One of its great strengths is the role it plays in tackling inequality – redistributing resources from the healthy to the sick, from the rich to the poor. It does this by allocating its resources in a way that takes account of the needs of different regions of the country, irrespective of their wealth, combined with access to care being based on a patient’s clinical need rather than their ability to pay.
The NHS also protects citizens from the catastrophic financial consequences of ill health that people can face in countries with health care systems that rely more extensively on private funding.
Both these aspects of the NHS are important in a country with already significant levels of income inequality and relatively low levels of welfare spending compared to other high-income countries. By way of comparison, the UK spends 21 per cent of its GDP on welfare, Germany 25 per cent and France 31 per cent.
The NHS’ other strengths include its good track record of treating chronic diseases such as diabetes and kidney disease. It is also a world leader in health research, recently emphasised by influential clinical trials on vaccines and treatments for Covid-19. It has a methodologically robust and transparent system for evaluating new drugs and medical technologies.
However, looking at international comparisons, the UK performs poorly on a number of fronts. Despite the gap narrowing in recent years, funding for healthcare is lower in the UK compared to many other high-income countries, at 10.3 per cent of GDP compared to 11.2 per cent in France, and 11.7 per cent in Germany, and the NHS bears the consequences of this.
In the UK we have three doctors for every 1,000 people, compared to three in France and four in Germany. We have seven nurses for every 1,000 people, in comparison to Germany’s 13 and Frances’s 10. In terms of hospital beds, we have two per 1,000 people compared to five in France and eight in Germany. We also have fewer diagnostic tools such as MRI and CT scanners.
As a result, in combination with poor welfare spending generally, the health of the UK lags behind that of many other wealthy nations and inequalities persist in key areas including life expectancy, cancer survival, and cardiovascular disease.
Even with these challenges, and against a backdrop of poor government decision making, the NHS has managed the Covid-19 pandemic well and was not overwhelmed despite significant pressure. In a matter of weeks, critical care capacity was massively expanded, many thousands of staff reallocated, and services re-organised to reduce transmission of coronavirus.
The NHS has also established world-leading clinical trials on vaccines and treatments, and vaccinated the UK population at an almost unimaginable pace.
However, its role in relation to its capacity to test for Covid-19, availability of Personal Protective Equipment, the cancellation and postponement of aspects of routine care and the discharging of people with Covid-19 from hospital to care homes must be critically examined.
The LSE-Lancet Commission on the future of the NHS, which brought together 33 leading research, policy, management and clinical experts from the four UK nations, argues that the NHS must be strengthened through investment and integration. We concluded that a fundamental structural reform of the NHS is not needed. Past experience has taught us that this is often disruptive and has little evidence of any benefit.
An ongoing increase in funding of at least 4 per cent per year, in real terms, for the NHS, social care, and public health is essential to ensure the health and care system can meet demand, rebuild post-pandemic and develop resilience against further major threats to health. A further immediate uplift of funding is needed for social care to improve financial protection by implementing long-overdue reform recommended by the Dilnot Commission, and for public health to reverse cuts over the last decade.
The only fair and equitable way to raise these funds is through broad-based and progressive taxation. We estimate this will require a 1p increase in Income Tax, National Insurance and VAT by the middle of the 2020s, rising to 2p for Income Tax and National Insurance by the end of the decade.
These funds must be spent wisely, including on providing the UK with more skilled health and care workers, strengthening programmes to prevent disease and disability, and increased investment in capital such as healthcare facilities, diagnostics, and health information technology.
This will be challenging, with government debt at the highest level since 1944-45. However, we argue that, similar to the establishment of the NHS post-Second World War, post-pandemic and post-Brexit, the UK has a once in a generation opportunity to invest in the health of all its population and secure the long-term future of the NHS.
Failure to take action risks eroding the NHS’ ability to provide high-quality health care for all and to respond to future major threats to health such as pandemics.
We can have a national health service that is once again the envy of the world, but we must be prepared to pay for it.
Dr Michael Anderson is co-research lead for the LSE-Lancet Commission
Elias Mossialos is professor of Health Policy at LSE and the co-chair of the Lancet Commission