Written by James Coker | Reporter, European Medical Journal | @EMJJamesCoker
As the UK’s National Health Service (NHS) enters the eighth decade of its life, there are many well-documented challenges that the institution is facing. The two most fundamental of these revolve around the UK’s ageing population and the growth of lifestyle-related diseases. The extra pressures these factors are bringing have raised concerns about the ability of the NHS to continue providing healthcare according to its core principles: universal availability and free at the point of use, funded by general taxation. There has been much discussion of a financial ‘black hole’ in the NHS budget in recent times, with increasingly higher levels of government funding required to enable the service to simply keep pace with demands.1 Longer-term solutions are required, and in this article we explore the various ideas that have been proposed for the maintenance of a system that to this day retains a vast amount of public support.2
It is arguable that the NHS has become a victim of its own success in terms of the changing age demographics of the UK. Recent data from the Office for National Statistics (ONS) showed that the proportion of UK citizens over the age of 65 years is getting significantly higher, and this is in the context of a rapidly growing population overall. In 1976, 14.2% of the population were above 65 years and by 2016 this had risen to 18.0%. This age group is projected to form around a quarter of the country’s population by 2046, at 24.7%. The analysis also laid bare the improvements in life expectancy there have been. The life expectancy for women born in 2015 is 82.8 years, which is 4 years higher than for women born in 1991. For men the difference is even greater: 73.4 compared with 79.1 years in those born in 1991 and 2015, respectively. Future projections are that life expectancy by 2036 will be 86.6 years for women and 83.7 years for men.3
While this is a cause for celebration, an ageing demographic is creating a greater strain on NHS services. A particularly major resultant issue is the marked increase in chronic diseases requiring long-term care, such as osteoporosis and chronic kidney disease. The elderly population also make up a substantial proportion of hospitalisation cases; a recent study showed that 41% of all adult hospital admissions are from those aged 65 years and above.4
Lifestyle-related diseases have also seen a substantial rise in recent years, with conditions such as Type 2 diabetes and smoking-related bronchitis believed to cost the NHS around £11 billion every year.5
So what are the different options for taking on these immense challenges?
How about simply dismantling the NHS altogether to pave the way for something completely different, such as an insurance-based model? This would essentially mean that individuals are responsible for financing their own care, avoiding spiralling costs to the taxpayer. However, such a policy could potentially lead to a large proportion of the population being without access to good healthcare due to financial barriers. In addition, the chances of any government actually dismantling the NHS are tiny; there is so much overwhelming support for this system of healthcare in the UK that the implementation of such a policy is virtually impossible for the foreseeable future.6
Competition and Market Forces
While full privatisation is extremely unlikely, there have been moves by successive governments to open up the provision of NHS services to private companies as well as to apply the principles of market forces internally in an attempt to drive up efficiency and performance. These initiatives have included a Payment by Results (PbR) funding system for hospitals, allowing patients a greater choice of which hospital they can attend, and enabling the best performing hospitals to become Foundation Trusts, with autonomy over spending. Could extending these market-based ideas further help the NHS cope with the increasing pressures? There are doubts about the efficacy of the policies already carried out, with the evidence suggesting that the impact of such reforms has been limited due to a variety of reasons, including a reluctance on the part of doctors and patients to fully utilise the availability of different choices.7 In addition, such moves have been viewed as antithetical to the NHS values by some.
Charges for Patients?
There are already certain aspects of NHS care that patients are usually charged for. These include prescription charges and eye tests, although there are variations in UK regions where healthcare policy is devolved, such as in Scotland. So, could individual patients be asked to make a contribution to their care in other parts of the service in the future? There have been suggestions in recent years that patients who use Accident and Emergency (A & E) Departments inappropriately should be charged a small fee for doing so. Unnecessary use of A & E has been found to be a big problem for hospitals, with one analysis of attendance in these departments in the North East of England revealing that under 30% of those attending actually required admission to hospital for emergency treatment. This has placed a huge burden on hospitals, both financially and in terms of being able to treat those with serious health problems quickly.8,9
Another proposal has been for stricter rules on so-called ‘health tourism’, which is the use of the NHS from non-UK citizens. Some estimates have found this to cost the NHS around £2 billion per year.10 While only UK citizens are entitled to NHS care free at the point of use, there are often practical difficulties in recouping the costs of care for overseas visitors. This has led to measures recently being put in place for such patients to be charged up front for their care.
