After calling the NHS’s telephone advice line, 111, he was dispatched to an urgent treatment centre, only to learn that he faced a long wait. The 32-year-old, from Bury, Greater Manchester, decamped to a local hospital’s accident and emergency department, the pain so intense he could barely “speak, walk or sit”. 

He was finally seen eight hours after arriving at A&E, leaving at 10am, only to discover that he had not received the results of his blood tests. That evening his ear drum perforated because of a build-up of fluid and he lost almost all hearing in it for a month and a half.

Given such statistics, is Britain’s generations-long experiment in meeting the needs of a demanding developed nation almost entirely from its tax base sustainable for another 75 years without radical changes in the way it is organised and funded?

Funding models: social insurance vs general taxation

For many years, the notion that the NHS should no longer be funded from general taxation has been a recurring theme. But the voices urging a switch have become more persistent in recent months as the service’s demonstrable failings have made a more credible case for change.

Some politicians from the nation’s ruling Conservative party — including a former health secretary, Sajid Javid — have suggested a move to a social insurance system, the model adopted by many of the UK’s European neighbours in the postwar period. Employees contribute a portion of their income to fund their healthcare, matched by a contribution from their employer.

Cradle to grave: is Britain’s NHS broken?

The first part of our two-part series examines how a postwar commitment to provide free healthcare to all became a sacred part of British national identity, with soaring costs and declining outcomes.

Read part 1 here

The funding scheme is superficially attractive. High-income countries with social insurance are achieving better results than the UK on measures such as heart attack and cancer survival. But experts are wary of overplaying cause and effect, underlining how hard it is to divorce a health system from its cultural and economic context.

Prof Sir Chris Ham, co-chair of the NHS Assembly, which advises NHS England, and a former director of strategy at the Department of Health, suggested that the method of raising funding for healthcare was not what mattered. “I think it’s the quantum of funding and the consistency of funding that makes the difference,” he said, referring to the boom and bust funding cycles to which the NHS has been subjected.

Reducing demand: the need to invest in preventative care

It is easy to point to the progressive loss of capacity during the past 30 years as the root of much of the NHS’s problems. Hospital bed numbers have more than halved over that period and the UK has fewer beds, scanners, doctors and nurses than similar nations, a situation worsened by the decade of austerity from 2010, the most sustained period of below-average funding growth in the NHS’s history.

The UK entered the pandemic at or near the bottom of a league table of comparable countries in relation to one- and five-year survival rates for multiple cancers, including those of the stomach, colon, rectum, pancreas and lung.

But expanding capacity will never be a long-term solution if demand continues to rise inexorably. Many experts believe that the single biggest imperative facing the system is to improve preventive care, forestalling conditions or treating them at an earlier stage before they require an expensive hospital admission.

The distribution of funding, especially over the past decade, has made this far harder. While under David Cameron the NHS received scant inflation-plus rises, funding in other crucial areas including disease prevention and social care was cut.

Experts believe it is this asymmetry that has done more than anything else to undermine the health service’s ability to meet the demands upon it — and it is here that change must come.

Ham said that since 2010, “we’re spending ever more on specialised acute hospital services, and the growth in spending on those services has outpaced very modest growth in spending on general practices, community nursing services, and of course, social care falls into that category too”. 

A plan to tackle the crisis in urgent and emergency care, published on January 30, had displayed the same flawed approach, he said. It promised additional beds, ambulances and staff “but had hardly anything to say about how you can do something to moderate the demand for those services rather than just increasing the supply of those services”, he added.

This hospital-centric approach is evident in the way the workforce has developed over the past 15 years. Ben Zaranko, senior research economist at the Institute for Fiscal Studies who has studied NHS productivity, said that, while the number of hospital consultants had risen by more than half between 2009 and 2022, the number of general practitioners had flatlined. As the number of elderly people requiring care increased — in itself a tribute to an NHS that has kept them alive for longer — the size of the social care workforce actually shrank in England in the 2021-2022 financial year.

