Health Care System and Reforms in the
United Kingdom: Lessons for Patient Protection and Affordable Care Act
Background
The
health care systems in the United Kingdom (UK) and the United States of America
(USA) have been very distinct in their structure, financing, efficiency and
effectiveness. The UK health care system has been considered better performing,
good quality, and less expensive, compared to the US health care system (Roe
and Liberman 2007; Blumenthal and Dixon 2012: 1353). The UK health care system
has undergone tremendous change in the last two decades. In July 2010, the
Department of Health presented a White Paper to the Parliament of the UK, which
laid out the new Governments’ strategy for the NHS. The strategy emphasized the
need to increase choice and control for patients, improving health care
outcomes, empowering health professionals, reducing bureaucracy, and improving
efficiency (Department of Health 2010: 3-6). This was followed by the Health
and Social Care Act, which was enacted in 2012 and came into effect on 1 April
2013. It proposed a drastic overhaul of the organizational structures and
financing of health care system in the UK[1].
Just a few months before the White Paper in the UK, the President of the United
States of America signed the Patient Protection and Affordable Care Act (ACA),
which aimed to improve the quality and affordability of care for all Americans,
increase quantity and efficiency of health care, and introduce measures to
contain costs of health care (Democratic Policy and Communication Centre. No
date)[2].
The
present paper will examine the experience of the United Kingdom in health care
reforms in the recent years, with a view to learn lessons for the
implementation of the ACA. The first section will discuss the key features of
the health care system in the UK, which will be followed by a short description
of the recent health care reform in the UK. A comparative analysis of the
recent health care reforms in the UK and USA will be discussed in the
subsequent section. The paper will also explore some of the key features of the
UK’s health care
system that would be desirable for the USA, and its feasibility.
Main features of the health care system in the United Kingdom
Health care in the UK is provided mainly through the National
Health Service (NHS), although the role of private sector is growing, especially
in the recent years (Perlman and Fried 2012: 611). The key features of the UK
heath care system are the following:
Organisational structure: The
NHS consists of the following healthcare systems: the National Health Services (England), NHS
Scotland, NHS Wales and Health and Social Care in Northern Ireland. Each of
these systems has its own specific characteristics, policies and regulations
and each system is administrated
separately. Overseas visitors are not entitled to receive free NHS treatment
excluding some exceptional cases.
Responsibility for publicly funded health care rests with the Secretary
of State for Health, who is accountable to the United Kingdom Parliament (Boyle
2011: xxiv). The Department of Health governs the NHS including various policy
decisions, budget and other related issues. The purchasing of services is
delegated to regional bodies (10 Strategic Health Authorities) and the
provision of health services to the local public providers (151 primary care
organizations, mainly Primary Care Trust) (Boyle 2011: xxiv). Strategic Health
Authorities are responsible for several other trusts such as Primary care
trusts, National Health Service trusts (acute trusts), Ambulance trusts, Care
trusts, and Mental Health trusts.
Coverage: For over six
decades, the UK has provided universal free health care to all its legal
residents through an organised network of service providers (Odeyami,
Nixon 2013: 111; Murray CJL et al. 2013:
997; Stevens 2004: 37). The NHS covers preventive services; inpatient and
outpatient (ambulatory) hospital (specialist) care; physician (general
practitioner) services; inpatient and outpatient drugs; dental care; mental
health care; learning disabilities care; and rehabilitation (Thomson et al.
2011: 19). Under the NHS, drugs prescribed by general practitioners, dentists,
and other independent prescribers are charged a fixed rate (Thomson et al.
2011: 19).
Payment mechanisms: Approximately
80 percent of the NHS funds are allocated directly to primary care trusts, and
the secondary providers are paid a set amount for each patient treated
according to the services provided (Perlman, Fried 2012: 616-7). Although the NHS services are universal and
free of charge at point of use, there is a range of health services that are
not covered by the NHS or are covered partially, leaving patients to pay for
these services through (a) direct payments or (b) co-payments.
(a)
Direct
payments: cover private treatment in NHS facilities, over-the-counter
medicines, ophthalmic care and social care.
(b)
Co-payments:
cover NHS prescriptions and NHS dental care (Boyle 2011: 96).
