A Guide to the NHS

Tony White

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315357614
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

To maximise the effectiveness of their work, NHS employees need a clear understanding of the structures and systems of the organisation in which they work. However, this information can be widely spread, hard to access and difficult to gain a working overview of, and the pace of changes and initiatives can seem almost dizzying. This book draws together a clear picture of the modern NHS, from funding and governance to reports, inquiries and overarching legislation. The book is clear and easy to understand and crucially includes full references to provide a one-stop point of access to the most detailed and up-to-date information available. This book is essential reading for workers in the NHS at all levels, including managers, administrators and clinical professionals. It is vital reading for managers and staff at commercial companies working with the NHS. It will also be of interest to campaigners, patient interest groups, researchers and journalists with an interest in the NHS. Specialty registrars and consultants can also find the information from the book, and much more, in The Doctor's Handbook Parts 1 & 2, by the same author. 'Rather than long narrative histories or complex explanations, the author signposts readers to sources of further information, making this book the quick guide so many of us need' - from the Foreword by Sir Ian Carruthers

A Guide to the NHS

1

Understanding the NHS

The aim of this chapter is to provide an outline of recent reforms and a brief summary of the structure of the NHS, both nationally and locally. It also reviews healthcare reforms in a worldwide context. Most of the following information can be downloaded from www.dh.gov.uk/PublicationsAndStatistics/fs/en; click on ‘Statistics’ but prepare to be overwhelmed by data. There are also other data sources for some information: for example NHS, British Medical Association (BMA) and medical college websites, although they do not always agree on statistics.

A statistical picture of the NHS

○ The NHS employs more than 1.5 million people, about 1 in 23 of the population.

○ Just short of half the workforce are clinically qualified, including some 120 000 hospital doctors, 40 000 general practitioners (working in about 10 000 practices), 400 000 qualified nurses and 25 000 ambulance staff.

○ Only the Chinese People’s Liberation Army, the Wal-Mart supermarket chain and Indian Railways directly employ more people.

○ 77% in the NHS are female.

○ The NHS costs more than £1500 annually for every person in the country.

○ 15.3 million patients attend A&E annually. 22% are admitted, 19% are referred to GPs and 39% are discharged. 2% are sports injuries.

○ There are 82.4 million outpatient appointments made annually, 8% fail to attend.

○ There are 3 million day case operations per year or 3.6 million if day case treatments are included.

○ There are nearly 9 million inpatient admissions every year.

○ On average the NHS deals with 1 million patients every 36 hours – that’s 463 people a minute or almost 8 a second.

○ Every day, approximately 700 000 people visit their general practitioner and about 100 000 visit their dentist.

○ A GP sees an average of 255 patients a week, so 23 million a month visit a GP.

○ A one-week stay in hospital costs £1100 and a night in intensive care costs £500.

○ Over 745 million prescriptions are dispensed each year, costing over £5 billion and representing 12% of all NHS expenditure.

○ There were 44 660 managers in the NHS in 2009, an increase of 11.9% on 2008 and 84% on 1999.

○ The total numbers of consultants in England are very difficult to ascertain but at September 2005 it was 31 993 (FTE = 29 613).

○ In 2008–09 the NHS employed 1600 management consultancies.

○ The NHS spent £584 million on agency staff in 2007–08.

○ The total number of GPs in the NHS is around 30 000 (in England, although 25% are part-time) working from about 10 000 practices (see below).

○ The vacancy rate for doctors and dentists posts in March 2009 was 5.2%.

○ NHS Direct handles over 26 000 calls a day. More than 850 000 people accessed its telephone and online services over the 2009 Christmas period alone.

○ 77% of funding comes from general taxation, 12% from the NHS share of national insurance contributions and 2% from patient charges.

○ Just under half of NHS spending goes on acute services. This amounts to about £800 per person per annum.

○ The NHS spends £14 billion in Scotland and £7 billion in Wales.

○ Over 40% of total hospital and community health services expenditure is for people over 64 years of age, though they represent just 16% of the population.

○ OECD countries are spending record amounts on healthcare, largely due to the rising cost of pharmaceuticals and the diffusion of modern medical technologies.

○ Staff costs account for two-thirds of all NHS expenditure.

○ The average sickness absence rate for the NHS in England was 4.6% (4th quarter 2009).

○ The NAO claims that 5000 people die each year from hospital-acquired infections, and that at any one time 9% of patients have a hospital-acquired infection.

○ The hospital-acquired infection problem is said to cost the NHS £1 billion a year.

○ The estimated cost of adverse events in the NHS is believed to be in excess of £2 billion a year.

○ The NHS spends an estimated £30 million a year on recruitment advertising.

○ The NHS spent over £584 million in 2007–08 on agency staff.

○ The Royal College of Nursing (RCN) reported that according to a Freedom of Information Act survey the government spent £350 million on external management consultants in the financial year 2008/09 (Nursing Times 10 May 2009). As a result the NHS is the fourth largest user of external consultancy and reducing the money spent on external management consultancy could deliver 11% of the expected reduction in government health spending announced in the 2009 budget. Indeed over three years (to August 2009) the DoH spent £470 million on some 100 contracts with management consultants.

○ NHS WiCs, of which there are currently 93, treat around 3 million patients a year.

