Comment
The National Health Service: value for money, value for many
www.thelancet.com Vol 385 March 14, 2015
But there is an asymmetry between the design of the NHS and the UK’s health and social care needs. Three decades of repeated, and mostly unproductive, organisational restructuring and ill-conceived financial allocation regimes have produced a hospital-centric NHS in which treating acute episodic illness is rewarded disproportionately more than disease prevention and maintenance of good health.10 Spending for hospitaldominated secondary care increased each year in real terms from £49·1 billion in 2003–04 to reach £68·8 billion in 2011–12 (a 40% increase), whereas that for primary care rose only 19·2% from £17·7 billion to £21·6 billion, respectively.10 Much of the increase in primary care was for medicines, but from 2007–08 general practice spending by primary care trusts fell each year, on average, by 0·2% in real terms.10 The consequences of underinvestment in public health, primary care, community services, and social care are all too apparent, with pressure on emergency services and acute hospitals, as primary and community services struggle to cope with rising demand. Meanwhile, some NHS hospital trusts face the risk of financial insolvency.11 Failures in safety and quality are also eroding confidence in the NHS.12 But there is an opportunity: chronic illness and disability can be managed effectively in primary, community, and social care settings; well-proven public health interventions can mitigate and manage health risks.13 The Five Year Forward View provides a glimpse of future possibilities.14 There are five considerations for the next UK Government to address if the asymmetry between the country’s needs and the NHS’s organisation is to be rectified. The first is system design. Bringing together general practice with nurses, community health services, mental health services, social care, and hospital specialists to create integrated out-of-hospital services holds much promise, especially if the—now orphan—public health function and emergency services are incorporated within the new institutional design: a person-centred health system. Conversely, transition to integrated primary and acute care dominated by hospitals would be a retrograde step, since it would reinforce the dominance of acute hospitals and starve primary care of funding. The changes, however, should emerge organically through local innovations that produce context-sensitive system design
Adrian Roots
The National Health System (NHS) is one of the proudest achievements of the UK. Established in 1948, the NHS has not only played an important part in improving the health of the nation, but has provided to citizens and residents of the UK financial protection during illness and sickness. The NHS provides value for money and value for many. The British public appreciates the NHS and its equity ethos—a defining and enduring characteristic that ensures all those who need care get it when they need it, free at the point of delivery. In the 2014 British Social Attitudes Survey, 89% of the public agreed that the government should support a tax-funded national health system, free at the point of use, that provided comprehensive care for all citizens, and 65% of the British public was satisfied with the NHS (compared with only 37% in 1997).1 Notwithstanding major limitations of comparative health-system analysis,2 cross-country studies rank the NHS favourably relative to the health systems of other high-income countries in relation to health outcomes achieved per person, amount of health expenditure, financial protection, and equity.3–5 Yet other studies identify opportunities for improving the efficiency of the overall health sector compared with what is achieved in other countries of the Organisation for Economic Cooperation and Development (OECD)6 and the health outcomes the NHS achieves, particularly mortality from diseases that are amenable to treatment.7 In looking to the future, however, the NHS is confronted by four transitions for which it is ill prepared: a demographic transition to an ageing population with a high dependency ratio; an epidemiological transition to chronic illness, disability, and multimorbidity;8 an economic transition with widening income and wealth inequalities; and a social transition to a public that expects responsive and personalised health services. The ageing population of the UK currently bears the brunt of a high burden of chronic disease, mental illness, and disability, where the rates of standardised years of life lost for ischaemic heart disease, chronic obstructive pulmonary disease, other cardiovascular and circulatory disorders, and breast cancer are significantly higher than in other western European countries, such as France, the Netherlands, Norway, and Sweden.9 The population of the UK faces major risk factors for ill health: tobacco use, hypertension, obesity, and physical inactivity.9
