2022

United Kingdom
Health system summary
 AUTHORS
Michael Anderson, Emma Pitchforth, Nigel Edwards,
Hugh Alderwick, Alistair McGuire, Elias Mossialos,
Cristina Hernández-Quevedo
Anna Maresso (Series Editor)

CONTENTS
How is the health system organized?������������������������������������ 3
How much is spent on health services? ������������������������������ 4
What resources are available for the health system? ������ 8
How are health services delivered?������������������������������������ 10
What reforms are being pursued? �������������������������������������� 12
How is the health system performing?�������������������������������� 13
Summing up ���������������������������������������������������������������������������� 19

This Health System Summary is based on the United Kingdom: Health System Review (HiT) published
in 2022. Health System Summaries use a concise format to communicate central features of country
health systems and analyze available evidence on the organization, financing and delivery of health
care. They also provide insights into key reforms and the varied challenges testing the performance
of the health system.

Main source: Anderson M, Pitchforth E, Edwards N, Alderwick H, McGuire A, Mossialos E. The United Kingdom: Health system
review. Health Systems in Transition, 2022; 24(1): i–192.
Please cite this publication as: Anderson M, Pitchforth E, Edwards N, Alderwick H, McGuire A, Mossialos E, Hernández-
Quevedo C (2022), The United Kingdom: Health System Summary, 2022. WHO/European Observatory on Health Systems and
Policies, Brussels.
ISBN 9789289059282 (PDF)
 How is the health system
organized? Four separate
health care systems
across the United Kingdom
in England, Scotland, Wales
and Northern Ireland are
ORGANIZATION responsible for delivering
The United Kingdom has a national health service and Wales, and the Health health services, free at
(NHS) with access based on clinical need, and not and Social Care Board in the point of use
ability to pay. Responsibility for health care services Northern Ireland are responsible
has been devolved to Scotland, Wales and Northern for commissioning or planning
Ireland since the late 1990s. These four separate health and care services in their respective areas.
health care systems across the United Kingdom are There is a complex landscape of health care regu-
responsible for delivering health services, free at the lators across the United Kingdom, with a UK-wide
point of use. At the local level, clinical commission- remit (e.g., General Medical Council) or specific to
ing groups in England (replaced by Integrated Care individual countries (e.g., Care Quality Commission
Systems by July 2022), health boards in Scotland in England).

PLANNING
England, Scotland, Northern Ireland and Wales have mandate, supported by detailed criteria and metrics. The
their own planning mechanisms, with different roles for NHS Long Term Plan was published in 2019 and sets
their own government, and the NHS, at both national out a plan for NHS England until 2029. At the local
and local levels (Box 1). In England, operational respon- level, this Plan provides the framework from which
sibility for the NHS has sat with NHS England since Sustainability and Transformation Partnerships and
2013. The UK Government sets legally binding objec- now Integrated Care Systems develop and implement
tives and budgets for NHS England through an annual 5-year plans locally.

BOX 1 | DISTRIBUTION OF HEALTH SYSTEM RESPONSIBILITIES

Since devolution in the late 1990s, the respective governments in England, Scotland, Wales, and Northern
Ireland have been responsible for organising and delivering healthcare services. The UK Government
allocates a set budget for healthcare in England, whereas Scotland, Wales, and Northern Ireland receive
a general block grant for public spending which is distributed according to funding priorities decided by
each devolved government. At the local level, clinical commissioning groups (CCGs) in England (replaced
by Integrated Care Systems by July 2022), health boards in Scotland and Wales, and the health and social
care board in Northern Ireland are responsible for commissioning or planning health and care services in
their respective areas. These local organisations are expected to implement priorities outlined with national
plans or strategies, such as the NHS Long Term Plan in England; the National Performance Framework in
Scotland; A Healthier Wales: long term plan for health and social care in Wales; and Commissioning Plan
Directions in Northern Ireland.

HEALTH SYSTEM SUMMARY: 2022 3

 PROVIDERS
General Practitioners (GPs) work under the General the United Kingdom by NHS or independent sector
Medical Services Contract negotiated between the hospitals. In England and Northern Ireland, NHS-owned
British Medical Association and NHS Employers, first hospitals are called trusts. Many NHS hospitals have
introduced in 2004. The contract is held with practices, satellite clinics to provide these services closer to patients,
not individual GPs. Specialized care is provided across particularly in large rural areas such as in Scotland.

How much is spent on health services?

FUNDING MECHANISMS Health
spending has gone
Public financing, collected through general taxation, is to the Barnett formula. According through cycles of
the primary source of funding for health in the United to this, the Treasury determines sustained growth and
Kingdom. The three largest taxes, which account for what changes in spending will austerity over the
approximately two thirds of revenue, are income tax, be made in England, and then last decade
national insurance contributions and value-added taxes. distributes funds according to a
Once revenue is collected by His Majesty’s Revenues and comparability percentage, which takes
Customs (HMRC), it is distributed by HM Treasury account of which powers are devolved and population
to the Department of Health and Social Care (DHSC) proportions. The DHSC then allocates funding to NHS
in England and the devolved administrations according England and arm’s length health agencies.

