There is no denying the pressures on the NHS. Beyond the headlines, the figures show starkly the rising costs of delivering healthcare; public spending on the health system ballooned from just 7.7% of total public spending in 1955/56 to 18.4% in 2015/16. There are also good indications that this still isn’t enough: two-thirds of NHS trusts were in financial deficit in 2015/16 and close to half last year.
Recent work by the Institute for Fiscal Studies and the Health Foundation has found that the government will have to increase health spending by more than 3% per year over the next 15 years just to maintain today’s levels of provision, and by 4% or more per year if services are to be improved.
There are many factors behind this intensification of financial pressures. The ageing of the population is one receiving much attention given that average health spending on a 70-year-old is approximately treble that on a 30-year-old, while spending on a 90-year-old is an estimated eight times more than that on a 30-year-old. The growing prevalence of chronic conditions is another pressing issue; almost 3.7 million people in the UK are living with diagnosed diabetes, double the number 20 years ago.
Money isn’t the only problem. While access to care appears to be relatively good in the UK in international comparisons, care quality has sometimes been found to be wanting. Child health in the UK is lagging behind other OECD countries on many indicators, including infant mortality, and survival rates for some cancers, such as breast and cervical cancer, remain below the EU average in spite of improvements.
The difficulty of policy change in this area
It is very difficult to change the direction of health policy for many reasons. Any theory of long-term change in the NHS needs to command broad support across government departments and political parties, and the demands of 24/7 media can act to keep the political focus on short-term challenges and emergencies instead of long-term strategy. The NHS is also an incredibly large and complex institution – it is the biggest employer in Europe – posing obvious challenges to reform.
Opportunities for change that could help to improve outcomes and control costs
1. Restructuring/different models of care
There seems to be a relatively good understanding of the models of healthcare delivery that function most effectively, providing a ready evidence base for policymakers to draw on. A greater emphasis on community health delivery seems promising – for example, neighbourhood-level primary care hubs with multidisciplinary teams and close links to pharmacists, GPs and hospitals. This sort of localised care could enable healthcare systems to better respond to local population risk factors, and provide more consistent, personalised care. Meanwhile, better access to specialist care could be facilitated via joint working across groups of hospitals. This has benefits in terms of standardisation, lower costs, better technology and higher productivity.
There may also be scope to make more use of virtual and on-demand care, with good examples already in operation, including American Well, Doctor on Demand, Babylon in the UK private sector and E-Consult in the NHS. Technological innovation could also enable more effective self-management of chronic conditions.
Even for those with long-term conditions, time spent interacting with healthcare services is very limited. This in turn implies that formal medical care can only do so much – what happens in day-to-day life is critically important for individual health outcomes. A greater focus on the social, economic and behavioural determinants of health, such as housing quality, alcohol consumption, diet, physical activity and smoking rates, therefore has significant potential to stop health problems emerging to start with, and enable existing chronic conditions to be managed better.
Potential for new funding models
There is also a pressing need for a debate about how health and related social services should be paid for, and who should pay. The IFS have pointed out that there simply isn’t room to cut other public service budgets further to divert more money into health, meaning further increases in health spending will necessitate either higher borrowing or higher taxes.
The idea of a ringfenced tax for health is being suggested with increasing frequency, though the Treasury remains formally opposed to it. It may also be worth considering options beyond funding via the tax system. Politicians should consider the option of asking individuals and employers to pay more for health directly.
The challenge is to promote the debate required around the future of the NHS without descending into the kinds of rancour which have undermined proper discussion in the past.