Financing: The UK operates
a low-cost health system (Perlman, Fried 2012: 615). It spends 9.6 percent of
gross domestic product (GDP) on health, with public funding accounting for over
81 percent of total health care spending (Odeyami, Nixon 2013: 112). A budget of the NHS is established by
the British government on a three-year period. The NHS is funded mainly by
public sources including, general taxation with a fixed budget available to
spend on services for the whole population and national insurance contribution
(Boyle 2011: xx). NHS funded services also include both NHS provider
organisations, and other providers of health services such as charities,
private organisations, and social enterprises. Public sources of finance for
health care are allocated by central government to the Department of Health,
which is then responsible for the further disbursement of monies (Boyle 2011:
69). This scheme of direct control of
spending has proved to be highly effective (Blumenthal and Dixon 2012: 1353).
Apart from the income the NHS receives for the provision of prescription drugs
and dentistry services to the general population, there is some income from
other fees and charges, particularly from private patients who use NHS services
(Thomson et al. 2011: 19)
Cost containment: The
financial crises of 2008 have urged reform of the NHS and its financial
structure. Reformed NHS of the UK assumes that control of spending has been
shifted to primary-care doctors to help “…to
counteract the power of hospitals to offer a level, mix, and type of service
without effective challenge” (Blumenthal and Dixon 2012: 1353). To control
utilisation and costs, the Government sets a capped overall budget for Primary
Care Trusts (PCTs), and the NHS trusts and PCTs are expected to achieve
financial balance each year (Boyle 2008). When there is a need for austerity,
the NHS limits services to patients and restricts staff compensation or
training opportunities (Blumenthal and Dixon 2012: 1353). Centralised
administrative system also has its impact on controlling the overhead costs
(Boyle 2008). However, the increased contracting in the 1990’s has resulted in
increase in administrative costs (Le Grand 1999: 31).
Medical delivery system: Health
care in the UK is separated mainly into primary and secondary care (Perlman and
Fried 2012:612). Apart from this, special care has been provided for people
with disability and mental health problems. The UK medical delivery system
consists of the following components (Boyle 2011: xxvi; Perlman and Fried 2012:
612-3):
·
NHS-funded
primary care: Self-employed
general practitioners (GPs) provide primary care for people- for any need of
general medical care, emergency care or for a referral of a patient to
specialized health care services. Every UK citizen has the right to register
with a GP. Primary care is provided free
of charge. General practitioners are paid by Primary Care Trusts[3].
·
NHS-funded
secondary care: Specialty care
is provided by salaried specialist doctors and other health care professionals
working in government-owned hospitals, which are managed by NHS trusts. There
are over 160 such trusts, including 100 foundation trusts[4]
overseeing 1600 NHS hospitals (Perlman and Fried 2012: 614).
·
Social
care: For those who need special care is
the statutory responsibility of 152 councils with adult social services
responsibilities. The provision of social care has been shifted from the public
sector to private- and voluntary-sector organizations.
·
Mental
health system: The mental
health system is a mix of primary care and community-based services supported
by specialist inpatient care. Services provided through the NHS are available
free at the point of delivery.
System principles and philosophy: The basis of key principles of NHS at its’ establishment in 1948
were: NHS meets the needs of everyone; is free at the point of delivery; and,
that it would be financed entirely from taxation[5]. These
core principles still guide the work of the NHS. The NHS constitution gives the following principles (Department
of Health 2013a:14-6; (Department of
Health 2013b: 3-4): (a) The NHS provides a comprehensive service, available to
all irrespective of gender, race, disability, age, sexual orientation, religion,
belief, gender reassignment, pregnancy and maternity or marital or civil
partnership status; (b) access to NHS services is based on clinical need, not
an individual’s ability to pay; (c) the NHS aspires to the highest standards of
excellence and professionalism; (d) patients are at the heart of everything the
NHS does; (e) the NHS works across organisational boundaries and in partnership
with other organisations in the interest of patients, local communities and the
wider population; (f) the NHS is committed to providing best value for
taxpayers’ money and the most effective, fair and sustainable use of finite
resources; and, (g) the NHS is accountable to the public, communities and
patients that it serves. The handbook of the NHS Constitution lists the
following NHS values (Department of Health 2013b:8) : (a) working together for
patients; (b) respect and dignity; (c) commitment to quality of care; (d)
compassion; (e) improving lives; and, (f) everyone counts.
