공지사항

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

. The National Health System in the UK has actually evolved to turn into one of the largest healthcare systems worldwide. At the time of writing of this evaluation (August 2010) the UK government in its 2010 White Paper "Equity and quality: Liberating the NHS" has revealed a method on how it will "create a more responsive, patient-centred NHS which attains results that are amongst the best worldwide". This review short article provides an introduction of the UK health care system as it presently stands, with emphasis on Predictive, Preventive and Personalised Medicine aspects. It intends to work as the basis for future EPMA posts to broaden on and provide the changes that will be carried out 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), originated in the consequences of the Second World War and became operational on the 5th July 1948. It was first proposed to the Parliament in the 1942 Beveridge Report on Social Insurance and Allied Services and it is the tradition of Aneurin Bevan, a former miner who ended up being a political leader and the then Minister of Health. He founded the NHS under the principles of universality, totally free at the point of shipment, equity, and paid for by main financing [1] Despite many political and organisational modifications the NHS stays to date a service readily available universally that takes care of people on the basis of need and not ability to pay, and which is funded by taxes and national insurance coverage contributions.

Health care and health policy for England is the obligation 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 nations the NHS has its own unique structure and organisation, but in general, and not dissimilarly to other health systems, healthcare comprises of two broad sections; one dealing with technique, policy and management, and the other with actual medical/clinical care which remains in turn divided into main (neighborhood care, GPs, Dentists, Pharmacists and so on), secondary (hospital-based care accessed through GP recommendation) and tertiary care (expert hospitals). Increasingly distinctions between the two broad areas are becoming less clear. Particularly over the last years and assisted by the "Shifting the Balance of Power: The Next Steps" (2002) and "Wanless" (2004) reports, steady changes in the NHS have actually led to a higher shift towards regional rather than central choice making, removal of barriers between main and secondary care and stronger emphasis 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 existing government's health method, "Equity and excellence: Liberating the NHS", stays supportive of the same concepts, albeit through possibly different mechanisms [4, 5]

The UK federal government has simply revealed plans that according to some will produce the most transformation in the NHS given that its beginning. In the 12th July 2010 White Paper "Equity and quality: Liberating the NHS", the existing Conservative-Liberal Democrat coalition federal government outlined a strategy on how it will "create a more responsive, patient-centred NHS which attains results that are amongst the very best in the world" [5]

This review short article will for that reason present an introduction of the UK healthcare system as it presently stands with the aim to function as the basis for future EPMA posts to expand and present the changes that will be executed within the NHS in the forthcoming 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 values, as they have been established by patients, public and staff and the rights, pledges and obligations of patients, public and staff [6] Scotland, Northern Ireland and Wales have also consented to a high level declaration declaring the concepts of the NHS throughout the UK, even though services might be supplied in a different way in the four countries, reflecting their various health requirements and situations.

The NHS is the biggest employer in the UK with over 1.3 million staff and a budget plan of over ₤ 90 billion [7, 8] In 2008 the NHS in England alone utilized 132,662 doctors, a 4% increase on the previous year, and 408,160 nursing personnel (Table 1). Interestingly the Kings Fund approximates that, while the total number of NHS personnel increased by around 35% in between 1999 and 2009, over the exact same duration the variety of supervisors increased by 82%. As a proportion of NHS staff, the number of managers increased from 2.7 per cent in 1999 to 3.6 percent 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 costs. The net NHS expenditure per head across the UK was least expensive in England (₤ 1,676) and greatest in Scotland (₤ 1,919) with Wales and Northern Ireland at roughly the very same level (₤ 1,758 and ₤ 1,770, respectively) [8]

Table 1.

