid GPs as little as possible. GPs in affluent areas could rely on income from their patients. Poorer people, if they could not pay the small fee, had little right to care but sometimes obtained it through the GP's charity.

Hospital care The tempo was slow by today’s standards, lengths of stay being numbered in weeks. Bed rest was a major form of treatment for heart attacks, ulcers, tuberculosis and childbirth. Something like a quarter of hospital beds were provided in voluntary hospitals. These varied from small hospitals in lesser towns supported by public subscription, to internationally famous teaching hospitals such as St Bartholomew's, Guy's and St Thomas ' with substantial investment income. A handful went back to a mediaeval origin and others were the result of the charity of the wealthy such as Thomas Guy in the 18th Century. Later some hospitals were developed in conjunction with universities, University College Hospital and the provincial teaching hospitals. Special hospitals concentrated on particular diseases or types of patients, children or women. But each voluntary hospital was a law unto itself, raising funds and deciding its admission policies. In London , the King's Fund had, since 1897, attempted to bring some order to the financial accounts, management, the location of voluntary hospitals, and to help with their costs. Patients were often charged and many hospitals were near bankrupt. Local authority services Most beds were provided in municipal hospitals by the local authorities of counties and large towns out of the rates.

They were a service to their ratepayers. Local authorities also provided maternity hospitals, hospitals for infectious diseases like scarlet fever, smallpox and tuberculosis, as well as those for the elderly, mentally ill and mentally handicapped and a variety of community services. The standard varied widely, depending upon the attitude of the Council Mentally ill people Mentally ill and mentally handicapped people were generally sent away to large forbidding institutions, not always for their own benefit, but because that was how the system worked. Admission was often for life. Under the poor conditions prevailing, many patients became worse rather than better and "institutionalised". However there was, in a true sense, asylum for people who could be 'strange' in private, and a basic standard of food and accommodation. Older people Older people who were no longer able to look after themselves fared particularly badly. Many ended their lives in the Public Assistance Institutions, the old workhouses feared by everyone. Workhouses changed their names in 1929, but their character and the stigma attached to them remained.

One of the early achievements in the NHS was the development of active geriatrics, when a start was made on dealing with the problem of the “back wards”, seldom visited by doctors, where people ended their days. 1948-1957 The National Health Service started on 5 July 1948 . It was a momentous achievement and, in spite of earlier professional opposition to some of the details, everybody wanted the new service to work. However, the weather was frightful, food was still rationed, there was a dollar economic crisis and a shortage of fuel. Yet the 1951 Festival of Britain, on the South Bank, provided a glimpse of a better future. The war had created a housing crisis - alongside post-war re-building of cities, the New Towns Act (1946) created major new centres of population which needed health services. Hospitals had little claim on the few building materials available - housing and schools came first. The distribution of consultant services was poor, for specialists were centred in the major hospitals in large cities where private practice was possible, not rural areas. In some large counties there were few consultants.

The NHS was founded at the time when massive innovation was occurring, some stimulated by war. The pharmaceutical industry was creating a flood of new drugs. Antibiotics, better anaesthetic agents, cortisone, drugs for the treatment of mental illness such as schizophrenia and depression, good diuretics for heart failure and the antihistamines all became available. Ultrasound was built upon wartime electronics expertise. These developments, while improving the lot of the patient, raised the cost of the NHS and Government had little experience of running a health service with an explosive tendency to expand. 1948 Royal Commission on Doctors' Pay First satellite, Treaty of Rome The principles of the NHS The NHS was based on principles unlike anything that had gone before in health care. Few other countries followed this pathway outside the eastern (Soviet) block. Others tended to rely on insurance based schemes. It was financed almost 100% from central taxation. The rich paid more than the poor for comparable benefits and Bevan regarded this as a crucial part of the scheme Everyone was eligible for care, even people temporarily resident or visiting the country. People could be referred to any hospital, local or more distant.

Care was entirely free at the point of use, although prescription changes and dental charges were subsequently introduced Administrative organisation The new service run by the Minister was "tripartite". Hospital services. The municipal and the voluntary hospitals were brought together in a single system in which all staff was salaried. Organisation was based upon 14 Regional Hospital Boards that oversaw local hospital management committees. The teaching hospitals were directly responsible to the Ministry of Health 'for they served the nation, not the locality.' Family doctors, dentists, opticians and pharmacists were self-employed under a contract for services from an Executive Council. The family doctor acted as gate-keeper to the rest of the NHS, referring patients where appropriate to hospitals or specialist treatment and prescribing medicines and drugs. However the GPs had been stretched by the war, as younger doctors were away, and their pay, status and morale was low. In 1955 some money was made available to GPs to develop group practices, the beginning of a major development. Dental services consisted of check-ups and all necessary fillings and dentures. Eye tests were provided by ophthalmic opticians on production of a GP referral note.