Performance on key dimensions: It
has been widely acknowledged that the UK health care system has been able to
produce better results at lower costs compared to many of its developed country
counterparts, especially the USA (see figures 2, 3 and 4). It has also been
reported that in the last two decades, mortality in every age group in the UK
has decreased, and disability prevalence has not increased (Murray et al. 2013:
1012). However, the above study also suggests that in comparison with other
developed countries, significant improvement in age-specific mortality in the
UK is only for men older than 55 years, and that the UK’s performance in
relation to chronic obstructive pulmonary disease has been significantly worse
than others in the same group of countries (Murray et al. 2013: 1016).
It
is emphasised in the Guidance to Health Care of the UK that quality is the
overriding priority for the healthcare system (Department of Health 2013b:4).
It means that rather than counting the number of performed surgeries one should
consider a patient’s opinion on the quality of a service provided to this
patient. It is thus concluded that: quality = good medical outcomes + safe care
+ good patient experience (Department of Health 2013a:35-38). NHS has successfully implemented pioneering
efforts in quality control in the last decade. One such example is that of
NICE, established in 1999 to improve standards of NHS (Pearson, Rawlins 2005:
2618-22). Quality issues are addressed through various regulatory and
assessment bodies. The health service has performed well during recent years.
It has: “…maintained or improved
performance against a range of indicators set out in the NHS Operating
Framework, while meeting the financial challenge” (Department of Health
2012: 5). Some of the major criticisms of the UK’s health care system include:
far too little emphasis on prevention; too much emphasis on reliance on
hospitals; and, quality of general practice, though high, is too variable (Ham
2013: 9). Reduction of waiting times for secondary care through NHS has not
yielded much success, while the private sector has an abundance of underused
facilities (Doyle, Bull 2000:
564).
Recent health reforms, emerging issues and policy
debates
Recent health
reforms: The NHS in England initiated the
most radical reforms with the implementation of the 2012 Health and Social Care
Act, and Care and Support Bill 2012[6].
These reforms include re-structure of the NHS, changes in the health care
commission, changes to health care education and are applicable to England
only. The reforms also focus on lowering medical costs and patient waiting
times and, in general, improvement of the health care services. The following are the aims of the Act (The
Royal College of Nursing, 2013): (a) a stronger voice for patients through a
patient-centered care approach (no
decision about me without me), and creation of Healthwatch England and
Local Healthwatch organisations to represent the voice of service users; (b)
focus on patient outcomes rather than processes; (c) extend choice and
competition; (d) overhaul of the commissioning structure; (e) increase autonomy
of providers with all NHS trusts becoming foundation trusts (FTs); and (f) new
approach to provider regulation- creation of a license issued by Monitor. Table
1 and 2 explains the major organizational changes in the Health and Social Care
Act (compiled from The Royal College of Nursing, 2013; Holmes 2013; Edwards
2013:1). For details of the complete health system structure within the UK
after the current reform, please see Figure 1.
Table 1: Changes to the commissioning system – from
April 2013
§
Abolition
of PCTs and strategic health authorities (SHAs)
§
NHS England (previously
known as the NHS Commissioning Board) established – provides leadership for
the NHS in England and commissions primary and specialist care. Has regional
and local offices throughout the country.
§
Clinical Commissioning Groups (CCGs)
commission the majority of local health services. Include the groups of GPs
from the geographical areas.
§
Transfer
of public health from the NHS to local authorities, with a new body - Public
Health England - taking a national leadership role.
§
Creation
of Health and Wellbeing Boards at
local level, bringing together people from commissioning, health care, social
care and public health to develop Joint Strategic Needs Assessments and Joint
Health and Wellbeing Strategies.
§
Healthwatch – the
independent ‘consumer champion’, replacing the patient representative bodies
Local Involvement Networks (LINks)
|
Table 2: Who commissions what according to the
Health and Social Care Act 2012
New
organisations
|
Services
|
NHS
England
|
Primary
medical services; dental services; community pharmacy; specialised services;
offender health care; heath care of the Armed Forces and their families
|
Clinical
commissioning groups (CCGs)
|
Planning
and designing health care; rehabilitative care; urgent and emergency care;
most community health services; mental health and learning disability
services. 152 Primary Care Trusts have been replaced by 211 CCGs.
|
Local
authorities
|
Public
health services. Works under the Health and Wellbeing Boards, and will
include: hospitals, health centres,
care homes, pharmacies etc.
|
Care
and Support Bill 2012[7]
proposed the establishment of national eligibility criteria to reduce local
variation in access; introduction of a code of conduct and minimum standards
for care workers; and, establishment of a capital fund to develop specialised
housing for older and disabled people.