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

The general 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 accountable for the direction of the NHS, social care and public health and delivery of health care by developing policies and strategies, securing resources, keeping an eye on performance and setting national requirements [9] Currently, 10 Strategic Health Authorities handle the NHS at a regional level, and Primary Care Trusts (PCTs), which currently manage 80% of the NHS' spending plan, offer governance and commission services, in addition to guarantee the accessibility of services for public heath care, and arrangement of neighborhood services. Both, SHAs and PCTs will disappear when the strategies detailed in the 2010 White Paper end up being executed (see section listed below). NHS Trusts operate on a "payment by outcomes" basis and acquire most of their income by providing healthcare that has been commissioned by the practice-based commissioners (GPs, etc) and PCTs. The main types of Trusts consist of Acute, Care, Mental Health, Ambulance, Children's and Foundation Trusts. The latter were produced as non-profit making entities, free of government control but also increased monetary responsibilities and are controlled by an independent Monitor. The Care Quality Commission regulates separately health and adult social care in England overall. Other expert bodies offer monetary (e.g. Audit Commission, National Audit Office), treatment/services (e.g. National Patient Safety Agency, Medicines and Healthcare Products Regulatory Agency) and expert (e.g. British Medical Association) regulation. The National Institute for Health and Clinical Excellence (NICE) was established in 1999 as the body accountable for establishing national standards and requirements associated with, health promotion and avoidance, evaluation of new and existing technology (consisting of medications and treatments) and treatment and care medical assistance, readily available throughout the NHS. The health research strategy of the NHS is being carried out through National Institute of Health Research (NIHR), the overall budget for which was in 2009/10 near 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 patients and the general public. Patient experience information/feedback is officially collected nationally by yearly survey (by the Picker Institute) and is part of the NHS Acute Trust efficiency framework. The Patient Advice Liaison Service (PALS) and Local Involvement Networks (LINks) support client feedback and involvement. Overall, inpatients and outpatients surveys have exposed that clients rate the care they receive in the NHS high and around three-quarters suggest that care has actually been great or exceptional [11]

In Scotland, NHS Boards have changed Trusts and offer an integrated system for tactical direction, performance management and clinical 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 provide services, with look after specific conditions delivered through Managed Clinical Networks. Clinical guidelines are released by the Scottish Intercollegiate Guidelines Network (SIGN) and the Scottish Medicines Consortium (SMC) advices on using brand-new drugs in the Scottish NHS. In Wales, Local Heath Boards (LHBs) strategy, protected and deliver healthcare services in their locations and there are 3 NHS Trusts providing emergency, cancer care and public health services nationally. In Northern Ireland, a single body, the Health and Care Board is supervising commissioning, performance and resource management and improvement of health care in the country and six Health and Social Care Trusts deliver these services (www.hscni.net). A variety of health companies support secondary services and handle a large range of health and care concerns including cancer screening, blood transfusion, public health etc. In Wales Community Health Councils are statutory lay bodies promoting the interests of the general public in the health service in their district and in the Patient and Client Council represent clients, customers and carers.

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

Like other nationwide healthcare systems, predictive, preventive and/or personalised medication services within the NHS have actually generally been provided and belong to illness diagnosis and treatment. Preventive medication, unlike predictive or personalised medicine, is its own established entity and pertinent services are directed by Public Health and offered either via GP, community services or medical facilities. Patient-tailored treatment has constantly been common practice for excellent clinicians in the UK and any other healthcare system. The terms predictive and personalised medicine though are developing to describe a a lot more technically advanced way of detecting illness and predicting response to the standard of care, in order to maximise the advantage for the patient, the general public and the health system.

References to predictive and customised medicine are significantly being introduced in NHS related information. The NHS Choices website explains how patients can get customised recommendations 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 and together with academic and industrial working together networks is investing a significant percentage of its spending plan in validating predictive and preventive healing interventions [10] The previous federal government thought about the development of preventive, people-centred and more efficient health care services as the means for the NHS to respond to the challenges that all modern health care systems are facing in the 21st century, specifically, high client expectation, ageing populations, harnessing of details and technological improvement, changing workforce and evolving nature of illness [12] Increased focus on quality (patient safety, patient experience and scientific effectiveness) has actually likewise supported development in early diagnosis and PPPM-enabling innovations such as telemedicine.

A variety of preventive services are provided through the NHS either through GP surgeries, neighborhood services or medical facilities depending upon their nature and include:

The Cancer Screening programs in England are nationally coordinated and include Breast, Cervical and Bowel Cancer Screening. There is likewise a notified choice Prostate Cancer Risk Management programme (www.cancerscreening.nhs.uk).

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

Various immunisation programs from infancy to their adult years, used to anyone in the UK for free and normally delivered in GP surgeries.

