Challenges in Care Delivery in the UK

1. Introduction to Care Delivery

The English residential care sector is a mix of for-profit and charitable provision, representing a diverse ownership landscape. In this context, care homes (also known as nursing, residential or residential care homes) occupy a pivotal position in the care of older people, offering accommodation, personal care, and sometimes nursing, to vulnerable individuals who require additional support . This often includes people with physical and learning disabilities, sensory impairment, and complex health-care conditions. People’s admission to care homes is, in the main, facilitated by population age (over 70 at time of admission is most frequent), but there are a number of other triggers. Factors that precipitate entry include cognitive impairment (44% of residents with dementia), poor living environment and pressure on primary carer. Referral is typically (85% of cases) through health professionals – especially general practitioners (GPs) (90%) and district nurses (6%). In low and middle-income countries (LMICs), older people with chronic conditions and multimorbid diseases often fall through the gaps in health service provision. This is particularly the case when they are further marginalized by living in poverty or belonging to minority groups. Older people also often experience multiple health conditions at the same time, either as multimorbidities (two or more chronic diseases) or as part of a syndemic (for example, diabetes and mental health conditions). Neither LMIC nor high-income country (HIC) health systems are effectively equipped to treat multimorbid disease. A final explanation is that the contemporary focus on non-communicable diseases as the priority for healthcare delivery in LMICs means that conditions more common in older people, such as dementia, are not a policy priority. This state of affairs comes in the wake of already-under-resourced health sectors, where supplies, human resources and infrastructure are in urgent need of investment, and underlies new concerns over the care of ageing populations in countries globally. Importantly also, where investments have been made in those priorities, much has tended to be invested in maternal and child health, with little left over for geriatric and older age care. This suggests potential gaps and weaknesses in the health-care delivery system to older people, even in HIC. Co-rostering of medical and nursing services improves the quality of health care delivered to patients. However, such service co-provision may also compromise clinical independence and generate significant power differentials between the two professions.

2. Historical Context of UK Healthcare

Anglicus meaning “sweet English sound,” was a mannerist word first offered to the South British Churches in the early 20th century but rejected by the British Committee for Ecclesiastical Collocation on the grounds that two archaisms can never make a heritage. Luckily, the free market offered a solution: in the United Kingdom, Anglican is now the legal, and more obviously modern, form. and with the benefit of hindsight the real motives of the clerical Bench for resisting change is clear enough. For under the false flag of historical continuity the South British churches had become a major player in the hitherto Anglican dominated ASKTA. To a sceptic it may look as if this ‘Anglicans’ commissioning the ecumenical NTVE, are trying to buy time for their arcane old methods. Given that the Church of England has now pledged itself to reach out and engage with the ‘globallonial’ populace those suspicions were wildly unfounded. The Free Church leaders foresaw the inadequacy of a patchwork National Church ill-equipped to minister to the Scottish or Northern Irish. Their plan was to sequester the historical name and paraphernalia of the existing churches in return for an annual stipend. In the fine print however they reserved the right to farm the name, particularly on the shelf of the Anglophones (Gorsky, 2013).

3. Current Structure of Healthcare Services

Four-fifths of health and social care service provision in the UK is carried out by the state. These provisions make health service provisions a natural public sector monopoly. A significant public-private distinction exists in health and social care services. The purpose of the creation of the NHS was to ensure a health service for all, free at the point of use and funded by taxation. Health care is exempt from VAT, but not all spending on products or services is health care. The use of ‘independent’ sector hospitals provides a means of reducing the administrative overload resulting from more demanding patients or unusual demands. While the use of private hospitals relieves the burden on public sector hospitals, this comes at the risk of dependence on them. There are a multitude of stories about arrangements between NHS hospitals and the independent sector leading to the latter cherry picking low risk, profitable treatments to the disadvantage of the former. Since the 2010 general election, NHS spending in England has increased each year in nominal terms. However, over the same period the wall of money has aged from a concrete barrier to a sagging fence. Relying on market mechanisms to increase the efficiency of state health and social care provision remains controversial, despite market discipline having played a role in health care procurement since the inception of the NHS. Independent sector providers can supply to the NHS in a variety of ways. Market mechanisms could be a means of controlling monitors, for example if the management of an ineffective trust were to be dropped by its local strategic health authority. Paradoxically, in regions like the Northwest the pressures cited for health service providers to break even by reducing elective surgery are also present for failing NHS trusts in social care provision. Sub-contracting care delivery is the most common private sector involvement in the public health care sector worldwide. Furthermore, it is claimed that health service outcomes improved after the use of market discipline to identify and make disinvestment in cardiology services.

4. Access to Care

Good access to primary care (general practice) is known to be an important determinant of population health; people who can easily see a local GP have better health outcomes. Papers have generally focused on quantitative measures. Policies in the UK aimed at improving access to general practice have tended to focus on the measurable aspects of access – for example, timeliness of access or number of appointments available to patients – rather than considering access as a complex, multivariable concept in a broader sense. In contrast, patients and staff describe accessing primary care as multifaceted and with a complicated set of influences, all interacting in a framework of complex adaptive systems. It is therefore important to explore how a ‘human fit’ understanding of access to primary care can contribute to improving policy and practice. Data analysis can sensitively support a polyvocal account of accessing primary care, in a transparent, replicable and reflexive way. Structure of provision - the broad framework within which general practice exists - differs between countries and is highly policy-dependent. This work is detailed against the structural governance and funding of general practice, particularly in the English NHS; it occurs in the ‘grammar’ defined by a confusingly complex set of healthcare policies. Investment in primary care by NHS England has sought to directly increase patient choice within a competitive market by providing greater convenience to patients, as opposed to providing equitable access to a qualified GP. What is described is how access to general practice is now discussed and measured in NHS England, focusing on same-day consultation rates, (absence of) waiting times, the choice of practitioner, and 7 or 8-day access to GP services. Reflectively, it details some of these measures of access and compares and contrasts these with publicly voiced concerns about accessing primary care at a local level.

4.1. Geographical Disparities

A commonly expressed concern is the North-South divide, with poorer services allegedly provided in the North of the UK than in the South. Several papers have assessed the North-South divide in relation to GPs and find little systemic evidence of it. One senses that the North-South divide is the perception concomitant with the identities of the government of the day, although some flooding is still required in areas of some constituencies of a given minister to persuade them that resources may be better spent in non-constituencies (Hole et al., 2008). In the UK, the Office for National Statistics produces a range of sub-national mortality data including SRs for the counties and UTLAs of England and the unitary authorities and LGD regions of the devolved countries. These have already been made subject to a robustness check, as current policies on health and other services, for example, GPs.

Other factors may influence the geographical distribution of health services. The so-called hierarchical model argues that health services are delivered from major urban areas and trickle down. From this perspective rural health care services may be seen as leached. A complimentary perspective is that of the inverse care law, although this longer term trend has been curtailed by, for example, changes in GP contracts in recent years. However, service provision is influenced by other criteria in concert with need; deprivation, household composition, age spread and telecommunications including the internet are local factors affecting the health service requirements of an isolated rural population. These act in conjunction with, or on top of, SIAs of the rural urban definition used. Thus if a perfectly resistant measure of isolation was used then the relationship between rural areas and GPs may be broken. This is because the aspatial relationship between such a rural index and GPs may be so opaque as to be trivial, although such a measure does not exist concerning rural isolation.

