National Health Service/RHB
{{See also|NHS Scotland|NHS Wales|Health and Social Care in Northern Ireland}}. The information in this article describes the current English public health service.
[[Image:NorfolkAndNorwichUniversityHospital(KatyAppleton)Aug2005.jpg|250px|thumb|Example of an NHS hospital in the UK.]]
[[Image:NHS NNUH entrance.jpg|thumb|250px||right|NHS hospital in England.]]
The '''National Health Service''' ('''NHS''') is the [[public ownership|publicly funded]] [[health care system]] of [[England]], created under the [[National Health Service Act 1946]], but [[History of the National Health Service|established in 1948]] under the [[post-war consensus|post-war]] Labour government of [[Clement Attlee]], as part of his "cradle to grave" reforms to build a [[welfare state]]. Since its founding, it has become an integral part of British society, culture and everyday life; the NHS was once described by [[Nigel Lawson]], former [[Chancellor of the Exchequer]], as "the national religion".<ref>{{cite web|author=New Statesman|title=NHS is becoming a four-letter word|date=2007-02-19| url=http://www.newstatesman.com/200702190025|accessdate=2007-05-11}}</ref>
Although the NHS provides the vast majority of healthcare in England, including [[primary care]], [[long-term care|long-term healthcare]], [[ophthalmology]] and [[dentistry]], Private healthcare has continued [[two-tier health system|parallel to the NHS]], paid for largely by private insurance - around 17% of the UK population have some form of private insurance,<ref>{{cite web|author=[[Department for Work and Pensions]]|title=Family Resources Survey|date=2003-2004| url=http://www.dwp.gov.uk/asd/frs/2003_04/pdfonly/frs_2003_04_report.pdf|accessdate=2007-12-04}}</ref> although it is GeneRally used as a top-up to NHS services.{{Fact|date=December 2007}}
[[As of 2007]], the NHS is the world's largest, centralised health service, one of the world's largest employers, employing around 1.3million people directly. The large majority of NHS services are provided without charge to the patient, beyond that already paid in taxes - NHS services are described as "free at the point of delivery," but some doctors are concerned that in the long-run this method of funding is unsustainable and not effective.
<ref>{{cite web|
author=Doctors for Reform|
title=Free at the point of delivery – reality or political mirage?|url=http://www.doctorsforreform.com/filedata/CopyofFreeatthepointofdelivery-realityorpoliticalmirage.pdf|accessdate=2007-05-11|format=PDF}}</ref> The costs of running the NHS are met directly from general taxation (hence "free at the point of delivery") - in 2007-08 the resource budget for the NHS is [[GBP|£]]87.6 billion, with a further [[capital budget]] of £4.2 billion.<ref>{{cite web|author=HM Treasury|title=Budget 2007|date=2007-03-21 | url=http://www.hm-treasury.gov.uk/media/3/4/bud07_completereport_1757.pdf|accessdate=2007-05-11|pages=p.293|format=PDF}}</ref>
The government department responsible for the NHS is the [[Department of Health (United Kingdom)|Department of Health]], headed by a [[Secretary of State for Health]] (Health Secretary), who sits in the [[Cabinet of the United Kingdom|British Cabinet]]. While NHS agencies and trusts are theoretically independent, they are subject to ministerial direction, with only [[NHS Foundations Trust|Foundation Trusts]] maintaining substantial degrees of autonomy.
==Establishment and History==
{{main|History of the National Health Service}}
In the aftermath of [[World War II]], [[Clement Attlee]]'s [[Labour Party (UK)|Labour government]] created the NHS as part of the "cradle to grave" welfare-state reforms, based on the proposals of the [[Beveridge Report]], prepared in 1942 by the economist and social reformer [[William Beveridge]]. Its three founding principles were:
{{cquote|
* that it meet the needs of everyone,
* that it be free at the point of delivery,
* that it be based on clinical need, not ability to pay<ref name="NHSCorePrinciples">{{cite web|author=NHS|title=NHS Core Principles|url=http://www.nhs.uk/aboutnhs/CorePrinciples/Pages/NHSCorePrinciples.aspx|accessdate=2007-06-11}}</ref>}}
These were revised and expanded during a period of NHS reform in July 2000.<ref name="NHSCorePrinciples"/>
The idea was that if Britain could work towards [[full employment]] and spend huge sums of money during the wartime effort, then in a time of peace equitable measures of social solidarity and financial resources could be redirected towards fostering public goods. Although most of the British felt that Churchill's leadership during the war was commendable, he expressed contempt for a number of popular ideas, in particular creating a system of national [[Publicly-funded health care|public health care]] and improving [[public education]]. Partly as a result of this Churchill was defeated in [[United Kingdom general election, 1945|the 1945 election]] by [[Clement Attlee]] and the [[Labour Party (UK)|Labour Party]], who won a landslide victory.<ref>Picknett, Lynn, Prince, Clive, Prior, Stephen & Brydon, Robert (2002). ''War of the Windsors: A Century of Unconstitutional Monarchy'', p. 190. Mainstream Publishing. ISBN 1-84018-631-3.</ref> The driving force behind this reformist agenda was popular enough, that eventually it constituted a '[[post-war consensus]]' which continued virtually unchallenged until the early 1970s, no matter which party controlled the government, coming to an end when the government of [[Margaret Thatcher]] was elected in 1979.
Attlee faced several momentous problems in rebuilding post-war Britain. Not a single hospital in London escaped the bombing that affected London, and the UK owed a large monetary debt to the United States, leading to stretched finances. As a consequence of this, the NHS received only £10 million for hospital investment, in comparison with £430 million for housing and £57 million for schools. This figure was only one-third of its pre-war level.<ref>{{cite web|author=Jonathan Hughes|title=The "Matchbox on a Muffin": The Design of Hospitals in the Early NHS|url=http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1044217&blobtype=pdf|format=PDF|page=2}}</ref> Of 2,500 hospitals and 500,000 beds inherited by the NHS after [[nationalisation]], 45% had been built before 1891 and 21% before 1861.<ref>{{cite book |last = Rivett | first = Geoffrey | title = From Cradle to Grave: 50 years of the NHS | publisher = Kings Fund | location= | date= 1998 | isbn = 1857171485 |page=p.5}}</ref>
[[Image:AneurinBevanStatueCardiff20050707 KaihsuTai.jpg|250px|thumb|left|A statue of Nye Bevan in [[Cardiff]]]]
[[Aneurin Bevan]], the newly appointed [[Health Minister]], was given the task of introducing the National Health Service. Bevan based his plan for the NHS on the [[Tredegar Medical Aid Society]] which was set up in his place of birth, and in fact, had been a member and later chairman of the [[Tredegar General Hospital|Cottage Hospital]] Management Committee in the late 1920s.
