The NHS is currently facing its annual winter of discontent; founded in the 1940s, to provide universal healthcare, the service is under severe financial strain.
All users of the NHS have one thing in common; they will not receive or have to pay a bill for the care they receive.
Their healthcare is free and universal and has been since the formation of the country’s National Health Service in 1948.
The population’s healthcare is funded through tax and compulsory national insurance contributions deducted from income, which also go toward many other state benefits.
But, as the demand for health care has increased across all levels of care – primary, secondary and tertiary – so has the strain on this once-coveted health system – particularly on its finances.
Healthcare budgets in the UK have been plateauing, with only minor increases in spending, as percentages of gross domestic product spent on it have been declining.
According to the Kings Fund, an independent health care charity, the National Health Service is halfway through its most austere decade ever. Figures from the World Bank reflect this: In 2009, the UK spent 9.8% of its GDP on health care; by 2014, it fell to 9.1%, according to the World Bank.
Along with this have come more people, who are living longer and with multiple conditions like diabetes and heart disease that require treatments also rising in cost. Meanwhile, hospital bed numbers have fallen, numbers visiting emergency rooms have risen, and the demand for social care – such as home care or equipment – in the community has increased with limited services in place to provide it, again leaving more people with fewer hospital beds.
“The current situation is unsustainable,” says Dr. Ian Eardley, vice president of the Royal College of Surgeons in the UK and practising surgeon at a hospital in Leeds. “There are patients who are medically fit but can’t get help in the community, or support, to leave hospital.”
Austerity has brought extended waiting times for people seeking elective or routine treatments, such as knee or hip surgery, while emergency treatments for serious issues such as cancer or heart attacks continue to be treated promptly.
Guidance requires anyone in the UK with signs of cancer be seen within two weeks, “But you can’t bring patients in for elective surgeries,” said Eardley, who further stressed the complexities surrounding people living longer.
“People often live longer with other medical problems being controlled and managed,” he says, adding that greater expectations by patients today and the tendency to discuss cases in greater detail all add time and strain to an already overwhelmed system.
Real National Health Service spending in 2015-16 increased by just 1.6%, according to the Kings Fund and the budget has been frozen for too long; more funding is needed to decrease the debt owed by hospitals whose budgets were not sufficient and to ensure a greater transition from care settings into the community.
The UK recently-announced Spring budget pledged £2 billion ($2.5 billion) toward adult social care over the next three years to “ease pressure on the NHS”.
£425 million ($525 million) was also announced to be invested in the NHS in the next three years, with £100 million ($125 million) going to Accident and Emergency departments in 2017-18, to help them manage increasing demand.
Experts welcome the investment, but believe it will not be enough. The UK is not exceptional, other countries have similar levels of health care coverage using a tax-based system, including Finland, Sweden, Portugal and Spain. The broad model of tax-based funding is common in quite a few countries.
A recent report from the Organisation for Economic Co-operation and Development highlighted that, although access to care in the UK is good, the quality of care is uneven and continues to lag behind that of many other countries.
It is worth noting that Germany and France, which spent 11.3% and 11.5% of their GDPs on health care, respectively, in 2014 and have more beds per capita, more doctors per 1,000 people and longer life expectancies.
Germany and France use a social insurance model to pay for their health care: Deductions are taken from income, but unlike in the US, everyone is covered, and companies don’t make a profit. Those contributing also “own” the organizations involved through boards and unions.
People pay a fee at the point of care, though it’s just $5 to $11 in Germany and $25 in France, which is often reimbursed.
The Western country spending the most on its health care is the US, which spent 17.1% of its GDP on healthcare in 2014.
Yet a series of factors – such as a lower life expectancy and uneven coverage – highlight that increased expenditure alone is not always a good thing. A system to manage it best is key.
The US is an outlier internationally and very few people would say the US model is good for the population.
Treatments and new technologies for conditions such as cancer often lead from the US, but the key issues are access and the varying amounts that could be charged as a fee to provide them.
The private insurance-based model in the US, covering only those who are insured, leads to companies in the industry working toward profit, which leads to more division and less universal coverage.
“If you have lots of money, you get good care,” Eardley says about US healthcare. “If you don’t have money, you don’t fit into the system,” he adds, calling such a system “wasteful.”
