The NHS is attacked on a variety of spurious grounds. Negative statements often being repeated uncritically and ad nauseam by some sections of the media until they become ‘common knowledge’. Here, John Puntis examines some of the most prominent, considers the evidence, and offers some counterarguments (Part 2 of this article).
“If the NHS is so good, why has no one else copied it?”
This question is meant to imply that the NHS is outdated and that a social insurance model or other form of funding would lead to better outcomes. Nigel Edwards of the Nuffield Trust pointed out that if we look at countries that have health systems funded largely out of tax, that are mostly free, comprehensive and have a provider sector that is substantially publicly owned (i.e. like the NHS), there are actually quite a few. Scandinavian countries have systems where the majority of the revenue is collected by tax and providers are owned by local government. The current Portuguese Health Care System was created in 1979 and based on the Bevanite National Health Service model; Italy, Spain and Malta also have health systems in many ways close to the NHS.
Of course, these countries do not replicate our NHS model in every detail but nevertheless have much in common, including now being the objects of ideological attack, and undermining of their public aspects through the growth of financialization and the promotion of the unevidenced view that privatisation brings efficiency. On the contrary, recent evidence from England suggests that outsourcing clinical services is associated with increased mortality. Where profit-hungry private equity firms have taken over hospitals in the US, there has been a 25% increase in complication rate (principally infections) observed among patients. The deficiencies of some social insurance-based European and other high-income country systems have been outlined by John Lister and include higher overall administration costs and transfer of cost of care to individuals, often disproportionately affecting those on lower incomes.
Enthusiastic introduction of market reforms in the New Zealand health service in 1993 is acknowledged to have led to neglect of both workforce and planning, and resulted in fiscal irresponsibility and excessive transaction costs. The legislation through which these reforms were imposed was eventually abolished while new laws re-established a National Health Service (first founded in 1938 and providing care ‘from cradle to grave’). Following this, through working together rather than in competition, patient care improved and demand on hospitals was reduced. In a recent review providing an international perspective, the benefits of public versus private health care were noted to include that the former reduced overall healthcare and administrative costs, helped in standardising services and creating a healthier workforce, prevented future costs, and guided the population to make better choices.
“We have given the NHS record funding” – so everything is alright
The NHS may indeed have ‘record funding’ – but this does not mean it is getting what it needs. More or less everyone (except those with overall responsibility for the service it seems) can see that the NHS is in crisis. The government consistently attempts to counter criticism of its appalling record with the claim it is providing record funding. This is, of course, a meaningless statement unless it is placed in the context of historical funding, current demand and is benchmarked against comparable countries. As Mark Thomas of the 99% Organisation pointed out, if his salary had increased £50 each year since starting work he would now have a record salary but would be living in poverty.
‘Record funding’ has in fact not taken into account increased demand from population growth over the last 13 years, the far greater numbers of the elderly and those with chronic conditions such as diabetes and obesity, together with the surge in mental health problems. After the creation of the NHS in 1948, spending increased every year by around 4% in order to help meet increasing demand. From 2010, growth in spending fell below this long-term average, meaning that by 2022 there was a £322 bn shortfall between what was actually provided and what would have been provided if historical increases had been maintained.
Health spending is often looked at as percentage of gross domestic product (GDP; this varies as the strength of the economy fluctuates) but more informatively, as per capita funding. The Financial Times published data shared from the Health Foundation examining health spending in the UK and Europe in the decade before Covid. Average day-to-day health spending in the UK between 2010 and 2019 was £3,005 per person – 18% below the EU14 average of £3,655. Matching spending per head to France or Germany would have meant an additional £40bn and £73bn (21% to 39% increase respectively) of total health spending each year in the UK. Similarly, analysis of Britain’s capital health spending on buildings, technology and equipment between 2010 and 2019 showed that an extra £33bn (a 55% increase) in cumulative UK investment would have been needed to match the EU14 average invested over the period.
John Burn-Murdoch is the Chief Data Reporter for the Financial Times and has produced some beautiful graphs very clearly illustrating how the so called ‘record funding’ of the Conservative government has caused immense damage. Among other things, these demonstrate how waiting lists swelled under Major, shrunk under Labour as funding increased, then climbed again under Tory austerity. While avoidable deaths had been falling steadily, this flattened off under austerity and is now on the rise; improvement in life expectancy has also stalled. Austerity produced a fall in total government spending, together with falls in spending on health care as % of GDP, public sector investment, and investment in health care. Burn-Murdoch also shows how the current crisis in the NHS damages productivity and relates among other things to no longer having enough beds.
The reality that ‘record funding’ actually amounts to nothing more than considerable underinvestment is set out in a report by the 99% Organisation. While nominal spend has continued to rise over the past two decades, when taking into account inflation, population growth, aging and increasing burden of disease – real spend per unit healthcare demand clearly shows a steady decline over the past 13 years. Among the G10 countries, only Italy spends a lower proportion of its GDP on health than the UK. The bottom line, therefore, is that we spend less on healthcare than other developed countries; our spending has not kept pace with the combination of inflation, population growth, population aging and increase in chronic illness.
This underfunding (aka ‘record spending’) has led to the unavailability of resources (staff, hospital beds, technology, etc) and so to poorer performance. To take one example, it is lack of staff and resources that are damaging cancer survival rates in the UK. As the Organization for Economic Cooperation and Development has put it: “The United Kingdom’s health system delivers good health outcomes relative to the level of health expenditure…..”, and as Anita Charlesworth, Director of Research for the Health Foundation observed, there is a simple choice to be made: “Either we are going to have lower quality healthcare relative to other countries or we spend more”. With 2.6 million now unable to work because of sickness, it is clear that an effective health service is necessary for a healthy economy, which in turn is required to tackle the social inequality that drives long term ill health. If the NHS fails, the economy fails with it.
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