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

. The National Health System in the UK has developed to become one of the biggest healthcare systems in the world. At the time of writing of this review (August 2010) the UK government in its 2010 White Paper "Equity and quality: Liberating the NHS" has actually revealed a technique on how it will "develop a more responsive, patient-centred NHS which achieves results that are among the best on the planet". This review post provides a summary of the UK healthcare system as it presently stands, with emphasis on Predictive, Preventive and Personalised Medicine components. It aims to serve as the basis for future EPMA short articles to broaden on and present the changes that will be implemented within the NHS in the upcoming months.

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

Introduction

The UK health care system, National Health Service (NHS), came into existence in the after-effects of the Second World War and ended up being functional on the fifth July 1948. It was very first proposed to the Parliament in the 1942 Beveridge Report on Social Insurance and Allied Services and it is the legacy of Aneurin Bevan, a previous miner who ended up being a politician and the then Minister of Health. He established the NHS under the concepts of universality, free at the point of shipment, equity, and paid for by central funding [1] Despite many political and organisational changes the NHS remains to date a service readily available generally that cares for individuals on the basis of need and not ability to pay, and which is funded by taxes and national insurance contributions.

Healthcare and health policy for England is the duty of the main federal government, whereas in Scotland, Wales and Northern Ireland it is the responsibility of the particular devolved governments. In each of the UK countries the NHS has its own distinct structure and organisation, but in general, and not dissimilarly to other health systems, health care makes up of 2 broad areas; one dealing with strategy, policy and management, and the other with actual medical/clinical care which is in turn divided into primary (neighborhood care, GPs, Dentists, Pharmacists etc), secondary (hospital-based care accessed through GP referral) and tertiary care (professional health centers). Increasingly distinctions in between the two broad areas are becoming less clear. Particularly over the last years and guided by the "Shifting the Balance of Power: The Next Steps" (2002) and "Wanless" (2004) reports, gradual changes in the NHS have caused a higher shift towards local instead of main decision making, removal of barriers in between main and secondary care and stronger focus on patient option [2, 3] In 2008 the previous federal government strengthened this instructions in its health strategy "NHS Next Stage Review: High Quality Look After All" (the Darzi Review), and in 2010 the present federal government's health strategy, "Equity and excellence: Liberating the NHS", stays helpful of the same concepts, albeit through possibly different mechanisms [4, 5]

The UK federal government has actually simply revealed plans that according to some will produce the most radical change in the NHS given that its inception. In the 12th July 2010 White Paper "Equity and quality: Liberating the NHS", the existing Conservative-Liberal Democrat union federal government detailed a strategy on how it will "create a more responsive, patient-centred NHS which achieves outcomes that are amongst the finest worldwide" [5]

This evaluation post will therefore present an introduction of the UK healthcare system as it currently stands with the aim to work as the basis for future EPMA posts to expand and present the modifications that will be executed within the NHS in the upcoming months.

The NHS in 2010

The Health Act 2009 developed the "NHS Constitution" which officially unites the function and principles of the NHS in England, its worths, as they have been established by patients, public and personnel and the rights, promises and responsibilities of patients, public and staff [6] Scotland, Northern Ireland and Wales have also accepted a high level declaration stating the concepts of the NHS throughout the UK, despite the fact that services might be provided differently in the four nations, showing their various health needs and scenarios.

The NHS is the biggest employer in the UK with over 1.3 million staff and a spending plan of over ₤ 90 billion [7, 8] In 2008 the NHS in England alone employed 132,662 doctors, a 4% boost on the previous year, and 408,160 nursing staff (Table 1). Interestingly the Kings Fund approximates that, while the overall variety of NHS personnel increased by around 35% between 1999 and 2009, over the same period the variety of supervisors increased by 82%. As a proportion of NHS personnel, the number of supervisors increased from 2.7 percent in 1999 to 3.6 per cent in 2009 (www.kingsfund.org.uk). In 2007/8, the UK health spending was 8.5% of Gross Domestic Product (GDP)-with 7.3% accounting for public and 1.2% for private spending. The net NHS expenditure per head throughout the UK was most affordable in England (₤ 1,676) and greatest in Scotland (₤ 1,919) with Wales and Northern Ireland at around the exact same level (₤ 1,758 and ₤ 1,770, respectively) [8]

Table 1.

