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The English Health Care System

by Ruth Thorlby and Sandeepa Arora, Nuffield Trust, London

What is the role of government?

Responsibility for health legislation and general policy in England rests with Parliament, the Secretary of State for Health, and the Department of Health.1 Under the Health Act (2006), the Secretary of State has a legal duty to promote a comprehensive health service that provides care free of charge, apart from services with charges already in place. Rights for those eligible for National Health Service (NHS) care are summarized in the NHS Constitution; they include the right to access to care without discrimination and within certain time limits for some categories, such as emergency and planned hospital care.2 The Department of Health provides stewardship for the overall health system, but day-to-day responsibility for running the NHS rests with a separate public body, NHS England.

NHS England manages the NHS budget, oversees 209 local Clinical Commissioning Groups (CCGs), and ensures that the objectives set out in an annual mandate by the Secretary of State for Health are met, including both efficiency and health goals. Budgets for public health are held by local government authorities, which are required to host “health and well-being boards” to improve coordination of local services and reduce health disparities.

Who is covered and how is insurance financed?

Publicly financed health care: In 2014, the United Kingdom (U.K.) spent 9.9 percent of GDP on health care, of which public expenditure, mainly on the NHS, accounted for 79.5 percent.3 The majority of funding for the NHS comes from general taxation, and a smaller proportion from national insurance (a payroll tax). The NHS also receives income from copayments, people using NHS services as private patients, and some other minor sources.

Coverage is universal. All those “ordinarily resident” in England are automatically entitled to NHS care, largely free at the point of use, as are nonresidents with a European Health Insurance Card. For other people, such as non-European visitors or undocumented immigrants, only treatment in an emergency department and for certain infectious diseases is free.4

Private health insurance: In 2015, an estimated 10.5 percent of the U.K. population had private voluntary health insurance, with 3.94 million policies held at the beginning of 2015.5 Private insurance offers more rapid and convenient access to care, especially for elective hospital procedures, but most policies exclude mental health, maternity services, emergency care, and general practice.6 Data on private insurers are not freely available, but according to the Competition and Markets Authority (2014), four insurers account for 87.5 percent of the market, with small providers making up the rest.7

What is covered?

Services: The precise scope of the NHS is not defined in statute or by legislation, and there is no absolute right for patients to receive a particular treatment. However, the statutory duty of the Secretary for Health is to ensure comprehensive coverage. In practice, the NHS provides or pays for preventive services, including screening, 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. For drugs or treatments that have not been appraised by NICE, the NHS Constitution states that CCGs shall make rational, evidence-based decisions.8,9

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 some services, such as examinations for employment or insurance purposes and the provision of certificates for travel or insurance.

Outpatient prescription drugs are subject to a copayment (currently GBP8.40, or USD12.14, per prescription item in England); drugs prescribed in NHS hospitals are free. NHS dentistry services are subject to copayments of up to GBP233.70 (USD338.00) per course of treatment.10 These charges are set nationally by the Department of Health. Out-of-pocket expenditure on health by households accounted for 14.8 percent of total expenditures in the U.K. in 2014. Also in 2014, the largest portion of out-of-pocket spending (42.4%) was for medical goods (including pharmaceuticals), followed by 35.9 percent on long-term care services, including residential care.11,12

Safety net: People who are exempt from prescription drug copayments include children age 15 and under and those ages 16 to 18 in school full-time; people age 60 or older; people with low income; pregnant women and those who have given birth 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 (USD42.00) for three months and GBP104.00 (USD150.00) for 12 months. Users incur no further charges for the duration of the certificate, regardless of how many prescriptions they need. In 2015, 89.7 percent of prescriptions in England were dispensed free of charge.13 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 2015, there were 34,592 general practitioners (full-time equivalents) in 7,674 practices, with an average of 7,450 patients per practice and 1,530 patients per GP.14 There were 43,632 hospital specialists and a further 51,460 hospital doctors in training.15 The number of solo practices was 843 in 2014, while there were 3,589 practices with five or more GPs. General practices are normally patients’ first point of contact, and people are required to register with a local practice of their choice; however, choice is effectively limited because many practices are full and do not accept new patients. In some areas, walk-in centers offer primary care services, for which registration is not required.

