Access & Coverage as an intermediate goal in the Health Care System of the United Kingdom

Access & Coverage as an intermediate goal in the Health Care System of the United

Kingdom — A look on health coverage

Introduction

Since the Brexit referendum in June 2016, Great Britain faces great political and economic challenges of immense social importance. Banks, businesses and even EU citizens working in the UK are worried and are partially leaving the country. Leaving the European Union threatens not only overall economic performance but will have far-reaching consequences for health and the National Health Service in the UK. Healthcare financing for British citizens in the EU and vice versa is at risk, as is access to medicines, technology, blood and organs for transplantation (Fahy et al., 2017). Access to good health services is an important component in order to attain universal health coverage of the population. Ensuring that everyone has equal access to services is a top priority for the NHS, as set out in the NHS Operational Planning and Contracting Guidance (NHS, 2017a). As most health care systems, UK has a minimum package of benefits to which the persons covered are entitled.

The aim of the present paper is to outline the scope of the benefit package in the British health care system. Therefore, firstly a short input on socio-economic and epidemiologic facts of the United Kingdom will be given and after that the British health system will be introduced. Finally the conceptual dimension of the intermediate goal Access & Coverage by the World Health Organization (World Health Organization, 2007) of a health system will be described in detail in order to outline the range of services and benefits to which the british citizens are entitled and to take a look on the criteria for decision making on the health basket in Great Britain.

Background

The United Kingdom consists of four constituent countries which are England, Scotland, Wales and Nothern Ireland and is a unitary parliamentary democracy and constitutional monarchy (Oram, 2016). With 66.4 million inhabitants and a GDP of 2.9 billion US dollars in 2018, the UK is one of the largest economies in the world (International Monetary Fund, 2019). Recently, the impending withdrawal from the European Union led to some turbulence within the country. As a result of Brexit, London will not only lose the European Banking Authority (EBA), but also the European Medicines Agency (EMA), which will severely reduce London's appeal to health care companies. Moreover, it is speculated that the supply of medicines to the UK will be affected. As a precautionary measure, the government has called on pharmaceutical companies to stock up a six-week supply of medicines (BBC News, 2018).

During the 20th century, life expectancy at birth has steadily improved in the UK, leading to a larger and older population. This was attributed to a healthier lifestyle of the elderly population, such as: reduced smoking rates and improvements in the treatment of infectious diseases and diseases such as heart disease. In recent years, however, progress has slowed down and even stagnation has occurred (ONS, 2018). Thus, Life expectancy at birth in the UK did not improve between 2015 and 2017, remaining 79.2 years for males and 82.9 years for females (see Figure 1).

Mortality rates in UK have steadily declined over time, both overall and for various reasons. Advances in medicine and public health, including better sanitation and provision of care services, vaccinations, improved infrastructure and safer water, have led to changes in the causes of death from communicable diseases to non-communicable diseases (Public Health England, 2019). The resulting improvements in life expectancy reflect a shift in the main causes of illness and death. In Particular, Over the last 10 years, mortality rates have declined especially due to heart disease and strokes in both men and women (see Figure 2).

Figure 1: Life expectancy 1990-2017 Source: (Institute for Health Metrics and Evaluation, 2018)

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Figure 2: Top 10 causes of death in 2017 and percent change, 2007 -2017, all ages Source: (Institute for Health Metrics and Evaluation, 2018)

The UK Health care system

The British health system is based on the idea of the welfare state of British parliamentarian William Beveridge. Public health care for the whole population is funded by taxes, so that almost all health services are free for all UK residents (NHS, 2019).

Since its founding in 1948, the National Health Service (NHS) has been the public, state-run healthcare system. The majority of its health care workers (such as doctors, carers or technical staff) work for it, and it has more than 1.5 million employees (The Health Foundation, 2019). The NHS is a government agency under direct government responsibility. It consists of four independent organizations: NHS England, NHS Wales, NHS Scotland and Health and Social Care in Northern Ireland. As each country has different policies and priorities, there are a number of differences between these systems. Since 80% of the United Kingdom’s population lives in England, it therefore has the largest health service.

Health expenditure in the United Kingdom has increased significantly in the last 70 years, a phenomenon common across developed economies. In 2017, UK health expenditure totaled £ 197.4 billion. This corresponds to approximately £ 2,989 per person or 9.6% of GDP, compared with 9.7% in 2016. This includes both government and non-government health expenditures. Therefore, the United Kingdom is slightly below the European Union average (see Figure 3). In real terms, total health expenditure increased by 1.1% in 2017, while real health expenditure per person increased by 0.5%; These were the lowest growth rates since the series started in 2013 (ONS, 2019).