Doctors were initially opposed to the reform measure and even organized to try to fight against it - not to a National Health Service, but more to the terms by which Bevan wanted. GPs had no wish to be servants of the state - which ultimately resulted in their independent contractual agreement. Consultants objected to their loss of private practice, resulting in the award system still distributed by consultants.<ref>{{cite web|author=J Tobias |title=In defence of merit awards |url=http://www.bmj.com/cgi/content/full/308/6934/974|date=[[9 April]] [[1994]]|accessdate=2007-12-09|publisher=[[British Medical Journal]]}}</ref> Bevan managed to push through the radical health care reform measure by dividing and cajoling opposition, as well as by offering the lucrative payment structures for consultants. On this subject he stated, "I stuffed their mouths with gold." On [[July 5]] [[1948]], at the [[Park Hospital]] in [[Manchester]], Bevan unveiled the National Health Service and stated, "We now have the moral leadership of the world."<ref>{{cite web|title=Five minutes to save the Conservative Party|url=http://www.telegraph.co.uk/opinion/main.jhtml?xml=/opinion/2001/10/07/do08.xml|date=October 2007|accessdate=2007-12-09|publisher=''[[Daily Telegraph]]''}}</ref>
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| [http://www.bbc.co.uk/wales/walesonair/database/nyebevan.shtml Speech by Aneurin Bevin]<br/>A speech given by Aneurin Bevin, the Minister of Health, in 1949, reviewing the first year of the NHS
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There were loud voices for the provision of healthcare to all in the United Kingdom, such as [[Political and Economic Planning]] (PEP), a pressure group of businessmen, educationalists, architects, economists, social scientists and MPs who issued an extensive report in the mid-1930s on the deficiencies of the current healthcare situation. Further back, [[Bertrand Dawson]]'s [[Dawson Report|report]] in 1919 laid down a plan for a future national health service.<ref>{{cite web|author=Geoffrey Rivett: The Development of the London Hospital System, 1823- 1982|title=Dawson Report|url=http://www.nhshistory.net/regions_&_districts.htm#The%20Dawson%20report|accessdate=2007-12-09}}</ref> Dr. [[A. J. Cronin]]'s highly controversial novel, ''[[The Citadel (novel)|The Citadel]]'', published in 1937, had fomented extensive dialogue about the severe inadequacies of health care. Cronin's ideas were essential to the conception of the NHS, and it has been suggested that they greatly contributed to the [[United Kingdom general election, 1945|Labour Party's victory in 1945]].<ref>Colin Harrison and Philip B. Gough, "Conversations: Compellingness in Reading Research," ''Reading Research Quarterly'' 31.3 (1996): 334-341.</ref> However, healthcare that was free at the point of delivery did exist before the NHS, under the [[National Insurance Act 1911]], which itself had replaced the primacy of [[Poor Law]] and [[workhouses]].
To this day, the [[Labour Party (UK)|Labour Party]] still considers the creation of the publicly-funded National Health Service one of its proudest achievements.<ref>{{cite web|author=Labour Party|title=Labour in government:Labour's policies on health|url=http://www.labour.org.uk/health|accessdate=2007-05-11}}</ref>
==Structure==
{{main|NHS Institutions and Organisations}}
===Organisation===
The NHS in England is controlled by the UK government through the [[British Department of Health|Department of Health]] (DoH), which takes political responsibility for the service.<ref name="State of the NHS"/> NHS bodies are divided into two categories; administrative providers, including Strategic Health Authorities and Special Health Authorities, and direct health providers, any [[NHS Trust]] providing direct healthcare services. The DoH controls [[Strategic Health Authority|Strategic Health Authorities]] (SHAs), which oversee all NHS operations in an area of England and are responsible for strategic supervision of the [[NHS Trust|trust]]s in their area. There are 10 SHAs, coterminous the nine [[Government Office Region]]s in most part, with the South East region split into South East Coast and South Central SHAs.
NHS Trusts are further split into Primary Care Trusts (PCTs), Mental Health Trusts (MHTs), Ambulance Trusts (ATs), Hospital Trusts (also known as Acute Trusts), Foundation Trusts and Care Trusts. Many Trusts are coterminous with local government regions.<ref name="structure"/>
[[NHS Primary Care Trust|Primary Care Trusts]] (PCTs) are the local health bodies in charge of providing and commissioning services. The 152 PCTs oversee 29,000 [[General practitioner|GPs]] and 18,000 NHS [[dentist]]s. In addition, they commission acute services from other NHS Trusts and the private sector, directly provide [[primary care]] in their locations, and oversee such matters as primary and secondary prevention, [[NHS Vaccination Programme|vaccination administration]] and epidemic control. PCTs are at the centre of the NHS and control 80% of the total NHS budget.<ref name="structure">{{cite web|author=NHS|title= NHS authorities and trusts|url=http://www.nhs.uk/aboutnhs/HowtheNHSworks/authoritiesandtrusts/Pages/Authoritiesandtrusts.aspx|accessdate=2007-05-11}}</ref>
There are 290 [[NHS Hospital Trust|NHS Hospital Trusts/Acute Trust]]s, which administer hospitals, [[treatment centre]]s and specialist care in about 1,600 NHS hospitals - Hospital Trusts maintain between two and eight hospital sites. They provide acute health services, as commissioned by PCTs. Hospital Trusts that perform well are invited to reclassify as Foundation Trusts.<ref name="structure"/>
[[NHS Foundation Trust]]s are a relatively new type of NHS Trust, run by the trust's staff with input from members of the public, who sit on the hospital board. They have more financial and operational freedom than other NHS Trusts, but remain within the NHS and are committed to reaching NHS performance targets. As of 2007, there are 67 Foundation Trusts in England.<ref name="structure"/> They were introduced under the [[Health and Social Care (Community Health and Standards) Act]], which established NHS foundation trusts, the [[Commission for Health Audit and Inspection]] and the [[Commission for Social Care Inspection]].