“We’ve become increasingly focused on the secondary, curative sector,” he said. “Imagine a world 15 years ago in which we hadn’t decided to squeeze public health, social care and district nursing, then maybe hospitals wouldn’t be in this position.”

Efficiency deficit: the case for more managers

One way of easing pressure on secondary care may be to recruit more managers. Contrary to the popular narrative of a bloated NHS bureaucracy, the health service has the lowest administrative costs among comparable health systems: just 2p in every pound. Experts say that compared not just with similar health systems but with other industries of a comparable size, the health service is notably undermanaged.

Zaranko noted that good managers freed up doctors’ time by running the system more efficiently — improving staff management; liaising better with GPs or easing the transfer of patients into the care system to free up frontline capacity in hospitals.

“I don’t doubt that saying ‘we’re going to have x many more docs and y many more nurses’ sounds better than ‘we’re going to improve the management structures of the NHS’ but by making short-term decisions, you can create long-term problems,” he said.

One way of altering the health system’s centre of gravity, providing care proactively and closer to people’s homes, may be to make better use of data and technology. Here, again, investment decisions have failed to support an approach that has proved demonstrably effective in other countries.

Anita Charlesworth, director of research at the Health Foundation, said: “We have not invested systematically in the infrastructure of data and analysis to really maximise the opportunities that a National Health Service should provide.”

Data should be used to identify people at risk and provide earlier intervention “but we’ve had totally false starts at a comprehensive IT and data strategy for the NHS and have not capitalised on the potential there”, she said.

Part of this reflected the UK’s “anti-managerial culture, the idea is that the only people who are really valuable in the care system are the people providing frontline care. So investing in things like data scientists who can help to guide and support this sort of work is seen as bureaucratic waste, rather than part of the 21st century healthcare team”.

Other countries have done this far more effectively and are reaping the rewards in more co-ordinated care and lower hospital admissions.

Denmark’s hospital system only has two electronic health record (EHR) systems — reduced from 13 originally — which are nationally integrated with GP systems, so that individual health accounts carry a complete record of patient treatment and activity. Danes are expected to accept digital communications unless exempted.

Dr Jørgen Kristensen, the chief executive of Denmark’s Central Jutland healthcare region who has worked on the digital transformation for more than 20 years, said the approach sped up discharge processes and cut the length of hospital stays by allowing doctors to communicate seamlessly with GPs and municipal social care systems. The latter must take patients or face paying fees to keep them in hospital that exceed the cost of caring for them in the community.

Looking further over the horizon, the NHS is seeking to harness the power of artificial intelligence in order to improve diagnosis and ultimately reduce burdens on the system. The government has run a £140mn “AI in Health and Care” award scheme to spur development of technologies with game-changing potential.

Award winners have included companies such as Caristo, which uses AI to analyse vascular inflammation in heart CAT scans, of which the NHS carries out nearly 200,000 a year, in order to identify potential heart attack victims up to seven years in advance.

Such technologies could not only save the NHS money on acute treatment, but by identifying and reaching potential future patients and prescribing them preventive treatments — from statins to a better exercise regime — they could keep people healthy and economically productive for longer.

Richard Sloggett, a health policy expert, argues that if this agenda is to be realised, however, it will require the Treasury to cease viewing health spending as a “sunk cost” and reframe it as an investment that may not deliver for years but will ultimately boost the economy by producing a healthier workforce.

Free at the point of use: an honest conversation about taxation

Although new ways of working are vital, experts say that, ultimately, the NHS simply needs more cash. While the UK spends above the OECD average on healthcare as a share of GDP, a study by the Health Foundation in November showed that it had spent about 20 per cent less per person on health each year than similar European countries over the past decade.

“It’s not because they’ve got social insurance or we have taxation. It’s because of the choices that their politicians and their governments have made,” Ham said.

Ham believes that politicians have fundamentally failed by not acting sooner to tackle the NHS crisis, revealing a key flaw in the UK’s political culture. After the first few years of austerity, the price being paid by the health service in longer waiting times and growing deficits was clear.

“So this is what the political system ought to be capable of responding to and acting on. And yet the coalition government and the Conservative government under various leaders has signally failed to do that.”