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Figure 3: Health expenditure, total (% of GDP) Source: (World Bank, 2019)

Most of the funding for the NHS comes from general taxes and a smaller part from social insurance (payroll tax). In addition, the NHS receives co-payment income, payment from individuals using NHS services as private patients, and some other minor sources. Since there is no statutory health insurance in the UK, the NHS pays for the cost of the health care system. Thus, NHS is responsible for the cost structure. Government-financed healthcare expenditure in 2017 accounted for 79% of total healthcare spending, at £155.6 billion. Out-of-pocket payments are still low and mainly concern prescription fees (mainly in England), cost of glasses and dental care, and long-term care contributions. In 2017, out-of-pocket payments totaled £31.5 billion and makes up about 15% of total health expenditure, which is the EU average (Eurostat Database, 2019a) (see Figure 4).

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Figure 4: Total current healthcare expenditure by financing scheme, UK, 2017 Source: (ONS, 2019)

NHS provides largely comprehensive care. However, there are differences in the coverage of some services. To varying degrees, decentralized administrations and local authorities are making decisions about which services to provide in the light of budgetary constraints.

The responsibilities of clinics and general practitioners are clearly defined in the UK. Outpatient care is mainly provided by general practitioners (GPs), dentists and ophthalmologists. Primary care is provided mainly through GPs, who act as gatekeepers for secondary care - most of the general practitioners work in group practices. The hospitals are responsible for inpatient and outpatient specialist care. Specialists who work in clinics are allowed to practice private practices but patients must pay for the costs themselves.

Access & Coverage in the British Health Care System – The benefit basket

According to WHO´s Framework for action Access & Coverage is one of the intermediate goals of a Health system:

“ A well-functioning health system ensures equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use. ”

WHO distinguishes three dimensions when defining the goal. First, countries seek to broaden the range of services and benefits to which their citizens are entitled. Secondly, they extend access to these health goods and services to broader populations, and ultimately to all citizens: the concept of universal access to these services. Protection against poverty and catastrophic spending is the third dimension. Countries are trying to provide citizens with social protection against the financial and social consequences of using healthcare (World Health Organization, 2007).

In literature and politics, the entitlement to universal access to a particular package of health services and social protection is referred to as universal coverage. In this context, the “coverage cube” is the most widely used framework (World Health Organization et al., 2010). (see Figure 5). It involves coverage with good health services (scope), coverage with a form of financial risk protection (depth) and - as a third feature – universality, which means that coverage should be for everyone (breadth). As it can be seen, the benefit basket is one of the three dimensions of health coverage (scope).

Figure 5: The coverage cube, 2010 Source: (World Health Organization et al., 2010)

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The terms access and coverage are also used to denote measurable targets, as well as desirable goals. For example, in epidemiological context the term coverage is used to measure the proportion of a target population that benefits from an intervention. Evans et al even distinguish between Access and Universal health coverage:

“ Universal health coverage is attained when people actually obtain the health services they need and benefit from financial risk protection. Access, on the other hand, is the opportunity or ability to do both of these things ” .

Accordingly, universal health coverage is not possible without universal access. Access has three dimensions: Financial affordability determines people’s ability to pay for services without financial hardship; Physical accessibility defines the availability of good health services; Acceptability captures people’s willingness to seek services (Evans et al., 2013).

Obviously there is no uniform definition of the terms access and coverage. These differences in usage evince the Multidisciplinarity of health systems. (World Health Organization, 2007).

In order to outline the range of services and benefits to which the british citizens are entitled and to take a look on the criteria for decision making on the health basket in Great Britain the definition of WHO’s Health report 2015 will be used as a basis. Following the definition , “ the goal of universal health coverage is that all people obtain the good-quality essential health services, including promotion, prevention, treatment, rehabilitation, and palliation, that they need without enduring financial hardship ” (WHO and World Bank, 2015). Most OECD countries already achieved universal health coverage and facing challenges to the sustainability while some countries are still in the progress of implenting (see Figure 6). In both situations, the Figure 6: Population coverage for a core set of definition and dynamic adjustment of a health services (includes public coverage and primary private health c overage) in OECD countries 2016 Source: benefit basket are key elements of health policies (oecd , 2018) within the countries.

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