In the nineteenth century medical care was provided by apothecaries, physicians and surgeons1. The latter two had superior qualifications and status, whilst the role of apothecaries (which evolved from Barber Surgeons and were initially only concerned with drugs) became more formalised in the 1815 Apothecaries Act. Part of the Act stated that, to become an apothecary, individuals must obtain a licence from the Society of Apothecaries and undertake an apprenticeship. During the early nineteenth century, the term General Practitioner (GP) was applied to the growing number of apothecaries who took the membership examination of the Royal College of Surgeons of England; and the introduction of the National Insurance Act (1911) guaranteed all working men free GP care. By the end of the nineteenth century, the practice of referring patients from general to specialist care had evolved.
Today, general practice forms the largest sector of the NHS2 and 90% of all contacts within the organisation take place in general practice. GPs are on the frontline of healthcare, dealing with the prevention, clinical diagnosis and treatment of medical conditions. The introduction of the new GP contract in April 2004 – the General Medical Services (GMS) Contract – fundamentally changed the way that primary practitioners work; explicitly setting out the duties they are expected to undertake and paying them for those services. The role of the GP is also beginning to diversify with the establishment of GPs with Special Interests (GPwSIs). These practitioners obtain additional expertise through training, in order to assess and/or treat patients who might otherwise have been referred to secondary care3. With an aging GP workforce, recruitment and retention issues are extremely pertinent at present. The Golden Hello and GP Returner schemes both offer financial incentives to encourage GPs to return to work or work in under-doctored areas. In addition, the number of places at medical school has been increased, which in time will give rise to a greater number of fully qualified doctors. In the future, the GP will deal with a more aged population with greater co-morbidities, requiring more tailored patient care. Technological advances and new patient diagnostics will aid the practitioner in providing care. In particular, emerging IT technologies will enable the use and transfer of electronic patient records and prescriptions. Patients will be given improved access to primary care and a choice of location/consultant for their outpatient appointments at the point of GP referral. From April 2005, Practice Based Commissioning (PBC) will be introduced in England, giving each surgery the right to receive a budget from their PCT to commission services from other providers.
In 1948, the Health Minister Aneurin Bevan established the NHS, an organisation providing free healthcare to the entire population. Today, the organisation can be divided into two sections: one dealing with strategy, policy and managerial issues; and the other dealing with the clinical aspects of care. The latter can be divided into primary care (including GPs, pharmacists, and dentists); hospital-based secondary care accessed via GP referral; and tertiary care (involving highly specialised doctors dealing with particularly difficult or rare conditions). The divisions between these sectors are becoming less distinct due to structural changes taking place in the NHS. In particular, the organisation is moving towards local decision making, breaking the barriers between primary and secondary care and enabling greater patient choice.
Each constituent country within the UK has its own healthcare structure, these are outlined below: In England5, the Secretary of State for Health is responsible for managing the NHS and is answerable to Parliament. At national level, healthcare is administered by the Department of Health (DH); whilst at local level Strategic Health Authorities (SHAs) oversee Primary Care Trusts (PCTs), who in turn commission GP services. In Wales6, the Minister for Health and Social Services is responsible for managing the NHS and is answerable to the National Assembly for Wales (NAW). At national level, healthcare is administered by the NHS Wales Department (NHSD); whilst at local level Local Health Boards (LHBs) commission primary, community and intermediate care.
In Scotland, the Minister for Health and Community Care is responsible for managing the NHS and is answerable to the Scottish Parliament. At national level, healthcare is administered by the Scottish Executive Health Department (SEHD); whilst at local level Primary Care Operating Divisions within NHS Boards oversee GP practices.
In Northern Ireland, the Minister for Health, Social Services and Public Safety (DHSSPS) is responsible for managing the NHS and is answerable to the Northern Ireland Office (NIO). At local level, four Health and Social Services (HSS) Boards oversee the Local Health and Social Care Groups (LHSCGs), which in turn plan and develop primary care services.
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