917
Comment
by drawing on the strengths of NHS organisations, notfor-profit institutions, and the private sector. The second consideration is stability for the NHS. Hard though it may be, the next UK Government needs to provide a period of stability for the NHS, without topdown reorganisation, while fostering local creativity and continuity in local NHS leadership. Creativity and innovation does not thrive in an environment of rigid regulation and risk aversion, however. The period of stability should be used to reduce the onerous regulation faced by NHS organisations, by rationalising the excessive number of regulatory agencies whose functions clearly overlap. The third is financing. The next UK Government should maintain per-person NHS funding in real terms, funding which takes into account population growth and ageing, both of which will increase demand on services. Increase in funding should be combined with up-front investments in primary care and community services to enable the creation of local solutions that draw on the social sector, as well as new technologies. A fourth consideration is empowerment of service users and local citizens by involving them in decisions on their care and the design of local health systems. The fifth, and undoubtedly the most important consideration, is the health workforce, which should be entrusted by the authorising environment to create local solutions and bring about change. Leadership development at all levels is an urgent priority. The NHS has stood the test of time, but it faces major threats. In 2012, the health expenditure in the UK was 9·3% of GDP, the average for the OECD, but far less than Canada (10·9%), Germany (11·3%), France (11·6%), and the USA (16·9%).15 Its achievements make a strong case for any responsible government to nurture the NHS by continued investment to generate greater value for
money through improved efficiency, effectiveness, and responsiveness, and to create value for many by upholding equity. Not doing so would have untold consequences for the British public and the social cohesion the UK enjoys. Rifat Atun Department of Global Health and Population and Department of Health Policy and Management, Harvard T H Chan School of Public Health, Harvard University, Boston, MA 02115, USA [email protected] I declare no competing interests. 1
2
3 4 5
6 7 8
9 10 11
12 13 14
15
Gershlick B, Charlesworth A, Taylor E. Public attitudes to the NHS: an analysis of responses to questions in the British Social Attitudes Survey. London: The Health Foundation, 2015. Smith PC, Papanicolas I, eds. Health system performance comparison: an agenda for policy, information and research. Maidenhead: Open University Press and European Observatory on Health Systems and Policies, 2013. Ingleby D, McKee M, Mladovsky P, Rechel B. How the NHS measures up to other health systems. BMJ 2012; 344: e1079. OECD. Health at a glance 2013: OECD indicators. Paris: OECD Publishing, 2013. Davis K, Stremikis K, Schoen C, Squires D. Mirror, mirror on the wall, 2014 update: how the US health care system compares internationally. New York: The Commonwealth Fund, 2014. OECD. Health care systems: getting more value for money. OECD Economics Department policy notes, no 2. Paris: OECD Publishing, 2010. Nolte E, McKee M. Variations in amenable mortality trends in 16 high income nations. Health Policy 2011; 103: 47–52. Osborn R, Moulds D, Squires D, Doty MM, Anderson C. International survey of older adults finds shortcomings in access, coordination, and patient-centered care. Health Aff (Millwood) 2014; 33: 2247–55. Murray CJ, Richards MA, Newton JN, et al. UK health performance: findings of the Global Burden of Disease Study 2010. Lancet 2013; 381: 997–1020. Jones NM, Charlesworth A. The anatomy of health spending 2011/2012. London: The Nuffield Trust, 2013. National Audit Office. The financial sustainability of NHS bodies. Report by the Comptroller and Auditor General National Audit Office. London: National Audit Office, 2014. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationery Office, 2013. McKee M, Stuckler D. Realising an election manifesto for public health in the UK. Lancet 2014; 385: 665–66. NHS England, Care Quality Commission, Public Health England, Monitor, NHS Trust Development Authority, and Health Education England. NHS five year forward view. London: NHS England, 2014. OECD. OECD health statistics 2014—frequently requested data. Paris: OECD Publishing, 2015.