Although these charges could provide an extra revenue stream for the NHS, for many people this concept is an unacceptable retreat from the founding principles of the service. There are also fears such policies would be an obstacle that prevents vulnerable people from receiving the treatment they need.
Saving money by increasing efficiency and reducing bureaucracy has always been an important political target. The NHS itself has acknowledged that within such a huge system, there are efficiencies that can always be made, enabling extra money to be spent in other areas. The service recently set out a 10-point efficiency plan as part of the Five Year Forward View published in October 2017. These include cutting costs of corporate services and administration, achieving better value for money in the purchasing of drugs, and freeing up hospital beds through extra funding to local authorities to improve social care.11 Whilst there is little doubt such measures can achieve financial savings for the NHS, this needs to be undertaken in conjunction with other initiatives to have a real impact. Additionally, it has been noted that the NHS is already one of the most efficient healthcare systems in the industrialised world.
As alluded to earlier, the cost of conditions associated with lifestyle, for example cardiovascular disease and Type 2 diabetes, is enormous.5 Therefore, an emphasis on promoting healthier lifestyles, thus helping prevent such ailments occurring in the first place, could relieve the burden on the NHS substantially. There has been a lot of focus on this area in recent years, and it has led to some controversial new laws, such as the introduction of minimum pricing for alcohol in Scotland.12 The extent to which government should be involved in this area is a matter for debate.
The greater use of technological innovations within the NHS is viewed by many people as a great potential means of relieving pressure on the service and providing care more efficiently.13 A recent blog from the European Medical Group covered a presentation given by Mr Cleveland Henry, Programme Director of the Innovations, Digital Futures & Digital Collaboration Service at NHS Digital, explaining the implementation of digital technology in the NHS. Whilst Mr Henry acknowledged that the health service has been slower than other sectors in fully utilising the technology available, there are significant strides now being made. This has included enabling patients to utilise a range of services online, such as access to their medical records and booking appointments and the use of modern communication methods such as Skype between doctors to speed up diagnosis and referrals. There are of course difficulties with pushing through such changes too quickly however, including ensuring that healthcare professionals unfamiliar with working with these types of technology are fully trained in their use. Nevertheless, if implemented in the right way, technology could certainly help the NHS cope with the increasing pressures it faces.
Although the NHS is not directly involved in the provision of social care in the UK as it is a separate model funded in a different way,14 there is plenty of evidence to suggest that improving social care services would substantially alleviate pressures on the service. It has been shown that when people who require long-term care do not have adequate access to social care, the NHS will generally have to bear the burden. For example, during last winter, a lack of available social care places led to thousands of mainly older patients recovering from cold-related illnesses being stuck on wards, blocking beds for new arrivals. The UK’s Chancellor of the Exchequer also recently warned that inaction on social care is no longer an option.15
There is no easy answer to this issue, and a number of proposals to address social care have proven unpopular; for example, the Conservative Party’s manifesto pledge in the 2017 General Election on this issue was dubbed the ‘dementia tax’ by the media.16
Overall, the NHS has proven to be a highly successful system, with vast improvements in measures such as life expectancy correlating with the existence of the service. The ability to access quality healthcare free at the point of use also enables peace of mind for many people in the UK. However, these successes have brought about new challenges that will only grow as time passes; in particular, caring for the increasing numbers of people who are vulnerable to long-term conditions, such as the elderly. Aspects of modern life have also meant a dramatic increase in lifestyle-related conditions that need to be treated. There are a number of ways in which these challenges can be met to ensure that the NHS provides healthcare whilst maintaining the core principles that led to its initial establishment. None of these are easy; some have proven to be quite controversial, such as the introduction of patient charges, whilst others, including reforming social care, could necessitate fundamental rethinks about how these services are provided.
