Ehsan kabir Solicitor | Area Health Authorities and Laws

1
Area Health Authorities and Laws

• Ehsan kabir Solicitor

2
No society can legitimately call itself
civilized if a sick person is denied medical aid
because of a lack of means.

• Aneurin Bevan
• Minister of Health
• 1946

3
United Kingdom

• The United Kingdom of Great Britain and Northern
  Ireland
• Commonly known as UK or Britain
• Constitutional monarchy and unitary state
  England, Northern Ireland, Scotland and Wales

4
Demographics

• Population (2010 est.) 62.2 M
• Annual population growth rate (2010 est.)0.56
• Major ethnic groups British, Irish, West Indian,
  South Asian
• Infant mortality rate (2009est.) 4.69/1,000
• Life expectancy (2009 est.) Males 77.8 yrs
  Females 82.1 yrs total 79.9 yrs
• Work force (2009, 31.5M) Services-80.4
  Industry-18.2 agriculture-1.4
• Average Total Fertility Rate (TFR) in 2008-1.96
  children per woman

5
THE BEVERIDGEan MODEL

• Named after William Beveridge, the social
  reformer who designed Britain's National Health
  Service.
• In this system, health care is provided and
  financed by the government through tax payments
• Mostly, hospitals and clinics are owned by the
  government
• Government and private doctors collect their fees
  from the government

6
Beveridgean model

• low costs per capita (Government controls what
  doctors can do and what they can charge)
• Great Britain, Spain, most of Scandinavia and New
  Zealand, Hong Kong, Cuba

7
Healthcare system in UK

• National Health Service (NHS)
• Shared name of three of the four publicly funded
  healthcare systems in UK
• National Health Service-England
• NHS Scotland
• NHS Wales
• Health and Social Care in Northern Ireland
  (HSC)-Northern Ireland
• Each system operates independently
• Politically accountable to the relevant
  government the Scottish Government, Welsh
  Assembly Government, the Northern Ireland
  Executive, or the UK government (for the English
  NHS)

8
Brief history

• 1834 Poor Law Amendment Act legal mandates
  for mandates for workhouses to provide health
  care for inmates and sick paupers
• 1870s evolving network of workhouses, isolation
  hospitals, asylums, volunteer hospitals
• 1919 Ministry of Health established
• 1942 Beveridge Report first comprehensive
  system, including access to both community-based
  care and hospital treatment

9
Brief history

• National Health Service Act 1948based on
  Beverage Report and the belief in post-World War
  II solidarity
• 1983 Griffith report
• 1989 Caring for People by England, Scotland,
  Wales
• 1990 National Health Service and Community Care
  Act shift resources to primary care
• 1990s Thatcher Revolution public-private
  ownership

10
Health Service Delivery
11
Organization and Administration
12
NHS Act of 1948 establishing theNational Health
Service

• Central administration
• Regional hospital boards
• Local health authorities
• Executive councils
• Tripartite of providers
• Hospital services
• Community services
• Family practitioner services

13
The National Health Service in 1948
Ministry of Health
Central Health Services Council
Regional Hospital Boards
Local Health Authorities
Executive Councils
Teaching Hospital Boards of Governors
Hospital Management Committees
Family Practitioner Services
Community Services
Hospital Services
14
Minister of Health

• Responsible for provision of all hospital and
  specialist services, for the quality of
  laboratory and blood products, major capital
  projects, and health research, and reported
  directly to the Parliament.

15
Tripartite providers

• Hospital services
• Organization was based upon 14 Regional Hospital
  Boards that oversaw local hospital management
  committees. 
• The teaching hospitals were directly responsible
  to the Ministry of Health 'for they served the
  nation, not the locality.'

16
Tripartite providers

• Community services
• Local authority health services were managed by a
  Medical Officer of Health.
• Community nurses
• School dentists
• Health centers

17
Tripartite providers

• Family practitioner services
• Family doctors, dentists, opticians, and
  pharmacists were self-employed under a contract
  for services from an Executive Council. 
• The family doctor acted as gate-keeper to the
  rest of the NHS, referring patients where
  appropriate to hospitals or specialist treatment
  and prescribing medicines and drugs.  