Pharmacists provided over the counter remedies and dispensed the GP’s prescriptions Local authority health services were managed by a Medical Officer of Health, who had lost command of municipal hospitals but still ran immunisation and maternity clinics, provided community nurses to support to the family doctors and oversaw the control of infectious diseases. There was a school dental service and a special priority service for expectant and nursing mothers and young children. A major innovation, health centres in the community, had been planned but few were built. These were to be premises with accommodation and equipment to enable family doctors, dentists, nurses, chiropodists and others to work together to provide a range of services on the spot. There were also to be specialist ear clinics at which patients could get an expert opinion and, if needed, a hearing aid. It had been hard to cost the day-to-day expenditure in advance and the taxpayer provided the same sums as previously available to each of the hospitals. High public expectations were encouraged. Hospital beds for tuberculosis and infectious diseases were soon closed as new treatment rendered them unnecessary, allowing cash to be released for other services, but new developments outpaced savings. Hospital delivery was increasing, cardiac surgery was being applied to rheumatic heart disease, and the first hip replacements were performed.

Estimates of the cost of the NHS were soon exceeded and within three years some modest fees were introduced, prescription charges of one shilling (5p) and a flat rate of £1 for dental treatment. A start was made on introducing consultant services in areas where they were deficient. Paying consultants, whatever their specialty, the same throughout the country helped. The District Hospital , a local hospital serving a natural geographic area, was an early concept and went back many years to the Dawson Report (1920). Such hospitals were coupled with university hospitals where more complex facilities were available. Balancing demands Many of the tensions of the early days of the NHS have challenged its senior management and successive governments ever since. The fundamental questions that tested Bevan and his colleagues - how best to organise and manage the service, how to fund it adequately, how to balance the often conflicting demands and expectations of patients, staff and taxpayers, how to ensure finite resources are targeted where they are most needed - continue to exist. Bevan foresaw this in speaking on 2nd June to a Royal College of Nursing conference. 'We shall never have all we need,' he said. 'Expectations will always exceed capacity.

The service must always be changing, growing and improving - it must always appear inadequate.' Increasing expenditure led to the appointment in 1953 of the Guillebaud Committee to 'enquire into the cost of the National Health Service'. The report (1956) [7] said that the committee found no opportunity for new sources of income or to reduce in a substantial degree the annual cost of the service. Indeed capital expenditure was too low. Guillebaud's comments and recommendations spread far wider than financial affairs and it was, in effect, the first major review of the NHS and its workings. The service's record 'was one of real achievement' and both parties now accepted the need for it, previously questioned in some quarters. 1958-1967 By the second decade the NHS was beginning to settle down. National Service was ending as the last conscripts entered the services. We had the Beatles and our first package holidays. Elizabeth David provided cooking inspiration. Treatment was improving as better drugs were introduced. During this decade polio vaccine became available, dialysis for chronic renal failure and chemotherapy for certain cancers were developed, all adding to costs.

Enoch Powell started the move towards the closure of the old asylums in his Church House speech. Powell's plan was for 'nothing less than the elimination of by far the greater part of this country's mental hospitals as they stand today' (1961). While much had already been done to appoint consultants in the major specialties throughout the country, their skills were not matched by the outdated and war-damaged buildings in which they worked. Powell's Hospital Plan, published in 1962, proposed the development of district general hospitals for population areas of about 125,000 and laid out a pattern for the future district by district. [8] The ten year programme was new territory for the NHS and it soon became clear it had underestimated the cost and time it would take to build new hospitals. But a start had been made and with the advent of postgraduate education centres, nurses and doctors could see a better future. 1958 First ATM Doctors' pay There were, however, problems for both GPs and hospital staff despite the slow development of a measure of trust between the professions and the Government.

The Royal Commission on doctors’ pay alleviated some of the arguments which had caused problems during the first decade by setting up a review body. Negotiations between the Government and GPs’ leaders led to the GPs' Charter, a new contract that provided financial incentives for practice development, and a substantial award which greatly raised GPs' morale. Practices slowly became better housed and better staffed, stimulating doctors to join together and the development of the modern group practice. Management Better management became a priority. The Cogwheel Report [9] in 1967 encouraged the involvement of clinicians. Hospital Activity Analysis was introduced to provide better patient-based information and in the hospitals 'divisions' were created to group medical staff by specialty to look at clinical/managerial problems. The Salmon Report [10] in 1967 encouraged the development of a senior nursing staff structure and raised the profile of the profession in hospital management. Porritt Report Attempts were made to reduce the disadvantages of the three part structure and there was growing acknowledgement of the complexity of the NHS and the importance of organisational change to meet future needs.

Maude, a former permanent secretary at the Ministry, had entered a note of reservation about it in Guillebaud (1956). In the 1962 Porritt Report, the medical profession also criticised the separation of the NHS into hospitals, general practice and local health authorities, called for unification and fired the debate on the structure of the NHS [11] 1968 - 1977 At the start of the third decade of the service clinical and organisational optimism prevailed in the NHS, but after the oil crisis of 1974 and the seven-day Israeli/Arab war, financial stringency reduced the growth rate of the NHS. Morale fell as such factors combined to bring the decade to an unpromising close. In the NHS attention turned to groups of patients who traditionally had a poor deal. The elderly, the mentally ill and handicapped, children’s services and the disabled were the subjects of reports, sometimes following scandals. Medical advances included the increasingly wide application of endoscopy and the advent of CAT (Computerised Axial Tomography) scanning. Transplant surgery was becoming increasingly successful and genetic engineering slowly began to influence medicine.