Most GPs (66%) are private contractors, and approximately 56 percent of practices operate under the national General Medical Services contracts, negotiated between the British Medical Association (representing doctors) and government. These provide payment using a mixture of capitation to cover essential services (representing about 60% of income), optional fee-for-service payments for additional services (e.g., vaccines for at-risk populations, about 15%), and an optional performance-related scheme (about 10%).16 Capitation is adjusted for age and gender, local levels of morbidity and mortality, the number of patients in nursing and residential homes, patient list turnover, and a market-forces factor for staff costs as compared with those of other practices. Performance bonuses are given mainly on evidence-based clinical interventions and care coordination for chronic illnesses. The proportion of income from these bonuses will fall when the new 2014–2015 contract is fully implemented, as the number of bonus-related services is reduced and funding rerouted into capitation.

The proportion of GPs employed in practices or on a salaried basis as locums (e.g., standing in when other GPs are unavailable) is increasing (currently around 20%). Most general practices employ other professionals such as nurses, whose duties include monitoring patients for blood pressure and providing minor treatments. General practice is undergoing a structural change, from single-handed “corner shops” to networked practices, including larger multipractice organizations using multidisciplinary teams of specialists, pharmacists, and social workers.17 The average income for combined GPs (contracted and salaried) in England was GBP91,000 (USD131,503) before tax in 2014–2015.18

Outpatient specialist care: Nearly all specialists are salaried employees of NHS hospitals, and CCGs pay hospitals for outpatient consultations at nationally determined rates. Specialists are free to engage in private practice within specially designated wards in NHS or private hospitals; the most recent estimates (in 2006) were that 55 percent of doctors performed private work, a proportion that is declining as the earnings gap between public and private practice narrows.19 Patients are able to choose which hospital to visit, and the government has introduced the right to choose a particular specialist within a hospital (not yet fully implemented). Most outpatient specialist consultations are carried out in hospitals, although consultation may take place in general practices. Some GPs “with specialist interests” also offer specialist consultations, paid on a per-session or fee-for-service basis.

Administrative mechanisms for paying primary care doctors and specialists: The bulk of general practices are reimbursed monthly for the services they deliver on the basis of data extracted automatically from practices’ electronic records. Some payments may require practices to enter data manually on the number of patients screened or treated for “enhanced services” that qualify for additional payments, such as diagnosis and support for patients with dementia. These data are collated and validated by NHS England.

After-hours care: GPs are no longer required personally to provide after-hours care to their patients (a small minority still do), but must ensure that adequate arrangements for its provision are in place. In practice, this means that CCGs contract mainly with GP cooperatives and private companies, both of which usually pay GPs on a per-session basis.

Serious emergencies are handled by hospital emergency departments. In some areas, less-serious cases are seen in urgent care centers or minor-injury units, which are staffed in a variety of ways and include both nurse-led and GP-led centers. Telephone advice is available on a 24-hour basis through NHS 111 for those with an urgent but not life-threatening condition.

Hospitals: Publicly owned hospitals are organized either as NHS trusts (currently 72) directly accountable to the Department of Health or as foundation trusts (currently 150)20 regulated by NHS Improvement, whose functions include the economic regulation of public and private providers.

Both NHS trust and foundation trust hospitals contract with local CCGs to provide services. They are reimbursed mainly at nationally determined diagnosis-related group (DRG) rates, which include medical staff costs and account for about 60 percent of income, with the remainder coming from activities not covered by DRGs, such as mental health, education, and research and training funds.21 Responsibility for setting those rates is shared between NHS England and NHS Improvement. In some areas, rates are not applied and payments are made for an overall service, such as emergency care. Also at the local level, fees for “years of care”—for example, for the total cost of the care a diabetic patient receives over 12 months—are being developed but as yet are not in widespread use. There is no cap on hospital incomes.