18
Reforming the NHS in 1974

• 14 Regional Health Authorities, covering all
  three parts of the NHS and incorporating the
  teaching hospitals, replaced the previous
  authorities.
• A new tier of Area Health Authorities was
  established, with boundaries largely co-terminous
  with local authorities, between the regions and
  the district health authorities that managed the
  hospitals.

19
Area Health Authorities

• The advantages were that the Area Health
  Authorities could unite the tripartite service
  and plan all NHS services in cooperation with
  local authorities.
• The disadvantages were that the system was
  complex and managerially driven and it soon
  earned criticism.

20
Reforming the NHS in 1990

• Griffith report in 1983 recommending
• That the NHS become more business-like
• Address the problem of growth of public
  expenditures, and
• Initiate internal market forces within the NHS.
• To create competition between hospitals and
  providers through a separation of purchaser and
  provider role.

21

• After the establishment of the internal market
  and the purchaser-provider split,
• 'purchasers' (health authorities and some family
  doctors) were given budgets to buy health care
  from 'providers' (acute hospitals, organizations
  providing care for the mentally ill, people with
  learning disabilities and the elderly, and
  ambulance services). 

22

• To become a 'provider' in the internal market,
  health organizations became NHS trusts,
  independent organizations with their own
  management, competing with each other.
• The first wave of 57 NHS Trusts came into being
  in 1991.
• By 1995 all health care was provided by trusts. 

23

• Self-governing trusts would be created to run
  hospitals and other services, and
• DHAs would be transformed into purchasers for
  their local constituencies.
• GP practices would become fundholders, become
  purchasers of some hospital services, and
  establish contracts for other services.

24

• The fundamental idea was to assure that funding
  would follow the patient and this competition for
  patients would stimulate increased efficiency and
  greater response to patient needs.

25
The NHS after the 1990 National Health Service
and Community Care Act
Secretary of State for Health
Department of Health
Regional Health Authorities
District Health Authorities
Family Health Services Authorities
GP Fund Holders
NHS Trusts
Special Health Authorities
GPs, dentists, opticians, pharmacists
Directly Managed Units
26
1990 National Health Service and Community Care
Act

• Overall mission was to shift resources to primary
  care by introducing fundamental change in the
  management of hospital and family practitioner
  services.
• The 1990 Act represents a major shift to
  community-based care, privatization,
  accountability, quality assurance, and cost
  containment that was envisioned over 30 years
  ago. (Gillie, 1963)

27
The NHS in the recent decade (1998-2007)

• A new type of body that encouraged public
  participation as members appeared, the NHS
  Foundation Trust. 
• Ultimately there were 10 strategic health
  authorities controlling some 200 primary care
  trusts that contracted with both public and
  private providers, trusts, hospitals, community,
  mental illness and ambulance, as well as managing
  GPs and primary health care.

28

• Secretary of state for health
• This is the government minister responsible for
  the NHS in England, and he or she is answerable
  to Parliament for the work of the NHS.

29

• Department of Health
• - responsible for the overall planning,
  regulation and inspection of the health service
• - develops policies and decides the general
  direction of healthcare.

30

• Strategic health authorities
• - 28 strategic health authorities in England.
• - look after the healthcare of their region
• - link between the Department of Health
• and the NHS.
• - make sure that national health
• priorities (such as cancer programmes)
• are integrated into local health
  plans.

31
Primary and secondary health services

• Primary care
• covers everyday health services such as GPs
  surgeries, dentists and opticians
• delivered by primary care trusts
• Secondary care
• specialized services such as hospitals,
  ambulances and mental health provision
• delivered by a range of other NHS trusts.

