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The National Health Service was established in the United Kingdom in 1948 as a universal, comprehensive service free at the point of delivery, which is publicly provided, funded, and accountable. Market incrementalism in England has eroded this system over three decades. The recently enacted Health and Care Act will erode it further. This article first explains briefly how legislation and policy initiatives in 1990, 2003, and 2012 furthered development of the market and private provision of health services, and then describes the main structural changes in the new Act and their implications. England is now moving decisively toward a marketized, two-tier, mixed-funding system with several similarities to the United States. [ABSTRACT FROM AUTHOR]

Objectives: To examine the impact of NHS-funded private provision on NHS provision, access and inequalities.Design: Ecological study using routinely collected NHS inpatient data.Setting: England.Participants: All individuals undergoing an NHS-funded elective hip arthroplasty in England from 2003/2004 to 2012/2013.Main Outcome Measures: Annual crude and standardised rates of hip arthroplasties per 100,000 population performed by NHS and private providers between 2004/2005 and 2012/2013.Results: Age standardised rates of hip arthroplasty increased from 116.4 (95% CI 115.4-117.4) to 148.7 (147.6-149.8) per 100,000 between 2004/2005 and 2012/2013. Provision shifted from NHS providers to private providers from 2007/2008; NHS provision decreased 8.6% and private provision increased 188% between 2007/2008 and 2012/2013. There is evidence of risk selection; private sector hip arthroplasties on NHS patients from the most affluent areas increased 228% from 10.8 (10.2-11.5) to 35.4 (34.3-36.5) per 100,000 compared to an increase of 186% from 8.8 (8.1-9.4) to 25.2 (24.1-26.4) per 100,000 among patients from the least affluent areas between 2007/2008 and 2012/2013. There was no statistically significant (p > 0.05) widening in any measure of inequality (absolute, relative difference and slope and relative slope of index inequality) in hip arthroplasty rates between 2004/2005 and 2012/2013.Conclusion: Private provision substituted for NHS provision and did not add to overall provision favouring patients living in the most affluent area. Continuing the trend towards private provision and reducing NHS provision is likely to result in risk selection and widening inequalities in provision of elective hip arthroplasty in England. [ABSTRACT FROM AUTHOR]

The authors describe the incremental approach to the marketisation of the English National Health Service (NHS) since the introduction of an 'internal market' in 1990 until the 2010 White Paper, 'Equity and Excellence: Liberating the NHS', and the subsequent Health and Social Care Bill published in January 2011. The introduction of a competitive market for a universal, tax-financed health system requires fundamental changes in regulation in order that market bureaucracy can be substituted for direct management. The components of reform are insufficiently captured by the framework of hierarchies and networks in new public management theories of decentralisation. [ABSTRACT FROM AUTHOR]

Background Alternative provider of medical services (APMS) legislation enables private commercial firms to provide NHS primary care. There is no central monitoring of APMS adoption by primary care trusts (PCTs), the new providers, or market competition. Aim The aims were to: examine APMS contract data on bidders and providers, patient numbers, contract value, duration, and services; present a typology of primary care providers; establish the extent of competition; and identify which commercial providers have entered the English primary care market. Design of study Cross-sectional study. Setting All PCTs in England. Method A survey was carried out in March 2008 gathering information on the number of APMS contracts, their value and duration, patient numbers, the successful tender, and other bidders. Results A total of 141 out of 152 PCTs provided information on 71 APMS contracts that had been awarded and 66 contracts that were out to tender. Of those contracts awarded, 36 went to 14 different commercial companies, 28 to independent GP contractors, seven to social enterprises, and two to a PCT-managed service; one contract is shared by three different provider types. In more than half of the responses information on competition was not disclosed. In a fifth of those contracts awarded to the commercial sector, for which there is information on other bidders, there was no competition. Contracts varied widely, covering from one to several hundred thousand patients, with a value of £6000-12 million, and lasting from 1 year to being open-ended. Most contracts offered standard, essential, additional, and enhanced services; only a few were for specialist services. Conclusion The lack of data on cost, patient services, and staff makes it impossible to evaluate value for money or quality, and the absence of competition is a further concern. There needs to be a proper evaluation of the APMS policy from the perspective of value for money and quality of care, as well as patient access and coverage. [ABSTRACT FROM AUTHOR]

