There is still time for the NHS to regain its status as the best health system in the world, argues Mark Britnell.
When the National Health Service was created, it was the envy of the world – and can be again if it is prepared to innovate and meet the challenges and opportunities presented by the globalisation of healthcare. In doing so, improved performance can help the global competiveness of the UK and expand GDP, to which the future prosperity of the NHS is inextricably linked.
In my role as Chairman of our Global Health practice, I have had the privilege of working in 32 different countries over the past two years, and firmly believe that the UK can resume its pre-eminent role in leading health system performance to “add life to years and years to life”, and also stimulate much needed economic growth.
The developed and developing parts of the world are facing two distinct challenges, which can no longer be neatly categorised as “East meets West” or “North meets South”. Rather, health systems either have “pains of old age” or “growing pains”. In the developed and economically mature parts of the planet, countries are experiencing pains of old age – sluggish or non-existent economic growth, a rapidly ageing population, an assertive “consumer citizen” and financial pressure on healthcare expenditure. Conversely, in the developing world, countries are experiencing growing pains – strong economic growth, a relatively young population, growing numbers of demanding middle class consumers and active citizens, poor infrastructure but large investment funds to improve access to, and the quality of, healthcare.
The NHS can offer solutions to both challenges, but it will need to move away from its heavily centralised system, which can curb entrepreneurial innovation. I have seen at first hand, through many discussions with executives and clinicians in public sector, private sector and government organisations, how the NHS has something to offer everyone around the world.
I have also seen – in every country – that we also have something to learn. During my travels, I carry a sort of mental algorithm around which I use to assess health system performance, and I have no doubt that the NHS can lead on nearly all of the parameters over the next decade.
I evaluate health system performance through a five ‘E’ matrix – equity (access to care and social solidarity), efficiency (the utilisation and productivity of finite resources), effectiveness (the quality and value of healthcare), experience (patient and public satisfaction and engagement) and entrepreneurship (the degree of system agility and ability to innovate).
Against these criteria, the NHS scores well, although there is room for improvement. There is both good and bad news.
Firstly, the good news: the internationally respected Commonwealth Fund has recently placed (June 2010) the English NHS second in a comparative study of seven developed nations. Trailing only the Netherlands, the NHS scored highly on equity, efficiency and an aspect of effective care, but ranked poorly on experience as defined by the ability of patients to control their own care. My own international experience suggests that we have a system which is highly equitable when compared to others. The efficiency of our system is second to none (although productivity and value could be much improved). With a little over nine per cent of GDP committed to healthcare in the UK, we should be proud of our achievements over the past ten years. When Tony Blair promised he would increase spending to the European average (which he did when the EU is taken as a whole), it is worth noting that Germany, France and the Netherlands didn’t stop spending and wait for us to catch up. All these systems now commit over 11 per cent of their GDP on health and still have difficult financial pressures to cope with.
On public and patient experience, I was recently at a conference in Chamonix with leading French policymakers, politicians and practitioners; and, much to their chagrin, their own international polling of public satisfaction with respective national health systems revealed that the NHS scored highest. There was much subsequent debate as to whether this could be explained by the Anglo-Saxon culture! Finally, we score less well on entrepreneurship, and this is a key reason for our poor record on productivity over the past decade. The NHS provides a great deal of comfort to the public, patients and practitioners that it will always be there, but lacks a cutting edge which can lead to complacency. We need both because the NHS is a very large system with an internal bureaucracy that has a tendency to be myopic on occasions.
Now the bad news: while the NHS is widely respected around the world, it is not necessarily copied or universally adopted. Across the global healthcare spectrum, countries range from largely public funding and public provision (for example, Scandinavia and UK) to private funding and private provision (for example, USA and India). Irrespective of the system, the NHS does have challenges to address. On effectiveness – the quality and value of care – our performance on outcomes is mediocre with average rankings for cancer survival, infant mortality and high variability in surgical and medical practice (especially following emergency admission). Like others – but our economic debt is greater – it could be argued that we are slowly sleep-walking into structural, fiscal and care problems for the elderly, both in the acute and chronic phases of hospital, residential or domiciliary care.
Equally, the ability of patients to have more choice and control over their care is distinctly average. The Commonwealth Fund ranked the NHS seventh out of seven for patient-centred care, which it defines as “care delivered with the patients’ needs and preferences in mind”.
As noted, our productivity is low even when compared against the private sector in the UK. An estimated 20 per cent productivity gap has emerged between the public and private sectors in the UK over the past decade, and this has partly occurred because the NHS has been protected (quite rightly) against some of the worst economic vagaries of the global recession. The disadvantages of protection have dimmed the need for entrepreneurship and innovation, and this is compounded by the bureaucracy associated with a heavily centralised health system. We can meet the efficiency challenge of four per cent per annum over the next four years by addressing a number of issues, which include the management and motivation of staff, the maximisation of value from assets deployed, greater commercial acumen in procurement and the more sophisticated application of integration (for chronic diseases) and competition (for planned care). We will also need a much greater degree of innovative disruption, especially around the adoption of technology where we have wasted a golden opportunity over the past decade. The old business model of care that developed over the 20th century will need to radically change if we are to meet patient, citizen and taxpayer needs of the 21st-century.
