Mark E Thomas recently spoke at the AGM of Doctors for the NHS who have kindly produced this transcript of the talk.

Introduction

We launched The Rational Policy-maker’s Guide to the NHS the day before the 75^th anniversary of the NHS last year, in the House of Commons. We have also taken it to Holyrood and to the Senedd. Margaret Greenwood MP held a Westminster Hall debate on the future of the NHS at which the report was discussed, and today’s presentation is based on a paper that we submitted to Lord Darzi, whose report seems to acknowledge a number of the points that we have made. So we have achieved a degree of traction and will continue to increase awareness and understanding of the modelling that lies at the heart of this report.

Imagine that you are a rational policy-maker and have been given the task of plotting the future course of the NHS. What would you do? You might start by asking yourself three questions:

1. What actually works in practice? There are about 200 countries in the world and most have health systems, but what works best?
2. The NHS is experiencing a lot of problems, but what is their root cause?
3. Is the NHS sustainable within our economy?

What works in practice?

We can try to benchmark the NHS’s performance against other systems around the world, but this is actually quite complicated because of their diversity.

There are three things you can ask of a healthcare system:

1. You can ask it to be effective, providing good quality in the outputs (healthcare services) it delivers.
2. You would like it to be efficient, delivering those outputs for a reasonable level of input, which in this case is money.
3. And you want it to be equitable in the care it delivers

In addition, we care very much about outcomes, although these are not all within the gift of the health system, often being strongly influenced by factors beyond its control. The USA has the lowest life expectancy in the OECD, but the main reasons do not lie within their poorly performing health system. The main reason is that so many people in the USA die before they reach the age of 45. They die early because of gun crime, drug overdoses and car accidents. Being in collision with an American car is much more dangerous than with most European cars. So context is important when looking at statistics.

We are interested in efficiency, but of course you have to put something in to get anything back from the system. If we look at the report from the Commonwealth Fund for 2013, you would see that the UK ranks first for effectiveness, safe care, coordinated care, cost to the person receiving care and efficiency, and ranked second for equity. It only ranked tenth out of eleven for ‘healthy lives’, but as we have noted, that is not all within the gift of the healthcare system. So there is no question that, as a healthcare system, the NHS was very, very good not very long ago.

The Commonwealth Fund produces a new report every three years or so and our ranking has certainly dropped, but over the long term the UK has had the best track record of any system, so the model on which it is founded is clearly proven. This is not wishful thinking or harking back to 1948. If you were a rational policy maker there is good evidence that the NHS model can work very well in practice.

So what has gone wrong?

The level of funding, the input to the NHS, is one of the obvious differences between the UK and other comparable countries.

The level of funding on UK healthcare (both NHS and privately funded) as a proportion of GDP is shown by the red line and is lower than in almost all comparable countries. We also have fewer hospital beds and fewer medical doctors per head of population. You can see the sharp kink in the curve – we had quite a rapid increase in funding until 2010, but there was then a change in government policy which was never declared, which resulted in a steady decline in spending as a proportion of GDP. You would get a similar picture if you were looking at spending in terms of dollars – we would be behind everywhere but Italy.

At the Westminster Hall debate, the government spokesperson said, “The NHS is getting record amounts of money.” In one sense that’s correct. The top line in the graph below shows the nominal amount of money going into the NHS, if you ignore inflation; if you ignore population growth; if you ignore the ageing of the population structure; and if you ignore the impact of the increased prevalence of chronic disease. But if you are a rational policy-maker you aren’t going to ignore those factors, because they are real.

The gap between the blue and orange line shows the huge decline in the value of the pound due to inflation. Then the population has grown, so if you are looking at real spending per head of population, we are on the grey line. The population has also aged, which also has an effect, but a relatively small one, because, when you look at it in detail, the majority of health spending takes place in the final two years of life, and we only die once. But then there is another very big gap, which brings us to the red line, and that is due to the explosion of morbidity, which has not been completely explained, but much of it does seem to be related to the effect of poverty and stress. So the main factors at play are inflation and the increase in chronic ill-health and, when these are taken into account, spending has failed to keep pace with need and we end up with a picture like this:

This shows deteriorating outputs – numbers of patients waiting for diagnosis or treatment, and numbers of patients seen within four hours of attending accident and emergency departments. Outputs are the direct result of NHS performance relative to demand. Numbers on waiting lists had been falling rapidly until the global financial crash, but then started rising rapidly, long before the pandemic struck. Emergency patients seen within four hours had exceeded the target of 95% for ten years, but began to fall increasingly rapidly after 2008 and plummeted after COVID struck.

The graph also shows deteriorating outcomes – which reflect a combination of the results of the healthcare system performance and other factors outside the control of the healthcare system. It shows that avoidable mortality in the UK had been high compared with peer countries, but has increased to a greater extent since 2011 and a fall in life expectancy at birth in the UK and the USA, but hardly anywhere else.

So funding for the NHS has fallen behind historical norms, and behind peer countries, and behind need. The result, unsurprisingly, is declining performance.

Is the NHS sustainable?

The third aspect we need to cover is the sustainability of the NHS in the context of the UK economy. This diagram may look rather strange for those unfamiliar with system dynamics, but it’s simpler than it looks.

