Intended for healthcare professionals


The two simple and very human reasons why all health systems, including the NHS, are bound to fail

BMJ 2023; 382 doi: (Published 11 September 2023) Cite this as: BMJ 2023;382:p2080
  1. Richard Smith, chair
  1. UK Health Alliance on climate change

Both hospital consultants and doctors in training in England have gone on strike and plan to continue to strike. They are striking for more money but also to save the NHS. They find that they don’t have the staff and resources to provide the care they have been trained to provide. Unfortunately, they are—like hamsters running on a wheel—stuck in a system that is unsustainable without reform that will feel very uncomfortable to everybody, which is, of course, why it doesn’t happen. Collapse may have to come first.

One phrase prompted me to write this piece. In an article on what may happen to the Tory party if it is wiped out, as many expect, at next year’s election, the political pundit Katy Balls speculates that a Labour government may collapse “blown apart by an NHS timebomb left ticking by the Tories.”1 She may well be right.

The two factors that make health systems unsustainable are both deeply human.

The first is the urge to care for the sick. Imagine a paediatrician confronted with an obese child and a child with meningitis. The paediatrician will inevitably concentrate on the child with meningitis who may well die without immediate care. Whole health systems do the same: they prioritise the sick. They are sickness not health systems. Similarly, those in pain and dying want care. This is deeply understandable, and resources flow to the sickness system despite health (sickness) systems accounting for 10-20% of health. Spend on the NHS has increased by 40% since 2010, whereas funding for factors more important for health as opposed to sickness—education, housing, transport, benefits, the environment, public health, and much more—has been cut. For example, funding per school pupil is lower today than it was in 2010 and funding of Sure Start, which strong evidence shows is beneficial for the health of the very young, has been cut by 50%. The NHS is now 44% of public expenditure, “crowding out,” as economists say, other programmes.

The result is an increasingly unhealthy population, which needs care from the health (sickness) system.

The second human factor is the urge to do more for the sick, to develop new tests and treatments, to cure incurable diseases. The main factor driving health (sickness) costs rising ahead of general inflation, which is seen in all health systems, is not ageing of the population, but the fact that there are more health professionals able to do much more. Ageing, of course, interacts with the capacity to do more as age is the main cause of needing those treatments. For example, despite a huge global effort to cure cancer, much of it successful at keeping people with cancer alive for longer, we have more cancer than ever—because our ageing bodies are programmed to develop cancer. The selfish gene has no interest in those past reproductive age. We have treatments that cost tens of thousands a year to keep some people with cancer alive for some months or even years longer than without the treatment, and naturally people want the treatments and doctors want to prescribe them.

Since 1948, when the NHS began the number of drugs in the formulary has increased from 240 to over 18 000, and the number of hospital consultants in England and Wales has increased from 3488 consultants in 1949 to 46 297 in 2018 in England—a 13-fold increase while the population grew by 30%. Those consultants are all extremely busy and unable to keep up with demand (a word I don’t like in this context). This is a phenomenon known, by economists, as supply-led demand.

In short, two simple human factors make health (sickness) systems unsustainable: more sick people and more health professionals able to do more for them.

Breaking out of this cycle will not be easy, but I’ve floated some ideas that revolve around devising a system that starts with health rather than sickness.2


  • Competing interests: none declared.

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