Johnnie's blog

The NHS sees a colossal 1 million patients every 36 hours, spending nearly £2 billion per week, making it a £100 billion-a-year-plus business. Aside from the banks, the only companies with a larger turnover in the FTSE 100 are the two global oil giants Shell and BP. Staggeringly, if the NHS were a country it would be around the thirtieth largest in the world, and with its 1.4 million employees, it is the third largest employer in the world. But do we deliver the quality care we all wish for and which we are capable of delivering?  And, more to the point, could it ever function as we need it to?

Our NHS spends around 65 per cent of its budget on staff but as we emerge from the pandemic its health and care workforce is under unprecedented pressure, the like of which we have not previously witnessed.

For years the rhetoric has been that underfunding has been to blame for the NHS woes.  In my career over more than 40 years that was certainly true initially.  But not so in the last decade.  Looking at comparison with an OECD (Organisation for Economic Cooperation and Development) analysis in 2016 – 6 years ago, we sat on the median for % of GDP spent on health, against a group of 21 other developed nations as this chart shows.

The OECD was founded in 1961 by 20 nations, namely Austria, Belgium, Canada, Denmark, France, West Germany, Greece, Iceland, Ireland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, Turkey, United Kingdom, and the United States. It therefore has a wide base giving it credibility in international comparison.

Eighty per cent of health care spending in the UK is financed through government expenditure, with the remainder coming from other expenditure, voluntary health insurance or other financing schemes. Australia, Canada and New Zealand use a similar approach for funding health care. This contrasts with countries such as Germany and France, which fund health spending much more through compulsory health insurance. 

Funding has increased since this bar chart was produced.  In 2019, the last pre-pandemic year, OECD figures show we spent 10.2 per cent of GDP on healthcare, against an OECD average of 8.6 per cent: more than Spain, Italy, Australia, or New Zealand, about the same as the Netherlands. In 2020 with pandemic funding, we were actually the biggest spenders anywhere apart from the United States. So it is impossible to make the case that the NHS is actually underfunded.

Given this level of spending, where is this money going because we are a long way behind our neighbours in outcomes? On CT and MRI scanners we were OECD bottom in 2016. On residential care beds 6th from bottom.  On cardiovascular deaths, in 2019 the UK recorded 132.3 per 100,000 population compared to 91.4 in France and 77.03 in Japan.  Of course, a major factor in cardiovascular deaths is lifestyle.  But less so cancer survival and right now in 2022, 5 year survival rates for lung cancer are 9.6% in the UK (internationally bottom) compared with 37.2% in Mauritius. For gastric cancer it is 18.5% in the UK, and 57.9% in South Korea. For prostate cancer it is 83.2% in the UK, and 100% in Tunisia. 

The predominant issue is not a lack of expertise, but rather a shortage in clinical capacity, resulting in delays to getting an expert opinion, specialist investigation and definitive treatment.  Pay a visit to your local A&E department and see.  Prof Carl Heneghan, an urgent care doctor and professor of evidence-based medicine at the University of Oxford, said “the NHS seems to be the only business .. that doesn’t know how to deal with demand and work with the needs of its customers.”

Meanwhile, management costs in the NHS have spiralled.  In 2018, two years prior to the pandemic, nurses and health visitors, excluding nurses in GP practices, stood at 284,000 full time equivalents (FTE), a decrease of 0.2 per cent (435) since 2016.  Meanwhile managers stood at 21,700 FTE, an increase of 3.3 per cent (687) on 2016, while senior managers stood at 10,300 FTE, a massive increase of 7.0 per cent (676) on 2016.  This was by far the largest expanding group.

It is worth noting that it is actually extremely difficult to find an accurate figure for the number and cost of managers in the NHS in order to compare internationally, as most national sources of information use different definitions for who is counted as a manager. Some count clinical managers, other sources do not. Best estimates suggest that the NHS spends roughly £8 billion of its £100 billion budget on pure management and administration. But a more sobering consideration is that the number of backroom staff in the health service has been creeping up, and now only 52.5 per cent are clinically trained staff actually delivering direct care.

While the number of NHS managers has grown there may be a range of reasons for this.  We have seen a plethora of policy initiatives that have increased the requirement both for management and administration. These include targets for waiting times; new regulators; published measures of hospital and PCT performance; outside consultant reports; expensive staff and patient surveys and extensive contracting out of a wider range of support services.  

