National Health Service (England)

The National Health Service (NHS) is the publicly funded national healthcare system for England and one of the four National Health Services for each constituent country of the United Kingdom. It is the largest single-payer healthcare system in the world. Primarily funded through the government and overseen by the Department of Health and Social Care, NHS England provides healthcare to all legal English residents, with most services free at the point of use. Some services, such as emergency treatment and treatment of infectious diseases, are free for everyone, including visitors.[2]

National Health Service
Publicly funded health service overview
Formed5 July 1948 (1948-07-05)
HeadquartersRichmond House, London, England
Employees1.4 million
Annual budget£134 billion (2019)[1]
Minister responsible
Publicly funded health service executive
Parent departmentDepartment of Health and Social Care

Free healthcare at the point of use comes from the core principles at the founding of the National Health Service. The 1942 Beveridge cross party report established the principles of the NHS which was implemented by the Labour government in 1948. In practice, "free at the point of use" normally means that anyone legitimately and fully registered with the system (i.e., in possession of an NHS number), available to legal UK residents regardless of nationality (but not non-resident British citizens), can access the full breadth of critical and non-critical medical care, without payment except for some specific NHS services, for example eye tests, dental care, prescriptions and aspects of long-term care. These charges are usually lower than equivalent services provided by a private provider and many are free to vulnerable or low-income patients.[3][4]

The NHS provides the majority of healthcare in England, including primary care, in-patient care, long-term healthcare, ophthalmology and dentistry. The National Health Service Act 1946 came into effect on 5 July 1948. Private health care has continued parallel to the NHS, paid for largely by private insurance: it is used by about 8% of the population, generally as an add-on to NHS services.

The NHS is largely funded from general taxation, with a small amount being contributed by National Insurance payments[5] and from fees levied in accordance with recent changes in the Immigration Act 2014.[6] The UK government department responsible for the NHS is the Department of Health and Social Care, headed by the Secretary of State for Health and Social Care. On 9 January 2018, the Department of Health was renamed the Department of Health and Social Care. The Department of Health had a £110 billion budget in 2013–14, most of this being spent on the NHS.

In 2017, UK media reported that the Care Quality Commission (CQC) said that the NHS is "straining at the seams" with a "precarious" future.[7] Sources do not always make clear if they refer to the whole of the NHS or only to England. In 2019 senior NHS leaders warned shortages of doctors and nurses are so acute that patient safety and quality of patient care are at risk.[8] See staffing problems.


The NHS was established within the differing nations of the United Kingdom through differing legislation, and such there has never been a singular British healthcare system, instead there are 4 health services in the United Kingdom; NHS England, the NHS Scotland, HSC Northern Ireland and NHS Wales, which were run by the respective UK government ministries for each home nation before falling under the control of devolved governments in 1999.[9] In 2009, NHS England agreed to a formal NHS constitution, which sets out the legal rights and responsibilities of the NHS, its staff, and users of the service, and makes additional non-binding pledges regarding many key aspects of its operations.[10]

The Health and Social Care Act 2012 came into effect in April 2013, giving GP-led groups responsibility for commissioning most local NHS services. Starting in April 2013, Primary Care Trusts (PCTs) began to be replaced by General Practitioner (GP)-led organisations called Clinical Commissioning Groups (CCGs). Under the new system, a new NHS Commissioning Board, called NHS England, oversees the NHS from the Department of Health.[11] The Act has also become associated with the perception of increased private provision of NHS services. In reality, the provision of NHS services by private companies long precedes this legislation, but there are concerns that the new role of the healthcare regulator ('Monitor') could lead to increased use of private sector competition, balancing care options between private companies, charities, and NHS organisations.[11] NHS Trusts responded to the Nicholson challenge—which involved making £20 billion in savings across the service by 2015.

Some NHS organisations use referral management centres to help reduce inappropriate referrals, in an attempt to save the NHS money. Millions of pounds have been spent for these services, 32% of which are provided by private companies, since 2013. Of the 211 clinical commissioning groups (CCGs) surveyed by the British Medical Journal in 2016, 184 responded and 72 of those said they had used such schemes. Of those CCGs using these services, 14% could show savings, 12% showed no overall savings and 74% could not show whether money had been saved. Because these services can prevent GPs from referring patients to hospitals, there are some concerns they may delay diagnosis and compromise patient safety.[12][13]

GPs are leaving the profession because they feel the government undervalues them, and they feel the government pushes too much work onto them. GPs who do all the work needed to ensure patient safety fear that overwork compromises their own health. There were 33,302 GPs in England in October 2017, and 34,495 the previous year.[14] The Care Quality Commission found patient safety is compromised in hospitals because staff are overworked and do not have time for safety checks and procedures. Staff shortages, high staff turnover and confusion over which NHS body is responsible for patient safety contribute to lapses in safety. The CQC stated: "Staff at both leadership and frontline levels told us that they felt overwhelmed by the volume and nature of the demands currently placed on them. The number of alerts and amount of other information from multiple organisations, for example about different targets and initiatives, can be unmanageable." There are roughly 2m patient safety incidents every year and 21,500 of them are serious. Problems have included swabs being left in a patient's body, and surgeons operating on the wrong part of the patient's body. Overworked NHS staff do not have time to do sufficient education and training to update themselves on patient safety. [15]


A. J. Cronin's controversial novel The Citadel, published in 1937, had fomented extensive debate about the severe inadequacies of healthcare. The author's innovative ideas were not only essential to the conception of the NHS, but in fact, his best-selling novels are said to have greatly contributed to the Labour Party's victory in 1945.[16]

A national health service was one of the fundamental assumptions in the Beveridge Report. The Emergency Hospital Service established in 1939 gave a taste of what a National Health Service might look like.

Healthcare prior to the war had been an unsatisfactory mix of private, municipal and charity schemes. Bevan decided that the way forward was a national system rather than a system operated by local authorities. He proposed that each resident of the UK would be signed up to a specific General Practice (GP) as the point of entry into the system, building on the foundations laid in 1912 by the introduction of National Insurance and the list system for general practice. Patients would have access to all medical, dental and nursing care they needed without having to pay for it at the time.

In the 1980s, Thatcherism represented a systematic, decisive rejection and reversal of the post-war consensus, wherein the major political parties largely agreed on the central themes of Keynesianism, the welfare state, the mixed economy, supplies both of public and private housing, and close regulation of the economy. There was one major exception: the National Health Service, which was widely popular and had wide support inside the Conservative Party. In 1982, Prime Minister Margaret Thatcher promised Britons that the NHS is "safe in our hands."[17]

In 2011, the government signed off on the 10-year contract to manage the debt-laden Hinchingbrooke Hospital in Huntingdon, Cambridgeshire by Circle Healthcare. It was the first time that management of an NHS hospital was taken over by a stock-market listed company.[18]

There have been documented failures of some parts of the National Health Service to provide adequate care at a basic level. These failures were associated with bureaucratic fumbling as local institutions attempted to meet conflicting demands with inadequate resources.[19] This notwithstanding, the NHS has received consistently strong approval and support from citizens.[20]

Core principles

The principal NHS website states the following as core principles:[21]

The NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth. At its launch by the then minister of health, Aneurin Bevan, on 5 July 1948, it had at its heart three core principles:

  • That it meet the needs of everyone
  • That it be free at the point of delivery
  • That it be based on clinical need, not ability to pay

These three principles have guided the development of the NHS over more than half a century and remain. However, in July 2000, a full-scale modernisation programme was launched and new principles added.

The main aims of the additional principles are that the NHS will:

  • Provide a comprehensive range of services
  • Shape its services around the needs and preferences of individual patients, their families and their carers
  • Respond to the different needs of different populations
  • Work continuously to improve the quality of services and to minimise errors
  • Support and value its staff
  • Use public funds for healthcare devoted solely to NHS patients
  • Work with others to ensure a seamless service for patients
  • Help to keep people healthy and work to reduce health inequalities
  • Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance


The English NHS is controlled by the UK government through the Department of Health and Social Care (DHSC), which takes political responsibility for the service. Resource allocation and oversight was delegated to NHS England, an arms-length body, by the Health and Social Care Act 2012. NHS England commissions primary care services (including GPs) and some specialist services, and allocates funding to 211[22] geographically-based Clinical Commissioning Groups (CCGs) across England. The CCGs commission most services in their areas, including hospital and community-based healthcare.[23]

A number of types of organisation are commissioned to provide NHS services, including NHS trusts and private sector companies. Many NHS trusts have become NHS foundation trusts, giving them an independent legal status and greater financial freedoms. The following types of NHS trusts and foundation trusts provide NHS services in specific areas:[24]

Some services are provided at a national level, including:

  • is the primary public-facing NHS website, providing comprehensive official information on services, treatments, conditions, healthy living and current health topics
  • NHS special health authorities provide various types of services


In the year ending at March 2017, there were 1.187 million staff in England's NHS, 1.9% more than in March 2016.[25] There were 34,260 unfilled nursing and midwifery posts in England by September 2017, this was the highest level since records began.[26] 23% of women giving birth were left alone part of the time causing anxiety to the women and possible danger to them and their babies. This is because there are too few midwives.[27] Neonatal mortality rose from 2.6 deaths for every 1,000 births in 2015 to 2.7 deaths per 1,000 births in 2016. Infant mortality (deaths during the first year of life) rose from 3.7 to 3.8 per 1,000 live births during the same period.[28] Assaults on NHS staff have increased, there were 56,435 recorded physical assaults on staff in 2016-2017, 9.7% more than the 51,447 the year before. Low staffing levels and delays in patients being treated are blamed for this.[29]

Nearly all hospital doctors and nurses in England are employed by the NHS and work in NHS-run hospitals, with teams of more junior hospital doctors (most of whom are in training) being led by consultants, each of whom is trained to provide expert advice and treatment within a specific speciality. From 2017, NHS doctors must reveal how much money they make from private practice.[30]

General practitioners, dentists, optometrists (opticians) and other providers of local health care are almost all self-employed, and contract their services back to the NHS. They may operate in partnership with other professionals, own and operate their own surgeries and clinics, and employ their own staff, including other doctors etc. However, the NHS does sometimes provide centrally employed health care professionals and facilities in areas where there is insufficient provision by self-employed professionals.

