United
Kingdom
The
National Health Service (NHS) is comprehensive and largely free at
the point of use. Charges are, however, made for pharmaceutical and
dental services and the NHS no longer provides general ophthalmic
services to the majority of the population. NHS expenditure totalled
almost £44 billion in 1997 or 1 3.7 per cent of total public
expenditure. The bulk (84 per cent) of NHS expenditure is financed
from general taxation.
Primary care
Primary
care is the area of the patient's first contact with thehealth
service. As such it includes not only medical care provided under
the general medical services (GMS), but also the community health
services and treatment in accident and emergency departments
of hospitals as well as dental and ophthalmic care. Using this broad
definition, primary care accounts for some 33 per cent of NHS
expenditure in the United Kingdom (UK).Prior to April 1996,
primary care was administered principally by family health services
authorities (FHSA) in England andWales, health boards in Scotland
and health and social services boards in Northern Ireland. Since
that date however, changes in England and Wales have made it the
responsibility of new unified health authorities which combine this
role with their other functions — assessing the health needs of
their resident populations and purchasing appropriate healthcare
from providers, usually NHS Trusts. All four countries within the UK
now therefore have a unified system. The move to devolution of
government within the UK is, however, going to lead to increased
diversification in the healthcare systems of the four
countries.Primary care services are provided for the most part by
independent contractors. Dental, and where appropriate, ophthalmic
practitioners are paid by fee-for-service and general medical
practitioners by a complex system of fees and allowances, described
in greater detail below.Pharmaceutical services are provided by
chemists and appliance suppliers who are also independent
contractors to the NHS, as well as by doctors, particularly those in
rural areas. Drugs and appliances are supplied under the NHS upon
receipt of a prescription provided by a general practitioner, with
the exception of certain 'over the counter' preparations. The
pharmaceutical services account for around ten percent of total NHS
gross expenditure. A charge is levied (currently £5.80 per item
supplied) for prescribed drugs, but an elaborate exemption mechanism
for groups such as the' elderly, the indigent and the young, as well
as for some patients with chronic, mainly endocrine diseases, means
that some 80 per cent of prescriptions are dispensed free.
General medical
services
General
medical services are those services provided by general
practitioners to patients on their lists (and in certain
circumstances to those on the list of other practitioners) for which
no remuneration is received other than from the health authority.
General medical services absorb around 30 per cent of gross
expenditure on primary care. The definition of GMS is crucial to
understanding the range of services provided. Although the
remuneration system for general practitioners specifically
recognises certain activities, others are undertaken at the total
discretion of the practitioner with no explicit remuneration. There
is currently much debate about the content of GMS, and about
the possibility of a more specific definition of core services to be
provided by all GPs.The general medical services are funded entirely
from general taxation and no charge is made to the patient for the
service rendered by the general practitioner under the NHS. There is
thus no financial barrier between patients and their first point of
contact with the health service.The importance of the general
medical services sector can be judged by the proportion of medical
care it deals with. Of nearly 300 million initial doctor contacts,
95 per cent are with general medical practitioners. Of these latter
some 12 percent will lie referred by the general practitioner to
hospital for tests, x-rays or further treatment, whilst nearly 90
per cent will be treated from start to finish by the general
practitioner. On average each person in the UK contacts their
general practitioner about five times per year. Of these
consultations, approximately 12.b per cent take place at the
patient's home and the remainder at the surgery or by telephone. The
number of patients per unrestricted principal in general practice is
around 1,850 and each general practitioner will therefore be
involved in around 9,000 consultations per year. Some 1,150 of these
will be in the patient's home. However, UK general practice is
increasingly focused on premises-based care, both in hours and out
of-hours, and increasing attention is being given to ways of getting
vulnerable patients to surgery premises for the delivery of high
quality clinical care.Over the course of the year each general
practitioner issues approximately 1 7,400 items or an average of 9.4
per patient.The regulations governing the general medical services,
the terms of service of general medical practitioners and the
current organisation of the discipline combine to provide the
consumer, ie, the patient, with substantial freedom of access to
general medical services. Each person may choose their general
practitioner. Equally, the individual practitioner is free to decide
whether or not to accept an applicant onto his or her list as a
patient. Under certain circumstances a patient may be assigned to
the general practitioner. A doctor's patients are not only those as
recorded by the health authority, but also those accepted as
temporary residents, those to whom certain specified services (contraceptive,
maternity, child health surveillance or minor surgery services) are
provided, and those to whom the doctor may be requested to give
treatment which is immediately necessary, for example, after an
accident or in an emergency.General practitioners are obliged to
render to their patients all necessary and appropriate personal
medical services of the type usually provided by general
practitioners. They can fulfil their obligation at their practice
premises, the patient's home or elsewhere in their practice area.
