NHS at 70: advancing health systems for all?
On 5 July 2018, the UK’s National Health Service (NHS) will celebrate a remarkable 70 years of existence. This is a time to both celebrate a great internationally renowned social institution, reflect on its present circumstances, and look to its future in a rapidly changing global context.
A constantly debated health service
Since the early part of the 20th century there has been a continuing debate in the UK about government’s role in ensuring that health needs are met. The establishment of the NHS in 1948, following the publication of the Beveridge Report in 1942, did little to end the debate, which has continued over the last 70 years. The NHS was a compromise of political and medical interests. Discussion has repeatedly returned to whether the NHS should be a local or centralised service, what relationship it should have with local government and local social support services whether doctors, managers or politicians should run the service, and whether it is affordable as a tax funded service.
These ongoing debates and constant changes in organisational structure have, since the financial crisis of 2008, taken place at a time of funding restraint in the public sector. While the NHS budget has continued increasing from year to year this has not been seen as sufficient to meet rising demand and needs of an ageing population, and overall the proportion of GDP spent on health has reduced.
Rising pressures from an aging population
By 2032, the population in England is predicted to grow by 8 million to just over 61 million, with 4.5 million of this increase from natural growth (births – deaths), and 3.5 million from net migration. The population’s life expectancy has been rising by five hours per day, and is expected to increase to 83 years for boys and 87 years for girls by 2032.
Over the next 20 years the population aged 65-84 will rise by 39 per cent, with those over 85 by 106 per cent. The number of people in England with three or more long-term conditions is expected to rise from 1.9 million in 2008 to 2.9 million this year. According to the Alzheimer’s Society, one in three people over 65 will develop dementia with a cost to the UK economy of £23 billion and around 4 million people are likely to need help with daily living by 2029.
The increasing demand on services is evident in hospital inpatient admissions in people aged over 75, which have increased in England by more than 50 per cent between 2000-01 and 2013-14, and will require the adult social care workforce in England – long labelled the ‘Cinderella service’ – to grow by one million by 2025.
Life expectancy gap widens between rich and poor in England
In 2017, the Commonwealth Fund’s fifth report on health care systems in 11 advanced economies put the NHS first out of eleven countries in terms of equity, prevention, safety, coordination and patient engagement, and third on access. However, it ranked the NHS very low in terms of health outcomes because of higher death rates from conditions that could have been prevented if timely and effective care had been provided and due to lower healthy life expectancy at age 60.
The performance of the NHS is only one factor contributing to the relatively poor health outcomes. In England, the life expectancy gap between richest and poorest neighbourhoods has widened since 2001. According to the Longevity Science Panel (LSP), on average, a boy born in one of the most affluent areas will outlive one born in one of the poorest by 8.4 years. That was up from 7.2 years in 2001. The LSP also found that death rates for 60 to 89-year-olds had improved for everyone between 2001 and 2015, but the biggest gains were recorded among the best-off. The result is that men and women in that age group, who were from the poorest parts of the UK, such as Middlesbrough or Hull, are now about 80% more likely than those from wealthiest parts of the country, such as parts of Berkshire or Buckinghamshire, to die.
Better health outcomes depend on reducing persistent inequalities
While there is wide acknowledgement of a number pressures on health systems, including the implications of people living longer with chronic illnesses, there is not enough on the persistent inequalities that inhibit poorer and more vulnerable communities from living healthy lives. This is true for people living in affluent countries, such as the UK, as it is for people in low and middle income countries.
As there is a renewed global effort to provide access to essential, quality health services for every human being by 2030, global and national leaders must work beyond the health sector to make improvements in education, rights, sanitation and other areas critical to better health. To do this and to tackle other critical questions concerning the likes of sustainable funding and the opportunities and risks associated with new innovations and technologies, they must be prepared to learn from and challenge one another.
These questions are relevant to everyone with an interest in health, whether as politicians, providers of care, or patients. As we look to the future of the NHS, they are especially important for us in the UK. Too often, we look at the NHS in isolation. Reflecting a strange form of British exceptionalism, we see it as unique. Yet it is not.
Working to advance health systems for all
In October 2018, researchers, policymakers, practitioners and advocates from across the world will be convening in Liverpool at the Fifth Global Symposium on Health Systems Research (HSR2018). The central question posed to participants will be: how can we advance health systems for all in the context of the Sustainable Development Goals?
HSR2018 will be a significant and timely platform for genuine mutual learning that goes beyond traditional and simplistic forms of knowledge transfer from advanced to developing health economies.
At the Institute of Development Studies (IDS) we are privileged to be working with UK and international partners to co-host HSR2018 as part of a wider and growing programme of work to enable mutual learning and exchanges of experiences between countries.
As we reflect on the NHS’ past, present and future, platforms such as HSR2018 present important opportunities for us all to learn from one another.
Tom Barker is Senior Health and Nutrition Convenor at IDS, and Communications Manager for Health Systems Global. Tom previously worked in UK health policy and research with the NHS Confederation.
Photo: NHS England