HEALTH EXPENDITURE
Health care expenditure accounted for 10.2% of including Sweden, Norway and Denmark (79.5% of
GDP in 2019 (Fig. 1), the eighth highest in the current health expenditure). Out-of-pocket payments
WHO European Region. The country’s per capita as a percentage of total expenditure on health have
health expenditure is over US$ 5087 PPP, remain- increased since 2005, reaching 17% in 2019 (Fig. 3),
ing below Germany and France, but above the EU/ while private insurance has decreased since 2000,
EAA average (Fig. 2). The percentage of total health reaching 2.8% of total expenditure on health. Private
expenditure in the United Kingdom coming from medical insurance is usually used to finance a few
public funds is above the EU/EEA average, similar select services not offered by the NHS or to access
to Germany but below most Scandinavian nations NHS-covered services more quickly.

OUT-OF-POCKET PAYMENTS
NHS care is mostly free at the point of access, but Direct payments can include private treatment, social
in some cases, patients do have to make co-pay- care, general ophthalmic services and over-the-counter
ments (for goods and services covered by the NHS medicines. However, some populations (e.g., individ-
but requiring cost sharing) and direct payments (for uals under 16 or over 60 years old, and those on low
services not covered by the NHS or for private treat- income), have recourse to reimbursement or exemption
ment). Co-payments can apply to dental care and, in for some co-payments, although this varies across the
England, outpatient medicine prescription charges. United Kingdom.

4 UNITED KINGDOM
FIG. 1 TRENDS IN 6 000 12

HEALTH EXPENDITURE, 5 000 10

2000–2019
4 000 8

Note:

US $ PPP

% GDP
3 000 6
PPP = purchasing power parity
Source: WHO Global 2 000 4
Expenditure Database, 2022.
1 000 2

0 0
2000 2005 2010 2015 2016 2017 2018 2019

Current health expenditure per capita Current health expenditure as % of GDP

Switzerland
FIG. 2 CURRENT Norway
Luxembourg
HEALTH EXPENDITURE Germany
Netherlands
(US$ PPP) PER Sweden
Austria
CAPITA IN WHO Denmark
Ireland
Belgium
EUROPEAN REGION Iceland
France
COUNTRIES, 2019 United Kingdom
Finland
EU/EEA/UK average
Malta
Italy
Notes: CHE, current Spain
health expenditure; PPP, Slovenia
Portugal
purchasing power parity. Czech Republic
Cyprus
Source: WHO Global Lithuania
Estonia
Expenditure Database, 2022. Greece
Slovak Republic
Poland
Croatia
Hungary
Latvia
Romania
Bulgaria

San Marino
Andorra
Israel
WHO Euro average
Monaco
Montenegro
Russian Federation
Serbia
Armenia
Bosnia and Herzegovina
The Republic of North Macedonia
Belarus
Turkey
Turkmenistan
Georgia
Ukraine
Republic of Moldova
Kazakhstan
Albania
Azerbaijan
Uzbekistan
Kyrgyzstan
Tajikistan

0 2 000 4 000 6 000 8 000 10 000

CHE in US$ PPP per capita

HEALTH SYSTEM SUMMARY: 2022 5

 FIG. 3 COMPOSITION OF OUT-OF-POCKET PAYMENTS, 2018

Public/compulsory VHI 5% OOP distribution

health insurance
Inpatient 1.6%
83%

OOP 12%
Outpatient care 12%

Medical goods 48.8%

Long-term care 36%

Preventative 1.6%

Note: OOP: out-of-pocket.

Source: OECD Statistics (data for 2020).

COVERAGE
All individuals, irrespective of their nationality or immi- NHS services (including maternity care services). The
gration status, are eligible to access primary, emer- NHS does not have an explicit list of benefits; instead,
gency and compulsory psychiatric care, free of charge. legislation outlines broad categories of health care ser-
Coverage for secondary care services, however, is only vices to be provide in the NHS. Major exclusions in
available for those who are ordinarily resident, i.e., any England include prescription charges, dental care and
person normally residing in the UK, resulting in undoc- optometry, but as already mentioned, exemptions exist
umented migrants being left without access to many (see also Box 2).

BOX 2 | WHAT ARE THE KEY GAPS IN COVERAGE?

The existence of an NHS across the United Kingdom whereby services are generally accessed free at the
point of delivery, irrespective of ability to pay, largely protects people from the risk of financial hardship
resulting from medical expenses. The United Kingdom reports some of the lowest rates of catastrophic
health spending in the world. These crucial benefits are generally enjoyed across the United Kingdom, but
exceptions provide stark reminders of the potential for adverse consequences.
The major gaps in coverage in the United Kingdom health and care system relate to social care, prescrip-
tion charges for medicines (in England), dental care and ophthalmic services. Despite targeted exemptions,
there is evidence of substantial difference in access to dental services by socioeconomic groups. For social
care, public funding is restricted (to a lesser extent in Scotland) so the potential for significant financial
costs being borne by individuals is substantial. The Dilnot Commission on social care in England found that
one in 10 older people could face catastrophic care costs of £100 000 in their lifetime. Nevertheless, access
to social care is means tested, and only those with assets lower than a certain threshold are eligible to
access publicly funded social care services. To mitigate against the risk of catastrophic costs for social
care, in late 2021, the United Kingdom Government announced that it would introduce a cap on the maximum
amount that individuals would have to pay for social care services in England over their lifetime, initially set
at £86 000 (€101 824). In 2021, both the Welsh and the Scottish Government launched consultations on the
prospect of developing a National Care Service, free at the point of use for all citizens.

