NATIONAL HEALTH SERVICE

ENGLAND

A PRECIOUS JEWEL: THE ROLE OF

GENERAL PRACTICE IN ENGLISH NHS

SUBMITTED BY:
DR. S. M. NIAZ MOWLA
DR. RAUFA RAHMAN
DR. RUKSANA AMIN EVA
DR. SALAUDDIN SHOPON
IMTIAZ AHMED
FARIDA YESMIN
RAKHAL CHANDRA DEY

FARIDA YESMIN

INTRODUCTION
The National Health Service (NHS) is the publicly

funded healthcare system for England.

largest and the oldest single-payer healthcare system
in the world.
Primarily funded through the general taxation system,
the system provides healthcare to every legal resident
in the United Kingdom, with most services free at the
point of use.
Some services, such as emergency treatment and
treatment of infectious diseases are free for everyone,
including visitors.

INTRODUCTION
The NHS provides the majority of healthcare in

England, including primary care, in patient care,

long-term
healthcare,
ophthalmology,
and
dentistry.

Private health care has continued parallel to the

NHS, paid for largely by private insurance: it is

used by about 8% of the population, generally as
an add-on to NHS services.

INTRODUCTION
There is no unified British NHS; theNational

Health
Service
in
ScotlandandNorthern
Irelandwas always separate.
The NHS in England deals with over 1 million
patients every 36 hours.
It covers everything from antenatal screening and
routine screenings such as the NHS Health Check
and treatments for long-term conditions, to
transplants, emergency treatment and end-of-life
care.

INTRODUCTION
In 2014, the Commonwealth Fund declared that

in comparison with the healthcare systems of 10

other developed countries the NHS was the most
impressive overall.

Best system in terms of efficiency, effective care,

safe care, co-ordinated care, patient-centred care

and cost-related problems.

It was also ranked second for equity.

BACKGROUND
Post-war consensus
In the years immediately after the Second World

War there was a period in British politics now

known as the 'post-war consensus'. Top of the list
was post-war recovery, but another priority was
the welfare of the people, directly involving the
National Health Service (NHS).

BACKGROUND
The Beveridge Report
The Beveridge Report of 1943 set out plans for the

future of post-war Britain. When Labour came to

power in 1945, an extensive programme of welfare
measures followed -including a National Health
Service (NHS). The Minister of Health,Aneurin
Bevan, was given the task of introducing the
service.

CORE PRINCIPLES
At its launch by the then minister of health,

Aneurin Bevan, on 5 July 1948, it had at its heart

three core principles:

That it meet the needs of everyone

That it be free at the point of delivery
That it be based on clinical need, not ability to

pay

PICTORIAL PLAN OF NEW HEALTH

SERVICE 1948

STRUCTURES
The National Health Service (NHS) was planned

as a three-tier, or tripartite, structure. At the top

was the Minister of Health and below were the
three tiers designed to interact with each other to
suit the needs of the patient Hospitals
Family
doctors,
dentists,
opticians
and
pharmacists
Local authority health services

STRUCTURES

DR. RAUFA RAHMAN

HOW DOES THIS NHS SYSTEM

WORK?
If a patient become ill, he/she visits his/her GP who

diagnoses his/her illness and if necessary either gives

him/her a prescription or arranges for him/her to see
a specialist at a hospital for a better diagnosis.
He/she may then need to be treated in hospital either
as a day patient or as an inpatient.
Throughout this sequence he/she receive the medical
care which the professionals the GPs, hospital
doctors and nurses, etc. consider he/she needs.

HOW DOES THIS NHS SYSTEM

WORK?

HAS THE NHS BEEN

SUCCESSFUL?
Supply-side incentives to economise on the use of

resources arise, first, from the way remuneration is

organised. Doctors are not generally paid a fee for
service. Thus there is no financial incentive to
oversupply. A second form of constraint is the NHS
budget (a macro efficiency point), coupled with the
control by the NHS over doctors behaviour and the
traditions of the medical profession in Britain. The
overall result is that there is no financial incentive to
supply excessive medical care.