Nor does he spare the Labour party. “I don’t think it emerges particularly well either because back in the 2015 general election it wasn’t making promises to address the NHS funding shortfall by increasing the budget because it was still in that phase where it wanted to be able to demonstrate to the public it was responsible with the public finances.

“So I see what’s happened as a failure of the political system as much as a failure of the NHS,” he added.

Given that the squeeze on the rest of Whitehall is probably at its limit, many believe new forms of revenue will need to be found if the sums going to the NHS are to increase.

For Prof Sir Michael Marmot, a health inequalities expert, the answer is higher taxes. “We have among the lowest tax rates in Europe . . . If we raised our level of taxation up to the average for OECD countries it would mean the tax take would go up by about 1 per cent of GDP. That could be done relatively painlessly,” he said.

Under pressure from his party to ease the tax burden further before the general election expected next year, Rishi Sunak, the UK’s Conservative prime minister, is unlikely to be swayed by such logic.

But Sloggett, who was a political adviser to Matt Hancock, former Conservative health secretary, believes a reckoning is long overdue over whether Britons are prepared to pay more for the NHS — at least in the short term — or accept some constraint on what the NHS will offer free of charge.

It is a debate that conspicuously failed to happen at the most recent general election in 2019, he said, drowned out by Boris Johnson’s promise of 40 new hospitals and Jeremy Corbyn’s insistence that the NHS would be on the table in trade talks with then US president Donald Trump.

“Is it any wonder that four years down the line we’ve got strikes, we’ve got waiting lists because we haven’t had the fundamental discussion about what we’re investing in.”

Sloggett believes there is no public appetite to change the NHS model but keeping faith with Aneurin Bevan’s concept means that big, testing questions can no longer be ducked.

“If you believe in ‘free at the point of use’, how are we going to pay for it and who pays what? The NHS will survive but what [services] will be included in that survival? In 2024, those are the conversations we have to have.”

This story originally appeared on: Financial Times - Author:Ella Hollowood

In July, it will be 75 years since the UK founded the tax-funded system of free care that, as a former finance minister once remarked, is the closest thing the multicultural nation has to a national religion.

Each “big birthday” has offered a chance for reflection about its future, and scarcely one has passed without the occasional prediction of its imminent demise. But, fittingly perhaps as it enters later old age, never before have its frailties been more exposed and the mismatch between resources and demand so apparent.

Founded in 1948 by Clement Attlee’s Labour government, the brainchild of his health minister Aneurin Bevan, the NHS was designed to improve heath outcomes for a population depleted by war and suffering ill health based on the 1942 blueprint for a more just society drawn up by the social reformer William Beveridge.

Before the service was set up, healthcare provision for those who lacked means was patchy. As late as the 1930s, more than 80 per cent of children in London and Durham showed symptoms of rickets, a sign of preventable malnutrition, according to Prof Roberta Bivins, a historian at Warwick university.

Cradle to grave: can the NHS be fixed?

The second of the FT’s two-part series looks at ways the health service can be reformed if it is to survive a further 75 years

Part 2 coming tomorrow

The level of ill health endured by many was made clear by Dr John Marks, who qualified on the first day of the new service and went on to lead the British Medical Association 40 years later. Quoted by public policy expert Nicholas Timmins, in his history of the welfare state, The Five Giants, Marks said: “There were women with prolapsed uteruses literally wobbling down between their legs that had been held in place with cup and stem pessaries . . . You would have men walking round with trusses holding these colossal hernias in.” 

The chosen form “fitted within their particular model of postwar planning ideology . . . you needed the health system to be plugged into the state”, he said.

The new service established a tripartite structure, divided between general practitioners, hospitals and community services, that remains essentially unchanged. GPs are still, for the most part, independent contractors running their practices like small businesses, a concession Bevan agreed as the price of overcoming their resistance to the new nationalised health system.

Bevan and Attlee had assumed that unfettered access to healthcare would improve the health of the population to such an extent that the cost of providing it would fall. However, neither anticipated how longer life expectancy and medical advances would radically change the costs and form of healthcare.

