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The British Health and Welfare System

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The National Health Service

Primary Care and General Practitioners

Secondary, Tertiary and Community Care

The Voluntary Sector

How the NHS is funded

How the NHS is organised

The NHS in Scotland, Wales, and Northern Ireland


Recent Reforms

'Our Healthier Nation'

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Health Index


The following section has been reproduced, and in some parts adapted, from UK Foreign and Commonwealth Office sources in 1999. See The NHS explained for more information.

For activities using this item prepared by Edyta Bracik of Radom College, go to Health System Issues - classroom materials.


The health and social welfare system is part of everyone's life in Britain. It provides help for anyone who is raising a family or who is elderly, sick, disabled, unemployed, widowed or disadvantaged.

Everyone at some point in their lives will receive help from its varied services, ranging from health checks for children, home help for disabled or elderly people or cash benefits to cover periods of unemployment.

The three pillars of the health and social welfare system are:

  • The National Health Service - the health of the community is the responsibility of the NHS, free to everyone who normally lives in Britain.
  • The personal Social Services - provided by local authorities for elderly and disabled people, those with mental disorders and for families and their children.
  • Social Security - designed to secure a basic standard of living for people who are unemployed, help for families and help towards the cost of disablement.

These publicly-funded services are among the Government's top priorities, and account for about half of all government spending. They are supported by the work of a great many voluntary social and health care organisations, and by carers who look after members of their own family or friends.

More than 90% of all health care in Britain is provided by the state through the NHS

The National Health Service

The NHS is a central element of the welfare state, present on virtually every high street in the form of local pharmacists and in every community and neighbourhood in the form of General Practitioners and dental services.

The NHS, which provides all these services, has a yearly budget of more than £41 billion. With one million staff, it is one of the largest employers in the world.

The principles on which it was founded at its creation in 1948 remain true today: that there should be a free, comprehensive health service for everyone according to need, regardless of their income.

NHS facts and figures (from

In a typical week:
  • 1.4 million people will receive help in their home from the NHS
  • more than 800,000 people will be treated in NHS hospital outpatient clinics
  • 700,000 will visit a NHS dentist for a check-up
  • NHS district nurses will make more than 700,000 visits
  • over 10,000 babies will be delivered by the NHS
  • NHS chiropodists will inspect over 150,000 pairs of feet
  • NHS ambulances will make over 50,000 emergency journeys
  • NHS Direct nurses will receive around 25,000 calls from people seeking medical advice
  • pharmacists will dispense approximately 8.5 million items on NHS prescriptions
  • NHS surgeons will perform around 1,200 hip operations, 3,000 heart operations and 1,050 kidney operations.

What does the NHS do?

The aims of the NHS are clear. They are to improve the health of the nation as a whole by:

  • promoting health
  • preventing ill health
  • diagnosing and treating injury and disease
  • caring for those with long-term illness and disability

To achieve these aims, the NHS provides a comprehensive range of care, nearly all of which is free:

  • primary care through family doctors, dentists and other health care professionals
  • secondary care through hospitals and ambulance services
  • tertiary care through specialist hospitals treating particular types of illness or disease

The NHS also collaborates with social services to provide community care

NHS staff

The NHS is Europe's largest employer with a workforce of nearly one million people. Nurses and midwives make up nearly half the entire workforce in England. Staff costs account for roughly 70 per cent of spending on hospitals and community health services.

The number of GPs in England has risen by nine per cent between 1987-1997, with all of the increase occurring amongst women. The number of ancillary and maintenance and works staff directly employed by the NHS has fallen since the introduction of competitive tendering which has led to many of these jobs being carried out by the private sector.

In September 1996 approximately 940,000 non-medical staff were employed in the NHS hospital and community health services:

  • 67 per cent of these staff were directly involved in patients care and 33 per cent were management and support staff
  • there were 332,660 nurses, midwives and health visitors
  • there were 167,430 administration and estates staff
  • just under 80 per cent of the non-medical workforce were female and over five per cent were from ethnic minority groups.

Family doctors

There were 28,937 GPs in England in October 1997. By 1996, nearly a third were female, compared with just over a fifth in 1986.

