HEALTHCARE AND PROSPERITY THE NHS
AT 75
July 2023
Chris ThomasABOUT THE AUTHORS
Chris Thomas is head of the Commission on Health and Prosperity at IPPR.
ABOUT THIS PAPER
This briefing paper advances IPPR’s charitable objective of advancing physical and mental health.
ACKNOWLEDGEMENTS
The author would like to thank David Wastell, Liam Evans, Parth Patel, Harry QuilterPinner, Abi Hynes and Richard Maclean for their contribution to this paper.
We would also like to thank partners of the Commission on Health and Prosperity.
Download
This document is available to download as a free PDF and in other formats at: http://www.ippr.org/research/publications/the-nhs-at-75
Citation
If you are using this document in your own writing, our preferred citation is: Thomas C (2023) Healthcare and prosperity: The NHS at 75, IPPR. http://www.ippr.org/research/ publications/the-nhs-at-75
Permission to share
This document is published under a creative commons licence: Attribution-NonCommercial-NoDerivs 2.0 UK http://creativecommons.org/licenses/by-nc-nd/2.0/uk/ For commercial use, please contact info@ippr.org
2 IPPR | Healthcare and prosperity The NHS at 75
Since the NHS’ first day in 1948, the nature of our health has changed profoundly. Infectious diseases are less prominent. Median survival following a cancer diagnosis has increased 600 per cent. Long-term conditions like dementia and type II diabetes have become more prevalent – as have mental health problems and the number living with obesity – and a greater number of us are living with multiple conditions (Dayan 2018).
In other words, the central challenge (and opportunity) has changed: from acute need, to chronic; from illness being a liability to health being an asset; and to the variability in health need demanding personalisation and prevention, not one size fits all.
That shift has changed the societal role healthcare plays. In the 1940s, it was about life and death. That is often still true today: but with more of us living, longer, with more long-term conditions, healthcare is increasingly also a central determinant of our life chances – much like education. Or in other words, poor healthcare not only costs people their lives, but increasingly their livelihoods and wider wellbeing.
This was the key finding in the first interim report of the IPPR Commission on Health and Prosperity. There, we found that onset of sickness had a profound impact on earned income; constituted a key barrier to economic participation; and worsened job satisfaction (Thomas et al 2023). We also found that sickness was both more prevalent – and more detrimental – to people in lower income groups.
New IPPR/YouGov for this paper explores this further, with a focus on the impact of healthcare disruption. As tables 1–3 show, we find that a) many people are struggling to access the NHS healthcare they need and b) people who struggle to access timely healthcare often had social or economic consequences – particularly, those who are already living with a life-limiting condition.
TABLES 1, 2 AND 3: PEOPLE ARE STRUGGLING WITH HEALTHCARE ACCESS, AND THIS CAUSES SIGNIFICANT ECONOMIC HARM
Which of the following, if any, describes your experience of accessing NHS healthcare services during the period since Covid-19 emerged in January 2020?
The most recent time you accessed NHS healthcare, how easy or difficult was it to get an appointment that suited you? [those who’d accessed NHS healthcare, n = 1330]
IPPR | Healthcare and prosperity The NHS at 75 3
Response All Those will a health condition impacting day-to-day life I found it difficult to access the healthcare services I need through the NHS 34% 51% I have been able to access the healthcare I need through the NHS 40% 40% I have not needed healthcare services 18% 5% Can’t remember/don’t know 7% 5%
Response All People with an illness impacting on dayto-day activities Easy (total) 66% 64% Difficult (total) 31% 35% Don’t know 3% 1%
Have you experienced any of the following as a consequences of your difficulty accessing the NHS healthcare you need (select all that apply) (n = 713)
WHO IS AT MOST RISK FROM POOR NHS HEALTHCARE?
In education, one challenge is that those with means can access far better provision – giving them a lifelong advantage over others. This is increasingly true of healthcare: those with means are able to access better, private healthcare even during times NHS healthcare is in crisis. This means the risk of poor healthcare – on both life, but also livelihood – is concentrated on those without means.
Our polling shows this in action. Since Covid-19 began, 37 per cent have used some form of private healthcare provision. But this use is far, far more common in ABC1 social grades than C2DE grades.
Source: IPPR/YouGov
The most common reason for going private was avoiding waiting lists (41 per cent), followed by accessing a procedure not available on the NHS (20 per cent). It was to avoid this two-tier system that Bevan originally stipulated the NHS should ‘universalise the best’ for all, so as to benefit everyone, equally.