Intensive care units were now widely available and new drugs appeared, including non-steroidal anti-inflammatory treatments. Kidney dialysis became more widely available and surgery established a place in the care of coronary heart disease. On the downside, new infections, such as Lassa Fever emerged. Changes in abortion law led to new pressures on gynaecological services. 1968 Health for all 2000 declaration In general practice, the GPs' charter was encouraging the formation of primary health care teams, new group practice premises and an increase in the number of health centres. As the result of the Hospital Plan, some new hospitals were appearing and providing people with a better and more local service. The organisation of hospital nursing services was changed by the Salmon Report (not to everyone's satisfaction) and nurse education by Briggs, while the advent of information technology saw the first steps in health service computerisation and clinical budgeting. From 1968 to 1974 debate continued on the how the NHS should be organised. Key issues included local government reorganisation (Seebohm) and the desire to improve the co-ordination of health and social services by matching the boundaries of health and local authorities.

Two plans for structural reorganisation fell by the wayside; the third was implemented in April 1974, but not until the Conservative Government that devised it had been replaced by Labour in a General Election. It created problems rather than solving them. 1974 NHS reorganisation Fourteen Regional Health Authorities, covering all three parts of the NHS and incorporating the teaching hospitals, replaced the previous authorities. Consensus management, a belief that in a multidisciplinary NHS all skill groups should have a voice in decisions, underpinned reorganisation. A new tier of Area Health Authorities was established, with boundaries largely co-terminous with local authorities, between the regions and the district health authorities that managed the hospitals. The advantages were that the Area Health Authorities could unite the tripartite service and plan all NHS services in cooperation with local authorities. The disadvantages were that the system was complex & managerially driven and it soon earned criticism. Within two years, a Royal Commission on the NHS was appointed to look into the problem areas. Just as strategic planning, long-range forecasts and reallocation were introduced, inflation reached 26 per cent and wage restraint came in. Industrial action hit the NHS while consultants were alienated by proposals to reduce private practice within the service.

Resources planning Resources had been distributed unevenly across the NHS since 1948 but now successive Ministers, Richard Crossman and Barbara Castle, set up a Resource Allocation Working Party reporting in 1976. [12] It produced a new system of allocation targets based on population, mortality and other factors. Subsequently differential allocations helped regions towards their targets. The gainers were in the north. The losers were Oxford regions that entered a period of distress lasting many years. 1978 - 1987 The fourth decade was characterised by the growing acknowledgement of the clear financial bounds within which the NHS operated. The NHS had become a victim of its own success. It could no longer even pretend to do everything medically possible. Genetic engineering was yielding its first drug successes and magnetic resonance imaging was introduced. Minimal access surgical techniques were introduced, while the number of operations for fractured neck of the femur and osteoarthritis of the hip was reaching almost epidemic proportions. Increasing numbers of heart and liver transplants were being performed and surgical treatment for coronary heart disease was becoming common. This was the decade when the first cases of AIDS appeared, foreshadowing the world-wide epidemic.

Developing countries could not even start to emulate the patterns of health care practicable in the West. Increasingly they looked to primary health care, the use of semiskilled workers based in the community, and collaboration between different sectors, agriculture, water, sanitation and education. In September 1978 the World Health Organization (WHO) and UNICEF called a conference at Alma-Ata in the USSR . Its declaration stressed that primary care was the route to Health For All; this was thought achievable by the year 2000 and at affordable cost. More people were being treated in more complex ways. This led to rising expectations of the health service in an increasingly elderly population with all its attendant health needs. Beginning in 1978, the winter of discontent, the service's financial problems were worsened by the oil crisis. NHS management tried to improve efficiency and there were continued attempts to set priorities between the sectors of the NHS, the elderly, the mentally ill and the acute services. NHS restructuring in 1982 tried to simplify the organisation. The area tier was abolished so that there were now 192 District Health Authorities responsible to the RHAs.

7 Special Health Authorities continued to manage London postgraduate teaching hospitals and the 90 Family Practitioner Committees that had matched the earlier Areas persisted unchanged. 1978 GP Contract White Paper Black Wednesday on stock market Consensus management had been criticised for its managerial slowness but the Royal Commission (1979) [13] had explicitly rejected general (as opposed to consensus) management in the NHS. This was contradicted only two years later in an influential government-sponsored report (1983) [14] by a leading businessman, Sir Roy Griffiths of Sainsbury's. General management was introduced in 1984, encouraging: one individual at every level of an organisation being responsible and having authority and accountability for planning and implementing decisions more flexibility in team structures greater emphasis on clear leadership Doctors were encouraged to become more involved with budget decisions. Audit and Performance indicators Closer examination of professional activity followed international concern about rising costs. Audit of the results of anaesthesia and surgery was introduced. The tension between increasing demand and finite resources prompted new experiments in clinical budgeting and a desire for better health service information. Performance indicators were introduced.

