How will we pay for health systems in a very different future?

Free healthcare at the point of need must remain a policy priority for the UK.

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On the 5th July the National Health Service will celebrate 70 years of existence. It grew out of a pact between the government and the people. As war-time politicians called on people to risk their lives for their country, they accepted that there had to be something worth fighting for.

Unlike the First World War, when politicians failed to deliver “a land fit for heroes”, they now committed to create a post-war welfare state. A new health service would care for the population “from the cradle to the grave”, with services that are “free at the point of use”. Yet, in the seven decades that followed, that commitment has been gradually eroded.

As long ago as 1951, the founding father of the NHS, Aneurin Bevan, resigned when the government of which he was a member introduced prescription charges. In 1994, the then Conservative government removed the universal entitlement to long-term care for those with complex needs, in effect removing the care of all except the poorest patients with dementia from the NHS.

Since 2010, governments have created a “hostile environment” for migrants, excluding growing numbers from NHS care, along with a worryingly large number of people who are entitled to care but are unable to meet the UK government’s Kafka-esque requirements to prove it.

At the same time, years of real terms cuts in funding have left the NHS increasingly difficult to cope. And as we look to the 2020s, the future seems grim. Even in the most optimistic scenario, Brexit will do very serious damage to the economy, while threatening the supply of everything the NHS needs to do its job: health workers, medicines, or technology. Inevitably, some British commentators are asking: “Can the NHS survive?” Others, among them some of the strongest supporters of Brexit, have long argued that it shouldn’t.

Yet if we dare to look outward to what’s happening at a global level, a quite different debate is taking place. The governments of the world, including the UK’s, have signed up to the 17 ambitious UN Sustainable Development Goals. In these, they have all committed to achieving universal health coverage (UHC) for every country.

This means, as defined by the World Health Organization (WHO), that every person should have access to the vital services they need without being pushed into poverty. The arguments in favour are overwhelming. We now can show, thanks to a global network of researchers co-ordinated by the University of Washington, that access to affordable high-quality care alleviates suffering and prevents premature death on a massive scale.

The benefits at an individual level are obvious, but we now also know that healthier people contribute to economic growth. And well-functioning health systems break the link between severe illness and impoverishment from catastrophic medical expenses, which impact not only on the individual concerned but on their family and, in many cases, their employees. In contrast, where governments disinvest in health, they risk creating widespread insecurity and, ultimately, the risk of a downward social and economic spiral. From this perspective, the question is not “can we afford the NHS?” but “can we afford not to have it?”

In October, researchers from across the world will be convening in Liverpool at the fifth Global Symposium of Health Systems Research (HSR2018). The overarching question they seek answers to is how we can advance health systems for all in the context of the Sustainable Development Goals. It will bring together some of the brightest and best in global health policy and research. They will be learning from us. Maybe we should use the opportunity to learn as much as possible from them?

And there are some big questions on the table. How will we pay for health systems in a very different future, with many older people, new forms of work, and changing views of society? How can we deliver health care appropriate to the needs of growing numbers of people with multiple chronic conditions, demanding a complex mix of specialist knowledge and care that addresses their overall needs? How can we harness the benefits of new technology while avoiding its risks?

These questions are relevant to everyone with an interest in health, whether as politicians, providers of care, or patients. As we look to the future of the NHS, they are especially important for us in the UK. Too often, we look at the NHS in isolation. Reflecting a strange form of British exceptionalism, we see it as unique. Yet it is not.

Many other countries, in Europe and further afield, have very similar systems and others still look to its founding principles, tax-funded, publicly provided, and free at the point of use, as ones to aspire to.

So this year, as we reflect on where the NHS has come from and where it is going, HSR2018 presents a superb opportunity, at the very least, for learning.

Martin McKee is Professor in Public Health at the London School of Hygiene and Tropical Medicine and member of Health Systems Global.