4 IPPR | Healthcare and prosperity The NHS at 75
Response All People with an illness impacting on dayto-day activities Less ability to maintain hobbies and interests 30% 50% Less ability to maintain social relationships 21% 33% Less enjoyment of work/job satisfaction 19% 29% Increased financial insecurity 17% 26% Difficulty maintaining work-life balance 16% 23% More difficulty working the number of hours you’d like 12% 19% Less ability to progress at work 10% 15% More difficulty finding work or staying in your current job 9% 16% None of the above 43% 22%
Source: IPPR/YouGov
All ABC1 C2DE Private healthcare Total Yes 17% 23% 10% Total No 78% 73% 83% Private dental care Total Yes 27% 32% 21% Total No 67% 63% 71% Any private healthcare Total Yes 37% 44% 26%
TABLE 4: THE NHS IS LOSING OUT TO PRIVATE HEALTHCARE PROVIDERS Did respondents use private healthcare, since January 2020 [n = 2014]
Good health broadly – and good healthcare more specifically – is vital to ensuring everyone has access to a good and prosperous life. The question this begs is obvious: seventy-five years on from the NHS’ foundation, is there a path to deliver this today?
Some suggest that adapting to the sheer level and complexity of chronic illness today demand a fundamental change in how the NHS operates. Arguments for a more contributory healthcare system, or a shift towards a social insurance model, are growing.
However, there is limited evidence either would work – and some evidence they would actually prove harmful, above beyond their substantial opportunity cost (for example, see Edwards 2022). These reforms simply do not respond to the core challenge the NHS faces: its difficulty keeping up with changing population health needs.
There is no reason why modernising the NHS should mean tearing up the service’s founding principles. Indeed, there remain few propositions that attract nearuniversal, cross-party support among the public – who, indeed, would support their expansion further into adult social care. There is also support to fund this through higher taxation.
TABLES 5, 6, 7 AND 8: PEOPLE SUPPORT THE NHS’ FOUNDING PRINCIPLES (INCLUDING EXTENSION TO SOCIAL CARE)
For each of the following statements, to what extent do you think the principle should still apply to NHS services today? [n = 2014]
IPPR | Healthcare and prosperity The NHS at 75 5
All Conservative Labour Free at the point of use when people need it Should still apply 89% 89% 95% Should not still apply 6% 8% 2% Provide a comprehensive service, available to everyone Should still apply 85% 81% 93% Should not still apply 9% 15% 4% Primarily funded through taxation Should still apply 83% 83% 92% Should not still apply 7% 9% 3%
For each of the following statements, to what extent do you think the principle should apply to adult social care in the UK?
Which, if any, of the following would you most like to see?
In general, thinking about how social care in the UK should be funded, which of the following, if any, comes closest to your view?
Source: IPPR/YouGov polling
But that is not to say the NHS does not need fundamental change. It can no longer function as an ‘illness’ service – that treats acute need, reactively, only once it emerges. Our health, society, equality, and economy demand it evolves into a ‘wellness service’: one that proactively identifies need, that delivers significantly more care in the communities we live, that focusses on prevention, and which provides us support throughout our experience of living with one or more long-term health conditions. That is, we need a prevention shift – from primary, through to tertiary prevention.
Progress towards this model of care has been slow. Despite committing to personalised care in various strategies, not least 2019’s Comprehensive Model for Personalised Care, the NHS is struggling to shift towards care models appropriate for an era defined by chronic, multiple conditions (tables 5–8).
6 IPPR | Healthcare and prosperity The NHS at 75
Percentage All Conservative Labour Free at the point of use when people need it Should apply 78% 77% 86% Should not apply 9% 12 8 Provider a comprehensive service, available to everyone Should apply 80% 80% 90% Should not apply 7% 9% 3% Primarily funded through taxation Should apply 72% 73% 82% Should not apply 10% 13% 7%
Response Percentage Increase taxes in order to maintain the level of spending needed to keep at least the current level of care and services 45% Reduce spending on other public services, such as education and welfare, in order to maintain the level of spending need 15% Reduce the level of care and services provided by the NHS so that you do not need to increase the current level spending 6%
Response Percentage Should be fully/mostly funded by government 68% Should by fully/mostly funded by charges to those who use the service 4%
Which, if any, of the following types of support or assistance have you been given? Please select all that apply. [n = 1330]
We must do far more to catalyse this shift. But doing so will require some fundamental changes in how we approach, fund, and locate healthcare. This will include the following.
A new focus
Our historic focus on longevity has served us well – but the prevalence of long-term, non-communicable conditions now requires a shift to focus on healthy life expectancy: or ‘putting life in life expectancy’. The evidence shows that setting an aspirational, cross-government mission can lead to health improvement and lower inequality – and we suggest government legislates a 30-year mission to make UK healthy life expectancy the highest in the world.
A shift to community
A wellness service would do more in the places people live, work, and grow. We need more services focused on communities and homes – from domiciliary social
IPPR | Healthcare and prosperity The NHS at 75 7
TABLE 9: PEOPLE ARE NOT RECEIVING PERSONALISED, PREVENTATIVE INTERVENTIONS DESPITE NHS COMMITMENTS
Intervention All People with an illness impacting on day-to-day activities A longer appointment to discuss your issue, diagnosis or condition 16% 22% A personalised care plan 5% 8% Formal education or training about your health condition or lifestyle 4% 6% Support from a link worker, peer support network/ expert, or care coordinator 4% 10% Access to additional technology 3% 5% A social prescription (e.g. befriending services, arts activities, group learning, cookery classes) 2% 3% Access to a personalised health budget 1% 2% None of the above 68% 59% Don’t know 6% 3%
Source: IPPR/YouGov polling
care, to integrated primary and community care services, to mobile screening services and health checks.