All of these matters are addressable and we can easily re-gain our mantel as the “pre-eminent health system globally”. Indeed, it is crucial that we give the 1.4 million people who work in the NHS the hope and belief that we are working towards a much brighter future for our health system. The unrelenting need to release four per cent efficiency per annum for four years (nor the latest structural re-organisation) should not be allowed to diminish our desire to be the best health system for patients and the public. It is possible, and we should more carefully marry (and not divorce or insulate as some are trying to do), for our desire for economic rejuvenation to be inextricably coupled with our quest to be the best health service. We cannot have one without the other. A compelling vision to be the best is much more motivating than another technocratic justification of reform.
A high value, efficient NHS is great for business and economic stimulation. Through the existing combination of general taxation, national insurance and small individual co-payment, the NHS does reduce the burden of high employer funding costs for healthcare associated with other systems in Europe and America. An efficient and effective NHS can keep people economically active, provide education and development that contributes to the generation of national wealth and export some of the best intellectual property and industrial flair to come out of health and life sciences. This will help us retain and extend our global position in life sciences, education and, ironically, the production of healthcare staff to address the looming under-provision of health workers across the globe over the next 20 years.
Let me give you just five examples of what we can export. Before doing so, I take as given the central importance of the UK’s need to have a strong life science, academic health science and bio-technology base. We still have the second strongest life science industry in the world, and this must be supported further. I’d like to turn to export and import ideas that the NHS can help UK plc with:
The twelfth five year plan of China calls for the creation of 30,000 hospitals and eye-watering levels of investment. Our experience of public-private infrastructure projects should mean that the NHS is well placed to advise, design, build and operate new facilities. After all, the NHS Plan stimulated the largest hospital construction programme in the world. Our national strengths in construction, financial services and project management could help the UK overseas. Our management capability could help run facilities. The global market for these services is enormous, ranging from Asia, South America, Eastern Europe and Africa. I believe that the link with climate and environmental sustainability is obvious, especially when one considers that modern infrastructure includes digital capability which is so crucial for e-health or m-health.
Secondly, our system of primary care with its comprehensive system of capitation and registration is widely admired and can be exported. In South America, Asia, Africa and the Middle East, excellent primary and community care services are a fundamental pre-condition for future economic prosperity, a healthy workforce and contented citizens. Governments in all these countries want to provide much greater access to care at affordable costs, and we can (with a little bit of imagination and commercial acumen) export our skills and help design and run services to the many poor, and often geographically-dispersed, communities.
Third, our education, training and development programmes can help others produce health workers of the future. This is a massive growth industry and we have yet to fully appreciate the fact that, as the developing economies mature, they will require their own healthcare staff and be less able to export them (the West has traditionally relied on these groups to address shortages). Simultaneously, the ageing population in developed economies will reduce the number of workers potentially attracted to health, thus creating a perfect storm – more healthcare need and less staff supply. Our educational institutions (stimulated by tight financial settlements) have started to roam the world and the NHS should catch-up, join-up and follow.
Fourth, our technology appraisal capability, medical devices industry, health data services and management knowledge “know-how” can be exported. We have sizeable companies in telehealth and telecare, technology firms and others, but they have been left to fend for themselves. Ironically, the most notable NHS success that I am asked to talk about when abroad is NICE, and we should consider exporting this idea along with other management innovations which can be sold under a banner of professional services.
Finally, and most controversially, the NHS needs to decide whether it wishes to compete in the rapidly growing market of medical tourism (a global market estimated in the order of $80 billion). This falls into three parts – outbound care, inbound care and academic health science centres and hospital brands. There is a large market in health tourism, which is centred on the East but spreading quickly. We need to decide whether we take part or let others pass us. Similarly, US-domiciled medical health academic science institutions dominate the Middle East and are exploring further. Do we wish to nationally support our five AHSCs and strong brands such as the Royal Marsden?
These five ideas combined could have a market value approaching £50 billion. They deserve serious consideration and I hope NHS Global – the organisation established to promote the NHS abroad and capitalise on its intellectual property – can rise to the challenge.
Since the creation of the NHS, there have been approximately four periods of serious retrenchment. These periods have tended to last only a couple of years because of the political pain they cause and the resumption of economic growth. We cannot afford to bet that this will happen automatically in the future, but, if we set our ambition to be the best health system in the world, we can help Great Britain back to economic growth and sustainable NHS prosperity. We can create a virtuous circle of growth and not a vicious spiral of slow degradation.
This essay appears in The next ten years published by Reform.