4.2. Socioeconomic Barriers

Introduction:

Preventative measures, such as screening, health checks and chronic disease monitoring, leave older people requiring even more health care (A. Ford et al., 2018). Some policies to improve access have been criticised because they are not sufficiently targeted at those with highest health need. Such policies may increase health care use by the worried well, increasing pressure on the system and counterproductively reducing access to those most in need. Previous research has found that older people, those in rural areas, and socio-economically disadvantaged groups are at particular risk of poor access and often have higher health need. The association between area disadvantage and poor access in England means that there are large numbers of people who fit into all three of these categories, but little evidence about them as a distinct group. Using national survey data, clinical quality outcomes, and published research to estimate the numbers and main health issues faced by socio-economically disadvantaged older people living in rural areas. Drawing on this research and a realist review of the literature looking at how socio-economically disadvantaged older people access health care, conducted focus groups with health professionals, patients, carers, patient groups and commissioners to explore the barriers faced by this population and to inform the development of targeted interventions.

European health care systems and governments are facing the challenge of how to finance ever-expanding health care costs and how to ensure equitable access to comprehensive health care for the population. Policy makers may favour restricting or blocking access to services because they believe this will save resources and consequently contain the growth of health care spending. However, a more satisfactory approach would be to compare the cost effectiveness of alternative, prospective policies for improving the operation of health care systems and hence access to services. In this respect, there has been much recent research on an analysis of the efficiency of primary care. Generally, the rhetoric of policy discussions in the UK has been about variations in quality of health care and poor access in the context of a national health service.

4.3. Cultural Competence

The fourth and final work package adopted an ethnographic process evaluation using participant observation over 12 months. Social semiotics were used to analyse electronic messaging, documenting the stream links, lines, and objects of communication. Conclusions: Although the pilot was supportive of integration, primary care staff faced barriers navigating separate systems and preserving distinct roles. The use of a single patient record was time consuming, whilst transfer of care feedback was lost between information systems. Further research is required into multi-professional electronic communication with greater consideration of workarounds and work burdens, and a focus on patient-centered communication. Greater attention to sense-making and social practice in the implementation of shared care initiatives is also needed, moving beyond analyses of data quality, reliability, and validity to consider how health professionals understand and use patient information (Adamson et al., 2011). It would be effective to train people on how to use the facilities and when they are available. Sessions with the interpreters should be introduced at a higher frequency, and staff need to take greater care with the interpreting booking form. An explanation of the research design in the DVD should be included. A switchboard training package covering the interpreting system and “how to get the best service for patients” will be made available to NHS Trusts in East London (Kai et al., 2007).

5. Quality of Care

The item most frequently linked to growing individuals, due to various reasons, such as: a stressful process; reduction in mobility; inhabiting vulnerable situations; curtailments to their social life; or being in later stages of life is impaired mental ability. This is applicable to any setting where individuals move, comprising tripping, falling, and being assailed. But, it is especially relevant in terms of someone's existence through coming to depend on a service-delivery environment. In the UK, it consists of Care (given the age 5-16); or Health and Social Care above that. This matter here shall henceforth be known as Care. Broadly speaking, such Care is provided through and maintained by individuals, in established residential and/or commercial infrastructures created for the purpose of providing Care. The spectrum is vast, but predominantly it concerns care homes and the like. Broadly speaking again, due to its essence as a service, this entire spectacle (the premises and the people) can be subsumed under the nominal care sector. This sphere is notorious and regulated. However, ensuring a Care Sector's service is not without its challenges. Four main areas of concern currently stand out. Topicality regards a general ill observance of the Minimum Standards. Emerging is the predicted issue of shielding the service against changes. Urgency however, to the growing concern of staff. And principality, advances the Call system. Whether considering the customer or the employee, collective analyses demonstrate the sector can create environments that easily lead to these issues. Few industries are so akin to being able to so readily do so.

Improving the quality of long-term care has been central to the agenda of UK Governments since the late 1980s. However, despite the investment in quality improvement mechanisms, there is ambiguity surrounding the quality of care received. Long-term care measures in England are explored. The number of adults over 85 is set to treble in the next 30 years, meaning that a growing number of frail elderly people will need care. It has been estimated that one in four elderly individuals develop dementia, a figure that increases to one in two for those over 85. Residential placements will be needed for these people, with the current total of 700,000 long-term care users likely to increase. Furthermore, the National Health Service and Community Care Act of 1990 redefined need, tightening thresholds to limit public long-term care funding. As a result, the percentage of the population over 65 in residential or nursing care has fallen to 470 users per 100,000 head of population, compared to 740 per 100,000 in similar industrialised countries. However, it is estimated that regional long-term care utilization varies by a factor of three.

5.1. Patient Safety Issues

Discuss patient safety issues relating to treatment by NHS professionals. Assess the seriousness of the patient safety issues identified in the Care Quality Commission's 2017 report on state of mental health services (Berzins et al., 2018). Any recent changes?

5.2. Standardization of Care

In the process of researching the comprehensive care of multi-morbid older inpatients in UK acute care facilities, it was observed that certain aspects of care were not meeting the Comprehensive Care Standard. For example, difficulties were encountered in implementing governance processes during an admission. At one site, physiotherapy was overlooked in the confusion of setting up and implementing an urgent post-take surgical review instead. At another site, social work input was absent from care plans, as it seemed that GPs were intended to provide community services to address the care plan goal of organizing community follow-up. Similarly, it was observed that care plans typically did not contain the full set of actions that must be taken with 48 hours left in admission (Xiong et al., 2023). For example, data with 48 hours left in admission at one site showed that while there was a care plan due with 83% of patient attendances, only 45% did have a care plan due. ADM were not always alerting the ward of the person’s admission. It was observed that Admitting Doctors (also known as General Medical Practitioners or ADM) were not present in person for 52% of ED reviews at two sites, indicating that comprehensive care planning was performed without examination of the patient. Usually, nursing care was overlooked altogether during an admission: data revealed that nursing care was documented as required for less than 5% of “potential disengagement” care plans. At the same time, constantly perusing the electronic medical record for data that your junior medical officer’s person-centred care goals have been achieved becomes dehumanizing, draining, and demoralizing. However, care plans frequently did not contain clearly documented goals that were patient-centered.

Much of the tediously and laboriously completed documentation was not always of substance. Despite the template vastly more paperwork would now need to be completed, efficient documentation would remain straightforward because the structure of the documentation would always be efficiently completed. The standardisation of documentation also raised concerns that a template would stifle the creativity of developing a comprehensive care plan with a truly multidisciplinary team. However, the template itself would be only that the documentation of consideration, decisions, and actions taken would all follow the same format. There would be nothing to prevent useful discussions between patient attendance and registrar both doing separate documentation, and NDP, SW, and CMO taking actions based on these discussions and then doing independent documentation. Additionally, fully documented patients are disproportionately pleasant for the discriminated against pt-care network, which has very technical for request, decision, and action. NASN, in particular, had been frustrated in a number of cases where they had initiated patient contacts but then no entries in his health record indicated that their involvement had taken place. Much of the omno’s patient contacts are only practicable through direct out-of-silo from the health record. However, when a template with clear placement of individualistic patient care goals has been introduced, it could be seen that nursing actions became much simpler to order in the care plan. Additionally, fully standardized care plans that would previously have been miscommunicated in longwinded discussions integrated with post-take handover now appeared in print. Furthermore, previously unseen delightful phrasing in multiple care plans and progress notes would greatly entertain both the agriculture science network and anyone else who read the care plans.

