Helen Salisbury: The NHS is not unsustainable
BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p991 (Published 02 May 2023) Cite this as: BMJ 2023;381:p991
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Dear Editor
In “The NHS is not unsustainable” [1], Dr Helen Salisbury asks whether we have “Too much healthcare in the UK? Too Little? Or just the right amount?”. She asserted that “Most people would agree that the country would benefit from more doctors and nurses, shorter waiting lists…”
This is not a question that can be answered. To illustrate this, let us exchange healthcare for something else: Do we have enough supermarkets, too many or too few? How about garages? Golf clubs? Restaurants? Coffee shops?
“Enough” means supply meeting demand, but that demand is not just desire. The demand for Italian sports cars for example is not how many people would want them if money was not a consideration.
Let us consider if we had a National Food Service with an aim of equality of access to the best food in the world irrespective of means. No doubt most people would agree that we would benefit from more Michelin starred restaurants. How would we know how many we ‘should’ have?
In the same way we cannot know how much we ‘should’ spend on healthcare, as the British people do not freely make that choice. They do not decide between buying an extra unit of healthcare or better food, or a warmer house.
Dr Salisbury incidentally quoted old figures for healthcare spending, 9.9% GDP in 2019. For 2022 they are almost 12%, 5th in the world and within 1% of the 2nd. Not including COVID funding which took the budget up to £200B. The budget for this year is over £180B, which is 50% more in real terms than 2009![2]
Dr Salisbury concluded her article by asking “What do you think we should prioritise for spending, above health?” This is an easy question. The fundamental role of government is to protect its citizens from physical force. In a country where violent crime is rising, where waiting lists for court cases are at an all time high, and where international dangers are the highest in a generation, the priority for funding is Police, Armed forces, and the Criminal Justice System.
The NHS is indeed unsustainable. Its budget has required real terms increases of 4% annually since being founded just to stand still. I would therefore reverse the question to Dr Salisbury, and ask her what other functions of government should reduced in order to prop up the NHS?
References:
1. Salisbury H. The NHS is not unsustainable. BMJ 2023; 381:991.
2. https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget
Competing interests: No competing interests
Dear Editor
There are no systems in which healthcare has been made "magically cheaper”, as rightly raised by Dr. Salisbury (1). The healthcare demand and need are increasing, and the costs are rising. This is an effect of aging populations and of the apparently never-ending growth in preventive, diagnosis, and treatment possibilities. Further, in many high-income countries including the UK, the gain in healthy and disability-free life expectancy has not matched the growth in total life expectancy (2). There is obviously a cost to the health system.
One misconception is to assume that if you improve the health of the population, you can stop the increase in healthcare costs. This is also an argument often used to promote prevention although preventing diseases will in some cases save money but in other cases will add to healthcare costs (3, 4). We should remember, first, that prevention aims to prevent or at least postpone diseases, increase life expectancy, and improve quality of life but does not aim to save money; second, that treatment for some conditions can be more cost-effective than prevention (4). Preventive interventions can limit the costs rise and be good investments (i.e., add a reasonable amount of benefits for the resources spent), but any improvement in population health opens new avenues for more prevention, more diagnosis, more treatment, and, as a result, more costs.
Another misconception is that identifying healthcare needs is easy and critical to predicting healthcare costs. Needs are however highly dynamic and context-specific, and they relate in complex ways to population health status (5). Trying to design a healthcare system and anticipate costs based on population needs is appealing but will not work if policymakers do not account for the rapidly changing demand and offer; that requires not only a need-oriented and patient-centered approach but also giving more weight to healthcare providers for designing the system. For a more cost-effective care delivery despite constrained resources, applying an evidence-based and user-informed strategy to healthcare is necessary more than ever for NHS and other healthcare systems.