Referrals to specialists were rare in the 1940s when most care was delivered by GPs, established from the start as gatekeepers to the wider system. While stays in hospital were far longer than they are now, they were often principally for convalescence from infectious diseases.

The initial cost estimates were also wildly short of the sums that turned out to be required. Its first year of operation cost £305mn, far outstripping the £170mn originally estimated in Beveridge’s 1942 report. The proportion of GDP absorbed by the NHS has risen from 2.24 per cent in 1948 to 9.17 in 2022.

As the public felt the impact of the service, its popularity soared. Levels of infectious disease fell precipitately. Life expectancy, which had been on a rising curve since the beginning of the century continued its upward course.

Yet, although the nation had by the 1950s warmed to the security the service brought, health for years was not prominent in political parties’ manifestos. It was not until the 1980s that the notion of the NHS as a repository of national values really took root, obliging any politician seeking national office to pay obeisance to it. This mindset frequently led to claims that only the election of one party over another could “save” the NHS.

Seaton suggests this process was the result of a conscious effort by left-leaning supporters, not least in the media, who perceived the service’s core model to be under threat during Margaret Thatcher’s premiership. A rash of television features about the horrors of US healthcare helped to shape the debate, implying any departure from the current model would subject Britons to the same iniquities as Americans.

In 1998, the anthropomorphic notion of the NHS’s “birthday” as an occasion for national thanksgiving was introduced for the first time, and included a special 50p coin. In 2012, Danny Boyle’s much-feted opening ceremony for the London Olympics, which sought to distil modern Britain for the world, featured a parade of dancing NHS nurses and sick children. By 2018, when Theresa May led celebrations of its 70th, the soft-focus approach had been uncritically adopted by the Conservatives, too.

The soaring costs of a national treasure

The decision to freight the NHS with meaning, and set up a narrative in which it must be protected even when other areas of public spending were not, has had a crucial impact on the way British state expenditure has evolved over the past 50 years.

Spending on the NHS has swallowed an ever-greater share of the public purse, as an ageing and growing population has irrevocably changed the demands on the system since the days when most barely lived long enough to collect their state pension, let alone develop the chronic diseases of old age — dementia, diabetes — that now come close to overwhelming its budget.

Since 1979-80, the health department’s budget has grown more than fourfold in real terms from £35bn to £164bn, expressed in 2021-22 prices, and it has doubled its share of the GDP pie, according to the Nuffield Trust, a think-tank.

Initially the vast sums the health service consumed did not have a big impact on other important areas of public expenditure. Anita Charlesworth, director of research at the Health Foundation, a charity, said this rising share of overall public spending was “accommodated without the need for substantial tax increases by a change in what the rest of the state was doing”: first the privatisation of the utilities and secondly the end of the cold war, which freed up funds from defence spending.

But as the share of public expenditure taken by the NHS has soared so too has politicians’ desire to find ways of ensuring that this bounty is better spent through multiple attempts at “reform”.

Nigel Edwards, chief executive of the Nuffield Trust, said that, in contrast to the often-touted idea that the NHS is untouchable due to the reverence in which Britons hold it, it is in fact the most reorganised health system in western Europe “by a country mile”.

The result has been an alphabet soup of acronyms, and some sharp strategic shifts as different politicians imposed their own visions on the service — from competition to collaboration, from tighter central control to increased devolution — but few obvious associated improvements to public health. He ascribes this to an ingrained NHS view that its primary accountability is to the secretary of state, not the patients it serves.

But Richard Sloggett, previously an adviser to former Conservative health secretary Matt Hancock, who now runs a health consultancy, argued that politicians, unable to risk alienating the electorate with any fundamental changes to the service’s funding model, had instead sought organisational change as a less politically dangerous way of attempting to improve its productivity.

However, even more than the health department or Number 10 itself, there is one bastion of government that has shaped the history and direction of the NHS: the Treasury, which under the British model exercises a rare — perhaps unique — degree of financial sway over the level of health service funding.

