JANUARY

ENGLAND
Hospitals: Publicly owned hospitals are organized either as NHS trusts (currently 98) directly accountable to the
Department of Health or as foundation trusts (currently 147) regulated by Monitor, an economic regulator of
public and private providers. Foundation trusts enjoy greater freedom from central control, have easier access
to capital funding, and are able to accumulate surpluses or run (temporary) deficits. Government wants all
hospitals (including those providing mental health and ambulance services) to become foundation trusts in the
near future.
Both trusts and foundation trust hospitals contract with local CCGs to provide services. They are reimbursed
mainly at nationally determined diagnosis-related group (DRG) rates, which include medical staff costs and
account for about 60 percent of income, with the remainder coming from activities not covered by DRGs, such
as mental health, education, and research and training funds (Department of Health, 2013c). Responsibility
for setting those rates is shared between NHS England and Monitor. In some areas, rates are not applied and
payments are made for an overall service, such as emergency care. Also at the local level, fees for “years
of care”—for example, for the total cost of the care a diabetic patient receives over 12 months—are being
developed but as yet are not in widespread use. There is no cap on hospital incomes.
An estimated 548 private hospitals and between 500 and 600 private clinics in the U.K. offer a range of services,
including treatments either unavailable in the NHS or subject to long waiting times, such as bariatric surgery
and fertility treatment, but generally do not have emergency, trauma, or intensive-care facilities (Competition
and Markets Authority, 2014). Private providers must be registered with the Care Quality Commission and with
Monitor, but their charges to private patients are not regulated and there are no public subsidies. Although the
volume of care purchased from private providers by the NHS has increased recently in areas outside of mental
health, NHS use of private hospitals remains low—3.6 percent of overall spending by commissioners on hospital
services in 2012–2013 (Nuffield Trust, 2014a).
Mental health care: Mental health care is an integral part of the NHS, which covers a full range of services.
Less serious illnesses—mild depressive and anxiety disorders, for example—are usually treated by GPs. Those
requiring more advanced treatment, including inpatient care, are treated by mental health or hospital trusts.
Some of these services are provided by community-based staff. About a quarter of NHS-funded, hospital-based
mental health services are provided by the private sector.
Over the past decade, policy has focused on increasing access to psychological therapies for mild to moderate
mental health problems, though there can still be long waiting times. Policies to improve care of more severe
conditions in the community have focused on outreach and early intervention, and there is an overarching aim
to ensure “parity of esteem” between mental health and other kinds of health services. A review conducted in
2012 suggested that mental health services have been underfunded compared with treatment of physical
illnesses (Centre for Economic Performance, 2012).
Long-term care and social supports: The NHS pays for some long-term care, such as for people with
continuing medical or skilled-nursing needs, but payments in recent years have been substantially reduced.
Most long-term care is provided by local authorities and the private sector. Local authorities are legally obliged
to assess the needs of all people who request it, but, unlike NHS services, state-funded social care is not
universal. With the exception of time-limited “reablement” services, some equipment and home modifications
(in some areas), and information services, residential and home care are needs- and means-tested. Full state
support for residential care, for example, is available only to those with less than GBP14,250 (USD20,123) in
assets who also have high levels of need, with a sliding scale applied up to GBP23,250 (USD32,832). There
is a national framework for assessing need, but local authorities are free to set eligibility thresholds for access
to funds, which has become progressively more restricted (Nuffield Trust, 2014b).
Those eligible are liable for some copayments, with some people contributing almost all of their “assessed
income,” including pensions. Beneficiaries can receive personal budgets to purchase their own care but can
also opt to have the local authority arrange it. Some additional allowances paid to users and carers are exempt
from means testing, such as “attendance allowance,” worth a maximum of GBP81.30 (USD115) a week.
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The Commonwealth Fund