HAS THE NHS BEEN

SUCCESSFUL?

The

individual consumption decision: The

decision about treatment is generally made by
doctors. This reduces the problem of imperfect
information. In addition, the patient is more likely
to trust a doctors decision based on clinical
judgement unclouded by financial motives.

HAS THE NHS BEEN

SUCCESSFUL?
Finance for the most part is out of general

taxation, thereby avoiding problems in insurance

markets, such as high probabilities of requiring
treatment, adverse selection and moral hazard.

Treatment is mostly free at the point of use. This

encourages
early
diagnosis,
reduces
the
externality problem and also has equity
advantages.

HAS THE NHS BEEN

SUCCESSFUL?
Macro

efficiency: The NHS is cheap by

international standards. It absorbs 6% of national
income, the US figure is approximately twice as
large.

Micro efficiency: NHS is not above criticism for

the way it allocates resources to different areas of

healthcare. But it also has advantages. Because
of its unified structure and because payment is
not generally based on fee for service.

CRITICISM
The critics argue that insufficient resources

have been devoted to health care so that there

is less care than consumers would like. This is
a consequence of funding the service from
taxation - there is no mechanism whereby
consumers can signal their willingness to pay
more. According to this view the fact that the
UK spends less of its GDP on health care than
other developed countries reflects a weakness of
the NHS rather than evidence of its efficiency.

CRITICISM
This also explains why the NHS appears to be

in continual financial crisis - waiting lists,

closed wards and an inability to treat
particular patients or particular conditions all
reflect a failure to devote sufficient resources
to health care.

CRITICISM
The system is not sensitive to consumer

preferences.
Doctors
have
considerable
independence or clinical autonomy. They
make decisions about patients treatment with
little reference to either the patients or the
managerial structure of the NHS. This has
resulted in a system which is unwieldy and
difficult to control and not responsive to
consumer demand.

CRITICISM
The NHS is not as efficient as it could be. Some

hospitals need to be closed and the resources

transferred into community health care. But
opponents, including some doctors, have
successfully delayed, and in some cases
prevented such changes from occurring. They
argue that the closure of any hospital is a loss
of NHS services regardless of how the resources
made available may be used to provide other,
more valuable, kinds of health care.

REFORMING THE NHS

Since it was founded in 1948, the NHS has

been subject to numerous reforms and

reorganizations. The three most recent sets of
major reforms were those started by The then Conservative government in 1989,
In 1997 by Labour government, and
More
recently
those
started
by
the
Conservative government in 2012.

STRUCTURE OF NHS AFTER

REFORM 2011

STRUCTURE OF NHS AFTER

REFORM2013

RAKHAL CHANDRA DEY

NHS GENERAL PRACTITIONERS

Free Access versus Gatekeeping
Britains taxpayer-funded National Health Service provides all

legal residents with healthcare free at the point of service.

Under the NHS, community-based family physicians known
as general practitioners, or GPs, are responsible for primary
care.

All British citizens are required to register with a local GP

surgery, or practice, and the process of consultation,

diagnosis, and treatment begins, as a rule, with an
appointment at that surgery.

NHS GENERAL PRACTITIONERS

Promoting Doctor-Patient dialogue
The average GP appointment is 10 minutes

long, and during this time the emphasis is on

two-way communication with the patient.
This focus on dialogue is reflected in
examination rooms that resemble counseling
offices
in
their
relaxed,
comfortable
atmosphere and lack of bulky medical
equipment, such as CT scanners.

NHS GENERAL PRACTITIONERS

Promoting Doctor-Patient dialogue
By building long-term relationships

with
patients and fostering an atmosphere of
honest dialogue, GPs encourage their patients
to open up about any number of concerns
that may be affecting their quality of life or
that of their family, from a husbands fierce
temper to a childs junk-food addiction.