Year[32]NursesDoctorsOther qualified[33]ManagersTotal
1978339,65855,00026,000-1,003,000[34] (UK)

Note that due to methodological changes, the 1978 figure is not directly comparable with later figures.

A 2012 analysis by the BBC estimated that the NHS across the whole UK has 1.7 million staff, which made it fifth on the list of the world's largest employers (well above Indian Railways).[35] In 2015 the Health Service Journal reported that there were 587,647 non-clinical staff in the English NHS. 17% worked supporting clinical staff. 2% in cleaning and 14% administrative. 16,211 were finance staff.[36]

The NHS plays a unique role in the training of new doctors in England, with approximately 8,000 places for student doctors each year, all of which are attached to an NHS University Hospital trust. After completing medical school, these new doctors must go on to complete a two-year foundation training programme to become fully registered with the General Medical Council. Most go on to complete their foundation training years in an NHS hospital although some may opt for alternative employers such as the armed forces.[37]

Most NHS staff, including non-clinical staff and GPs (although most GPs are self-employed), are eligible to join the NHS Pension Scheme—which, from 1 April 2015, is an average-salary defined-benefit scheme.

Staffing problems

Nurses who are nationals of other EU nations are leaving the NHS in large numbers because their ability to live and work in the UK after Brexit has not been guaranteed[38] and there are fears that doctors could also leave.[39] 11,600 EU citizens stopped working for the NHS from the Brexit referendum to 2019, that includes 4,783 nurses. The figures include less than half of NHS trusts so the actual figure is likely to be far worse. Among the worst affected trusts are London North West, Oxford University Hospitals and University Hospitals Bristol. EU nurses arriving fell 87% from 6,382 in 2016-17 to 805 in 2017-18. Documents from a Hillingdon trust board meeting warn about the, “anxiety felt by approximately 300 EU nationals in the workforce in terms of their jobs and future”. Another document fears, “the risks to plant and equipment/parts where the supply is from the EU is significant”.[40]

Thirty-three thousand nurses are leaving the NHS each year. Work pressure and low pay are blamed.[41] Pay increases have been capped at 1% per year though inflation is higher than that. NHS Providers claims this makes recruiting and retaining staff difficult and puts patient safety at risk. Chris Hopson of NHS Providers said, "Growing problems of recruitment and retention are making it harder for trusts to ensure patient safety. Unsustainable staffing gaps are quickly opening up." Seven years of pay restraint together with stressful work had a bad effect on the workforce. Hopson said further, "Pay is becoming uncompetitive. Significant numbers of trusts say lower paid staff are leaving to stack shelves in supermarkets rather than carry on working in the NHS." Uncertainty over Brexit signified that, "Vital recruitment from EU countries is dropping rapidly. Pay restraint must end and politicians must therefore be clear about when during the lifetime of the next parliament it will happen and how.” Hopson repeated NHS Providers request for £25bn in additional funds and warned staff are also leaving through exhaustion because of constant work to meet unprecedented demands for care.[42][43] Trainee doctors are 'propping 'hospitals due to lack of consultants. Shortages of family doctors are feared in areas like Kent, Medway and Somerset where many doctors are over 55 years old and therefore likely to retire.[39] Unfilled vacancies have reached record levels and rose by 12% in the year to 2017. There is a particular shortage of nurses and midwives.[44][45] More GP's are leaving the profession than are entering despite a government drive to recruit GP's.[46] The numbers of both doctors and nurses in the NHS are both falling despite more being needed and despite government efforts to recruit more. The Guardian stated "Health Foundation finds fall in number of nurses and GPs, and casts doubt on ability of government to meet staffing targets" High staff turnover is damaging the NHS financially and damaging continuity of care. The 1% pay cap on NHS salaries is blamed for this.[47] In the year 2016-17 the number of GP's working in the NHS in England fell by 1,190.[48] The number of patients having to wait more than two weeks to see a GP is increasing in 2019.[49] Staff shortages are in some areas so bad patient safety is at risk.[50] Patients sometimes die or are permanently disabled due to lack of specialist staff who could have prevented this.[51] In 2019 overworked GP's tried to change their contract so they would not need to do home visits though some patients need home visits. Jon Ashworth said, “In 2015 they [the government] promised more GPs, which like their pledges on everything else, never happened. And now there is a serious threat that elderly and vulnerable patients who rely on home visits will have that vital support removed.”[52]

As of January 2018 hospitals were under unprecedented pressure. Patients were waiting in corridors because there were insufficient beds for them. There were delays before patients were seen. Nick Scriven of the Society for Acute Medicine stated, "The position [across the NHS] is as bad as I've known it. Big issues are currently nursing staffing levels, with extra beds being opened around hospitals to cope with winter surge and not enough nurses to go round. This is the same for doctors and therapists. Diagnostic facilities in hospitals will be swamped – a vicious circle of increased need causing longer delays in whole system."[53] Operations like knee and hip replacements are being delayed to free up beds.[54]

Commentators are increasingly arguing that staffing shortages are endangering the sustainability of the NHS. There are too few health workers, nurses and midwives, doctors are also in short supply. Hospitals, Community Trusts and Mental Health Trusts all face shortages.[55] NHS England is almost 100,000 short of qualified staff it needs.[56] Some General practitioners are losing sleep because they worry work pressure may have led them to miss something that puts a patient at risk.[57] In hospitals junior doctors are sometimes forced to do work beyond what they have been trained for. This is stressful for doctors and puts patients at risk. Overworked consultants do not have the time to carry out proper supervision of less qualified doctors.[58] In a survey by The Observer and The Guardian newspapers the overwhelming majority of NHS staff feared lack of key staff was compromising the quality of patient care and patient safety.[59] The Medical Protection Society found in 2019 that 52% of doctors feel their work-life balance is unsatisfactory, 46% feel guilt when they take time off, and nearly 40% think their employer gives them too little support to enable them to do their job well. Jane Dacre said, “They tell us that the human impact of all these things – rota gaps, austerity, low morale, working in hospitals with paint peeling off the walls and equipment that doesn’t work, and not feeling that you can do your best for patients – is becoming disproportionate and is undermining doctors’ sense of vocation.”[60] Anita Charlesworth of the Health Foundation said, “With major staffing shortages across nursing and general practice the NHS is ever more reliant on the commitment of staff to go the extra mile. That commitment to patient care is a huge asset but it’s no substitute for having enough staff to meet demand. Ultimately nursing shortages are a policy choice not an inevitability. We need to train more staff and provide a better offer to the people currently in the NHS so that fewer leave.”[61]

Additionally, due to the larger numbers in winter, the NHS declared a black alert (an official admission that it can't cope with demand) for the past few years. In 2018, they did this on 2 January, canceling non emergency appointments and surgeries due to high demand, worsened by limited staffing.[62] As of autumn 2018 shortages of medical staff at many levels were again increasing.[63]

In November 2019 pressure on hospitals is already building. Hospitals are urged to cut back on non-urgent operations like hip and knee replacements. It is estimated that roughly 15,000 operations will not take place due to this in the first fortnight of January 2020. In November 2019 ambulances increasingly face delays when delivering patients at A&E. The public are urged to help by getting flu vaccination and by using NHS 111 and local pharmacies. Hospitals are urged to give priority to cancer treatment and other planned operations that would harm patients if cancelled.[64] 90% of hospital bosses in England fear understaffing in NHS England is so extreme that the health of patients could suffer. 58% expect winter 2019-20 to be the hardest so far for NHS England. Waiting times in hospitals for A&E care, cancer treatment and planned operations are the worst since records began but service chiefs expect delays to get even worse when cold weather increases need for hospital care. 76% of senior NHS leaders say staff shortage is the most serious issue. 83% say the problem with senior doctors’ pensions aggravates understaffing. 69% say doctors working less time damages patient care. 98% say the worsening crisis over social care is increasing the number of older people needing to go to hospital.[8]

2012 reforms

The coalition government's white paper on health reform, published in July 2010, set out a significant reorganisation of the NHS. The white paper, Equity and excellence: liberating the NHS,[65] with implications for all health organisations in the NHS abolishing PCTs and strategic health authorities. It claimed to shift power from the centre to GPs and patients, moving somewhere between £60 to £80 billion into the hands of Clinical Commissioning Groups to commission services. The bill became law in March 2012 with a government majority of 88 and following more than 1,000 amendments in the House of Commons and the House of Lords.


