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

. The National Health System in the UK has actually developed to end up being one of the largest healthcare systems in the world. At the time of writing of this review (August 2010) the UK federal government in its 2010 White Paper "Equity and quality: Liberating the NHS" has actually revealed a strategy on how it will "produce a more responsive, patient-centred NHS which accomplishes results that are among the very best in the world". This evaluation article provides an overview of the UK health care system as it currently stands, with focus on Predictive, Preventive and Personalised Medicine aspects. It intends to act as the basis for future EPMA articles to expand on and provide the modifications that will be executed within the NHS in the upcoming months.

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

Introduction

The UK healthcare system, National Health Service (NHS), came into existence in the consequences of the Second World War and ended up being operational on the 5th 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 tradition of Aneurin Bevan, a former miner who ended up being a politician and the then Minister of Health. He established the NHS under the principles of universality, free at the point of delivery, equity, and paid for by central funding [1] Despite many political and organisational modifications the NHS stays to date a service readily available universally that looks after individuals on the basis of requirement and not ability to pay, and which is funded by taxes and national insurance contributions.

Health care and health policy for England is the duty of the central government, whereas in Scotland, Wales and Northern Ireland it is the duty of the particular devolved governments. In each of the UK nations the NHS has its own distinct structure and organisation, however overall, and not dissimilarly to other health systems, healthcare comprises of 2 broad areas; one handling 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 recommendation) and tertiary care (specialist hospitals). Increasingly distinctions in between the two broad sections are ending up being less clear. Particularly over the last decade and directed by the "Shifting the Balance of Power: The Next Steps" (2002) and "Wanless" (2004) reports, progressive modifications in the NHS have actually resulted in a higher shift towards local instead of main decision making, removal of barriers between main and secondary care and stronger focus on client option [2, 3] In 2008 the previous government reinforced this instructions in its health technique "NHS Next Stage Review: High Quality Look After All" (the Darzi Review), and in 2010 the present federal government's health technique, "Equity and quality: Liberating the NHS", remains helpful of the very same ideas, albeit through potentially different systems [4, 5]

The UK government has actually just revealed strategies that according to some will produce the most radical modification in the NHS given that its beginning. In the 12th July 2010 White Paper "Equity and quality: Liberating the NHS", the present Conservative-Liberal Democrat coalition government described a strategy on how it will "develop a more responsive, patient-centred NHS which achieves outcomes that are among the best worldwide" [5]

This evaluation article will therefore present a summary of the UK healthcare system as it currently stands with the aim to work as the basis for future EPMA articles to broaden and provide the modifications that will be executed within the NHS in the upcoming months.

The NHS in 2010

The Health Act 2009 established the "NHS Constitution" which formally unites the function and concepts of the NHS in England, its worths, as they have actually been established by clients, public and staff and the rights, pledges and duties of clients, public and personnel [6] Scotland, Northern Ireland and Wales have actually also consented to a high level declaration stating the principles of the NHS throughout the UK, despite the fact that services may be provided in a different way in the 4 nations, reflecting their various health needs and circumstances.

The NHS is the largest 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 physicians, a 4% boost on the previous year, and 408,160 nursing staff (Table 1). Interestingly the Kings Fund approximates that, while the overall number of NHS staff increased by around 35% in between 1999 and 2009, over the very same period the variety of managers increased by 82%. As a percentage of NHS personnel, the number of supervisors increased from 2.7 per cent in 1999 to 3.6 per cent in 2009 (www.kingsfund.org.uk). In 2007/8, the UK health costs was 8.5% of Gross Domestic Product (GDP)-with 7.3% accounting for public and 1.2% for personal costs. The net NHS expense per head across the UK was lowest in England (₤ 1,676) and greatest in Scotland (₤ 1,919) with Wales and Northern Ireland at approximately the exact same level (₤ 1,758 and ₤ 1,770, respectively) [8]

Table 1.

