England

Background and History

The National Health Service (NHS) was established in 1948 as one of a series of reforms originating in the 1942 government white paper known as the Beveridge Report, which helped to establish the modern British welfare state following World War II. One initial aim of the NHS was to change the way people accessed and paid for care, making taxpayers collectively responsible for funding it. In this sense, the improved distribution of services and equity of care were primary considerations from the beginning.1

Since then, the NHS has been responsible for a number of medical breakthroughs, including the world’s first computed tomography scan in 1971 and the birth of the world’s first baby conceived through in vitro fertilization in 1978.2 In 2019, the NHS started trialing the use of artificial intelligence (AI) and telemedicine technologies through the NHS AI Lab, with the aim of increasing patient attendance at appointments, supporting staff, and providing more equitable access to care.3

The Role of Public Health Insurance

English citizens, other people who are ordinarily resident, and those with a U.K. Global Health Insurance Card are covered by public health insurance.4 Individuals visiting England for more than six months must pay the Immigration Health Surcharge to access care.5 The rights of those eligible for NHS care are outlined in the NHS Constitution for England. These include the right to access care without discrimination and within specific time limits for certain categories, such as emergency and planned hospital care.6

Services Covered Under Public Health Insurance

NHS services that are free of charge for all residents include:9

• Preventive care
• Inpatient hospital care
• Outpatient hospital care
• Maternity care
• Primary care
• Rehabilitative care
• Clinically necessary home visits (including postnatal home visits and home visits following discharge from hospital)
• Mental health care
• Palliative care.

NHS services that are means-tested:10

• Clinically necessary dental care
• Eye care
• Long-term care
• Assistive devices.

Cost-sharing arrangements for publicly covered services are rare. Some NHS services are means-tested (for example, clinically required dental care, eye care, long-term care, and prescription payments).11 Others need to be paid out of pocket, including vaccinations not covered by national insurance (for example, hepatitis B, rabies, and yellow fever) and most types of cosmetic dental care.12

Safety Nets

In 2025, about 89 percent of medication prescriptions from community pharmacies in England were dispensed free of charge.13 People who are exempt from prescription drug charges include:14

• Children under age 16
• Full-time students ages 16 to 18
• People age 60 and older
• People with low incomes who receive certain benefit payments
• Pregnant women and women who have given birth in the preceding 12 months
• People with a valid medical exemption certificate
• People in receipt of war pensions or armed forces compensation programs.

The standard prescription charge for people who are not exempt is GBP 9.9 (USD 12.6).15 Those who have multiple or ongoing prescriptions can buy a prescription prepayment certificate, which covers all NHS prescriptions, including dental, and allows people to cap the amount they pay for prescriptions for a period of either three or 12 months.16

Other safety nets include assistance with dental and eye care. People under age 18 (or under age 19 and in full-time education), pregnant and recently pregnant women, hospital dentists’ patients, prisoners, and people with low incomes who receive certain benefits are not liable for dental costs.17 Eye tests are free for those under age 18 (or under age 19 and in full-time education), those over age 60, people with low incomes who receive certain benefits, people with (or who have close relatives with) glaucoma, and people who are registered blind or partially sighted. In addition, individuals under age 18 and those with low incomes who qualify can obtain financial support to meet the cost of corrective lenses (glasses or contact lenses).18

Transportation costs to and from specialist appointments or diagnostic tests are also covered for people who qualify under the NHS Low Income Scheme.19

The Role of Private Health Insurance

In 2023, 12 percent of the U.K. population had private medical insurance.20 People can purchase supplementary private medical insurance, but they can’t opt out of the public system.21 Private health insurance in the U.K. differs from private health insurance in the U.S., for instance, because it doesn’t usually cover emergency medical treatment or maternity care, and treatment by a private specialist under private insurance usually requires a referral from an NHS general practitioner (GP).22 Some employers offer private insurance as a benefit, but individuals can also purchase policies.23

The Role of Government 

The U.K. Parliament, the Secretary of State for Health, and the Department of Health and Social Care are responsible for health legislation and general policy in England. Health care services are provided to the NHS via NHS trusts. Trusts are public sector organizations within the NHS that serve either a geographical area or a specialized function (such as mental health services). All NHS hospitals are operated by acute, mental health, specialist, or community trusts; in mid-2024, there were 215 trusts.24

NHS England was a government-funded body that operated independently of the Department of Health and Social Care. Its responsibilities included the day-to-day running of the NHS, which includes managing the NHS budget and overseeing elements of the 42 integrated care systems.25 However, in March 2025, the U.K. government announced its plans to abolish NHS England. The government stated that bringing NHS England under direct ministerial control would streamline accountability and reduce administrative duplication with the Department of Health and Social Care. As such, over the next two years, NHS England’s functions are being merged into the Department of Health and Social Care.26