Summary [ABSTRACT FROM PUBLISHER]

Abstract The objective of this study was to compare hospitalisation rates by cause of admission, hospital death rates and length of stay for residents from nursing and residential care homes with those in the community. This is a retrospective study of acute hospital emergency admissions in one health district, Merton, Sutton and Wandsworth between April 1996 and March 1997. Data linkage and manual look up were used to derive emergency hospital admissions for residents of care homes aged 65 and over. Admission rates were calculated for cause, length of stay and hospital death for residents of care homes and in the community with relative risks. The relative risk of emergency admission from a care home compared with the community was 1.39 for all diagnoses, 2.68 for all injuries, and 3.96 for fracture of neck of femur. The relative risk of dying in hospital for care home residents was 2.58 overall, and 3.64 in the first 48 hours of a hospital stay (all P -values <0.0001). Admission rates were higher from residential than from nursing homes. There was some increase in admissions from homes during holiday periods and over Christmas. In conclusion, there are major difficulties in monitoring admissions from nursing and residential care homes due to poor quality recording and inaccuracies in NHS coding. This was compounded by an absence of data on the age and sex profile and healthcare needs of the resident population in care homes. Prospective studies are required to ascertain when admission is avoidable and when it is appropriate. The information strategy needs to ensure that routine data sources are capable of monitoring the use of hospital services by residents of care homes. [ABSTRACT FROM AUTHOR]

The article discusses the argument concerning the potential of the licence conditions imposed by Monitor on National Health Service (NHS) foundation trusts in reducing the hospital services. Topics include the introduction of the NHS foundation trusts under conditions set out in "authorisations" in 2003, the assertion of Monitor regarding the power of arbitration, and the legal duty of commissioners for the arrangement of services.

The article reports that the U.S. Health and Social Care Act 2012 will replace the administrative structure of the NHS in England and its implications on existing routine data systems and the production of routine statistics. As stated, under the Act, unlike primary care trusts (PCTs), commissioning groups will no longer have responsibility for geographical areas and their practices will be able to recruit patients living anywhere in England. It also states that some health services for which PCTs are responsible will be out of the health service entirely or may be provided under the new public health system.

The authors discuss the impact of the Health and Social Care Bill of 2011 on the National Health Service (NHS) in England. They note the bill's movement toward eliminating the NHS through the British Parliament, and facilitating the introduction of a U.S.-style health system. Moreover, the authors cite significant legal consequences of Bill which include weakening the accountability of the Secretary of State to Parliament for the provision of services to patients in the NHS.

Biomedical health services and health systems research require timely, complete, accurate and accessible data relating to geographical populations in order to facilitate needs assessment and planning of medical care, new medicines and technology. The international trend towards competition and privatisation has largely proceeded as if data generation were immune to market fragmentation and loss of universal coverage. By examining recent reforms to the English National Health Service, the authors show that this is not the case. Routine and population data are products of administrative systems and the nature, completeness and quality of data available to clinical and public health researchers are substantially impaired by market reforms. [ABSTRACT FROM AUTHOR]

The authors look at the policy of the Department of Health in England on confidential commercial data. They cite that the changes made by the department to the British National Health Service (NHS) allow it to avoid scrutiny. They note that the assessments of six commuter walk-in centre pilot programs published within the issue of "British Journal of General Practice" were limited due to a lack of access to contract and patient data. They argue that commercial confidentiality is aimed at concealing the failure of the policy of the department.

The article presents the authors' view on the fate of the government agency the National Health Services (NHS). Topics discussed include the authors' opinion on the 2012 Health and Social Care Act and its impact in the government's healthcare services, the similarity of the care organizations created by the U.S. Affordable Care Act of 2010 to the clinical commissioning groups of Great Britain and the authors' call for the creation of a legislative bill to restore the NHS in Great Britain.