There are thirteen [[Emergency Medical Services in the United Kingdom|NHS Ambulance Services Trusts]], responsible both for emergency medical services to hospital, and in some areas, [[patient transport]] services, on behalf of the NHS trusts.<ref name="structure"/>
[[NHS Mental Health Services Trust]]s provide health and social care for people with mental health problems, and frequently cooperate with [[NHS Care Trust]]s, which provide both health and social care in accompaniment to primary care. They are established where the NHS and local authorities feel a closer relationship between health and social care is necessary.<ref name="structure"/> The [[Health Act 1999]] was created with the specific aim of linking NHS bodies and local authorities responsible for health and welfare functions.
The [[NHS Act 1977]] split the NHS into two parts - hospital health care and community health services, including health visitors and midwives, and family health services, those provided by GPs, dentists, opticians and chemists.
In addition, several [[Special Health Authority|Special Health Authorities]] provide services and, in some cases, to the devolved NHS administrations, setup under the [[NHS Act 1977]]. These include [[NHS Health and Social Care Information Centre|The Information Centre]] , [[NHS Blood and Transplant]], [[NHS Direct]], [[NHS Professionals]], [[NHS Connecting for Health]] and the [[National Institute for Health and Clinical Excellence]] (NICE).<ref name="structure"/>
===Staff===
As of March 2005, the NHS had 1.3 million workers, and is variously the third or fifth largest workforce in the world, after the [[People's Liberation Army|Chinese Army]], [[Indian Railways]] and (as argued by Jon Hibbs, the NHS's Head of News, in a press release from [[March 22]] [[2005]]) [[Wal-Mart]] and the [[United States Department of Defense]].<ref>{{cite web|last = Trefgarne|first = George|title = NHS reaches 1.4 million employees|publisher = [[The Daily Telegraph]]|date=2005-03-23|url = http://www.telegraph.co.uk/money/main.jhtml?xml=/money/2005/03/23/cnnhs23.xml|accessdate=2006-09-15}}</ref> The number of NHS Staff has increased sharply under the Blair government, which took power in 1997. The total number of staff has risen by 300,000 from around 1million in 1997 to 1.3million in 2006. However, it has been argued that the effectiveness of this boost in staffing has been limited, as the number of administrators has risen more than doctors and nurses and the number of managers has risen from just over 20,000 to almost 40,000, with a corresponding increase in bureaucracy.<ref>{{cite web|last = Carvel|first = John|title = Record rise in NHS consultants and midwives|publisher = [[The Guardian]]|date=2005-03-23| url =http://politics.guardian.co.uk/publicservices/story/0,11032,1443862,00.html | accessdate = 2006-09-15 }}</ref><ref name="State of the NHS">{{cite web|url=http://news.bbc.co.uk/1/shared/spl/hi/guides/456900/456959/html/nn5page1.stm|title=BBC "State of the NHS": Staff Numbers|publisher=[[BBC News Online]]}}</ref>
[[As of 2006]], NHS employees totalled around 1.34million, down from 2005 when the workforce reached a record total of just over 1.37million<ref>{{cite web|url=http://www.ic.nhs.uk/statistics-and-data-collections/workforce/nhs-staff-numbers/nhs-staff-1996--2006|title=NHS Staff 1996-2006|publisher=Information Centre:NHS Special Health Authority|accessed=04-12-2007}}</ref>
<ref>{{cite web|url=http://www.ic.nhs.uk/pubs/nhsstaff|title=NHS Staff 1995-2005|publisher=Information Centre:NHS Special Health Authority|accessed=04-12-2007}}</ref>
As well as this, there has been some criticism of [[Agenda for Change]] (AfC), the new NHS grading and pay system for all NHS staff, with the exception of doctors, dentists and some senior managers. It covers more than 1 million staff. Some staff have attempted to secure back pay, after they gained grades under AfC - they believe this suggests they were underpaid under the previous pay system.<ref>{{cite web|title=Agenda for Change|publisher= Health Management Specialist Library|date=March 2007|url =http://www.library.nhs.uk/healthmanagement/ViewResource.aspx?resID=251404| accessdate=2007-12-04}}</ref>
However, there have been steep increases in the wages for Consultants, GP's and Nurses, due to new contracts negotiated by them. GP's now rank among the best paid family doctors in Europe, with average pay at around £100,000.<ref>{{cite web|url=http://news.bbc.co.uk/1/shared/spl/hi/guides/456900/456959/html/nn4page1.stm|title=BBC "State of the NHS":Pay|publisher=[[BBC News Online]]}}</ref> There has been significant criticism of these new pay deals - the Consultant's new contract cost £150 million more than expected, due to inaccurate government predictions.<ref>{{cite web|title=MPs attack consultant pay hikes|publisher=[[BBC News Online]]|date=2007-11-22| url =http://news.bbc.co.uk/1/hi/health/7104063.stm| accessdate = 2007-12-04 }}</ref>
[[General Practitioner]]s, dentists, opticians and other providers of local healthcare, are almost all self-employed, and contract their services back to the NHS. They may operate in partnership with other professionals, own and operate their own surgeries and clinics, and employ their own staff, including other doctors. However, the NHS does sometimes provide centrally employed healthcare professionals and facilities in areas where there is insufficient provision by self-employed professionals. The NHS effectively pays for nearly all doctors and non-private sector hospitals in [[England]].
==Funding==
===The commissioning system===
The principal fundholders in the NHS system are the [[NHS Primary Care Trust]]s (PCTs), who commission healthcare from hospitals, GPs and others.[http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Commissioning/Worldclasscommissioning/index.htm] PCTs disburse funds to them on an agreed tariff or contract basis, on guidelines set out by the Department of Health. The PCTs receive a budget from the Department of Health on a formula basis relating to population and specific local needs. They are required to "break even" - that is, they must not show a deficit on their budgets at the end of the financial year, although in recent years cost and demand pressures have made this objective impossible for some Trusts. Failure to meet the financial objective can result in the dismissal and replacement of a Trust's Board of Directors.