6 UNITED KINGDOM
PAYING PROVIDERS
Primary care doctors are paid predominantly through activity-based payments for units of care delivered are
risk-adjusted capitation, with some fee-for service activ- used, based upon tariffs set out within the Payment by
ities such as vaccination. There is a decreasing use of Results program (in England) for both inpatient and
pay-for-performance as part of the Quality Outcomes outpatient care. Dentists working for the NHS receive
Framework, but an increasing trend for GPs to work activity-based payments, while pharmacists receive a
as salaried doctors. Hospital consultants (specialists) combination of retained profits (difference between what
are salaried doctors with top-up payments to incentiv- they pay for drugs and the amount the Department of
ize performance, known as clinical excellence awards Health and Social Care reimburses them), fixed budgets,
in England, distinction awards in Scotland and com- fee-for-service, pay-for-performance, and payments for
mitment awards in Wales. In hospital acute care, over-the-counter medications (Fig. 4).

FIG. 4 | PROVIDER PAYMENT MECHANISMS IN THE UNITED KINGDOM

Hospital
Acute
GPs Specialists Outpatient Dentists Pharmacies
Hospitals
services

Risk-adjusted Salaried Activity based Salaried Activity based A combination

capitation, doctors payments for doctors payments of retained
with some with top-up units of care with top-up (NHS staff); profits, fixed
fee-for- payments to delivered. payments to Fee-for- budgets, fee-
service incentivise incentivise service for-service,
activities. performance. performance. (private pay-for-
Decreasing providers). performance,
use of pay-for- and payments
performance. for over-
the-counter
medications.

HEALTH SYSTEM SUMMARY: 2022 7

 The health and
What resources are care systems have
a long history of reliance
available for the health on foreign staff; however,

system?
Brexit has already impacted
the ability to recruit health
and care staff from the
EU

HEALTH PROFESSIONALS
The number of doctors (2.95 per 1000 inhabitants; the country, it will take several years for the additional
2019 data) and nurses (7.78 per 1000; 2018 data) in training places to impact the GP workforce.
the United Kingdom is still lower than many other The United Kingdom has lower levels of nurses
high-income countries (Figures 5a & 5b). Despite an per 1000 population than most other high-income
ongoing policy agenda to shift care from hospital closer countries, and this trend has continued over the last
to home within the community, most of this increase decade. These reductions in nursing numbers are more
in physician numbers has been concentrated in hospital acute among different types of registered nurses. The
consultants. This is a trend seen in all United Kingdom impact of Brexit on the United Kingdom health and
constituent countries, which all continue to experience care workforce is yet to be fully realized, but the United
challenges in improving recruitment and retention of Kingdom has already seen a considerable drop in the
the GP workforce. While there have been ongoing number of EU-trained nurses registering to work in
attempts to increasing training numbers for GPs across the country.

FIG 5A NUMBER OF
5
PRACTICING PHYSICIANS United States
France
FOR 1000 POPULATION 4 United Kingdom
Italy
IN THE UNITED
Physicians per 1 000

3 Germany
KINGDOM AND Canada

2
COMPARATOR
COUNTRIES, 2002–2019 1

Source: OECD Health Statistics, 2021. 0

2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019

FIG 5B NUMBER OF
PRACTISING NURSES 14
United States
FOR 1000 POPULATION IN 13
France
12
THE UNITED KINGDOM 11
United Kingdom
Italy
AND COMPARATOR
Nurses per 1 000

10 Germany
9 Canada
COUNTRIES, 2000–2019
8
7
Source: OECD Health Statistics, 2021.
6
5
4
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019

8 UNITED KINGDOM
HEALTH INFRASTRUCTURE
The overall number of hospital beds in the United According to the latest available data, the United
Kingdom is lower than most other high-income coun- Kingdom has fewer CT scanners and MRI units per
tries, and has decreased between 2000 and 2018, from capita than most other OECD countries (Fig. 7). As
4.1 to 2.5 beds per 1000 people (Figure 6). This trend is the United Kingdom continues to have poorer cancer
seen in most high-income countries, and in part, reflects survival than most other high-income countries in part
trends such as an increasing use of day surgery, reduced due to delayed diagnosis, there is a growing need to
length of stay and a shift to provide care closer to home review diagnostic capacity. This will be challenging as
in the community. Numbers of hospital beds do also a significant proportion of diagnostic capacity in the
vary across the United Kingdom, with England having United Kingdom, particularly for MRI scanners, is
lower numbers of hospitals beds per 1000 people than supplied through private providers, rather than within
in Scotland, Wales and Northern Ireland. NHS hospitals.

