Post-pandemic, there is a historic opportunity to strengthen the NHS and improve health and care for all, according to a new LSE-Lancet Commission on the future of the NHS. The report is the first comprehensive analysis of the initial phases of the COVID-19 response and the main opportunities and challenges facing the NHS.
The NHS is internationally held up as a leading example of universal health care, but in widespread analyses, the Commission highlights how far the health of the UK population lags behind that of other high-income countries. The authors point to comparatively low funding for the health service, as well as the long-standing impact of poorly resourced social care and public health programmes on the health of the nation, driving inequalities, and leaving the NHS poorly placed to pick up the pieces.
The Commission, formed in 2017, brings together 33 leading research, policy, management, and clinical experts from the four constituent countries of the UK. It is published alongside four health policy papers published in The Lancet and The Lancet Digital Health, and an editorial from The Lancet.
The report warns against any further major reorganisation of the NHS, which would be disruptive and fail to deliver the intended benefits. Instead, it argues for building on the common strengths of the NHS, with a focus on investment, integration of existing services, and disease prevention, to improve health and care and reduce widespread inequalities.
Among the Commission's key recommendations is a call to increase funding via increased taxation, to help support resource management, recruiting and retaining staff, disease prevention, improving early diagnosis, continual improvement in care, and improving integration between health, social care and public health.
"Without concerted action and increased funding, we risk the UK falling further behind other high-income countries in health outcomes and life expectancy, continued deterioration in service provision, worsening inequalities, increased reliance on private funding, and an NHS that is poorly equipped to respond to future major threats to health", warns co-research lead of the Commission Dr Michael Anderson from the London School of Economics and Political Science (LSE), UK. "The NHS is under our custodianship and we have a responsibility to current and future generations to secure its long-term survival." [1]
"For many decades the NHS was the envy of the world, and it remains one of the most comprehensive and equitable healthcare systems in the world. But for the NHS to be truly the envy of the world again, politicians will need to be honest with the public that this will require increased taxation to meet the funding levels of other comparable high-income countries", says Commission co-chair Professor Elias Mossialos from LSE, UK. "Given the major role of social circumstances in health inequalities, such as housing, employment, education and environment, it is crucial that this extra funding for the NHS and social care doesn't come from cuts to other public services and welfare budgets." [1]
The NHS: a leading example of universal health coverage, let down by the erosion of social care and public health "The NHS has been a world leader for universal health coverage for over 70 years, providing care based on need, not ability to pay, for over 66 million people from cradle to grave", says co-chair of the Commission Professor Alistair McGuire from LSE, UK. "It was envisioned as one element of a comprehensive welfare system, but decades of costly reorganisations, years of austerity, extreme cuts in funding to social care, and an erosion of public health capacity have widened inequality and left the NHS under-resourced and ill-prepared for the COVID-19 pandemic." [1]
The COVID-19 response has shown many aspects of the health and care system at its best: health and care workers have responded with outstanding skill and dedication; the innovation in understanding treatments, vaccines, and mobilising the vaccination programme; the way hospitals worked together to expand critical care capacity; and the rapid expansion of remote consultations.
But the events of the past year have also exposed chronic weaknesses in the NHS, including poor coordination between sectors (eg, discharging people with undiagnosed COVID-19 from hospital to care homes), chronic underfunding, a fragmented public health service, and ongoing staffing shortfalls that pose a threat to the delivery and quality of care, particularly within primary care and mental health services. In England alone, there are approximately 200,000 staff vacancies combined across NHS and social care, with one in 12 posts in the NHS and one in 14 posts in social care unfilled.
"During the pandemic, the NHS has struggled in the face of poor decision making by government, including delayed implementation of social distancing measures, poor coordination with local authorities and public health teams, a dysfunctional track and trace system, and a lack of consultation with devolved nations", says co-research lead Dr Emma Pitchforth from the University of Exeter, UK. [1]
She continues: "Staff morale is at rock bottom because of real term pay cuts and the relentless workload, and the pandemic will leave a challenging legacy of additional mental health needs, a growing backlog of people waiting for elective care, and extra support needed for those living with the after-effects of COVID-19. The pandemic has also laid bare stark socioeconomic and racial inequalities in the UK, and the catastrophic consequences for health." [1]
Health of the UK lags behind its European peers, with stark health inequalities Despite seven decades of universal free health care, improvements in life expectancy have slowed markedly in all four UK nations since 2010, and the health of the population is now lagging behind that of many of the EU15 and G7 countries [2] (table 1).
