Intended for healthcare professionals


NHS in 2017:Keeping pace with society

BMJ 2017; 356 doi: (Published 05 January 2017) Cite this as: BMJ 2017;356:i6738
Read all the articles in this series on the NHS in 2017
  1. Gareth Iacobucci, senior reporter, The BMJ
  1. giacobucci{at}

Nearly 70 years since its establishment, the NHS is struggling to care for a vastly changed population. In the second article of his series, Gareth Iacobucci examines how societal trends have affected the health service

The NHS’s ability to provide universal, equitable, comprehensive, high quality healthcare that is free at the point of use is being tested by challenges facing society as a whole. One of the biggest of these is demographic change.

The UK has an ageing population—the median age rose from 33.9 years in 1974 to 40 years in 2014, a rise of 6.1 years. By 2024, there are predicted to be more people aged over 65 than aged 0-15.1 The number of people living with multiple chronic conditions is also growing rapidly. In England, this is forecast to have increased from 1.9 million in 2008 to 2.9 million by 2018.2

These trends have increased costs and pressure on the NHS. The Department of Health estimates that long term conditions now account for 70% of total health and social care spending in England.3 The picture is similar across the UK; the Scottish government estimates that long term conditions account for 80% of all general practice consultations and over 60% of hospital bed days, for example.4

The government estimates that the average cost of providing hospital and community health services for someone older than 84 is around three times greater than for a person aged 65 to 74.5 In 2014, 1.5% of the UK’s population was aged 85 or older. This is projected to rise to 3.6% by 2039.6

In acknowledgment of the changing needs of the population, NHS England’s Five Year Forward View has set out an ambition to integrate family doctors, hospitals, and social care.7

“The future will see far more care delivered locally but with some services in specialist centres, organised to support people with multiple health conditions, not just single diseases,” it says.

Scotland legislated to fully integrate NHS and local council care services in April 2016.8 And, unlike England, both Scotland and Wales have abolished the split between purchasers and providers of healthcare (in 2004 and 2009 respectively) to aid integration.

Social determinants

Another factor placing pressure on the NHS is social deprivation, which has a well established link to health inequalities.9 10 Poor housing costs the NHS in the UK an estimated £760m (€900m; $950m) a year,11 and charities report that homelessness—which greatly reduces people’s life expectancy12—is on the rise.13

The NHS is also grappling with the first increase in child poverty in absolute terms for almost two decades—a likely side effect of the austerity measures imposed since 2010.14

A recent study by Public Health Wales found that children who are exposed to adverse experiences such as abuse or domestic violence are much more likely to have long term health problems in later life.15

Interlinked are the public health challenges caused by rising rates of alcohol consumption (box) and obesity. Approaches to tackling the alcohol problem have varied across the UK. Scotland passed legislation to set a minimum unit price in 2012 and recently defeated a legal challenge from the drinks industry, paving the way for implementation.17 England has dragged its feet,18 but ministers have now agreed to assess the evidence after a review by Public Health England backed the policy.19

Alcohol statistics16

  • Alcohol misuse costs the UK economy an estimated £7.3bn each year

  • Over 15 000 people die annually in England from alcohol related illnesses

  • Attendances at emergency departments with alcohol poisoning doubled between 2008-09 and 2013-14, from 72.7/100 000 population to 148.8/100 000

  • Inpatient admissions specific to alcohol increased by 63.6% from 2005-06 to 2013-14

NHS England’s chief executive Simon Stevens has described obesity as “the new smoking” in terms of its impact on avoidable illness and rising healthcare costs.20 About a quarter of the UK population aged 16 and over is obese,21 while rates of overweight and obesity in children and young people in the UK are among the highest in Europe.22 23

Poor diet is contributing to rising rates of obesity and type 2 diabetes,24 and this is compounded by a substantial proportion of British adults not meeting recommended levels of physical activity.25

The annual cost to the NHS of treating obesity and its consequences is estimated at £6.3bn in 2015 and projected to rise to £9.7bn by 2050 26 unless urgent action is taken to reverse the trend.

The UK government’s 2011 responsibility deal relied on voluntary action by the food and drinks industry to tackle harm. It was widely condemned as too “light touch” by medical professionals27 28 and has proved ineffective in improving the public’s health.29 30 31 The government has since indicated a willingness to consider tougher measures23 in areas where there is clear evidence, such as sugary drinks and obesity.32

With evidence emerging from Mexico that taxing soft drinks containing sugar can help reduce consumption,33 the UK government has committed to introduce a sugar tax in 2018.34 But this levy will not be introduced at the point of sale, and the government’s childhood obesity strategy has been fiercely criticised for being watered down after failing to impose mandatory restrictions on sugar in food, advertising, or two-for-one deals on unhealthy food, amid claims of lobbying from industry.35

Wider cuts to public health services since the move from the NHS to local government also threaten to undermine efforts to improve prevention, with budgets cut by 3.9% a year on average until 2010-21.36 This shift to local government was designed to help public health professionals tackle wider determinants of people’s health but has exposed services such as sexual health, addiction, and weight management to budget cuts.37

Deserving and undeserving?