FIG. 6 TOTAL HOSPITAL 15

United States
BEDS PER 1000 12
France
United Kingdom
POPULATION IN THE Japan
Total beds per 1 000

9 Italy
UNITED KINGDOM AND Germany
SELECTED COUNTRIES, 6
Canada

2000–2019
3

0
Source: OECD Health Statistics, 2021.
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
MAGNETIC RESONANCE IMAGING (MRI) AND COMPUTED TOMOGRAPHY (CT)
FIG. 7
SCANNERS

MRI scanners CT scanners

per million per million
population population

United Kingdom 7.2 9.4

Note: Data for United
2.9 (Mexico) 6.1 (Colombia)
Range among Kingdom is from 2014.
to to
OECD countries Source: OECD Health
40.3 (USA) 60.7 (Australia)
Statistics, 2021.

HEALTH SYSTEM SUMMARY: 2022 9

 DISTRIBUTION OF HEALTH RESOURCES
Across the United Kingdom, England has 2.3 hospital and strategic vision to support hospital building pro-
beds per 1000 people compared with 3.8 per 1000 in grammes in Northern Ireland between 2017 and 2020, a
Scotland, 3.4 per 1000 in Wales and 3.1 per 1000 in period of 3 years when Northern Ireland was without a
Northern Ireland. It is difficult to explain these varia- government (Griffin, 2019). In England, the government
tions; however, it is likely that a combination of polit- has committed to a hospital building programme over
ical, historical, managerial and financial factors has the next decade, which aims to build 40 new hospitals
contributed. There is a higher level of public spending by 2030.
per capita in Northern Ireland, Scotland and Wales, As with capital, there are lower numbers of nurses per
than in England. However, even with the highest level 1000 population in England, compared with Scotland,
of funding per capita, Northern Ireland still has a lower Wales and Northern Ireland. For doctors, England has
number of hospital beds than in Scotland and Wales. lower numbers compared with Scotland and Northern
There have also been limited opportunities for leadership Ireland, but similar numbers to Wales.

The last two

decades have seen
a trend towards greater

How are health services independent sector provision of

publicly-funded elective care in
delivered? England as the government has
sought to promote competition
between healthcare
providers
PRIMARY AND AMBULATORY CARE
The United Kingdom enjoys a high-quality primary care increasingly means not only a GP but a whole
care service that provides continuous and compre- team of doctors, nurses, midwives, health visitors and
hensive care, while acting as a first point of contact other health care professionals such as dentists, phar-
to access other health care services (Box 3). Primary macists and optometrists in a community setting.

BOX 3 | WHAT ARE THE KEY STRENGTHS AND WEAKNESSES OF PRIMARY CARE?

An international comparison conducted in 2013 indicated that the United Kingdom had a strong
primary care system, with the United Kingdom scoring highly on all indicators of primary care qual-
ity, except for continuity of care in which the United Kingdom was scored as moderate. No more
recent studies exist, and while the United Kingdom primary care system may have been weakened
since due to significant workforce pressures, it still performs well on many other aspects of primary
care quality indicators, including relatively low rates of avoidable hospital admissions for congestive
heart failure, hypertension and diabetes-related complications. These priorities have been promoted
through the Quality and Outcomes Framework, which incentivises regular health checks and medi-
cation reviews for patients with several chronic diseases. GPs are also trained so they are equipped
with the generalist skills required for the changing health needs of the population that are becoming
increasingly complex and experiencing higher levels of multi-morbidity. However, there are some
important weaknesses to the primary care system. Although the gatekeeping mechanism provided by
GPs may improve health system efficiency, it has been cited as a factor contributing to the delayed
diagnosis and poor cancer survival reported by the UK. Moreover, significant workforce pressures
and geographical variation in density of GPs have resulted in significant inequities in access to GPs
across the country.

10 UNITED KINGDOM
There is also an increasing use of the voluntary sector planning, on-going care for patients with chronic
in some situations, such as those involving mental conditions, antenatal care, preventive services, health
health or long-term conditions. Primary care nurses promotion, outpatient pharmaceutical prescriptions,
include both practice and district nurses; practice nurses sickness certification and referrals for more spe-
work in GP practices, whereas district nurses work for cialized care. Increasingly, GPs are now seeking
community health service providers to deliver care in to adapt the provision of GP services towards a
patients’ homes. hybrid model involving a combination of face-
GP surgeries provide a range of services, including to-face and remote consultations that best meet
routine diagnostic services, minor surgery, family patients’ needs.

HOSPITAL CARE
Secondary inpatient care is accessed on either an emer- hospitals. In Wales, especially, patients use hospitals
gency or an elective basis. Independent sector hospitals across the border in England if they are actually closer
are typically not equipped to manage emergency care, than the nearest one in Wales. Various efforts are under-
and if patients experience postoperative complications way to strengthen the delivery of integrated care services
following surgery, they are typically transferred to NHS (Box 4).

BOX 4 | ARE EFFORTS TO IMPROVE INTEGRATION OF CARE WORKING?