There are also glaring health inequalities in the UK between the richest and poorest and between ethnic groups, particularly for preventable illness. Men in the least deprived areas of England can expect to live 18.6 years longer in good health than those in the most deprived areas, while for women the difference is 17.9 years (table 4).
The UK has done well at improving oral health and some chronic diseases like diabetes and kidney disease, compared with the EU15 and G7 countries. But it has not kept pace for many other health outcomes, such as deaths from cardiovascular disease, cancer survival, and infant mortality (table 1). The UK is also falling behind in terms of resources, with fewer nurses and doctors per person, and a lower number of hospital beds and medical equipment, than most EU15 and G7 countries (table 2).
The authors note that explanations for the UK's worsening relative performance and widening health inequalities include the squeeze on public finances since 2010 that affected many areas of public policy, particularly cuts in social care services, and the relatively high level of income inequality in the UK compared with other G7 and EU15 countries (figure 3). Also important is that treatment continues to be prioritised over prevention, with funding for public health continuing to fall relative to NHS funding.
Recommendations for the NHS - looking to 2030 and beyond Against this background, the Commission draws on evidence from across the UK and internationally, as well as lessons from the pandemic, to set out seven policy recommendation (panel 4) to secure the NHS' future as a better, fairer health service, and to strengthen its resilience to future health shocks and major threats to health (including an ageing population, the rise of multiple conditions, climate change, and antibiotic resistance). With recommendations to: 1. Commit to annual increases in funding of 4% in real-terms for the NHS, social care, and public health over the next decade, as well as an immediate additional uplift in funding for social care and public health. 2. Develop a 'spending wisely' framework to optimise how resources are managed across health and care services at national, local, and treatment levels. 3. Create a sustainable, skilled and fit-for-purpose health and care workforce, coordinated on a UK-wide basis and tied into NHS and social care expenditure plans. 4. Strengthen prevention of disease and disability with cross-governmental action and earmarked funding, and preparedness to protect against major threats to health. 5. Develop and enhance diagnostics and novel routes to diagnosis to improve treatment outcomes and reduce inequalities. 6. Enable the routine use of data to become a health and care system that learns from every patient encounter, generating evidence to promote innovation and better care for individuals and populations. 7. Improve integration across all sectors and providers of health and care services through, for example, strengthening primary care, removing the requirement to promote competition in England, and linking electronic health care records. Put 1p on income tax, national insurance, and VAT to secure the future of the NHS and social care The Commission points out that UK healthcare spending as a share of gross domestic product (GDP) is lower than the G7 country average (UK GDP spent on healthcare: 10.3%, vs G7 average GDP spent on health 11.4% in 2019). And this is compounded by relatively low levels of welfare spending (UK 20.6% GDP vs EU15 average 24.4%, G7 average 23.3%; table 2).
In a new analysis of health and care spending projections, the Commission recommends that to achieve the other six recommendations and meet future demand, ensure staff pay keeps pace with average earnings, and to invest in capital to protect against major threats to health, that funding for the NHS, social care, and public health should increase by at least 4% every year in real terms over the next 10 years.
The Commission also calls for an independent analysis of health and care workforce and resource needs to ensure transparency in financial planning.
Alongside this long-term funding commitment, the Commission recommends a one-off injection in social care spending (£3.2 billion in England in 2018/19 terms) and public health (also £3.2 billion in England in 2018/19 terms). This is needed for social care to improve financial protection for the most vulnerable, including making the means test for social care more generous by raising the point at which people have to pay for their own care from £23,250 to £100,000, and introducing a cap on care costs of £75,000. And for public health to reverse cuts in the public health grant, better allocate resources to ensure fairer funding that better matches local needs, and to secure sustained investment in the public health workforce against future threats.
The Commission estimates that to implement all these funding recommendations will cost £102 billion in total in real-terms, or 3.1% of gross domestic product in 2030, that could be achieved with the help of progressive, broad-based general taxation, that is backed by growing public support [3], and would leave the UK's tax burden slightly above the average of the G7 countries, but still below the EU15 average.
Based on tax revenue before the pandemic, the report proposes raising personal income tax, national insurance, and value-added tax (VAT) contributions by 1 British pence (1p) each by 2025-26, and increasing personal income tax and national insurance to 2p by 2030-31. The changes would be phased in along with rises to several other, smaller taxes, including corporate and wealth taxes (panel 5). The authors note that the projections do not include the costs of responding to the pandemic and depend on economic growth [4].