32
NHS trusts

• - distinct legal entities w/n the NHS
• - run by a board of directors and a chairman
  appointed by the Secretary of Health
• - rationale stimulate a managed care system,
  with incentive to reward efficiency, quality and
  cost effectiveness and provide citizens with
  choices.

33
The different types of Trusts

• Primary care trusts
• about 300 primary care trusts in England.
• decide what health services their area needs and
  have responsibility for making sure these are
  delivered efficiently
• Primary care trusts are responsible for services
  you access directly such as
• GPs
• Dentists
• Pharmacists
• Opticians
• NHS Direct
• NHS walk-in centres

34
Primary Care Trusts

• decide on the amount and quality of services
  provided by hospitals, dentists, patient
  transport and population screening.
• responsible for generally improving local health
• make sure that NHS organizations work effectively
  with councils.
• Receive about 75 of the NHS budget.
• control funding for hospitals, which are managed
  by NHS trusts called "acute trusts".

35
NHS Trusts

• run most hospitals and are responsible for
  specialised patient care and services, such as
  mental health care.
• make sure that hospitals provide high quality
  health care and spend their money efficiently and
  some pay for private treatment to clear backlogs
  and waiting lists.
• employ most of the NHS workforce from hospital
  doctors and radiographers to security staff.
• NHS trusts which oversee 1,600 NHS hospitals and
  specialist care centers

36
Types of NHS Trust

• Acute trusts
• look after hospitals that provide short-term
  care, such as Accidents and Emergencies,
  maternity, surgery, x-ray
• 175 acute NHS trusts
• Care trusts
• work in both health and social care and they can
  carry out a variety of services, such as mental
  health services.
• generally set up when the NHS and a local
  authority decide to work closely together

37

• Mental health trusts
• number of specialist mental health trusts in
  England, providing care, such as psychological
  therapy and specialist medical and training
  services for people with severe mental health
  problems
• 60 mental health trust

38

• Ambulance trusts
• There are over 30 ambulance services for England,
  each run by its own trust.
• responsible for providing transport to get
  patients to hospital for treatment
• 12 ambulance trust

39
Foundation trusts

• High-achieving NHS trusts can opt out of NHS
  control and receive foundation status
• more freedom and financial flexibility and less
  central control and monitoring.
• owned by their community, local residents,
  employees and patients
• have the power to manage their own budgets and
  shape their healthcare provision according to
  local needs and priorities
• more access to funds for investment (public or
  private sector)
• currently 115 available

40
Private Health Care

• smaller than the NHS and does not have the same
  structures of accountability.
• does not have to follow national treatment
  guidelines and health plans and it does not have
  responsibility for the health of the wider local
  community.
• Private health insurance
• Secondary care in the private sector specialized
  health treatment
• Diagnostic tests for certain conditions, one-off
  specialist treatment such as visiting a
  dermatologist, specific operations in a private
  hospital, non-essential treatment such as
  cosmetic surgery and treatment for addiction or
  rehabilitation

41
Private hospitals

• over 300 private hospitals in the UK.
• provided by private hospital groups and the NHS
  also provides a number of private patient units
  within its hospitals.
• licensed by the local healthcare authority, which
  conducts two inspections a year.
• not regulated by the national inspection bodies
  that monitor NHS organizations.

42
Health human resources
43
HUMAN HEALTH RESOURCES

• 90,000 doctors (2.1 per 1000 pop) (OECD 2002)
• 3 Categories
• Hospital consultant
• General Practitioner
• -gatekeepers all citizen register with a GP
• -1 1800 approval for practice gt2,500 financial
  incentives
• - group practice
• - additional reimbursement opportunities rural
  practice payments
• -Augment income through dispensing of drugs

44

• 3. Public Health Doctor in Community Medicine
• -smallest
• -can advance to senior appointments as District
  or Regional Public Health Director

45

• 300,000 nurses
• 40 of the NHS budget
• Initial core course then select a branches of
  nursing for specialization (adult, children
  etc..)
• 150,000 healthcare assistants
• 22,000 midwives
• 13,500 radiographers
• 15,000 occupational therapists