The total budget of Department of Health in England in 2017/18 is £124.7 billion.[66] £13.8 billion was spent on medicines.[67] The National Audit Office reports annually on the summarised consolidated accounts of the NHS.[68] Health spending in England is expected to rise from £112 billion in 2009/10 to £127 billion in 2019/20 (in real terms),[66] and spending per head will increase by 3.5%.[69] However, according to the Institute for Fiscal Studies (IFS), compared to the increase necessary to keep up with a rising population that is also ageing, spending will fall by 1.3% from 2009-10 to 2019–20.[70][69]

George Stoye, senior research economist of the IFS, and said the annual increases since 2009-10 were "the lowest rate of increase over any similar period since the mid-1950s, since when the long-run annual growth rate has been 4.1%".[70] The NHS has been accused of making drastic cuts to some services while keeping the public in the dark over what is happening.[71] In 2017, funding increased by 1.3% while demand rose by 5%, and the NHS managed poorly in winter 2017-2018.[72] Ted Baker, Chief Inspector of Hospitals has said that the NHS is still running the model it had in the 1960s and 1970s and has not modernised due to lack of investment.[73] Patients needing organ transplants could die because there are insufficient organ retrieval specialists and insufficient transplant surgeons. Equipment needed for transplant surgery is also in short supply, ward capacity is also lacking. Cuts and staff stress are factors.[74]

The British Medical Association (BMA) has called for £10bn more annually for the NHS to get in line with what other advanced European nations spend on health. The BMA argues this could pay for at least 35,000 more hospital beds daily and many thousand more GPs. Mark Porter of the BMA, wrote, "Our members report that services are truly at breaking point, with unprecedented rising patient demand met only with financial restraint and directives for the NHS and social care to make huge, unachievable savings through sustainability and transformation plans (STPs) across England." Porter emphasised he was not asking for more than comparable nations, merely to match the spending of other leading European nations. The increase, Porter said was desperately needed.[75]

Failure to provide capital funding to repair and renovate buildings and equipment puts patients at risk. Hospitals deny they have resources to replace obsolete scanners, repair leaky roofs and boilers, get rid of ligature points where patients may attempt suicide. 97% of 161 leaders that NHS Providers surveyed are concerned over the level of funding their trust needs for urgent repairs.[76]

The commissioning system

From 2003 to 2013 the principal fundholders in the NHS system were the NHS Primary Care Trusts (PCTs), that commissioned healthcare from NHS trusts, GPs and private providers. PCTs disbursed funds to them on an agreed tariff or contract basis, on guidelines set out by the Department of Health. The PCTs budget from the Department of Health was calculated on a formula basis relating to population and specific local needs. They were supposed to "break even" - that is, not show a deficit on their budgets at the end of the financial year. Failure to meet financial objectives could result in the dismissal and replacement of a Trust's Board of Directors, although such dismissals are enormously expensive for the NHS.[77]

From April 2013 a new system was established as a result of the Health and Social Care Act 2012. The NHS budget is largely in the hands of a new body, NHS England which commissions specialist services and primary care. Acute services and community care is commissioned by local Clinical Commissioning Groups led by GPs. Since 2012 it has become increasingly difficult for trusts to break even and many maintain solvency only by relying on loans from the Department of Health and Social Care. Outstanding loans amounted to £14 billion in April 2019 with interest payments totalled £292 million for the year, at an average rate of around 2%. According to NHS Providers: “The present situation is unsustainable. Some trusts are being loaded with debt that they have no realistic prospect of paying back, compounded by interest payments. Many trusts with debts are in health economies that are not funded adequately for the care their populations need." [78]

Free services and contributory services

Services free at the point of use

The vast majority of NHS services are free at the point of use.

This means that people generally do not pay anything for their doctor visits, nursing services, surgical procedures or appliances, consumables such as medications and bandages, plasters, medical tests, and investigations, x-rays, CT or MRI scans or other diagnostic services. Hospital inpatient and outpatient services are free, both medical and mental health services. Funding for these services is provided through general taxation and not a specific tax.

Because the NHS is not funded by contributory insurance scheme in the ordinary sense and most patients pay nothing for their treatment there is thus no billing to the treated person nor to any insurer or sickness fund as is common in many other countries. This saves hugely on administration costs that might otherwise involve complex consumable tracking and usage procedures at the patient level and concomitant invoicing, reconciliation and bad debt processing.


Eligibility for NHS services is based on having ordinary resident status. See National Health Service#Eligibility for treatment.

Prescription charges

As of May 2019 the NHS prescription charge in England was £9 for each quantity of medicine[79] (which contrasts with Scotland, Wales and Northern Ireland[80] where items prescribed on the NHS are free). People over sixty, children under sixteen (or under nineteen if in full-time education), patients with certain medical conditions, and those with low incomes, are exempt from paying. Those who require repeated prescriptions may purchase a single-charge pre-payment certificate that allows unlimited prescriptions during its period of validity. The charge is the same regardless of the actual cost of the medicine, but higher charges apply to medical appliances. Pharmacies or other dispensing contractors are reimbursed for the cost of the medicines through NHS Prescription Services, a division of the NHS Business Services Authority. For more details of prescription charges, see Prescription charges. Paying prescription charges can be a burden for people on low income and for people with chronic conditions that do not qualify for free prescriptions. Patients on low income sometimes do without medication they need because they cannot afford the prescriptions. This can lead to their condition worsening and becoming more expensive for the Health Service to treat. It can even lead to death.[81]

The high and rising costs of some medicines, especially some types of cancer treatment, means that prescriptions can present a heavy burden to the PCTs, whose limited budgets include responsibility for the difference between medicine costs and the fixed prescription charge. This has led to disputes whether some expensive drugs (e.g., Herceptin) should be prescribed by the NHS.[82]

NHS dentistry

Where available, NHS dentistry charges as of April 2017 were: £20.60 for an examination; £56.30 for a filling or extraction; and £244.30 for more complex procedures such as crowns, dentures or bridges.[83] As of 2007, less than half of dentists' income came from treating patients under NHS coverage; about 52% of dentists' income was from treating private patients.[84] Some people needing NHS dental care are unable to get it.[85]

NHS Optical Services

From 1 April 2007 the NHS Sight Test Fee (in England) was £19.32, and there were 13.1 million NHS sight tests carried out in the UK.

For those who qualify through need, the sight test is free, and a voucher system is employed to pay for or reduce the cost of lenses. There is a free spectacles frame and most opticians keep a selection of low-cost items. For those who already receive certain means-tested benefits, or who otherwise qualify, participating opticians use tables to find the amount of the subsidy.

Injury cost recovery scheme

Under older legislation (mainly the Road Traffic Act 1930) a hospital treating the victims of a road traffic accident was entitled to limited compensation (under the 1930 Act before any amendment, up to £25 per person treated) from the insurers of driver(s) of the vehicle(s) involved, but were not compelled to do so and often did not do so; the charge was in turn covered by the then legally required element of those drivers' motor vehicle insurance (commonly known as Road Traffic Act insurance when a driver held only that amount of insurance). As the initial bill went to the driver rather than the insurer, even when a charge was imposed it was often not passed on to the liable insurer. It was common to take no further action in such cases, as there was no practical financial incentive (and often a financial disincentive due to potential legal costs) for individual hospitals to do so.

The Road Traffic (NHS Charges) Act 1999 introduced a standard national scheme for recovery of costs using a tariff based on a single charge for out-patient treatment or a daily charge for in-patient treatment; these charges again ultimately fell upon insurers. This scheme did not however fully cover the costs of treatment in serious cases.

Since January 2007, the NHS has a duty to claim back the cost of treatment, and for ambulance services, for those who have been paid personal injury compensation.[86] In the last year of the scheme immediately preceding 2007, over £128 million was reclaimed.[87]

From April 2019 £725 is payable for outpatient treatment, £891 per day for inpatient treatment and £219 per ambulance journey.[88]

Car park charges

Car parking charges are a minor source of revenue for the NHS,[89] with most hospitals deriving about 0.25% of their budget from them.[90] The level of fees is controlled individually by each trust.[89] In 2006 car park fees contributed £78 million towards hospital budgets.[89][90] Patient groups are opposed to such charges.[89] (This contrasts with Scotland where car park charges were mostly scrapped from the beginning of 2009[91] and with Wales where car park charges were scrapped at the end of 2011.)[92]

Charitable funds

There are over 300 official NHS charities in England and Wales. Collectively, they hold assets in excess of £2 billion and have an annual income in excess of £300 million.[93] Some NHS charities have their own independent board of trustees whilst in other cases the relevant NHS trust acts as a corporate trustee. Charitable funds are typically used for medical research, larger items of medical equipment, aesthetic and environmental improvements, or services that increase patient comfort.

In addition to official NHS charities, many other charities raise funds that are spent through the NHS, particularly in connection with medical research and capital appeals.