Each of the arrows represents a cause-and-effect relationship. Consider the red arrows: these refer to the way NHS capacity affects the performance of the economy – the capacity loop. The economy is driven by people, particularly by healthy people of working age. If there are more of them, the economy can perform better and if you have fewer of them, the economy will perform worse. If there are members of the population that require treatment, and you treat them successfully, the healthy population increases, but if you lack the capacity to treat them, the performance of the economy suffers. So capacity is vital, but if you don’t fund it, you don’t get the capacity, and if your economy is not performing well, you face plenty of arguments that we just can’t afford to fund it any more. Therefore, this is a self-reinforcing cycle, which can either be a vicious cycle or a virtuous circle, depending on which way it is going. If you improve the health of the population, you improve the health of the economy, your budget constraints relax, so you have the capacity to treat more people – a virtuous circle.

Then we have the ‘poverty loop’, which reflects Sir Michael Marmot’s work on the social determinants of health. A poorly performing economy usually leads to greater levels of deprivation. Deprivation affects people’s lifestyles; their housing, diet, exercise and stress levels, affecting their health. And there is plenty of evidence that more people need treatment in a society that is very unequal, reducing the healthy population and further weakening the economy – a vicious cycle.

And then we have the ‘prevention loop’, in green. The WHO has calculated that every £1 spent on prevention of disease reduces the cost of treatment by £4, because you reduce the number of people falling ill. When you spend £1 on care, the general economy benefits by £4, so every £1 spent on prevention should benefit the overall economy by 4 x £4 – about £16.

So these are the elements we decided to model, to see if former Chancellor Sajid Javid had a point when he said, “We can’t afford the NHS.”

There is one element that we couldn’t decide how to incorporate in the model, which related to the impact of an excessive demand on staff. If staff are overloaded, morale and retention are damaged, reducing capacity within the healthcare system and imposing an additional load on the staff that remain. Morale is damaged further by inadequate pay and conditions, and by the moral injury of seeing a deterioration in the health of the population you serve.

All of these self-reinforcing cycles interact with one another, so it is really quite a delicate and unstable system and, whichever rational policy-maker has their hands on the levers of power, they need to understand the delicacy of the system.

One reaction to a picture like this is to say, “That looks horrendously complicated: I’m just going to ignore it.” But simply ignoring it doesn’t change the real world, and the real world is telling us that these really are quite important concepts. The red line in the graph below is the number of people of working age forced out of the workplace by ill health, and you can see those numbers shooting up until 1997, before gradually declining until about 2017, which was the last time that we had an NHS of world-class ranking. The numbers have been shooting up again since then and now include about 2.8 million people, about 8% of the workforce. A recent poll of UK business leaders showed that this is by far the number one issue they want the government to address.

Our analysis shows that the long term effects of continuing with this policy of underfunding would cripple the UK economy.

The grey line indicates the current GDP, at about £2.4 trillion and the green line shows the OECD’s prediction for the economy in 2060, at about £3.8 trillion. Based on their modelling, if we carried on at our current level of spending on healthcare we would fall a long way short of that predicted level of growth, but if we continued with the revealed government policy of continuing to drive down spending, the economy would collapse – potentially zero growth between now and 2060, which is practically unheard of in modern history. Of course, if a collapse were imminent, the government would probably change course and try a different strategy, but the options might be very limited economically by that time.

So, what strategic options should we consider?

We might consider the radical step of funding the NHS properly. Or increasing spending on disease prevention. Or tackling both absolute and relative poverty. A policy that combined these elements might produce an expenditure curve like this.

Under this policy, the level of funding increases rapidly over five years, to peak at about 14% of GDP, while you deal with the backlog of demand of about 8 million people currently sitting on waiting lists and becoming increasingly unwell, together with treating the natural demand of people who would be anticipated to fall ill during that period. So you would need to build up quite a bit of additional capacity until the backlog has been cleared, after which capacity requirements reduce, assisted by the reduced burden of disease anticipated through preventative health measures and poverty reduction policies. The pattern of initial spending might look frightening to begin with, but it would in no way behave as Sajid Javid implied — that spending would spiral ever upward to consume almost the entire economic output of the country. The opposite is true: if the UK is to have a strong economy, it must have a strong NHS.

Conclusion: Don’t Gamble with the NHS

Our conclusion is that a rational policy-maker would recommit to the fundamental principles of the NHS and would not take an enormous gamble by switching to an unproven model.

It is conceivable that, at some time in the future, artificial intelligence may have reach a stage where some of the activities currently performed by highly trained doctors could be safely automated, but it is by no means certain that that will happen any time soon.

It is conceivable that a further reorganisation of the NHS might enhance its performance, but I have never in my life seen a reorganisation that made any great improvement. It would be a gamble, and I do not think a rational policy-maker would take such a gamble when they had a proven model to hand. By all means do pilot studies, in limited areas of the service, but measure the impact carefully, over a sufficiently long period of time before deciding whether to roll out the changes more widely.

We practice evidence-based medicine: let’s embrace evidence-based policy-making

• We have shown that we do have a proven model, which was the best in the world until recently, so there is no need to look for an alternative.
• The root cause of our current difficulties is underfunding.
• The NHS is sustainable, if it is properly funded, but if you don’t fund it properly, the whole economy becomes unsustainable.

A rational policy-maker would:

• recommit to the fundamental business model of the NHS;
• fund it in line with need;
• invest in prevention;
• tackle the social determinants of ill-health.

The UK cannot afford an alternative strategy.

While there are many operational improvements which can and should be made, they should be made within this strategic context and be introduced with great care, given the strategic weakness and fragility of today’s NHS.

We cannot afford to gamble with the NHS.

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 Read the report in full: The Rational Policy-maker’s Guide to the NHS is available to download, free of charge: https://99-percent.org/wp-content/uploads/2023/06/NHS-report-for-print.pdf