5.3. Patient Satisfaction

About 94% of attendees expected regular visits but barriers included conflicting commitments, long distance, caring for others, tiredness, waiting times, and inability to understand the doctor or, for some, their diagnosis. Attendees complained that, at admission, they were not informed about certain important aspects of their treatment that were later performed without their consent. Requests for visits to discuss questions or for explanations of diagnoses or treatments were refused by a few doctors because they were ‘too busy’. Attendees who were afraid initially waited for non-existent treatment. There was also fear because they heard that other people died in hospital. People wanted the opportunity to talk to female nurses during hospitalization but this was hampered by the small number of nurses and fear because male attendants were also present when they had to take a bath. People wanted better information about what was happening to them and the reasons. There was concern about delays in carrying out tests. Often tests were delayed by long waiting times to obtain the requisite form to give to the doctor. Staff at some small hospitals dispensed medications to patients after burying them on the premises. People sometimes received the wrong dose or successful drugs, and some were concerned that the drugs were perhaps no longer effective as they had been buried on the premises for 4-5 years. Some people received tablets from relatives or friends who were doctors, asking them to try them. People complained about the conduct of various tests, required for surgical fitness or diagnosis, which was costly and often repeated several times (Zakariya Imam et al., 2007).

6. Workforce Challenges

One of the most vociferous topics during the COVID-19 pandemic has been the staff working in the NHS. The general public will have been inspired by the heroism of individual staff but also be dismayed that they were put in extreme situations with far too little resource and preparation to support them. The NHS has always worked in a sea of competing ideas and policies, and health staff have felt this acutely as their work has been managed, regulated, and restructured in rapid and complex ways (Anderson et al., 2021).

Since its implementation in spring 2016 the return to practice programme has supported BME nurses to reregister following a break. The most recent figures show it had enabled 265 (14 %) former BME nurses to stand by patient care. This is important when the number of BME nurses and the overall need in the service are considered. The Multidisciplinary Advanced Clinical Examination is the medical college of doctors training to be A&E consultants in the UK.

Like many internationally trained clinicians applying, B was a doctor in Ghana with many years of experience in A&E. Upon arrival in the UK, B initially worked as an A&E department healthcare assistant before moving into a less acute setting picking up very favourable practical references. Yet despite being an experienced clinician with advanced unscheduled care training who spent most of hard-earned NHS salary on the exam cost, B was unable to secure a substantive job and networked with her UK trained colleagues. After 3 years B eventually found an A&E role but it’s part-time, band 5, requiring a commute to the other end of the city.

The National Health Service has long relied on foreign staff to a greater extent than health services in many other high-income countries. In 2018, some 13 % of NHS workers reported themselves as non-British and a further 6 % reported themselves as BME. Since the 1970s NHS jobs have been advertised in countries like the Philippines, where huge numbers are trained but where few have the resources or support at home to do so. This is one of the reasons why over the years many Filipino health staff have settled, made family lives, homes in the UK, and contributed long service to our collective health and social care.

6.1. Staff Shortages

One long-standing challenge in care delivery is staffing shortages. For several years, the National Health Service in the United Kingdom has been experiencing a staffing crisis caused by too few staff. This has led to a large number of unfilled positions, growing workloads for remaining staff, and patients not getting the care and attention they need. The UK historically relied on foreign staff, but fewer staff are coming and more are leaving.

The Global Code of Practice on International Recruitment of Health Personnel includes principles aimed at securing global health equalities. These state that the recruitment of health-care professionals must adhere to fair and ethical practices. Social responsibility, transparency, and sustainability are emphasised. In particular, there should be no recruitment from developing countries facing a shortfall of health-care staff. The Health and Care Workforce Strategy for England, with an accompanying Interim People Plan, highlighted the severity of national shortages in many areas from the early career progression level upwards. The difficulties in recruiting and retaining staff are often ‘disguised’ by the levers used to cover these shortages such as temporary, agency, or bank shifts, which are expensive and are reliant on health-care professionals being willing to work elsewhere ad hoc. An analysis of the health and social care workforce provided a detailed breakdown of difficulty in recruiting and retaining staff across the wider workforce. It states that workforce challenges are ‘the most significant that NHS Scotland has faced’. A similar analysis identified areas of recruitment and retention difficulty in different parts of NHS Wales. Two months later, concerns were voiced that some forty-two staff groups are in shortage across the NHS. And at the end of 2019, alarm was expressed that general practice is ‘at breaking point’ as many family doctor’s surgeries were not seen to be viable going forward. On its fourth-year anniversary, the promise to recruit 5,000 additional general practitioners in England by 2030 looked further away than ever. Meanwhile, the number of unfilled clinical vacancies in hospitals rose to over 9,300 by September 2019. Career progression options in the fields of nursing and allied health professions are also limited, thereby affecting demand and supply. In short, demand for new workforce planning policies to be aligned to outcome measures of staffing is united in the NHS. Regarding the latter, political party manifestos suggest a fifty thousand reduction in workforce staffings that is currently unrealistic in light of extensive clinical vacancies.

6.2. Burnout and Retention

A survey of health and care managers in Scotland reported that 38% of 86 respondents indicated that they often leave work feeling exhausted and that their work is emotionally draining (Anderson et al., 2021). Burnout was also linked to a poor work-life balance, leading to accumulated time off work. Just four of the respondents did not take advantage of the self-report question, “in the last 12 months have you experienced: emotional exhaustion,” which was a 69-item inventory within a longer survey of 86 health and care managers in Scotland. A 180-day survival curve showed that the unshocked group had significantly lower survival compared with the shocked group. In the univariate analysis, shockable rhythms (odds ratio [OR] 2.123 (1.671, 2.692), P < 0.001), CPR time (P < 0.001), and sudden collapse (OR 0.551 (0.377, 0.807), P = 0.002) were found to be independent predictors for the survival outcomes. Patients with hospital cardiac arrest presented significant heterogeneity among patient subgroups. Hospital-based measures should be appropriate with consideration of the prehospital process and patient-related factors, thereby avoiding harm and waste of resources. The interpretation of results also requires the consideration of the hospital-based measures prevalence and its local circumstances.

Medical doctors employed in health care institutions are a professional group showing a high level of work-related burnout. The level of burnout in all the clinical groups was high and it was particularly in consultants working in sparsely populated regions (McNicholas et al., 2020). Staffing levels and working hours have been quantified and quality indicators numbers of admissions, mean length of stay, and numbers of discharges and deaths was used. The discriminative validity of these measures was confirmed. According to the explanatory factor analysis, the structure of integrative measures of patient care quality is clear and interpretable. Irrational casemix-related demands (low nursing workload case mixes), excessive duty difficulty scale value hierarchical position at the ward.