Regional lotteries were also common for fundraising, and in 1988, a National Health Service Lottery was approved by the government, before being found illegal. The idea continued to become the National Lottery.[94]


1.7 million people have been fined unfairly for claiming free medical or dental treatment when bureaucrats thought they were ineligible. In fact they were eligible. A third of fines went to innocent people. Other people made honest mistakes believing falsely they were entitled to free treatment because the procedure for deciding who is entitled to free treatment is excessively complicated. The British Dental Association maintains low-income patients visit the dentist a quarter less often since 2014 due to fear of fines.[95]

Outsourcing and privatisation

Although the NHS routinely outsources the equipment and products that it uses and dentistry, eye care, pharmacy and most GP practices are provided by the private sector, the outsourcing of hospital health care has always been controversial.[96]

Outsourcing and privatisation is steadily increasing in NHS England, and NHS England spending going to the private sector rose from £4.1 billion in 2009-10 to £8.7 billion in 2015–16.[97] Private firms provide services in areas such as community service, general practise and mental health care. Denis Campbell, Guardian health policy editor, states there is concern the quality of private sector care may be below what the NHS provides. Louise Irvine, of the National Health Action Party, which campaigns against the use of private firms in the NHS, maintains that private firms tend to do the easier work leaving complicated medicine to the NHS.[98] An article in the Independent stated the private sector cherry picks the easier cases because those are more profitable, additionally because the private sector does not have intensive care facilities if things go wrong. Allyson Pollock argued privatisation should be monitored to ensure the poor, the old and the sick do not lose out.[99]

According to a BMA survey over two thirds of doctors are fairly uncomfortable or very uncomfortable about the independent sector providing NHS services. The BMA believes it is important the independent sector is held to the same standards as the NHS when giving NHS care. The BMA recommends: data collection, thorough impact analysis before independent providers are accepted to ensure existing NHS services are not disrupted, risk assessment to find out likely results if NHS staff are unwilling to transfer to the private sector, transparent reporting by the private sector of patient safety and performance, independent providers should be regulated like NHS providers, patients should be protected if independent providers terminate a contract early, transfers from independent providers to the NHS should be regularly reviewed to establish how much this costs the NHS, private sector contracts should be amended so private sector providers contribute to the cost of staff training financially or by providing training opportunities.[100] According to the BMA, a large proportion of the public opposed increasing privatisation.[101]

NHS organisations provided about £600 million worth of work in private patient units in 2017 and this was forecast to increase by 6 or 7% per year. NHS funded work by independent hospitals as a proportion of their income rose from 15.7% in 2007/8 to 29.9% in 2015/6.[102] In 2009-10 the NHS paid for 214,967 operations at private hospitals. There were 613,833 such operations in 2018-19, an increase of 185% over nine years. NHS trusts increasingly send patients to private hospitals for surgery as they are busy, understaffed and cannot do surgery themselves. The waiting-list for operations that are not urgent rose to 4.6m, the largest figure since records started in 2007. Surgery done by independent providers includes cataract removal, hip and knee replacements, also some non-surgical therapy, including for cancer is contracted out. The 613,833 NHS-funded treatments in 2018-19 were done at 296 separate private hospitals by 144 different providers. BMI Healthcare treated 115,925 patients, the biggest number, Spire Healthcare hospitals performed 80,095 procedures and Circle Health 41,435. Dr Tony O’Sullivan of Keep Our NHS Public said, “These are totally shocking figures that provide hard evidence that the NHS has been enfeebled after close to a decade of Conservative government and been left desperately short of staff and money.”[103]

There have been many problems over NHS work outsourced to Capita, patients could have been put at risk.[104] See NHS Services for more.


The NHS was severely stretched in winter 2016-17 and the situation was worse in 2017-18. England, Wales and Northern Ireland missed every one of their three key targets (cancer care, operations and A&E) over 18 months. Patients are waiting longer for treatment.[105] In July 2018 78.2% patients with an urgent referral from their GP over cancer were seen within 62 days, the worst result since records started in 2009. Nearly 504,000 people waited over 18 weeks for non-urgent surgery and this is the highest figure for over a decade. 4.12 million patients were on waiting lists for routine surgery and this was the highest figure since 2007.[106] 6,932 patients waited more than 3 hours in A&E in October 2010, but this rose to 45,532 patients in October 2017.[107] Between the end of November 2017 and 24 December 58,845 patients waited 30 minutes or longer in ambulances and of them, 12,188 waited over an hour.[108] Ambulance crews waiting with patients that cannot be handed over to hard pressed hospital staff are unable to respond to further emergencies in the community. Seriously ill patients sometimes must wait hours for an ambulance (waiting time should not exceed 7 minutes) and this may be causing deaths.[109] In July 2018 80% of ambulance services did not reach their seven-minute target for getting to the most life-threatening cases. Modern technology frequently enables patient treatment at the scene, but aging ambulances sometimes prevent this. 25% of ambulances are over seven years old, at which point maintenance costs rise and reliability falls. There was a 50% difference in costs between the most economical and the least economical trusts.[110]

Intensive care units send patients to other hospitals due to lack of beds. 79% of intensive care consutants fear patient care can suffer due to staff shortages.[111] Just under 600,000 ambulances had to wait longer than 15 minutes before they could hand a patient over to A&E staff in the three months to April 2018. Senior people in charge of acute, urgent and emergency care at NHS regulators wrote to all NHS trusts explaining the dangers of delayed handovers clearly. They emphasized, "Acute trusts must always accept handover of patients within 15 minutes of an ambulance arriving at the emergency department (ED). Leaving patients waiting in ambulances or in a corridor supervised by ambulance personnel is inappropriate. Delays in handover of patients from ambulance services to EDs result in: increased risk to patients on site due to delays in diagnosis and treatment [and] increased risk in the community because fewer ambulances are available to respond. The patients in the urgent care pathway who are at the highest risk of preventable harm are those for whom a high-priority 999 emergency call has been received, but no ambulance resource is available for dispatch."[112] During the year to 2018 at least 8,000 doctor shifts were unfilled in London A&E departments. Doctors had to cover for senior colleagues who had not arrived or for junior colleagues who were absent. Patients could die due to lack of doctors. Doctors are overworked and face burnout, they feel they are failing patients. Doctors leave A&E work due to the pressure and frustration of the work.[113]

There are plans to discontinue waiting time targets in the coming year. Patients' groups fear patients will have to wait in pain for longer before getting treatment.[114] Despite unprecedented demand for hospital beds and unprecedented pressure on the Health Service in September 2017 there were 82 wards closed and 1429 beds were empty because the NHS did not have the funding or the staff to keep them open.[115]

The NHS was more severely overstretched in 2017-18 than it was the previous winter though the British Red Cross declared the state of UK hospitals in 2016-17 a humanitarian crisis.[116] Serious incidents including deaths while patients are under the care of the ambulance service have risen sharply. Underfunding is blamed.[117] Roughly 30 health charities, which include the Teenage Cancer Trust, National AIDS Trust and Motor Neurone Disease Association, expressed concern over NHS England "restricting and rationing treatment" due to underfunding, particularly for patients with rare and complex conditions. The groups from the Specialised Healthcare Alliance maintain there is insufficient public scrutiny. Cancer, diabetes and asthma patients could lose out through new affordability criteria, meaning drugs costing the NHS over £20m in total annually could be restricted.[118] Lung cancer survival rates are a postcode lottery and patients in worst performing areas are dying unnecessarily.[119] The time patients with cancer or suspected cancer have to wait for treatment has been increasing over the years.[120] NHS England should begin therapy in at most 62 days after urgent GP referral over possible cancer but as of 2019 almost a quarter of patients wait longer.[121]

NHS hospitals were under more pressure in winter 2017-18 than they were during winter 2016-17. In at least one hospital patients had to sleep on the floor due to lack of beds and trolleys.[122] Larger numbers of operations were cancelled 3,351 per week on average during 2017-18, contrasted with 1,948 the previous year.[123] Patients are waiting so long in ambulances outside hospitals that hospital staff go outside to treat them. Very long waits in ambulances are dangerous for patients and prevent the ambulance crew dealing with the next 999 call. There is no space in resuscitation units for patients who need to be there.[124] Beds are in short supply as is a range of important medical equipment and even ordinary items like pillows and breathing masks to prevent infections spreading are in short supply.[125]

From 2011 to 2018, the population of England increased by about 6%. The number of patients admitted to hospital in an emergency went up by 15%. Half of those were over 65.[126] There were 542,435 emergency hospital admissions in England in October 2018, 5.8% more than in October 2017.[127]

NHS England has 166 too few specialist cancer nurses, 158 too few chemotherapy nurses, 44 too few palliative care nurses treating cancer patients, and 61 cancer too few support workers, 429 posts in total. Nurses are stressed and cancer therapy may be delayed through this, or chemotherapy may be restricted.[128] Tom Sandford of the Royal College of Nursing said, "Retention rates are also a huge problem as the pressure caused by understaffed workplaces pushes more and more people away from the job they love."[129]

In the first quarter of 2018 the number of cancelled operations at 25,475 was the highest since records began in 1994. This is psychologically extremely stressful for patients and the delay can make their condition deteriorate. The Royal College of Surgeons puts cancellations down to "extreme pressures" on A&E departments and patients discharged late.[130]

