ANALYSIS
WiththeUK ’ s current approach, financial risks are shared across a large population, and general taxation is the cheapest way to raise funding without the large overheads of insurance or patient payment systems. Proponents of alternative ways of funding will need to demonstrate how the benefits of change will outweigh the increase in overheads and the costs of changing to a system of insurance, private payments, or co-payments. The principle of collective contribution is about solidarity and sharing risks. It is a natural accompaniment to a system free at the point of need and is a unifying factor at a time when society is becoming less cohesive. Financial issues are discussed in more depth in a later article from the BMJ Commission. Universality, equality, and equity The NHS Constitution states: “ [the NHS] is available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy, and maternity or marital or civil partnership status. ” However, major inequalities in access and in health outcomes exist between different groups of service users. In 2022, the difference in healthy life expectancy between the highest and lowest local authority areas in the UK was 19.8 years for women and 17.8 for men. 18 The NHS also needs to consider equity. This means recognising that people do not all start from the same place, and acknowledging and adjusting for imbalances. Allocation of resources and opportunities should therefore be based on what is needed by different groups to access appropriate services equally and to achieve equal outcomes. Against this background, it is important to make equity more explicit in operational policy and to stress the importance of measuring and achieving equality of outcomes. People from black and Asian backgrounds, as well as recent migrants, make up a higher proportion of NHS staff than their representation in the wider population. They also suffer worse access to services and poorer health outcomes, from maternal services to surgery and mental health. Given their numbers, tackling the disadvantage and inequalities affecting these groups will make a major contribution to reducing inequalities overall. 19 Some asylum seekers, undocumented migrants, and many recent migrants do not always have full access to services, and many have to pay a fee for them (even those who work for the NHS). These issues must be addressed, but are beyond the scope of this paper. The NHS performs well on equity in international comparisons of health systems, such as the Commonwealth Fund, but this is not the whole story. The NHS was designed to meet the needs of everyone, including the poorest. Today, however, inequity in access to services and health, and the ability of people with higher incomes to express needs, claim rights (often described as the inverse care law), and to opt for private care, leaves the poorest at greatest disadvantage. Covid-19 starkly revealed these inequalities. Were Bevan redesigning the NHS today he would surely ask why the service was failing those most in need. These issues are also discussed more fully in a later article from the BMJ Commission. Summary We have argued that the NHS is a comprehensive service with some limited exceptions, where resources are managed through waiting lists and other practical means, and that the aspiration to being
comprehensive needs to be retained as a spur to innovation and development. We have also argued that being (very largely) free at the point of need promotes equity and is a practical and appropriate approach to improving the health of the population. Any movement away from it is likely to be expensive and without certainty of improvement. The other founding principles of universality, decisions based on clinical need, and collective contributions follow from the first two, and are relatively uncontentious. In summary, we believe that the NHS founding principles are still appropriate today and provide a strong foundation for the future. We recommend that the government in place after the next election re-commits to these principles as part of a wider set of actions. These include giving immediate priority to tackling inequalities in access and outcomes and paying particular attention to the disadvantage and racism suffered by different ethnic groups both as patients and staff of the NHS. Much can be learned from other health systems in both high and low income countries. 2021 The NHS is not unique; most western European systems are based on comprehensiveness and universality and have different ways of managing the issues raised here. All have some exceptions and/or charges. Private and insurance based systems, as in the US, ration by the ability to pay and often do not cover vital areas such as mental health. Other systems combine public and private health approaches and have many exclusions and co-payments. Meanwhile, the lowest income countries have predominantly out-of-pocket payment systems. The NHS has a serious financial problem to resolve, but the central issue is a health problem, which can only be dealt with through changing the approach to health and healthcare. Financial solutions need to follow health ones. The next section briefly discusses three areas for development which will help the NHS perform its role. These are wider policies on health and wellbeing, the roles of patients and the public, and technology and data. We conclude with recommendations. Future developments Policies on health and wellbeing It is well understood that social, economic, commercial, and environmental determinants shape a large proportion of an individual ’ s health status. 22 The NHS can only directly affect these as an employer and anchor institution in local communities. We therefore recommend the creation of a cross-government and cross-sectoral health and wellbeing policy where wellbeing is, as described by the World Health Organization, “ a state of mind ” encompassing “ quality of life and the ability of people and societies to contribute to the world with a sense of meaning and purpose. ” 23 We argue for the development of such a policy and the introduction of a UK version of the “ health for all policies ” approach pioneered in other countries, and placing new emphasis on the importance of communities, social structures, wellbeing and health creation. 24 This would be characterised by: • Strengthening the roles of all parts of society — government, families, businesses, communities, schools, and more — in promoting health and wellbeing, protecting the public, and preventing disease. An example would be the recent Healthy Homes Bill, which, if passed, would have laid a duty on the
the bmj | BMJ 2024;384:e078903 | doi: 10.1136/bmj-2023-078903
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