They are under no obligation to give treatment personally, provided
that they take all reasonable steps to ensure continuity of
treatment. Notwithstanding this, they are responsible ultimately for
any treatment given by those to whom they delegate, unless that
person is also a general practitioner principal.Access to general
practice is made as easy as possible by a combination of
organisational factors. Firstly, the Medical Practices Committee is
charged with the efficient distribution of general practitioners
across the country. This Committee categorises areas as 'designated',
'open', 'intermediate' or 'restricted'. Designated areas and, to a
lesser extent, open areas are thought to be under-doctored.
Intermediate areas are deemed balanced and restricted areas are
deemed over-doctored. The success of distributing general
practitioners (the direction of labour in this respect being
negative rather than positive) can be gauged by the fact that no
general practitioners now practice in designated areas, compared
with 20 per cent 20 years ago.Two other features of the organisation
of general practice lend themselves to easier access by patients.
The first of these is the progressive reduction in average list size,
which has taken place over the period since 1969. The second is the
emergence of group practices.Group practices include partnerships
and also groups of doctors that have no business relationship but
rather one of organisation. A single-handed general practitioner can
combine with others to form a group practice, provided that they
spend a certain amount of time at common practice premises. Eighty
per cent of all general practices in the UK are group practices, and
the great majority of those are also partnerships. The average size
of a group practice is four 'principals in general practice'. There
has also been a significant increase in the employment of ancillary
staff in general practice and in the attachment to practice of staff
paid by health authorities, such as health visitors, nurses and
midwives.
Remuneration of the
general practitioner
General
practitioners are remunerated by means of a number of fees and
allowances. Over half are related to list size (capitation-based)
and others to recognised item of service work. General practitioners
are also paid various allowances, and are eligible for bonus or
target payments for the achievement of certain levels of childhood
immunisation and cervical cytology coverage. These four elements for
a general practitioner's income currently, or average, account for
53 per cent, 1 9 per cent, 21 per cent anr seven per cent
respectively. These fees are recommended each yeai by the Review
Body on Doctors' and Dentists' Remuneratior (DDRB). They are set so
as to provide the average general practitionei with the recommended
net income felt appropriate by the DDRR after practice expenses have
been met, and a recommended gros;-income sufficient to reimburse
indirectly all the average general practitioner's practice expenses
which are not reimbursed directly. Those practice expenses are
calculated through an annual survey of general practitioners' tax
returns.Other payments are also made to general practitioners as
direct reimbursements of expenses. Such payments cover premises,
staff, computer expenses and drugs in varying proportions, all othel
expenses are met by general practitioners from their gross fees and
allowances. In cases where the general practitioner practises in
partnership, remuneration may not be in direct proportion to
personal list size or indeed, the personal service provided. Rather,
it will be dictated by an agreed partnership share. This share
reflects, amongst other factors, the individual general
practitioner's contribution 1<;the practice capital, seniority in
the practice and share of total practice workload.During the
financial year 1997/98 payments under the general medical services
totalled some £130,418 per unrestricted principal. Of this total,
44 percent were direct reimbursement of expenses. Of the 56 per cent
remaining, 34 per cent was capitation based. Average intended net
income for 1997/98 was £46,450.
Beyond the internal
market
Since 1991,
the NHS has been organised as an internal market with purchasers or
commissioners, on the one hand, and providers ol health services, on
the other. Providers are mostly hospitals o( groups of hospitals now
reconstituted as free standing NHS trusts, the remainder largely
being community trusts providing community health services.
Purchasers are the health authorities described above. The
relationship between purchasers and individual providers takes the
form of contracts and purchasers receive the necessary funds by way
of a weighted capitation formula. This takes' into account the age
structure and socioeconomic characteristics of the authority's
resident population.Eligible general practitioners are allowed to
opt for what is termed fundholder status. If they have more than
5,000 patients (3,000 foi community services fundholding) on their
practice lists they can be allocated resources to enable them to act
as purchasers in place of the health authority for their own
patients in respect of a defined range of services. These may
include outpatient services, diagnostic tests, the provision of
medicines and certain inpatient and day case treatments mostly
elective surgery. A number of total purchasing pilots, in which
general practices or groups of practices either purchase or provide
the full range of services required by thc'ii patients, are
currently being evaluated. To continue with fundholding status, the
fundholders must demonstrate that their contracts foi purchasing are
well-managed within their allocated budgets.The UK government is
currently embarking on a series of reforms of the health service
which will abolish the internal market in it1 current
form and will group all general practitioners in
geographically-based groups. These groups, primary care groups in
England, will have functions which will include the development of
primary care, focusing on improving standards through a process
called clinical governance, commissioning of secondary care services
and improving the health of their local populations. There will be
significani differences in the systems as they apply to the
different countries of the UK as devolution progressively takes
effect.
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