○ 46 NHS-run Treatment Centres have been opened as of May 2009. More than 304 000 patients have been treated from April 2003 to March 2006.

○ 21 Independent Sector Treatment Centres (ISTCs) and a mobile ophthalmology unit have been opened as of May 2009 in which 80 000 elective procedures and 38 000 diagnostic assessments have been carried out.

○ There are 6.3 million ambulance service calls a year, that’s 360 calls an hour or 6 calls every minute. And NHS ambulances make over 50 000 emergency journeys each week.

Problems with the statistics

Conflicts in quoted figures from different authorities appear to be common and I looked at the reason for this with regard to waiting lists. It is difficult to interpret but it gives a clue to the reason for the variations in published figures. There have always been differences between the official figures acknowledged for patient waiting times, those published by the Department of Health (DoH) and the waiting times taken from hospital episodes statistics (HES). These appear to be mainly because of the different ways in which the times were calculated.

HES waiting times are worked out as the maximum waiting time and timed from the date at which the decision is taken to put the patient on a waiting list, until the point at which they are admitted and the treatment takes place. But the HES waiting times include days when the patient isn’t available for treatment; for example, due to illness or holidays. Such days are called suspensions or deferrals from the waiting list.

Before December 2003, all DoH official waiting times were worked out as the date a patient was put on a trust’s waiting list to the date they were admitted. Unlike the HES waiting times, they did not include suspensions or deferrals. There were problems with the method for working out official waiting times due to the definitions for calculating the time when patients were suspended or deferred that were unclear. This led to inconsistencies and local interpretations. There were even suggestions that some trusts were using ‘phantom’ suspensions to keep patients off waiting lists so that government targets could be met. Another anomaly that arises is that the waiting list time does not include any investigations. So, for example, a patient referred for a replacement hip operation would not start their waiting list time clock until all investigations were completed. The system also gave no way of reflecting the overall waiting time if a patient moved from a waiting list at one trust to a list at another.

In December 2003 a Data Set Change Notice (DSCN 37/2003) was issued. The changes set out in this document attempted to ensure that the DoH official waiting times more closely reflect the patients’ perceptions of how long they have waited. The DSCN and background documents give the official guidance on this. The new DoH official waiting times are worked out from the date at which the patient is placed on a waiting list at any provider until the date at which the patient is admitted for the treatment. This is regardless of which provider gives the treatment. For example, with their consent, the patient may be moved from the waiting list at one provider to that of another provider, who may be able to treat them more quickly. This might be as a result of the Patient Choice initiative decision.

The change to the official waiting times doesn’t mean that they are calculated as the difference between the date when the patient is added to the waiting list and the operation date. However, if the treatment does not take place (e.g. if the patient is sent home with a cold), the waiting time continues to be counted until the date of the admission that does result in the treatment taking place. Patients can be suspended from a waiting list for short periods of time while they are unavailable for admission for social or medical reasons. Patients may also refuse at least two admission dates that they are offered. In this case they are considered to have self-deferred and the waiting time is then counted from the earliest date offered. The total number of days for periods in which the patient was suspended or was self-deferred can be subtracted from the total waiting time.

Patients may also cancel appointments or not turn up on an accepted admission date they had previously accepted. In this case the waiting time is reset to zero and the clock restarts from the date on which the patient failed to attend. Planned admissions are used where a patient is waiting for treatment for clinical reasons, rather than until resources become available. Such patients are usually excluded from waiting times calculations, although there is no reason why the time waited should not be recorded because the time between clinical events could have significance.

Comparing HES- and NHS-derived waiting times is difficult. It is possible for the HES waiting time to be greater than, equal to, or less than the NHS derived waiting time. Well, I said it was a complex business, but if you want to try to make sense of it go to HES online at www.hesonline.nhs.uk. This is a Hospital Episode Statistics data warehouse containing details of all admissions to NHS hospitals in England. It includes private patients treated in NHS hospitals, patients who were resident outside of England and care delivered by treatment centres (including those in the independent sector) funded by the NHS. HES also contains details of all NHS outpatient appointments in England.

HES is the data source for a wide range of healthcare analysis for the NHS, government and many other organisations and individuals. It contains admitted patient care data from 1989 onwards, with more than 12 million new records added each year, and outpatient attendance data from 2003 onwards, with more than 40 million new records added each year.

(The HES Service and the HES website are run by Northgate Information Solutions on behalf of The NHS Information Centre for Health and Social Care.)

A similar problem arose in trying to identify the number of GPs. The statistics do not often give a figure in context; for example, whether for UK or England alone, whether including GP retainers and GP registrars, or whether total number of whole-time equivalent (WTE) numbers. For example, www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4112146 gives a figure for the total number of GPs (excluding GP retainers and GP registrars) in England as at 31 December 2004 as 31 798. The NHS Information Centre at www.ic.nhs.uk/webfiles/publications/nhsstaff2008/gp/BulletinSept2008.pdf gives a figure of 27 347 in 2008. And at www.parliament.uk in a parliamentary answer in House of Commons in 2008 the latest available figure was given as 33 364 in 2007; see www.publications.parliament.uk/pa/cm200708/cmhansrd/cm080707/text/80707w0033.htm.

Overview of NHS

Since its launch the NHS has grown to become the world’s largest publicly funded health service. It is also one of the most efficient, most egalitarian and most comprehensive. The sys...