An estimated 548 private hospitals and between 500 and 600 private clinics in the U.K. offer a range of services, including treatments either unavailable in the NHS or subject to long waiting times, such as bariatric surgery and fertility treatment, but generally do not have emergency, trauma, or intensive-care facilities.22 Private providers must be registered with the Care Quality Commission and with NHS Improvement, but their charges to private patients are not regulated, and there are no public subsidies. Although the volume of care purchased from private providers by the NHS has increased recently in areas outside of mental health, NHS use of private hospitals remains low—3.6 percent of overall spending by commissioners on hospital services in 2012–2013.23

Mental health care: Mental health care is an integral part of the NHS and covers a full range of services. Less-serious illnesses—mild depressive and anxiety disorders, for example—are usually treated by GPs. Those requiring more advanced treatment, including inpatient care, are treated by mental health or hospital trusts. Some of these services are provided by community-based staff. About a quarter of NHS-funded, hospital-based mental health services are provided by the private sector.

Over the past decade, policy has focused on increasing access to psychological therapies for mild-to-moderate mental health problems, although there can still be long waiting times. Policies to improve the care of more severe conditions in the community have focused on outreach and early intervention, and there is an overarching aim to ensure “parity of esteem” between mental health and other kinds of health services. A review conducted in 2012 suggested that treatment of mental health, by comparison with that of physical illnesses, has been underfunded.24

Long-term care and social supports: The NHS pays for some long-term care, such as care for people with continuing medical or skilled-nursing needs, but payments in recent years have been substantially reduced. Most long-term care is provided by local authorities and the private sector. Local authorities are legally obliged to assess the needs of all people who request it, but, unlike NHS services, state-funded social care is not universal. With the exception of time-limited “reablement” services, some equipment and home modifications (in some areas), and information services, residential and home care are needs- and means-tested. Full state support for residential care, for example, is available only to those with less than GBP14,250 (USD20,592) in assets who are also assessed as having high levels of need, with a sliding scale applied up to GBP23,250 (USD33,600). There is a national framework for assessing need, but local authorities are free to set eligibility thresholds for access to funds, which has become progressively more restricted.25 Plans to impose a cap on total out-of-pocket spending on long-term care have been postponed until 2020.

Those eligible are liable for copayments, with some people contributing almost all of their “assessed income,” including pensions. Beneficiaries can receive personal budgets to purchase their own care or can opt to have the local authority arrange it. Some additional allowances paid to users and carers are exempt from means testing, such as “attendance allowance,” worth a maximum of GBP82.30 (USD119.00) a week.

In 2009, the private sector provided 78 percent of residential care places for older people and the physically disabled in the U.K.26 The NHS provides end-of-life palliative care at patients’ homes, in hospices (usually run by charitable organizations), in care homes, or in hospitals. Separate government funding is available for working-age people with disabilities.

diagram of health care system

What are the key entities for health system governance?

The Department of Health and the Secretary of State for Health are ultimately responsible for the health system as a whole. The Health and Social Care Act 2012 transferred important functions to NHS England, including overall budgetary control, supervision of CCGs, and, along with Monitor (now NHS Improvement), responsibility for setting DRG rates for the provision of NHS services. NHS England also commissions some specialized low-volume services, national immunization and screening programs, and primary care. It is responsible for setting the strategic direction of health information technology, including the development of online services to book appointments, the setting of quality standards for electronic medical record-keeping and prescribing, and the IT infrastructure of the NHS.

The National Institute for Health and Clinical Excellence (NICE) sets guidelines for clinically effective treatments and appraises new health technologies for their efficacy and cost-effectiveness. The Care Quality Commission (CQC) ensures basic standards of safety and quality through provider registration and monitors care standards achieved (described further below). It can require closure of services if serious quality concerns are identified.

NHS Improvement licenses all providers of NHS-funded care and may investigate potential breaches of NHS cooperation and competition rules, as well as mergers involving NHS foundation trusts. Where such mergers are found to be prima facie undesirable, they are referred to the Office of Fair Trading and the Competition Commission.

Healthwatch England promotes patient interests nationally. In each community, local Healthwatches support people who make complaints about services; quality concerns may be reported to Healthwatch England, which can then recommend that the CQC take action. In addition, local NHS bodies, including general practices, hospital trusts, and CCGs, are expected to support their own patient engagement groups and initiatives. The Department of Health owns NHS Choices, the primary website for public information about health conditions, the location and quality of health services, and other information. The website, which also offers a platform for user feedback, received 27 million visits a month in 2012–2013.27

What are the major strategies to ensure quality of care?