Evidencing and investing in prevention
We have a systematic approach to clinical evidence, led by NICE. Yet, we do not systematically evidence, evaluate and invest in preventative interventions. A new ‘what works’ centre – modelled on the Education Endowment Fund – could support more evidence on prevention, from the social determinants, to vaccines, to early diagnosis. A Health Creation Fund, to strategically invest in implementing the evidence, could help translate initiatives - with the highest potential for health, justice and prosperity – from theory and into practice.
Spending more on primary, community, mental health, and public health
The UK spends relatively little on public health, and over-invests on acute care compared to community, primary and mental health services. Rebalancing this is a precondition for delivering a modern healthcare service – and should be seen as the ‘strings attached’ to any increase in NHS funding.
In early autumn, the IPPR Commission on Health and Prosperity will release its second interim report – exploring these shifts in more detail, and outlining a new, long-term blueprint for future-proof health and social care services.
8 IPPR | Healthcare and prosperity The NHS at 75
REFERENCES
Ball A (2023) ‘Patient safety data shows a twenty-five percent increase in safe incidents resulting in harm or death’, Ringrose Law. https://www.ringroselaw.co.uk/2023/01/04/ patient-safety-data-shows-a-25-increase-in-safety-incidents-resulting-in-severe-harmor-death/
Bhatnagar P, Wickramasinghe K, Wilkins E, Townsend N (2016) ‘Trends in the epidemiology of cardiovascular disease in the UK’, BMJ Heart p1944-1949. https://heart.bmj.com/ content/102/24/1945
Dayan M (2018) Death through the decades Nuffield Trust. https://www.nuffieldtrust.org.uk/ news-item/death-through-the-decades
Edwards N (2022) Myth 3: We should copy other countries and adopt a social insurance model, Nuffield Trust. https://www.nuffieldtrust.org.uk/news-item/myth3-we-should-copy-other-countries-and-adopt-a-social-insurance-model
Head A, Fleming K, Kypridemos C, Schofield P, Pearson-Stuttard J, O’Flaherty, M (2021) “Inequalities in incident and prevalent multimorbidity in England 2004-19: a population based, descriptive study” Lancet Healthy Longevity https://www.thelancet.com/ journals/lanhl/article/PIIS2666-7568(21)00146-X/fulltext
Kingston, A et al (2018) ‘Projections of multi-morbidity in the older population in England to 2034: estimates from the Population Ageing and Care Simulation (PACSim) model’ Age and Ageing, p374-380. https://academic.oup.com/ageing/article/47/3/374/4815738?login =false
Macmillan (undated) Living after diagnosis. https://www.macmillan.org.uk/documents/ aboutus/newsroom/livingaftercancermediancancersurvivaltimes.pdf
Newsinger, J (2018) ‘War, empire and the Atlee government 1945 – 1951’, Race and Class, p6176. https://journals.sagepub.com/doi/10.1177/0306396818779864
OECD (2022) ‘Health spending’, dataset. https://data.oecd.org/healthres/healthspending.htm
ONS (2022) ‘Health state life expectancies by national deprivation deciles, England’, dataset. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/ healthinequalities/bulletins/healthstatelifeexpectanciesbyindexofmultipledeprivationi md/2018to2020
ONS (2023) ‘Economic inactivity by reason’, dataset. https://www.ons.gov.uk/ employmentandlabourmarket/peoplenotinwork/economicinactivity/datasets/ economicinactivitybyreasonseasonallyadjustedinac01sa
Papanicolas I, Mossialos E, Abel-Smith B, Gundersen A, Woskie L, Jha AK (2019) ‘Performance of UK National Health Service compared with other high-income countries: observational study’, British Medical Journal p1-11. https://www.bmj.com/content/367/ bmj.l6326
Rebelledo I, Charlesworth A (2022) ‘How does UK health spending compare across Europe over the past decade’, Health Foundation. https://www.health.org.uk/news-andcomment/charts-and-infographics/how-does-uk-health-spending-compare-acrosseurope-over-the-past-decade
IPPR | Healthcare and prosperity The NHS at 75 9
ABOUT IPPR
IPPR, the Institute for Public Policy Research, is the UK’s leading progressive think tank. We are an independent charitable organisation with our main offices in London. IPPR North, IPPR’s dedicated think tank for the North of England, operates out of offices in Manchester and Newcastle, and IPPR Scotland, our dedicated think tank for Scotland, is based in Edinburgh. Our purpose is to conduct and promote research into, and the education of the public in, the economic, social and political sciences, science and technology, the voluntary sector and social enterprise, public services, and industry and commerce.
IPPR
8 Storey's Gate London SW1P 3AY
E: info@ippr.org
www.ippr.org
Registered charity no: 800065 (England and Wales), SC046557 (Scotland)
This paper was first published in December 2022. © IPPR 2022
The contents and opinions expressed in this paper are those of the authors only.