The Structure and Current Affairs of the NHS

History and Structure of the NHS

 

The National Health Service (NHS) was founded in 1948 on three core principles: 

1. That it meets the needs of everyone 
2. That it be free at the point of delivery 
3. That it be based on clinical need, not ability to pay

 

The NHS aspires to put patients at the heart of everything it does and is accountable to the public, communities and patients that is serves. Under the Mental Health Act of 1959, the distinction between psychiatric hospitals and NHS hospitals was abolished, so that patients with mental illness could be treated in NHS hospitals. 

 

The majority of primary care in the NHS is delivered by general practitioners (GPs), but also by dentists, opticians and pharmacists. Secondary care is provided by specialists and healthcare professionals to whom patients are often referred through a GP. Tertiary care is provided to patients by specialised doctors and nurses in specialised hospitals, such as a plastic surgery unit. Patients can only access tertiary care through the NHS when they've been referred by a health professional working in secondary care. 

 

The NHS has undergone important structural changes in recent years. The Stafford Hospital Scandal, commonly known as Mid-Staffs came to national attention in 2009. In 2008, an investigation of Stafford Hospital by the Healthcare Commission alerted high mortality rates in patients admitted into emergencies. It was concluded that >1000 avoidable deaths occurred in Stafford Hospital between 2005-2008 due to poor patient care or neglect. A public enquiry was led by Sir Robert Francis, who concluded that it was unsafe to infer that there was any particular number of deaths that could have been avoided at the Mid-Staffordshire NHS Foundation Trust from the given statistics. Following this investigation, reforms throughout the NHS followed a number of recommendations, including staff line guidelines, protection for whistle-blowers and training. The first Francis report (2010) cited a “historic understaffing of nurses" as one of the number of reasons for poor patient care. 

 

In 2012, the Health and Social Care Act led to an enormous reorganisation of the NHS and its funding. A commissioning board was created, with three main commissioning bodies: 

• Clinical Commissioning Groups (CCGs)
• NHS England 
• Public Health England 

CCGs ensure that health and care services provided meet the needs to a given population. A CCG is a group of hospitals and services that cover a geographical area. For example, a CCG in an area with higher incidences of mental health issues may allocate a greater proportion of its funds to that sector. NHS England is a public body that oversees the budget, planning, delivery, and day-to-day operation of CCGs in the NHS in England. The role of Public Health England is to protect and improve the nation's health and to address inequalities. 

 

Major changes have also been implemented in the contracts of junior doctors employed by the NHS. The junior doctor contract controversy began in 2013, when junior doctors felt that their rota shift and pay were unfair to the doctors and unsafe for patients. This ultimately led to the junior doctor strikes in 2015. Following this, the Department of Health and Social Care (DHSC) introduced a contract with the intended aim of making pay fairer, and the end goal of spreading both emergency and elective services across seven days of the week. The British Medical Association (BMA) and the DHSC engaged in negotiations, which led to disagreements over certain points of the proposed contract. 

 

The Review Body on Doctors’ and Dentists’ Remuneration (DDRB) makes recommendations to the Prime Minister (Boris Johnson) and the Secretary of State for Health and Social Care (Matt Hancock). The review body have to consider the need to recruit, retain and motivate doctors and dentists. The DDRB’s recommendations have lead to a pay raise for junior doctors in their new  2016 contract, with a basic salary of ~£27,000 in FY1, compared to the previous ~£23,000 earned. The new contract also protects junior doctors from any unfair consequences that may come from whistleblowing (approaching management about an unsafe practise or concern). 

The concern with the new contract is that it is designed for a 7-day NHS, but does not account for additional staff. Many junior doctors are concerned that it will increase stress, tiredness and burnout among their peers, and that patient care will suffer as a result. In 2016, 98% of Junior Doctors rejected the contract. As a result, in 2019, the BMA agreed a deal with NHS employers and the DHSC, bringing an investment of £90 million over the next 4 years for junior doctors. Junior doctors and medical students had a chance to vote, and it was overwhelmingly in favour of accepting the changes. 

