HEALTH SERVICES

1. Introduction
The main objective of this paper is to explain and evaluate how people make use of
health services within the Unite Kingdom. The aim will be to explore certain factors which
may bear an impact on accessing health services, the way people make use of health
services and an examination of factors which could contribute to the incorrect use of these
services.
In terms of general access to health services, research suggests that a variety of
factors can influence accessibility. People in poor countries tend to have less access to
health services than those in better-off countries, and within countries, the poor have less
access to health services. Although a lack of financial resources or information can create
barriers to accessing services, the causal relationship between access to health services
and poverty also runs in the other direction. When health care is needed but is delayed or
not obtained, peoples health worsens, which in turn leads to lost income and higher health
care costs, both of which contribute to poverty (Annals of the New York Academy of
Sciences Volume 1136, Issue 1)
2. Access to Health Services

FIGURE 1. Conceptual framework for assessing access to health services.

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Figure 1 illustrates, the 4 main elements that influence our access to healthcare within
the context of the UK (working from the centre of the framework). These elements are
categorized as geographical, availability, financial and acceptability. Below, these elements
are explained with the aid of hypothetical examples centred around a character based on a
farm and how each element would impact him.
2.1 Geographical
2.1.1

How long does it take us to get to a service delivery point?

Example: Jack lives in the country, about 20 minute ride on the bus to
his primary care giver his GP. Jack has just turned 73 years of age and
has always made the journey with ease. Unfortunately Jack has come
down with a head cold that has escalated to a cough. With the first snow
falling, and limited bus services, Jack calculates that the normal 20 min
journey might now take 40 minutes and feels he is not up to it.

2.1.2

How far is the service delivery point from our location?

Example: Jack calls the doctor after the cough becomes chronic and at
times he finds himself breathless. The doctor visits Jack on the farm,
prescribes him some antibiotics but also refers Jack to a specialist. The
specialist is almost 40 miles away from the farm and Jack doesnt feel
he is well enough for the journey.

2.2 Availability
2.2.1

Operational hours?
Example: Jack eventually decides to make the drive and go see the
specialist, unfortunately the hours to the re from 09:00 13:00, making
it extremely difficult for Jack to access. Jack gets up very early to take 3
busses (2 hours) to get to the hospital for his appointment at 09:00.

2.2.2

What type of services is available?

Example: Jack meets with the specialist who informs him that he needs
to do more tests and would like Jack to go to another hospital where
they have the facilities and equipment to do all the tests.

2.2.3

What are the waiting times?

Example: Jack arrives at the new hospital, 30 minutes late due to heavy
snow and is informed that due to the snow the doctor are running over 2
hours late and would he like to wait or make another appointment on a
different date?
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2.3 Financial
2.3.1

What is the relationship between the cost of the service and the willingness
and ability of the users to pay for it?

Example: Jack realises that he needs to wait the 2 hours as the financial
implication of returning to the farm and making another trip is too high.

2.3.2

What is the economic health cost having the services there?

Example: Jack enquires if there is a hospital nearer to his house
providing the service as the 2 hour, 3 busses journey takes allot out of
him. The doctor explains that due to the specialist equipment and the
closures of several hospitals in the area, that there was no closer
hospital to be treated in

2.4 Acceptability
2.4.1

Response between health service providers and individuals (social and

cultural expectations) or communities

Example: The doctor then explains to Jack that he has Small-cell-lung

Cancer and that smoking is 90% of the time the cause of lung cancer
and that he needs to stop smoking. Jack takes great offence and tells
the doctor that his mother smoked all her years and did not die from
lung cancer.

2.4.2

Expectations from the user

Example: Jack asks the doctor when will the surgery will take place and
how long he would be in hospital, as he would like to be with his family
on Christmas. The doctor then explains to Jack that unfortunately the
cancer has spread too far and surgery is not an option. The doctor also
explains to Jack that due to his age and re-occurring infections he wont
even be a candidate for chemotherapy and advises Jack that palliative
care is the only option for him. Jack is unhappy and says that he will
seek a second opinion as this could not be the only option.

