“You are entitled to your own opinions, but not to your own facts.”
Patrick Moynihan, four-time US Senator

Is the NHS failing? Research shows the introduction of factual evidence into a polarised debate actually makes the two sides less likely to agree than to agree. However, as a doctor I like cold, hard facts. In our line of work anything less is morally wrong and overtly dangerous.

So here is the NHS. Just the facts (with references). 

  1. The population of the UK is an estimated 65.1 million. 
  2. 1 in 20 GP surgeries have closed or merged since 2013. 57 closing down in 2016 alone.
  3. The NHS England budget is £117 billion for 2016/7 and will rise after inflation to £120 billion by 2019/20. 
  4. Every 36 hours the NHS will treat 1,000,000 patients. 
  5. Accident and emergency departments recorded their worst ever waiting times in 2016/7.
  6. Hospitals recorded their worst ever waiting times for elective surgery in 2015. 
  7. The NHS in England has 149,808 doctors, 314,966 nurses, and employs 1.3 million people. 
  8. 19% of NHS staff and 29.5% of NHS doctors are non-British
  9. The average age of recent migrants to the UK is 26.
  10. Healthcare costs change with age: a 20-year old costs an estimated £500 per year, a 65-year old £3750 per year and an 85-year old £7500 per year. 
  11. The population of the UK over 65 in 1975 was 1 in 8. Today it is 1 in 6. By 2050 it will be 1 in 4. There are 1.5 million people over 85 in the U.K today. 
  12. The NHS buys many drugs from Europe and the USA paying in Euros (€) and US dollars ($).
  13. Health tourism, foreign citizens using the NHS, costs the NHS an estimated £1-300 million per year. A new overseas surcharge recouped £289m in 2015. This is 0.3% of the total NHS budget. 
  14. Stationery costs the NHS £146m/year. 
  15. Compared internationally the NHS achieves above average outcomes, with average funding and below average staff numbers. OECD.
  16. Health costs rise each year in developed countries, above real world inflation. This is broken down into staff wage inflation, new technologies, population growth, new drugs and medical advances. 
  17. The NHS was estimated to require £30 billion by 2020 to meet predicted demand. To date, it has received £4.5 billion. 
  18. Social care is estimated to require £4 billion by 2020 to maintain current service. 
  19. The ratio of people working to those retired is called the Old Age Dependency Ratio (OADR). This was steady at around 300 retirees for every 1000 people working from the 1980s to 2006, but has now since started to rise. With retirement age changes, it will still increase by 20% by 2037 to 365.

So 1 in 6 of the UK population [1] is over 65 [11] at a healthcare cost in this group averaged at £3750 per year [10]. That’s 10.8 million people, which is £40.5 billion a year. The 1.5 million people over 85 require £11.25 billion a year. 

As the ratio of working people to those retired increase [19] and the population age [11] these costs will climb. Over the next twenty years these numbers will double, as the baby boom generation of post-World War Two retire and age.

Now for some opinions. Let me be clear. I’m not “blaming” old people.  I’m talking about my father (77), my grandmother (82). These are people I love and care about. Day in and day out I look after their generation, and I see a system failing them, and not facing up to realities or requirements to provide them the care they deserve.

In healthcare the failings in one area tend to domino into others. As GPs close at record rates [2] and social care is progressively cut back [17] the burden on hospitals is doubled- both at the front end admitting unwell patients from the community and at the back end attempting to safely discharge them.

Unfortunately this is not how we are looking at the situation. 

Immigrants I hear you say? Back to some facts.

The median age of a recent U.K. migrant is 26, compared to the median national age of 40. [9] The average annual cost of a 26-year old in terms of healthcare is around £500. Which makes sense- how often does the average twenty old see the doctor? I went to the GP maybe three times in my twenties. The population doesn’t utilise healthcare equally, which is exactly why the NHS funding model works at all. 

I’d be remiss to not mention the other side of the equation; the large migrant population that work for the NHS. The NHS is the world’s fifth largest employer, employing 1.3m people. [7] 19% of all staff are non-British, 29.3% of doctors and 21.2% of nurses. [8]. 

Which is a good time to mention Brexit.