6.3. Training and Development

In the Vision for Adult Social Care, the Department of Health and Social Care committed to the development of a workforce strategy, which was published in 2018 following delayed completion of the consultation exercises held in 2017. Addressing the key challenges facing this workforce – including the difficulty of recruiting staff, high turnover, and inconsistencies in the education and training available – was seen as essential to improving people’s experiences of care. The strategy recognized a growing pressure on the workforce and increased demand for adult social care. Of particular concern was that the number of people aged 65 and over in the UK was projected to increase substantially in the coming decades, particularly those aged 85 and over. When then-chief inspector of adult social care gave a keynote address at a conference last year, she reiterated the urgency of introducing social care reforms. To address these challenges, the Long Term Plan for the National Health Service committed to training more general practitioners and offering staff flexible working options. For adult social care, an ambition was set to ensure the workforce was able to provide high-quality service to more people. As part of this, a consultation was launched on proposals for workforce development funded by the apprenticeship levy. There was widespread acknowledgment of the scale of the task ahead, with many people being trained each year for the next 10 years. Other initiatives were highlighted, such as the establishment of local government’s work and the development of a digital strategy. Yet investment in skills and training is not only constrained by financial difficulties, but also by the government’s prolongation of uncertainty about the future of social care. Besides recommendations for improvement, cohesiveness and alignment of the available responses were offered. The 10-year commitment represents an important development in terms of workforce training, but a more comprehensive and detailed plan will be required going forward to provide a sustainable workforce. The following analysis has emerged from the responses to the consultation on Expectations and Challenges in the Delivery of Care.

7. Funding and Resource Allocation

In the UK, changes in care delivery models might be needed to improve the patient experience. The healthcare delivery changes should be cognizant of distinctions to care models. In the UK, the NHS is responsible for healthcare services. Social care is the responsibility of local councils and is means-tested. There have been concerns and criticisms over inadequate quality and variation in the social care provided. There have been proposals that the two separate systems could be better integrated.

A theoretical model simulates the effect of two policy change options to social care on the choices of providers and commissioners of care. The first option means council care users are given personal budgets, allowing them to purchase care from any provider. The second option allows councils to top-up any amount a care user contributes to care, providing the total is under the council’s own care costs. The simulation finds that introducing personal budgets would reduce the share of council care provided by food rated provision by 12%. However, it might also increase the share of council care choices by care users that are worse for the user’s health or QOL. The second policy could be set to increase the share of “good” choices without affecting the share of “bad” or “intermediate” choices.

Treatment experiments of the influences of different policy “potent doses” on the provider’s over-prescription of healthcare services suitable for self-treatment found that offering strong financial incentives to provide more appropriate care delivery increase “appropriateness” by 34 percentage points. It also found that introducing a “hard stop” rule leads to 100% of consultations resulting in “appropriate” care deliveries.

7.1. Budget Constraints

One universal challenge to care provision in the UK, as in other countries, are budget constraints. The systems of finance in the UK have always been potentially problematic, with a fairly tight percentage of the GDP allocated to the NHS since its inception; this meant the UK started from a worse position than others in terms of healthcare expenditure allocations on a government to government basis (J.E. Harding & Pritchard, 1970). The lack of money is fundamentally the biggest problem, and for 2014-2015 a significant amount of debt has to be taken on by the NHS, a sum totalling a historically high £2.1 billion. This debt problem is of particular concern following 2007, since 2013 has seen the best health results in the UK since records began for various reasons.

There are two basic models of how budget constraints could lead to poor quality care. A lack of money could mean that the necessary equipment, drugs, and people to provide good care are simply not there. This argument might be taken to indicate that all State-run health services will tend to be of a lower quality than private services, since the latter have no set budget, and rich individuals have much greater latitude to get care when they need it. Germany and France have always had around 9% of their budgets going to health care, so budget has hardly been a consideration for their healthcare systems. In Britain’s case: “health outcomes are at least as good as those in any other western European nation. If the desired aim for a healthcare system is the growth of professional fiefdoms, accompanied by risk aversion and blame management, the NHS succeeds beyond its wildest dreams.” The alternative formulation of this argument is that an NHS budget was set on a path destined to fail, i.e. it was established with the mark of Cain on it, and thus the “healthcare market” in the UK could only collapse at some point.

7.2. Inefficient Resource Use

Inefficiency in Service Provision can be the most difficult of both challenges to address. Efficiency is often seen as the most cost-effective way to use resources in order to reach certain outputs – for example, number of patients treated and waiting times, or lives saved and life years gained (Kerasidou, 2019). The notion of efficiency is indispensable in comparison with the management of scarce resources. Parents, teachers and taxpayers want students to be treated well but they also want all the medical materials they need to have at that time. Society needs to find the best use of scarce resources and make resources go deeper. In high-income countries, healthcare represents the category of services among the public addressing increased scrutiny on behalf of austerity measures. The increased demand for healthcare is faced globally, but even those countries that manage to improve GDP funding for healthcare still have a problem to make the most funding count in an efficient manner. This one increases the emphasis placed on performance measurement and the setting of operational targets and protocols to stimulate efficiency in the delivery of care. In current years, however, the presence of a sequential multidimensional service offered in combination with increasing demand has raised doubts concerning the compatibility of empathy and efficiency.

The art of efficiency is to make the best mix of the type and results of outputs and the volume of inputs to reach your objectives. It can often give a perspective of effectiveness, two sides of the same coin. With claims to scarce resources, attention and more weight are given to those who may demonstrate to be more efficient. Much of the confrontation and doctrine of competition targets the hegemony of public utilities and contracted out services. The deregulation of the public service sector typically involves the laying down of operational provisions and targets deemed to be satisfied for the protection of a dominant operator. Moreover, contract operators must report to the authority meeting a set of service quality and provision objectives and submit to compensation penalties if they fail to meet specified targets. Successful outcomes could include the imposition of a financial sanction or compensation to the beneficiary as a civil penalty akin to some form of redress against failure of adequate services. Paradoxically, the punishment of the standard breakdown is contingent upon the establishment of relatively ambiguous means of interpretation.

8. Technological Integration

Since 1948 the NHS has faced intermittent crises of care delivery, workforce, resources and political management, with various interruptions to service quality and safety. The current Crisis in Care report (Øvretveit, 2017) documents continuing examples of suboptimal care across a range of categories, beyond hospitals, in community health services, general practice, dentistry and residential care. The most immediate causes of these in this government period include NHS planning that relied on unrealistic efficiency gains, the impacts of recent exogenous austerity--mainly from cuts in real terms social care funding and in the rates of payment to the providers of health services. Political choices, an NHS and local government finance structure that is not well suited to the most expensive service users, centralization and performance evaluation, especially their focus on inside hospital goals, have all contributed. How current governance and information systems have magnified these challenges in care delivery in the UK, will be discussed. It is argued that improvements in tax-funded systems must target governance and software structures to genuinely support interventions at the most locally effective, user and patient-friendly level of service provision. This implies actively scaling down certain currently failing commitments of the NHS Long-Term Plan by shifting routine primary care to software-enabled local community services, labor restructuring and monitoring, in order to create immediate improvements at the point of service in publicly-funded care. Given recent political commitments to major new NHS funding settlements, it is argued that the efficacy and equity of these expenditures depend, as much or more than on the size of the cash injection, on the design and quality of supporting tax and information systems. Standardization of locally focused care delivery governance systems, an open-compliance based digital care marketplace app, cash-on-hand software allocations for monitoring output compliance, the progressive alignment of commissioning bodies, software, user and provider staff, and generally the steady but dynamic regulation and improvement in the technical, legalistic and data analytic software surrounding the interactions between the citizen, their landscape of accumulated digital data and the distributed provision of their local care interventions by the fractured, transient or tandemed employment of a medley of usually sectorally isolated health, social, private, public and volunteer service providers.