46

• 7,500 opticians
• 10,000 health visitors
• 6,500 paramedics
• 90,000 porters, cleaners and other support
  staff
• 11,000 pharmacists
• 19,000 physiotherapists
• 24,000 managers
• 105,000 practice staff in GP surgeries

47
Health Care Administration

• Expertise in the planning and evaluation of
  services in the NHS.
• Present at all level (regional, district )

48
NHS HOSPITALS

• Capacity 400,000 beds
• Absorbs over half of the NHS budget
• Sizes ranges from the small community facility to
  the large District Hospital
• Average length of stay 8.8days (1991), 12.5 (1981)

49
Health Financing
50
Health Finance

• NHS principle on health finance financed almost
  100 from central taxation
• The rich paid more than the poor for
  comparable benefits
• Public funding through taxation
• Efficient (lower administrative costs)
• Services are free to patients at the point of
  use.

51
Financing Scheme

• Small co-payment on few services (e.g.
  prescription drugs, optician and dental services)
• 80 of patients are exempted from these
  co-payments namely pregnant women, mothers,
  children, most elderly persons patients with
  chronic diseases
• Small but growing private sector (10-20)

52
Financing Scheme

• It pays general practitioners on a
  capitation basis and hospital physicians largely
  on a salaried basis.

53
Financing Scheme

• Before the 1990 monolithic bureaucracy
• Prior to the reforms, each health district
  authority was provided a fixed budget with no
  incentive for good performance.
• Greater efficiency and shorter waiting lists
  meant more referrals from other districts without
  an offsetting transfer of resources. Increase
  productivity added to workloads but not revenues.
  

54
Financing Scheme

• The reforms replaced the centralized hierarchical
  NHS bureaucracy with a quasi-market mechanism.
• Establishment of the internal market and the
  purchaser-provider split
• A provider/purchaser split purchasers of
  health care, regional health authorities and
  general practice fund holders are allocated
  budgets to purchase services for their
  populations

55
Financing Scheme

• These purchasers are distinct from
• providers (mainly hospitals)
• The incentives for efficiency and a responsive
  system come as providers compete for contracts
  with purchasers
• The Thatcher reforms of 1993, created an internal
  market and GP fundholders, adding choice and
  competition to a system where little or either
  existed

56
Financing Scheme

• To become a provider health organizations
  became NHS trusts, independent with their own
  management and competing with each other
• NHS Trust hospitals served as primary providers
  of specialty services to GPFHs

57
Financing Scheme

• GP fund holding
• Family doctors were given budgets with which to
  buy health care from NHS trusts (and also from
  the private sector)
• Two tier system Patients of GP fund holders were
  often able to obtain treatment more quickly than
  patients of non-fund holders
• Supporters said fundholding saved money and was
  more efficient.  

58
Financing Scheme

• Establishment of NHS Trust and General
  Practitioner Fund Holders (GPFH) organizations
• Provide care and purchase services for their
  patients including hospital services,
  pharmaceutical care, health visiting, district
  nursing, dietetic and chiropody services
• Quicker access to hospital care and consultants

59
Financing Scheme

• A patient-focused service (patient choice, an
  expanding independent sector and providing extra
  capacity)
• Competitive providers, giving hospitals and GPs
  incentives to change (Payment by results, money
  following patients)
• Active purchasers - giving PCTs purchasing power
  and practice-based commissioning)
• Cost effectiveness and affordability, (tariffs
  and commissioning)

60
Financing Scheme

• The NHS had become a service provided to all
  without payment, but the provision was no longer
  necessarily by a publicly owned infrastructure
• Private sector organizations came to build and
  operate hospitals under the public/private
  partnerships, and to run clinical services such
  as Independent Treatment Centers and some NHS
  Walk-in Centers
• "Contestability" - the introduction of
  competition between providers - became
  significant. 
• Private practice was now an important part of a
  new and more sophisticated market. 

