The issues...
As the UK election results become clear on 5 July 2024, we also mark the 76th anniversary of the National Health Service (NHS). Described by Bevan as ‘a great and novel undertaking’, the NHS consistently tops the list of the UK’s most cherished institutions. Despite this, the NHS faces significant pressures, with criticisms and failings often highlighted in the media.
Revitalising and sustaining the NHS will be high on any government’s first 100-day agenda. All healthcare systems face myriad challenges, the most pressing being rising costs which no country can contain. The UK spends about 11.3% of its GDP on healthcare, slightly less than Germany (12.7%), France (11.9%), and Japan (11.5%), and similar to Austria and Switzerland.
Technology and rising multimorbidity are key drivers of healthcare costs. Advances in technology boost costs faster than inflation due to new, expensive treatments, greater detection, and higher demand. Multimorbidity (two or more chronic illnesses) raises costs due to complex treatments and care needed. Multimorbidity is increasing worldwide across all ages, and with population ageing. In England, the number of people with multimorbidity is projected to nearly double from 19.2 million in 2019 to 35.3 million by 2049.
Workforce shortages exacerbate these challenges. Health systems require sufficient health workers; services depend on their availability, accessibility, acceptability, and quality. The World Health Organisation (WHO) estimates a shortfall of 10 million health workers worldwide by 2030. The NHS Long Term Workforce Plan highlighted an expected shortfall of 260,000 to 360,000 staff by 2036/37. Shortages lead to overburdened staff, longer wait times, and compromised care quality, potentially increasing costs due to inefficiencies and missed early-stage illnesses.
The solutions...
Addressing these issues requires a multifaceted approach, and a challenge is what to prioritise. Headline figures, such as the 7.6 million people waiting for hospital treatment, will be important, but alongside this a more systematic approach may be necessary. That is why four interconnected components needs to be considered together and simultaneously:
- Improving care in community settings
- Re-investing in training and conditions for the workforce
- Recognising and supporting the value of unpaid carers, and self-care
- Developing frugal technologies for independence
First, improving care in community settings through greater investment in community support, social and primary care, including out-of-hours care, is essential. Focus should be on those with complex conditions and multimorbidity, who dominate service use, and for whom early impact can be achieved. More services should be available out-of-hours, not just clustered during regular hours. Involving local communities in developing new models is vital. Supporting people with complex illnesses in the community can help hospitals focus on acute care, reducing waiting lists. Palliative care and some charities provide good models of holistic care and value for money but are overly reliant on charitable funding.
Second, boosting education and conditions for the workforce, especially in social care, nursing, and allied health professions, is fundamental. Making these professions flexible, well-supported, and attractive ensures a skilled workforce. In the context of multimorbidity, patients often see multiple specialists, risking fragmented care. We need more clinicians who can work safely and with confidence across specialisms and disciplines, putting the person before their diseases. Rehabilitation offers significant opportunities, and fostering independence should be a focus for all health professionals and policymakers.
Third, recognising and bolstering the contributions of self-care and informal carer support, transforming the patient-carer-professional relationship into a collaborative partnership is pivotal. Such a transformation goes beyond education and tools, acknowledging that people with chronic diseases often have extensive knowledge about their conditions. Carers UK estimates that 6.4 million people in the UK provide unpaid care, valued at £162 billion a year in 2021 – around total cost of the NHS. Yet to date informal carers are rarely considered in self-care interventions, and their role and needs are too seldom recognised. A wider pool of caregivers, including volunteers and auxiliary workers essential to much social care, must also be included.
Fourth, advancing ‘frugal technologies’ is paramount. Developing cost-effective technologies that enable independence, maintain activity, and support health through home adaptations and AI could be beneficial. Emphasizing 'frugal' innovation in funding, training, and partnerships is crucial to pivot attention towards lower cost technologies and medicines.
Moving forward...
Healthcare systems must adapt to these changes, focusing not only on disease prevention but also on recovery, health maintenance, and mitigating health declines as multimorbidity rises. We need short-term progress alongside longer term investment in prevention.
To ensure the NHS is resilient, the solutions and improvements an incoming government might consider include prioritising community health and social care, investing in workforce development, valuing informal caregiving and self-care, embracing frugal technology, all adapted to the realities of growing multimorbidity and evolving population needs and preferences.