Is the NHS the world’s best healthcare system?

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By Pamela Duncan and Juliette Jowit

On its 70th birthday, there are reasons to celebrate Britain’s favourite institution, though it has changed beyond all recognition from the service set up in 1948

Nothing inspires national pride quite like the National Health Service. More than two-thirds of respondents in a recent pollsaid they considered the establishment of the institution, which turns 70 this week, to be Britain’s greatest achievement.

But it is a very different thing now compared with its earliest incarnation, when health boards took control of 2,751 of Britain’s 3,000 hospitals, which had been run by charities or local authorities. It is not just the illnesses, facilities, technologies and demographics that are different, but the service’s very purpose.

“When the NHS was founded it was intended to keep the workforce healthy, reduce premature death and allow a dignified end for everyone,” said Robert Freeman, a consultant orthopaedic surgeon. “There has been significant mission creep since and the NHS now has a much broader scope with a focus on prolonging life almost irrespective of quality.”

How has the NHS changed in 70 years?

The NHS has changed beyond all recognition since it treated its first patient, 13-year-old Sylvia Diggory, on 5 July 1948. At the time, government expenditure on the health service stood at about £14bn, at 2016-17 rates: by 2016-17 the figure had grown to £144.3bn. In terms of spend per capita this equates to around £260 in 1950 compared with £2,273 in today’s money.

he number of workers required to cater to the country’s care needs has also grown dramatically. At the time of the NHS’s foundation there were 12,000 full-time-equivalent hospital and community medical staff (doctors and dentists) across England and Wales. Today there are almost 110,000 such positions in England alone.

Equivalent figures for nurses begin in 1962, at which time there were 88,579 full-time positions, compared with 285,093 in 2017.

However, not all things have grown exponentially. The number of beds available in hospitals has dropped dramatically across the decades as care patterns have changed, especially as recovery times from surgery have got shorter.

Over the same period the UK’s population has grown, from about 50 million to 66 million, and the demographic shift towards an older population has heaped pressure on the NHS. When the NHS was founded in 1948, life expectancy was 66 for men and 70 for women. Today, it is 79.2 years for males and 82.9 years for females.

What has it got better at?

In 1948 people were most likely to die of infections and heart conditions. Fast-forward 70 years and the most common causes of death are cancer, suicide and heart conditions.

Cancer treatment has been a success story, with death rates peaking in the late 1980s before falling back to well below where they were in 1960, linked to the decline in smoking rates. However, survival rates in the UK still lag behind the European average, linked to people being diagnosed late.

Infant mortality rates have been reduced by more than 80% since 1960. Deaths from strokes and heart disease have fallen steeply, linked to greater use of preventive medication including statins and drugs to reduce blood pressure, and to the decline in smoking, which is partly the result of policies such as the indoor smoking ban.

… and worse at?

Waiting times for treatment are a nagging sore for the NHS. As of May this year, about 4.2 million people were waiting for consultant-led, non-urgent hospital treatment in England, and almost 3,000 of those had been waiting for more than a year. Accident and emergency statistics are also cause for concern: here the target is for 95% of people to be seen within four hours in standard emergency units; over the winter, the rate fell below 80% in some months.

Mental health care is a key area of concern. The need for care for people with anxiety, depression and other disorders has risen but NHS services are struggling to keep up. Experts say there is an acute shortage of beds, a rising number of cases where patients are sent more than 60 miles (100km) for inpatient care – notably for eating disorders – and a dire lack of specialist personnel such as psychiatrists and specialist mental health nurses.

What about the availability of drugs and treatments?

In 1949 the entire NHS drugs bill came to little more than an estimated £30m. By 2016 it was £16bn in England alone.

In the intervening period the service has embraced a wide range of treatments and interventions, in step with scientific breakthroughs and social change, including vaccinations, transplants, contraception, abortion, MRI scanning, IVF, joint replacements, chemotherapy, antidepressants and bariatric surgery.

The prodigious cost – more than £250 for every person in the country – does not cover everything. A special body, the National Institute for Clinical Excellence, was set up in 1999 to decide which drugs are good value for money in England. Its guidelines can be controversial, particularly when it decides that certain drugs, while effective clinically, are not necessarily cost-effective.

What about reforms?

On April Fools’ Day in 1991 the NHS in England introduced the internal market. It was a huge shake-up under which health authorities stopped running hospitals and instead began buying healthcare from them or other hospitals for the patients in their area. Thus began the split between “purchasers” and “providers”. The providers became the first NHS trusts, which are still in place today. Scotland, Wales and Northern Ireland have a different system, using health boards, which have no such split.

Twenty years later came another shake-up of the NHS in England, this time so big “you could probably see it from space”, according to David Nicholson, then the service’s chief executive. Hundreds of primary care trusts and other NHS bodies were to be replaced with new GP-led clinical commissioning groups as part of changes designed to put doctors in charge and empower patients.