Access to NHS Services

The NHS was created with the idea in mind that everyone should have access to

good healthcare regardless of ones socioeconomic status. Discussing the core principles, it
is explained that, when it was launched by the then minister of health, Aneurin Bevan, on
July 5 1948, it was based on three core principles: that it meet the needs of everyone that it
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be free at the point of delivery, that it be based on clinical need, not ability to pay. These
three principles have guided the development of the NHS over more than 60 years and
remain at its core.
(http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx)
Even though the core principles might be true to all UK & EU Citizens living within the
UK, the quality and access may vary hugely. People who live in major cities (London,
Manchester, Liverpool, and Birmingham to name but a few) have more access to services
than people living in rural areas (Cherwell, Wealden, Newark and Sherwood and East Devon
to name but a few). The proximity of the services differs greatly as well as the types of
services available.
Where one resides in the UK is not the only concern regarding access to health care;
ones occupation will also influence ones access to health care (the hours one works, the
type of employment, whether or not one is able to take time off from work), including
language and ones belief system. All these things play a significant role in access to health
care.

Figure 1 Illustrates The NHS Health and Care system as of April 2013 (Structure of the
NHS www.nhs.uk)
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The people are at the heart of the present NHS Health and Care system in the UK,
as illustrated in Figure 1, with a wider range of health care providers that will provide patients
with more choice and value.
The NHS provides all their health care services through organisations known as
trusts. The following 5 are the main types of NHS trusts:

NHS Primary Care

NHS Hospital Trusts, often referred to acute trusts

NHS Ambulance Services Trust

NHS Mental Health Trusts

NHS Care Trusts

The NHS suggest that one should consider whether one could treat oneself at home,
whether the local pharmacy could assist, if one should see ones GP, use a walk-in centre,
call NHS 111, use a minor injuries unit or dial 999 in an emergency.

Figure 2 Illustration of primary care and secondary care within the NHS
(http://www.yas.nhs.uk/AboutUs/..images/nhs_how_we_fit.gif)
The difference between primary care and secondary care is where and with whom
one receives the service as indicated above in Figure 2. Primary care is ones local health
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care, the services that most often brings one in contact with the NHS; GPs, NHS walk-in
centres, dentists, pharmacists and optometrists. These services are provided and managed
by Clinical Commissioning Groups (CCGs) previously known as primary care. Whereas
secondary (acute) care is the care one would receive in a hospital. This may be either
unplanned emergency care (including surgery) or planned specialist care (including surgery).
Planned care would usually mean that a professional in a primary care setting has referred
you to a specialist, who is a secondary care provider.
3.1 Primary health care
In order for one to understand the access to primary health care, one should
understand the professionals and services covered in Primary health care.
3.1.1

Traditionally the professionals that make up an Primary Health Care Team

(PHCT) are:

Doctors
o

General Practitioners (GP) partners

GP assistants

GP registrars

Other salaried doctors

A practise manager

Nurses
o

Practise nurses

Nurse practitioners

Community nurses

Support staff
o

Receptionist

Secretaries

Clerical Staff

Midwives

Health Visitors

3.1.2

The premises of the ones primary care could also be used for secondary
care services

Hospital consultants

Diagnostic imaging

Operating services

3.1.3

Allied Health services may also work closely with PHCT

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Physiotherapy

Dietetics

Podiatry

Pharmacy

Counselling

Social Services

Complimentary Therapists
o

Acupuncture

Homeopathy

3.2 Access to Health Services

3.2.1

NHS General Practitioner

Every UK resident is entitled to NHS GP services. Once one has decided which
practice to register with (within your catchment area), one can access the service. New
patients might be refused, if one is outside the catchment area or if the GP surgery patient
list have reached full capacity, the NHS Choices website advises.
Many practises use different methods to reserve appointments. The favoured
method for an appointment in most practises is to contact the practise telephonically, others
include internet appointments and many now also have patient (EMIS) access. One has to
formally register with the practise by completing the required forms and most practices
require a health assessment upon registering.
In bigger practises, some make use of telephone triage to assess patient needs and
which professional the patient could see. Once the appointment is made, the patient have
access to the professional.
Unfortunately due to oversubscribed practises, patients are often told that no
appointments are available and are not advised of alternative service like the nearest walk-in
clinic or to contact the NHS 111. Due to this, patients often go to A&E, regardless whether it
is an emergency or life threatening, which sequentially then puts a strain on A&E
accompanied by long waiting periods. Apart from this people often make appointments they
dont keep and essentially hinder others from the service.
3.2.2