The level of acute hospital services likely to be available in London in the future was examined by the London Health Planning Consortium. If money was to be moved to the north, into the Shire counties, and into services that had been under-resourced such as mental illness and the elderly, acute services would have to be cut in central London . A process of merger of hospitals and medical schools in London began. Community care Clinical advances placed increasing demands on nursing and medical staff. One option for the NHS was to move care from a hospital to a community setting. Community nursing was examined and the Government established two reviews, of general practice and nursing in primary health care (Cumberlege). Yet by 1987 health authorities throughout the country were in debt, waiting lists were growing and hospital wards were being closed - despite evidence of higher spending, steady increases in staff numbers and the treatment of more patients. Neither the public nor the health care professions were satisfied and the service was increasingly subjected to scrutiny in the media. 1988-1997 The consumer society was taking off. Long haul holidays, increasing reliance on consumer credit and the advent of Sky satellite TV (1989) reflected our changing expectations.

Yet the fifth decade opened with widespread uneasiness about the NHS. Younger people were cynical about whether they could rely on the NHS; older ones thought that many things had been better in the past. Hospital throughput had risen and new radical treatments demanded great stamina of patients. Evidence-based medicine, clinical effectiveness and medical audit were to the fore, internationally as well as in the UK . A White Paper in 1987 laid out the Conservatives' goals for a new contract for GPs. Early the following year Mrs Thatcher announced that the NHS as a whole would be reviewed. During 1991-97, a period of limited growth, an "internal market" was introduced throughout the UK, changing health authorities' responsibilities by separating the roles of purchaser and provider. The NHS experienced the most significant cultural shift since its inception , outlined in the 1989 White Paper, Working for Patients, [15] which passed into law as the NHS and Community Care Act 1990. The internal market was the Conservative Government's attempt to address problems, such as growing waiting lists, which had risen in the 1980s as a result of shortage of money while demand rose inexorably.

The proposals had been designed to increase the responsiveness of the service to the consumer, to foster innovation and to challenge the monopolistic influence of the hospitals on a health service in which community based services were increasingly important. Competition was one of the keys. 1988 Scots vote for devolution Labour back in power Before the 1990 Act a monolithic bureaucracy ran all aspects of the NHS. After the establishment of the internal market and the purchaser-provider split, 'purchasers' (health authorities and some family doctors) were given budgets to buy health care from 'providers' (acute hospitals, organisations providing care for the mentally ill, people with learning disabilities and the elderly, and ambulance services). To become a 'provider' in the internal market, health organisations became NHS trusts, independent organisations with their own management, competing with each other. The first wave of 57 NHS Trusts came into being in 1991. By 1995 all health care was provided by trusts. The wider problems of the country’s health were considered in The Health of the Nation [16] published in 1991 which set out diseases and conditions that might be helped by health promotion in the NHS.

GP fund holders Many family doctors were given budgets with which to buy health care from NHS trusts (and also from the private sector) in a scheme called GP fund holding. Each year more and more GPs joined. Those who did not have their own budgets had services purchased for them by health authorities that bought 'in bulk' from NHS trusts. Patients of GP fund holders were often able to obtain treatment more quickly than patients of non-fund holders. This led to accusations of the NHS operating a two tier system, contrary to the founding principles of the NHS of fair and equal access for all to health care. Supporters said fundholding saved money and was more efficient. Labour in power again In May 1997 Labour came back to power. Observers credited the internal market with improving cost consciousness in the NHS, but at a price: that the competition it encouraged between 'providers' saw unnecessary duplication of services. The new Labour government began to change things, pledging the abolition of the internal market. Though it said it would build on what had worked but discard what had failed, in the event it discarded some successes and introduced a period of instability. A new white paper issued under Frank Dobson by the Department of Health, The New NHS. Modern.

Dependable [17] , suggested that the service would be based on partnership and driven by performance. Once more there were attempts to improve matters by changing structure. 1998 – 2007 In this decade the NHS was controlled by Labour throughout. The country saw a boom in the property and financial markets and later the debacle of Northern Rock, worldwide financial crisis and a swing to the right. The accession of new countries to the European Community was followed by substantial immigration. The increasing capacity of curative medicine, the availability of more and more expensive drugs for the control of cancer and AIDS, and the developments in psychiatry in the community added to costs. The spectre of the rationing of care was never far from the surface internationally. Imaging and non-invasive surgery continued to improve and genetic medicine was said to promise a future of personalised treatment. 10 Downing Street became involved in the NHS as never before. Successive Secretaries of State, Frank Dobson, Alan Milburn, John Reid, Patricia Hewitt and Alan Johnson produced a series of plans, white papers and organisational changes. The NHS Plan of 2000 was the most significant.

