The UK National Health Service was launched in 1948 and has grown to become the world’s largest, most efficient, egalitarian, and comprehensive publicly funded health service in the world. It is funded centrally from national taxation, and its core principle is that it is free at the point of delivery, apart from charges for prescriptions, optical and dental services. The rights of patients, carers, families, staff, and the pledges of the NHS are set out in an NHS Constitution.
Before the Covid pandemic of 2020/21 the NHS employed more than 1.5 million people including 36,000 general practitioners, 280,000 nurses, midwives, and health visitors, 20,000 ambulance staff, 135,000 scientific, therapeutic, and technical staff, 35,000 managers and 45,000 consultants.
The service in England treated 1 million patients every 36 hours, and total spending by the Department of Health and Social Care in 2019/20 approximated £143 billion. This is set to rise to £163 billion by 2023. UK health expenditure amounts to 11.9% of GDP.
The NHS is divided into two sections called Primary and Secondary Care. Primary Care is the first point of contact with the service for most people and is delivered by a wide range of independent contractors including General Practitioners (GPs), dentists, pharmacists, and optometrists. Secondary Care can be either elective or emergency. Elective care means planned specialist medical or surgical care, usually in a hospital setting, following referral from a primary or community health professional such as a General Practitioner (GP, or Family Practitioner in the US). The term Tertiary care is used to describe some highly specialised areas for patients with complex needs.
Integrated Care Systems (ICSs) have recently taken over from Clinical Commissioning Groups or CCGs. These are area-based agencies responsible for planning local health services and reducing inequalities. England is being divided into 42 ICSs in the largest legislative overhaul in a decade (July 2022). They will vary a lot in their structures and complexity and be overseen by an Executive body - NHS England and will integrate care to improve health outcomes in all age groups and across previous boundaries such as local authorities, public health and mental health services.
PRIMARY CARE
Primary medical care in the UK is delivered by GPs who have been trained in the full range of common medical and surgical conditions affecting the population. The majority are now organised into Health Centres or
Practices containing up to 20 GPs working as a team to provide for their local patients. Each GP has an average of 2250 residents registered with their personal practice. All UK residents must register with a GP, and they will then obtain free healthcare for illness, routine health checks, vaccinations etc. The community-based GP is therefore the cornerstone of the NHS providing most medical care in the UK.
Healthcare professionals, including medical students, should be registered with a GP close to where they live.
GPs deal mainly with chronic health problems, and less urgent acute disorders that can be managed at home. When a patient sees a GP with a more complex problem, the GP will refer them for an outpatient appointment with a consultant specialist. The waiting time for a consultation should be a few weeks and should not exceed 18 weeks to completion of treatment, although multiple pressures have now seriously eroded these targets.
When a patient has a more acute problem, they may consult a GP for an urgent appointment or telephone consultation (dial 111), with onward referral to acute hospital services via an Accident & Emergency (A&E) Department (ER in the US) or an Acute Admissions Unit (AAU). In a serious emergency, patients may self-present to A&E or summon an ambulance (dial 999) directly to their location, where after assessment by paramedics, they will, if necessary, be taken directly to the nearest A&E department. Targets for A&E waiting times of 4 hours were set centrally but are often breached.
SECONDARY CARE
The basic unit of secondary care is the NHS Trust. There are 219 Trusts overseeing 1,600 NHS hospitals and specialist care centres. Within NHS hospitals, senior clinicians ranked as consultants (Attendings in the US) are organised into teams within the same specialty (General Medicine, Cardiology, Gastroenterology). Most consultants will be ward-based and will provide emergency services on a rota as well as more specialised services within their area of expertise in clinics (out-patients). Most consultants supervise teams of qualified doctors undergoing specialist training. A typical department will comprise several consultants, a few middle-grade doctors – Trust doctors or Specialist Registrars (SpRs) - supported by more junior doctors known as Core Trainees (CT1 or 2) and underpinned by several newly qualified doctors in the first and second years (FY1 or 2) of post-graduate training.
Consultants’ timetables include in-patient ward rounds, supported by trainees, with further time spent in clinics, theatres or with administration. Most consultants will work on an emergency rota, commonly referred to as “on take”, assessing new emergency admissions within their specialty, and admitting patients to hospital when necessary.
An SGU student in the UK is typically attached to a specific consultant’s department where they will work, observe, and be taught by all the clinical staff, directed by the consultant. Teaching includes skills in history taking, physical examination, practical procedures, and the development of clinical management plans. The student will attend with the team in A&E when on take, and in clinics, theatres and on ward rounds. Learning is backed up by a range of academic activities including tutorials, seminars, lectures, practical sessions, and larger educational meetings such as Grand Rounds and multidisciplinary team meetings (MDTs).
The NHS is the most comprehensive free healthcare system in the world and is immensely valued by the UK public. It has provided the widest ranging and the most intensive learning opportunities of any international healthcare system.
Covid challenged all health systems, with previous emergency medical planning focused on pandemic ‘flu. To date (October 2022) there have been 23.8 million cases of Covid in the UK, with 208,000 deaths, including several hundred healthcare workers. In 2020, routine services were suspended for months and are only now recovering, with long waits for elective surgery and clinic appointments. The NHS only survived due to the efforts of very dedicated staff.
Recruitment and retention remain serious issues, with more staff taking early retirement or leaving healthcare, and it is hoped that ICSs will help to address these issues.
The Covid pandemic also marked great scientific achievements, and in the UK we deployed the world’s first Covid-19 vaccinations (AstraZeneca) in December 2020. This technology will undoubtedly lead to further advances in the treatment of many diseases, including cancer over the next decade, and only you, as the doctors of the future will be able to fully appreciate the long-term consequences of the past 2 years.
-David L Stoker MD FRCS
SGU Associate Dean of Clinical Studies (UK)