Post No.: 0932
Furrywisepuppy says:
The National Health Service (NHS) in the UK is a complex system made up of many organisations. It has been subject to constant reforms and is considered indispensable yet controversial.
Note that when we talk about the NHS, there are really different versions for England, Scotland, Wales, and Northern Ireland (where it’s called Health and Social Care). This leads to some differences across these nations (e.g. the abolition of the prescription charge in Scotland, Wales and Northern Ireland). In this post, we’ll be primarily focusing on the NHS in England.
Before the NHS, access to healthcare was largely dependent on your ability to pay for treatment. Where healthcare was available for free or cheaply, there was a patchwork of different services with varying levels of quality and access. The NHS was conceived to rectify these issues – as a largely tax-funded, universal healthcare system for all that is free at the point of use.
Service is principally made on the basis of need, not ability to pay. “No society can legitimately call itself civilised if a sick person is denied medical aid because of a lack of means” as chief architect of the NHS, Aneurin Bevan, asserted. Woof!
People don’t need to pay to see an NHS doctor, although they may need to pay for some things like dental treatment and spectacles.
It’s not perfect though. Some criticised that the move towards using private providers to improve patient choice and service competition appeared to be at odds with trying to achieve a tighter integration of primary and secondary care, social care, mental health and community health services – albeit in recent years there’s been a shift towards focusing on collaboration. Health inequalities between the rich and poor are also still vast today.
More of us are living longer and many people have multiple conditions that require regular, ongoing care. The NHS will need to evolve to account for this and other challenges, like workforce shortages and the impact of pandemics and climate change, as the population and its needs evolve.
The NHS plays its part in keeping England healthy – but staying healthy is much more than about seeing your general practitioner or visiting a hospital – many other factors, like where we live, our work, what and how much we consume, how much exercise we do, and genetics, will impact upon our health too.
Health is determined by a complex interaction between our individual and lifestyle factors (age, gender, constitutional factors); social and community networks (the supportiveness of friends, family, neighbours and others); factors like education, work, unemployment, housing, living and working conditions, agriculture and food production, water and sanitation, vaccinations, green spaces, laws, healthcare services; and general physical, socio-economic, cultural and environmental conditions.
Most experts agree that the ‘broader determinants of health’ are more important than healthcare in ensuring a healthy population. Only an estimated 15-25% of what affects the length and health-related quality of our lives is related to the healthcare and social care services we receive. A strong correlate is someone’s socio-economic status, whereby economic hardship is highly correlated with poor health, and increased levels of education are correlated with improved health. Lifestyle factors, like smoking, drinking alcohol to excess, our diet and physical activity levels, are impactful. Chronic stress and social isolation can be as impacting on our health as smoking. Genes also matter (e.g. South Asian ethnicities are more prone to developing diabetes). It all adds up.
Public health is the all-embracing term that seeks to respond to all these wider issues, and public health initiatives can be enacted at the national government and local authority levels (e.g. to support you having a healthy diet, providing children’s services, drug addiction services, screening services for different forms of disease, immunisations, more green spaces and cycle lanes, tackling air pollution, unemployment and online disinformation regarding health – anything that helps improve people’s well-being and prevents ill health).
In England at least, there’s a clear relationship between deprivation and life expectancy. Between 2017-2019, there was a life expectancy gap of nearly 8 years between women living in the least and most deprived areas. For men, this gap was 9.4 years. >60% of the population have a negative or fatalistic attitude towards their own health, particularly amongst more disadvantaged groups. And life expectancy inequalities due to deprivation have only widened in recent years.
It’s not just about the quantity of life but quality of life too, or people’s healthy life expectancy i.e. how much time people spend in good health over the course of their lifetimes. Between 2017-2019, there was a healthy life expectancy gap of nearly 2 decades between people living in the least and most deprived areas. People in the most deprived areas spend roughly a third of their lives in poor health. So they spend, on average, a far greater proportion of their already far shorter lives in poor health.
Yet health inequalities are largely preventable. There’s an economic as well as social justice case for addressing these inequalities – healthier people at work generate more taxes and cost less in welfare payments and costs to the NHS. Action on health inequalities requires action across all the social determinants of health, including education, occupation, income, home and community.
However, the NHS has, overall over the past decade, not given health inequalities as much priority as other issues like reducing waiting times and meeting financial targets.
Some question whether those who repeatedly rely on the NHS for what are considered self-inflicted, preventable problems should be served by a publicly-funded service? Well our health is both the responsibility of ourselves as individuals and of the state. The state should provide services that are easy to access but we should use NHS services responsibly. The NHS should employ enough staff and treat them fairly but we must pay our taxes to fund this. The state should improve efficiency and reduce waste but we should look after our own health too. The state should provide advice and support to help us stay healthy but we should also support our own communities. And the NHS should treat all patients equally but we must not take the NHS for granted.