The circulation of NHS workforce according to main personnel groups in the UK in 2008 (NHS Information Centre: www.ic.nhs.uk)

The total organisational structure of the NHS in England, Scotland, Wales and Northern Ireland in 2010 is shown in Fig. 1. In England the Department of Health is responsible for the instructions of the NHS, social care and public health and shipment of healthcare by developing policies and methods, protecting resources, keeping an eye on efficiency and setting national standards [9] Currently, 10 Strategic Health Authorities handle the NHS at a local level, and Medical care Trusts (PCTs), which presently control 80% of the NHS' budget plan, offer governance and commission services, in addition to ensure the availability of services for public heath care, and provision of neighborhood services. Both, SHAs and PCTs will disappear as soon as the strategies outlined in the 2010 White Paper become carried out (see section listed below). NHS Trusts run on a "payment by results" basis and obtain the majority of their income by providing health care that has been commissioned by the practice-based commissioners (GPs, etc) and PCTs. The primary types of Trusts consist of Acute, Care, Mental Health, Ambulance, Children's and Foundation Trusts. The latter were developed as non-profit making entities, free of government control but likewise increased financial responsibilities and are managed by an independent Monitor. The Care Quality Commission regulates independently health and adult social care in England overall. Other professional bodies provide monetary (e.g. Audit Commission, National Audit Office), treatment/services (e.g. National Patient Safety Agency, Medicines and Healthcare Products Regulatory Agency) and professional (e.g. British Medical Association) guideline. The National Institute for Health and Clinical Excellence (NICE) was developed in 1999 as the body accountable for developing national standards and requirements related to, health promo and avoidance, evaluation of new and existing innovation (consisting of medicines and treatments) and treatment and care medical assistance, available across the NHS. The health research study strategy of the NHS is being executed through National Institute of Health Research (NIHR), the total budget for which remained in 2009/10 close to ₤ 1 billion (www.nihr.ac.uk) [10]

Fig. 1.

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

Section 242 of the NHS Act specifies that Trusts have a legal duty to engage and include clients and the general public. Patient experience information/feedback is formally collected nationally by annual survey (by the Picker Institute) and is part of the NHS Acute Trust performance structure. The Patient Advice Liaison Service (PALS) and Local Involvement Networks (LINks) support client feedback and participation. Overall, inpatients and outpatients surveys have exposed that patients rate the care they receive in the NHS high and around three-quarters indicate that care has been great or exceptional [11]

In Scotland, NHS Boards have actually replaced Trusts and supply an integrated system for tactical instructions, performance management and medical governance, whereas in Wales, the National Delivery Group, with suggestions from the National Advisory Board, is the body performing these functions (www.show.scot.nhs.uk; www.wales.nhs.uk). Scottish NHS and Special Boards deliver services, with look after particular conditions delivered through Managed Clinical Networks. Clinical guidelines are released by the Scottish Intercollegiate Guidelines Network (SIGN) and the Scottish Medicines Consortium (SMC) suggestions on the use of brand-new drugs in the Scottish NHS. In Wales, Local Heath Boards (LHBs) plan, secure and deliver healthcare services in their areas and there are 3 NHS Trusts supplying emergency situation, cancer care and public health services nationally. In Northern Ireland, a single body, the Health and Care Board is supervising commissioning, efficiency and resource management and improvement of health care in the nation and six Health and Social Care Trusts provide these services (www.hscni.net). A number of health agencies support secondary services and deal with a large range of health and care problems including cancer screening, blood transfusion, public health etc. In Wales Community Health Councils are statutory ordinary bodies advocating the interests of the general public in the health service in their district and in Northern Ireland the Patient and Client Council represent clients, clients and carers.

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

Like other nationwide health care systems, predictive, preventive and/or personalised medicine services within the NHS have generally been offered and are part of disease diagnosis and treatment. Preventive medication, unlike predictive or customised medication, is its own established entity and appropriate services are directed by Public Health and used either by means of GP, social work or health centers. Patient-tailored treatment has constantly been common practice for great clinicians in the UK and any other healthcare system. The terms predictive and customised medicine though are developing to describe a far more technically sophisticated method of detecting illness and forecasting reaction to the standard of care, in order to increase the advantage for the client, the public and the health system.

References to predictive and customised medication are progressively being introduced in NHS associated info. The NHS Choices site explains how patients can get personalised guidance in relation to their condition, and offers information on predictive blood test for illness such as TB or diabetes. The NIHR through NHS-supported research study and together with scholastic and industrial teaming up networks is investing a considerable proportion of its spending plan in verifying predictive and preventive restorative interventions [10] The previous government thought about the development of preventive, people-centred and more productive healthcare services as the ways for the NHS to react to the obstacles that all contemporary health care systems are facing in the 21st century, namely, high patient expectation, aging populations, harnessing of info and technological advancement, altering labor force and evolving nature of disease [12] Increased focus on quality (patient safety, patient experience and clinical effectiveness) has also supported development in early medical diagnosis and PPPM-enabling technologies such as telemedicine.

A number of preventive services are delivered through the NHS either by means of GP surgical treatments, social work or medical facilities depending on their nature and consist of:

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

The Child Health Promotion Programme is handling problems from pregnancy and the very first 5 years of life and is provided by community midwifery and health visiting teams [13]

Various immunisation programs from infancy to adulthood, provided to anybody in the UK for free and typically provided in GP surgical treatments.