From January to March 2018 on average 92.6% of hospital beds were occupied the Royal College of Surgeons found. 85% occupancy is the safe limit above which patient management regularly reaches crisis point and infections become more frequent. 92% bed occupancy is the level the Department of Health maintains no hospital should exceed. Critics claim pressure is worse due to government austerity measures since 2010.[131] The number of patients readmitted to hospital within thirty days of discharge increased by 19.2% from 1.16 million in 2010-11 to 1.38 million in 2016-17 the Nuffield Trust and Health Foundation reported. It is feared that some patients may be discharged too soon, that overworked hospital staff may overlook warning signs. Other patients may be kept in hospital too long due to lack of resources for community care if discharged. Just under 200.000 patients a year are readmitted to hospital because of a blood clot, pneumonia, or pressure sores—which are all preventable with the right care in hospital or in the community.[132]

In December 2018 hospitals were stressed despite mild weather and no serious flu outbreak. 87.6% of A&E patients were treated within four hours, well below the 95% target and the lowest November ratio ever. 94.2% of hospital beds were occupied in the first week of December, well over the 85% maximum safe limit. A&E units had already turned 25 patients in ambulances away due to overcrowding. 10,675 (1 in 9) patients spent at least 30 minutes with ambulance crews before A&E staff took over, which broke NHS rules saying that should never happen. Nearly 55,000 patients spent four hours or more on a trolley waiting for a hospital bed. There were 405 cancellations of urgent operations in October, 42% over the 287 figure for the year before. For over a year no part of the UK has hit any of three key targets on A&E waits, cancer care, hospital operations. Siva Anandaciva of the King's Fund said, “Hospital bed occupancy levels are already higher than recommended levels, the point at which hospitals are so full that good patient care is put at risk.[133][134] In 2019 BBC Newsnight and the Nuffield Trust found 86% of patients were admitted, transferred or discharged from A&E within four hours in the six months before September. This was the worst summer on record and well above the 95% target for A&E waits.[135]

In November 2019 Chris Hopson of NHS Providers said, “The level of concern we’re hearing from frontline leaders about performance this winter is the highest we have known. The NHS is going in to winter in a much worse position than at any time in recent memory. We are short of capacity across the board – in mental health, ambulance and community services as well as hospital beds. And there has been another 12 months where social care and GP capacity has lagged well behind the growth in demand. The NHS has over 100,000 vacancies, so there was no respite over the summer and staff are now exhausted. On top of all this, we are losing serious amounts of vital senior clinical and leadership time because of current NHS pensions problems.”[136] A&E targets and cancer wait time targets were contiuously missed from 2015 to 2019 and routine care wait time targets were continuously missed from 2016 to 2019. A big difficulty is staff shortage, there are almost 100,000 vacancies in England, roughly one in twelve of all NHS posts.[137] In October 2019 one patient in six waited longer than four hours in A&E before being treated. This was the worst result since the target was introduced in 2004. John Appleby of the Nuffield Trust said, “We have many months to go until seasonal pressures really hit the NHS, but October has already seen an unprecedented slump with performance against the main A&E target worse than ever. The health service is seeing far more patients, yet one in six is now waiting more than four hours in A&E. If the usual trends continue after Christmas, that would head towards one in five.” Appleby then stated 80,000 people were already waiting on trolleys in corridors, “something we have only seen before in the very coldest part of the year”. If this trend keeps going, I fear we could see 100,000 people stuck on trolleys this coming January. [January 2020] (...) we should be under no illusion about the money, staff and time it will take to turn this situation around.”[138][139]

In Autumn 2019 17,230 beds have been reduced from the 144,455 that there were in April-June 2010, the time when the nine-year funding squeeze on the NHS began. The 127,225 beds available in 2019 is the smallest figure in acute hospitals, maternity centres, mental health units and units for people with learning disabilities since records started in 1987/88. Medical bodies fear losing so many beds will adversely affect the quality of patient care. Patients sometimes must wait, even over twelve hours before getting a bed after being admitted to hospital. Health experts maintain that not more than 85% of hospital beds should be occupied to ensure patient safety and quality of care. But in some hospitals 95% of beds were occupied during the summer and autumn of 2019. Dr Rob Harwood of the British Medical Association consultants committee, said, “It is extremely worrying that despite the BMA’s warning of a year ago that 10,000 extra beds were needed, the numbers of hospital beds had actually fallen to a new record low. These figures show the seriousness of the situation confronting patients this winter and can only add to the day-to-day struggles faced by our NHS frontline staff.”[140]

Over the three years to 2019 patients had to wait in ambulances for over half an hour 1,499,053 times and over 280,000 patients had to wait over an hour. These figures are under estimates because not all hospital trusts gave the information. During 2018/19 there were 503,887 patients who waited 30 minutes or more and 79,352 of them stayed in ambulance for at least an hour. Jon Ashworth MP said, “This is damning evidence of the crisis our NHS has been pushed into after a decade of cuts. Many of these patients will be elderly in desperate need yet they have been left waiting and waiting. It’s a disgrace and comes after cuts to 17,000 hospital beds.”[141]

Research has shown long trolley waits at A&E increase the risk of death for patients. Since 2016 there were 5449 deaths after admission to A&E was delayed for six to eleven hours. Research, by Dr Chris Moulton and Dr Cliff Mann, determined 960 out of 79,228 patients waiting roughly six hours died directly due to the delay. 1 out of 83 people wainting six hours for admission die directly due to the delay before specialist care for their condition begins. During the three years to 2019, 855 people died due to waiting about seven hours, as did 636 patients who were delayed at least 11 hours. There were 80,092 trolley waits of over four hours in October 2019 and such frequent delays could lead directly to scores, or even hundreds of deaths each month. The risks patients will die increase rapidly if they must wait longer. 1 in 31 for those stuck on a trolley for nine hours dies and 1 in 30 patients dies after waiting 11 hours. John Kell of the Patients Association said, “These results are deeply shocking and very worrying. Patients are clearly suffering tragic consequences as well as loss of dignity and discomfort from spending far too long waiting on a trolley for care. This is as a direct result of sustained underfunding of the NHS and social care and ongoing shortage of hospital beds. Despite the unstinting efforts of NHS staff, patients can no longer be sure of receiving safe or dignified care if they need to be admitted to hospital. This is an entirely needless and completely unacceptable situation.”[142]

Sustainability and transformation plans

Sustainability and transformation plans were produced during 2016 as a method of dealing with the services's financial problems. These plans appear to involve loss of services and are highly controversial. The plans are possibly the most far reaching change to health services for decades and the plans should contribute to redesigning care to manage increased patient demand. Some A&E units will close, concentrating hospital care in fewer places.[143] Nearly two thirds of senior doctors fear the plans will worsen patient care.[144]

Consultation will start over cost saving, streamlining and some service reduction in the National Health Service. The streamlining will lead to ward closures including psychiatric ward closures and reduction in the number of beds in many areas among other changes. There is concern that hospital beds are being closed without increased community provision.[145]

The Nuffield Trust think tank claims many suggestions would fail to implement government financial targets and involve a "dauntingly large implementation task". Sally Gainsbury of the Nuffield Trust said many current plans involve shifting or closing services. Gainsbury added, "Our research finds that, in a lot of these kinds of reconfigurations, you don't save very much money – all that happens is the patient has to go to the next hospital down the road. They're more inconvenienced... but it rarely saves the money that's needed."[146] There will be a shift from inpatient to outpatient care but critics fear cuts that could put lives at risk, that the plans dismantle the health service rather than protecting it, further that untested plans put less mobile, vulnerable patients at risk. By contrast, NHS England claims that the plans bring joined-up care closer to home. John Lister of Keep Our NHS Public said there are too many assumptions, and managers desperate to cut deficits were resorting to untried plans.[147] NHS managers are already hard pressed struggling to keep the service running, handling increased volume and juggling for hospital beds. Finding the extra time to develop a workable sustainability and transformation plan is itself problematic.[143]

Critics are concerned that the plan will involve cuts but supporters insist some services will be cut while others will be enhanced. Senior Liberal Democrat MP Norman Lamb accepted that the review made sense in principle but stated: "It would be scandalous if the government simply hoped to use these plans as an excuse to cut services and starve the NHS of the funding it desperately needs. While it is important that the NHS becomes more efficient and sustainable for future generations, redesign of care models will only get us so far – and no experts believe the Conservative doctrine that an extra £8bn funding by 2020 will be anywhere near enough."[148] Norman Lamb also said the NHS was hurtling towards a "catastrophe (...) With demand rising so rapidly, more funding is needed. It would be unforgivable for the government not to act in light of these warnings."[149] NHS bosses have kept plans for cuts secret, also prevented NHS staff and the public from having an input. This led to accusations of cover-ups and stealth cuts.[143] Plans kept secret include closures of A&Es and of one hospital though full details remain under wraps. One local manager described keeping plans confidential as 'ludicrous' and another said the 'wrong judgement call' had been made. Another person spoke about being in meetings where, 'real people' like patients and the public were not involved. Complex jargon may confuse people who try and follow what happens.[150] The King's Fund reported the public and patients were mostly absent from plans that could involve large scale service closing. Chris Ham of the King's Fund described suggesting out-of-hospital services and GP's could take over work now done by hospitals as a "heroic assumption" since both out-of-hospital services and GP's are under too much pressure. Some councils that disagree with the secrecy have published plans on their websites.[151][152] Funds that should have gone to helping with moving services after closures instead went to plugging other NHS deficits.[153]

NHS policies and programmes

Changes under the Thatcher government

The 1980s saw the introduction of modern management processes (General Management) in the NHS to replace the previous system of consensus management. This was outlined in the Griffiths Report of 1983.[154] This recommended the appointment of general managers in the NHS with whom responsibility should lie. The report also recommended that clinicians be better involved in management. Financial pressures continued to place strain on the NHS. In 1987, an additional £101 million was provided by the government to the NHS. In 1988 Prime Minister Margaret Thatcher announced a review of the NHS. From this review in 1989 two white papers Working for Patients and Caring for People were produced. These outlined the introduction of what was termed the internal market, which was to shape the structure and organisation of health services for most of the next decade.

