JANUARY

ENGLAND
immunization, and vaccination programs; inpatient and outpatient hospital care; physician services; inpatient
and outpatient drugs; clinically necessary dental care; some eye care; mental health care, including some care
for those with learning disabilities; palliative care; some long-term care; rehabilitation, including physiotherapy
(e.g., after-stroke care); and home visits by community-based nurses.
The volume and scope of these services are generally a matter for local decision-making, but the NHS
Constitution also states that patients have a right to drugs or treatment approved in technology appraisals
carried out by the National Institute of Health and Clinical Excellence (NICE), if recommended by their clinician
(Department of Health, 2013b). For drugs or treatments that have not been appraised by NICE, the NHS
Constitution states that CCGs shall make rational, evidence-based decisions (Department of Health, 2013b). 2
There is no routine reporting of how individual clinical commissioning groups make decisions, but a study of
predecessor organizations found considerable variation (Nuffield Trust, 2011). There is also evidence of wide
variations in access to some treatments, such as hip replacements (Royal College of Surgeons in England, 2014).
Cost-sharing and out-of-pocket spending: There are limited cost-sharing arrangements for publicly covered
services. Out-of-pocket payments for general practice are limited to services that fall outside the purview of the
NHS, including examinations for employment or insurance purposes and the provision of certificates for travel
or insurance.
Outpatient prescription drugs are subject to a copayment (currently GBP8.20, or USD11.60, per prescription
item in England); drugs prescribed in NHS hospitals are free. NHS dentistry services are subject to copayments
of up to GBP222.50 (USD314.00) per course of treatment. 3 These charges are set nationally by the Department
of Health. Out-of-pocket expenditure on health by households accounted for 11.9 percent of total expenditures
in the U.K. in 2013 (Office for National Statistics, 2015). In 2013, the largest portion of out-of- pocket spending
(34%) was for pharmaceuticals, followed by about 20 percent on medical appliances and equipment (Office for
National Statistics, 2015). 4
Safety net: People who are exempt from prescription drug copayments include children under age 16 and
those 16 to 18 in school full time; people age 60 or older; people with low income; pregnant women and those
who have had a baby in the past 12 months; and people with cancer, certain other long-term conditions, or
certain disabilities. Patients who need large amounts of prescription drugs can buy prepayment certificates
costing GBP29.10 (USD41.10) for a period of three months and GBP104 (USD147) for 12 months. Users incur no
further charges for the duration of the certificate, regardless of how many prescriptions they need. In 2013, 90
percent of prescriptions in England were dispensed free of charge (Health and Social Care Information Centre,
2014a). Young people, students, pregnant and recently pregnant women, prisoners, and those with low incomes
are not liable for dental copayments. Vision tests are free for young people, those over 60, and people with low
incomes, and financial support to meet the cost of corrective lenses is available to young people and those with
low incomes. Transportation costs to and from provider sites also are covered for people who qualify for the
NHS Low Income Scheme.
How is the delivery system organized and financed?
Primary care: Primary care is delivered mainly through general practitioners (GPs), who act as gatekeepers for
secondary care. In 2014, there were 36,920 general practitioners (full-time equivalents) in 7,875 practices, with
an average of 7,171 patients per practice and 1,530 patients per GP. There were 40,443 hospital specialists
and a further 53,786 hospital doctors in training (Health and Social Care Information Service, 2015a, 2015b).
The number of solo practices is currently 843, while there are 3,589 practices with five or more GPs (Health
2
A total of 533 appraisals were carried out between March 2000 and August 2014.
3
Please note that, throughout this profile, all figures in USD were converted from GBP at a rate of GBP0.71 per USD, the
purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for England.
4
Including consumer spending on drugs and medical products not covered by the NHS, such as glasses, dental treatment, and
spending on hospital and outpatient care.
50
The Commonwealth Fund