Integrated care systems are partnerships comprising NHS organizations and local authorities, among others, which take collective responsibility for health services across defined geographical areas.27

Some of the public agencies involved in health care governance in England include the following:

• The Care Quality Commission monitors the overall performance of integrated care systems and has regulatory oversight of health and social care providers.28
• The National Institute for Health and Care Excellence (NICE) sets guidelines for clinically effective treatments and assesses the efficacy and cost-effectiveness of new health technologies.29
• NHS Digital creates and oversees national information technology and data services in health care and uses data to improve treatment.30

Integration and Care Coordination 

In July 2022, the NHS established 42 integrated care systems to cover England. The aim was to improve cooperation between the NHS, local councils, social services, and other agencies.31 Integrated care systems replaced clinical commissioning groups, which were statutory NHS bodies that had been responsible for planning and commissioning health services for local regions since 2013.32

Integrated care systems are designed to integrate health and care services to help patients access the services they need as quickly as possible in a location that is convenient for them. They are also intended to confront inequities in outcomes, experience, and access; improve productivity in the health service; and create better value for money.33

Overview of the Delivery System

The NHS in England is a diverse ecosystem of providers, each serving a particular purpose or specialization. These providers can be broadly categorized into four groups:34

• Primary care is typically a patient’s first point of contact and includes GP surgeries, community pharmacies, dentists, and eye care.
• Secondary care includes planned or elective care that is usually provided in hospitals. It also includes urgent and emergency care, such as emergency and nonurgent telephone services, ambulance services, hospital emergency departments, out-of-hours GP services, and mental health care.
• Tertiary care includes highly specialized treatments, such as neurosurgery and transplants.
• Community health includes services such as district nursing, child health services, health visiting, and sexual health services.

Primary Care

GPs are most patients’ first point of contact for nonurgent health concerns, providing preventive care, managing chronic disease, and referring patients to specialists.35 In 2024, there were 64 GPs for every 100,000 people in England. As of October 2025, there were 38,649 GPs (full-time equivalent [FTE]), including trainees but excluding ad-hoc locums.36 In 2025, there were nearly 6,200 GP practices in England, with a median of 8,988 patients for every practice.37

The main subgroups of GPs are GP partners, who hold an ownership stake in a general practice, and salaried GPs, who are employed by a practice with a fixed salary and don’t have an ownership stake in the practice.38 Over the past decade, the number of GP partners has fallen by 25 percent, dropping from 24,491 in 2015 to 18,367 in 2025. In contrast, the number of salaried GPs has increased by 81 percent, representing nearly half (48%) of the workforce in 2025. Fewer trainees and newly qualified doctors are opting for partnership roles, and the decline in partner numbers spans nearly every age bracket, with the steepest fall (73%) among GPs ages 30 to 34. Multiple pressures are driving the decline, from the demanding workload and bureaucracy tied to partnership to the financial exposure of unlimited liability. These challenges discourage prospective partners and add strain to those who remain, while some practices offer few opportunities for new partners to join.39

In 2022–23, the average pretax income for GPs (contracted and salaried) in England was GBP 110,200 (USD 140,741).40

GPs are not required to provide out-of-hours care. Most parts of the U.K. have some form of GP service available 24 hours a day. However, challenges such as a lack of incentives to work out of hours mean that many GPs don’t provide these services.41

General practices also employ nurses, who play a role in most aspects of primary care, including screening and managing patients with long-term conditions and providing minor treatments. Advanced nurse practitioners have higher clinical qualifications and are able to assess, manage, and prescribe medication for some health conditions. In September 2025, there were 16,706 nurses (FTE) working in general practice.42 NHS nurses in the U.K. (across all health care settings) face challenges that include understaffing, overwork, and low pay — the average nurse’s salary is estimated to be between GBP 35,000 and GBP 40,000 (USD 44,699 and USD 50,085) per year.43 In December 2022, this led to nurses striking for the first time in the history of the Royal College of Nursing.44

Outpatient/Specialist Care

Aside from mental health services, secondary care in England is mainly provided at hospitals. It includes planned or elective care, emergency care, and out-of-hours services.45

Nearly all specialists are salaried employees of an NHS hospital, and their salaries are agreed as part of a national contract between the Department of Health and Social Care and the British Medical Association. In 2024, there were 118 hospital specialists for every 100,000 people in England. As of July 2025, there were 71,722 hospital specialists (FTE).46