===Drugs charges===
The rising costs of some medicines, especially some types of cancer treatment, means that prescriptions can present a heavy burden to the [[NHS Primary Care Trust|PCTs]] whose limited budgets include responsibility for the difference between medicine costs and the fixed prescription charge. This has led to disputes in certain cases (e.g. over [[Herceptin]]), as to whether such drugs should be prescribed.<ref name="Herceptin">{{cite web | title = Q&A: The Herceptin judgement | publisher = [[BBC News]] |date=2006-04-12 | url = http://news.bbc.co.uk/2/hi/health/4684852.stm | accessdate = 2006-09-15 }}</ref>
===NHS dentistry===
NHS dentistry is not as widely available as it once was, and the private sector has expanded to fill the gap. There has been a decreasing availability of NHS dentistry in many areas and a trend towards dentists accepting private patients only, (with the shortfall being particularly acute in rural areas), <ref>{{cite web | title = NHS dentists (FAQs) | publisher = NHS England | url =http://www.nhs.uk/AboutNHSservices/dentists/Pages/DentistsFAQs.aspx#q04 | accessdate = 2007-12-05 }}</ref> leaving an estimated 2 million people without dental care (of the UK population of [http://www.statistics.gov.uk/CCI/nugget.asp?ID=6 60.6million] in August 2007).<ref>{{cite web|url=http://news.bbc.co.uk/1/hi/health/4656079.stm|title=Q&A: NHS dentistry|published=2007-03-28|accessed=2007-12-05}}</ref> There have been several widely reported cases of patients resorting to pulling their own teeth out.<ref>{{cite web | title = Patients pull own teeth as dental contract falters | publisher = [[Guardian Unlimited]] | url =http://www.guardian.co.uk/medicine/story/0,,2191204,00.html | accessdate = 2007-12-05 }}</ref> The DoH has been blamed for this by the [[British Dental Association|BDA]]; in calculating demand and provisioning for the new dentistry contract, brought in on the [[1 April]] [[2006]], they used data from three years previously. The government has given has given £2.3billion to PCT's<ref>2006-07 Dentistry Budget</ref> to commission services, but suggests that problems with the new contract relate to the overall need for NHS reform. [[As of 2007]], just over 50% of the income of dentists comes from private patients, up from 42% in 1999-2000.<ref>{{cite web | title = Call for Dentists' NHS-work quota |publisher=BBC| url = http://news.bbc.co.uk/1/hi/health/6711379.stm}}</ref>
===General Practitioner contract===
At the founding of the NHS, GP's were reluctant to become "servants of the state", and an independent contract was agreed. Especially under the Blair government, GP salaries have increased substantially, now averaging over £100,000. Under the current contract, they are paid according to whether they treat patients or not, the theory being that this improves patient care, although the GP contract has been criticised - the DoH has spent £300 million more than it budgeted for, and GPs are no longer responsible for their patients 24 hours a day.<ref>{{cite web |title=Investing in general practice:The new general medical services contract|publisher=[[BBC News Online]]|url =http://www.bma.org.uk/ap.nsf/Content/investinggp}}</ref><ref>{{cite web |title=GPs negotiate new contract|publisher=[[BBC]]|url =http://news.bbc.co.uk/1/low/health/1938975.stm}}</ref>
===Financial state===
Since the election of the Blair government, healthcare spending has increased dramatically in an attempt to bring UK health spending in line with the European average of around 9% of GDP. Although this level has now been reached, and increases in the healthcare budget are now slowing down dramatically, many trusts are being forced to "balance the book" due to overspends.When [[Patricia Hewitt]] was [[Secretary of State for Health]], she consistently asserted that the NHS would balance the books, and would be in balance at the end of the financial year 2007-8;<ref>{{cite web | title=I will carry the can for NHS, says Hewitt|date=2006-03-09 | url=http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2006/03/08/uhewitt.xml&sSheet=/portal/2006/03/08/ixportaltop.html |accessdate = 2007-02-28}}</ref> There has been sharp criticism of this, with the Health Editor of ''[[The Times]]'' noting that it requires unique skills to create a crisis despite an increase in spending of £40 billion.<ref>{{cite book |last = Mandelstam | first = Michael | title = Betraying the NHS: Health Abandoned | publisher = Jessica Kingsley Publishing | location= | date= 2006 | isbn = 1843104822|page=p.38}}</ref> In fact, at the end of the [[financial year]] 2006-07, the NHS had a total surplus of £515 million, following a £547 million deficit in 2005-06.[http://news.bbc.co.uk/1/hi/health/7056758.stm] In the financial year 2007-08, a £1 billion surplus was predicted, although this has been revised up to £1.8 billion a month after the previous prediction,[http://news.bbc.co.uk/1/hi/health/7105928.stm] and when the finances of Foundation Trusts are included in the figure this rises to just over £3 billion.<ref name="FT3bn">{{cite web | author=''[[Financial Times]]''| title=NHS heads for £3bn budget surplus|date=[[November 23]] [[2007]]| url=http://www.ft.com/cms/s/0/9ac91f90-9951-11dc-bb45-0000779fd2ac,dwp_uuid=f0d249de-e821-11db-b2c3-000b5df10621.html | accessdate = 2007-12-09}}</ref>]
As each division of the NHS is required to break even at the financial year-end, the service should in theory never be in deficit - although individual trusts and hospitals have been running financial deficits, with some of the blame put on PFI.<ref>{{cite web|url=http://www.guardian.co.uk/medicine/story/0,11381,1169102,00.html|title=www.guardian.co.uk/medicine/story/0,11381,1169102,00.html<!--INSERT TITLE-->}}</ref> However, a study by Professor Nick Bosanquet for the Reform think tank predicts a true annual deficit of nearly £7bn in 2010.<ref>{{cite web | author=YouGov| title=NHS: How Well Is Our Money Being Spent?|date=2006-03-09 | url=http://www.yougov.com/interactive/humphrysMain.asp?jID=3&aId=2978&sID=5&pID=&wId=0&UID= | accessdate = 2006-09-01}}</ref>
The reduction in spending has largely been due to the "parachuting in" of turnaround teams into trusts to reduce overspends - the cost of these has been put at £36 million for the 100 trusts that were accruing deficits.<ref name="FT3bn"/>
==NHS policies and programmes==
===Reforms under the Thatcher government===
{{seealso|Thatcher Ministry|Premiership of Margaret Thatcher}}
The 1980s saw the introduction of modern management processes (''General Management'') in the NHS to replace the previous system of consensus management. This was outlined in the Griffiths Report of 1983.<ref>{{cite book | author=Manfred Davidmann| title=Reorganising the National Health Service: An Evaluation of the Griffiths Report | edition=Second edition | year=1985 | id=ISBN 0-85192-046-2 | url=http://www.solbaram.org/articles/nhs.html}}</ref>
This recommended the appointment of general managers in the NHS with whom responsibility should lie. The report also recommended that clinicians be better involved in management. Financial pressures continued to place strain on the NHS. In 1987, an additional £101 million was provided by the government to the NHS. In 1988 the then [[Prime Minister]], [[Margaret Thatcher]], announced a review of the NHS. From this review and in 1989, two [[white paper]]s ''Working for Patients'' and ''Caring for People'' were produced. These outlined the introduction of what was termed the "internal market", which was to shape the structure and organisation of health services for most of the next decade, until the fall of the [[Conservatives (UK)|Conservatives]] in the [[United Kingdom general election, 1997|1997 General election]].