Employers need to continue to show a growing interest in the well-being of their workforce too.
Social care covers a wide range of activities, from child protection to end-of-life care. It’s all around us, from unpaid family members caring for their elderly, ill, disabled or mentally unwell relatives at home, to paid professionals (e.g. social workers, occupational therapists) employed in social care. The former group dwarfs the latter. Social care is becoming increasingly vital as the population gets older. Just keeping someone company for a few hours per week can improve their life immensely.
Local councils can assess your needs, supply information and advice, provide short-term support called reablement, safeguard vulnerable persons from abuse and neglect, and purchase and monitor care from a range of organisations. The vast majority of those employed in adult social care are care workers for home care agencies or in care homes, residential or nursing. It combines issues like health, housing and welfare. We often hear about people being stuck in hospital because of problems in arranging social care. Therefore social care is a key area that needs tighter integration with other services.
Most NHS care is delivered directly by publicly-owned NHS organisations. But private companies also play a role, like in community dentistry, optical care and community pharmacy. Most GP practices are private partnerships too. Some view the increasing involvement of private companies and services means that the NHS is being sold off to the highest bidder and that this undermines the NHS’s core values. Others contend that provided patients receive care that’s timely and free at the point of use, it doesn’t matter who the provider is. Conflicts of interest must be managed if private providers hold seats on integrated care boards (ICBs) however, otherwise they’ll just award themselves the contracts.
Foreign nationals taking advantage of ‘health tourism’ account for only a fraction of a percent of the NHS budget (and it’s not like UK nationals don’t venture abroad as health tourists elsewhere! Although the cost of fixing the mistakes of foreign hospitals when these people return to the UK is an extra burden on the NHS).
Some claim that the NHS is a bottomless pit – but spending on healthcare has historically annually grown due to factors like rising patient expectations, expensive medical and new technological advances, and an ageing population (people surviving longer to experience older age-related health problems, like needing hip operations, means that the NHS is a victim of its own success!)
Depending on the metrics used and how they’re measured, the NHS can be ranked highly or lowly amongst healthcare systems within Europe in terms of care process, access to care, range and reach of services and treatments provided, administrative efficiency, patient rights and information, equity, healthcare outcomes, and the prevention of disease through public health initiatives.
But compared to other high-income countries, the UK doesn’t spend a particularly high proportion of its GDP on healthcare; whereas a decade of historically low funding increases has left services facing huge pressures and a workforce crisis. This means that the NHS is far from inefficient – it makes the most of the under-funding and under-staffing it receives. For one of the most complex organisations in the world, it has proportionally far fewer managers than large private organisations. Its relative efficiency has been used to justify lower spending on health but to the point of squeezing its budgets too far. If we want better care, we’ll need to spend more on health, just like those countries that provide a higher quality of care do.
Indeed maybe a publicly-funded universal healthcare system shouldn’t be so good at keeping people alive just so that they grow old and develop more health problems in the long run due to living to older ages?(!) Many age-related diseases only manifest after people have already passed their genes onto the next generation (i.e. had children) hence such diseases don’t get selected out. And because more people are living longer, more cases of these diseases are manifesting. People dying younger would also help solve the pensions problem(!)
Of course this is absurd – the solution should be about helping people live longer and also longer healthily and productively.
The NHS also needs to adapt to the needs of a changing society and demographics. We need to learn from COVID-19 for future pandemics. This crisis highlighted how much the country cherished the NHS though.
More at-home diagnostics, digital therapeutics, making use of personal health data captured through health apps and wearables, genome sequencing and personalised medicine, AI, telemedicine, and other new technologies, could improve the accuracy of some diagnoses, change where and how care is delivered, and offer novel ways to prevent, predict, detect and treat illness.
Previously, the Health and Social Care Act 2012 encouraged competition between services but that was the erroneous approach. So the primary aim of the Health and Care Act 2022 is to support collaboration to provide patients with a more joined-up rather than fragmented experience of health and care.
More and more people rely on the support of multiple different services, like mental as well as physical health care, or health as well as social care. Mental and physical health overlap – there’s good evidence that addressing both these needs together is better for patients and is more cost-effective. One of the worst things is having to explain your condition and medical history to someone different… for the sixth time! So a more integrated and coordinated experience will result in far better furry patient experiences and outcomes.
Another aim of better integration is to better address the broader determinants of health within local populations, which requires the communication and collaboration between the NHS, local authorities, the voluntary, community and social enterprise sector (VCSE), and other partners.
Woof!
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