Discusses the advantages and disadvantages of community oriented primary care as a method of teaching and applying public health skills in Great Britain. Description of King's Fund pilot project; Factors for needs assessment; Support for health authorities.

Background This article describes the issues encountered when designing a study to evaluate recruitment of minority ethnic groups into clinical cancer research in order to monitor adherence to the principles for good practice set out in the Department of Health, Research Governance Framework, England. Methods (i) A review of routine data sources to determine whether their usefulness as a source of data on prevalence of cancer in the population by ethnic category. (ii) A local case study at one hospital trust to ascertain whether the ethnicity of cancer trial participants was representative of admitted cancer patients. Results (i) The lack of a comparator population makes it problematic to assess recruitment levels by ethnic group in clinical research. (ii) The odds of being in a trial were 30% lower for a member of a minority ethnic group compared to a white cancer patient after adjusting for disease, age and gender, OR 0.70 (0.53 to 0.94). These results differed for each ethnic group; Asian patients did not appear under-represented while Black and Chinese did so. However, there are important caveats to the findings based on the limited recording of ethnicity. Conclusions The lack of available data on the ethnicity of participants in clinical research and the prevalence of cancer in the population according to ethnicity makes it difficult to design a study to monitor representation of minority ethnic groups. This information is necessary to assess adherence to the Research Governance Framework principle that research evidence reflects the diversity of the population. [ABSTRACT FROM AUTHOR]

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Objectives: To analyse and report on sports-related injuries using enhanced injury data collected by the testbed for the NHS emergency care injury data set and admissions data collected from inpatients., Design: Ecological study design., Setting: Two Oxfordshire NHS England hospitals., Participants: Emergency department attendees and inpatients aged 0-19 years with sports injuries., Main Outcome Measures: Data were analysed from 1 January 2012 to 30 March 2014 by age, gender sport, injury location, injury mechanism and diagnosis including concussion/post-concussion, bone fractures and ligament damage. Admissions data were analysed from 1 January 2012 to 24 January 2015., Results: Children and adolescents aged 0-19 years accounted for almost half (47.4%) of sports injury-related emergency department attendances and almost one-quarter (23.5%) of sports injury-related admissions for all ages. The highest rates of attendance occurred at 14 years for boys (68.22 per 1000 person-years) and 12 years for girls (33.72 per 1000 person-years). For male 0-19-year-olds the three main sports were (in order) football (soccer), rugby union and rugby league and for females, trampoline, netball and horse-riding. The largest gender differences were in netball where injuries were predominantly in females and in wheeled motorsports where injuries were predominantly in males. Almost one-quarter of emergency department sports-related injuries recorded were fractures, the highest percentage to the upper limbs., Conclusions: Public health departments in local authorities and schools should consider target sports injury prevention at children in the first four years of secondary school. For younger age groups, trampolines in the home warrant improved safety. Rugby and horse-riding should also be a focus for interventions.