In 1990, the [[NHS and Community Care Act (1990)|National Health Service & Community Care Act]] (in England) defined this "internal market", whereby Health Authorities ceased to run hospitals but "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients. The "providers" became [[NHS Trust|independent trusts]], which encouraged competition but also increased local differences.<ref>{{cite web |title =NHS competition 'costs lives'| publisher = ''[[BBC News Online]]''|date=[[29 January]] [[2003]]|url =http://news.bbc.co.uk/1/hi/health/2701899.stm|accessdate = 2007-12-09}}</ref>
===Reforms under the Blair government===
{{seealso|Blair Ministry|Premiership of Tony Blair}}
These innovations, especially the "fund holder" option were condemned at the time by the [[Labour Party (UK)|Labour Party]]; opposition to what was claimed to be the [[Conservative Party (UK)|Conservative]] intention to [[privatise]] the NHS became a major feature of Labour campaigning in the 1997 and subsequent British elections. Although the incoming government of [[Tony Blair]] (1997) stated its intention to remove the "internal market" and abolished fundholding, in effect the market was strengthened and fundholding reintroduced as part of Blair's ongoing reforms to modernise the NHS.
The Blair government oversaw the [[NHS Plan]], published in 2000, which outlined the Blair government's plans for NHS reform - designing the health service around the patient, investing more into healthcare, examining the relationship between the private sector and the NHS, tackling waiting times for treatment and reducing [[inequality]].<ref>{{cite web |title =The NHS Plan: a plan for investment, a plan for reform| publisher = ''[[British Department of Health|Department of Health]]'' |date=[[1 July]] [[2000]]|url =http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002960|accessdate = 2007-12-09}}</ref>
Driving these reforms have been a number of factors. They include the rising costs of medical technology and medicines, the desire to increase standards and "patient choice", an [[ageing population]], and a desire to contain government expenditure - reflecting in the increasing use of [[Private Finance Initiative]]s.
Reforms have included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous [[clinical governance|clinical]] and [[corporate governance]]. In addition, [[Modernising Medical Careers|medical training]] has been restructured, and new services have been developed to help manage demand, including [[NHS Direct]]. A new emphasis has been given to staff reforms, with the [[Agenda for Change]] agreement providing harmonised pay and career progression. These changes have, however, given rise to controversy within the medical professions, the media and the public. During 2005 and 2006 hospitals began to lay off staff as a consequence of these reforms and the financial stringency accompanying them, further adding to controversy.<ref>{{cite web | title = 20,000 job cuts forecast as more NHS hospitals join critical list | publisher = ''[[The Times]]'' |date=2006-03-24| url =http://business.timesonline.co.uk/tol/business/economics/budget_2007/article695081.ece|accessdate = 2006-12-09}}</ref>
Whilst leaving services free at point of use, the government has encouraged outsourcing of medical services and support to the private sector. Under the [[Private Finance Initiative]], an increasing number of hospitals have been built (or rebuilt) by private sector consortia; hospitals may have both medical services (such as [[Independent Sector Treatment Centre|"surgicentres"]]),<ref>{{cite web | title = New generation surgery-centres to carry out thousands more NHS operations every year | publisher = [[Department of Health (United Kingdom)|Department of Health]] |date=2002-12-03 | url = http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4026000&chk=0NNhMe | accessdate = 2006-09-15}}</ref> and non-medical services (such as catering) provided under long-term contracts by the private sector. In 2005, surgicentres (ISTCs) treated around 3% of NHS patients (in England) having routine surgery, expected to rise to 10% by 2008.<ref>{{cite web | last = Hewitt | first = Patricia | authorlink = Patricia Hewitt | title = Even Nye Bevan's NHS saw a role for the private sector | publisher = [[The Guardian]] |date=2005-07-02 | url = http://www.guardian.co.uk/comment/story/0,3604,1519575,00.html | accessdate = 2006-09-15 }}</ref>
Given ongoing redundancies within the NHS, accusations of staff cuts and "privatisation" are now made against the Blair government, often by NHS staff unions such as [[UNISON]].<ref>{{cite web |title=Keep the NHS working - A national issue | url=http://www.unison.org.uk/healthcare/keepnhsworking/pages_view.asp?did=3370 | accessdate = 2006-10-07 | publisher = [[UNISON]]}}</ref>
As a corollary to these initiatives, the NHS has been required to take on pro-active socially "directive" policies, for example, in respect of [[Tobacco smoking|smoking]] and [[obesity]]. This ''health promotion'' was previously stressed by Lord Dawson in his report in 1920 and in the 1937 report on health services by the PEP.<ref>{{cite book |last = Rivett | first = Geoffrey | title = From Cradle to Grave: 50 years of the NHS | publisher = Kings Fund | location= | date= 1998 | isbn = 1857171485|page=4}}</ref>
==National Programme for IT==
{{main|National Programme for IT}}
The [[National Programme for IT]] (NPfIT) was formally established in October 2002, following several Department of Health reports on IT strategies for the NHS. On [[April 1]] [[2005]] a new agency called [[NHS Connecting for Health]] (CfH) was formed to deliver the programme. Connecting for Health absorbed both staff and workstreams from the abolished [[NHS Information Authority]], the organisation it replaced. Believed to be the largest IT project in the world,<ref>{{cite book |last = Brennan | first = Sean | title = The Nhs It Project: The Biggest Computer Programme in the World... Ever! | publisher = Radcliffe Publishing | location= Abingdon | date= 2005 | isbn = 1857757327|page=Preface, vi}}</ref> it has encountered major problems, and is running significantly behind schedule and above budget, with friction between the Government and the programme contractors - [[Accenture]] left most of its contracts in September 2006, after previously writing off $450 million from its accounts due to significant delays, which it blamed on [[iSoft]]. The contracts which Accenture left were taken over by [[Computer Sciences Corporation]].