[18] The "New Labour" internal market applied only to England and in a period of sustained increase in funds. PCTs contracted selectively with providers, and practice based commissioning with indicative budgets seemed an extension of the GP fundholding model. The turmoil hardly bears recounting, with the formation, dissolution and rearrangement of the structure and responsibilities of NHS authorities and trusts. NHS Foundation Trusts, a new type of trust with more independence, which encouraged public participation as members, appeared. For a while there were 10 strategic health authorities controlling some 200 primary care trusts that contracted with both public and private providers, trusts, hospitals, community, mental illness and ambulance, as well as managing GPs and primary health care. In parallel, new systems of financial flow, payment by results and a tariff system brought instability to the finances of the NHS. Health service computing finally began to deliver results, with transmission of data, reports, radiographs and prescriptions, between hospitals, surgeries and pharmacies. Patient choice for elective surgery was introduced from 2006. 1998 Labour losses in local elections Regulation increased. The National Institute for Clinical Excellence assessed the cost-effectiveness of new drugs and technologies.

The Healthcare Commission looked at the quality, governance and financial management of trusts. Bristol and Shipman were followed by a tightening of professional regulation. There was a drive for ‘modernisation’, changing skill mix and looking at effective ‘clinical pathways’ to increase capacity and reduce hospital waiting lists. Money increased. The NHS showed signs of becoming an electoral liability and Tony Blair made a commitment on Frost on Sunday (the most expensive breakfast in British history) increasing the growth rate of the NHS substantially for five years. A report [19] by Derek Wanless underpinned the recognition that the NHS was, by the standards of the developed world, grossly under resourced. A major expansion of training for doctors and nurses, and the establishment of new medical schools followed. However mistakes in the negotiation of contracts, particularly with GPs and consultants, added to the pressure on funds and led to a temporary financial crisis.

The money helped the implementation of the NHS Plan, four principles of which were A patient-focussed service (patient choice, an expanding independent sector and providing extra capacity) Competitive providers, giving hospitals and GPs incentives to change (Payment by results, money following patients, the prospect of "failure") Active purchasers - giving PCTs purchasing power and practice-based commissioning) Cost effectiveness and affordability, (tariffs, legal contracts and commissioning) Provision was no longer necessarily by a publicly owned infrastructure. Labour achieved a change that, had it been attempted by the Conservatives, would have faced immense opposition. Private sector organisations came to build and operate hospitals under the public/private partnerships, and to run clinical services such as Independent Treatment Centres and some NHS Walk-in Centres. "Contestability" - the introduction of competition between providers - became significant. Private practice was now an important part of a new and more sophisticated market. Labour's traditional desire to look at health care from a community and public health perspective led to policies rather than achievements (with the exception of a ban on smoking in public places). The decade ended as it had begun with reviews, Lord Darzi's of the services in London [20] and related reviews of the other SHAs.

Quality was now being made central to NHS development, amid fears that the world wide economic downturn would have a substantial effect on the NHS. 2008- 2017 The seventh decade opened amidst international financial crises with rising unemployment, attempts to ease the recession by public spending, and the knowledge that public services would soon suffer at best a reduced growth rate and at worst significant cuts. Clinical advances in genetic medicine, stem cell research, drugs particularly for cancer, and imaging would clearly increase the pressure on the NHS. Labour's period in power ended with the 2010 election when a Lib/Conservative coalition was formed. The new Secretary of State, Andrew Lansley, had developed and published proposals for change in 2007 while in opposition. They were modified during the course of coalition discussions, and changed again over the coming months. The new ideas did not seem to relate to current problems in the service. A White Paper appeared [21] , followed by a Bill, proposing to alter NHS structure yet again, phasing out Strategic Health Authorities and Primary Care Trusts, establishing NHS England and giving Clinical Commissioning Groups, heavily influenced by GPs, the majority of the NHS budget for hospital services.

The Act was passed after violent controversy in 2012, inducing chaos while one of the worst financial crises was hitting the NHS, Itr was implemented in April 2013. A new Secretary of State (2012) and NHS England Chief Executive (2014), Jeremy Hunt and Simon Stevens, attempted to calm and manage the system that was increasingly in deficit, estimating the additional money that might be needed. He produced a fine-year forward look suggesting new service models, and called for Sustainability and Transformation Plans. With the Conservative election victory, Hunt remained as Secretary of State. Financial problems loomed ever bigger and by May 2016 the annual deficit reached £2.5 billion. Wider issues The NHS: what can we learn from history? | History Extra Directory The NHS: what can we learn from history? Virginia Berridge explores the history of the NHS and asks whether this unique system provides the best way to keep us in shape. This article was first published in BBC History Magazine in 2009 Tuesday 15th September 2009 Labour politician Aneurin Bevan, the chief architect of the National Health Service, 20 August 1945.

