Britons have long been devoted to their National Health Service (NHS), founded on the principle of universal healthcare, free at the point of delivery. At the same time, they have often grumbled about the standard of the healthcare it provides. This familiar tension has never been as great as today. For once, talk of a crisis is not hyperbole. The NHS is crumbling. Yet the will to fix its problems is lacking. As another winter crisis draws closer, politicians and voters alike need to face some hard questions about ends and means.
The crucial point is straightforward. For years the UK spent much less on healthcare than comparably prosperous nations. Set aside the US, the global outlier: the US’ per capita health spending is more than twice as high, but Britain also spends less per person on health than Canada, Australia, France, Denmark, the Netherlands, Germany and many others. The shortfall narrowed during the COVID-19 pandemic, partly because the NHS lacked the resilience needed to meet the emergency’s demands, but years of throttled spending and meager investment have had the predictable result.
The NHS has higher avoidable mortality rates than other advanced healthcare systems, with below-average survival rates for many cancers. More than 7.4 million people are currently waiting for treatment; many have been in line for more than a year. Ambulance waiting times have spiked. Getting an appointment with a general practitioner (the doctors who serve as gatekeepers to specialist services) has become unbearably slow. The UK went into the pandemic with far fewer hospital beds, diagnostic scanners, doctors and nurses than most of its peers.
Why would anybody be surprised?
In the decade of fiscal austerity following the financial crisis of 2008, the UK spent far less than its European peers on healthcare. To match median outlays per person in the EU14 (members that joined the bloc before 2004), it would have needed to spend another ￡40 billion (US$50.8 billion) a year. To match Germany, it would have had to raise its spending by 40 percent.
British Prime Minister Rishi Sunak’s government has rolled out a ￡2.4 billion plan to help fill about 110,000 vacant NHS jobs by training, retaining and recruiting more healthcare professionals. That is not nearly enough to fill the void. Essentially, there are only two ways to do that. One is to hike taxes by enough to support much greater spending; the other is to lean more heavily on private healthcare provision. The UK is viscerally opposed to both.
Granted, this is not just about money. The NHS relies on a command-and-control structure that militates against innovation and responsiveness to patient needs. The government has acknowledged this, but its reforms to date have been timid. New “integrated care systems” linking service providers by area have been hobbled by too many targets and constraints. Local providers should be given more freedom and held accountable to local authorities. Devolved care in Germany and Finland, for example, might serve as a model.
The system’s use of data needs to change. Information is fragmented and not interoperable, which blocks effective diagnosis, treatment and preventive care. Again, the government says it agrees; again, its proposals fall short of what is needed.
The UK’s social care model is also failing in ways that add to the difficulties of the NHS. Lack of provision for those with chronic and long-term needs leaves hospitals unable to discharge patients. This adds to costs and drains economic productivity as people quit jobs to look after family members in need. Reform was promised last year, then shelved due to lack of funding.
Simply throwing money at a broken model is not the answer. Structural reforms are essential if new funding is to be spent cost-effectively. Nonetheless, some combination of more public spending (hence higher taxes), greater reliance on cost recovery (through charges and co-payments) and a bigger role for private provision is unavoidable if standards are to be restored and improved.
Reverence for the fabled post-World War II system that recently “celebrated” its 75th birthday in Westminster Abbey is not helping. As healthcare gets more expensive, demographic pressures raise costs, and voters demand faster and better services, something has to give. Painful as it might be for the UK to consider, a new model is likely to be required. The government should be honest with voters and dare to engage them in this choice. Nostalgia is not the remedy.
The Editors are members of the Bloomberg Opinion editorial board.
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