Arnaud Chiolero, epidemiologist and professor of public health, Stéphane Cullati, senior lecturer in epidemiology and public health, from the Population Health Laboratory (#PopHealthLab), University of Fribourg, Switzerland
References
1. Salisbury H. The NHS is not unsustainable. BMJ 2023; 381:991.
2. Spiers GF, Kunonga TP, Beyer F, Craig D, Hanratty B, Jagger C. Trends in health expectancies: a systematic review of international evidence. BMJ Open 2021; 11(5): e045567.
3. Smith R. A four minute guide to the rudiments of health and healthcare for those responsible for maintaining health systems. BMJ 2023; 380:107.
4. Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? Health economics and the presidential candidates. N Engl J Med 2008; 358(7):661-3.
5. Wright J, Williams R, Wilkinson JR. Development and importance of health needs assessment. BMJ 1998; 316(7140):1310-3.
Competing interests: No competing interests
Dear Editor
Salisbury rightly points out that debates about funding the NHS reduce essentially to a public viewpoint on the equitable distribution of healthcare. She is also right in implying that health is more valuable than any other commodity or opportunity in life, because health is instrumental to almost everything else. But, in advocating for increased funding, Salisbury overlooks that healthcare is only one amongst many determinants of health. Over and above NHS services, health has many social determinants: housing, education, nutrition, etc. In order to advance the equitable distribution of health, attention is required to each and every one of the social determinants of health. Simply prioritising healthcare and NHS funding, without careful analysis of resource allocation to other health-determinants, would not be a meaningful public service.
Competing interests: No competing interests
Re: Helen Salisbury: The NHS is not unsustainable
Dear Editor
We read with interest of Dr Salisbury’s arguments against the ‘unsustainability’ of the NHS. The National Health Service (NHS) has been described as "unsustainable" at various points in its 75-year history. In recent years, the same arguments have been brought up repeatedly: a greying population, treatment cost and complexity, and the omnipresent impact of covid and strikes...
‘There is widespread concern amongst physicians that increasing pressure to take on ever more work is impeding their ability to practice the high standards of medicine to which they aspire. Uncertainty, frustration and even despondency are beginning to threaten the sense of commitment to the NHS of many physicians...’ (1)
Sound familiar? This was written in 1995.
There has been rising sociopolitical concern for the past few years that the current method of free at the point of use, nationally funded healthcare may no longer be appropriate to the needs of today’s Britain. This is not a new argument, and is indeed one which has been repeated many a time over the NHS’s entire existence.
The crisis of the 1990s was resolved by the Blairite government improving funding and reforming healthcare delivery with policies such as separating purchasers from providers and introducing market forces into the NHS. With surprise, it worked! Over a ten-year period, patients who had been on a waiting list for more than 6 months from 283866 to 199; 20,000 more consultants and general practitioners were recruited, and more than 150 general practices were opened. (2, 3)
The calls that the NHS is ‘unsustainable’ are fear-mongering and cyclical. With an ageing population and a greater disease burden due to medical advances, we like many other healthcare services globally, should expect to see a real-terms cost rise. This is unavoidable but reflects the value we place on human life, whether that person be old or young.
Healthcare needs and healthcare delivery in the UK have changed significantly since the formation of the NHS but the NHS will adapt to serve the needs of its population, constrained only by the proportion of funding that the UK government chooses to allocate to it. Adapting can take place in many ways, whether that is through increasing funding to encourage prevention and early intervention to reduce the burden on hospitals, greater integration between health and social care, or harnessing the use of digital technology, such as telemedicine and electronic health records to increase efficiency and labour yield.
1. Turnberg L. Letter to the fellows and members of the Royal College of Physicians, December 14th 1995. In: Reynolds EH. Letter to the Editor: a feeling of déjà vu.
2. Griffiths R. Community Care: Agenda for Action, London: HMSO, 1988.
3. Department of Health. Hospital activity statistics www.performance.doh.gov.uk/hospitalactivity/data_requests/index.htm
Competing interests: No competing interests