NHS 111

HEALTH SERVICES

The NHS 111 is a service that replaced NHS Direct to assists the UK public with
health services when they need a health service fast but not in a life threatening situation.
This service is also accessible to hearing impaired users as well as non-English speakers
that can request a translator.
The NHS 111 is available 24 hours a day, 7 days a week and is a free call from both
mobile phones and landlines. When one calls, the adviser will ask a series of questions
and input that data (answers given by the caller). A clinical assessment will assist the
adviser with the urgency of the call and advise which service one would need thereafter.
According to NHS 111 Statistics September 2014, There were 995,555 calls
offered on the NHS 111 service in September 2014 equivalent to 30 thousand per day or 11
million per year. This was the lowest rate per day since January 2014 (29 thousand)
Most people make use of the NHS 111 when battling to get an appointment with a
GP and over a weekends. NHS 111 assist to take the pressure off the 999 as well as A&E
Department. The NHS 111 is a fast and easy way to assist one to get the correct help at
whatever time.
3.2.3

NHS-Walk-in Centres (WICs)

NHS WICs are usually managed by nurses (and some may offer access to doctors)
are available to everyone. The NHS website indicates that one does not require and
appointment and most centres are open all year round including outside normal office
hours, this is only true for a few WICs. Most WICs require you to make an appointment
prior to your visit and operate during normal business hours usually.
NHS WICs are usually a complimentary service to the traditional GP service,
however they were not designed to treat long term conditions or life threatening problems.
They treat minor illnesses and injuries such as;

Infections and rashes

Fractures and lacerations

Stomach aches

Emergency contraceptives

Stitches and dressing care

Minor burns and strains

Stop smoking support

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The waiting times at a WIC could be long depending on the amount of people at the
WIC as it is based on a first come first serve basis. Most WIC are also not equipped to deal
with certain injuries such as fractures (even though the NHS specifically informs the public
that this is one of the WIC services) as they might not have access to a x-ray.
3.2.4

NHS Dentists

Good quality NHS dental services are available for everyone and even though the
NHS website suggests that one should not have to register with and NHS dentist, most NHS
dentists are oversubscribed and have a full patient list which results into lengthy waiting
times to access a dentist or the need to contact another surgery.
The NHS will provide any treatments that you require to keep your teeth and gums
healthy and free of pain, which includes:

Dentures

Root Canal

Fillings (including white fillings)

Preventative treatments

Crowns and bridges

The NHS will not however provide any treatment you would not need, but would like
to have to enhance your appearance like teeth whitening.
NHS Dentistry is not free of charge for every UK resident but rather to specific
groups. The following groups are entitled to free dental care:

Under 18s

Under 19s thats in full time education

Pregnant woman or if you had a bay in the last 12 months

If your are staying in a hospital and your treatment is being done by the
hospital dentist

Other groups include people who:

Are on income support

Job seekers allowance

Pension credit

Universal credit

If you are the named person on tax credit exemption certificate

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If you are named on a valid HC2 certificate

There are 3 bands within the NHS Dental Charges, ranging from 18.50 to 219.00
pending on the course of treatment. Due to these fee allot of people do not attend their
appointments due to insufficient funds which in turn is not just time wasted but also the
another patients time that could have been seen but were not able to get an appointment.
3.2.5

NHS Pharmacists

Pharmacists work all over the country in the community in different premises,
making their service extremely accessible to the UK population. Community pharmacists not
only prepare and dispense prescription and non-prescribed medicines, but are also able to
give advice on common problems such as colds, aches, pains, healthy eating and stopping
smoking.
You dont require an appointment or the need to register with a pharmacist and can
speak to them in confidence about your most personal symptoms. There are many
pharmacies that are able to provide one with a private consultation without being overheard
by others.
There is a cost on every prescription but there are various ways that you can get
help with the costs of prescriptions through the NHS.
Unfortunately pharmacies are not able to assist you with all your medical
requirements and access is limited to their opening times or the stores opening times.
3.2.6

NHS Opticians

NHS eye healthcare professionals are available to everyone and there is no need to
register with a specific one, but an appointment should be made prior to the visit.
It is advised that we visit a ophthalmic every 2 years for an eye test. An NHS sight
test is free of charge if clinically necessary, unfortunately it is up to your ophthalmic
practitioner to weather the sight test is necessary or not.
All children under the age of 16 receive free of charge eye sight tests as well as
some other groups including Low Income Support and Pregnant woman or woman who had
a baby within the last 12 months.