Many of these roles could be sacrificed and concentrated on managers who are experts in delivering, enabling and fostering great specialty care. When I trained in NHS management as an adjunct to being an active A&E Consultant, I was often reminded that a senior manager in any company would likely be an expert in the work involved.  I would hate to use a garage, a jeweller or an electrician where this was not the case.

The 2016 data showed that the UK had 2.8 doctors per 1,000 population, which is way below the average of 3.6 for the OECD basket of countries.  The UK also has fewer nurses per 1,000 population (7.9) than average, positioning the UK next to the Czech Republic and far behind Germany (13.3 nurses per 1,000 population) or Switzerland (18 nurses per 1,000 population).

The number of hospital beds in the UK (2.6 beds per 1,000 population) is substantially lower than the average of 4.4 beds for the basket of countries. Bed levels in the UK are similar to those in Canada and New Zealand and far below those in Germany and Austria.

A consequence of the low number of available beds has been constant pressure on levels of hospital bed occupancy, which puts pressure on patient flow and waiting times as demands for emergency and planned treatment continue to increase. The Care Quality Commission has said the NHS is now ‘straining at the seams’ with more than 90 per cent of hospital beds occupied – far higher than the 85 per cent level recommended for safe and efficient care.  In fact this does not show the acute bed occupancy which for many Trusts runs near 100%.  It is the acute beds which ‘drain’ A%E and if these are full this causes the immense backlog in A&E that we observe, and further upstream, in ambulance off loading, and ultimately in 999 paramedic response times being so poor. The fact that acute hospital bed occupancy remained high at the start of the pandemic reduced our ability to respond to Covid. It is now associated with a substantial increase in the time patients wait for both urgent, GP and planned hospital care.  

As already detailed, on any clinical outcome (eg out-patient waits, surgery waiting lists, investigation waits, cancer treatment waits and survival and cardiovascular outcomes), the UK is lagging far behind other major nations. The bottom line and the gold standard has to be this – do we deliver the quality care we all wish for and which we are capable of delivering?  And the answer very clearly is that we don’t.  Which answers my first question in my opening paragraph.

So if our funding is not greatly different from other developed nations, but our services are, we can conclude only two things.  Firstly, we may be playing catch-up: ie the funding deficit has been so poor for so long that there is a lot to fund – new scanners, efficient wards, modern labs, etc – and this will take more time.  But quite a few years have now elapsed with good funding. So, secondly, are we overspending on non-clinical staff?  Can we justify dozens of NHS CEOs earning more than the Prime Minister?  Has the NHS simply become too massive, too top-down and too distantly regulated?

We are a complete outlier in being the only large country where most health services are organised by the government.  I doubt that organisations of this size can actually be managed from the top without a great deal more delegation and freedom.

The French health care system is one I admire.  In its 2000 assessment of world health care systems, the World Health Organisation (WHO) found that France provided the “best overall health care” in the world. So it is worth looking at.

Most consultants in France are self-employed, using their own premises. Patients select the specialist they wish directly, making a call in the morning and maybe being seen that afternoon, thus avoiding long waits. And these specialists each function as independent businesses, also avoiding a complex centrally governed structure. Patients tend to know who they need to see, be it a gynaecologist, dermatologist or paediatrician.

It is not just the NHS central organisation which is problematic, but its near 100% central funding in advance.  In France approximately 77% of health expenditures are covered by government funded agencies, reclaimed retrospectively as care occurs.  The entire population must pay compulsory health insurance. The insurers are non-profit agencies that annually participate in negotiations with the state to ensure fairness and equality.

Here in the UK I have witnessed far more reforms than I could possibly remember over my career, all designed to gently adjust the nation’s perceived precious asset. No political party has dared ever to open a debate on whether the system is right for the present day, with the prevailing view of the population being that it is the ‘envy of the world’.  Sadly, I hope you can see, it is no where near the envy of the world.

Let me be clear, I have no criticism for our staff, our expertise or our world-leading research. During the pandemic the NHS staff were applauded weekly in public, and rightly so.  Many were working at heroic levels.  The staff are great.  Our medicines and interventions are world-class.  It’s the establishment behemoth, the bureaucratic and inflexible system to deliver these which is the problem.

At this moment the most critical question is whether our outcomes can justify the NHS existence in its present form, and moreover whether the tide of public opinion will eventually drive a radical sea change to replace our habit of constant incremental reform.  Has the time come for an honest national, cross-party debate? The appointment of a cross party apolitical senior health cabinet minister maybe? And a determination to use the present excellent funding in order to deliver equally excellent care and outcomes. I sincerely hope so.

Dr John Sloan, Retired A&E Consultant