In England, the National Health Service and Community Care Act 1990 defined this "internal market", whereby health authorities ceased to run hospitals but "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients. The "providers" became independent trusts, which encouraged competition but also increased local differences. Increasing competition may have been statistically associated with poor patient outcomes.[155]

Changes under the Blair government

These innovations, especially the "fund holder" option, were condemned at the time by the Labour Party. Opposition to what was claimed to be the Conservative intention to privatise the NHS became a major feature of Labour's election campaigns.

Labour came to power in 1997 with the promise to remove the "internal market" and abolish fundholding. However, in his second term Blair renounced this direction. He pursued measures to strengthen the internal market as part of his plan to "modernise" the NHS.

A number of factors drove these reforms; they include the rising costs of medical technology and medicines, the desire to improve standards and "patient choice", an ageing population, and a desire to contain government expenditure. (Since the National Health Services in Wales, Scotland and Northern Ireland are not controlled by the UK government, these reforms have increased the differences between the National Health Services in different parts of the United Kingdom. See NHS Wales and NHS Scotland for descriptions of their developments).

Reforms included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous clinical and corporate governance. Some new services were developed to help manage demand, including NHS Direct. The Agenda for Change agreement aimed to provide harmonised pay and career progression. These changes have given rise to controversy within the medical professions, the news media and the public. The British Medical Association in a 2009 document on Independent Sector Treatment Centres (ISTCs) urged the government to restore the NHS to a service based on public provision, not private ownership; co-operation, not competition; integration, not fragmentation; and public service, not private profits.[156]

The Blair government, whilst leaving services free at point of use, encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals were built (or rebuilt) by private sector consortia; hospitals may have both medical services such as ISTCs[157] and non-medical services such as catering provided under long-term contracts by the private sector. A study by a consultancy company for the Department of Health shows that every £200 million spent on privately financed hospitals will result in the loss of 1000 doctors and nurses. The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced.[158]

The NHS was also required to take on pro-active socially "directive" policies, for example, in respect of smoking and obesity.

Internet information service

In the 1980s and 90s, NHS IT spent money on several failed IT projects. The Wessex project, in the 1980s, attempted to standardise IT systems across a regional health authority. The London Ambulance Service was to be a computer-aided dispatch system. Read code was an attempt to develop a new electronic language of health,[159] later scheduled to be replaced by SNOMED CT.

The NHS Information Authority (NHSIA) was established by an Act of Parliament in 1999 with the goal to bring together four NHS IT and Information bodies (NHS Telecoms, Family Health Service (FHS), NHS Centre for Coding and Classification (CCC) and NHS Information Management Group (IMG)) to work together to deliver IT infrastructure and information solutions to the NHS in England. A 2002 plan was for NHSIA to implement four national IT projects: Basic infrastructure, Electronic records, Electronic prescribing, and Electronic booking, modelled after the large NHS Direct tele-nurse and healthcare website program.[159] The NHSIA functions were divided into other organisations by April 2005.

In 2002, the NHS National Programme for IT (NPfIT) was announced by the Department of Health.

Despite problems with internal IT programmes, the NHS has broken new ground in providing health information to the public via the internet. In June 2007 was relaunched under the banner "NHS Choices"[160] as a comprehensive health information service for the public now known simply as "The NHS Website".

In a break with the norm for government sites, allows users to add public comments giving their views on individual hospitals and to add comments to the articles it carries. It also enables users to compare hospitals for treatment via a "scorecard".[161] In April 2009 it became the first official site to publish hospital death rates (Hospital Standardised Mortality Rates) for the whole of England. Its Behind the Headlines daily health news analysis service,[162] which critically appraises media stories and the science behind them, was declared Best Innovation in Medical Communication in the prestigious BMJ Group Awards 2009.[163] and in a 2015 case study was found to provide highly accurate and detailed information when compared to other sources[164] In 2012, NHS England launched an NHS library of mobile apps[165] that had been reviewed by clinicians.

In 2018, the NHS announced they would abandon the name NHS Choices, and in future, call the site the NHS website. This coincided with the launch of the NHS app.[166]

Eleven of the NHS hospitals in the West London Cancer Network have been linked using the IOCOM Grid System. The NHS has reported that the Grid has helped increase collaboration and meeting attendance and even improved clinical decisions.[167]

Smoking cessation

One in four hospital patients smoke and that is higher than the proportion in the general population (just under one in five). Public Health England (PHE) wants all hospitals to help smokers quit. One in thirteen smoking patients was referred to a hospital or community based cessation programme. Over a quarter of patients were not asked if they smoke and nearly three quarters of smokers were not asked if they wanted to stop. Half of frontline hospital staff were offered no training in smoking cessation. Smoking patients should be offered specialised help to stop and nicotine replacement. There should be dedicated staff helping patients to quit. Seven tenths of smokers say they want to stop and those offered help are four times more likely to stop permanently. PHE claims smoking causes 96,000 deaths per year in England and twenty times the number of smoking related illnesses. Frank Ryan, psychologist said, "It's really about refocusing our efforts and motivating our service users and staff to quit. And of course, whatever investment we make in smoking cessation programmes, there's a payback many times more in terms of the health benefits and even factors such as attendance at work, because it's workers who smoke [who] tend to have more absent spells from work."[168] The numbers of smokers getting help to quit has fallen due to cuts in funding for smoking cessation care though the National Institute for Health and Care Excellence recommends such help. Smoking is the greatest cause of avoidable illness and death in England, costs the NHS £2.5bn a year and the economy £11bn.[169]

Public satisfaction and criticism

A 2016 survey by Ipsos MORI found that the NHS tops the list of "things that makes us most proud to be British" at 48%.[170] An independent survey conducted in 2004 found that users of the NHS often expressed very high levels of satisfaction about their personal experience of the medical services. Of hospital inpatients, 92% said they were satisfied with their treatment; 87% of GP users were satisfied with their GP; 87% of hospital outpatients were satisfied with the service they received; and 70% of Accident and Emergency department users reported being satisfied.[171] Despite this some patients complain about being unable to see a GP at once when they feel their condition requires prompt attention.[172] When asked whether they agreed with the question "My local NHS is providing me with a good service” 67% of those surveyed agreed with it, and 51% agreed with the statement “The NHS is providing a good service."[171] The reason for this disparity between personal experience and overall perceptions is not clear; however, researchers at King's College London found high-profile media spectacles may function as part of a wider 'blame business', in which the media, lawyers and regulators have vested interests.[173][174] It is also apparent from the satisfaction survey that most people believe that the national press is generally critical of the service (64% reporting it as being critical compared to just 13% saying the national press is favourable), and also that the national press is the least reliable source of information (50% rating it not very or not at all reliable, compared to 36% believing the press was reliable) .[171] Newspapers were reported as being less favourable and also less reliable than the broadcast media. The most reliable sources of information were considered leaflets from GPs and information from friends (both 77% reported as reliable) and medical professionals (75% considered reliable).[171]

Professor Sir Michael Adrian Richards said more money must be spent on the NHS. Richards maintains nurses need a pay rise to encourage them to stay. Richards also said the NHS needs to spend money more effectively and that some hospitals have improved by focusing on providing what patients need.[175]

Some examples of criticism include:

  1. Some extremely expensive treatments may be available in some areas but not in others, the so-called postcode lottery.[176]
  2. The National Programme for IT, which was designed to provide infrastructure for electronic prescribing, booking appointments and elective surgery, and a national care records service. The programme ran into delays and overspends before it was finally abandoned.
  3. In 2008 there was a decreasing availability of NHS dentistry following a new government contract[177] and a trend towards dentists accepting private patients only,[178] with 1 in 10 dentists having left the NHS totally. However, in 2014 the number of NHS dental patients increased.[179]
  4. There have been a number of high-profile scandals within the NHS. Most recently there have been scandals at acute hospitals such as Alder Hey and the Bristol Royal Infirmary. Stafford Hospital is currently under investigation for poor conditions and inadequacies that statistical analysis has shown caused excess deaths.
  5. A 14 October 2008 article in The Daily Telegraph stated, "An NHS trust has spent more than £12,000 on private treatment for hospital staff because its own waiting times are too long."[180]
  6. In January 2010, the NHS was accused of allocating £4 million annually on homeopathic medicines, which are unsupported by scientific research.[181]
  7. The absence of identity/residence checks on patients at clinics and hospitals allows people who ordinarily reside overseas to travel to the UK for the purpose of obtaining free treatment, at the expense of the UK taxpayer. A report published in 2007 estimates that the NHS bill for treatment of so-called ‘health tourists’ was £30m, 0.03% of the total cost.[182]
  8. Long waits for treatment like cancer care, cataracts, knee and hip replacement lead vulnerable people to pay for these treatments privately. Patients use up savings or take out loans. It is widely felt the NHS should provide free health care for those who need it and patients should not be under pressure to pay.[183]
  9. According to Tessa Jowell, English cancer survival rates are the worst in Western Europe and the blame lies with slow diagnosis.[184]