It became law in 2012, after an unprecedented “pause”, and took effect on 1 April 2013. Theresa May, the prime minister, and Jeremy Hunt, the health secretary, now admit the changes – the brainchild of the then health secretary, Andrew Lansley – have been very damaging.

Can we afford it?

Last month May unveiled plans for a real-terms annual budget rise of 3.4% for the NHS until 2023-24, giving NHS England £20.5bn more a year by the end of the period.

While the money has been welcomed as an essential investment to ease the pressure on the NHS, some argue that it will not be enough to dramatically transform patient outcomes, particularly while social care – provided by local councils, not the NHS – remains patchy and inadequate, resulting in large numbers of older people being marooned in hospitals.

Is the NHS the world’s best health service?

The US-based Commonwealth Fund, a respected global health thinktank, last year ranked the British health system as the best of 11 well-off countries. The NHS performed better than its counterparts on fairness, ease of access and administrative efficiency, although the study acknowledged that outcomes for people with potentially fatal diseases fell short of those in western Europe and Australia.

Spending as a share of GDP is lower than in many western European peers: the government has spent just over 7 percent of GDP on public health each year over the past decade. Including private healthcare spending, the 2016 total was 9.7% of GDP – slightly higher than the OECD average.

A more recent report by the King’s Fund thinktank, which analysed health data from 21 OECD countries, said the UK was falling behind other countries, with among the lowest per capita numbers for doctors, nurses and hospital beds in the western world.

“If the 21 countries were a football league then the UK would be in the relegation zone in terms of the resources we put into our healthcare system, as measured by staff, equipment and beds in which to care for patients,” said the King’s Fund’s chief analyst, Siva Anandaciva.

Last winter more than 186,000 had to wait with ambulance crews outside A&Es for 30 minutes or more before being admitted.

What next?

Only three months after the foundation of the NHS, its architect, Nye Bevan, said: “I have been exhorting the general public in the last few weeks to make use of this National Health Service prudently, intelligently and morally, because if too great a strain is placed upon it at the beginning it might break down, and because things are free is no reason why people should abuse their opportunity.”

Seventy years later, his words are prophetic indeed. The catch-22 is that improving people’s health generally prolongs their lives, putting more pressure on the NHS – it costs five times more to look after an 80-year-old than a 30-year-old. Numbers of over-75s and over-85s are due to soar over the next decade, and pressures will only increase.

“The demographic is different, it’s moved on from the idea of fixing people, and now it’s much more about supporting people with long-term conditions,” says Ben Gershlick, a senior economic analyst at the Health Foundation. “That is a different stress on the service.”

Much, but not everything, will depend on funding. Gershlick says a 4% budget hike would enable the NHS to improve the number of mental health patients getting treatment from four in 10 to seven in 10, boost capital spending, reduce waiting times and, crucially, do more in the field of prevention to stop people needing the NHS in the first place.

Anything below May’s proposed 3.4% budget hike would mean few policy alternatives other than trying to maintain current standards, he said.

The longer-term aspiration is to introduce what it is hoped will be more efficient ways of caring, such as by providing more care in or near people’s homes. There are concerns that financial pressures will increase calls for greater privatisation of healthcare. The private sector has always provided some services within the NHS, but there is currently little political support for extending this.

What was there before the NHS?

From the end of the middle ages, most people in Britain depended on amateurs with nothing more than a reputation as wise healers who could set bones, brew herbs, or even perform magic.

There were though three small hospitals. And from these grew a patchy network of paid-for hospitals, local council healthcare for rate-payers and later for workers (though they could only go to hospital for tuberculosis), and charitable beds in ‘voluntary hospitals’ or attached to workhouses.

In the 1800s first specialist hospitals – for example maternity and orthopaedics – and later rural cottage hospitals emerged.

Patients were often referred by doctors in general practice (today’s GPs).

As today, standards varied considerably. There are reports of nurses putting tins of oil under the legs of cots to deter cockroaches from climbing up.

In the 19th century, health treatment was typically available only to the wealthy, and health outcomes were startlingly bad compared to today’s standards: middle-class men might live to 45, and they were the lucky ones.

In 1911, David Lloyd George’s National Insurance Act followed the example of Bismarck’s Germany in bringing in a system that provided for health and unemployment cover in return for monthly payments out of wages (it started at four pence a week). But it only applied to workers, and only covered a limited number of health complaints. Many patients still had to pay to visit a doctor or stay in hospital, pushing many families into debt.

In 1948 the prime minister, Clement Attlee, asked the public to be patient with the newly nationalised service as “there are bound to be early difficulties with staff, accommodation and so on.” By the day of the launch, 94% of the public were enrolled with the NHS.

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