(Photo by John F Stephenson/Topical Press Agency/Getty Images) What was British health care like before the NHS? The organisation of health care in Britain before 1948 – and access to it – had significant drawbacks. In 1911, the chancellor, Lloyd George, established a system of National Health Insurance. This offered benefits to the contributor below a certain level of income, and did not include dependants. Contributions were not graduated according to income but were paid at a flat rate – approximately half by the employee and half by the employer. In return for their contributions, individuals received cash benefits for sickness, accident and disability. These were paid at a fixed rate, regardless of severity – and were distributed through insurance companies. Contributors also had the right to free but limited care from a doctor on a local list or panel –yet were only entitled to hospital treatment when suffering from tuberculosis. As for doctors, they received a ‘capitation fee’ – a standard payment for each panel patient. Lloyd George’s insurance service may have been Britain’s largest pre-1948 health care system, yet it wasn’t alone in providing medical assistance.

The Poor Law offered relief to the most impoverished Britons, and workhouses provided their own infirmaries. The public health system in local government also provided a wide range of services, such as support for school meals and health education. By the 1930s, it had expanded its hospital provision, taking on Poor Law hospitals. The other major hospital system offering care to patients before the advent of the NHS was that of the voluntary hospitals. The majority of these were initially supported by donations from subscribers who had the right to sponsor patients for admission. Yet, by the 1930s, they found themselves in the midst of a financial crisis. In short, Britain’s health care system, pre-1948, did not work well. It was a patchwork of institutions which were not accessible according to need. The two primary deficiencies were lack of access to hospital care and lack of access to health care for dependants – the families of working men. Many of these had no formal health cover and had to use self-medication or medicines bought over the counter from the local pharmacist. As a result, an illness, or paying for medical attendance at a birth, could cause major financial problems for families across the country.

How did the NHS differ from what had preceded it? The National Health Service, which came into existence on the ‘appointed day’, (5 July 1948), was the first health system to offer free medical care to the entire population at the point of need. The service was paid for out of taxation, and was not based on the insurance principle, with entitlement following contributions. Before and during the war it was thought that the public health service in local government would provide the eventual basis for a national system. However, hospitals were nationalised and, significantly, the role of local government was limited. The new service was totally free until 1951, when charges were imposed for prescriptions, dental care and spectacles. What’s wrong with the structure of the NHS? The chief problem with the structure of the NHS was that, from the outset, it was a compromise set in place to secure the support of the medical profession. The Labour government that founded it wanted to establish a locally administered entity but was confronted by a profession that was hostile to a salaried service within local government.

The minister of health, Aneurin Bevan, was well aware that the NHS simply couldn’t survive without the support of the doctors, and so secured their backing by nationalising the hospitals. The upshot is a service that has been consistently criticised for its ‘democratic deficit’ – the loss of local democracy that resulted from it being taken out of the control of local councillors. The NHS has also attracted criticism for its lack of integration. When established, it was divided into three individual parts: hospitals, local government services and general practice – each of which tended to operate separately from one another. What does history teach us? The model of the NHS, centrally funded out of taxation and thus politically directed, was quite different from that of other health systems reorganised after the war. Universal access was a tremendous step forward – in particular for women. The removal of fear of illness cannot be underestimated and, as a result, the NHS was popular at its inception and its ideal has remained so. Indeed, politicians have not interfered with these founding ideals, despite a flirtation with insurance in the 1980s. NHS tax funding has meant that health matters are far more sensitive in the UK than in insurance-based countries.

Politicians have tried to find solutions to the problems of health care delivery in relentless reorganisations of the service or in the establishment of central targets – one recent example being general practice appointment booking. Despite the NHS’s early acquired reputation for financial profligacy, it was in fact a cost-effective service. The initial financial estimates for the service assumed that it would be funded out of local and not national taxation and so had underestimated its true cost. In recent years politicians have increased the proportion of funding given to the NHS. Instead, it’s the NHS’s structure that has led to its continuing problems. The pre‑NHS service may have been fragmented but the NHS tripartite service (hospitals, local government services and general practice) also left much to be desired. The ‘polyclinic’ has been advanced by government adviser Ara Darzi as a new solution to the problem of bringing together specialists, other services and general practitioners. But this is not a new idea. Indeed, health centres were intended to be the unifying force in the NHS in 1948 – though few were built.

The original NHS was a doctor-dominated service, and negotiations between GPs and the government continue to take centre stage, as seen in the recent rise in GP pay and the conflict over surgery opening hours. Despite the NHS’s success, private medicine retains a role, now taking a new form in the shape of health care companies, who provide primary care or the private funding of hospital building. The NHS of 1948 was dominated every bit as much by hospitals as it was by doctors. This dominance has continued and is represented currently through the prominence given to foundation hospitals, which seem rather like the old voluntary hospitals reborn. The pre-eminence of hospitals had one immediate consequence for the NHS: it became preoccupied with curing sickness rather than promoting good health. As a result, public health services were downgraded in value, and have struggled to find a role within the health system ever since, losing their position in local government altogether in the 1970s.