The circulation of NHS workforce according to primary staff 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 displayed 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 healthcare by developing policies and methods, securing resources, keeping track of performance and setting national standards [9] Currently, 10 Strategic Health Authorities manage the NHS at a local level, and Medical care Trusts (PCTs), which presently control 80% of the NHS' budget plan, supply governance and commission services, as well as ensure the schedule of services for public heath care, and provision of neighborhood services. Both, SHAs and PCTs will disappear when the strategies laid out in the 2010 White Paper end up being carried out (see section listed below). NHS Trusts operate on a "payment by results" basis and obtain the majority of their income by providing healthcare that has been commissioned by the practice-based commissioners (GPs, and so on) and PCTs. The primary kinds of Trusts consist of Acute, Care, Mental Health, Ambulance, Children's and Foundation Trusts. The latter were created as non-profit making entities, devoid of federal government control however likewise increased financial responsibilities and are regulated by an independent Monitor. The Care Quality Commission manages individually health and adult social care in England in general. Other specialist bodies supply 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) regulation. The National Institute for Health and Clinical Excellence (NICE) was developed in 1999 as the body responsible for establishing nationwide guidelines and requirements connected to, health promotion and prevention, evaluation of new and existing technology (consisting of medications and procedures) and treatment and care clinical assistance, readily available across the NHS. The health research strategy of the NHS is being implemented through National Institute of Health Research (NIHR), the total budget plan for which remained in 2009/10 near ₤ 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 states that Trusts have a legal responsibility to engage and involve patients and the public. Patient experience information/feedback is formally collected nationally by annual study (by the Picker Institute) and belongs to the NHS Acute Trust efficiency structure. The Patient Advice Liaison Service (PALS) and Local Involvement Networks (LINks) support patient feedback and involvement. Overall, inpatients and outpatients surveys have actually revealed that clients rate the care they get in the NHS high and around three-quarters indicate that care has been extremely great or excellent [11]

In Scotland, NHS Boards have changed Trusts and provide an integrated system for tactical instructions, efficiency management and scientific 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 provided through Managed Clinical Networks. Clinical standards are published by the Scottish Intercollegiate Guidelines Network (SIGN) and the Scottish Medicines Consortium (SMC) advices on the usage of new drugs in the Scottish NHS. In Wales, Local Heath Boards (LHBs) strategy, safe and provide health care services in their locations and there are 3 NHS Trusts offering 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 enhancement of health care in the nation and six Health and Social Care Trusts deliver these services (www.hscni.net). A number of health companies support ancillary services and handle a wide range of health and care issues consisting of cancer screening, blood transfusion, public health etc. In Wales Community Health Councils are statutory ordinary bodies promoting the interests of the general public in the health service in their district and in Northern Ireland the Patient and Client Council represent patients, customers and carers.

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

Like other national healthcare systems, predictive, preventive and/or personalised medicine services within the NHS have actually traditionally been used and are part of illness medical diagnosis and treatment. Preventive medicine, unlike predictive or customised medicine, is its own established entity and appropriate services are directed by Public Health and offered either through GP, social work or healthcare facilities. Patient-tailored treatment has constantly been typical practice for great clinicians in the UK and any other healthcare system. The terms predictive and customised medication though are developing to describe a much more technically advanced method of identifying illness and anticipating reaction to the requirement of care, in order to maximise the advantage for the patient, the public and the health system.

References to predictive and personalised medication are progressively being presented in NHS associated information. The NHS Choices website describes how patients can acquire customised advice in relation to their condition, and offers info on predictive blood test for illness such as TB or diabetes. The NIHR through NHS-supported research study and together with scholastic and business working together networks is investing a significant proportion of its budget in verifying predictive and preventive therapeutic interventions [10] The previous federal government thought about the advancement of preventive, people-centred and more productive health care services as the means for the NHS to react to the obstacles that all modern-day health care systems are facing in the 21st century, specifically, high client expectation, ageing populations, harnessing of details and technological advancement, altering labor force and evolving nature of disease [12] Increased emphasis on quality (client safety, client experience and clinical efficiency) has likewise supported innovation in early medical diagnosis and PPPM-enabling innovations such as telemedicine.