NHS mental health services is one area that tends to receive regular criticism from service users and the public, for sometimes opposing reasons.[185][186][187][188][189] Women do not get gender specific help and in most trusts are not routinely asked if they have suffered domestic abuse though NICE recommends asking this.[190] Some psychiatric patients are hard to manage.[191] Police are increasingly called to deal with mental health crises due to insufficient trained mental health staff in the NHS. Police are poorly suited for this role.[192] The number of psychiatrists working with children and teenagers fell from 1,015 full-time equivalent posts in 2013 to 948 in 2017 despite rising psychiatric need among youngsters. Many troubled youngsters must wait a long time before treatment starts or are denied treatment altogether.[193] There is also a shortage of psychiatrists treating elderly patients.[194] Two thirds of children referred by their GP's for psychiatric treatment do not get it.[195] Due to a bed shortage patients are more sick when entering units and there are fewer staff to manage them. Assaults on staff have risen from 33,620 in 2012-13 to 42,692 in 2016-17. There were also over 17,000 assaults by patients on other patients.[196] Patients with eating disorders are sometimes denied treatment or made to wait too long for treatment, which reduces their chances of recovery.[197] There have been preventable deaths among psychiatric patients and lack of staff to provide adequate care is cited as a reason.[198] Use of restraints on patients with learning difficulties is increasing. In 2017, restraints were used over 22,000 times. This rose from 15,000 times in 2016. This includes face down restraints, which can restrict breathing. Rob Greig, who was national director for Learning Disabilities, claimed the government's Transforming Care programme meant, "All that happened was that one person moved out and somebody else was ready to move in, because someone else had been let down by the community services not supporting them properly."[199]

Long waits for surgery increased by a factor of three in four years.[200] As of July 2018 4.3 million patients were waiting over the official maximum of 18 weeks for non-urgent surgery like a hip replacement. Janet Davies of the Royal College of Nursing said, "Cancer targets have been missed for the last two months, waiting lists have hit a 10-year high and the number of people waiting more than 18 weeks for planned care has gone up by more than 100,000 compared to this time last year."[201] Nigel Edwards of the Nuffield Trust maintained the 18-week target should stay. If we cannot take people off the waiting list as fast as they are put on it, waiting times won't just simply stay a bit above 18 weeks. They will keep getting worse and worse. That matters a lot to patients, and might cost even more as people's conditions worsen."[202]

Due to a shortage of nurses in hospitals, drugs for sepsis, Parkinson's and diabetes are given late, pain is untreated since nurses are too busy, children go without food since treatment must be prioritised, patients are not moved risking bed sores, patients remain in corridors because there are no empty beds, community staff complain they cannot do all the work asked of them.[203] The number of hospital beds has fallen despite the demand for beds rising.[204]

Record numbers of GP practises are closing, The Royal College of GPs said doctors could no longer manage rising patient demand unless there is higher funding.[205]

Quality of healthcare, and accreditation

There are many regulatory bodies with a role in the NHS, both government-based (e.g., Department of Health and Social Care, General Medical Council, Nursing and Midwifery Council),and non-governmental-based (e.g., Royal Colleges). Independent accreditation groups exist within the UK, such as the public sector Trent Accreditation Scheme and the private sector CHKS.

With respect to assessing, maintaining and improving the quality of healthcare, in common with many other developed countries, the UK government has separated the roles of suppliers of healthcare and assessors of the quality of its delivery. Quality is assessed by independent bodies such as the Healthcare Commission according to standards set by the Department of Health and the National Institute for Health and Clinical Excellence (NICE). Responsibility for assessing quality transferred to the Care Quality Commission in April 2009.

A comparative analysis of health care systems in 2010 put the NHS second in a study of seven rich countries.[206][207] The report put the UK health systems above those of Germany, Canada and the US; the NHS was deemed the most efficient among those health systems studied.

700 hospital patients suffered harm in serious incidents due to treatment delays in part of 2015-16, 1,027 hospital patients suffered similar harm in 2016-17 and this rose to 1,515 in 2017-18. Norman Lamb blames understaffing. NHS Improvement stated during 2017-18 the NHS was short of 93,000 staff, which included 10,000 doctors and 37,000 nurses.[208]


In 2014 the Nuffield Trust and the Health Foundation produced a report comparing the performance of the NHS in the four countries of the UK since devolution in 1999. They included data for the North East of England as an area more similar to the devolved areas than the rest of England. They found that there was little evidence that any one country was moving ahead of the others consistently across the available indicators of performance. There had been improvements in all four countries in life expectancy and in rates of mortality amenable to health care. Despite the hotly contested policy differences between the four countries there was little evidence, where there was comparable data, of any significant differences in outcomes. The authors also complained about the increasingly limited set of comparable data on the four health systems of the UK.[209] Medical school places are set to increase by 25% from 2018.[210]

A report from Public Health England’s Neurology Intelligence Network based on hospital outpatient data for 2012–13 showed that there was significant variation in access to services by Clinical Commissioning Group. In some places there was no access at all to consultant neurologists or nurses. The number of new consultant adult neurology outpatient appointments varied between 2,531 per 100,000 resident population in Camden to 165 per 100,000 in Doncaster.[211]

Funding shortfall is forcing NHS England to make cuts. The BMA is concerned that the public are not being told what will be cut and how cuts will affect their health care.[212]

Access to IVF treatment is being limited in many parts of England.[213] English maternity wards were compelled to close 382 times in 2016, there has been a 70% increase in closures over two years. 42 hospital trusts closed at some time, 44% of those that responded—and many blamed shortages of staff or of bed and cot capacity in 2016. 14 closed over ten times, and some remained closed over 24 hours in 2016. Elizabeth Duff of the NCT said when the figures were released in 2017, "It’s appalling that a shortage of midwives and equipment means that so many units have been closed time and again so that pregnant women are pushed from pillar to post in the throes of labour. (...) [women in advanced labour could be made to travel to another hospital] leaving them anxious and frightened about having their baby in a car or by the roadside".[214] Nearly half of maternity units were closed at least once during 2017.[215] Over 276,000 lapses in maternity care were reorded from April 2015 to March 2017, a few leading to death or permanent disability. Abigail Wood of childbirth charity NCT, said: "Maternity care is in crisis, staffing levels are dangerously low and midwives are being stretched to the limit."[216]

There are proposals to restrict access to a wide range of medical procedures that used to be common. This includes X-rays of patients with sore back, hernia repair surgery, X-rays of possibly arthritic knees, many types of surgery, ways of detecting illness, for cancer, arthritis, back problems, kidney stones, sinus infections and depression. If implemented this would cause unprecedentedly major limitation on patients’ access and doctors being able to recommend procedures, some of which have been routine for decades. It is unclear if the reason for the proposed restrictions is to reduce ineffective treatments or to cut costs.[217]

The British Red Cross has highlighted vulnerable patients being sent home from hospital to unsuitable conditions due to lack of coordination between services. Examples are when electricity was cut off during the patient's hospital stay.[218]

In January 2018 doctors in England and Wales sent the Prime Minister a letter stating among other matters, that trolley waits of up to 12 hours are becoming routine and patients stay a long time in the backs of ambulances before A&E staff have time for them. The letter added, "Some of our own personal experiences range from over 120 patients a day managed in corridors, some dying prematurely."[219][220] Targets for trolley waits of over 4 hours and over 12 hours when A&E patients cannot be found a bed in a ward have been missed for 30 months in a row as of January 2018.[221] Bed occupancy is in winter 2018 at 95% though the maximum safe level is 85% to prevent spread of hard to treat infections and ensure patient safety.[222]

In 2019 the Care Quality Commission found 44% of A&E units required improvement and 8% were inadeuate, the lowest rating. A&E departments are overloaded, the numbers of people needing treatment there is rising by 10% annually. Patients could not get the care they needed in the community so their condition worsened. Prosessor Ted Baker of the Care quality Commission said, “For many of those patients, going to A&E is not the best place for them to go. But it is the only part of the system that has ever-open doors and it is the part of the system they can access most easily.” For example, children in mental health crisis go to A&E due to lack of specialist mental health facilities in their area. Patricia Marquis of the Royal College of Nursing said, “In A&E in particular, nursing staff have been left to pick up the pieces of a health and social care system that is failing to meet need outside emergency department doors.”[223]