What are your views on this vast and multifaceted topic? What would you like to see the NHS do differently to meet the new challenges it faces in the modern world? Are there any ideas that we have not included which should be considered? Please send us your thoughts and join the debate on twitter @EMJReviews, and our Facebook and Linkedin pages.
- Cowburn A. NHS ‘staring into the abyss’ as two thirds of trusts report deficits. 2016. Available at: https://www.independent.co.uk/news/uk/politics/britain-s-health-service-staring-into-the-abyss-as-two-thirds-of-nhs-trusts-report-deficits-a7430141.html. Last accessed: 25 June 2018.
- Ipsos MORI. What do the public think about the NHS? 2017. Available at: https://www.ipsos.com/ipsos-mori/en-uk/what-do-public-think-about-nhs. Last accessed: 25 June 2018.
- Office for National Statistics. Overview of the UK population: July 2017. 2017. Available here: Last accessed: 25 June 2018.
- AGE UK. Later Life in the United Kingdom. 2018. Available at: https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/later_life_uk_factsheet.pdf. Last accessed: 25 June 2018.
- Hughes D. Illnesses associated with lifestyle cost the NHS £11bn. 2016. Available at: https://www.bbc.co.uk/news/health-37451773. Last accessed: 25 June 2018.
- Campbell D. NHS privatisation would be ‘political suicide’, says thinktank. 2018. Available at: https://www.theguardian.com/politics/2018/feb/01/nhs-privatisation-would-be-political-suicide-says-thinktank. Last accessed: 25 June 2018.
- The King’s Fund. Competition and choice. Available at: https://www.kingsfund.org.uk/publications/reforming-nhs-within/competition-and-choice. Last accessed: 25 June 2018.
- North Tees and Hartlepool NHS Trust. Warning from region’s hospital bosses on misuse of A&E services. 2017. Available at: https://www.nth.nhs.uk/news/warning-on-misuse-of-accident-and-emergency/. Last accessed: 25 June 2018.
- Worley W. NHS in crisis: The worst reasons people visit A&E when they shouldn’t. 2016. Available at: https://www.independent.co.uk/news/uk/home-news/nhs-crisis-worst-reasons-people-visit-ae-when-they-shouldnt-a6954296.html. Last accessed: 25 June 2018.
- Silver K. Health tourism charges come into force in England. 2017. Available at: https://www.bbc.co.uk/news/health-41692815. Last accessed: 25 June 2018.
- NHS England. Funding and efficiency. Available at: https://www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/funding-and-efficiency/. Last accessed: 25 June 2018.
- Carrell S, Brooks L. Scotland awaits minimum alcohol pricing with mixed emotions. 2018. Available at: https://www.theguardian.com/society/2018/apr/27/scotland-minimum-alcohol-pricing-mixed-emotions. Last accessed: 25 June 2018.
- Milburn A. Technology and innovation are key to saving the NHS. 2017. Available at: https://www.theguardian.com/commentisfree/2017/oct/22/technology-and-innovation-key-to-saving-the-nhs. Last accessed: 25 June 2018.
- The King’s Fund. What is social care and how does it work? Available at: https://www.kingsfund.org.uk/projects/what-is-social-care. Last accessed: 25 June 2018.
- Walker P, Stewart H. NHS faces year-round crisis over lack of social care, says council chief. 2018. Available at: https://www.theguardian.com/society/2018/mar/12/nhs-faces-year-round-crisis-over-lack-of-social-care-says-council-chief-lambeth. Last accessed: 26 June 2018.
- Inman P. ‘Dementia tax’ and social care funding: the Conservative plans explained. 2017. Available at: https://www.theguardian.com/society/2017/may/18/social-care-funding-what-are-the-conservatives-proposing. Last accessed: 26 June 2018.