A variety of preventive services are delivered through the NHS either by means of GP surgical treatments, neighborhood services or health centers 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 also an informed choice Prostate Cancer Risk Management programme (www.cancerscreening.nhs.uk).

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

Various immunisation programmes from infancy to adulthood, provided to anybody in the UK for free and generally delivered in GP surgical treatments.

The Darzi evaluation set out six essential clinical objectives in relation to care in the UK including, 1) dealing with weight problems, 2) reducing alcohol damage, 3) dealing with drug addiction, 4) reducing smoking rates, 5) improving sexual health and 6) improving psychological health. Preventive programmes to resolve these issues have remained in location over the last decades in different forms and through various efforts, and include:

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

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

Family preparation services and avoidance of sexually sent disease programmes, typically with a focus on young individuals

A variety of prevention and health promotion programmes associated with way of life choices are provided though GPs and social work consisting of, alcohol and cigarette smoking cessation programmes, promo of healthy consuming and exercise. 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 existing government's 2010 "Equity and excellence: Liberating the NHS" White Paper has set out the vision of the future of an NHS as an organisation that still remains real to its founding concept of, offered to all, totally free at the point of usage and based upon requirement and not ability to pay. It likewise continues to support the principles and values specified in the NHS Constitution. The future NHS is part of the Government's Big Society which is construct on social solidarity and involves rights and obligations in accessing collective healthcare and making sure reliable use of resources hence providing better health. It will provide health care outcomes that are amongst the very best worldwide. This vision will be executed through care and organisation reforms focusing on 4 locations: a) putting patients and public initially, b) improving on quality and health results, c) autonomy, responsibility and democratic legitimacy, and d) cut administration and improve efficiency [5] This technique makes references to concerns that are relevant to PPPM which shows the increasing influence of PPPM principles within the NHS.

According to the White Paper the concept of "shared decision-making" (no decision about me without me) will be at the centre of the "putting focus on client and public first" plans. In truth this includes plans emphasising the collection and capability to access by clinicians and clients all patient- and treatment-related information. It likewise includes higher attention to Patient-Reported Outcome Measures, greater option of treatment and treatment-provider, and notably personalised care preparation (a "not one size fits all" approach). A freshly developed Public Health Service will combine existing services and place increased emphasis on research study 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 regional Health Watches (based on the existing Local Involvement Networks - LINks).

The NHS Outcomes Framework sets out the concerns for the NHS. Improving on quality and health results, according to the White Paper, will be achieved through revising objectives and healthcare concerns and developing targets that are based on medically trustworthy and evidence-based procedures. NICE have a main role in establishing recommendations and requirements and will be expected to produce 150 brand-new standards over the next 5 years. The federal government prepares to establish a value-based pricing system for paying pharmaceutical business for providing drugs to the NHS. A Cancer Drug Fund will be developed in the interim to cover client treatment.

The abolition of SHAs and PCTs, are being proposed as ways of offering higher autonomy and responsibility. GP Consortia supported by the NHS Commissioning Board will be accountable for commissioning health care services. The introduction of this kind of "health management organisations" has been rather questionable but potentially not totally unexpected [14, 15] The transfer of PCT health enhancement function to regional authorities intends to provide increased democratic legitimacy.

Challenges facing the UK healthcare system

Overall the health, along with ideological and organisational obstacles that the UK Healthcare system is facing are not dissimilar to those dealt with by numerous national health care systems throughout the world. Life span has actually been progressively increasing across the world with occurring boosts in chronic diseases such as cancer and neurological disorders. Negative environment and lifestyle impacts have produced a pandemic in obesity and associated conditions such as diabetes and heart disease. In the UK, coronary heart problem, cancer, renal disease, mental health services for adults and diabetes cover around 16% of total 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 health problems, early death and special needs. Your House of Commons Health Committee warns that whilst the health of all groups in England is improving, over the last ten years health inequalities between the social classes have widened-the gap has increased by 4% for males, and by 11% for women-due to the fact that the health of the rich is enhancing much quicker than that of the poor [16] The focus and practice of health care services is being changed from generally using treatment and encouraging or palliative care to increasingly handling the management of persistent disease and rehabilitation regimes, and offering illness avoidance and health promo interventions. Pay-for-performance, changes in policy together with cost-effectiveness and pay for medications issues are becoming a vital element in brand-new interventions reaching clinical practice [17, 18]