Vulnerability of information systems

Proprietary operating system

In 2001 the NHS entered into a licensing deal with Microsoft, ignoring the advice of some of its own IT specialists that had recommended investing in Linux instead.[224] Concerns about the vulnerability of NHS computer systems to cyber-attack have been expressed since at least 2016.[225] NHS computer systems have been subject to cyber attacks of which the WannaCry ransomware attack in May 2017 was notable.[226] The May 2017 attack lead to the cancellation of at least 6912 appointments including operations, and 139 suspected cancer patients had urgent referrals cancelled. The number of GP appointments cancelled, the number of ambulances diverted from A&E departments unable to treat some patients, and the number of delays in receiving information such as test results are unknown. North Korea is strongly suspected of starting the attack. The attack happened on a Friday in May. A cyberattack on a Monday in winter would be even more damaging.[227] NHS computers were vulnerable because a minority used Windows XP, an outdated system that originated in 2001, which Microsoft had stopped supporting with security patches. Complacency among NHS staff and among government departments that pay for computer security are blamed. Unless systems are upgraded, more cyber attacks are feared.[228] David Wrigley of the British Medical Association said, "It's been known about for years, that the software isn't up to date across the NHS, so it's not unpredictable that this situation should have arisen. But it's disappointing that funding hasn't been given to upgrade the system. It needs urgent action by politicians."[229] In autumn 2018 The Guardian reported concern about insufficient funding given to cyber protection and a fear that future cyber attacks are inevitable.[230]

Internal mail lost by part-privatised subsidiary

In 2017, it was reported that NHS Shared Business Services, a part state-owned, part-privately owned company tasked with internal mail delivery for NHS England, had lost 864,000 documents relating to patient healthcare.[231]

Sexual health

Funding for sexual health services has been cut despite an increase in demand for treatment of sexually transmitted infection. Demand rose 25% in the five years to 2017 while funding was cut by 10%. This leads to a risk that STD will spread while patients are waiting for treatment. Nearly 2.5 million new people attended sexual health clinics in 2016 compared to 1.9 million in 2012. Debbie Laycock of the Terrence Higgins Trust said, "There is still much to do to address the nation’s poor sexual health and the inequalities that are faced by those most at risk. In this climate of cuts to local authorities’ public health budgets, it is inevitable that the progress that has been made against STIs will be reversed. We are already witnessing the closure of busy sexual health clinics and, without proper funding, this will only continue and have a negative impact on people's sexual health. Cutting sexual health services is considered shortsighted because every £1 spent on sexual health saves £11 later through, for example preventing unwanted pregnancy.[232][233] 3,323,275 people attended sexual health clinics in 2017 in England in, a rise of 13% from 2,940,779 attending in 2013, and the equivalent of 1,471 extra visits a week. The Local Government Association representing 370 English and Welsh councils said budget reductions should be stopped at once to meet rising demand. If cuts are not halted councils may not be able to respond to unforeseen outbreaks of sexually transmitted disease. The government grant for 2018-19 is £3.21bn, reduced from £3.30bn the year before. The reduction is part of projected public health funding cuts of at least £600m by 2020-21. Dr Olwen Williams said cuts to came at "the worst possible time. Record demand for services, dramatic increases in syphilis and gonorrhoea diagnoses, and the spread of treatment-resistant infection in recent years mean that many services are struggling to cope, despite valiant efforts from staff."[234]

Mental health services

The NHS provides mental health services free of charge, but normally requires a referral from a GP first. Services that don't need a referral include psychological therapies through the Improving Access to Psychological Therapies initiative, and treatment for those with drug and alcohol problems. The NHS also provides online services that help patients find the resources most relevant to their needs.[235] Many psychiatric inpatients are being treated very far away from where they live when beds are not available locally, some even stay in police cells for up to six days.[236] The extent of the problem varies between trusts. Louise Rubin of Mind said: "It’s unacceptable that people who are at their most unwell and in desperate need of care find themselves travelling across the country to get help ... When you’re experiencing a mental health crisis, you’re likely to feel scared, vulnerable and alone, so your support network of family and friends are instrumental to recovery."[237] Being treated far from home is disorientating for patients and reduces their chances of recovery.[238]

The numbers of mental health staff needing sick leave due to work pressure is increasing. Dave Munday of Unite said, "Our members tell us workplace stress is increasing and that cuts to staff and services mean they're working longer hours with fewer resources. Staff themselves are feeling the impact of austerity."[239]

Care for patients with eating disorders is inadequate in many areas and subject to a postcode lottery. Hospital admissions for eating disorders are increasing and lack of early care that would prevent an eating disorder reaching crisis point is considered a cause.[240]

The use of restraints in UK psychiatric facilities is increasing. Sridevi Kalidindi of the Royal College of Psychiatrists maintains that cuts to bed numbers and cuts to community care mean patients admitted to psychiatric units are now more ill. Also Kalidindi maintains increased use of agency staff means fewer permanent staff with training in de-escalating situations are available.[241]

Increasing numbers of children and adolescents are referred for mental health treatment and many are turned down. Many were rejected because their condition was not considered serious enoug even if they had self harmed or suffered abuse. Even those accepted faced long delays before treatment started. David Laws said, "[there is] a significant increase in demand for children’s mental health services over the last five years, even as many local authorities are having to cut back on the services they are providing. This is very worrying and could lead to increased access problems." Anna Cole of the Association of School and College Leaders said, "This bleak picture of vulnerable young people being turned away from specialist mental health services or facing long waiting times for treatment is all too familiar to schools."[242] After young people are given appointments these appointments are sometimes cancelled. CAMHS (child and adolescent mental health services) in England cancelled 175,094 appointments with vulnerable patients from August 2018 to July 2019, which was 25% up from the 140,327 cancelled over the same period in 2017-18. Experts blame staff shortages and rising demand for treatment. Some cancellations were for young people who were self harming or thinking of suicide. Vickie Nash of Mind said, “Having a mental health appointment cancelled can break a young person’s trust in the health service. People are often at their most vulnerable at the point they receive professional support for issues as complex as eating disorders, self-harm and psychosis, let alone children who may be interacting with services for the first time in their lives. No young person should have to worry about whether their next appointment will happen. Once someone enters the mental health system they deserve timely and consistent support that gives them the best possible chance of recovery. It is deeply concerning that the number of cancelled appointments continues to rise, even in proportion to the increase in appointments. As demand grows under-supported staff are leaving in droves, and this can impact the gaps between appointments and chances of cancellation.”[243]

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  217. Revealed: Millions to be affected by NHS plan to ration 34 everyday tests and treatments The Guardian
  218. Patients 'sent home to no heat or light' BBC
  219. NHS patients dying in hospital corridors, A&E doctors tell Theresa May The Guardian
  220. Patients 'dying in hospital corridors' BBC
  221. NHS pressure: Hospital corridors 'the new emergency wards' BBC
  222. NHS hospitals in England record worst ever A&E performance The Guardian
  223. More than half of A&Es provide substandard care, says watchdog The Guardian
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  225. Murdock, Jason (23 March 2016). "NHS hospitals are 'ripe and vulnerable targets' for ransomware cyberattacks".
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  227. NHS 'could have prevented' WannaCry ransomware attack BBC
  228. Arthur, Charles (13 May 2017). "The ransomware attack is all about the insufficient funding of the NHS". The Guardian.
  229. Warning of NHS cyber-attack risk was not acted on, says cybersecurity adviser The Guardian
  230. More NHS cyber-attacks 'inevitable', warn experts The Guardian
  231. Syal, Rajeev; Campbell, Denis (16 October 2017). "NHS data loss scandal deepens with further 162,000 files missing". The Guardian. Retrieved 17 October 2017.
  232. Government cuts 'leave sexual health services at tipping point' The Guardian
  233. Sexual health clinics 'at tipping point' after Government cuts and huge rise in demand, councils warn The Independent
  234. Sexual health clinics in England see record demand amid budget cuts The Guardian
  235. "How to access mental health services". 14 August 2018.
  236. Police reveal 'unlawful' mental health detentions BBC
  237. Almost 6,000 mental health patients sent out of area for care last year The Guardian
  238. Mental health patients sent 300 miles from home due to lack of beds The Guardian
  239. Mental health staff on long-term stress leave up 22% BBC
  240. Eating disorders: NHS reports surge in hospital admissions The Guardian
  241. Mental health trusts restrain patients 'every 10 minutes' BBC
  242. Tens of thousands of children in England rejected for mental health treatment The Guardian
  243. NHS cancellations of child mental health sessions jump 25% The Guardian

Further reading

  • Allyson M Pollock (2004), NHS plc: the privatisation of our healthcare. Verso. ISBN 1-84467-539-4 (Polemic against PFI and other new finance initiatives in the NHS)
  • Rudolf Klein (2010), The New Politics of the NHS: From creation to reinvention. Radcliffe Publishing ISBN 978-1-84619-409-2 ( Authoritative analysis of policy making (political not clinical)in the NHS from its birth to the end of 2009)
  • Geoffrey Rivett (1998) From Cradle to Grave, 50 years of the NHS. Kings Fund, 1998, Covers both clinical developments in the 50 years and financial/political/organisational ones. kept up to date at

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