The CQC regulates all health and adult social care in England. All providers, including institutions, individual partnerships, and solo practitioners, must be registered with the CQC, which monitors performance using nationally set quality standards and investigates individual providers when concerns have been raised (e.g., by patients). It rates hospitals’ inspection results and can close down poorly performing services. New “fundamental standards” for all health and social care came into force in 2015.28 The monitoring process includes results of national patient experience surveys.

NICE develops quality standards covering the most common conditions occurring in primary, secondary, and social care. National strategies have been published for a range of conditions, from cancer to trauma. There are national registries for key disease groups and procedures. Maximum waiting times have been set for cancer treatment, elective treatments, and emergency treatment. A website, NHS Evidence, provides professionals and patients with up-to-date clinical guidelines. Support is also provided by NHS Quality Improvement, part of NHS England.

Information on the quality of services at the organization, department, and (for some procedures) physician levels is published on NHS Choices. Results of inspections by the CQC are also publicly accessible. The Quality and Outcomes Framework provides general practices with financial incentives to improve quality. General practices are awarded points (which determine a portion of their remuneration) for keeping a disease registry of patients with certain diseases or conditions and their management and treatment. For hospitals, 2.5 percent of contract value is linked to the achievement of a limited number of quality goals through the Commissioning for Quality and Innovation initiative. In addition, DRG rates for some procedures are linked to best practice.

All doctors are required by law to have a license to practice from the General Medical Council. Similar requirements apply to all professions working in the health sector. A process of revalidation every five years is being introduced for doctors. Providers of hospital services also must be registered with the CQC.

What is being done to reduce disparities?

The Secretary of State, NHS England, and CCGs have a legal duty to “have regard” for the need to reduce health disparities, although the applicable legislation does not specify what actions need to be taken. NHS England publishes an annual report on the actions taken and progress being made in reducing disparities in access and outcomes, by gender, disability, age, socioeconomic status, and ethnicity.29 Strategies include ensuring that local areas receive adequate resources to tackle inequalities and that the outcomes for at-risk groups are routinely monitored.

What is being done to promote delivery system integration and care coordination?

GPs increasingly work in multipartner practices that employ nurses and other clinical staff, who carry out much of the routine monitoring of patients with long-term conditions. These practices also have some of the features of a medical home—that is, they direct patients to specialists in hospitals or to community-based professionals, like dietitians and community nurses, and hold treatment records of their patients. GPs are responsible for care coordination as part of their overall contract; to improve coordination for older patients, the latest version of the contract (2014–2015) requires practices to have a “named accountable GP” for all patients over age 75. GPs also have financial incentives to provide continuous monitoring of patients with the most common chronic conditions, such as diabetes and heart disease.

The 2012 Act charged NHS England, Monitor, and CCGs with promoting integrated care, i.e., closer links between hospital- and community-based health services, including primary and social care. The health and well-being boards within local authorities are intended to promote integration between NHS and local authority services, particularly at the intersection of hospital and social care.

Practical initiatives include the Better Care Fund (GBP3.9 billion, or USD5.6 billion), pooled from existing health and social care budgets, for integration projects by local health and social care commissioners starting in 2015–2016. These funds are being used to improve the discharge process for hospital patients, reduce reliance on long-term care, and improve access to out-of-hospital care.

What is the status of electronic health records?

The NHS number assigned to every registered patient serves as a unique identifier. All general-practice patient records are computerized. Since April 2015, GP practices have been contractually obliged to offer patients the choice of booking appointments and ordering prescriptions online. As of March 31, 2016, practices are required to offer patients access to their detailed coded record—including information about diagnoses; medications and treatments; immunizations; and test results. Practices are not required to allow patients access to information that clinicians enter in free-text fields. Where electronic records are not available to patients, such as in dentistry, they can request a paper copy. Records are not routinely linked among providers.

The NHS had aimed to make primary, urgent, and emergency care services paperless by 2018, and all other parts of the NHS by 2020. However, this time line has already slipped, and a recent independent review of digital use in the NHS suggests that 2023 is a more reasonable target for trusts to reach digital maturity.30

NHS Choices will serve as a single point of access for patients to register with a GP, book appointments and order prescriptions, access apps and digital tools, speak to their doctor online or via video link, and view their full health record.31

How are costs contained?