The programme is divided into a number of key deliverables. These are:
*The [[NHS Care Records Service]] (NHS CRS)
*[[Choose and Book]], an electronic booking service
*A system for the [[Electronic Transfer of Prescriptions (NHS)|Electronic Transmission of Prescriptions]] (ETP)
*A new [[N3 (NHS)|national broadband IT network for the NHS]] (N3)
*[[Picture archiving and communication systems|Picture Archiving and Communications Systems]] (PACS)
*IT supporting GPs including the Quality Management and Analysis System ([[QMAS]]) and a system for GP to GP record transfer.
*[[NHSmail]] – a central email and directory service for the NHS.
Originally expected to cost [[pound sterling|£]]2.3 billion over three years, in June 2006 the total cost was estimated by the [[National Audit Office]] to be £12.4 billion, over 10 years.<ref name="mythbusters-cost-spiralling"/> However, reports in the media have claimed that unpublished internal Government documents estimate the likely final cost to be far higher; between £20-30 billion.<ref>{{cite web|title= Bill for hi-tech NHS soars to £20 billion|publisher=[[Daily Telegraph]]|date=2004-10-12|url =http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2004/10/12/nnhs12.xml|accessdate=2007-12-09}}</ref>
In April 2007, the [[Public Accounts Committee]] of the [[British House of Commons|House of Commons]] issued a 175-page damning report on the programme. The Committee chairman, [[Edward Leigh]], claimed "This is the biggest IT project in the world and it is turning into the biggest disaster." The report concluded that, despite the probable expenditure of £20 billion, "at the present rate of progress it is unlikely that significant clinical benefits will be delivered by the end of the contract period."<ref>{{cite web|title=Patients 'won't benefit from £12bn IT project'|publisher=[[Daily Telegraph]]|date=2007-04-18| url =http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/04/17/ncomputer17.xml|accessdate=2007-12-09}}</ref> This is in stark CONTRAST to the National Audit Office's June 2006 Report, which noted that the NPfIT was necessary, well managed, and on budget.<ref name="mythbusters-cost-spiralling">{{cite web|title=The cost of the National Programme for IT is spiralling|publisher=[[NHS Connecting for Health]]|url=http://www.connectingforhealth.nhs.uk/factsandfiction/mythbusters/the-cost-of-the-national-programme-for-it-is-spiralling|accessdate=2007-12-09}}</ref>
As well as cost issues, there has been concern over whether medical staff using the system will support it,<ref>{{cite web | last = Carvel | first = John | title = Family doctors to shun national database of patients' records | publisher = Guardian Online |date=2007-11-20 | url = http://www.guardian.co.uk/society/2007/nov/20/nhs.health | accessdate = 2007-12-06 }}</ref> whether security on the system will be sufficient to [[data protection|protect]] patient information, and whether the creation of a patient database infringes [[medical privacy|patient privacy rights]].<ref>{{cite web | last = Wearden | first = Graeme | title = NHS dismisses claim of IT security glitch | publisher = [[ZDNet]] |date=2004-11-15 | url = http://news.zdnet.co.uk/0,39020330,39173812,00.htm | accessdate = 2006-09-15 }}</ref>
It is argued by the NHS and the Government that major investment in IT is necessary - fragmented information systems prevent health services providing complete data, and damage [[patient care]] where doctors may not have an overview of [[medical record|patients records]] held other NHS bodies. There are also concerns about inaccurate [[dosage]]s or errors due to misfiled or incomplete forms.<ref>{{cite web|title=The case for IT in healthcare – supporting the patient safety agenda|publisher=[[NHS Connecting for Health]]|url=http://www.connectingforhealth.nhs.uk/about/case/healthcare|accessdate=2007-12-09}}</ref>
==Criticism==
{{main|Criticism of the National Health Service}}
===Access controls and waiting lists===
In making health care a largely "invisible cost" to the patient, health care seems to be effectively free to its consumers - there is no specific NHS tax or levy. To reduce cost and ensure that everyone is treated "from each according to their ability as each according to their needs," there are a variety of "gatekeepers." The GP functions as a primary gatekeeper - without referral from a GP, it is often impossible to gain higher courses of treatment, such as an appointment with a consultant. These are recognised as necessary, for as Bevan noted in 1948 when giving a speech in the House of Commons, "we shall never have all we need...expectations will always exceed capacity".<ref>{{cite web|url=http://www.egovmonitor.com/node/14545|title=TCSR 07 - Health: The Public Expects|date=[[24 September]] [[2007]]|retrieved=2007-12-09|publisher=eGov Monitor}}</ref>
There has been concern about opportunistic "[[health tourists]]" travelling to Britain and using the NHS while paying nothing.<ref>{{cite web|url=http://www.medicalnewstoday.com/articles/7671.php|title=Tougher rules to ensure that people do not abuse NHS services|date=[[26 April]] [[2004]]|retrieved=2007-12-09|publisher=Medical News Today}}</ref> British citizens have been known to travel to other European countries to take advantage of lower costs, and because of a fear of hospital-acquired superbugs and long waiting lists.<ref>{{cite web|url=http://news.bbc.co.uk/1/hi/programmes/politics_show/7127602.stm|title=Health tourists could get refund|date=2007-12-07|retrieved=2007-12-09|publisher=[[BBC News Online]]}}</ref>
NHS access is therefore controlled by medical priority rather than [[price mechanism]], leading to waiting lists for both consultations and surgery, up to months long, although the Labour government of 1997-onwards made it one of its key targets to reduce waiting lists. In 1997, the waiting time for a non-urgent operation could be two years, while there are ambitions to reduce it to 18 weeks - although there is oppostion from doctors.<ref>{{cite web|url=http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/02/20/nhealth20.xml|title=Doctors attack Blair's waiting list pledge|date=2007-02-21|retrieved=2007-12-09|publisher=[[Daily Telegraph]]}}</ref> It is contested that this system is fairer - if a medical complaint is acute and life threatening, a patient will reach the front of the queue quickly. In the NHS, everyone that required treatment will eventually receive it, while the same cannot be said of a [[free-market]] healthcare system.