Introduction: Childhood injury is a leading cause of mortality and morbidity worldwide with the most socio-economically deprived children at greatest risk. Current routine NHS hospital data collection in England is inadequate to inform or evaluate prevention strategies. A pilot study of enhanced data collection was conducted to assess the feasibility of collecting accident and emergency data for national injury surveillance., Aims: To evaluate the reliability and feasibility of supplementary data collection using a paper-based questionnaire and to assess the potential relationship between income deprivation and incidence of paediatric injury., Methods: Clinical staff conducted an audit of injuries in all patients under 16 years between June and December 2012 through completion of a questionnaire while taking the medical history. Descriptive statistics were produced for age, sex, time of arrival, activity at time of injury, mechanism and location of injuries. The association between known injury incidence and area level income deprivation (2010 English Index of Multiple Deprivation [IMD] Income Deprivation Domain from home postcode) was assessed using Spearman's rank correlation. Representativeness of the audit was measured using z-test statistics for time of arrival, age, sex and ethnicity., Results: The paper audit captured 414 (6.5%) of the 6358 under-16 injury-related attendances recorded on the NHS Care Record Service Dataset. Comparison of the audit dataset with NHS records showed that the audit was not representative of the larger dataset except for sex of the patient. There was a positive correlation between injury incidence and income deprivation measured using IMD score where data were available (n = 384, p < 0.001). Nearly half of the attendances were due to falls, slips or trips (49.8%) and more than half were due to either leisure (32.9%) or sport (18.1%) activities., Conclusion: There is evidence of area level income inequalities in injury incidence among children attending the Royal London Hospital. The audit failed to capture a high proportion of cases, likely due to the paper-based format used. This study highlights the importance of routinely collecting enhanced injury data in computerized hospital admission systems to provide the necessary evidence base for effective injury prevention. The findings have contributed to plans for implementation., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objectives: The pound5 billion English Independent Sector Treatment Centre (ISTC) programme remains unevaluated because of a lack of published contract data and poor quality data returns. Scotland has a three-year pilot ISTC, the Scottish Regional Treatment Centre (SRTC), the contract for which is now in the public domain. This study aims to conduct an independent evaluation of the performance of the SRTC during the first year of operation., Design: A retrospective analysis of the SRTC comparing activity as reported by hospital episode statistics returned to ISD Scotland with: volume and cost data in the SRTC contract; a 10-month audit carried out by management consultants Price Waterhouse Coopers (PWC); and an internal NHS Tayside performance report., Setting: All day-case and inpatient activity at the SRTC from 1 December 2006 to 31 January 2008., Main Outcome Measures: Activity and cost., Results: The annual contract was based on patient referrals to the SRTC and not actual treatments. The contract was awarded on the basis of 2624 referrals a year, total value of pound5,667,464. According to ISD data, the SRTC performed 831 procedures (32% of annual contract) in the first 13 months worth pound1,035,603 (18%). PWC's figures report 2200 referrals (84%) to the SRTC at a cost of 2,642,000 (47%) in the first 10 months., Conclusions: Basing the SRTC contract on payments for referrals rather than actual treatment represents a major departure from normal standards of reporting and commissioning and may have resulted in over-payment for referrals for patients who did not receive treatment of up to pound3 million in the first 10 months. The PWC report falls well below the standards one would expect of an independent evaluation and we were unable to validate PWC's analysis and the claim of value for money. If wave-one ISTCs in England perform similarly to the SRTC then as much as pound927 million may have been paid for patients who did not receive treatment. We recommend a moratorium on all ISTC contracts until the contracts have been published and properly evaluated with respect to work paid for and actual work carried out and quality of care.

Background: Reviews of peer-reviewed health studies have highlighted problems with their methodological quality. As published health studies form the basis of many clinical decisions including evaluation and provisions of health services, this has scientific and ethical implications. The lack of involvement of methodologists (defined as statisticians or quantitative epidemiologists) has been suggested as one key reason for this problem and this has been linked to the lack of access to methodologists. This issue was highlighted several years ago and it was suggested that more investments were needed from health care organisations and Universities to alleviate this problem., Methods: To assess the current level of methodological support available for health researchers in England, we surveyed the 25 National Health Services Trusts in England, that are the major recipients of the Department of Health's research and development (R&D) support funding., Results and Discussion: The survey shows that the earmarking of resources to provide appropriate methodological support to health researchers in these organisations is not widespread. Neither the level of R&D support funding received nor the volume of research undertaken by these organisations showed any association with the amount they spent in providing a central resource for methodological support for their researchers., Conclusion: The promotion and delivery of high quality health research requires that organisations hosting health research and their academic partners put in place funding and systems to provide appropriate methodological support to ensure valid research findings. If resources are limited, health researchers may have to rely on short courses and/or a limited number of advisory sessions which may not always produce satisfactory results.