Intended for healthcare professionals


The NHS at 70: Loved, valued, affordable?

BMJ 2018; 361 doi: (Published 12 April 2018) Cite this as: BMJ 2018;361:k1540
  1. John Appleby, director of research and chief economist1,
  2. Kamran Abbasi, executive editor2
  1. 1Nuffield Trust, London
  2. 2The BMJ, London
  1. john.appleby{at}

How is it possible to sustain the NHS and retain its core principles?

With the NHS celebrating its 70th birthday this year and engulfed in a sense of crisis, it’s easy to wonder how much longer it can go on. The NHS is more than an organisation. It is a set of principles about how we value health, at both an individual and a societal level. It is the value we attach to dealing fairly with the risk and uncertainty of ill health. And it is an expression of one of the fundamental roles of the state: to protect its citizens.

The NHS today, in many respects, is in much better shape than in its younger days. More care is provided, in better ways, to more people. Care is also more evidence based, less paternalistic, and less institutionalised. It is improved by technological developments such as safer anaesthesia, modern obstetric care, and more effective medicines. The proportion of national wealth spent on the NHS has doubled.1 Staff numbers outstrip increases in the population the NHS serves. Perhaps most importantly, it retains huge public support.

Rationing decisions

The NHS’s creation was an explicit rejection of what were, and remain, unfair ways of rationing healthcare through pricing and ability to pay, which left many people without healthcare or reliant on charity. Rationing is inevitable in a world of finite resources and increasing demand for health services, but has the NHS found acceptable ways of matching resources to demand?

Establishing the National Institute for Health and Care Excellence (NICE) was a milestone in implementing a systematic and transparent approach to rationing, but NICE tackles only a small proportion of the rationing decisions that need to be made. As Rudolf Klein described, the NHS still also relies on rationing by delay, deterrence, and deflection.23

Rationing is inevitable in a world of finite resources and increasing demand for health services

A major, and often overlooked, rationing decision is the political choice exercised on the total NHS budget. This sets the financial envelope within which all other rationing decisions are confined. In the past 70 years UK spending on the NHS has increased around 10-fold in real terms.4 Much of this is funded by an expanding economy, coupled with political decisions to spend comparatively more on the NHS, mainly through spending less in other sectors—notably defence, housing, and now privatised public utilities and services. With a doubling to over 7% of GDP devoted to the NHS, plus the amount spent on private healthcare, the UK is in the middle of the pack when comparing its health spending with other European countries. On other metrics, such as spending per head and the numbers of beds, doctors, and nurses per head of population, the NHS fares less well by comparison.

Despite the overall spending increase, the NHS finds itself struggling to meet demand, even though many NHS organisations are overspending their budgets. So, what comes next? How much should we spend on the NHS? When is enough enough?

Increasing NHS funding more quickly than GDP is unsustainable in the long run. Indeed, how do we improve the way funders and the public exercise their preferences on how much to spend on the NHS? Is there a better method than national elections for reconnecting the public with the hard economic consequences implicit in decisions about spending levels for health?

Improving productivity

In an economic sense, as with other industries, we’d expect the NHS in time to become more efficient in the way it converts its inputs (money) into outputs (activity) and outcomes (health). But the NHS, like other countries’ health services, suffers from William Baumol’s “cost disease”: where a labour intensive business finds it hard to improve its productivity.56 Although the NHS struggles to match the increases generally achieved in other industries, its productivity improved at a rate of just under 1% a year from 1995—and more recently the NHS improved more quickly than the rest of the economy.7

Indeed, the NHS has made some significant gains, such as reductions in length of stay and switching from branded to generic drugs.8 These gains partially offset the need to increase funding further. But we need to understand better the underlying drivers of such improvements and how they might be stimulated to maximise future gains in productivity. Other factors, such as patient experience and integrated care, are important but harder to define in terms of economic productivity.

The NHS is important. Its values are on the side of a better vision for humanity

Universal coverage

As part of the sustainable development goals, all member states of the United Nations are committed to achieving universal health coverage by 2030. Universal health coverage already exists in the UK, thanks to the NHS, which is observed keenly by the rest of the world as a natural experiment. The NHS experiment does show, however, that achieving universal health coverage is only the beginning of the debate.

In the NHS’s 70th year, the debate is at a critical point about the service’s very essence and its sustainability. Over the coming months we’ll examine the NHS’s achievements and future prospects, focusing on 10 questions that range from how the service is funded to how it is best delivered by staff and experienced by users (see box). The NHS inspires passionate opinions from those who use it, those who deliver its services, and those who observe its progress from a distance. We urge you to join the debate. The NHS is important. Its values are on the side of a better vision for humanity.

In all of this, we argue that one founding principle of the NHS is inviolable: all people should have access to health services that is based on need and free at the point of delivery. As we open up The BMJ’s pages for an intense, urgent, and necessary debate on the future of the NHS, this is the one principle on which we will not move.

Ten questions on the future of the NHS

  1. What should be the scope of the NHS, and how do we decide this?

  2. What outcomes/quality can we expect from a publicly funded service that is free at the point of care, and how might the NHS improve?

  3. How do we know if the NHS is adequately funded, and what metric should be used?

  4. If the NHS is publicly funded does it also have to be publicly provided?

  5. How good is NHS policy making?

  6. What drives productivity, and how do we embed those characteristics?

  7. What might we learn from how clinical specialties have evolved?

  8. Will data, big and small, affect our health and the way we care for sick people?

  9. What are the best investments for society, unrestricted to the health sector, which will result in the greatest benefits to health?

  10. What models of funding are best for a healthy and just society?


  • Competing interests: The authors have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance: Not commissioned, not externally peer reviewed.


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