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3.3 Access to NHS secondary care

3.3.1

NHS Emergency and Urgent Care

One should only call 999 and visit an A&E for life-threatening emergencies such as:

Loss of consciousness

Fits that are on going

Acute confused state

Breathing difficulties

Bleeding that cant be stopped

Any life-threatening emergencies

Major A&E departments offer a 24 hours service, 365 days a year, however, all
hospitals do not have an A&E. Anyone can access, all one needs to do is find the nearest
A&E and go there. On arrival the staff will assess the severity of the emergency and decide
on further action.
A recent newspaper article in the Mirror reported the following: An investigation has
revealed 74 trusts are struggling to fill vacancies as staff are sacked or quit under the strain
of day-to-day life on emergency units There is a huge amount of stain on A&E departments
and not enough A&E doctors to facilitate the demand of patients coming through A&E doors.
People abuse A&E departments with non-life-threatening cases in many scenarios
due to the lack of knowledge of the amount of pressure, lack of staff, number of people and
that only it should only be used in life-threatening emergencies within A&E departments.
3.3.2

NHS Social Care

NHS Social Care system provides a service to those who need help and assistance
in everyday life by allowing them their dignity and independence. Social care covers adult
services, children services and wheelchair services of which adult services include the
following:

help in your home with things like cleaning and shopping

disability equipment and adaptations to your home

day centres to give you or the person who cares for you a break

day care for your child if either you or they are disabled

care homes
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support for carers

financial support

To access these services one needs to contact ones local adult services within ones
local authoritys social services or be referred to adult services by another professional in
primary care. Adult services are responsible for assessing peoples need for community
care or social care services.
One of the major concerns of Adult social services is that from the day you contact
adult services they have 28 days before they need to the actual assessment to take place
and then thereafter depending on the need or the eligibility criteria, it could take up to
another 6 months for the decided care plan to be actioned.
3.3.3

NHS Mental Health

Mental health services are free of charge to all UK residents on the NHS. You will
usually require a referral from your GP to be able to access them. However there are some
mental health services that will allow people to refer themselves for help. This commonly
includes services for drug and alcohol problems, as well as some psychological therapy
services.
Ones GP surgery may be able to provide one with these services or one might find
them within, a large local health centre, a specialist mental health clinic, or hospital.
Depending on the treatment required, it might be provided on a one-to-one basis or in a
group with others with similar difficulties, and therapy sometimes also involves partners and
families.
The NHS website advises that if one has concerns about a persons social
circumstances the correct path to follow would be to contact social services, however if If
you or someone you know experiences an acute emergency, you should call 999 and ask for
the ambulance service or the police.
People often abuse this service in order to be able not to work but claim state
benefits due to the mental illness they supposedly have.
3.3.4

NHS Ambulance Services

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The NHS Ambulance services range from urgent care, planned health care to and
can include transport service.
Life-threatening care can be accessed through dialling 999 and asking for the
ambulance services. According to the NHS website, once the 999 call is received they are
divided into 2 categories to provide the best service for the situation:

Immediately life threatening life-threatening calls will receive an

ambulance capable of transporting the patient safely within 19 minutes of
the request for transport being made.

All other calls For conditions that are not life threatening, response
targets are set locally

Unfortunately the above times are not realistic numbers due to allot of NHS
Trusts closing down hospitals and A&E that are only available at certain hospitals. Apart
from longer traveling times, road works and traffic has a huge impact on the route and
time an ambulance will take to reach the intended person.
999 calls are also not always life-threatening which diverts the service from serious
injured and ill patients.
3.4 NHS vs Private
There are various discussion one could consider when comparing the NHS services and
those of Private Health care, unfortunately there will always be pros and cons in every
discussion. One however need to look at the comparison of a patients journey for different
perspectives to comprehend the differences.
Cigna, a private medical provider of private health care have done just that;
the following diagram (https://www.cigna.co.uk/downloads/medical/articles/Experience
%20the%20difference%20-%20diagram.pdf) below shows the patient journey from three
perspectives:

NHS Patient

Private Patient

Cigna private Patient

This highlights the five main steps in the patient journey and compares these across
the 3 and through reforms it has made many efficiency improvements in recent years. But
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there are still limits in the NHS in terms of access to care and patient choice. As an example,
an NHS patient may be referred to a private hospital for a consultation but they'll have to
attend a group clinic where they are unlikely to be seen by a consultant. Then they'll have to
meet stringent criteria to have access to some surgical procedures and must then wait a
minimum of 14 weeks to have the treatment.
Once in hospital the different experience for an NHS and private patient continues.
Private patients often have their own private room and services. Private healthcare also
means more personal care. Consultations are based on individual appointments rather than
clinics. Follow up care is one to one. And members of Cigna's medical plans enjoy an even
better experience. Our nurses can provide advice and support throughout the patient
journey. They can help patients get the information they need from their consultant, provide
additional support through the Care Co-ordination Programme and continue to support the
patient and their family in their recovery after treatment is completed.
(https://www.cigna.co.uk/media/product-news/experience-the-difference/index.html)

With the above one can argue that Cigna used this as a marketing tool to sell their
product and have not disclosed the cons to NHS vs Private Health care.
Pamela Brooks, a health journalist edited a base document written by John Illman a
medical writer, discussing the pros and cons of private medical insurance, which included
the following:
Pros
No queues: although waiting times on the

Cons
Not all conditions are covered: it depends

NHS have improved to a maximum of 18

on your policy and any previous medical

weeks between referral and treatment, you

conditions, but most policies only cover

won't have to wait this long for private

short-term illness or injury.

treatment.
Peace of mind: if the worst happens, your

Some appointments and treatments are

treatment will be as quick as it can be.

not covered: once you've got a referral

Many people are also concerned about the

from your GP, you need to call your

problem of MRSA in NHS hospitals.

insurance company to check they will cover

the costs before you see the consultant or

Choice: you can choose your consultant

arrange any treatment.

It can be difficult to know which PMI

and where you want to be treated, with the

policy suits you: with so many companies

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HEALTH SERVICES

proviso that some policies restrict treatment

offering PMI, it's worth talking to an

to set lists of hospitals

independent financial adviser, who can help

you see the differences between the
policies. Advisers at insurance companies
can only discuss their own policies and
can't give you advice on how it compares

Private room: you don't have to worry

with others.
You get what you pay for: the more cover

about being on a mixed-gender ward.

you want, the higher your premium will be.

Depending on your policy, you may have an

ensuite bathroom.
Unrestricted visiting hours.

Premium costs are rising above the level

of inflation: medical treatment costs are
rising by 10 per cent each year, according
to group health intermediary Mercer. When
insurers' costs rise, premiums tend to rise in

Personal care: a retinue of medical

line with the costs

Expertise: private hospitals might not have

students won't accompany your

the same depth of expertise found in teams

appointment with the consultant, you won't

within the NHS or all departments on one

be kept waiting for hours to see them and

site. So if you have a problem with your

you will have more time to discuss your

mouth, it might not be easy to coordinate

symptoms.

treatment between a dental department and

pecialist claim team: your insurer may

the ENT (ear, nose and throat) unit.

Time constraints: if your consultant also

have a team that deals specifically with a

works in the NHS, your treatment will need

certain type of condition, such as cancer,

to be given in the time he or she has free

who can help advise you.

from the NHS.

All the information above is available at http://www.netdoctor.co.uk/focus/pmi/advantages.htm

3.5 Conclusion
There are a huge number of factors that influence how people in the UK access
health care. With all services, regardless whether or not in health care, there will always be
pros, cons and misuse. It seems that one of the biggest hurdles within the NHS is trying to
educate a nation the use of the right service for the right need.

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With a growing population and people living longer because of this improved and
expanded services, the strain on the NHS will grow bigger year by year and people will make
more and more misuse of services in order to fill their individual needs.
References
GP Services at Breaking Point with longer waiting times Available at
http://www.independent.co.uk/news/uk/home-news/gp-services-at-breaking-point-withlonger-waiting-times-on-the-way-claims-survey-8772361.html Accessed on 27 November
2014
Transforming Primary care available at
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/304139/Transf
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Inclusive Practise Available at
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29 November 2014
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http://www.nhs.uk/NHSEngland/AboutNHSservices/mental-health-servicesexplained/Pages/accessing%20services.aspx Accessed on 3 December 2014

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http://www.nhs.uk/NHSEngland/AboutNHSservices/Emergencyandurgentcareservices/Page
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accessed 30 November 2014
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http://www.nhs.uk/NHSEngland/AboutNHSservices/pharmacists/Pages/pharmacistsandche
mists.aspx Accessed 30 November 2014.
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Accessed 3 December 2014

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