The NHS measures medical need in terms of [[Quality Adjusted Life Years]] (QALY), a method of quantifying the benefit of medical intervention.<ref>{{cite web|url=http://www.library.nhs.uk/healthmanagement/ViewResource.aspx?resID=123545#1|title=Quality Adjusted Life Years (QALYs)|date=March 2006|retrieved=2007-12-09|publisher=[[National Library for Health]]}}</ref> It is argued that this method of allocating healthcare means some patients must lose out in order for others to gain, and that QALY is a crude method of making life and death decisions.<ref>{{cite web|url=http://www.jr2.ox.ac.uk/bandolier/band24/b24-7.html|title=So what is a QALY?|retrieved=2007-12-09|publisher=Bandolier}}</ref>
===Superbugs===
{{seealso|Maidstone and Tunbridge Wells NHS Trust}}
There have been several fatal outbreaks of [[Antibiotic resistance|antibiotic-resistant]] [[bacteria]] ("superbugs") in NHS hospitals, such as [[Methicillin-resistant Staphylococcus aureus|Methicillin-resistant ''Staphylococcus aureus'']] (MRSA) and ''[[Clostridium difficile]]''. This has led to criticism of standards of hygiene across the NHS, with some patients buying private health insurance or travelling abroad to avoid the perceived threat of catching a "superbug" while in hospital, although the DoH has pledged £60 million for a "deep clean" of all NHS England hospitals. The most deadly outbreak of Clostridium difficile was in two hospitals of the Maidstone and Tunbridge Wells NHS Trust, [[Kent]], with 80-90 deaths attributed directly to the outbreak, a contributing factor in another 124 and a probable factor in another 55, according to the [[Healthcare Commission]]s Report.<ref>{{cite web|url=http://www.healthcarecommission.org.uk/_db/_documents/Maidstone_and_Tunbridge_Wells_investigation_report_Oct_2007.pdf|title=Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust|date=October 2007|retrieved=2007-12-09|publisher=[[Healthcare Commission]]}}</ref>
It is theorised that the increased use of strong [[antibiotics]] and [[disinfectants]] in modern society may account for the increase prevalence of resistant bacteria, although others argue that the introduction of private cleaning contractors into the NHS has been partly to blame, looking to save money at the cost of a loss of [[hygiene]].
===Coverage===
The lack of availability of some treatments due to their perceived poor [[cost-effectiveness analysis|cost-effectiveness]] sometimes leads to what some call a "postcode lottery".
<ref>{{cite web|url=http://www.politics.co.uk/issueoftheday/health/cancer/nhs-postcode-lottery-$447113$447113.htm|title=NHS 'postcode lottery'|publisher=politics.co.uk|date=2006-08-09|accessed=2007-12-09}}</ref><ref>{{cite web|url=http://news.bbc.co.uk/1/hi/health/4420584.stm|title=Why some drugs are not worth it|date=[[9 March]] [[2005]]|accessed=2007-12-04}}</ref> [[NICE]], the National Institute for Health and Clinical Excellence, are the first gatekeeper, and examine the cost effectiveness of new and relatively expensive drugs - most prescription is untouched by the guidelines they issue. Until they have issued guidance on the cost and effectiveness of new or expensive medicines, treatments and procedures, Primary Care Trusts are unlikely to offer to fund courses of treatment. The same of true of the [[Scottish Medicines Consortium]], NICE's counterpart in Scotland.<ref>{{cite web|url=http://news.bbc.co.uk/1/hi/scotland/6284532.stm|title=Cancer [...] rejected for NHS use|date=[[9 July]] [[2007]]|accessed=2007-12-04|publisher=[[BBC News Online]]}}</ref>
There has been considerable controversy about the public health funding of expensive [[drugs]], notably [[Herceptin]], due to its high cost and perceived limited overall survival. The campaign waged by cancer victims to get the government to pay for their treatment has gone to the highest levels in the [[Court of Appeal|courts]] and the [[Cabinet of the United Kingdom|Cabinet]] to get it licensed.<ref name="Herceptin"/><ref>{{cite web|url=http://www.nice.org.uk/page.aspx?o=328396 | title=Update on Herceptin appraisal | publisher=National Institute for Health and Clinical Excellence | accessdate=2006-12-01}}</ref> The [[British House of Commons|House of Commons]] [[Health Select Committee]] criticised some [[[...] companies]] for bringing in drugs that cost on and around the £30,000 limit that is considered the maximum worth of one QALY in the NHS.
===Private Finance Initiative===
{{seealso|Private Finance Initiative|Public-Private Partnership}}
Before the idea of PFI came to prominence, all new hospital building was by convention funded from the [[HM Treasury|Treasury]],as it was believed it was best able to raise money and able to control [[government spending|public sector expenditure]]. In June 1994, the Capital Investment Manual (CIM) was published, setting out the terms of PFI contracts. The CIM made it clear that future capital projects (building of new facilities) had to look at whether PFI was preferable to using public sector funding. By the end of 1995, 60 relatively small projects had been planned for, at a total cost of around £2 billion. Under PFI, buildings were built and serviced by the private sector, and then leased back to the NHS. The Labour government elected under [[Tony Blair]] in 1997 embraced PFI projects, recognising that public spending needed to be curtailed.<ref>{{cite book |last = Rivett | first = Geoffrey | title = From Cradle to Grave: 50 years of the NHS | publisher = Kings Fund | location= | date= 1998 | isbn = 1857171485 |page=p.437}}</ref>
[[Image:University_College_Hospital_-_New Building_-_London_-_020504.jpg|250px|right|[[University College Hospital]], London, built under a PFI contract by [[Amec]] and [[Balfour Beatty]], opened in 2005.]]