Integrated care boards pay hospitals for outpatient consultations at nationally determined rates. Specialists are also free to practice privately within specially designated wards in NHS or private hospitals. In 2022, the Department of Health and Social Care estimated that 20 percent of specialist doctors in the U.K. worked in private practice, with about 2 percent exclusively performing private work.47

Physician Education and the Workforce

As of September 2025, the NHS in England had 100,023 vacancies, an improvement from the same period in 2024 when there were 109,919.48

However, factors such as discontentment and burnout are driving many health care professionals to work abroad: 30 percent of doctors are likely to move abroad to practice medicine in the next 12 months.49 In addition, a combination of staff shortages and slower pay increases in the NHS than in the private sector contributed to strikes by health care workers in 2023–24, especially among trainee doctors.50

In 2022, the U.K. had 13.5 medical graduates for every 100,000 people, compared with the Organisation for Economic Co-operation and Development (OECD) average of 14.2. However, this was an increase from 12.9 for every 100,000 people in 2016.51 Medical students in England pay GBP 9,250 (USD 11,813) per year to study. This adds up to GBP 46,250 (USD 59,067) for their five years of study. Medical and dental students can apply for the NHS Bursary, which is based on household income and covers the final two or three years of tuition, depending on course length.52

Hospitals

As of 2024, England had 1,140 hospitals.55 These hospitals are organized by 202 trusts, including about 10 ambulance trusts. Many trusts operate multiple hospitals. For example, Manchester University NHS Foundation Trust manages 10 acute and specialist hospitals.56

In March 2025, there were 142,157 hospital beds in England.57 In 2025, it was estimated that consultant-led beds had halved over the preceding 30 years. Medical advances have contributed to the decline because patients can now be treated outside of hospital settings.58 For example, in April 2025, there were 12,724 virtual beds (20 for every 100,000 people registered with a GP), enabling patients to get hospital-level care at home.59

In 2024, the density of nursing and midwifery personnel in England was 652 for every 100,000 people, which is low for the region – the European average was 826 for every 100,000 people in 2022. However, it is an increase from 2015, when England had 623 nursing and midwifery personnel for every 100,000 people. As of July 2025, there were 392,690 nurses and midwives (FTE) in England.60

Mental Health Care

The NHS in England spent GBP 16 billion (USD 20 billion) on mental health services in 2022–23, which is about 14 percent of its total budget.64

In 2024, about 3.8 million people in England accessed mental health, learning disability, and autism services, up by nearly 40 percent since 2019. Among these, one million were children; those age 16 were found to be the most likely to seek support, with one in five girls age 16 seeking treatment.65

Between June 2022 and June 2024, the number of people in contact with mental health services increased by 21 percent for adults (ages 18 to 64) and by 29 percent for children and young people. Yet the number of interactions they had with these services only rose by 9 percent for adults and 11 percent for children and young people. Long wait times for appointments are an issue, with children and young people waiting a median of 142 days for a second appointment.66 In the second quarter of 2025, there were 18,192 mental hospital beds in England, and 89 percent of overnight mental hospital beds were occupied.67

The 10 Year Health Plan for England, published in July 2025, aims to address wait lists, improve care, and streamline processes. The government intends to invest up to GBP 120 million (USD 153 million) in dedicated mental health emergency departments to allow patients to get same-day specialist care. It also plans to recruit an additional 8,500 mental health workers and expand mental health support teams in schools.68

There has been a steep increase in the number of mental health workers in England over the past decade — from 109,028 in 2015 to 159,471 (FTE) in 2025.69

The NHS Talking Therapies program for anxiety and depression was implemented to improve the delivery and accessibility of evidence-based, NICE-recommended psychological therapies. It allows both GP and self-referrals; in 2024–2025, 91.6 percent of patients had their first appointment within six weeks.70 About 1.2 million people accessed these services in 2024–25.71

Long-Term Care and Social Support

The NHS has struggled with an underfunded social care sector, which often led to roadblocks in health care delivery.72 In 2023, total long-term care expenditure was only 3.1 percent higher than in 2022.73 Some individuals with complex long-term health conditions receive funding from the NHS, but the majority of adult social support is funded via local authorities on a means-tested basis.74

The NHS pays toward long-term care (at home or in residential facilities), including end-of-life care, for eligible individuals with care needs arising from illness, disability, or accident.75 Long-term services range from high-intensity services, such as nursing care, to lower-intensity support in the community. Some individuals with complex long-term care needs qualify for free health and social care arranged and funded solely by the NHS.76

