The National Health Service

The National Health Service (NHS) provides comprehensive health care throughout the United Kingdom. The NHS provides medical care through a tripartite structure of primary care, hospitals, and community health care. The main element in primary care is the system of general practitioners (family doctors), who provide preventive and curative care and who refer patients to hospital and specialist services. All consultations with a general practitioner under the NHS are free.

The other major types of primary medical care are dentistry and pharmaceutical and opthalmic services. These are the only services of the NHS for which charges are levied, though persons under age 16, past retirement, or with low incomes are usually exempt. Everyone else must pay charges that are below the full cost of the services involved.

Under the Department of Health in England are four regional health directors who oversee area health authorities, whose major responsibility is to run the hospital service. (Overseeing the health authorities in Scotland, Wales, and Northern Ireland is the responsibility of their respective parliament or assembly.) Hospitals absorb more than two-thirds of the NHS budget. All hospital treatment under the NHS is free, including consultations with doctors, nursing, drugs, and intensive care, whatever the type of medical problem and however long the hospital stay. Hospital doctors are paid a salary rather than a fee for service but can combine salaried work for the NHS with a private practice.

The Community Health Service has three functions: to provide preventive health services; to act as a liaison with local government, especially over matters of public health; and to cooperate with local government personal social service departments to enable health and personal care to be handled together whenever possible.

Individuals can register with any NHS general practitioner in their area who is prepared to add them to his or her list of patients. Anyone who wishes to change to another doctor may do so. Except in emergencies, patients are referred to a hospital by their general practitioner, allowing patients an element of choice.

Apart from the charges mentioned above, treatment under the NHS is free to the patient. The service is almost entirely funded by government revenues, with less than 5 percent of NHS revenue coming from charges. This arrangement is unique among industrialized countries. There is no substantial reliance on private medical insurance (as, for example, in the United States).

The NHS budget, like that for any other government service, is determined by negotiations between the Treasury and the spending departments, as modified by subsequent discussion in the cabinet. The resulting figure is a budget for the NHS as a whole. The division of money throughout the United Kingdom is partly constrained by a formula designed to improve the geographic distribution of medical resources. Each regional authority divides its total funds among the area health authorities.

Alongside the NHS is a system of private medical care both for primary care and for hospital treatment. Although it grew somewhat in the 1980s and ’90s, the sector absorbs only about one-tenth of the total expenditure on doctors and hospital inpatient care. Most private care is financed by voluntary private medical insurance.

Although the NHS is a popular institution, it is not without problems: resources are scarce, many hospital buildings are old, there are waiting lists for nonurgent conditions, the distribution of health care by social class and by region is less equal than many would wish, and management needs to be improved. The advantages, however, are enormous. The NHS is very inexpensive by international standards; in the late 1990s, for example, the United Kingdom spent about half the percentage of GDP on health care as the United States. Despite such low spending, health in the United Kingdom, measured in terms of infant mortality and life expectancy, matches that in comparable countries. The variation in the quality and quantity of treatment by income level is smaller than in most other countries. The system is able to direct resources toward specific regions and specific types of care. Treatment is free, whatever the extent and duration of illness, no one is denied care because of low income, and no one fears financial ruin as a result of treatment.

Cash benefits

The current system of cash benefits, though substantially modified since its introduction in 1946, is based on the 1942 “Beveridge Report.” Every employed person pays a national insurance contribution, which since 1975 has taken the form of a percentage of earnings, although contributions are due only on amounts up to about 150 percent of nationwide average earnings. Employers collect the contribution, and there is also an employer contribution. Separate arrangements exist for the self-employed. The revenue from contributions goes into the National Insurance Fund.

Insured individuals are entitled to unemployment compensation, cash benefits during sickness or disability, and a retirement pension. There are also benefits for individuals injured in work-related accidents and for widows. Whether or not they receive an insurance benefit, all are eligible for a noncontributory benefit. Employees who lose their jobs through no fault of their own receive lump-sum redundancy, or severance, payments, whose cost is met in part by their employers and in part from a general levy on employers.

The major noncontributory benefits, paid out of general tax revenues, offer poverty relief to individuals and families whose income and savings fall below some prescribed level. The benefit of last resort is income support (formerly called the supplementary benefit); it is payable to individuals whose entitlement to insurance benefits has been exhausted or has left them with a very low income and to those who never had any entitlement to an insurance benefit. Other means-tested benefits assist low-paid working families with children and help people on low incomes with their housing costs. An important class of noncontributory benefits is not means-tested, the major example being the child benefit, a weekly tax-free payment for each child, usually payable to the mother.

The 1946 system has changed substantially over the years, with a burst of reform in the mid-1970s, including an increase in earnings-related pensions, and another in the late 1990s. In the late 1990s a working-families tax credit replaced income support for low-paid working households with children, and the government introduced a national minimum wage. The government also introduced a children’s tax credit to provide additional support to low- and middle-income families. There was a review of the benefit system in 1985 that changed the detailed workings of several benefits in 1988 but left the basic structure intact.

Primary and secondary education

Overall responsibility for education and children’s services in England rests with the Department of Education, which is accountable to Parliament. Separate departments of education are headed by ministers who answer to the assemblies in Scotland (Education and Lifelong Learning Department), Wales (Department of Education and Skills), and Northern Ireland (Department for Education). State-funded primary and secondary education are a local responsibility, generally overseen by the local authority. There is also a small private sector.

Primary education is free and compulsory from age 5 to 11. Secondary education is organized in a variety of ways for children aged 11 to 19 and is free and compulsory to age 16. In most parts of the United Kingdom, secondary schools are comprehensive; that is, they are open to pupils of all abilities. Pupils may stay on past the minimum school-leaving age of 16 to earn a certificate or take public examinations that qualify them for higher education.

The state finances primary and secondary education out of central and local tax revenues. Most expenditures take place at the local level, though about half of local revenues derive from the central government. Under the government of Prime Minister Tony Blair, a new type of school was introduced—academies, which receive their funding directly from the central government (though they are eligible for some local funding and were initially required to have private sponsors). Academies operate independently of the local authority and have greater freedom than traditional (“maintained”) state schools over their curriculum and finance, as well as teachers’ pay and conditions. Academies generally arise from underperforming schools that have been given over to a new provider, whereas free schools, another new type of institution, operate as academies do but differ from them in that they are wholly new schools. Although the Conservative–Liberal Democrat coalition government led by David Cameron pushed for a significant expansion of academies and free schools, in the early 2010s they still constituted only a small percentage of state-funded schools.

Private schools

Alongside the state sector, a small number of private schools (often called “public schools”) provide education for a small percentage of children. Their existence is controversial. It is argued that private schools divert gifted children and teachers and scarce financial resources from state schools and that they perpetuate economic and social divisions (an argument that some have extended to include academies and free schools). The counterarguments focus on their high quality, the beneficial effects of competition, and parents’ freedom of choice.