Primary care and General Practitioners (GPs)

The vast majority of people are seen by primary care services in the community. They remain the first points of contact most people have with the NHS: between them they cater for about 90 per cent of patient contacts with the health service, at half the cost of hospital care. The Government's long-standing policy is to build up and extend these services to relieve the more costly secondary care services of hospital and specialist services.

Primary care is provided by family doctors, dentists, opticians and pharmacists, who work within the NHS as independent practitioners. Other professionals involved in primary care include district nurses, health visitors, midwives, speech therapists, physiotherapists, chiropodists, dieticians and counsellors.

General Practitioners (GPs) or family doctors are present in every community and they remain the backbone of the health service. They provide essential primary care and act as gatekeepers to other services, referring patients on when necessary. Every year there are some 250 million GP consultations and some six million people visit a pharmacy every day.

Visits to doctors or dentists may be for treatment or for preventative advice. Preventing ill-health is an important part of a GPs work, and most GPs run programmes to prevent heart disease and stroke, to manage chronic diseases such as asthma and diabetes and to improve childhood immunisation rates.

About 80 per cent of GPs work in partnerships or group practices - often as members of primary health care teams. Primary health care teams also include health visitors, district nurses and midwives who are salaried NHS staff, and sometimes social workers and other professionals employed by the health authorities. GPs often work in health centres which offer people a range of health services in one place.

Other key primary care professionals include:

midwives who care for women throughout pregnancy, birth and for 28 days after the baby is born. Some are based in hospital and some go out into the community.

health visitors who promote health for families and are responsible for preventative action. They aim to identify the health needs of the local population and work closely with other NHS colleagues.

district nurses who care for people in their homes or elsewhere outside the hospital setting. Like health visitors, they offer advice in health promotion and education.

How primary care is developing

The 1997 NHS Primary Care Act introduced greater flexibility in the delivery of primary health care services for patients. The new law allows GPs, dentists, NHS trusts and NHS staff to develop, with health authorities and health boards, new ways of delivering their primary care services.

From October 1998 pilot schemes begin in areas with high levels of illness and where it is often difficult to recruit GPs. There are two types of scheme:

  • one which will enable NHS trusts or GP practices to employ GPs on a salary (instead of a self-employed basis), with the aim of giving patients who live in areas of high health risk access to a flexible family doctor service
  • one to create primary health care 'one-stop shops' where GPs, community nurses and other professionals work as a single team in the community offering a range of services from eye tests to counselling

The new Primary Care Groups - local partnerships between family doctors and community nurses - will be expected to play an increasing role in taking decisions about services for patients. This is an integral part of the new reforms in the NHS.

Secondary care

While Primary Care Groups may be the first points of call, secondary care, managed by NHS Trusts, deal with any further treatment or care someone may need. This can range from health advice to some of the most sophisticated treatment in the world.

There are around 300 district general hospitals in England, found in many large towns and cities. They provide a range of services from the care of the elderly to maternity services, supported by services such as anaesthetics, pathology and radiology. Almost all district hospitals have accident and emergency departments for emergency admissions.

Patients either attend as day cases, in-patients for a longer stay, or outpatients. There are also patients who attend wards for treatments such as dialysis. The advent of new treatments has meant the trend has been towards more patients treated as day care and fewer long-stay wards.

Tertiary care

Some hospitals provide specialist services such as heart and liver transplants, treatments for rare cancers and craniofacial services. These specialist services cover patients over more than one district or region.

There are also specialist hospitals of international renown such as the Hospital for Sick Children at Great Ormond Street, Moorfields Eye Hospital and the National Hospital for Neurology and Neurosurgery. As well as offering highly specialised treatments, these hospitals are also centres for teaching and international research.

Hospital building under the Private Finance Initiative

The Government wants to promote a partnership between the public and private sectors in many areas of industry and services. The Private Finance Initiative (PFI) was launched in 1992 for this purpose: in the health service it means encouraging private companies to help finance the design, construction and running of NHS buildings and support services.