With the NHS in the midst of the biggest funding crisis in its history, funding treatments for health conditions caused by “lifestyle” decisions, such as smoking or alcohol misuse, is under close scrutiny.

The Royal College of Surgeons reports that over a third of clinical commissioning groups in England are restricting access to routine surgery such as hip and knee replacements for patients who smoke or are obese until they stop smoking or lose weight.38 Commissioners insist such policies are evidence based, but the college warns that they contravene national clinical guidance.

Although some commentators advocate not treating patients for conditions related to factors such as smoking or alcohol misuse,39 40 any such moves risk undermining the NHS’s founding principles by giving credence to the notion that some patients are more deserving of treatment than others based on their lifestyles.

Great expectations

The most recent survey of British social attitudes41 shows that public satisfaction with the NHS remains high but there are concerns about its future and funding. The pressure is heightened by increased public expectations and high demands; 72% of people expect the NHS to provide drugs and treatments irrespective of cost,42 an impossible demand in today’s financial climate.

The advisory body the National Institute for Health and Care Excellence (NICE) has been criticised in the media for not recommending some costly new treatments.43 44The pharmaceutical industry has also come under pressure to lower the cost of new treatments that are too expensive for the NHS to fund, such as the breast cancer drug trastuzumab emtansine (Kadcyla).45

Successive governments have been accused of stoking public expectations,46 with various initiatives designed to offer patients greater choice and convenience, such as walk-in centres, seven day access, choose and book, and personal budgets.

With the NHS unable to meet current levels of demand, perhaps now would be a sensible time for the government to digest that when offered a trade-off, patients rank choice less important than other factors such as quality of care and good communication from staff.42

Rise of digital technologies

The government believes new technologies will be the answer to some of these challenges, such as improving prevention and managing demand. For example, it believes advances such as mobile phone apps have the potential to reduce the burden on the NHS by “empowering people to take charge of their own health by providing information, support and control.”47

There is scepticism48 about whether the government can achieve its ambitious target to make the NHS paperless by 2020, especially since it emerged that money to implement new technologies is being held back until the end of this parliament because of financial pressures.49 The NHS has a poor record with national IT projects, most notably the previous Labour government’s national programme to create a single, central electronic care record for patients and connect general practices and hospitals. The project cost an estimated £10bn but was scrapped in 2011 after failing to successfully digitise acute and community care.50

The health secretary, Jeremy Hunt, says he has learnt the lessons from Labour’s “over-centralised, over-specified and ultimately impossible to deliver” programme, and instead wants locally developed solutions.51

The NHS cannot afford similar mistakes again, so Hunt would be wise to heed the advice from Greenhalgh and colleagues, who recommend “improving and augmenting the best of the NHS’s current systems” rather than reinventing the wheel.52

Climate change

The global problems of air pollution and climate change are set to have a growing effect on the NHS in the coming years.

A report from the Royal College of Physicians and the Royal College of Paediatrics and Child Health estimates that poor air quality already contributes to 40 000 deaths a year in the UK53 and identified adverse effects “from a baby’s first weeks in the womb all the way through to the years of older age.” These include damage to fetal development; links to asthma, diabetes, dementia, obesity, and cancer; and increased risks of heart attacks and strokes in later life.

The report cites an analysis for the European Commission which suggests that if the UK acted to reduce greenhouse gas emissions to target levels by 2050, it could prevent 5700 deaths, 1600 hospital admissions for lung and heart problems, and 2400 new cases of bronchitis a year—with an overall economic benefit of €3.9bn a year. Given those statistics, the report’s call for the government to put in place policies to “reduce pain, suffering, and demands on the NHS” deserves to be heard and acted on.

The uncertainty over Britain’s position in Europe has also prompted concerns that it may retreat from the international debate around tackling the harms from climate change.54 Before the EU referendum, the recently formed UK Health Alliance on Climate Change, which includes numerous royal colleges, the BMA, The BMJ, and the Lancet among its members, wrote to the health secretary to warn him that the NHS was ill equipped for dealing with the risks posed by extreme weather events such as flooding and heatwaves, which are becoming more intense and frequent.55

The NHS must also play its part in reducing carbon emissions from fossil fuels, to which it is a major contributor. Although the NHS reduced its emissions by 11% between 2007 and 2015, it is currently on course for a 30% reduction by 2050, far below the Climate Change Act’s target of 80%.56

With climate change identified as the biggest global health threat of the 21st century,57 it is imperative the UK remains a leading voice in advocating change.


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