The Darzi review set out six key clinical goals in relation to enhancing preventive care in the UK including, 1) taking on obesity, 2) lowering alcohol harm, 3) dealing with drug addiction, 4) decreasing smoking cigarettes rates, 5) enhancing sexual health and 6) enhancing psychological health. Preventive programs to attend to these concerns have actually been in location over the last decades in different types and through various initiatives, and consist of:

Assessment of cardiovascular threat and identification of people at greater danger of heart disease is typically preformed through GP surgeries.

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

Family preparation services and avoidance of sexually transmitted disease programs, often with an emphasis on youths

A variety of avoidance and health promotion programs connected to way of life choices are provided though GPs and social work including, alcohol and smoking cigarettes cessation programmes, promo of healthy eating and exercise. A few of these have a specific focus such as health promo for older individuals (e.g. Falls Prevention).

White paper 2010 - Equity and quality: liberating the NHS

The existing 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 true to its starting concept of, offered to all, free at the point of usage and based upon need and not capability to pay. It likewise continues to promote the principles and worths defined in the NHS Constitution. The future NHS is part of the Government's Big Society which is build on social solidarity and requires rights and duties in accessing cumulative health care and ensuring effective usage of resources therefore delivering better health. It will deliver health care outcomes that are amongst the very best worldwide. This vision will be carried out through care and organisation reforms focusing on 4 locations: a) putting patients and public initially, b) enhancing on quality and health results, c) autonomy, responsibility and democratic legitimacy, and d) cut administration and enhance efficiency [5] This technique refers to problems that are appropriate to PPPM which shows the increasing impact of PPPM concepts 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" strategies. In reality this consists of strategies stressing the collection and ability to gain access to by clinicians and patients all client- and treatment-related info. It also includes greater attention to Patient-Reported Outcome Measures, greater option of treatment and treatment-provider, and importantly personalised care planning (a "not one size fits all" technique). A recently developed Public Health Service will unite existing services and location increased emphasis on research analysis and assessment. Health Watch England, a body within the Care Quality Commission, will provide a more powerful patient and public voice, through a network of local Health Watches (based upon the existing Local Involvement Networks - LINks).

The NHS Outcomes Framework sets out the priorities for the NHS. Improving on quality and health outcomes, according to the White Paper, will be attained through modifying objectives and healthcare top priorities and establishing targets that are based on clinically reliable and evidence-based steps. NICE have a central function in establishing suggestions and standards and will be anticipated to produce 150 brand-new standards over the next 5 years. The federal government plans to develop a value-based rates system for paying pharmaceutical companies for providing drugs to the NHS. A Cancer Drug Fund will be developed in the interim to cover patient treatment.

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

Challenges dealing with the UK health care system

Overall the health, in addition to ideological and organisational obstacles that the UK Healthcare system is dealing with are not different to those faced by many nationwide health care systems across the world. Life expectancy has actually been progressively increasing across the world with occurring increases in persistent illness such as cancer and neurological disorders. Negative environment and lifestyle impacts have actually created a pandemic in obesity and associated conditions such as diabetes and cardiovascular disease. In the UK, coronary heart disease, cancer, renal illness, mental health services for adults and diabetes cover around 16% of overall National Health Service (NHS) expenditure, 12% of morbidity and between 40% and 70% of mortality [3] Across Western societies, health inequalities are disturbingly increasing, with minority and ethnic groups experiencing most major illnesses, early death and impairment. Your Home of Commons Health Committee cautions 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 gap has actually increased by 4% for guys, and by 11% for women-due to the truth that the health of the abundant is improving much quicker than that of the bad [16] The focus and practice of healthcare services is being changed from generally providing treatment and helpful or palliative care to significantly dealing with the management of persistent disease and rehabilitation routines, and offering illness prevention and health promo interventions. Pay-for-performance, changes in guideline together with cost-effectiveness and spend for medications problems are becoming a critical factor in new interventions reaching scientific practice [17, 18]

Preventive medicine is sturdily developed within the UK Healthcare System, and predictive and customised techniques are significantly ending up being so. Implementation of PPPM interventions may be the option however also the cause of the health and health care challenges and issues that health systems such as the NHS are facing [19] The effective intro of PPPM needs scientific understanding of illness and health, and technological development, together with thorough techniques, evidence-based health policies and proper policy. Critically, education of healthcare specialists, clients and the public is likewise paramount. There is little doubt nevertheless that utilizing PPPM appropriately can assist the NHS attain its vision of providing healthcare results that will be amongst the very best in the world.

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