In May 1997, in order to boost the PFI, the new Government passed legislation which made the powers of NHS Trusts clearer when signing PFI agreements. Further schemes costing £2,500 million have since been announced, amounting to the biggest hospital building programme in the history of the NHS.

From June 1997 details of PFI projects with a capital value of £1 million or more have been published so that communities know what is being planned for their local health service.

Community Care

Social services have the lead responsibility for community care services to meet the needs of older people, people with disabilities, mentally ill people or other vulnerable members of society. The NHS, however, has an important role in providing some services and in collaborating closely with social services to plan and deliver community care.

Here the role of the NHS includes helping to assess people's needs for community care, liaising with social services over hospital discharges to make sure people get the continuing care they need, as well as delivering some services. The NHS makes an important contribution to community care services. For example, district nurses provide nearly 2.5 million episodes of care annually.

The contribution made by the Voluntary Sector

The voluntary sector plays an important role in supporting patients and health services. The Government gives grants to a large number of voluntary organisations working in health and personal social services in recognition of the valuable work they do.

The money - over £60 million - goes mainly to national organisations dealing with:

  • children
  • older people
  • carers
  • people from ethnic minorities
  • people with HIV/AIDS
  • people suffering from drug or alcohol misuse.

How is the NHS funded?

The NHS is free at the point of delivery to anyone normally resident in Britain. All taxpayers, employers and employees contribute to this cost.

About 82 per cent of the cost of the health service is paid for by general taxes.

The rest comes from:

  • A proportion of National Insurance contributions (paid by working people and employers) - 12.2 per cent
  • Charges towards the cost of certain items, such as drugs prescribed by GPs, dental treatment and sight tests - 2.3 per cent. (Children and adults who may have difficulties paying are exempted from these charges)
  • Land sales and other schemes for generating income - less than one per cent

In addition:

  • health authorities are free to raise funds from voluntary sources
  • some NHS hospitals take private patients who pay the full cost of their accommodation and treatment

How is the NHS organised?

Central Government is directly in charge of the NHS, led by the Secretary of State for Health and a team of ministers at the Department of Health. The Department is responsible for planning a health strategy in England.

Within that department, management of the service is led by the NHS Management Executive. The NHS Management Executive is responsible for developing policies which ensure the quality of health services. The Executive has eight regional offices, which liaise with the health authorities in their region.

Services are administered by a range of health authorities and health boards throughout Britain. There are 100 health authorities in England and five in Wales, 15 health boards in Scotland and four health and social services boards in Northern Ireland. They are all responsible for identifying the health care needs of the people living in their area. They also arrange for services from doctors, dentists, pharmacists and opticians and administer their contracts.

Community health councils (local health councils in Scotland) represent the opinion of local people on the health services provided and on any planned changes.

Health authorities and boards cooperate closely with the local authorities in charge of social work, environmental health, education and other services.

The NHS in Scotland, Wales and Northern Ireland

Following the devolving of power to: Scotland, Northern Ireland and Wales in 1999, separate ministries responsible for Health and the NHS in these three countries were set up (although Social Security remains one of the 'non-devolved' powers ).

In Scotland there is a Minister for Health and Community Care, and details of the NHS in Scotland can be found on their web site (

Wales, rightly proud of the role played by Welshman Aneurin Bevan (Health Minister in 1948) in the establishment of the National Health Service, has a Ministry of Health and Social services to supervise the NHS in Wales ( The National Assembly in Wales is responsible for policy direction and for allocating funds to the NHS in Wales.

As part of the Northern Ireland Executive, the Department of Health, Social services and Public Safety was established. (


A comprehensive monitoring programme in England and Wales is designed to:

  • keep track of HIV infection
  • inform policy
  • plan relevant services and
  • develop HIV/AIDS projections.

Up to the end of June 1997, 14,431 cases of AIDS had been reported in Britain. The number of recognised HIV infections was 29,599. The majority (59 per cent) were homosexual or bisexual males, but 20 per cent were heterosexual non-injecting drug users.

Monitoring programmes confirm HIV infection is found throughout England and Wales among those groups at greatest risk, but rates are much higher in London than elsewhere.