In an effort to provide more integrated social and health care, especially for older and disabled people,
the Better Care Fund was announced in 2013. As of 2020/2021, the fund consists of £6.7 billion, collected
from CCGs in England (replaced by Integrated Care Systems by July 2022) and local authorities. CCGs
and local authorities are expected to agree a combined spending plan, which focuses on integrating
care and avoiding hospital admissions by supporting people at home. Subsequent evaluations have
concluded that while the fund has not achieved the expected reductions in emergency admissions to
hospital or delayed transfers of care, the fund has encouraged integration of health and social care at
the local level.
Principal health reforms in each of the UK constituent countries are focusing on facilitating cross-sectoral
partnerships and promoting integration of services in a manner that improves the health and well-being
of local populations, moving away from competition. These include the establishment of integrated care
systems in England, integrated joint boards in Scotland, regional partnership boards in Wales and integrated
partnership boards in Northern Ireland. Policies are also being developed.

PHARMACEUTICAL CARE
Patients are not charged for pharmaceuticals used in years of age, those with low incomes, during pregnancy,
inpatient care. Patients in England are however charged and for chronic diseases such as diabetes or epilepsy, so
for prescriptions in the community at a fixed flat rate that about 90% of all prescriptions are distributed free
of £9.15 (€10.80) per item as of 2020/2021. Patients of charge. Prescription charges were abolished in Wales
can also pay for a yearly subscription service capped at in 2007, in Scotland in 2011 and in Northern Ireland
£105.90 (€125) per year. Exemptions cover a broad range in 2010.
of people, including individuals under 16 and over 60

HEALTH SYSTEM SUMMARY: 2022 11

 LONG-TERM CARE
Long-term care in the United Kingdom is a blend to older people; people with physical disabilities,
of health and social care, provided in a combination frailty, and sensory impairment; people with learning
of residential/institutional care and care provided in disabilities; people with mental health problems;
the community within people’s homes. The NHS people who misuse substances and to other vulnerable
funds long-term care for patients with complex health people. Residential or nursing care is provided in
needs, through schemes such as NHS Continuing homes specifically for that purpose, provided by a
Health care in England, and Hospital-Based Complex range of for-profit and not-for-profit independent
Clinical Care in Scotland. Long-term care is provided providers.

DENTAL CARE
Publicly financed dental services in the United Kingdom services; and also in schools to screen children for
consist of a three-part system: general dental services in problems. Charges exist to access dental care in all
the community; secondary and tertiary dental services United Kingdom constituent countries. For individ-
in acute hospitals for difficult problems; and com- uals who access dental services privately, they pay for
munity dental services in clinics and nursing homes, private dental care through private insurance plans or
provided for those who cannot use general dental directly out-of-pocket.

Principal health
What reforms are being reforms in each country

pursued?
are focused on promoting
integration of care and
facilitating cross-sectoral
partnerships that improve the
Health policy has been devolved in the United 1 to 3 million people. In health and wellbeing of
Kingdom since the late 1990s, with governments Scotland, legislation over the local populations
in England, Scotland, Wales and Northern Ireland last decades has focused on cre-
taking different approaches to health care reform. ating bodies, known as Integrated
A list of major policy reforms is contained in Box Joint Boards, to facilitate joint work for health and
5. Health policy diverged in the 2000s, as reforms social care between the NHS and local authorities, and
in England emphasized choice and competition as responsibilities for managing joint budgets for local
the route to improve quality of care, while govern- populations. In Wales, the 2014 Social Services and
ments in Scotland and Wales dismantled the internal Wellbeing (Wales) Act established regional partnerships
market and promoted cooperation. There has been boards with responsibility for planning and develop-
some policy convergence in recent years, as reforms ing local services to improve health and wellbeing in
in all countries encouraged collaboration between their area. In Northern Ireland, there is currently a
local agencies and integration of health and social consultation on the development of a new planning
care services. model to strengthen the delivery of integrated health-
More recently, in England, the NHS is undergoing a care services centred around the creation of five Area
structural reorganisation, with Clinical Commissioning Integrated Partnership Boards, that will be responsible
Groups being replaced from July 2022 with Integrated for improving health and wellbeing of local popu-
Care Systems, which will be responsible for delivering lations, with progress monitored against agreed key
health and social care services to local populations of performance indicators at the national level.

12 UNITED KINGDOM
 BOX 5 | KEY HEALTH SYSTEM REFORMS OVER THE LAST 10 YEARS

YEAR POLICY REFORM

ENGLAND
2012 Health and Social Care Act
2014 Care Act
2014 NHS Five Year Forward View
2019 NHS Long Term Plan
2021 Health and Care Bill (Pending)
SCOTLAND
2004 NHS Reform Act
2010 The Healthcare Quality Strategy for NHS Scotland
2014 Public Bodies (Joint Working) (Scotland) Act
2016 National Clinical Strategy for Scotland
2018 Public Health Priorities for Scotland
2020 Establishment of Public Health Scotland
2022–26 Establishment of National Care Service (Pending)
WALES
2014 Social Services and Wellbeing (Wales) Act
2015 Well-being of Future Generations (Wales) Act
2018 A Healthier Wales: our Plan for Health and Social Care
2023 Establishment of National Care Service (Pending)
NORTHERN IRELAND
2016 Health and Wellbeing 2026: Delivering Together
2021 Health and Social Care Bill (Pending)