Preventive medicine is solidly developed within the UK Healthcare System, and predictive and customised methods are increasingly ending up being so. Implementation of PPPM interventions may be the service however also the reason for the health and healthcare difficulties and predicaments that health systems such as the NHS are dealing with [19] The effective intro of PPPM requires scientific understanding of disease and health, and technological advancement, together with thorough methods, evidence-based health policies and suitable policy. Critically, education of health care specialists, patients and the public is also critical. There is little doubt nevertheless that harnessing PPPM properly can assist the NHS achieve its vision of delivering healthcare results that will be amongst the best worldwide.

- 1. Delamothe T. NHS at 60: founding concepts. BMJ. 2008; 336:1216 -8. doi: 10.1136/ bmj.39582.501192.94. [DOI] [PMC totally free short article] [PubMed] [Google Scholar]- 2. Shifting the Balance of Power: The Next Steps. Department of Health publications. 2002. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4008424
- 3. Wanless D. Securing health for the entire population: Final report-February 2004. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4074426
- 4. Professor the Lord Darzi of Denham KBE High quality care for all: NHS Next Stage Review last report. Department of Health publications. 2008. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825
- 5. White paper Equity and quality: Liberating the NHS. Department of Health publications. 2010. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
- 6. The NHS Constitution for England. Department of Health publications. 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093419
- 7. NHS Hospital and Community Health Services: Medical and Dental personnel England 1998-2008. The NHS Information Centre. 2009. www.ic.nhs.uk/webfiles/publications/nhsstaff2008/medandden/Medical%20and%20Dental%20bulletin%201998-2008.pdf
- 8. House of Commons Health Committee: Public Expenditure on Health and Personal Social Services. The House of Commons. 2008. www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/cmhealth.htm
- 9. The DH Guide A guide to what we do and how we do it. Department of Health publications. 2007. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/index.htm
- 10. NIHR Annual Report 2009/10: Embedding Health Research. National Institute for Health Research. 2010. www.nihr.ac.uk/Pages/default.aspx
- 11. Leatherman S. and Sutherland K. Patient and Public Experience in the NHS. The Health Foundation. 2007. www.health.org.uk/publications/research_reports/patient_and_public.html
- 12. NHS 2010-2015: from good to excellent. Preventative, people-centred, productive. Department of Health publications. 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_109876
- 13. Updated Child Health Promotion Programme. Department of Health publications. 2009. webarchive.nationalarchives.gov.uk/+/ www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_083645.
- 14. Klein R. What does the future hold for the NHS at 60? BMJ. 2008; 337: a549. doi: 10.1136/ bmj.a549. [DOI] [PMC free article] [PubMed] [Google Scholar]- 15. Ham C (2007) Clinically incorporated systems: the next step in English health reform? Briefing paper. London Nuffield Trust.
- 16. Health Inequalities Third Report of Session 2008-09. House of Commons Health Committee. 2009; Volume I. www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/286/28602.htm.
- 17. Clinicians, services and commissioning in chronic illness management in the NHS The requirement for collaborated management programs. Report of a joint working celebration of the Royal College of Physicians of London, the Royal College of General Practitioners and the NHS Alliance. 2004. www.rcgp.org.uk/PDF/Corp_chronic_disease_nhs.pdf.
- 18. Hughes DA. From NCE to NICE: the function of pharmacoeconomics. Br J Clin Pharmacol. 2010; 70( 3 ):317 -9. doi: 10.1111/ j.1365-2125.2010.03708. x. [DOI] [PMC free post] [PubMed] [Google Scholar]- 19. Griggs JJ. Personalized medication: a perk of benefit? Clin Pharmacol Ther.