NHS GENERAL PRACTITIONERS

Respecting patient choice

Another important aspect of the NHS is its

policy of treating healthcare as a doctorpatient partnership, offering patients a set

of options and empowering them to make
evidence-based choices, instead of placing
all power in the hands of the doctor.

NHS GENERAL PRACTITIONERS

Incentivizing Cost-Effective Quality Care

Another important feature that expanded the

role of GPs in NHS is a capitation payment

system. Roughly 70% of the NHSs funding of
general practices is in the form of capitation
payments tied to the number of community
residents registered at each surgery. This method
guarantees a basic income for GPs and
eliminates financial incentives to over-treat and
over-test in order to recover personnel and
equipment costs.

NHS GENERAL PRACTITIONERS

Standardizing Quality of Care

The Quality and Outcome Framework (QOF)

indicators are based largely on recommendations

from NICE, an independent public agency
involved in the development of evidence-based
clinical standards. These frameworks are
contributing to the standardization of healthcare
quality throughout Britain, ensuring that people
all over the country have access to the same
high-quality care.

DR. SALAUDDIN SHOPON

GENERAL PRACTITIONERS IN
BANGLADESH
Right to healthcare was recognized as one of the

fundamental rights for every Bangladeshi citizen in

the very first constitution of the newly liberated
People's Republic of Bangladesh in 1972.

Directorate General of Health Services and later

Directorate of Family Planning was established by

the Government as independent Departments
under the Ministry of Health and Family Welfare,
to provide backbone for delivering primary health
care in Bangladesh.

GENERAL PRACTITIONERS IN
BANGLADESH
General practice is an essential part of medical care of

Bangladesh.
GPs are also the first point of contact for most patients.
The majority of the work is carried out during
consultations in the surgery and during home visits.
GPs provide a complete spectrum of care within the
local community dealing with problems that often
combine physical, psychological and social components.
They increasingly work in teams with other professions,
helping patients to take responsibility for their own
health.

GENERAL PRACTITIONERS IN
BANGLADESH
They attend patients in surgery and primary care

emergency centers if clinically necessary, visit their

homes and will be aware of and take account of
physical, psychological and social factors in looking
after their patients.
GPs call on an extensive knowledge of medical
conditions to be able to assess a problem and decide on
the appropriate course of action.
They know how and when to intervene, through
treatment, prevention and education, to promote the
health of their patients and families.

GENERAL PRACTITIONERS IN
BANGLADESH
The wide mix of general practice is one of the major

attractions. There can be huge variation in the needs of

individual patients during a single surgery. No other
specialty offers such a wide remit of treating everything
from pregnant women to babies and from mental illness
to sports medicine.
Individual doctors may develop special interests in
diverse areas.
General practice gives the opportunity to prevent
illness and not just treat it.

GENERAL PRACTITIONERS IN
BANGLADESH
There are opportunities to become involved in hospital

work, in education of those training to be general

practitionersor in local issuese.g. local medical
committees or clinical commissioning groups.

GPs can reach a relatively high income early in their

career and it is one of the specialties most suited to

part time and flexible working.

IMTIAZ AHMED

COMPARISM OF GP BETWEEN
ENGLAND AND BANGLADESH
In the England, physicians wishing to become GPs take

at least 5 years training after medical school, which is

usually an undergraduate course of five to six years
leading to the degrees of MB,ChB/BS.
In Bangladesh it is five years MBBS course followed by
a year of compulsory rotatory internship. The
internship requires the candidate to work in all
departments for a stipulated period of time, to undergo
hands-on training in treating patients. The registration
of doctors is usually managed by state medical
councils.

COMPARISM OF GP BETWEEN
ENGLAND AND BANGLADESH
In England General practice is for most people the first

and most commonly used point of access to the NHS,

whichever of these roles GPs fill, the vast majority of
GPs receive most of their income from the NHS.