 

In 2014, the NHS Five Year Forward View encouraged increased cooperation between health services, including between family doctors and hospitals, physical and mental health services, and health and social care. The NHS Long Term Plan of 2019 outlines a number of key things to improve over the next 10 years:

 

Children:

• Extra support for pregnant mothers to aim to reduce the number of stillbirths and child deaths
• Taking further action on childhood obesity 
• Increasing funding for young people’s mental health 
• Increasing care for children with autism and learning disabilities 
• Delivering the best treatment for children with cancer, including further development of CAR-T cell therapy 

 

Major Health:

• Preventing number of heart attacks, strokes and cases of dementia 
• Promoting early diagnosis of cancers
• Increasing investment for the treatment of lung conditions 
• Increasing investment for mental health care by over £2Bn per year, to increase the number of people who get therapy for depression and anxiety 

 

Ageing community:

• Increased support and funding for the elderly 
• Upgrading NHS staff to support people in care homes
• Giving people more say about the care they would like to receive and where they receive it, particularly towards the end of the patients' lives

 

Early screening is important in reducing disease progression, and in prevention of complications associated with this. This reduces the mortality rate, but is also cost-effective for the NHS, as shortening the (effective) treatment will require less medication.

 

Patients are becoming increasingly dependent on prescribed medication, namely antidepressants, sleeping tablets and painkillers. One aim of the long term plan is to prevent drugs from being the first option to treat mental health conditions, and instead promoting counselling services or other types of assistance. 

 

In the NHS England’s 5 year forward view, there is an aim to restructure the NHS into a public/private enterprise, including the creation of accountable care organisations (ACOs) which will be able to turn to private insurers when they are faced by tax funding shortages. The question is whether the ACOs will be under the control of NHS England or whether they will be controlled by insurance companies such as Virgin Care and United Healthcare. If the latter is true, many believe that it could lead to a complete privatisation of the NHS. 

 

 

Organ Donations 

 

Every year, hundreds of patients in the UK die before they were able to receive a transplant. From spring 2020, England is changing from an opt-in to an opt-out system in the hope to increase organ donations. 

 

 

Euthanasia and Assisted Dying 

 

Euthanasia is the act of deliberately ending a patient’s life to relieve suffering. Active euthanasia involves injecting a patient, such as one suffering with terminal cancer, with an overdose of muscle relaxants to end their life. Passive euthanasia involves the withdrawal of treatment that is necessary to maintain life. For example, withholding antibiotics from a patient with a bacterial pneumonia. Assisted suicide is the process by which a physician intentionally gives the patient the means to take the lethal medication themselves. 

 

Euthanasia and assisted suicide are illegal in the UK, however, they are legal in several countries such as Canada, Belgium and the Netherlands. In a bill brought forward to the House of Commons in 2015, the legalisation of euthanasia was rejected. 

 

In the UK, assisted dying provides end-of-life care to facilitate the death of those patients that are already terminally ill. This is very different from euthanasia and assisted suicide, where the deaths of patients who are not already dying are brought about (e.g. paralysed patients or patients that are developing Huntington’s disease may choose to use it).

 

Arguments For: 

• Not providing a patient with their desired treatment is taking away their autonomy (the right to decide over their own body): Autonomy is one of the four pillars of medical ethics.
• Euthanasia can end the intolerable suffering caused by (terminal) illness. Prolonging life and suffering ignores the ethical ideology of non-maleficence, which states that medical practitioners must act to prevent harm. On the other hand, prematurely ending a person’s life may also be classified as causing harm.
• In the absence of assisted dying, patients would die on their own, causing increased suffering. Many UK citizens travel abroad to Swiss facilities to end their life. They would have chosen a death among their family members at home if they could have.

Arguments Against: 

• Many people argue that ‘Doctors would become executioners’.
• In Belgium, child euthanasia is now legalised. This wants to be prevented in the UK. 
• Although autonomy is a pillar of medical ethics, patients still don't have the right to demand treatment and doctors can refuse treatments if they don’t believe it’s in the patient’s best interest. 
• It could be argued that the potential negative consequences of this legislation outweigh the small number of people this would benefit. 

 

Ageing population 

 

Thanks to the medical advancements in recent years, the number of elderly people in the UK is rapidly raising. In addition to diseases such as Alzheimer’s and Parkinson’s disease, many elderly people have complex social needs and require additional support. As life expectancy is increasing, the NHS is in urgent need for investment into the social care sector to form a properly funded, properly directed health and social care sector with general practise, hospitals and social are all working together. 

 

 

Mental health 

 

The NHS aims to develop and implement a new national program for mental health by 2020, for which the government is aiming to increase the funding for mental health by over £2Bn annually. This is also essential for women experiencing perinatal mental health problems, most commonly depression and anxiety. For men aged between 20-49, suicide is the current leading cause of death. One of the aims of the new mental health plan is to reduce prescriptions for anti-depressants and instead make other services the first option for treating mental illness. 

