At Breaking Point or Already Broken? The National Health Service in the United Kingdom

Excerpt – “Crisis,” “collapse,” “catastrophe” — these are common descriptors from recent headlines about the National Health Service (NHS) in the United Kingdom. In 2022, the NHS was supposed to begin its recovery from being perceived as a Covid-and-emergencies-only service during parts of 2020 and 2021. [..]

In the background of this acute [COVID] crisis, waiting lists for specialist consultation have been growing and now exceed 7 million patients (in a country of 66 million people), up from 4.4 million before the pandemic. There is substantial consensus about the causes of these crises, though different experts weight the contributory factors differently.

The primary contributor is long-term underinvestment in health services. The United Kingdom adhered to health system orthodoxy in reducing expenditures by running a “just-in-time” system with high hospital-bed occupancy. The number of hospital overnight beds per 1000 population declined by about 10% between 2010–2011 and 2019–2020, while the number of day-only beds increased by about 13%. In terms of beds per 1000 population, the country ranks second-lowest among 24 European countries, with 2.4 beds as compared with an average of 5.0 (and 7.8 in Germany). The minimal resilience built into the system made the large impact of a surge in pandemic-related hospitalizations unavoidable. [..]

According to the World Bank, U.K. health system spending rose from 7.0% to 9.8% of the gross domestic product between 2000 and 2009, then plateaued at 10.2% in 2019, during the current governing party’s “austerity policy.” The country’s per-capita spending on health is about 18% lower than the median among 14 European countries. Although the government increased health spending during the pandemic, and again in recent months in an attempt to reduce waiting lists, we are relearning the lesson that the effects of a decade of underinvestment cannot be rapidly reversed. Some of the additional short-term funding is siphoned off to pay for more expensive locum agency personnel and other stopgap solutions. [..]

The prevalence of undiagnosed and undertreated hypertension and hypercholesterolemia is high in the United Kingdom, which also has the highest prevalence of obesity among large European countries — burdens that increase demand on the NHS. An early and severe influenza season was a tipping point this winter. Covid-19 persists, and on some days in early January, more than 12,000 inpatients had confirmed Covid-19 infections — not that far short of the 20,000 patients admitted at the peak of the first wave in mid-April 2020, though daily Covid-19 mortality was 90% lower. [..]

To many Britons, the entire system feels broken, but there is little consensus on how to repair it. Both major political parties agree that increased government funding is not the only solution and call for NHS “reforms,” but they disagree on the shape of those reforms. [..] The Conservative government is accused of deliberately underfunding the NHS in order to force patients into private health care and usher in a two-tier system. If that’s the intention, it ignores the fact that though private capital might support building of more facilities, most of the clinical staff would be trained over many years in the NHS, which would make staffing a zero-sum game. There is broad agreement that better integration of primary care with hospital-based and social care is urgently needed, along with better-integrated medical record systems and a focus on disease prevention. [..]

The state of the NHS makes for much misery among patients and frustration among already exhausted health professionals. And the rest of the world should care as well: 75 years ago, the United Kingdom became the first large country to make health services “free at the point of care” and paid for by collective taxation, and the NHS has become the model for many other systems that seek to remove the profit motive from health care provision in the name of equity and cost control. As goes the NHS, so goes this paradigm.

Full article, DJ Hunter, New England Journal of Medicine, 2023.7.13