The Darzi evaluation set out six essential clinical objectives in relation to enhancing preventive care in the UK including, 1) taking on weight problems, 2) lowering alcohol harm, 3) treating drug addiction, 4) reducing smoking rates, 5) enhancing sexual health and 6) improving psychological health. Preventive programs to deal with these concerns have been in place over the last decades in various kinds and through different initiatives, and include:

Assessment of cardiovascular threat and identification of people at greater threat of cardiovascular disease is usually preformed through GP surgical treatments.

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

Family planning services and avoidance of sexually transferred disease programmes, often with an emphasis on youths

A variety of avoidance and health promo programmes related to lifestyle options are delivered though GPs and social work including, alcohol and smoking cigarettes cessation programs, promo of healthy eating and physical activity. Some of these have a specific focus such as health promotion for older individuals (e.g. Falls Prevention).

White paper 2010 - Equity and excellence: liberating the NHS

The current government's 2010 "Equity and excellence: Liberating the NHS" White Paper has actually set out the vision of the future of an NHS as an organisation that still remains real to its starting concept of, offered to all, totally free at the point of use and based upon need and not ability to pay. It likewise continues to support the principles and worths specified in the NHS Constitution. The future NHS belongs to the Government's Big Society which is develop on social uniformity and involves rights and obligations in accessing cumulative healthcare and making sure effective use of resources hence providing much better health. It will provide healthcare outcomes that are among the very best in the world. This vision will be implemented through care and organisation reforms focusing on four locations: a) putting patients and public initially, b) enhancing on quality and health outcomes, c) autonomy, accountability and democratic authenticity, and d) cut bureaucracy and improve performance [5] This strategy makes references to issues that are pertinent to PPPM which suggests the increasing impact of PPPM principles within the NHS.

According to the White Paper the concept of "shared decision-making" (no choice about me without me) will be at the centre of the "putting emphasis on patient and public very first" plans. In truth this consists of plans stressing the collection and ability to gain access to by clinicians and clients all client- and treatment-related information. It likewise includes higher attention to Patient-Reported Outcome Measures, higher choice of treatment and treatment-provider, and significantly customised care preparation (a "not one size fits all" method). A recently developed Public Health Service will bring together existing services and location increased focus on research analysis and assessment. Health Watch England, a body within the Care Quality Commission, will provide a more powerful client and public voice, through a network of local Health Watches (based on the existing Local Involvement Networks - LINks).

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

The abolition of SHAs and PCTs, are being proposed as ways of supplying greater autonomy and responsibility. GP Consortia supported by the NHS Commissioning Board will be responsible for commissioning healthcare services. The introduction of this type of "health management organisations" has been rather controversial however possibly not absolutely unforeseen [14, 15] The transfer of PCT health enhancement function to regional authorities intends to provide increased democratic legitimacy.

Challenges dealing with the UK healthcare system

Overall the health, as well as ideological and organisational challenges that the UK Healthcare system is facing are not different to those dealt with by many national health care systems across the world. Life expectancy has been steadily increasing across the world with taking place increases in chronic diseases such as cancer and neurological conditions. Negative environment and lifestyle influences have actually produced a pandemic in obesity and associated conditions such as diabetes and heart disease. In the UK, coronary heart disease, cancer, kidney disease, mental health services for adults and diabetes cover around 16% of total National Health Service (NHS) expense, 12% of morbidity and in between 40% and 70% of mortality [3] Across Western societies, health inequalities are disturbingly increasing, with minority and ethnic groups experiencing most serious health problems, premature death and impairment. The House of Commons Health Committee warns that whilst the health of all groups in England is enhancing, over the last 10 years health inequalities in between the social classes have widened-the space has increased by 4% for males, and by 11% for women-due to the reality that the health of the rich is improving much quicker than that of the poor [16] The focus and practice of health care services is being changed from typically using treatment and helpful or palliative care to increasingly dealing with the management of chronic disease and rehab regimes, and using disease avoidance and health promo interventions. Pay-for-performance, modifications in guideline together with cost-effectiveness and spend for medications issues are becoming a crucial factor in new interventions reaching clinical practice [17, 18]

Preventive medication is solidly established within the UK Healthcare System, and predictive and personalised methods are progressively becoming so. Implementation of PPPM interventions might be the solution but also the reason for the health and healthcare obstacles and issues that health systems such as the NHS are facing [19] The efficient intro of PPPM needs clinical understanding of disease and health, and technological development, together with detailed techniques, evidence-based health policies and appropriate policy. Critically, education of health care professionals, patients and the public is also paramount. There is little doubt however that harnessing PPPM appropriately can help the NHS accomplish its vision of providing health care results that will be among the finest on the planet.

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