Applications for EU nurses have dropped , record numbers are leaving, and the NHS buys a lot of drugs from the continent in Euros (€) [12], which now cost more at current exchange rates. Additionally the NHS loses income from research subsidies to NHS hospitals and staff from the EU. 

But at least we’ll save money on health tourism? Right?

Health tourism costs £1-300m a year to the NHS [13] which is just 0.3% of the total budget. [2] In 2015 a new overseas surcharge recovered £289 million from this group. The aim of the surcharge is to make £500 million for the NHS by 2017, a £200 million profit.

So in summary it’s not about immigrants, it’s about realistic planning for the NHS to continue its excellent work as the population demographic changes. 

The NHS consistently achieves above average health outcomes for below average staffing per population and average OECD funding. [15] Although it may not seem like it, on a healthcare system level it’s one of the most efficient in the world. 

So is it failing? These are the facts.

GP waiting times are up, A&E [5] and elective surgery times [6] at record waits, while the NHS recorded its largest ever deficit last year, £2.45 billion in the red. The NHS is about £25.5 billion short of cash right now [17]. 

I’ll leave you to make your own opinion on that.

Lastly healthcare costs rise year on year regardless [16] which is known as health inflation.  While this means healthcare gets more expensive, it’s also part of the reason life expectancies have risen across the developed world for the past fifty years.

So what will change things? 

Well for the long-term future we have a smaller number of people paying for the healthcare of a larger retired population. We can address this meaningfully in one of three ways;

  1. Raise retirement age. Unpopular yes, but I’m talking about my own retirement here. Supporting this with aggressive public health improvement would be sensible.
  2. Have more babies. The low birth rate of the 1970s shifted the OADR in the wrong direction. To restabilise the ratio we need more young people. 
  3. Increase immigration. Unpopular again, but still correct. Immigrants come with an education (80-90% of recent immigrants have completed full-time education vs 50% UK average) [9], low health costs for their working lives, and more likely to retire back to their origin countries. The Office for Budget Responsibility agrees – the public sector debt by 2050 is predicted to be 145% of GDP, but with immigration, 120%. 

A combination of all three is probably needed.

In the short term your opinion may not have changed. But if it has, there is really only a single fact that will change the situation. That’s your vote.

Write to your MP, handwritten is best. Find their address here.

“Dear Sir/Madam,

I want this government to prioritise and fund the NHS. I hold you personally responsible for its failings and will vote accordingly at the next general election. Please act wisely.”

Yours faithfully,
[Your Name Here]

But that’s just my opinion. 

First published on the Junior Doctor blog

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One Comment

  1. Umesh Prabhu says:

    Dear Dominic, really enjoyed your excellent summary about NHS and learnt a lot as well. I want to thank you and please do keep in touch with me.

    I am very proud and passionate about NHS and have done various leadership roles and been Medical Director for 16 years!

    You are right on many counts but when NHS wastes £20 Billion out of its £117 Billion, why should we give more fund? What NHS needs is transformation fund and transform NHS and social care together! If not NHS and social care both will not last or survive!

    Also each year 20000 patients die and 55000 patients suffer more than 6 months or permanently disabled in our NHS due to ‘medical errors and 90% of them are preventable by good leadership, good team working and robust governance and accountability! It is the good leadership and accountability is missing in our NHS!

    NHS also got to invest in good IT and without any of these, if we just invest more money more money will be wasted!

    It is doctors, nurses, all other clinical staff who should take on leadership roles and transform NHS and social care! This is what STPs are supposed to do. But unless we get leadership, governance and accountability right for all STP leaders and NHS stops working in silos, we will continue to waste public money and NHS will continue to harm patients and sadly many staff also suffer because of the culture of bullying, harassment, victimisation and so on!

    NHS must focus on culture and good governance and for that we need good leaders at every level of the NHS from top to bottom!

    I am not a fan of privatisation but sad reality is we are not able to increase efficiency or make NHS safer and better, then NHS has to be privatised as potential medico-legal bill is around £20 Billion of Duty of candour is really implemented in our NHS!

    Let us doctors stop blaming politicians but work with politicians, educate them and help them to transform both NHS and social care and let us make both of the the safest, the best and most vibrant health and social care in the world!

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