Health Care Spending Overview

Public funding for health services in England comes from the Department of Health and Social Care’s budget. In 2023–24, the department spent GBP 188.5 billion (USD 240.7 billion). The vast majority of this expenditure (94.4%) went toward day-to-day items, such as salaries and medications. NHS England received the bulk of the day-to-day spend: it was allocated GBP 171 billion (USD 218 billion) for health services in 2023–24.77

Overall, the U.K. devoted 11.1 percent of its gross domestic product (GDP) to health care in 2024. Government spending accounted for 81.3 percent of health expenditure. Out-of-pocket expenditures accounted for 14.6 percent of health care spending, followed by prepaid private spending at 4.2 percent.78

Pharmaceutical Spending

In 2023, 9.7 percent of U.K. health care spending was on pharmaceuticals, equaling USD 620 per person.79 This expenditure was split across the following categories:80

• Community-prescribed medications: 50.8 percent
• Over-the-counter medications: 24.1 percent
• Vaccines/immunizations: 7.4 percent
• Pharmaceuticals administered as part of a course of treatment: 17.7 percent.

The Voluntary Scheme for Branded Medicines Pricing and Access is an agreement between the Department of Health and Social Care, NHS England, and the Association of the British Pharmaceutical Industry.81 It caps the allowed total sales value of branded medicines to the NHS each year. The cap increases by 2 percent each year, and any sales that exceed the cap are repaid to the Department of Health and Social Care through a levy.82

Cost Sharing and Out-of-Pocket Spending

Out-of-pocket consumer health expenditures, including hospital treatments, medical goods, and other health services and products, accounted for 14.6 percent of total U.K. health expenditures in 2024. In 2023, the largest portion of out-of-pocket spending was for long-term care and dental services.83

No one in the U.K. has been pushed below the poverty line because of household health expenditure. This remained consistent between the earliest available data from 1999 and the latest available data from 2020.84

How Are Costs Contained?

In 2025, the government estimated that the NHS’s expenditure in a single year was higher than the total economic output of Greece. As of 2025, the NHS accounts for 38 percent of its day-to-day spending and is projected to increase to 40 percent by the time of the next election (2028).85

In its 10 Year Health Plan, the government hopes to contain costs by changing how the NHS’s finances are managed. This includes addressing bureaucratic issues, for instance, by merging departments with overlapping roles (for example, NHS England, see The Role of Government).86

Another initiative is to change how NHS providers are financed for the quality of care they deliver — rewarding those who deliver high-quality care (through bonuses) and withholding payment from those who deliver poor-quality care. Prior to the 2025 reforms, the NHS spent billions on provider deficits every year. In 2025, the government sought to contain this cost by ensuring that the GBP 2.2 billion (USD 2.8 billion) deficit support fund would not go to agencies that failed to meet their targets. By 2026–27, this fund will be completely phased out.87

Poor-quality treatments are also being addressed. NICE quantifies the expected quality and length of life patients can gain (known as quality-adjusted life years, or QALYs) to assess the value of medical interventions. QALYs help determine a cost-effectiveness threshold that enables the government to stabilize its outputs.88 Through the 10 Year Health Plan, the government is giving the agency the ability to withdraw treatments that are no longer cost-effective.89

The government is also targeting funds that are wasted due to poor productivity. In 2025, outpatient appointments cost the government GBP 14 billion (USD 18 billion). The government hopes to contain this cost by improving the NHS App, enabling patients to more easily book appointments, request follow-up appointments, and access virtual care.90

Health Outcomes

Average life expectancy in England has declined at an annualized rate of change of 1.6 percent since 2000. Women live about four years longer than men: in 2023, life expectancy at birth was 79.3 years for men and 83.2 years for women.99

Aside from biological differences, this gap is affected by lifestyle factors (men are more likely to engage in risky behaviors, such as smoking and alcohol abuse) and hazardous occupations (men are more likely to work in dangerous occupations with a higher risk of accidental death).100

The data also show that life expectancy is lower for men and women in local authorities with the highest levels of socioeconomic deprivation. People in the most deprived areas (top 10%) of England are three times more likely to die before age 70 than people in the least deprived areas (bottom 10%).101 This is mainly a result of more deaths caused by lung cancer, heart disease, and respiratory diseases.102 Women living in the most deprived areas spend more than 19 years longer in poor health than those in the least deprived areas.103

Overall, 64.5 percent of adults in England were classed as overweight or obese in 2024. People living in the most deprived areas were found to be more likely to be living with obesity. Nearly four in 10 (37.4%) of those living in the most deprived areas were found to be living with obesity, compared to just 19.8 percent of those living in the least deprived areas.104