Costs in the NHS are constrained by a global budget that cannot be exceeded, rather than through patient cost-sharing or direct constraints on supply. NHS budgets are set at the national level, usually on a three-year cycle. CCGs are allocated funds by NHS England, which closely monitors their financial performance to prevent overspending. They are expected to achieve a balanced budget each year.

Since 2010, the allocation of funds by the central government has grown much more slowly than the long-term historical rate, which averaged 4 percent in real terms between 1949–1950 and 2010–2011.32 Between 2010–2011 and 2014–2015, average real-term growth in spending on health rose by 1.2 percent and is projected to rise by 1.1 percent between 2015–2016 and 2020–2021.33

The mismatch between funding, demand, and the cost of providing services has led to NHS hospitals and other providers recording a deficit of GBP3.7 billion (USD5.3 billion) for 2015–2016 and a projected gap of GBP6.0 billion (USD8.7 billion) by 2020–2021, even if hospitals can continue to create efficiencies of 2 percent a year.34

Although some of the savings targets have been met in the past five years, the financial pressure on the NHS is being associated with some deterioration in the quality of care—notably waiting time targets.35

Cost-containment strategies to date include freezing staff pay increases, supporting the increased use of generic drugs, reducing DRG payments for hospital activity, managing demand, and reducing administration costs. In 2016, NHS Improvement launched a program to help hospital providers generate savings through more efficient use of staff, more cost-effective purchasing of drugs and medical equipment, and better management of estates and facilities, which, if implemented, could save GBP5.0 billion (USD7.2 billion) by 2020.36 There are a number of tools whereby local purchasers can maximize value by addressing unwarranted variations in utilization and clinical practice, provided by the government-funded Rightcare program. Local purchasers can also run competitive tenders for certain services.

The costs of prescription (branded) drugs are contained by the Pharmaceutical Price Regulation Scheme. The latest scheme, lasting five years through 2018, regulates the profits that drug companies can make selling drugs to the NHS. It is a voluntary scheme, negotiated between the U.K. government and the pharmaceutical industry, with new medicines to be introduced to the NHS at prices set by the manufacturer as long as they remain within the profit cap.37 This scheme runs parallel with the cost-effectiveness appraisals by NICE, which tends not to recommend new drugs as cost-effective if they exceed GBP20,000–GBP30,000 (USD28,900–USD43,350) per Quality Adjusted Life Year (QALY).

What major innovations and reforms have been introduced?

In October 2014, NHS bodies, led by NHS England, published the Five Year Forward View, which sets out the challenges facing the NHS and strategies to address them.38 These include pilot programs across England to test new models of care known as “vanguards.” To date, there are 50 vanguard sites testing such innovations as scaled-up primary care, enhanced health care in long-term care homes, vertically integrated hospital and community care, and networks to improve emergency care. NHS England hopes that these will lead to better tools for identifying those at risk of becoming high-need, high-cost patients, and to the development of capitated contracts to encourage providers to collaborate in the care of complex patients. The Five Year Forward View also sets out strategies to improve health and well-being, including a diabetes prevention initiative.39 All NHS areas are also expected to implement full seven-day working weeks in hospitals and general practice by 2020, as pledged in an election manifesto in 2015.

To accelerate the process of reform, in December 2015 the government announced a new approach that involves all local purchasers and providers coming together across 44 local “footprints” to create multiyear plans to transform services, based on a conglomerated budget for their local populations.40 Although the legal responsibility of individual NHS organizations to break even remains unchanged, this approach calls for organizations to collaborate, and represents an important break with the previous policy of competition.

Acknowledgements

The authors would like to acknowledge Anthony Harrison, the author of earlier versions of this profile.

References

1In cases where data for England are unavailable (e.g., financial or funding data), U.K. data are used instead.

2Department of Health, NHS Constitution for England, updated Oct. 14, 2015.

3Office for National Statistics, UK Health Accounts: 2014, May 19, 2016.

4Department of Health, Guidance on Implementing the Overseas Visitors Hospital Charging Regulations, 2015.

