Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: The NHS is not unsustainable

BMJ 2023; 381 doi: (Published 02 May 2023) Cite this as: BMJ 2023;381:p991
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

This week I visited two older patients of mine who recently had surgery for cancer. I’m fairly sure that, when I first qualified, similar operations would not have been offered to people of very advanced years. This shift may have come about because our surgery and perioperative management have improved, or maybe because more patients now in their late 80s and early 90s are in good general health and therefore fit for surgery. Whatever the reason, lives are extended—or made more comfortable—at a later age than we once thought possible.

I think about such patients whenever I hear commentators say that the cost of the NHS is unsustainable. Are they suggesting that my patients should not have had their surgery? The idea that NHS spending is in some way too high is not new, and I grow weary of these arguments that come round again and again, especially around the time of budgets and elections. The logical response is to ask, do we have too much healthcare in the UK? Too little? Or just the right amount?

From my seat in the GP surgery I’m aware of things that we’re not doing because they’ve been deemed low priority, or that we’re doing only after years of delay and suffering. We may have thoughts about unhelpful spending at the end of life, or about expensive interventions that do not, on balance, benefit the patient—but these are exceptions. Most people would agree that the country would benefit from more doctors and nurses, shorter waiting lists, and newer facilities with roofs that don’t leak.

The King’s Fund has reported that we spend about 9.9% of our gross domestic product on health, which is a bit less than our neighbours in France, Germany, and the Netherlands.1 There doesn’t seem to be much scope for improving the efficiency of the NHS: we get good value for money in comparison with other systems and achieved remarkable increases in productivity from 2004 to 2017.12 If we need more healthcare rather than less it will inevitably cost more, although we need to factor in the wider economic gains of having fewer people off sick and awaiting treatment. People who claim that the cost of a fully functional NHS is unsustainable are really arguing that they don’t want healthcare to be paid for out of general taxation: money contributed by all, according to their means, so that care can be given on the basis of need and regardless of ability to pay.

If you look around the world at other systems, there isn’t another model that magically makes healthcare cheaper—although there are many that make the distribution of care less equitable and enable insurance intermediaries to make money. So, next time someone suggests that the NHS is unsustainable, ask them: “Do you want less healthcare overall? Or is it the equitable distribution that’s the problem?” A good follow-up question is, “What do you think we should prioritise for spending, above health?”