61
Private Market

• 12 of Britons have Supplementary Insurance--an
  employment perk
• Doctors hospitals treat both public and private
  patients
• Private insurance pays for dental, vision, some
  prescription drugs (although 80 of all
  prescription drug payments are waived due to age,
  pregnancy, youth, poverty)

62
Economic Factors

• Revenues
• 83 NHS funding from taxes
• 13 from employer-employee contributions
• 4 User fees
• Expenditures
• NHS accounts for 88 of health expenditures
• Private Insurance (SI) 4 of expenditures
• 3/4 of NHS budget goes to workforce salaries
• 1/10th of NHS budget goes for drugs

63
Health Care Expenditures

• Expenditure on healthcare in the UK was 136.4
  billion in 2009
• The graph on the next slide shows the current
  price expenditure on healthcare within the UK for
  the years 19972009.

64
Current price expenditure on healthcare from year
19972009
Source Office for National Statistics
65
Expenditure on healthcare as a percentage of GDP
(19972009)
Source Office for National Statistics
66
Public and private health expenditure as a
percentage of GDP 19972009
Source Office for National Statistics
67
Breakdown of Budget for NHS
68
Breakdown of Health Spending
69
NHS expenditure, by age
70
Health Care Expenditures in Comparison to Other
Countries

• (Spending per capita (2,160) in the United
  Kingdom in 2002 was just 41 percent of the United
  States level (5,267) and a little more than half
  when expressed as a ratio to GDP (7.7 percent as
  opposed to about 15 percent)

71
Total health spending in G7 countries
72
http//scienceblogs.com/denialism/2009/05/what_is_
health_care_like_in_th.php
73
(No Transcript)
74
Health Regulation
75
Health Regulation

• CQC
• HPA
• NICE

76
CQC

• Care Quality Commission 
• Regulates all health and adult social care
  services in England, including those provided by
  the NHS, local authorities, private companies or
  voluntary organisation
• Also protects the interests of people detained
  under the Mental Health Act

77
CQC

• Makes sure that essential common quality
  standards are being met where care is provided,
  from hospitals to private care homes
• Has a wide range of enforcement powers to take
  action on behalf of people who use services if
  services are unacceptably poor.
• Brings together independent regulation of health,
  mental health and adult social care for the first
  time
• Aims to make sure better care is provided for
  everyone, whether thats in hospital, in care
  homes, in peoples own homes or elsewhere.

78
HPA

• Health Protection Agencys
• A non-departmental public body
• Role is to help protect UK public health by
  giving support and advice to the NHS, local
  authorities, emergency services, the Department
  of Health and any other organisations that play a
  part in protecting health

79
HPA

• Operates from three major centres
• The Centre for Infections at Colindale
• The Centre for Radiation, Chemical and
  Environmental Hazards at Chilton
• The Centre for Emergency Preparedness and
  Response at Porton
• HPA Act requires the agency to be accountable for
  the standards of the healthcare services it
  provides as if it were an NHS authority
• Is subject to the Care Quality Commission's
  Annual Health Check and measured against the
  Department of Health's Standards for Better
  Health

80
NICE

• National Institute for Health and Clinical
  Excellence
• An independent organisation that provides
  national guidance on the promotion of good health
  and the prevention of ill health.
• Set out in a 2004 white paper, Choosing health
  making healthier choices easier and is intended
  to help people to make well informed choices
  about their health

81
NICE

• NICE guidance is produced by healthcare
  professionals, NHS staff, patients and carers,
  members of the academic world and other members
  of the wider healthcare community

82
NICE Guidance

• Guidance is developed for the following areas
• Public health guidance on the promotion of good
  health and the prevention of ill health for those
  working in the NHS, local authorities and the
  voluntary sector, and the wider public
• Health technologies guidance on the use of new
  and existing medicines, treatments and procedures
  within the NHS 
• Clinical practice guidance on the appropriate
  treatment and care within the NHS of people with
  specific diseases and conditions

83
CHALLENGES AND REFORM
84
Reforms

• Increase in demand at zero pricing
• Growing public expectations
• Advances in costly medical technologies
• Ageing population

85
A. 1990 National Health service and Community Act

• 2 objectives
• To improve ability to control the NHS financially
  by separating health from social care. Free
  but controlled NHS in practice meant making
  doctors more accountable to government. This
  required restricting the clinical autonomy of
  doctors
• To increase the efficiency of the NHS by
  improving both productive efficiency and
  allocative efficiency .