Significant
investment is
required to rectify the

How is the health system United Kingdom’s relative poor

performance in terms of health

performing? outcomes, address growing

backlogs for elective care, and
develop more sustainable
and resilient healthcare
systems
HEALTH SYSTEM PERFORMANCE MONITORING AND
INFORMATION SYSTEMS
There is often a lack of transparency and accountability Providers of healthcare in all UK constituent
in national and local-level decision making in the United countries are required to collect data on activity,
Kingdom, exacerbated by limited public involvement. workforce and performance indicators to feedback to
Despite efforts for broader public involvement in NHS their respective health care information organizations,
accountability such as the publication of performance NHS Digital in England, Public Health Scotland in
measures, and initiatives to promote patient choice in Scotland (formerly undertaken by the Information
England, these have not translated into public involve- Services Division), Digital Health and Care Wales in
ment in policymaking. Wales, and the Information and Analysis Directorate

HEALTH SYSTEM SUMMARY: 2022 13

 within the Department of Health in Northern Ireland. of remote consultations to minimize transmission
Positively, the development of health information of infection, efforts to develop mobile applications
technology has accelerated in each United Kingdom to monitor the spread of disease, and the develop-
constituent country during the COVID-19 pandemic ment of shielded patients lists to issue guidance to
through, for example, the rapid increase in availability vulnerable patients.

ACCESSIBILITY AND FINANCIAL PROTECTION

Despite universal access to primary, emergency and medical expenses, with the United Kingdom reporting
compulsory psychiatric care, established residency some of the lowest rates of out-of-pocket expenditure
status determines NHS coverage for secondary care and catastrophic health spending in Europe, as well
services. This means that undocumented migrants are as internationally (Cooke O’Dowd, Kumpunen and
left without access to many NHS services, including Holder, 2018).
maternity care services among particularly vulnerable Nevertheless, the United Kingdom also reports one
pregnant women. The NHS provides care across the of the highest levels of unmet need for a medical exam-
United Kingdom, covering the spectrum from preven- ination due to cost, waiting times or travel distances, at
tion, treatment, rehabilitation to palliation. Services are 4.5% in 2019. This differs between high- and low-in-
generally free at the point of delivery and are provided come households, with 3.3% of high-income households
irrespective of ability to pay. This coverage protects reporting unmet need compared to 4.9% of low-income
people from the risk of financial hardship resulting from households (Figure 8).

Estonia
FIG. 8 UNMET NEEDS FOR A Greece

MEDICAL EXAMINATION (DUE TO Romania

Finland
COST, WAITING TIME OR TRAVEL United Kingdom

DISTANCE), BY INCOME QUINTILE, Latvia

Poland
EU/EEA COUNTRIES, 2019 Iceland
Slovenia
Slovak Republic
Source: Eurostat database, 2021.
EU-28
Ireland
Belgium
Denmark
Italy
Portugal
Bulgaria
Croatia
Lithuania
Sweden
France
Cyprus
Hungary
Norway
Switzerland
Czech Republic
Germany
Richest quintile
Austria
Poorest quintile
Spain
Total
Luxembourg
Netherlands
Malta

0 5 10 15 20

% of population
14 UNITED KINGDOM
HEALTH CARE QUALITY
Despite the many challenges facing the health system, The United Kingdom does, however, report relatively
public satisfaction with the NHS remains relatively high avoidable hospital admission rates for respiratory
high (Box 6). There is consensus that UK citizens have diseases including asthma and chronic obstructive pul-
access to a high-quality and well-developed primary care monary disease. Suggested factors driving these trends
system, evidenced by relatively low rates of avoidable include lack of availability of pulmonary rehabilitation,
hospital admissions for congestive heart failure, hyper- poor adherence to inhaler therapy and delayed referral
tension and diabetes-related complications (Figure 9). to specialist services.

BOX 6 | WHAT DO PATIENTS THINK OF THE CARE THEY RECEIVE?

While public confidence in the NHS is still high in comparison to health systems in other countries, several
headlines in recent years have reported drops in confidence, particularly with general practice (63% satis-
faction in 2018, the lowest since 1983, although this recovered to 68% in 2019), inpatient (64% satisfaction
in 2019) and emergency services (54% satisfaction in 2019). Overall satisfaction with the NHS was 60% in
2019, with patients citing the quality of care received, accessing care free at the point of use and a good
range of services, as key reasons for high satisfaction. The main reasons people gave for being dissatisfied
with the NHS were staff shortages, waiting times for GP and hospital appointments, and the perception that
the government does not spend enough money on the NHS. Surveys also indicate that 90% of the public
support the founding principles of the NHS and that two thirds (66%) were willing to pay more of their own
taxes to support the NHS. In contrast, satisfaction with social care services is markedly lower than with
the NHS, with only 29% satisfaction in 2019.