8.1. Telemedicine

Telecardiology screenings can significantly reduce heart disease in Black men. A new study finds that health screenings with cardiologists can significantly reduce outcomes for Black individuals with heart disease. The results provide evidence that giving patients the same attention and time as other patients can improve outcomes and, in the process, begin to address, in part, racial disparities in health outcomes. The findings could have implications for similar racial disparities in other diseases, including cancer and infectious diseases.

Following health screenings, the study randomly assigned Black participants who had visited the cardiology group for a healthy heart day, or had been referred by their doctor after a telecardiology intervention, to one of two groups. The attention control group was given the same 15-minute video about heart disease and treatments seen by millions of patients at group. Still, it did not depreciate the time it took for the patient to meet with a cardiologist. Alternatively, Black participants were reassigned to the cardiology news group, where they met a cardiologist, underwent health screenings that included checks of blood pressure, cholesterol, and diabetes. At the end of their meeting, they were sent with printed guidebooks that included personalized information about their condition but also general information about heart disease and potential resources. A phase of continuous process evaluation throughout the study was important as it confirmed the adherence of the intervention and was a better standard in future, similar projects (Singh et al., 2022).

The results showed that while the attention control group saw their cardiologists for the same amount of time and attention as the cardiology news group, and healthy year day and telemedicine participants that received magazines and healthy heart pots after they met a cardiologist. Participants who received magazines and posts at the group that received unhealthy conclusions went 78% for 40% and 57% after telemedicine. No other demographic group displayed this magnitude of improvement. Additionally, improvements in the blood pressure were greatest for patients with the highest scores at baseline. This indicates that changes were largely driven by men with prehypertension levels, although trends were consistent across groups, showing improvements for all groups with high blood pressure at screening (Salehahmadi & Hajialiasghari, 2013).

8.2. Electronic Health Records

Electronic Health Records (EHR) (also known by Health Informatics and Information Technology industry as EPR: Electronic Patient Records) are clinical, diagnostic as well as prescription and test results information that are collected by different health sector operators to gain better understanding of patient/s and accordingly define upcoming medical care and interventions. It takes this information storage from a combination of locally stored cabinets and online databases of convicted patients. There are generic difficulties in introducing Information and Communication Technologies (ICT) to support existing practices within routine health care environments. As EHR coverage will get wider, and thus number of interaction actors will increase, there appear problems related with matching individuals’ cognitive systems and practices with incorporated application features. Therefore, issues that arise at different times and more or less persistently as an effect of using an IT system appear. Some of these obstacles relate to inadequate software design and ambiguous training procedures whereas others can be seen as a result of general implementation of new technologies. They involve physicians and nurses personal characteristics and work organization systems. These diverse difficulties are monitored in quite wide social, cultural as well as geographical location and cannot be illustrated completely in a typical study. Other problems are Cyprus specific and cannot be observed elsewhere (Robertson et al., 2010). On the other hand, some of the problems remain generic.

8.3. Data Security Concerns

Introduction

Healthcare is prone to cyber-attacks for several reasons, many of which were exacerbated when healthcare services had to work remotely in response to COVID-19. There are several types of data security concerns. Most notably about data breaches, which may come on a large scale in a rapid and uncontrolled manner. Beyond data breaches, many people are concerned about the security and privacy of their data, including health records, writ large. Research on public perceptions shows worrisome but complex findings. People have both high expectations and resigned acceptance. It is also known that people tend to prioritize the benefits of digital services over any potential costs.

Data security concerns in electronic health records relate to privacy and confidentiality (Papoutsi et al., 2015). Given the forthcoming new data system that the NHS is building, such concerns became urgent and are the topic of this study. It should be noted that security and privacy are not the main issue here: the importance and sensitivity of (some) data in EHR are taken for granted. In the health informatics literature this point is often made by practitioners with the advice to privacy advocates to ‘just get over it.’ It is widely recognised that security and (patient) confidentiality are paramount in health informatics, largely because the former is needed for the latter (Coventry et al., 2020). It is hard to overstate how essential patient confidentiality is, although it is often taken for granted, or thought of as done through a few key procedures and therefore easily assured.

9. Policy and Regulation

The relationship between health and social care has been at the forefront of the government’s agenda for a number of years. In a cabinet reshuffle in January 2018, Secretary of State for Health Jeremy Hunt had his responsibilities widened to include social care. Interestingly, Hunt’s speech also proposed the further integration of health and social care. Crucially, Hunt’s successor, Matt Hancock, retained the same responsibilities. In July 2018, Hunt and Hancock were officially the longest-serving health and social care Secretaries since those roles were combined. This came at the same time as Hunt and Hancock secured an above-inflationary settlement for the NHS. It was a 4.4 per cent real-terms increase, representing an extra £20.5 billion over five years. There remained a question about the balance of political emphasis and tangible results. There were reasons for thinking a new approach to health and social care was necessary. Aging population patterns require significantly more resources for what the New Policy Institute terms “pensions, the NHS and social care.” Despite the new money for the health service, pressures remained. Social care funding had continued to peak at a lower level than during the Coalition administration. People continue to be eligible for care only after they have spent down most of their assets (Mark Booth, 2019). Some claim this means that “84 per cent of the care we get in this country is from unpaid carers.” This leads to “substantial personal and economic benefits” but leaves the elderly at risk of isolation and insufficient help. Social care was “designed for Victorian times,” and so a proactive effort aimed at rethinking policy was required. This led to the “IMBE” priority: integrating health and social care so that each individual is treated as an integrated person, instead of being divided into different areas. An increased stress was placed on prevention. The rise in the state pension age to fifty-five meant that the self-evident improvement – or at least the extension – of healthy life was “probably the primary aim” because the increase in old age “had happened far quicker than anyone anticipated.” Finally, attention was paid to the advances that might enter the medical field in the mid-term. Merged with the processes of genomic sequencing, this could lead to “precision pharma.” In 2019, the Health Secretary noted the unreasonable levels of claims for whiplash injuries, as this “contributed to sky-high premiums for all drivers.” The government aimed to “crack down” on the “fraudulent” claims, ultimately reducing the cost of motor insurance by £1.2 billion, while ensuring “whiplash claims” fell by as much as 60 per cent. The initiatives comprised an increase of the small claims limit from £1,000 to £5,000 for all road traffic accident claims, which would “discourage minor, exaggerated, frivolous or fraudulent claims,” and the introduction of a fixed “set of tariffs for whiplash injuries with a duration of up to two years.” This would “provide more clarity to claimants on the compensation they will be paid and bring payment for all other injuries in line with more serious claims including those covering the same injury in other contexts,” and “making it easier to predict the cost of settling claims.” In addition, the creation of a portal for “whiplash injuries” with a duration of up to two years would “make the process more simple, timely and transparent for claimants” to use. Booth responded in very reasonable terms. The costs of motor insurance had come down a lot over the previous decade, “largely thanks to rigorous control of cold-calling,” so there was no evidence of this huge saving that would be passed on. It was desirable that minor injuries were treated appropriately, but the new scheme risked generating more money for the insurers, and the complex incentives seemed to ignore the results of the 2013 “Jackson reforms,” which suggested that a considerable amount could be saved on costs. Furthermore, the introduction of “tariffs for injuries” was of concern, as the effects of the scheme on the rehabilitation of claimants remained unclear; this was in addition to the previously unexplained claim that the new scheme would better align payments.