Emerging issues and policy debates: The recent reforms are
aimed to move away from the top-down approach of the NHS to a people-centered
approach led by the clinical practitioners, with a view to improve
accountability and transparency. Hence the proposal to abolish Primary Care
Trusts and hand over the power largely to groups of GPs has also invited
criticisms due to the fact that the GPs are best trained to be clinicians, and
not to be managers (Guardian 2011).
There is an on-going debate among scholars that new reforms will
threaten accountability of the NHS (Davies 2012: 564; Klein 2010: 292). It is
argued that there are three reasons for this threat: the reforms make the
relationships between the Secretary of State for Health and the NHS more
complex, “…they create opaque
networks of non-statutory bodies which may influence NHS decision-making, and
(especially in relation to competition) they ‘juridify’ policy choices as
matters of law” (Davies 2012: 564).
Another debatable issue is whether the NHS becoming a market player is
beneficial - there is no sufficient evidence that competition in the NHS market
have a positive impact on the quality, equity, or efficiency of health care
services (Brereton, Vasoodaven 2010: 37; Ronald, Rosen 2011: 1361; Asthana 2010: 815). Moreover, it is also feared that
over emphasis on market forces through the abolition of PCTs and formation of
CCGs will undermine core NHS services and put patients at risk (Homes
2013:1169). There are also doubts that the new English reform will fulfil its
goal to promote integration between health care and local government – in fact,
it is argued, that this attempt may merely “…fragment
rather than integrate care” (Roland, Rosen 2011: 1365). Moreover,
procurement and competition rules are contentious
and confusing (Edwards 2013: 1).
It
has also been argued that the report by McKinsey and Company published in by
the Government 2010 is the basis of the current health care reforms in the UK.
The report made recommendations on how to save up to £20 billion by 2014
through regulated competition, improved choice for patients, and increased cost
savings, but with little prior benchmarking (Maynard 2013a: 1). Despite the
introduction of increasing role of private sector through Independent Sector
Treatment Centers (ISTCs) in the early 2000s, the expected outcomes such as
‘value for money’ have been not been achieved, and the intended benefits are yet to materialise
(Vaid N No date: 10). ISCTs are owned and operated by private companies and are
aimed to expand NHS capacity, reducing waiting times and increase patient
choice (Department of Health 2005). Critics argue that in any emergency, choice
does not matter, but the quality and timely care is important (Guardian 2011).
The
recent NHS reform has its adverse impact on the health workforce as well as the
users. Many Members of Parliament argue that the efficiency savings may be at
the expense of service cuts and staffpay (O’Dowd 2013). For example, a recent
study from British Medical Association suggests that specialty trainees and
newly qualified GPs in the UK are experiencing rising levels of stress and a
deteriorating work-life balance due to poor job security and the rapid and
evolving change that the NHS experienced in 2011 and 2012 (Jaques 2013). From
April 1, the public health staff from previous PCTs has been moved to local
authorities under the newly formed Public Health England. This would have a
major negative impact on the structure of public health delivery and planning
(Holmes 2013: 1170; O’Dowd 2013a:1). On the other hand, long waiting times has
been one of the key factors for user dissatisfaction with the UK health care
system (Odeyami and Nixon 2013: 115; Klein 2006: 413-5).
The UK health care system and the ACA
Distinction between the UK health care reform and the ACA
The
health systems of the USA and UK were always considered as very distinct.
Blumenthal and Dixon aptly summed up the main distinctions between two systems:
“The NHS covers all citizens, is
tax-funded, is free at the point of service, and is governed centrally.
Conversely, the US health-care system is funded by a patchwork of private and
public insurance, imposes large point-of-service fees on many users, and
provides care through private, not-for-profit, and public providers in a
largely competitive delivery system that is proudly ungoverned” (Blumenthal
and Dixon 2012: 1352).