AVOIDABLE HOSPITAL ADMISSION RATES FOR ASTHMA, CHRONIC OBSTRUCTIVE

FIG. 9
PULMONARY DISEASE, CONGESTIVE HEART FAILURE, HYPERTENSION AND DIABETES-RELATED
COMPLICATIONS, 2017

400
United States
350 France
United Kingdom
Admission rates per 100 000

300
Japan
250 Italy
Germany
200
Canada
150

100

50

0
Asthma COPD CHF Hypertension Diabetes

Source: OECD Health Statistics, 2021.

HEALTH SYSTEM SUMMARY: 2022 15

 For hospital care, the United Kingdom reports particularly Mortality rates are also poor for hospital admission
poor performance in terms of mortality following hospital associated with acute myocardial infarction when com-
admission associated with ischaemic and haemorrhagic pared to other high-income countries, and only lower
stroke when compared to other high-income countries. than those reported in Japan and Germany (Figure 10).

IN-HOSPITAL MORTALITY RATES (DEATHS WITHIN 30 DAYS OF ADMISSION) FOR

FIG. 10
ADMISSIONS FOLLOWING ACUTE MYOCARDIAL INFARCTION AND STROKE, 2017

30
United States
France
25
United Kingdom
Admission rates per 100 000

20 Japan
Italy
15 Germany
Canada
10

0
AMI Haemorrhagic stroke Ischaemic stroke

Source: OECD Health Statistics, 2021.

HEALTH SYSTEM OUTCOMES

Increases in life expectancy have stalled in the United life expectancy are similar across UK constituent coun-
Kingdom, and now the health of the population is tries, although there remain significant differences in
lagging behind that of many other comparable high-in- life expectancy between each UK constituent country,
come countries (McKee et al., 2021). These trends in with life expectancy consistently reported as higher in

BOX 7 | ARE PUBLIC HEALTH INTERVENTIONS MAKING A DIFFERENCE?

The United Kingdom and its devolved administrations have introduced several national policies that have
demonstrated benefit in terms of improving population health or impacting health behaviour change. A smok-
ing ban in public places was introduced in July 2007 (March 2006 in Scotland), and subsequent analyses have
demonstrated this had a positive effect of declining smoking rates and improving cardiovascular health. In
2018, the UK Government introduced a tax on manufacturers of soft drinks related to sugar content, which
1 year after implementation, resulted in a 10% reduction in sugar content in soft drinks, without impacting
sales. Scotland introduced minimum unit pricing for alcohol purchases in 2018, and Wales followed suit in
2020, with subsequent analysis demonstrating an 8% reduction in alcohol sales in both of these countries.
There is also evidence from the United Kingdom that several specific public health programmes or
interventions are either cost-saving or cost-effective, for example, pre-conception care, case management
programmes and chronic disease management programmes. However, the degree to which these inter-
ventions can be implemented is dependent upon funding, and while the economic case for investment in
prevention is strong, too often policymakers ignore this evidence and have prioritised funding for treatment
over prevention.

16 UNITED KINGDOM
England than in the other three nations, with Scotland comparable high-income countries such as France and
lagging far behind. Germany. The United Kingdom performs better in
When focusing on international comparisons, the relation to preventable mortality (i.e., mortality that
United Kingdom reports an age-standardised amenable could have been avoided through effective public health
mortality rate (i.e., mortality that should not occur if and primary prevention interventions) reporting an
people have access to timely and effective health care) age-standardised mortality rate of 47.3 per 100 000 in
of 84.4 per 100 000 in 2016, that is above many other 2016, France and Germany (Figure 11; see also Box 7).

FIG. 11AMENABLE Amenable mortality Preventable mortality

AND PREVENTABLE
0 50 100 150 200 250 300 350 400 0 50 100 150 200

Romania Hungary
MORTALITY IN UNITED Bulgaria Romania
KINGDOM AND OTHER Latvia Croatia

EEA COUNTRIES, 2000 Lithuania Poland

AND 2017 Hungary Slovakia

Slovakia Bulgaria
Source: WHO Mortality Database.
Estonia Lithuania
Amenable causes as per list
by Nolte & Mckee, 2004. Croatia Latvia