Deaths and taxes: stronger global tobacco control by 2025 See Editorial page 915 See Comment page 924 See Series page 1029 For WHO Framework Convention on Tobacco Control see http://www.who.int/fctc/ about/en/
918
10 years ago the WHO Framework Convention on Tobacco Control (FCTC) entered into force, and more than 170 countries have now signed this treaty.1 This anniversary marks an appropriate time to review progress on global tobacco control. First, smoking cessation is now common among adults in high-income countries but remains uncommon among adults in many low-income and middle-income countries
(LMIC) where most smokers live.2 Global annual cigarette sales rose from 5 trillion sticks in 1990 to about 6 trillion today.1 Roughly 1 ton of tobacco produces about 1 million cigarettes and causes one death; thus, each trillion cigarettes consumed annually should eventually cause about a million deaths annually.3 In China, where 40% of the world’s cigarettes are consumed, cigarette production rose by 30% since 2000.4 Meanwhile, in India small, locally www.thelancet.com Vol 385 March 14, 2015
The National Health Service: value for money, value for many
www.thelancet.com Vol 385 March 14, 2015
But there is an asymmetry between the design of the NHS and the UK’s health and social care needs. Three decades of repeated, and mostly unproductive, organisational restructuring and ill-conceived financial allocation regimes have produced a hospital-centric NHS in which treating acute episodic illness is rewarded disproportionately more than disease prevention and maintenance of good health.10 Spending for hospitaldominated secondary care increased each year in real terms from £49·1 billion in 2003–04 to reach £68·8 billion in 2011–12 (a 40% increase), whereas that for primary care rose only 19·2% from £17·7 billion to £21·6 billion, respectively.10 Much of the increase in primary care was for medicines, but from 2007–08 general practice spending by primary care trusts fell each year, on average, by 0·2% in real terms.10 The consequences of underinvestment in public health, primary care, community services, and social care are all too apparent, with pressure on emergency services and acute hospitals, as primary and community services struggle to cope with rising demand. Meanwhile, some NHS hospital trusts face the risk of financial insolvency.11 Failures in safety and quality are also eroding confidence in the NHS.12 But there is an opportunity: chronic illness and disability can be managed effectively in primary, community, and social care settings; well-proven public health interventions can mitigate and manage health risks.13 The Five Year Forward View provides a glimpse of future possibilities.14 There are five considerations for the next UK Government to address if the asymmetry between the country’s needs and the NHS’s organisation is to be rectified. The first is system design. Bringing together general practice with nurses, community health services, mental health services, social care, and hospital specialists to create integrated out-of-hospital services holds much promise, especially if the—now orphan—public health function and emergency services are incorporated within the new institutional design: a person-centred health system. Conversely, transition to integrated primary and acute care dominated by hospitals would be a retrograde step, since it would reinforce the dominance of acute hospitals and starve primary care of funding. The changes, however, should emerge organically through local innovations that produce context-sensitive system design
Adrian Roots
The National Health System (NHS) is one of the proudest achievements of the UK. Established in 1948, the NHS has not only played an important part in improving the health of the nation, but has provided to citizens and residents of the UK financial protection during illness and sickness. The NHS provides value for money and value for many. The British public appreciates the NHS and its equity ethos—a defining and enduring characteristic that ensures all those who need care get it when they need it, free at the point of delivery. In the 2014 British Social Attitudes Survey, 89% of the public agreed that the government should support a tax-funded national health system, free at the point of use, that provided comprehensive care for all citizens, and 65% of the British public was satisfied with the NHS (compared with only 37% in 1997).1 Notwithstanding major limitations of comparative health-system analysis,2 cross-country studies rank the NHS favourably relative to the health systems of other high-income countries in relation to health outcomes achieved per person, amount of health expenditure, financial protection, and equity.3–5 Yet other studies identify opportunities for improving the efficiency of the overall health sector compared with what is achieved in other countries of the Organisation for Economic Cooperation and Development (OECD)6 and the health outcomes the NHS achieves, particularly mortality from diseases that are amenable to treatment.7 In looking to the future, however, the NHS is confronted by four transitions for which it is ill prepared: a demographic transition to an ageing population with a high dependency ratio; an epidemiological transition to chronic illness, disability, and multimorbidity;8 an economic transition with widening income and wealth inequalities; and a social transition to a public that expects responsive and personalised health services. The ageing population of the UK currently bears the brunt of a high burden of chronic disease, mental illness, and disability, where the rates of standardised years of life lost for ischaemic heart disease, chronic obstructive pulmonary disease, other cardiovascular and circulatory disorders, and breast cancer are significantly higher than in other western European countries, such as France, the Netherlands, Norway, and Sweden.9 The population of the UK faces major risk factors for ill health: tobacco use, hypertension, obesity, and physical inactivity.9