Experts in the UK are eager to stress the cost-efficiency of the National Health Service; according to the Royal College of General Practitioners, the UK pays the least per patient than most countries in the West.
In comparison with the US, Europe’s universal coverage, with tax- and social-fund-based financing through contributions, spends less and has more care with better outcomes.
Many countries on the continent still have a small sector of patients using private insurance. In the UK, an estimated 11% of the population has private insurance, often through their employers. In Germany, top earners can opt out of the public system and pay privately instead, representing an estimated 10% of Germans.
At the core of the debate around health care, money alone is not the issue; it’s the model of care.
“Healthcare should be free at the point of delivery,” says Dr. Richard Kerr, a council member of the Royal College of Surgeons in the UK and consultant neurosurgeon at a large regional hospital in Oxford. “There is a fee structure behind it, but when a patient comes to see me … the issue of money never comes into it.”
Kerr believes countries worldwide can learn from those on mainland Europe, such as Germany and France, where the population receives great care, in his opinion, with good quality but pays more for it through taxes. “They are taxed higher but have much more investigative healthcare.”
“We should look at the different models of health care and take the good aspects of it … without getting rid of the basics of what we’ve got,” he says. “But what you get for your buck is more here.”
With the UK being more cost-efficient, he ponders whether that is something to be proud of. “If you receive the same level of care with less money,” that is indeed a point of pride. But with patient waiting times up to 20 weeks in some cases, he adds, that is not the case.
The neuroscience department at his hospital in Oxford is the regional hospital, a point of tertiary care where patients requiring specialist procedures are referred from their district hospitals. It serves more than 2.8 million people across a 100-mile radius, with just 60 beds in his main ward and another 13 in the intensive care unit.
The building is just a decade old, light and airy in design, but he stresses the shuffling he and his team do on a regular basis between main wards and the ICU to ensure that all patients can access a bed and undergo their procedures.
Staffers borrow beds between the departments, he explains, so spare beds in the ICU will sometimes be used for his less severe cases. But he shows further frustration with the lack of social care resources for patients away from his hospital, such as the provision of home carers or equipment to keep them mobile, or changes to make their homes more accessible or to help them access day centres. These are crucial, he believes, particularly as the population continues to live longer.
Between 2014 to 2015, 72% of more than 1.8 million new requests for social care support requested from councils in England were clients aged 65 and over, according to NHS data.
In addition to keeping beds unnecessarily occupied, resulting in a “domino effect,”; if a patient has social care needs, a busy environment (like a hospital) isn’t the best place for them.
Neurosurgical procedures vary also greatly, with some patients needing just 24 hours to recover while others have stayed as long as 100 days.
“We have to cancel patients at short notice sometimes,” says Kerr, “not only leaving patients untreated but leaving surgeons unable to do their jobs.”
“There is pressure on us now, but this is not new,” he said of demands on the wards and his outpatient clinics. “My clinic overruns. It always does … so there’s frustration there.”
But Kerr wants to carry these realities forward and kick-start a debate to get the UK government investing more for even greater efficiency, enabling greater capacity to deliver care.
“When I’m old and crumbly, I don’t want to have to wait,” he says, thinking of his patients. He and others in the field want reform or restructuring to get people discussing what healthcare is, as its meaning has changed dramatically since the National Health Service’s inception.
“We need a commission,” he claims, stating a need to push for patients, cross-party politicians, policymakers and medical practitioners to come together to define what is meant by healthcare.
“We need a debate asking, what do you want out of health care?” Kerr says. “Do you want to continue treating everything? Yes, you do, but we can’t do it under the current financial envelope.”
Currently within the health service, certain conditions are not covered – such as more cosmetic procedures – leaving some patients unsatisfied.
The need to identify what people on each side of the debate believe healthcare to be, and which aspects they prioritise, will help manage expectations as well as resources, Kerr explains, not only in the UK, but also more globally.
He believes this will lead to a happier and more satisfied patient base, particularly among those left behind – either waiting in the UK or uninsured in the US. But it won’t be easy.
“Healthcare is incredibly complex. … The growing number of older people with multi-morbidities are having very very complex trajectories through the health and social care system. We shouldn’t underestimate the challenges.”