The NHS – what lessons from a 70-year-old system of universal health coverage?
“Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide”
- British Secretary for Health, Nye Bevan, 1952
The United Kingdom’s National Health Service turned 70 years old this month.
The NHS was launched on 5 July 1948 by then British Health Secretary Nye Bevan after the Second World War.
It was the first time anywhere in the world that completely free healthcare was made available on the basis of citizenship rather than the payment of fees or insurance, although there are patient fees for some services today. Funded by the UK Government, it is an example of a comprehensive public system of universal health coverage.
Since that time, the NHS grown to become an icon of British society. It is the fifth largest employer in the world with 1.7 million employees and costs a hefty price tag of £149 billion each year to keep it going. The NHS is ubiquitous in British society – its creation topped a poll earlier this year of things Britons are most proud of in British history.
Its 70th anniversary generated all sorts of official celebrations, royal visits, tea parties and city buildings being lit up at night.
There’s no doubt the NHS provides a reasonably good system of universal health coverage for Britons. Patients can see a doctor, undergo specialist treatment and receive emergency services without paying anything, provided you are happy to be allocated and registered by the government. Many ailments and diseases are treated relatively well and there is a nationwide system of medical facilities and services all paid for by the government.
If you're a British citizen or resident you can get treated, usually at no cost.
But like any 70-year-old system, there’s debate about whether it is fit-for-purpose for the modern age. As one commentator said, it might be a case of ‘you get what you pay for’.
The UK performs worse than a range of other countries in treating things like cancer, stroke and heart attacks. More people are dying in the UK from these diseases relative to other countries. For example, in cancer the UK performs below average and poorly in some cases in terms of the proportion of cancer patients still alive five years after diagnosis.
Paying for the NHS in the future is a major topic of debate in the UK. Basically, the scheme has been short of funds and running on the edge for years. The UK government recently promised a £20 billion increase in NHS funding over five years. Although the details of how this will be funded have not been decided yet, there’s speculation that increased taxes may be required. Talk of a ‘Brexit dividend’ for funding the NHS has met with widespread scepticism, slogans on the side of campaign buses aside.
There is also debate about the need for a hypothecated tax specifically dedicated to fund the NHS in the future, rather than the funds just coming out of the government’s general revenue, perhaps something like Australia’s Medicare Levy. This has been debated for some time in the UK. While this has been resisted in the UK in the past, there is a renewal of this debate in the UK given the growing recognition that there is an emerging funding problem for the NHS.
There’s pressure for the NHS to spend its money better, get more efficient, recruit more staff and use new technology.
A recent report by NHS Improvement, an evaluation body of the NHS, found that the NHS repeatedly failed to meet its waiting time targets for a range of health services and that there are around 100,000 staffing vacancies that need to be filled.
Last winter the UK was full of stories of overcrowded accident and emergency wards overflowing with patients due to the cold weather, ambulances queuing outside hospitals and hospitals unable to cope with large numbers of flu patients hit by a particularly strong strain of influenza (the so‑called ‘Aussie flu’). At the beginning of this year, the NHS set new record lows for the worst performance on waiting times in history.
When put under strain, you can almost see the NHS system bursting at the seams before your eyes and that great British tradition of queuing seems to be in force in hospital waiting rooms, doctor surgeries and ambulance dispatch call centres.
Britons queue for the cricket at Lords, queue for the Underground, queue for Wimbledon and they queue for healthcare.
And the NHS can be a dinosaur when it comes to adopting technology. One recent report said the NHS “does not have a strong track record in implementing it” and needs to get better at assessing technology options. In an incredible example of this, the NHS is the world’s largest purchaser of fax machines due to a ‘stubborn resistance’ to using new technology. Most NHS patient records are still kept on paper with inefficient data exchange between different services which leads to major additional costs in time and money.
So, does the NHS provide a model of universal health coverage for other countries?
Organisations like the WHO and the World Bank are doing a lot of work on UHC. The head of the WHO, Dr Tedros, has often said that countries have different needs and structures and will need to choose a model that is best for their circumstances.
If you were designing a new system of universal health coverage today from scratch, you might do things quite differently compared to if you were designing one 70 years ago.
New technologies, big data, digital health, artificial intelligence, mobile technologies, drones, robotics, innovative private capital markets, globalisation, freer international migration, public-private partnerships and emerging economies might fundamentally change the best ways to provide health services and financial protection to a country’s population.
For example, emerging African countries building a system of UHC today might want to consider how to use emerging technologies, innovative practices and financial techniques to ‘leapfrog’ some of the ageing infrastructure and structural problems that characterise systems like the NHS. This might help 'future-proof' their health systems.
In any event, at 70 years old the NHS provides lessons – both good and bad – for those tasked with designing and implementing UHC in other countries.
Long-term sustainable funding is critical, a sufficiently skilled and staffed workforce is vital, having sufficient infrastructure capacity is imperative, and embracing new technology is essential.
One thing the NHS does demonstrate to other countries is the benefit in UHC having political priority. In Britain, the NHS has this in spades.
The NHS is talked about everywhere and has entered the British cultural psyche.
Which will probably put it in good stead for the next 70 years.