2 Diversity of health care providers

Before the introduction of the National Health Service (NHS) in 1948, there was a patchwork of public, private and voluntary provision (Keen et al 2001). Since the establishment of the NHS, when hospitals were nationalised, most of the organisations providing health care to NHS patients have been state-owned. General practitioners (GPs) are a notable exception to this, being self-employed and operating largely under a nationally negotiated contract. However, a small proportion of the care of NHS patients, mainly in the areas of mental and sexual health, has continued to be provided by independent organisations, either profitmaking or not-for-profit. Moreover, NHS hospitals and commissioners have used spot contracting (ie, ad hoc arrangements negotiated locally) with the private sector in order to reduce NHS waiting times (and the number waiting) (Keen et al 2001).