Addressing Health Inequities

In the U.K., there are health inequities across ethnic and gender groups. For example, some minority ethnic groups are more likely to report poor health than people who identify as white British. The poorest health is reported by the white Romani and Irish Traveller group. Along with Pakistani and Bangladeshi groups, these groups are most likely to report low health-related quality of life in later life. The South Asian population is more likely to suffer from cardiovascular disease and diabetes than others.105

In 2021, the rate of Black women dying after the end of their pregnancy in England was 2.9 times higher than the rate for white women.106 In 2023, the Black infant mortality rate for England and Wales was 6.1 deaths for every 1,000 live births, compared with three deaths for every 1,000 live births among white infants.107

When it comes to women’s health, research has found that gynecological appointments in the U.K. have more than doubled since 2020. About 630,000 people were on wait lists for women’s health issues in 2024, including endometriosis and menopause care.108

In October 2025, the government announced its renewal of the Women’s Health Strategy as part of its 10 Year Health Plan. Some important objectives include reducing wait lists for gynecology appointments, eliminating cervical cancer by 2040, and making emergency hormonal contraception free at NHS pharmacies. The government has also implemented “Jess’s Rule,” which requires GPs to think again if a patient returns three times without a diagnosis or with worsening symptoms.109

From a clinical perspective, the NHS is implementing the evidence-based Core20PLUS5 framework, which defines specific population groups and clinical focus areas in its efforts to reduce health care inequities.110

Many factors causing health inequities are beyond the health care system’s control. “If you live in a poorer area, you’re likely to die sooner and live in poorer health,” says Hugh Alderwick, director of policy at the Health Foundation, a U.K. health think tank.

To bring health care to more deprived areas, the government plans to bring care out of hospitals and into communities, alleviating pressures on GPs and accident and emergency units. It aims to roll out neighborhood health services and centers so that patients can be treated closer to home. Prior to this announcement, trials of these neighborhood teams across England had reduced hospital use. For example, in the city of Derby, these trials led to 1,400 fewer short hospital stays and 2,300 fewer ambulance callouts for urgent but not immediately life-threatening cases among the population that is age 65 and over.111

There are no data available for the share of the population that reports an unmet need for medical care.

Health Care Innovation

In July 2025, the U.K. government launched its 10 Year Health Plan for England, which aims to shift care from hospitals to communities, from analogue to digital, and from sickness to prevention. The plan laid out ways to tackle workforce challenges, including introducing a new operating model, upgrading technology, improving transparency, and understanding how to better approach NHS finances.112

However, according to the Health Foundation’s Hugh Alderwick, the NHS is likely to continue to struggle until the government comprehensively reforms the social care system and formulates a strategy to reduce broader health inequities. Another problem, he says, is new governments implementing new health structures before giving existing ones a chance. Alderwick offers the recently formed integrated care systems (see Integration and Care Coordination) as an example: “I think the biggest risk is that, ultimately, the impact of integrated care systems is going to be strongly influenced by what national government does – how much funding it puts in the health system, [and] whether it properly funds social care and public health services, and its wider strategy for improving the nation’s health. Yet policymakers often underplay their own role in shaping and constraining what local leaders can do – particularly in a highly centralized political system.”

Health Care Technology

Following the 10 Year Health Plan, in 2025, the government invested more than GBP 2 billion (USD 2.5 billion) in technology to improve care. As part of the “analogue to digital” aim of the plan, the government hopes to improve support to staff by utilizing AI to improve treatment and operations. For patients, the objectives are:

• To create a single patient record that can be accessed by all health care professionals with the patient’s consent
• To improve the NHS App to make it easier for patients to manage appointments and discuss their care
• To create an NHS companion (virtual assistant) by 2035 to act as a doctor in patients’ pockets.113

Some changes were already being felt in 2025. In April 2025, 87 percent of hospitals offered services via the NHS App, up from 20 percent in July 2024. Between July 2024 and April 2025, reforms to the NHS App prevented 1.5 million hospital appointments from being missed.114

In addition to the single patient record, the government has coinvested GBP 600 million (USD 766 million) with the Wellcome Trust into the Health Data Research Service to improve data availability for scientists and researchers, supporting diagnoses and the development of treatments.115

The Health Foundation’s Hugh Alderwick feels positive about these developments — as long as they are steered in the right direction. “I think new technology is a means to an end, so a health system needs to think about how it can use new technology to meet its own objectives, like improving care for people with long-term conditions and reducing health inequities, rather than thinking about new technology as an end in itself,” he says. “The risk is that we are driven by the priorities of the market rather than the health system.”