9.1. Government Policies

Successive Westminster governments’ tendencies to deprofessionalise nursing and devalue health improvement has left the service workforce and service configuration unprepared to rise to the challenge of responding to current complex health needs. Instead, the UK health service has a historical configuration and staffing model focused on acutecare hospitals dealing with longstanding high treatment need issues that of course still predominate. Current complex needs emerging since the 1960s onwards addressed in social care or community & primary care (McKee et al., 2021). However, despite the long term planning implications of key reports, and particularly the black report in 1980 supporting the need for a more sophisticated health economy, comprehensive integrated joined up responses addressing social, mental and physical health have not come to the fore, instead services appear stretched by need that didn't just suddenly arrive unanticipated, rather was gestating and partially recognized for decades. In looking for a solution it is difficult to avoid the conclusion that government policy aimed at providing a health service rather than a reactive illness service has been transparently inadequate and short term aiming but for temporary electoral gains where they reflect economic policy and neoliberal social thinking. Detailed responses to this policy arena are readily formulated and Keynesian vs market based economic policy dispute is evident in many grand national societal areas, but it is a separate approach to the more grounded but reactive issues addressed in the rest of the correspondence.

9.2. Regulatory Challenges

One of the most important questions the NHS faces in the coming years is how to integrate health and social care. Public and political debates often take for granted the belief that integration is in and of itself a good thing. Moreover, so the rhetoric goes, self-evidently, health care and social care should be brought together such that one smoothly merges with the other. The UK government is planning to reform structures on both sides of the border between health and social care, but the divergence is indicative of the need to be much more specific in questions about why care integration might be advantageous and how it can best be achieved (Mark Booth, 2019).

Service integration was also understood in 2003 as a watchword of the long-term strategy for health and social care in Wales, although 13 years later the Organisation for Economic Co-operation and Development highlighted the relatively poor performance in Wales on integrated care and it calls for “renewed emphasis on whole system change”. In Wales, both the Wanless report and the Parliamentary review saw service integration as paramount. A plan for primary care published in 2009 has resulted in valuable changes to the engagement of primary care but overall progress has been very different to that in Scotland (Willson & Davies, 2020). Because of the small population size and high unit costs, it has been argued that the best method of providing health and social care to the Scottish islands is to integrate the provision of these two services.

Implementation issues for integrating health and social care must necessarily be of a local nature. There exists a partial division between the NHS and social care in England and Scotland and a very different pattern in Wales. In addition to 9 health boards, Welsh Government legislation has created a complicated series of partnerships with 22 regional partnerships boards and 7 public service boards, all having different and overlapping geographic footprints. In a parallel exercise, 64 primary care clusters are intended to develop locally appropriate services. A further complication has come with the introduction of a national network of lead roles with aspirations to supervise the cluster-based work and to feed into strategic national priorities. A financial model has been developed to incentivise some cluster activities and give the lead roles financial responsibilities, although it’s yet to be tested in practice. An inquiry reporting in 2017 found limited evidence of reduced pressure on general practitioners or secondary care.

10. Patient-Centred Care

Internationally, the measurement and provision of patient-centred care is receiving growing attention in the policy and academic communities, and the focus of recent interventions. Patient-centred care is perceived to provide a valid measure of the consideration given to the quality of care, and is particularly relevant given the increasing recognition of the importance of non-communicable diseases in low and middle income countries, and the increasing amount of chronic and long-term care required. There is a recognized and growing importance of engaging patients, families and communities in health services, and a desire to provide more responsive care at the primary level. This paper examines the level of patient-centred care provision in a health centre in Eastern Uganda using a mixed methods approach. It finds that care at the health centre is perceived to be particularly poor in decent care provision. Quantitative results show this variable to be the strongest predictor of a negative evaluation of care in the negative binomial regression model, and a significant predictor in the binary logistic regression model. Simple descriptive statistics show that the level of patient-centered care provision is assessed considerably poorer by patients than by a convenience sample of care health providers at the health centre.

10.1. Involvement in Decision Making

How much care can the NHS afford to give? Who gets it? Is it good enough; does it feel right to the people who deliver and receive it? These questions lie at the heart of recent, ongoing and future policies, strategies and media debates into the ‘modernization’ and ‘renewal’ of health care in the UK. Underlying them are assumptions and aspirations regarding rights to treatment and care, social obligations, patients’ entitlements and responsibilities to, in, and for their illness, concern for the experience and involvement of people involved in health care (Entwistle et al., 2007).

The opportunities, processes and impacts of involvement, in medicine and care delivery, have attracted attention across a broad range of academic disciplines in the social sciences, medicine, nursing and management, and been the focus of considerable policy (and resource) investment. Of particular concern are understandings and experiences of decision-making – an arena which, comprising situations and tasks, communicative skills, information exchange and choices, is central to treatment and care. Thus, the moves towards and establishment of patient ‘informed choice’ and ‘shared decision-making’ are prominent and contentious developments in the administration, organization and delivery of treatments within the NHS (D. Doekhie et al., 2018). On the part of the (new) Government there is a stated ambition that ‘patients will have a real say in the decision-making process’; professional organizations are to be involved in this ‘enormous culture change’ that will lead to a ‘genuinely shared health care’. This new spirit of involvement may be widely seen as positive and politically more desirable than well-documented accounts of exclusion or paternalism in patients’ care experiences. However, as the working practices and everyday realities of patient involvement and, particularly, treatment choices, become visible and evaluated, a somewhat different picture may emerge and highlight the significant challenges of realizing, and delivering, more informed and shared decisions in diverse settings.

10.2. Holistic Approaches

‘Holistic’ approaches to provision of care is an age-old debate, fragmenting care is not delivering it in a truly holistic fashion. However, care delivery may be considered fragmented at transitions of care points, such as admission to or discharge from hospital. Contemporary debates question whether the notion of holism should be the goal of care delivery or conversely be perceived as the biggest micro-perspective problem facing the delivery of care today (Jester & Green, 2019). Clarification of definitions is necessary, pertaining to the terms ‘delivery’, ‘holism’ and ‘care’. (Harvey et al., 2018) denote care delivery as the ‘broader context within which provisions of care occurs’. This may relate to the US understanding of healthcare delivery which covers not only how care is provided, but also how it is paid for and by whom. Care providers come from an array of traditional and alternative professions, non-professional services, and social networking. Other sources of care may be as informal as the care given by a neighbour or as formal as that provided by a paid or unpaid carer. Regarding holism, it is recognised as traditionally the focus of nursing care practices. However, over recent decades, biomedicine has increasingly adopted a holistic discourse and it is now common practice for interactions between HCPs and patients to incorporate holistic language. This is demonstrated by the adage ‘there is more to you than just your condition’. Contemporary millennial duty of care is of greatest priority among healthcare professions, even though care delivery should be focused to a broader spectrum of personal and public care initiatives. Thus, care may need to be dispersed so it may encompass primary, secondary, and tertiary domains of intervention. Expanding discourse on postoperative care brings in new networks of personal and community obligation to help in the process of recovering welfare and healthy life for all people. Cascade care models introduced in order to help people in a better and more qualitative way, targeting vulnerable groups. International documents obligate professionals to offer help to those who are in need due to different reasons. Educational models of care broaden the network of professionals who are obligated to act as caregivers. In broader terms, care could be defined as a broad array of care delivery and management of health services encompassing a comprehensive field of care accommodations in varying social, cultural and institutional contexts.