However, in the wake of the Wanless Report of 2004, strenuous moves have been made to reorientate the service towards what is now called Primary Health Care (PHC) – and the government has adopted a more holistic approach, enabling a wider range of practitioners to deliver health care. This places GPs, dentists and midwives at the heart of the service. As such, community pharmacists can now be seen as building on the practice of ‘counter prescribing’. The ‘democratic deficit’ within the service has continued to elude resolution. Patient and public participation in the structure of the NHS has traditionally been limited and so, with patient choice firmly back on the agenda, the government is reassessing patient input once more. Three lessons from history 1) The NHS ideal of universal access at the point of need was unique and has retained its popularity. Politicians are likely to remain ultimately responsible through government tax funding. 2) Delivery of the ideal continues to present problems. The structures put in place in 1948 were flawed, giving doctors too great an influence, a focus on sickness rather than positive health, and a lack of democratic input.

3) Such structural problems, or attempts to deal with them, are often presented as new initiatives, when they have a history. How ‘polyclinics’ or local democracy operated in the past could inform today’s policy discussions. Professor Virginia Berridge directs the Centre for History in Public Health at the London School of Hygiene and Tropical Medicine. She is the author of Marketing Health: Smoking and the Discourse of Public Health in Britain, 1945–2000 (OUP, 2007). Britain Plans to Decentralize National Health Care - The New York Times The New York Times Europe |Britain Plans to Decentralize Health Care Search Continue reading the main story LONDON — Perhaps the only consistent thing about Britain ’s socialized health care system is that it is in a perpetual state of flux, its structure constantly changing as governments search for the elusive formula that will deliver the best care for the cheapest price while costs and demand escalate. Even as the new coalition government said it would make enormous cuts in the public sector, it initially promised to leave health care alone.

But in one of its most surprising moves so far, it has done the opposite, proposing what would be the most radical reorganization of the National Health Service , as the system is called, since its inception in 1948. Practical details of the plan are still sketchy. But its aim is clear: to shift control of England’s $160 billion annual health budget from a centralized bureaucracy to doctors at the local level. Under the plan, $100 billion to $125 billion a year would be meted out to general practitioners, who would use the money to buy services from hospitals and other health care providers. The plan would also shrink the bureaucratic apparatus, in keeping with the government’s goal to effect $30 billion in “efficiency savings” in the health budget by 2014 and to reduce administrative costs by 45 percent. Tens of thousands of jobs would be lost because layers of bureaucracy would be abolished.

Continue reading the main story In a document, or white paper, outlining the plan , the government admitted that the changes would “cause significant disruption and loss of jobs.” But it said: “The current architecture of the health system has developed piecemeal, involves duplication and is unwieldy. Liberating the N.H.S., and putting power in the hands of patients and clinicians, means we will be able to effect a radical simplification, and remove layers of management.” Advertisement Continue reading the main story The health secretary, Andrew Lansley, also promised to put more power in the hands of patients. Currently, how and where patients are treated, and by whom, is largely determined by decisions made by 150 entities known as primary care trusts — all of which would be abolished under the plan, with some of those choices going to patients. It would also abolish many current government-set targets, like limits on how long patients have to wait for treatment. The plan, with many elements that need legislative approval to be enacted, applies only to England; other parts of Britain have separate systems. The government announced the proposals this month. Reactions to them range from pleased to highly skeptical.

Many critics say that the plans are far too ambitious, particularly in the short period of time allotted, and they doubt that general practitioners are the right people to decide how the health care budget should be spent. Currently, the 150 primary care trusts make most of those decisions. Under the proposals, general practitioners would band together in regional consortia to buy services from hospitals and other providers. It is likely that many such groups would have to spend money to hire outside managers to manage their budgets and negotiate with the providers, thus canceling out some of the savings. David Furness, head of strategic development at the Social Market Foundation, a study group, said that under the plan, every general practitioner in London would, in effect, be responsible for a $3.4 million budget. Photo The new British government’s plan to drastically reshape the socialized health care system would put local physicians like Dr. Marita Koumettou in north London in control of much of the national health budget. Credit Andrew Testa for The New York Times “It’s like getting your waiter to manage a restaurant,” Mr. Furness said. “The government is saying that G.P.’s know what the patient wants, just the way a waiter knows what you want to eat.

But a waiter isn’t necessarily any good at ordering stock, managing the premises, talking to the chef — why would they be? They’re waiters.” But advocacy groups for general practitioners welcomed the proposals. “One of the great attractions of this is that it will be able to focus on what local people need,” said Prof. Steve Field, chairman of the Royal College of General Practitioners, which represents about 40,000 of the 50,000 general practitioners in the country. “This is about clinicians taking responsibility for making these decisions.” Please verify you're not a robot by clicking the box. Invalid email address. Please re-enter. You must select a newsletter to subscribe to. Sign Up Privacy Policy Dr. Richard Vautrey, deputy chairman of the general practitioner committee at the British Medical Association, said general practitioners had long felt there were “far too many bureaucratic hurdles to leap” in the system, impeding communication. “In many places, the communication between G.P.’s and consultants in hospitals has become fragmented and distant,” he said.