The
National Health Service (NHS), the health care system in the UK was founded as
a publicly-funded body that provides universal health care services to all its
legal residents. Since then, NHS is about national identity, and pride for the
UK (Holmes 2013: 1170). Until recently, the private sector played only a
complementary role, with just 11 percent of the population covered by private
insurance providers in 2004 (Foubister
et al. 2006: xv). However, the private sector
traditionally played important role in providing psychiatric services, long
term residential care for people with learning disabilities, care of elderly
people, termination of pregnancy, and through reduction of waiting list
initiatives (Doyle and Bull 2000:
563). Since 2002, NHS contracted several Independent Sector Treatment Centres
(ISTCs), privately owned, but publicly
funded treatment centres to treat NHS patients with the aim of reducing waiting
lists, increasing competition among providers, facilitating innovation and
reducing spot purchasing prices, and thereby trying to ensure value for money
(Vaid N No date: 8-10). The future of
the UK health care is likely to involve more extreme forms of McDonaldization (Waring, Bishop 2013:
154). Health care in the UK is much cheaper compared to the USA and several
other developed countries (Refer Table 3).
Table
3: Health care expenditure and example private health insurance formats in the
UK and USA
Country
|
THE (% GDP) 2010
|
Per capita HE
(US$) 2010
|
Public HE (%
of THE) 2010
|
Out of Pocket
Expenditure (% of THE) 2007`
|
Private
health insurance (% of THE) 2007
|
UK
|
9.6
|
3503
|
81.3
|
11.1
|
2.9
|
USA
|
17.9
|
8362
|
44.9
|
13.5
|
35
|
Source:
Doran T, Roland M. 2010- compiled from several other sources.
The recent UK health care reform aims to
contain cost through increased competition, improved efficiency, and thereby
offers more choices for people for health care. It has taken steps to
completely overhaul the organizational structures to make it more action at the
local level. Major focus of the UK reform is to make the clinicians more
accountable, including for taking care of the public health functions at the
local level. On the other hand, although the ACA is aimed to ensure that all Americans
have access to quality, affordable health care, and to transform the health
care system, major focus is on increasing the
insurance coverage. Insurance regulation, expansion of Medicaid (to people with
incomes up to 133 percent of the Federal Poverty Level), and ensuring of
individual and employer mandates are the key actions in the ACA (Lischko, Waldman 2013: 107-11). Harrington summarises the ACA as
follows: “[ACA will] significantly expand
health insurance coverage in the United States through its individual mandate,
premium subsidies, and expanded eligibility for Medicaid. The law will
transform private health insurance markets through its creation of state-level
exchanges and federal government prescription of individual and small-group
health insurance benefits, coverage, and allowable underwriting/rating
criteria” (Harrington 2010: 707). Blumenthal emphasizes that the ACA will
improve health system performance, in particular “…payment policy, organization and infrastructure, public health, and essential information for healthcare
decision making” (Blumenthal 2012: 1953).
Health reforms in both the countries are politically highly
sensitive issue, and hence both the UK reform and the ACA have and are facing
severe resistance at the political level as well as from pressure groups
(Guardian 2011; O’Dowd 2013, Homes 2013; Lischko, Waldman 2013; Oberlander
2012). However, the difference in the way the political leadership in both the
countries planned the implementation of the reform are worth discussing. In the
UK, the political resistance has not prevented the leadership from going ahead
with the reform and plan for its implementation at one go (Timmins
2012: 148). This does not mean that the UK is ready for its implementation, but
as Timmins (2013), the leadership pursued for reform at a record speed mainly looking at the history of reforms in the
country. In contrast, the resistance in the USA for the
reform process has been extremely complex, and this has been mainly dealt with
by allowing greater flexibility through regulations and guidance and the
possibility of the waiver of certain provisions (Lischko,
Waldman 2013: 134). The US reform implementation also has been done in a paced
manner with its different provisions, and there is still lack of clarity on how
many states would be ready for implementation of major provisions by October
2013 (Oberlander 2012:2166).
Similarities between the UK health care reform and the ACA
Universality: With the
introduction of the ACA and new reform in the UK American and British health
systems acquired many similar features. The NHS of the UK provides service
available to all and free of charge. In 2010 the ACA proclaimed that almost 95%
of the Americans will have access to quality, affordable health care by 2019 (United
States Department of Labour No date), although critics argue that the US system
inherently creates inequity (Light 2003: 27) Secondly, quality is the
overriding priority for the healthcare system of the UK and the USA will create
a new program to develop community health teams supporting medical homes to
increase access to community-based, coordinated care (United States Department
of Labour No date).