917
Comment
by drawing on the strengths of NHS organisations, notfor-profit institutions, and the private sector. The second consideration is stability for the NHS. Hard though it may be, the next UK Government needs to provide a period of stability for the NHS, without topdown reorganisation, while fostering local creativity and continuity in local NHS leadership. Creativity and innovation does not thrive in an environment of rigid regulation and risk aversion, however. The period of stability should be used to reduce the onerous regulation faced by NHS organisations, by rationalising the excessive number of regulatory agencies whose functions clearly overlap. The third is financing. The next UK Government should maintain per-person NHS funding in real terms, funding which takes into account population growth and ageing, both of which will increase demand on services. Increase in funding should be combined with up-front investments in primary care and community services to enable the creation of local solutions that draw on the social sector, as well as new technologies. A fourth consideration is empowerment of service users and local citizens by involving them in decisions on their care and the design of local health systems. The fifth, and undoubtedly the most important consideration, is the health workforce, which should be entrusted by the authorising environment to create local solutions and bring about change. Leadership development at all levels is an urgent priority. The NHS has stood the test of time, but it faces major threats. In 2012, the health expenditure in the UK was 9·3% of GDP, the average for the OECD, but far less than Canada (10·9%), Germany (11·3%), France (11·6%), and the USA (16·9%).15 Its achievements make a strong case for any responsible government to nurture the NHS by continued investment to generate greater value for
money through improved efficiency, effectiveness, and responsiveness, and to create value for many by upholding equity. Not doing so would have untold consequences for the British public and the social cohesion the UK enjoys. Rifat Atun Department of Global Health and Population and Department of Health Policy and Management, Harvard T H Chan School of Public Health, Harvard University, Boston, MA 02115, USA [email protected] I declare no competing interests. 1
2
3 4 5
6 7 8
9 10 11
12 13 14
15
Gershlick B, Charlesworth A, Taylor E. Public attitudes to the NHS: an analysis of responses to questions in the British Social Attitudes Survey. London: The Health Foundation, 2015. Smith PC, Papanicolas I, eds. Health system performance comparison: an agenda for policy, information and research. Maidenhead: Open University Press and European Observatory on Health Systems and Policies, 2013. Ingleby D, McKee M, Mladovsky P, Rechel B. How the NHS measures up to other health systems. BMJ 2012; 344: e1079. OECD. Health at a glance 2013: OECD indicators. Paris: OECD Publishing, 2013. Davis K, Stremikis K, Schoen C, Squires D. Mirror, mirror on the wall, 2014 update: how the US health care system compares internationally. New York: The Commonwealth Fund, 2014. OECD. Health care systems: getting more value for money. OECD Economics Department policy notes, no 2. Paris: OECD Publishing, 2010. Nolte E, McKee M. Variations in amenable mortality trends in 16 high income nations. Health Policy 2011; 103: 47–52. Osborn R, Moulds D, Squires D, Doty MM, Anderson C. International survey of older adults finds shortcomings in access, coordination, and patient-centered care. Health Aff (Millwood) 2014; 33: 2247–55. Murray CJ, Richards MA, Newton JN, et al. UK health performance: findings of the Global Burden of Disease Study 2010. Lancet 2013; 381: 997–1020. Jones NM, Charlesworth A. The anatomy of health spending 2011/2012. London: The Nuffield Trust, 2013. National Audit Office. The financial sustainability of NHS bodies. Report by the Comptroller and Auditor General National Audit Office. London: National Audit Office, 2014. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationery Office, 2013. McKee M, Stuckler D. Realising an election manifesto for public health in the UK. Lancet 2014; 385: 665–66. NHS England, Care Quality Commission, Public Health England, Monitor, NHS Trust Development Authority, and Health Education England. NHS five year forward view. London: NHS England, 2014. OECD. OECD health statistics 2014—frequently requested data. Paris: OECD Publishing, 2015.
Deaths and taxes: stronger global tobacco control by 2025 See Editorial page 915 See Comment page 924 See Series page 1029 For WHO Framework Convention on Tobacco Control see http://www.who.int/fctc/ about/en/
918
10 years ago the WHO Framework Convention on Tobacco Control (FCTC) entered into force, and more than 170 countries have now signed this treaty.1 This anniversary marks an appropriate time to review progress on global tobacco control. First, smoking cessation is now common among adults in high-income countries but remains uncommon among adults in many low-income and middle-income countries
(LMIC) where most smokers live.2 Global annual cigarette sales rose from 5 trillion sticks in 1990 to about 6 trillion today.1 Roughly 1 ton of tobacco produces about 1 million cigarettes and causes one death; thus, each trillion cigarettes consumed annually should eventually cause about a million deaths annually.3 In China, where 40% of the world’s cigarettes are consumed, cigarette production rose by 30% since 2000.4 Meanwhile, in India small, locally www.thelancet.com Vol 385 March 14, 2015