Advertisement Continue reading the main story The plan would also require all National Health Service hospitals to become “foundation trusts,” enterprises that are independent of health service control and accountable to an independent regulator (some hospitals currently operate in this fashion). This would result in a further loss of jobs, health care unions say, and also open the door to further privatization of the service. The government has promised that the new plan will not affect patient care and that the health care budget will not be cut. But some experts say those assertions are misleading. The previous government, controlled by the Labour Party, poured money into the health service — the budget is now about three times what it was when Labour took over, in 1997 — but the increases have stopped. The government has said the budget will continue to rise in real terms for the next five years, but it is unlikely that the increases will keep up with the rising costs of care and the demands of an aging population. “The real mistake that is being made by the health secretary is to drive through an ideologically determined program of reorganization which is motivated by the principle of efficiency savings,” said Robin Durie, a senior lecturer in politics at the University of Exeter.

“History shows clearly that quality will suffer as a consequence.” Dr. Durie added, “The gulf between the rhetoric of the white paper and the technicalities of what is involved in the various elements of the overall reorganization being proposed is just extraordinary.” For example, he asked, how will the government make good on its promise to give patients more choice — a promise that seems to require a degree of administrative oversight — while cutting so many managers from the system? “How will the delivery of all this choice be funded?” Dr. Durie asked. “And how will the management of the delivery of choice be funded?” Dr. Vautrey said the country needed to have a “mature debate about what the N.H.S. can and cannot afford.” He said: “It is a sign of the mixed messages that government sends out. They talk about choice and competition and increased patient expectations at the same time as they tell the service they need to cut costs and refer less and prescribe less. People need to understand that while the needs of everyone may be met, their wants will be limited.” As they prepare for the change, many doctors are wondering whether it will be permanent this time around.

Advertisement Continue reading the main story “Many of our colleagues have seen this cycle of change repeatedly,” Dr. Vautrey said. “Many would look at previous reorganizations and compare it to this one and wonder how long the current change will last before the next one comes along.” A version of this article appears in print on July 25, 2010, on Page A11 of the New York edition with the headline: Plan to Remake British Health Care Would Put Local Doctors in Charge. Order Reprints | Today's Paper | Subscribe How Does Britain's National Health Service Work? - TIME Follow @TIME In recent weeks, opponents of Barack Obama's health-care-reform plans have criticized Britain's National Health Service (NHS) in an effort to counter the President's proposals for greater government involvement in health care. Republican Senator Chuck Grassley of Iowa suggested that his Democratic colleague Edward Kennedy would have been left to die in Britain because doctors would have refused the 77-year-old treatment for his brain tumor, and former House of Representatives Speaker Newt Gingrich wrote in an article that British health care is run by "Orwellian" bureaucrats who put a price tag on life.

Meanwhile, the lobby group Conservatives for Patients' Rights (CPR) has been running scare ads with horror stories from British patients on its website. TIME takes a look at what the NHS is really all about. What is the NHS? The NHS is a rare example of truly socialized medicine. Health care is provided by a single payer  the British government  and is funded by the taxpayer. All appointments and treatments are free to the patient (though paid for through taxes), as are almost all prescription drugs. The maximum cost of receiving any drug prescribed by the NHS is $12. (Read "The Year in Medicine 2008: From A to Z.") How was it formed? The NHS officially came into being in July 1948, in the wake of World War II, to replace an inadequate system of volunteer hospitals that had, during the war, come to rely on government funding. Doctors and conservative politicians vehemently opposed the NHS in the run-up to its formation, using many of the arguments that opponents of greater government involvement in the U.S. cite today.

According to Geoffrey Rivett, author of From Cradle to Grave  The First 60 Years of the NHS, the then head of doctor's body the British Medical Association (BMA), Charles Hill, gave a radio address in 1948 in which he asked, "Do you really want the state to be your doctor?" Today, the BMA is a champion of the NHS and resists any privatization initiatives. In a statement on Aug. 14, BMA chairman Dr. Hamish Meldrum said, "The NHS is not perfect. But the market-style philosophy of the U.S. is a lesson we could do well without." How does NHS health care compare with U.S. health care? Like most developed countries, Britain ranks above the U.S. in most health measurements. Its citizens have a longer life expectancy and lower infant mortality, and the country has more acute-care hospital beds per capita and fewer deaths related to surgical or medical mishaps. Britain achieves these results while spending proportionally less on health care than the U.S.  about $2,500 per person in Britain, compared with $6,000 in the U.S.

For these reasons, the World Health Organization (WHO) ranked Britain 18th in a global league table of health-care systems (the U.S. was ranked 37th). However, there are measures by which the U.S. outperforms Britain: for instance, the U.S. has lower cancer mortality rates. (See how to prevent illness at any age.) Does private health insurance exist in Britain? Yes, and it works in a similar way to health insurance in the U.S. Many employers offer private health-insurance plans as a perk to workers  a minority of patients opt out of the NHS system to receive their medical treatments privately. Private patients can choose their specialists and avoid waiting lists for non-emergency procedures; NHS patients wait an average of about eight weeks for treatments that require admission to a hospital, four weeks for out-patient treatments and two weeks for diagnostic tests. While NHS patients have a choice of hospitals, they cannot always choose their specialist.

Question: In which year was the National Health Service established in Great Britain?
Answer: 1948