Pay for performance:
Both health systems encourage so-called “pay-for-performance” schemes: “In the USA the ACA’s value based purchasing
initiatives will reward hospitals with increased Medicare payments for improved
quality of care and penalise low-performing institutions … Similar
pay-for-performance developments are underway in England” (Blumenthal and
Dixon 2012: 1354). Third similar feature of two health systems is on-going
trainings and education of medical staff.
Market players: Next similar
feature is that both health systems now have autonomous ‘market players’
(United States Department of Labour No date; Davis 2012: 564; Allen et al. 2011: 77). The government of the
UK proposed a commercial system which reduced the role of the NHS to government
player equivalent to Medicare and Medicaid in the US (Pollock and Price 2011:
803). Among similar feature may be listed recent focus on health inequalities
reduction – as important issues as ever before for both countries (Curtis and
Leonardi 2012: 640). The UK system still maintains a strong primary care base
built around GPs, similar to family practitioners in the USA (Doran,
Roland 2010: 1023).
Features
or policies in UK health care system that would be desirable for the U.S.
The
socio-political contexts in both the UK and USA are different. There are
several widespread beliefs about health care in the USA. Replicating the
successful institutions such as NICE from the UK in the USA resulted in failure
(Pearson 2005). Hence a pragmatic approach by assessing the feasibility would
be important before implementing any aspects of health reforms from other countries.
Primary care: The UK health
system traditionally focused on primary care, and on reduction of health
inequalities. The USA health care system may consider focusing on reducing
health inequalities with in the country not only by increasing insurance
coverage, but also expanding focused work on affordability and accessibility
such as Medicare and Medicaid for the most vulnerable populations. ACA faces
several challenges related to ensuring universal coverage.
Effective
budget control and regulation of private sector: The control of budget by the Central
government in the UK for NHS found to be very effective (Blumenthal and Dixon 2012: 1353). This is mainly feasible due to
the fact that over 80 per cent of the health care budget is centrally managed
in the UK. In the US, no binding overall budget is set prospectively for
federal spending on Medicare and Medicaid (Blumenthal and Dixon 2012: 1353). As health care in the USA is
predominantly taken care through private insurance coverage, effective budget
control and regulation of private sector is important.
Quality and equity: The
UK considers issues of quality and equity as a high priority. Thus, it is
interesting to mention at least some actions for enhancing equity and improving
quality of health care. For example, in
2010 Equality Act (that covers England, Wales and Scotland) came into effect to
legally protect people from discrimination and reduce inequalities, among all,
for care (Equality Act 2010). This Act clarifies the definitions of
discrimination and expands positive duties on public authorities to advance
equality in respect of all protected characteristics (Hepple 2010: 11), which
is an important part in moving towards improved health care service. It is
worth noting that the budget of the NHS allocates a significant proportion of
funds (around 13%) to tackle and prevent inequalities (Ashtana 2010: 818).
Also, another example is a new organisation “HealthWatch[8]”
launched in 2013 to gather and represent opinions and concerns of patients
about health and social care services.
Conclusion
This paper was prepared to compare public health
systems employed by the UK and the US.
The UK has six decades of experience with a nationalized health care
system, which is free at the point of use. The UK health care system has been
considered successful overall, and continues to evolve. For the USA, important issues include primary
care coverage, budget maintenance, quality, and equity. With the passage of the
ACA, the USA will be able to rely on the UK experience for valuable lessons as
they implement the new law.
[1] The Health and
Social Care Act was passed on 27 March 2012, and came in to effect starting 01
April 2013, and aims to rapidly reorganise the NHS. Refer http://www.legislation.gov.uk/ukpga/2012/7/pdfs/ukpga_20120007_en.pdf Accessed 30 May
2013.
[2] http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf Accessed 30 May
2013.
[3] Primary Care
Trusts are formed by the have been formed by GPs.
[4] Refer: http://www.nhsconfed.org/priorities/political-engagement/Pages/NHS-statistics.aspx Accessed 20
April 2013.
[6] http://www.publications.parliament.uk/pa/jt201213/jtselect/jtcare/143/143.pdf Accessed 20 May
2013
[7] http://www.publications.parliament.uk/pa/jt201213/jtselect/jtcare/143/143.pdf Accessed 20 May
2013
