Intended for healthcare professionals


A four minute guide to the rudiments of health and healthcare for those responsible for maintaining health systems

BMJ 2023; 380 doi: (Published 13 January 2023) Cite this as: BMJ 2023;380:p107
  1. Richard Smith, chair
  1. UK Health Alliance on Climate Change

Health and healthcare are different things

Conversations about health quickly turn into conversations about healthcare, but healthcare is concerned mostly with sickness. Health is not a product of health systems.

Healthcare accounts for only 10% of health

Health is hard, probably impossible, to define, but by any definition healthcare accounts for only around 10% of health. The health of people is determined by other factors—their life circumstances, environment, genes, and lifestyle, all of which are intermingled.

Increasing funding of healthcare paradoxically worsens health

Spending more on healthcare crowds out funding on benefits, pensions, education, housing, public transport, urban redesign, the arts, sports, and other activities that are more important for health than healthcare. This sets up a vicious circle where poorer health means more sickness that the health system must help treat.

The costs of healthcare rise primarily because of the possibilities of doing more to respond to sickness

The costs of healthcare have risen faster than inflation since the NHS and other health systems began mainly because of new tests and treatments. We hear all the time that costs are rising because of ageing of the population, but that is not the main driver, although it is the old who consume most of the new tests and treatments.

Increased supply is an important driver of demand

More doctors, more treatments, more tests, and more intensive care beds means more activity. Intensive care units fill up just as new roads and new prisons do, and people, particularly the dying, are anxious to take treatments that may (but often don’t) extend their lives.

Longer lives are accompanied by longer spells of poor health

The 1980s saw the birth of a very attractive idea: the “compression of morbidity.” The idea was that the length of life was fixed—at around 85—and that better environments and healthcare would mean that people became steadily healthier, compressing the time between becoming sick and the inevitable death at 85. Sickness would reduce and costs fall. Unfortunately, “compression of morbidity” remains a fantasy. The length of life has increased (until recently when it fell for many) and the length of time spent in poor health has increased even more.

Prevention is not cheaper than treatment, particularly in the long term

Mainly for the reason described above prevention is often not cheaper than treatment, particularly in the long term.

Few patients are cured

When the NHS began, sickness was mainly due to infectious disease and trauma, both of which can potentially be reversed or “cured.” Now most of healthcare is concerned with people with multiple long term conditions that cannot be cured.

The division between health and social care makes no sense

Most deaths are now from frailty (which might be called old age) and dementia. These patients at the end of their lives need care not treatment. This is also true of many people who are disabled. To have healthcare free and charge for social care makes no sense, particularly with healthcare’s capacity to consume ever more resources.

There is huge variation in all aspects of healthcare

Wherever you look in healthcare—whether people take their sickness to doctors, GP referrals to hospitals, infection rates in hospitals, prescribing rates, outcomes of treatment—you see huge variation, most of which is unexplained. Attempts to reduce variation have largely failed.

Cost and quality in healthcare are not correlated

If you pay more for a hotel or a bottle of wine you get a better experience, but this is not true for healthcare. The correlation between cost and quality is weak in healthcare, partly because of the huge variation described above.

How well people do with long term conditions is determined by them and their carers not by the health system

If you have meningitis whether you live or die will be determined not by you but by clinicians. But for every person with meningitis there are tens of thousands with long term conditions like diabetes, arthritis, heart failure, and asthma. How well these people do is determined mainly by themselves and their carers—how they react, what they eat, how they exercise, and whether they change their lives and take their treatments.

Most caring is done not by health professionals but by family and friends

A person who has diabetes, any long term condition, or is dying sees health professionals for only a few hours a year. The rest of the year people must be cared for by themselves, family, and friends.

Healthcare, particularly hospital care, is dangerous

About one in 10 of people who go into hospital suffer an adverse event, and about one in a hundred will be killed. Primary care is less dangerous.

Healthcare cannot reduce inequalities on health

Inequalities in health—for example, the 15-year-gap in life expectancy between rich and poor—are determined mostly by social (and political) factors. Healthcare can do little about inequalities.

A higher ratio of primary to hospital care means more patient satisfaction, better outcomes, and lower costs

Hospitals are the most expensive part of the health system and consistently more money goes to hospitals than to primary care. Yet we have long known that a higher ratio of primary to hospital care means more patient satisfaction, better outcomes, and lower costs.


  • Competing interests: none declared.

  • Provenance and peer review: not commissioned, not peer reviewed.