How old is NHS

Health policy

Thomas Gerlinger

Prof. Dr. Dr. Thomas Gerlinger is professor at AG 1: Health Systems, Health Policy and Health Sociology at the Faculty of Health Sciences at Bielefeld University

Kai Mosebach

Born 1970, political and health scientist, substitute professor in the social and health department at the Gochschule Ludwigshafen am Rhein.

The national competencies for protecting the population from health hazards ("Public Health") are distributed in Great Britain among various ministries and result in a high level of coordination effort. Here, too, the key political position is held by the national health ministry.

Signpost at the entrance to the Royal London Hospital. The NHS Walk-in Center is an outpatient, nurse-led facility for the treatment of minor injuries and illnesses (& copy picture alliance / Photoshot)

Public Health: Coordination and integration of ministries, municipalities and the NHS

The municipalities are traditionally responsible for population-related interventions such as education and awareness-raising, housing policy and broad areas of health protection (hygiene, food safety, environmental protection). Public health measures are therefore planned by the municipal health authorities and implemented in specific programs and projects.

The three Labor Governments (since 1997) have made better cooperation between the national health service and local health authorities to combat socially related health inequalities an important public health objective. Both the promotion of preventive and health-promoting interventions and the development of local health strategies should contribute to this. There are numerous programs to integrate the work of the National Health Service (NHS), the local health authorities and non-state actors. Health Action Zones (HAZs), for example, have been set up in regions particularly affected by health problems. In addition, there is an officer for public health problems on the board of directors of each primary care trust, who, in cooperation with a public health team, is supposed to bring about better coordination between the national health service and local health authorities.

Care structures of the English health system

Primary Health Care: The Gatekeeper System in Transition

Family doctor care is provided by general practitioners (GPs) who usually work in group practices. To do this, patients register in a patient register of their family doctor on site. A free choice of doctor, as is the case in Germany for general practitioner care, is not easily possible, although patients can change the general practitioner responsible. However, the newly elected general practitioner must accept the patient and add it to their own register.

The general practitioners treat their patients in their practice or refer them to institutions for specialist (secondary) health care (hospitals and intermediary organizations) for further treatment. With the exception of emergencies, there is therefore no direct access to hospital services for patients in Great Britain. Rather, the family doctor acts as a "gatekeeper" for the patient and guides him / her on the path of treatment through the NHS.

In an international comparison, the supply of general practitioners in Great Britain is significantly below the supply density in Germany. In the UK in 2011 there were around 40,000 general practitioners (Thomson et al. 2013). This brought about 0.7 general practitioners for every 1,000 residents. This is slightly less than in Germany, where a good 60,000 doctors were active in primary care in 2011 (0.75 per 1,000 inhabitants) (Rosenbrock / Gerlinger 2013). If the specialists are also included, the density of doctors in Great Britain is significantly lower than in Germany: In terms of all doctors, there were 2.8 doctors per 1,000 inhabitants in Great Britain this year, and 3.8 in Germany (OECD 2013).

In addition to the general practitioners, dentists, pharmacists and opticians also work as independent small business owners for the NHS and together provide the group of health services known as Family Health Services. In addition, supplementary services are provided by municipal hospitals, day clinics and municipal health services. This includes, for example, the caring and nursing activities of community nurses, health visitors, midwives and nursing staff ("Community Health Services"). Family doctors work closely in primary health care teams with these professional groups and the local health authorities. Primary health care therefore not only includes curative measures to cure and treat acute or chronic diseases, but also preventive and health-promoting measures to improve the general health of the local population ("Family Health Services" + "Community Health Services" = "Primary Care") ).

Both a nationwide telephone service ("NHS Direct") and facilities for the treatment of minor injuries and illnesses run by specially trained nurses ("NHS Walk-In Centers") relieve the general practitioners' practices, which are usually run as group practices. The NHS Walk-In Centers are mainly located in the center of smaller and larger cities.

Facilities for the treatment of minor injuries and illnesses

Medical specialist care: hospitals and intermediary organizations

Primary care and specialist (secondary) care have traditionally been strictly separated in Great Britain due to the dominance of the gatekeeper system and the concentration of specialist medical activities in the hospital sector. In an international comparison, the hospital density in Great Britain is historically very low. In 2011 there were only 3.0 acute beds per 1,000 inhabitants in Great Britain and 8.3 in Germany (OECD 2013).

The rigid boundary between outpatient primary care and inpatient specialist care is becoming more permeable due to medical progress ("minimally invasive medicine" and "standardization of surgical interventions") and the political promotion of competition in the secondary sector. On the one hand, qualified general practitioners can also carry out minor operations and specialized diagnostic procedures on an outpatient basis. On the other hand, hospitals tend to outsource simple interventions on the basis of highly standardized surgical procedures from the hospital to outpatient - private as well as state-run - day and outpatient clinics ("treatment centers"). Specialist care in Great Britain is now based not only on numerous state and municipal hospitals, but also on private hospitals and numerous (private and state) day and outpatient clinics. At the beginning there were around 400 acute hospitals in the English NHS (often with several clinic locations). Almost 150 of them had the status of an "NHS Trust" and around 250 that of an "NHS Foundation Trust"). Public hospitals provide the bulk of inpatient care in England (around 90 percent). Private houses are still of little importance for the time being.

Vulnerable social groups

Personal social services

Another important area of ​​the UK health system is the provision of supportive personal social services to vulnerable social groups of adults and children. These groups of people in need of help include elderly people in need, the mentally ill and people with physical and mental impairments. Although these services are largely funded by the municipalities on the basis of means tests (see above), they are usually not provided by them. The private sector plays an important role in the group of these personal social services, which in England includes both corporations and charities.

Long-term care of adults is provided either in private or communal nursing homes, private residential complexes or at home by private or communal care services. In 2006, 259,200 people were cared for in 2,200 facilities, 80 percent of whom were over 65 years of age. The share of municipal institutions has been declining for years and in 2006 was only ten percent. Correspondingly, the proportion of private service providers has grown - from 20 percent in 1993 to 90 percent in 2006. In 2009, just under 400,000 were assessed on their application to see whether they had a need for social services (Boyle 2011) .. Here too For social services, the share of private service providers, at around 70 percent, is significantly higher than services that the needy received directly from municipal institutions (30 percent). The majority of the social services are provided to older people over 65 years of age.

For better integration of medical and social care for people with multiple illnesses or with disabilities and mental illnesses, primary care trusts or other NHS care facilities such as acute hospitals ("NHS trusts") or psychiatric hospitals ("NHS Mental Health Trusts") can work together Establish institutions jointly with the local authorities ("Care Trusts"). Despite the high political importance assigned to this integration of medical and social care sectors, so far only a few joint voluntary partnerships have been formed between NHS actors and local authorities.