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Ditching the NHS for a new model won’t fix healthcare

As the workforce plan is released, international comparisons highlight the best prescription for the health service.

By Siva Anandaciva

Today marks a landmark moment – the first comprehensive long-term strategy for the NHS workforce, and the first step to making the health service’s staffing sustainable.

The Long Term Workforce Plan, which commits an extra £2.4bn towards additional education and training places for clinical staff, comes after years of chronic NHS labour shortages, as well as existing staff being stretched thinly. Indeed, new analysis by the King’s Fund shows just how badly a new approach is needed. We compared the UK with international healthcare systems and found that the UK has strikingly low levels of key clinical staff, with fewer doctors and nurses per head than most of its peers.

The plan has been released a few days before the NHS turns 75. But what would the health service see if it looked in a mirror? It would see a health service that some now describe as being in “permacrisis”, pressures exacerbated by the Covid-19 pandemic. Satisfaction with the NHS has fallen to a 40-year low.

Some commentators have asked whether the NHS has outlived its usefulness, and whether “the NHS model” – which offers a comprehensive range of services that are taxpayer-funded and free at the point of use – is sustainable. International comparisons can offer some much-needed insight.

Some policymakers are now looking at other countries for more fundamental ways to change the NHS model in England. These include proposals by Sajid Javid, the former health secretary, to introduce charges for some GP and hospital appointments – a common practice in some countries, including France and Sweden. Other senior politicians have called for the UK to adopt social health insurance – used in Germany and Austria, for example.

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But health systems are closely embedded in the society, culture and history of their home countries. There is clearly a danger in thinking of health systems as mechanical constructs that can be broken down, exported, and then reassembled in another country.

By comparing the NHS to peer countries, the first and most obvious finding is that the UK health system is neither a leader nor a laggard overall. But the UK still possesses some distinctive strengths and weaknesses. Although health spending overall is roughly average at best, capital investment lags behind many other advanced economies. It is no surprise, therefore, that the UK compares poorly in its level of key equipment and facilities such as diagnostic technology and hospital beds.

The UK healthcare workforce is also an outlier on many measures. We have a high reliance on foreign-trained staff and strikingly fewer doctors and nurses per head compared with our peers.

The UK health system fares better in protecting its population from the financial consequences of ill health or injury. And the UK performs well on some measures of efficiency, including generic prescribing rates and spending on administration.

But while we are in the middle of the pack on several of the factors that contribute to our health – such as levels of smoking and drinking – we perform poorly on measures of life expectancy and avoidable mortality. And survival rates from major killers such as cardiovascular disease and cancer remain relatively poor. Improving on these measures requires action, both within the remit of the health system itself and on the wider factors that make us healthy, such as education, housing and employment.

Our analysis suggests two broader lessons for the government and policymakers. First, there should be more focus on the outcomes that countries achieve and how they achieve them. It would be fruitful to pick out and learn from specific aspects of another country’s healthcare system, such as how countries develop clinical workforce strategies or reform primary care.

Second, there is no country that gets everything right and no model of healthcare that systematically fares better than another. The Chancellor, Jeremy Hunt, recently said he wants the NHS to achieve “Scandinavian quality alongside Singaporean efficiency”, obliquely highlighting that few countries can have it all on healthcare.

It is far more common for health system reforms to promote change within their existing model, rather than switching models entirely. None of this should be taken as an excuse for accepting the current state of the UK health service. But as the NHS turns 75, does a cross-border comparison suggest that the NHS model is broken? Or is there at least a better model the UK should adopt? The evidence is weak.

When the National Health Service Bill was introduced to the House of Commons in March 1946, Nye Bevan said he believed the proposals “will lift the shadow from millions of homes. It will keep very many people alive who might otherwise be dead. It will relieve suffering.” Seventy-five years later, this remains a noble goal – and a goal that is perhaps more likely to be achieved by improving, rather than dismantling, the model we have.

[See also: Wes Streeting and Phil Whitaker in conversation]

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