 

 

Health Tourism 

 

Every year, the NHS spends over £1Bn in treatment for non-British citizens. Since 2017, providers of NHS treatment are required to ensure patients are eligible for free care by providing relevant documentation, and to charge them up front if not. This only applies to non-urgent cases; A&E, general practise and infectious disease treatment are exempt. 

 

 

Public Health Measures and Childhood Obesity 

 

In developed countries such as the UK, most deaths are now caused by non-communicable diseases, such as cancer and cardiovascular disease. There is ever-growing evidence that lifestyle choices such as smoking, alcohol consumption and obesity increase the risk of acquiring these types of diseases. 

 

The sugar tax was introduced in 2018, with the aim of reducing the amount of sugar in soft drinks. The money made from this tax would be invested in school sport and breakfast clubs. Dealing with childhood obesity is a major aim of the NHS long term plan. Childhood obesity levels in the UK are rising and the government has invested money to ensure children in schools engage in 60 minutes of sport or physical activity every day. 

 

Similar to the sugar tax, the UK government has contemplated introducing a ‘fat tax’, which would increase tax on unhealthy foods. However, this law is unlikely to pass, in particular because it is likely to affect those with a low income, who may not be able afford healthier, more expensive foods. 

 

 

Antibiotic Usage 

 

Due to random mutations in their DNA, bacteria can develop resistance to particular antibiotics, reducing the effectiveness of antibiotic treatments. The surviving bacteria in a patient’s body pass on the antibiotic resistance genes to the next generation, culminating in a rapidly reproducing bacterial colony. The practise of using antibiotics on livestock has contributed to the wide spreading of antibiotic resistant bacteria. 

 

GPs are being encouraged to reduce the number of antibiotic prescriptions. There’s also a movement towards developing new antibiotics. Combination therapy is often used to treat antibiotic resistant bacterial infections, as using two or more drugs simultaneously can increase the effectiveness. A more controversial option is the use of phage therapy. This process involves killing bacteria by infecting a host with bacteriophages. Successful studies have been conducted, but the risk of ingesting a virus makes this treatment currently unused. 

 

 

Use of Medical Cannabis 

 

Since 2018, specialised NHS doctors are allowed to prescribe cannabis-derived medicine under exceptional circumstances, such as in cases of children with extreme epilepsy. Medical cannabis can also be a successful treatment for Tourette’s syndrome patients. However, whilst the law has changed, scientific trials have been called for to ensure the safety of medicinal cannabis, meaning that it may not be available for several years. 

 

 

Artificial Intelligence in Medicine

 

Artificial intelligence (AI) is the ability for a computer or other machine to perform actions thought to require intelligence. AI could be an important tool for the future of medicine. For instance, diagnosis is all about recognising patterns. Computers could be programmed to read data using algorithms in order to detect changes that could enable earlier diagnosis of certain diseases. For example, AI could be used to recognise patients’ CT scans and health records to create a specific radiotherapy dose. Virtual nursing is another potential use of AI in medicine. Robots could measure a patients pulse, temperature, respiration and oxygen saturation, giving doctors regular updates on their patient’s health. Finally, robotic surgery is being developed to carry out routine operations with extreme precision. This is also partnered with a decrease in the staff required and the  time saved, making it a promising prospect for the future of the NHS.

  

Brexit and the NHS

 

The Leave Campaign promised that, as a result of Brexit, funding for the NHS would substantially increase, due to freed up money that wouldn’t be spent on the EU. However, it is now becoming apparent that the costs associated with leaving outweigh those that are being saved. The number of European workers in the NHS has dropped since 2016 and is expected to drop even further once Britain fully leaves the European Union, especially in the case of a no deal Brexit. This would add onto the staffing crisis that the NHS is already experiencing. 

 

If the UK leaves with a no-deal it could lead to border disruptions and delays, jeopardising pharmaceutical supply chains and affecting a large proportion of NHS medication, such as chemotherapeutics for cancer treatment and insulin for diabetics. The government has revealed that there will be a mass stockpiling of medicine in the event of a no-deal Brexit. However, this act will cost the NHS millions of pounds instead of improving its funding. 

 

Additionally, Brexit will cause the UK to loose out on a large proportion of their scientific research funding, which is provided by the EU. British scientists are being removed from EU grant applications, as the new status of the UK makes these applications weaker. Overall, the effects of Brexit on the NHS and on medical research are for the most part, uncertain.