"This report outlines an ambitious, long-term vision that looks beyond the election cycle", says Professor McGuire. "Our collective ambition should be as much about preventing ill-health and keeping people healthy as it is about treating people when they are sick. This means the NHS, social care, and public health working in partnership with other public services, civil society, and communities to improve the nation's health, and deliver a health system that is prepared for future health shocks. The COVID-19 pandemic has shown us that health and national economic prosperity cannot be disentangled, and health must be a key area as we rebuild post-COVID." [1]
A Lancet editorial published alongside the report states: "The focus on universal health care must shift from providing the minimum finance required to deliver services, to the equitable provision of health, including public health security, healthy communities, and fully integrated health research. During the COVID-19 pandemic, the UK's research system has made critical contributions to saving lives, but must be further strengthened and better coordinated with clinical care. A health system envisaged through the traditional view of an overhead delivering certain services--eg, the NHS seen through the dimensions of workforce, products, money, and services--is not enough to deliver health to a population or to protect a population from health threats. There is a real danger that the success of the UK vaccination programme is obscuring the scale of the reforms necessary to protect and strengthen the health of the UK population. Broader concepts of health and wellbeing must be placed at the centre of government policy. Investment in public services that reduce inequality is necessary to maintain and improve population health and protect the UK population from future health threats. Lessons from the UK and NHS show that universal health care is broader than health-care provision alone, and that a healthy population must be considered a prerequisite for health security and preparedness."
INFORMATION:
NOTES TO EDITORS
This Commission was funded by the London School of Economics and Political Science Knowledge and Exchange Impact Fund (KEI) which was established using funding from the Higher Education Innovation Fund (HEIF). A full list of authors and their institutes is available in the Commission.
[1] Quotes direct from authors and cannot be found in text of Commission.
[2] The EU15 countries are Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden, and the UK. The G7 countries are the UK, Canada, France, Germany, Italy, USA, and Japan.
[3] https://www.nuffieldtrust.org.uk/research/public-satisfaction-with-the-nhs-and-social-care-in-2019-results-and-trends-from-the-british-social-attitudes-survey
[4] These projections give an indication of the amount of spending that is required for a long-term funding settlement for the NHS, assuming that GDP growth in the long term returns to pre-pandemic projections. It is too early to estimate the additional funds that are required for the NHS to respond to the pandemic, or to address the growing unmet need for health services that has been caused by the pandemic.
The labels have been added to this press release as part of a project run by the Academy of Medical Sciences seeking to improve the communication of evidence. For more information, please see: http://www.sciencemediacentre.org/wp-content/uploads/2018/01/AMS-press-release-labelling-system-GUIDANCE.pdf if you have any questions or feedback, please contact The Lancet press office pressoffice@lancet.com
Quotes from devolved nations:
Scotland:
"Health inequalities within Scotland have widened in recent years - with women and men living in the least deprived areas likely to live 17 and 13 years longer in good health, respectively, than those in the most deprived places. There have undoubtedly been some positive developments, including free school meals and work to further integrate health and social care, but we need to do more to tackle the underlying causes that drive health inequalities if Scotland is to fulfil its potential to become a healthier nation", says Commission co-author Professor Moira Whyte from The University of Edinburgh, UK.
Wales:
"The NHS in Wales has a massive hill to climb", says Commission co-author Professor Emeritus Marcus Longley from the University of South Wales, UK. "COVID-19 has knocked many non-urgent services for six. The challenge now is to get these services up and running in new ways, with a much greater focus on adding value for patients, and greater efficiency. This crisis has reminded us yet again, that people in disadvantaged communities die earlier, after longer ill health than in more advantaged communities. The pandemic must be a clarion call for action for the whole of society, with the NHS playing its part."
He continues, "As the Commission recommends, Wales must focus on working together to improve health, putting good quality social care on to a sustainable footing, and developing a strategy for our future workforce which actually meets the needs of a changing service. Wales' comparative advantage compared with some of the UK is that we don't have a competition-obsessed and fractured NHS, we have legislated for sustainability in public services and health, and local government and the third sector believe in working together. Wales is big enough to make change happen, but small enough to understand what's needed."
Northern Ireland:
"The NHS in Northern Ireland faces many of the same issues as other parts of the UK in respect of unmet needs, insufficient funding, health inequalities and the unrealised potential of prevention and integration. But in some areas our issues are arguably more acute, our waiting times for secondary care, for example, are the worst of any part of the UK", says Commission co-author Professor Ciaran O'Neill from Queen's University of Belfast, UK. "Recommendations in the report around funding, workforce planning, the need to strengthen prevention and improve integration will resonate strongly in Northern Ireland. Unlike other parts of the UK, however, acting on recommendations will require consensus across political parties that are very different in outlook and for whom the common good and self-interest may not always coincide."
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