HIV is still being transmitted in some homosexual and bisexual men, and injecting drug users are still taking part in high-risk behaviour such as sharing injecting equipment, particularly among younger users and women.

Recent reforms

In December 1997, the new Government set out a ten-year programme of reforms in a White Paper called 'The New NHS'. This was put into action as The NHS Plan in July 2000. The main points include the creation of:

  • about 500 Primary Care Groups - teams of GPs and community nurses, covering populations of about 100,000 - to take control of most of the NHS budget from April 1999. They will eventually become Primary Care Trusts and will provide all the normal GP services, as well as taking over the running of local community hospitals
  • NHS Direct - a 24-hour telephone hotline staffed by nurses to help reduce pressure on hospitals and GPs by giving on-the-spot health advice
  • NHSnet - a computer network allowing patients to get quicker test results and specialist advice in the local surgery, and book appointments
  • a guarantee that all patients with suspected cancer will see a specialist within two weeks
  • two new national bodies, the National Institute for Clinical Excellence and the Commission for Health Improvement - to issue guidelines on best practice, monitor the extent to which they are followed, and sort out problems
  • Health Action Zones which will operate particularly in deprived areas and which will overcome barriers between different authorities and professions so that they work together and improve their services to patients.

Education and Prevention

Treating illness is the core business of the NHS. But promoting health and preventing disease is a very important part of the work of health services. Infectious diseases, such as polio, which were the scourge of past generations, have largely been eliminated, but there is still a long way to go in combating the major 'killer diseases' of the West such as heart disease and cancer.

The new strategy: 'Our Healthier Nation'

In February 1998, the Government outlined new plans for a wide-ranging strategy to tackle the underlying causes of ill-health. 'Our Healthier Nation' recognises the impact on health that poverty, poor housing, unemployment and a polluted environment can have.

It aims to take action to end the inequalities in health between people in different occupations, ethnic groups, geographical areas and between men and women. Action will be based on information from an independent review of inequalities in health and life expectancy.

The strategy identifies three key settings for action:

  • Healthy schools - focusing on children
  • Healthy workplaces - focusing on adults
  • Healthy neighbourhoods - focusing on older people
  • In schools, for example, a new Internet Website - Wired for Health ( - will mean every child and teacher in the country will be able to find facts on health at the touch of a button.

The strategy has four priority areas for action:

  • heart disease and stroke
  • accidents
  • cancer
  • mental health

To head the new strategy, the Government has appointed, for the first time, a Minister for Public Health. One of the Minister's roles is to make sure policies across all government departments - whether it be road traffic, housing or employment - are evaluated for their potential impact on people's health. In addition to concerted Government action, partnership with local organisations will help deliver improvements to health and tackle inequalities.

The Government also has strategies for action to:

  • discourage drug and alcohol misuse and smoking
  • encourage healthy eating and exercise
  • encourage people to take up opportunities for health screening and vaccination
  • reduce teenage pregnancies

In Scotland, Wales and Northern Ireland, strategies reflect the regional variations in health.

Wales - targets include cancers, cardiovascular disease, maternal and child health, physical disability, mental handicap and mental health and injuries.

Scotland - its strategy emphasises coronary heart disease, cancer, HIV/AIDS, accidents, dental and oral health, smoking, alcohol and drug misuse.

Northern Ireland - targets have been set for circulatory and respiratory diseases, cancers, maternal and child health and mental health.

Health Action Zones


Health Action Zones are a new initiative to bring together NHS organisations with others outside the NHS to develop a local strategy for improving the health of local people. Ten zones went live in April 1998.

Within these zones, health authorities, NHS Trusts, GPs, nurses, health visitors, midwives, pharmacists, dentists, opticians and all others involved in delivering NHS services at a local level are working in partnership with local authorities, community groups, the voluntary sector and local businesses.

One of their aims is to find ways of breaking through current organisational barriers and to encourage co-operation across the NHS to tackle inequalities and offer better health care to local people.

Produced in Poland by British Council � 2003. The United Kingdom's international organisation for educational opportunities and cultural relations. We are registered in England as a charity.