Poland Slovenia

Czech Republic Czech Republic

EU-28 Estonia

Greece EU-28

United Kingdom Greece

Portugal Denmark

Germany Belgium

Ireland Luxembourg

Malta Germany

Finland France

Slovenia Austria

Denmark United Kingdom

Austria Netherlands

Belgium Spain

Cyprus Finland

Italy Portugal

Sweden Ireland

Netherlands Italy

Spain Norway

Luxembourg Switzerland

Norway Iceland

France Malta

Iceland Cyprus

Switzerland Sweden

2000 2017 or latestt

HEALTH SYSTEM SUMMARY: 2022 17

 HEALTH SYSTEM EFFICIENCY
The Commonwealth Fund has consistently named the Kingdom has the lowest per capita health expenditure,
United Kingdom as the most efficient health system except for Italy, and the highest amenable mortality per
among 11 high-income countries because of factors such 100 000 population, except for the United States.
as relatively low expenditure levels per capita as a propor- Regarding technical efficiency, the United Kingdom
tion of GDP and low administrative costs resulting from compares favourably to other countries. For example, in
a single payer system based on general taxation. However, 2018, the United Kingdom had an average length of stay
the latest report from the Commonwealth Fund does for inpatient care of 6.8 days, below the OECD average of
also acknowledge the UK’s poor performance in terms of 8.1 days. The United Kingdom also performs a relatively
health outcomes, with the United Kingdom performing high proportion of surgical procedures such as cataract
second from worst on the composite indicator of healthy surgeries, at 97.8%, and tonsillectomies, at 62.2%, in 2019,
lives, due to relatively high rates of amenable mortal- as day cases rather than inpatient procedures, compared
ity, comparatively high infant mortality rates and low to OECD averages of 37.8% and 76.6%, respectively.
healthy life expectancy at age 60 years, despite ranking Historically, the United Kingdom is known as a country
as the most technically efficient. with one of the highest rates of generic prescribing in the
These findings are reflected in Fig. 12, which shows world, at 85% as a share of volume in 2017, compared to
that when compared to other G7 countries, the United the OECD average of 52% (see also Box 8).

FIG. 12 AMENABLE MORTALITY PER 100 000 POPULATION VERSUS HEALTH EXPENDITURE PER
CAPITA, 2017

250

200
Amenable mortality per 100 000

150

100 United Kingdom Canada

United States
Germany

50 Italy
France

0
0 2 000 4 000 6 000 8 000 10 000 12 000

Health expenditure PPP$ per capita

Source: WHO Global Expenditure Database, 2022; WHO Mortality Database.

18 UNITED KINGDOM
 BOX 8 | IS THERE WASTE IN PHARMACEUTICAL SPENDING?

The United Kingdom has relatively low levels of pharmaceutical spending per capita when compared to
other high-income countries. For novel pharmaceuticals, the United Kingdom has developed a robust and
transparent system of Health Technology Assessments, that, coupled with frequent confidential price dis-
counts negotiated as part of patient access schemes, has achieved dual benefits of facilitating access to
patients and limiting the potential budget impact of introducing novel and expensive pharmaceuticals. For
established pharmaceuticals, the United Kingdom is a relatively high prescriber of generic medicines when
compared to other high-income countries, accounting for 85.3% of all prescriptions in terms of volume in
2017, compared to 30.2% in France, and 29.2% in Germany.
Medical professionals are trained to prescribe exclusively using generic names, and for the rare cir-
cumstances in which a prescriber may use brand names, community or hospital pharmacists will typically
substitute for generic alternatives. The National Institute for Health and Care Excellence (NICE) also produces
widely utilized clinical guidance that explicitly considers the cost-effectiveness of alternative medications,
to encourage evidence-based practice. Other efforts include an initiative by NHS England called “items
which should not be routinely prescribed in primary care”, that have worked with local commissioners and
GP practices to reduce prescribing of medicines of low clinical effectiveness or where more cost-effective
alternatives exist.

Summing up
The COVID-19
Established in 1948, the NHS led glob- pandemic has facilitate meaningful integration between
ally in terms of universal health cover- emphasised some of health care services, such as unlinked
age. The underlying principles, that the the enduring strengths and health information technology systems,
NHS should be funded predominantly weaknesses of the NHS and duplication of governance arrangements
through progressive general taxation, the healthcare systems and a lack of strategic planning. Northern
that care be comprehensive, and access across the United Ireland is the only United Kingdom con-
be based on clinical need and not on ability Kingdom stituent country where the NHS and social
to pay, are still largely true. This has provided care are fully organizationally integrated,
several key benefits including high levels of pro- although efforts to promote such integration
tection against the financial consequences of ill-health, with cross-sectoral partnerships in England, Scotland
the redistribution of wealth from the rich to the poor and Wales have accelerated in recent years. While the
and relatively low administrative costs. Devolution in COVID-19 pandemic has been responsible for major
the late 1990s led to the development of four distinct setbacks in objectives outlined in UK national strategies
health care systems in the United Kingdom, but these and plans, it has also accelerated developments such as
health care systems retain more commonalities than the use of teleconsultation and online tools to access
differences. primary care services, and greater integration between
Several barriers persist across the four nations to health and social care services.

HEALTH SYSTEM SUMMARY: 2022 19

 POPULATION HEALTH CONTEXT
KEY MORTALITY AND HEALTH INDICATORS

LIFE EXPECTANCY (YEARS)

Life expectancy at birth, total 81.2

Life expectancy at birth, male 78.4
Life expectancy at birth, female 82.4

MORTALITY (PER 100 000)

All causes 895.9

Circulatory diseases* 192.6
Malignant neoplasms* 216.4
External causes of death* 34.9
Infant mortality rate (per 1 000 live births) 3.7
Maternal mortality rate (per 100 000 live births) 6.5

Notes: *Age-adjusted rates with the European standard population

2010. Life expectancy and infant mortality data are for 2019. Mortality
data are for 2016. Maternal mortality data are from 2017.
Source: WHO Regional Office for Europe, 2022; World Bank, 2022

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Keywords:
DELIVERY OF HEALTH CARE
EVALUATION STUDIES
FINANCING, HEALTH
HEALTH CARE REFORM
HEALTH SYSTEM PLANS – organization and administration
UNITED KINGDOM

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