5LaingBuisson, Health Cover UK Market Report, 12th ed., Aug. 2015.

6King’s Fund, The UK Private Healthcare Market: Appendix to the Commission on the Future of Health and Social Care in England: Final Report, 2014.

7Competition and Markets Authority, Private Healthcare Market Investigation, April 2, 2014.

8Department of Health, The NHS Constitution for England, updated Oct. 14, 2015.

9A total of 533 appraisals were carried out between March 2000 and August 2014.

10Please note that, throughout this profile, all figures in USD were converted from GBP at a rate of GBP0.692 per USD, the purchasing power parity conversion rate for GDP in 2015 reported by OECD (2016) for England.

11Office for National Statistics, UK Health Accounts: 2014, May 19, 2016.

12Including consumer spending on drugs and medical products not covered by the NHS, such as glasses, dental treatment, and spending on hospital and outpatient care.

13Health and Social Care Information Centre, Prescriptions Dispensed in the Community: England, 2005–15, July 5, 2015.

14Health and Social Care Information Centre, General and Personal Medical Services, England 2005–2015.

15Health and Social Care Information Centre, Healthcare Workforce Statistics, England, March 2016.

16Health and Social Care Information Centre, Investment in General Practice, 2010/11 to 2014/15, England, Wales, Northern Ireland and Scotland, Sept. 17, 2015.

17King’s Fund and Nuffield Trust, Securing the Future of General Practice: New Models of Primary Care, July 2013.

18Heath and Social Care Information Centre, GP Earnings and Expenses: 2014 to 2015, Sept. 14, 2016.

19GHK Consulting Ltd. and Office of Fair Trading, Programme of Research Exploring Issues of Private Healthcare Among General Practitioners and Medical Consultants: Population Overview Report for the Office of Fair Trading, 2011.

20NHS Confederation, Key Statistics on the NHS; accessed Aug. 30, 2016.

21Department of Health, A Simple Guide to Payment by Results, March 25, 2013.

22Competition and Markets Authority, Private Healthcare Market Investigation, 2014.

23Nuffield Trust, Public Payment and Private Provision: The Changing Landscape of Health Care in the 2000s, May 2013.

24Centre for Economic Performance and London School of Economics, How Mental Health Loses Out in the NHS: A Report by the Centre for Economic Performance’s Mental Health Policy Group, June 2012.

25Nuffield Trust, Focus On: Social Care for Older People—Reductions in Adult Social Services for Older People in England, March 2014.

26LangBuisson, Laing’s Healthcare Market Review, 2013.

27NHS Choices, Transparency, Transaction, Participation: Annual Report 2012/13.

28Department of Health, Hard Truths: The Journey to Putting Patients First, Volume One of the Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry, Jan. 2014.

29NHS England, Our 2014–15 Annual Report: Health and High Quality Care for All, Now and for Future Generations, July 21, 2015.

30R. M. Wachter, Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England, Report of the National Advisory Group on Health Information Technology in England.

31Department of Health, Personalised Health and Care 2020—Using Data and Technology to Transform Outcomes for Patients and Citizens: A Framework for Action, Nov. 2014.

32Nuffield Trust, NHS and Social Care Funding: The Outlook to 2021/22, Nuffield Trust, July 2012.

33Nuffield Trust, Health Foundation, and King’s Fund, The Autumn Statement: Joint Statement on Health and Social Care, Nov. 2016.

34S. Gainsbury, Feeling the Crunch: NHS Finances to 2020, Nuffield Trust, Aug. 2016.

35Nuffield Trust and Health Foundation, Closer to Critical? Quality Watch Annual Statement, 2015.

36Department of Health, Operational Productivity and Performance in English NHS Acute Hospitals: Unwarranted Variation—An Independent Report for the Department of Health by Lord Carter of Coles, Feb. 2016.

37Department of Health and ABPI, The Pharmaceutical Price Regulation Scheme 2014, Dec. 2013.

38NHS England, Five Year Forward View, Oct. 2014.

39NHS England, Five Year Forward View: Time to Deliver, June 4, 2015.

40NHS England, Delivering the Forward View: NHS Planning Guidance 2016/17–2020/21, Dec. 2015.