Even countries whose health systems are primarily funded from the national tax base like the NHS — the Scandinavian countries, for example — have a “countervailing tier” of regional control that ensures they are not entirely in thrall to a central finance ministry, Edwards said.

He laments the Treasury’s inability to invest for the longer term, and says few counterparts around the world take so narrow a view of their remit to balance the books even at the expense of the nation’s welfare.

The only time in recent decades that the NHS has been relatively amply funded — producing huge improvements in waiting times and a doubling of patient satisfaction — was during the New Labour years, 1997-2010.

Edwards points out this was the only time that the Treasury was circumvented; in January, 2000 Tony Blair used an appearance on a Sunday morning political programme to announce that he was raising spending on the NHS to the European average by the end of the following parliament. His chancellor, Gordon Brown had not been told in advance. Afterwards a splenetic Brown reportedly told Blair that he had “stolen my fucking budget”.

The repercussions of austerity

After years of largesse, much of the state of the NHS today can be traced to the impact of 10 years of post-financial crisis austerity that began under David Cameron’s coalition government in 2010. It was not simply the amount of funding it received, but its distribution, and the impact on the rest of Whitehall that made the difference — and it was in part the need to keep very public faith with a beloved institution that sowed the seeds of some of the current problems.

Cameron, anxious to be seen to show fealty to the NHS, which had cared for his severely disabled son and to which he had a genuine commitment that some Tory predecessors had lacked, decreed that the NHS must be protected with real terms increases.

However, other departments, such as criminal justice and local government, suffered deep cuts “in an attempt to create the headroom for the health service to grow without taxes needing to rise”, Charlesworth said.

Budget streams with a crucial impact on the health of the nation — infrastructure, preventive health, medical education and, perhaps most crucially, local government, which funds social care — also faced real term cuts during his administration.

The result, said Professor Sir Michael Marmot, a global expert in the impact of “social determinants” such as housing and nutrition on health, is that in the past decade improvements in life expectancy first slowed, then reversed — a process exacerbated, but not caused, by the pandemic, he added.

“There was a sharp interruption in the curve in 2010,” he said. “Life expectancy stopped improving at the same rate, health inequalities increased. Life expectancy for the poorest people went down.”

The NHS is currently living through its worst ever winter. Ambulance response times and waits in A&E departments in England are at record levels, with help taking, on average, more than 90 minutes to arrive even to suspected heart attack and stroke victims.

In December more than 54,500 patients waited over 12 hours in emergency departments after clinicians decided they needed a hospital bed. That is the highest-ever number and almost treble the figure for May last year.

But as politicians consider how to arm the NHS for the future, they must reckon with national sentiment as well as the day to day reality of a health service under unimaginable pressure, just as they have done for the past 75 years.

The latest set of British Social Attitudes findings, released last year, showed satisfaction with the service falling to its lowest level since 1997. “Confidence in the NHS being there for people is dropping. But yet at the same time, we’re not seeing any shift in support for the principles,” said Dan Wellings, a senior fellow at the King’s Fund, who specialises in public attitudes to health and social care.

“The public does not want a different model. They just want this one to work.”

He added that as recently as last year — with every NHS metric flashing red — an Ipsos poll asking what made people proudest to be British showed “the NHS . . . is still the top answer by some considerable margin”. 

In future, however, trade-offs will become increasingly painful for other areas of vital state spending, Charlesworth suggested. As well as the NHS, social care and pensions are all likely to increase as a share of GDP as the baby boomer generation reaches old age. “There is very little other activity undertaken by the state that you could look to cut,” she warned.

But with a historian’s long view, Bivins recalls previous crises, when the parlous state of the health service had prompted doom-laden predictions about its capacity to survive. “History is not a predictive science, but I would say we have seen all this before,” she said.

She suggests the rich symbolism of the NHS may be its best guarantor of long term survival.

“The establishment of the NHS has been called ‘the least sordid political act’,” she said. “And I think that that’s really still true. People still look at it and say ‘we did this thing for everyone’.”

Additional reporting by Federica Cocco and Ella Hollowood

This story originally appeared on: Financial Times - Author:Ella Hollowood