In Bangladesh has no health service system like as

NHS, England for GP Practitioners. GPs have practice

individually. No contractual arrangement for GPs.

COMPARISM OF GP BETWEEN
ENGLAND AND BANGLADESH

General practice contracting and finance in England,

most GPs are independent contractors, not direct

employees of the NHS.

In Bangladesh perspective no

contracting and finance.

General practice

COMPARISM OF GP BETWEEN
ENGLAND AND BANGLADESH
In England, GPs focused on the care of chronic health

problems; the treatment of acute non-life-threatening

diseases; the early detection and referral to specialized
care of patients with serious diseases; and preventative
care including health education and immunization.

In Bangladesh a GP may be routinely involved in pre-

hospital emergency care, the delivery of babies,

community hospital care and performing lowcomplexity surgical procedures. Sometimes GPs work
in primary care centers where they play a central role.

DR. RUKSANA AMIN EVA

IMPLICATION OF NHS IN
BANGLADESH
1. Health Insurance for every citizens regardless of their
socio-economic conditions and mode of income.

Flowchart above shows the Basic Health care insurance model.

IMPLICATION OF NHS IN
BANGLADESH
2. Specialists doctors should practice only the specialty
they are trained in.
3. Separations of General Practitioners as a separate
specialty.
4. Ensure work place security for the doctors.

IMPLICATION OF NHS IN
BANGLADESH
5. Initiate Emergency Medical Services (EMS) response
team service: Call 111/999

Six points on the Star of Life

IMPLICATION OF NHS IN
BANGLADESH
6. Audit asks the question: 'Are we actually doing what
we believe is the right thing, and in the right way?'
(unlike research, which asks 'What should we be
doing?').
Audit can be used to evaluate various aspects of
patient care:
Structure of care - e.g., the availability of a clinic in a
locality.
Process of care - e.g., waiting times for an
appointment at the clinic.
The outcome of care - e.g., the number of patient
who got treatment in one year.

IMPLICATION OF NHS IN
BANGLADESH
7. Services free at the point of use like it is available
with NHS:
This means that people generally do not pay
anything for their doctor visits, nursing services,
surgical procedures or appliances, consumables
such as medications and bandages, plasters, medical
tests, and investigations, x-rays, CT or MRI scans
etc.
Hospital inpatient and outpatient services are free,
both medical and mental health services.
Funding for these services is provided through
general taxation and not a specific tax.

IMPLICATION OF NHS IN
BANGLADESH
8. Prescription charges should be structured as:

People over sixty, children under sixteen (or under

nineteen if in full-time education), patients with
certain medical conditions, and those with low
incomes, are exempt from paying.

Those who require repeated prescriptions may

purchase a single-charge pre-payment certificate
which allows unlimited prescriptions during its
period of validity.

IMPLICATION OF NHS IN
BANGLADESH
9. Health screening for over 40s:

Everyone over 40 years old should be offered health

checks for heart disease, stroke, diabetes and kidney
disease under new government plans.

DR. S. M. NIAZ MOWLA

SOME RECOMMENDATIONS TO
SECURE THE GP IN BANGLADESH
1. A national framework for primary care

2.
3.
4.
5.
6.

A new alternative contract for primary care

Regulation that supports primary care redesign
Shared electronic records
An extended primary care team
New opportunities for education and training in
primary care

ENGLAND ONLY HAD ONE

NATIONAL RELIGION: THE NHS

.CARELESS WITH THE HEART

OF THE NHS

DAVID CAMEROON

WHAT ABOUT OUR HEALTH

SERVICE?

 The development of larger-scale organisations or

networks, with new forms of service provision,

different skill-mix, and fresh professional and
leadership opportunities, promotion of health care
and planning at the national, divisional, local, and
community levels, promotion of medical services at
all levels, and effective decentralization of health
services to enhance the services of health facilitiesare very important steps to improve our healthcare
system like NHS in England.

General Practice in
Bangladesh health service
system is a precious jewel.