86

• Introduction of the internal market by separating
  purchasing and providing functions
• purchasers' (health authorities and some family
  doctors) were given budgets to buy health care
  from 'providers' (acute hospitals, organizations
  providing care for the mentally ill, people with
  learning disabilities and the elderly, and
  ambulance services)
• Creation of NHS trusts with greater freedom to
  set pay levels and to borrow for capital projects

87

• Fund holding for larger GP practices allowing
  them to purchase certain patient services direct
  from providers
• Elevation of GP status
• Many family doctors were given budgets in a
  scheme called GP fund holding.
• Fund holding saved money and was more efficient.
• GPFH must have a minimum of 7000 patients
  enrolled and can purchase a number of provider
  services directly on behalf of their patient

88
CHALLENGES

• Concerns that GPs might engage in practices to
  maximize their budgets such as excluding high
  risk, high cost patients or under referring
  patients to hospitals
• Waiting lists are an epidemic problem
• UK only spent 6.8 of GDP on health care hence
  the numbers of doctors4, nurses, therapists and
  hospital beds were insufficient to match the
  increasing demand and, therefore, the waiting
  times for treatment lengthened

89

• Equity in access issue is unsolved
• Health workers are paid considerably less than
  their counterparts in other countries

90
B. NHS Plan of 2000

• 4 principles
• A patient-focused service (patient choice, an
  expanding independent sector and providing extra
  capacity)
• Competitive providers, giving hospitals and GPs
  incentives to change
• Active purchasers
• Cost effectiveness and affordability, (tariffs,
  legal contracts and commissioning)

91

• Health care system based on cooperation not
  competition
• Private sector organizations came to build and
  operate hospitals under the public/private
  partnerships, and to run clinical services such
  as Independent Treatment Centres and some NHS
  Walk-in Centers
• Emphasis on efficiency and quality through
  creation of NICE (National Institute of Clinical
  Excellence) and CHI (Commission for Health
  Improvement)

92

• Consumer choice
• Means to address problem on waiting list
• This innovation meant that spare capacity in one
  hospital can be used to shorten queues at
  another, speeding treatment for patients and
  making more efficient use of resources.
• Hospitals that fail to deliver lose money

93
CHALLENGES

• Tax revenue for financing NHS will depend on the
  rate of economic growth hence there is a
  continuing debate as to whether NHS should be
  exclusively funded by general taxes and national
  insurance contributions or instead adopt some
  form of social health insurance
• How to cope up with advances in technology in
  tax-funded system

94
CHALLENGES

• How to address the rising alcohol misuse and
  obesity
• Prime minister needs for greater integration and
  efficiency, with more emphasis on prevention
• Those In poorer communities are still those with
  poorer health

95
Sources

• http//www.dh.gov.uk/en/Aboutus/MinistersandDepart
  mentLeaders/index.htm
• http//www.nhshistory.com/nhsplan.pdf
• http//en.wikipedia.org/wiki/Healthcare_in_the_Uni
  ted_Kingdom
• http//www.nhs.uk/NHSEngland/thenhs/Pages/thenhsho
  me.aspx
• http//mighealth.net/uk/index.php/The_Health_Care_
  System_in_the_UK
• http//www.disabled-world.com/medical/healthcare/u
  k-healthcare/
• http//www.statistics.gov.uk/articles/nojournal/he
  althcare-expenditure-may2011.pdf

96
Thanks