11. Impact of COVID-19 on Care Delivery

While the UK struggles with the implications of the COVID-19 pandemic in terms of care delivery, researchers predict the impacts are likely to persist into the longer run. The coronavirus pandemic has had huge impacts on the National Health Service (NHS) (Propper et al., 2020). Patients suffering from the illness have placed unprecedented demands on acute care, particularly on intensive care units (ICUs). There has therefore been an effort to dramatically increase the resources available to NHS hospitals in treating these patients. This has involved reorganisation of hospital facilities, redeployment of existing staff and a drive to bring in recently retired and newly graduated staff to fight the pandemic. These increases in demand and changes to supply have had large knock-on effects on the care provided to the wider population. So, in turn, the changes will demand adaptation by researchers and health professionals alike to understand their likely implications. The paper suggests the cessation and postponement of some medical treatments, in response to both a direct result of this policy and changes in patient behaviour. There have been large falls in both general and acute admissions to hospital. Falls were particularly pronounced for those aged over 60, suggesting this group took the stay at home message to heart. For comparison, visits to A&E that turned out not to result in admission fell by 43% relative to their normal level. Initial results suggest there has been an increase in mortality caused by cancers and also by mental health conditions. Patterns of past care suggest those most likely to be affected by these disruptions will be older individuals and those living in more deprived areas. There is a worry that the switch to remote monitoring of patients will widen the digital divide and therefore be particularly harmful to the groups who are least able to care for themselves.

11.1. Service Disruptions

Service disruptions can be broadly categorised as unscheduled and scheduled disruptions. Unscheduled disruptions are those that are not a part of the intended plan and can be caused by either patient-related factors or non-patient factors. Scheduled disruptions are part of the intended plan, but represent changes to the baseline case. They may have been planned at the last minute or before and occur due to reasons such as scarcity (e.g.: lack of beds, staff, or other resources), due to political priority, or due to other reasons. The metric in the planned sub-type is the percentage of disruptable resources that are disrupted. Also included are the types of service delivered, changes in service type and service interruption. These metrics describe the occurrence of unscheduled interruptions to the service of care for a patient. It is argued that these metrics do not depend on a specific disruption, but rather examine the dynamic changes or disruption models at a higher level of abstraction (Burnett et al., 2012).

It is found that in an 80-case derivation study set of cardiac surgeries, patient-related reasons account for the most disruptions associated with unscheduled disruption codes, about 75% in various analyses (given that in most cases multiple disruptions are coded). The most common reasons were ‘‘patient not ready’’ with 32%, or 24.7% of the disruptions, and ‘‘patient cancelled’’ with 21%, or 16.3% of the disruptions. The latter (patients cancelled) is an idiosyncratic factor for cardiac surgeries and not surprisingly is deemed somewhat less relevant for the revision. On the other hand, ‘‘patient not ready’’ disruptions were found relevant at 32%. Importantly, however, schedule and communication factors accounted for almost a quarter of the disruptions. This is a substantial finding further supporting the relevance of using service disruptions as the analysis constructs.

11.2. Long-term Effects on Healthcare

The UK COVID-19 pandemic has become a focal point of attention in the political, economic and health arena, among others, and a growing body of research continues to reveal the long-term effects on healthcare. Despite many of the positive developments in treating COVID-19, the pandemic has also highlighted issues that are inherent in the design and provision of healthcare services. The mental health burden has been exacerbated and underpinned by a reduced capacity or capacity of clinical and community-based mental health services. The healthcare infrastructure in lower-resource settings has been extensively highlighted and these stories often focus on the lack of oxygen, drugs and personal protective equipment, and the difficulty in accessing remote or rural areas. Participating countries have made significant financial contributions to the COVAX facility, which aims to harmonize the distribution of vaccines around the world. The British Health Secretary announced that the country was about to vaccinate the entire adult population - a news story juxtaposed with footage of queues of ambulances outside hospitals and overflowing morgues (Fang et al., 2024). This means a widespread postponement of other treatments, as happened during the April 2020 blockade. However, the pandemic’s secondary impact on healthcare was found in the communities hardest hit since January 2020. While these stories often focus on the acute stage, there are large numbers of people who continue to suffer from a wide range of symptoms several months after their acute COVID-19 symptoms have resolved. The morbidity has ranged from the relatively mild, albeit debilitating, to the severe, and this spectrum has been colloquially referred to as Long COVID. It is estimated that tests have been positive by 5-10% of those who received them. This fast - and not unexpected rise in LC patients places new and significant pressure on the UK healthcare system. On one hand, late diagnosis can result in deficiencies in the right care for the symptoms that have evolved for a long time, partly because there are existing gaps in knowledge about the disease. On the other hand, thousands of new patients are likely to exacerbate delays and backlogs in already overwhelmed systems, taking resources that could otherwise be assigned to new infections or backlogs of elective care. Emergency facilities grew in ICUs during the first wave, and now the NHS Red List - referred to as the waiting list for treatment including cancer and heart disease - has increased by 20%.

12. Comparative Analysis with Other Countries

Although the UK health system is not unique in its financing, coverage, and delivery of healthcare, the way it is managed and delivered to the population is distinct and is changing at a different rate to countries with parallel health policy and system organization. The focus group discussions by groups of international researchers discussed the way in which the health systems in the countries of interest to this study are organized and embraced issues of decentralization, governance and accountability, resource allocation, quality of care, staff training, and composition. Using comparable data from several international organisations, the study compared the UK health system with those of nine other countries across seven main domains: population and healthcare coverage, health and long term care spending, structural capacity, utilisation, access, quality, and population health. Additionally, single-payer and healthcare reforms in two other countries are also briefly reviewed, namely, Canada and Sweden (Papanicolas et al., 2019).

Unfortunately, the overall evaluation of the NHS was that other health systems are performing better than the UK. There was no single area where the UK was the best performing. Hence, there is still much work to be done to reach healthcare policy goals set by the government. It is expected that patient outcomes will suffer if the new basis for managing the health service in England compromises the ability of the system to improve in other critical areas. Such a compromise may inadvertently fail to realize the original aspirations for reforms. This is an unusual situation and one that is sufficiently challenging to warrant a major investment of time and resources to quantify the dynamics involved.

12.1. Lessons from the US Healthcare System

The horrific events of the past decades, from the World Trade Center attacks in 2001, various earthquakes, Cyclone Aila, SARS, the April 2013 Rana Plaza building collapse and the Covid-19 pandemic, have demonstrated that large-scale and unanticipated catastrophic events are always a possibility (Chintamaneni et al., 2023). These occurrences have raised the question of accountability and regulations in disasters. To tackle the problem of access to high-quality healthcare, it is crucial to identify and analyze potential barriers within the financial, geographic, social, and systemic domains. Despite its recent advances and emergence of innovative programs, India's healthcare system continues to experience severe disparities. For example, by using artificial intelligence with patient data for the early detection of in-hospital mortality, sepsis, and re-admission rates, the healthcare system has experienced many successes in enhancing access to care, patient safety, development of medical technology, application of artificial intelligence, management of chronic diseases, and public awareness. Moreover, the Patient Protection and Affordable Care Act was signed into law to fulfill the commitment to make vital improvements on the healthcare system. Officially known as the Affordable Care Act, it enhances the healthcare system by expanding Medicaid eligibility and is shaped into a major civic option where citizens can purchase health insurance with government subsidies. The Act establishes a comprehensive and inclusive health insurance system by promoting cooperation amongst employers, citizens, and the government. Subsequently, it made an impact on a widespread range of matters including the quality of care in hospitals, patient satisfaction, disease prevention; measurable changes among clinical practices. By it affected longevity, inter alia, the tractability to care for the family and the recurrence of prior chronic illness. Lastly, very low-income Americans have had the acquisition to private coverage for the first time in the past decades.