Under the [[Private Finance Initiative]], an increasing number of hospitals have been built (or rebuilt) by private sector consortia, although the government also encouraged private sector treatment centres, so called [[Independent Sector Treatment Centre|"surgicentres"]].<ref>{{cite web | title = New generation surgery-centres to carry out thousands more NHS operations every year | publisher = [[Department of Health (United Kingdom)|Department of Health]] |date=2002-12-03 | url = http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4026000&chk=0NNhMe | accessdate = 2006-09-15}}</ref> There has been significant criticism of this, with a study by a consultancy company which works for the Department of Health showing that for every £200 million spent on privately financed hospitals the NHS loses 1000 doctors and nurses. The first PFI hospitals contain some 28% fewer beds than the ones they replaced.<ref>{{cite web | author=[[George Monbiot]] | title=Private Affluence, Public Rip-Off |date=2002-03-10 | url=http://www.monbiot.com/archives/2002/03/10/private-affluence-public-rip-off/ | accessdate = 2006-09-07 | publisher = [[The Spectator]]}}</ref> As well as this, it has been noted that the return for construction companies on PFI contracts could be as high as 58%, and that in funding hospitals from the [[private sector|private]] rather than [[public sector]] cost the NHS almost half a billion pounds more every year.<ref>{{cite web | author=PublicFinance.co.uk | title=PFI hospitals ‘costing NHS extra £480m a year’|url=http://www.cipfa.org.uk/publicfinance/news_details.cfm?News_id=30216| accessdate=2007-12-08}}}</ref>
===Scandals===
{{main|Medical scandals in the NHS}}
Several high-profile medical scandals have occurred within the NHS over the years such as the [[Alder Hey organs scandal]] and the [[Bristol Inquiry|Bristol heart scandal]]. At [[Alder Hey]], there was the unauthorised removal, retention, and disposal of [[human tissue]], including [[children]]’s [[organ (anatomy)|organs]], between 1988 and 1995. The official report into the incident, the [[Redfern Report]], revealed that [[[...] van Velzen]], the Chair of Fetal and Infant [[Pathology]] at Alder Hey had ordered the "unethical and illegal stripping of every organ from every child who had had a postmortem." In response, it has been argued that the scandal brought the issue of organ and tissue donation into the public domain, and highlighted the benefits to medical research that result.<ref>{{cite web|url=http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VRT-42M1F8F-1&_user=10&_coverDate=03%2F06%2F2001&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=67b17cc793cad6b374cabdeccdf6189b| title=Checks and balances needed for organ retention|publisher=Science Direct|date=2001-03-19|accessdate=2006-12-04}}</ref>
==See also==
{{Commons}}
{{Wikiquote}}
*[[Healthcare in the United Kingdom]]
*[[Emergency Medical Services in the United Kingdom]]
*[[Publicly-funded health care]]
*[[Socialized medicine]]
*[[Health Forecasting]]
*[[Health policy analysis]]
*[[School health services]]
*[[List of NHS Trusts]]
*[[NHS Scotland]]
*[[NHS Wales]]
*[[Health and Care NI]]
*[[Private hospital]]
*[[BUPA]]
==References==
{{reflist|2}}
==External links==
* [http://www.dh.gov.uk/ Department of Health]
* [http://www.nhs.uk/ NHS in England]
* [http://www.nhs.uk/aboutnhs/HowtheNHSworks/Pages/aboutthenhs.aspx About the NHS]
* [http://www.nhs.uk/Tools/Pages/NHSTimeline.aspx?Tag= NHS Timeline]
===Shared and other UK health services and related government sites===
* [http://www.nhsconfed.org/ The NHS Confederation]
* [http://www.library.nhs.uk/ National Library for Health] previously known as the ''National Electronic Library for Health''
===Devolved government-run NHS services===
* [http://www.dhsspsni.gov.uk/ Department of Health, Social Services and Public Safety (Northern Ireland)]
* [http://www.healthandcareni.co.uk/ Health and Care Northern Ireland]
* [http://www.show.scot.nhs.uk/ NHS Scotland]
* [http://www.wales.nhs.uk/ NHS Wales]
===Other sites===
*[http://news.bbc.co.uk/1/shared/spl/hi/guides/456900/456959/html/nn1page1.stm NHS guide]
*[http://news.bbc.co.uk/hi/english/events/nhs_at_50/special_report/newsid_119000/119803.stm BBC coverage of NHS 50th anniversary]
*[http://www.cradleofnhs.org.uk/medical.htm History of the Tredegar Medical Aid Society]
*[http://www.nhshistory.com/ From Cradle to Grave - the first 50 years of the NHS 1998 - 2007] (online version of [[Geoffrey Rivett]]'s book, ''From Cradle to Grave'')
==References==
*{{cite book |last = Rivett | first = Geoffrey | title = From Cradle to Grave: 50 years of the NHS | publisher = Kings Fund | location= | date= 1998 | isbn = 1857171485}}
*{{cite book |last = Mandelstam | first = Michael | title = Betraying the NHS: Health Abandoned | publisher = Jessica Kingsley Publishing | location= | date= 2006 | isbn = 1843104822}}
*{{cite book |last = Brennan | first = Sean | title = The Nhs It Project: The Biggest Computer Programme in the World... Ever! | publisher = Radcliffe Publishing | location= Abingdon | date= 2005 | isbn = 1857757327}}
==Further reading==
*{{cite book |last = Klein | first = Rudolf | title = The New Politics of the NHS: From creation to reinvention | publisher = Radcliffe Publishing | location= | date= 2006 | isbn = 1846190665}}
*{{cite book |last = Pollock | first = Allyson | title = NHS plc: the privatisation of our healthcare | publisher = Verso | location= | date= 2004 | isbn = 1844675394}}
*{{cite book |last = Rivett | first = Geoffrey | title = The Development of the London Hospital System, 1823- 1982 | publisher = King's Fund | location= | date= 1986 | isbn = }} Available at [http://www.nhshistory.net/Londonshospitals.htm nhshistory.net]
[[ar:خدمة الصحة الوطنية (المملكة المتحدة)]]
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[[it:Servizio sanitario nazionale]]
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[[ro:National Health Service]]
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