12.2. Insights from Scandinavian Models

There’s persistent interest in the performance of health systems, how to measure it, and how to learn from successful practice in other countries. There’s been strong interest in the health system designs of other countries, especially when their systems achieve apparently reasonable results at relatively low cost or include some features that are considered to be advanced or attractive. Among the high-income countries, the contrasting experiences within Scandinavia of Finland and Sweden that are sometimes linked together due to the similarities in their socio-political and welfare models are self-evident areas of interest for the European and other welfare states. On the supply side, the organization of the five health systems is broadly similar, comprising a comprehensive primary care sector and a secondary care sector that is largely publicly owned, relying occasionally on private providers (Charles Smith, 2016). The main concern in the secondary sector is that the lack of competitive pressure may contribute to the high waiting times for non-urgent care seen in some countries. The Nordic experience suggests that high levels of clinical performance can be secured without major recourse to competitive markets. The generally good collaborative relationships amongst Nordic countries offers a model for securing better understanding and standardization within broader groupings of countries (Tynkkynen et al., 2022). These opportunities have not yet been exploited, possibly because of it is the lack of widespread good performance data. Addressing this information weakness would be a high priority, with the primary benefit of improving patient care, but also providing a potentially valuable resource for enhancing the design and assessing efficiency of primary care.

13. Future Directions in UK Healthcare

The COVID-19 pandemic has underscored the importance of collaboration among health systems and reinforced political commitment to strengthen the health system’s resilience. Moving beyond the COVID-19 pandemic, there are many compelling reasons for policy leaders in China, the United Kingdom, and other countries to explore how to deepen collaboration. Both China and the UK face similar pressures of an ageing population and a rising burden of non-communicable diseases. The COVID-19 pandemic has further exacerbated the challenges for health systems. Policymakers in China and the UK face some similar short-term choices. As the pandemic recedes, do health systems shift to pre-pandemic modes of operation or persist with some of the innovations adopted during the pandemic (and if so, which ones)? In the UK, this choice applies not just in the National Health Service in England but also in the other NHS countries. Many of the innovative practices seen in response to the pandemic are likely to require collaboration across different parts of the health and social care system, so policy options for the NHS in Scotland, Northern Ireland and Wales may span devolved and reserved powers. However, these challenges are matched by opportunities for innovation and renewal across the integrated health and social care system. Collaboration-based approaches to AI and innovation offer scope to enhance patient outcomes and experience, when properly aligned with the health and health care needs of NHS patients.

13.1. Innovative Care Models

Care provision in the UK is currently suboptimal. People living in care homes are at increased risk of ill health, and this combined with the running of the business of care homes means that care home residents may have difficulty in accessing health care (Goodman et al., 2015). This report on research to improve health care delivery to care home residents took place in three parts: 1) a synthesis of the evidence relating to the care of care home residents; 2) primary research to investigate current practices and develop and pilot an intervention to improve health care delivery to and in-reach from primary care to care home residents; 3) qualitative interviews with care home managers, primary care nurses and general practitioners regarding the research process. The first and second portions of the research have been reported on separately. This paper reports the findings of the interpretive interview study which took place in a rural and urban area of NW England.

Cardiometabolic outcomes form the focus of attention integrating systematic review evidence on effective health care delivery and healthcare utilisation modelling. An economic model is developed accommodating the full joint distribution of outcomes and process of care variables, delivered within a health economic framework that accommodates multiple model structures. The integrated model is transferred to National Institute for Health Research OPTIMAL research group, within which it shapes study protocols investigating health care delivery to UK care home residents. This work provides a detailed account of theoretical and practical challenges overcome when developing a hybrid data generating model that is generalizable to the multidisciplinary and complex health economic subject of care homes.

13.2. Policy Recommendations

This paper sets out challenges in care delivery to be aired with UK policy and proposes the development of a health insurance industry. The long-term funding gap in the health sector and the long-term supply-side pressures on the provider side are reviewed. By extending social insurance models to cover healthcare, and then social care, it is proposed that significant potential health gains can be generated from high assessment health payments and health insurance industries.

Welfare assessment of health and care provisions in the UK is far from new and it is also well-trodden ground. Whilst there are no solutions to be feeble-mindedly proposed, there are still questions to be asked and critiques to be aired. Given the long-observed unwelcome expenditure pressures of the NHS, and the U-turn of a previous government, any subsequent government or governments that promised more putatively to increase spending may find it difficult to avoid the same political difficulties. In fact, it is reported that the current government plans to significantly cut per capita spending to the levels seen in a previous year, and then frozen per capita spending thereafter given an aging population and increasing demand for healthcare. At the same time, it has been noted that there is lacking transformation of care provision in their long-term report on the NHS. 5 years seen a marked slowdown in NHS improvement and no underlying improvement in NHS productivity since a previous year.

The care delivery industries can suffer from the typical public sector problems of being resistant to innovation and change, central or local providers can exploit their natural monopolistic advantages with incumbent staff, and subsequent increases in prices and operation costs loom. Taking all of these challenges, it is argued an increasing reliance on substitute provision and more competition is not only desirable but necessary to lastly solve health care delivery problems. These issues can all be linked to observations and seem to suggest that the underlying funding gap will remain and only gather speed. Four potential sources of persistent health and welfare improvements if market-led changes are considered.

14. Conclusion

Discussion was held with 59 UK care home care staff, 9 care home managers, and 7 community-based older persons’ healthcare staff and community nurses. Participants were recruited from 3 care homes and the subsequent 3 district nursing teams they were registered with in 1 UK healthcare trust. Three focus groups were held with care staff, 4 individual interviews with managers, and 1 focus group with community healthcare staff. Group and individual interviews were analysed thematically (Robbins et al., 2013).

For care staff, the awareness, uptake, and knowledge of healthcare their residents were entitled to receive were raised as issues. Care staff reported difficulties in accessing healthcare for residents, barriers for residents in articulating health needs, and the response of healthcare professionals to requests for physician review to be provided. Concerns were raised about timeliness of care responses and overall continuity. For healthcare staff, care home staff and manager practices were raised as concerns, specifically related to end-of-life care planning. Care home staff and managers reported feeling caught between a lack of GP input or input perceived to be of poor quality, and public health nurses who they felt were over-reactive to requests for review. Care home managers expressed frustration at being blamed by healthcare staff for poor access and lack of overall primacy regarding healthcare responsibility for their residents.

This research adds to the evidence demonstrating tensions in the delivery of healthcare in UK care homes. However, notably, tensions were also raised despite health care professionals’ and care staffs’ opposing points of view.

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