“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).
- The population of the UK is an estimated 65.1 million.
- 1 in 20 GP surgeries have closed or merged since 2013. 57 closing down in 2016 alone.
- The NHS England budget is £117 billion for 2016/7 and will rise after inflation to £120 billion by 2019/20.
- Every 36 hours the NHS will treat 1,000,000 patients.
- Accident and emergency departments recorded their worst ever waiting times in 2016/7.
- Hospitals recorded their worst ever waiting times for elective surgery in 2015.
- The NHS in England has 149,808 doctors, 314,966 nurses, and employs 1.3 million people.
- 19% of NHS staff and 29.5% of NHS doctors are non-British.
- The average age of recent migrants to the UK is 26.
- Healthcare costs change with age: a 20-year old costs an estimated £900 per year, a 65-year old £3750 per year and an 85-year old £7500 per year.
- 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.
- The NHS buys many drugs from Europe and the USA paying in Euros (€) and US dollars ($).
- 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.
- Stationery costs the NHS £146m/year.
- Compared internationally the NHS achieves above average outcomes, with average funding and below average staff numbers. OECD.
- 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.
- The NHS was estimated to require £30 billion by 2020 to meet predicted demand. To date, it has received £4.5 billion.
- Social care is estimated to require £4 billion by 2020 to maintain current service.
- 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. [https://mobile.twitter.com/kthopkins/status/819897520457392129] 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 £900. 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;
- Raise retirement age. Unpopular yes, but I’m talking about my own retirement here. Supporting this with aggressive public health improvement would be sensible.
- 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.
- 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 it’s failings and will vote accordingly at the next general election. Please act wisely.”
Yours faithfully,
[Your Name Here]
But that’s just my opinion.
References
Fact 1 https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/mar2017
Fact 2
http://www.gponline.com/nearly-200-gp-practices-closed-2016-alone-nhs-data-suggest/article/1421367
Fact 3, 4 and 7
http://www.nhsconfed.org/resources/key-statistics-on-the-nhs
Fact 9
http://www.cream-migration.org/publ_uploads/CDP_22_13.pdf
Fact 13
https://fullfact.org/health/health-tourism-whats-cost/
https://www.nao.org.uk/wp-content/uploads/2016/10/Recovering-the-cost-of-NHS-treatment-for-overseas-visitors-Summary.pdf.
Fact 14
https://www.nao.org.uk/wp-content/uploads/2011/02/1011705.pdf
Fact 15
OECD. http://www.oecd.org/els/health-systems/health-data.htm
Fact 16
https://juniordoctorblog.com/2016/01/05/its-the-spin-that-wins/
Fact 19
http://visual.ons.gov.uk/uk-perspectives-the-changing-population/
juniordoctorblog.com 
Good article, thanks. There is a fourth option though, however unpalatable it may be to many. At present just over half of the population take more money from other taxpayers over their lifetime, than they give back. Arguably the post-WWII social security system (unique to Europe) is failing: provision of welfare and healthcare to everyone, regardless of their contribution to society, becomes unsustainable when there are more people taking out than there are contributing. (We know that there is no support for increasing the taxes further to fund either the NHS or social care: the proposed referendum by Surrey County Council was widely expected to result in a refusal by their electorate to allow them to increase council tax to do just that.)
The fourth option is therefore effectively ‘rolling back the NHS’; reducing it to providing the bare minimum of core services, including ED etc, and relying on private insurance for the remainder. Those unable to pay for expensive care would have to do without. This would be market forces in action: those most able to contribute to society would be remunerated accordingly, while those making the least contribution would be least able to draw on the resources of other taxpayers. This model would also allow punitive charges to be levied on smokers, drinkers and the overweight, via insurance premiums, reducing the moral hazard of forcing other people to subsidise the consequences of poor life choices, and thus incentivising better choices (or not; either way though, not imposing unfair costs on those who choose more wisely). We can not continue to demand infinite output from the NHS, with finite resources.
I certainly hope we adopt this course of action. I am doing my best to ensure that if necessary, however, I can follow friends and colleagues who have gone to work in places like Dubai and the Cayman Islands, where people are allowed to keep what they earn, rather than have it taken from them to fund the social and health care of an ageing generation who seek to impose on younger people the adverse consequences of their failure to save for their retirement, health and care needs, and a separate section of society, perhaps call them the ‘poor life choices mob’, who represent a ‘resource black hole’.
Do I take it that up until now you have happily had the advantages of the welfare state it’s health education services etc. You may have driven a car, used public transport before it was privatised etc. Now this was all set up and paid for by the older generation for your and everyone else’s benefit by us older folk and our parents and at the same time as everyone else was paying off the war debt to he US and now you are complaining that you might have to make a contribution. Really? Actually the system required us working people contributed so that if we were unable to save for retirement our we would receive a basic pension. You talk as if it’s a life choice to become rich. There is no factual basis for your argument and even less logic.
Well, yes, that’s the fourth option if the answer to the question posed is yes. But there is a strong moral argument why the majority of people don’t want that. Unfortunately, while you could perhaps argue that people smoking, drinking, having poor diet etc. are making poor life choices, you can’t make generalisations about why people end up in low-paid jobs, have to claim benefits during their working life or don’t have large pensions. Some of the most essential jobs in our society are unskilled and therefore low paid, but we all benefit (e.g. refuse collection for example). Some jobs require extraordinary physical stamina and therefore require people to retire early (e.g. firefighter). Outside of the statistics, people become ill or have accidents in their 20s, 30s, 40s and 50s. They may be graduates, they may not, they may have children or not, they could be at any stage of their life but through no fault of their own, not be able to work for a long or short period of time. Not everyone has an in depth understanding of pensions and many are reliant on their company accountants having made wise investments or, if they work in the public sector, successive governments throughout their working life. People may be restricted as to where they can move to for work because of availability of jobs, house prices, having children in school, their partner’s work location, extended family who they may be reliant on or who may be reliant on them. This is the reality and this is why the NHS model benefits everyone, whereas the model you describe doesn’t. Essentially you’ve got to decide how much you think individuals should be self-reliant v benefitting as part of a society that pools its resources.
Dear Incognito,
When I lived in Turkey, there were people with no legs who couldn’t afford a wheelchair, and they had to get around by tying a roll of carpet onto their backsides and loping along on their knuckles, When they wanted to get on the bus they would tug at people’s trousers begging someone to haul them up the steps by their armpits.
I don’t give tuppence why those people cannot afford a wheelchair and some comfort, I don’t give tuppence if it serves them right because they lost their legs through “poor life choices”, I simply don’t want Britain to be like that and I don’t want to live anywhere like that again. I would be happy to pay more than 50% of my earnings if that’s what it costs to make sure everyone around me has a better life than that.
Oh and by the way, if you get Hashimotos disease and get really fat, or heart condition that stops you exercising, or a painful arthritic disease that makes walking agnoy for you, or one of many other medical conditions, you just might rethink your smug, ignorant belief that being fat is a “poor life choice”.
Great stuff. Thanks. But PLEASE “ITS failings” not “it’s failings” – which is simply short for “it is failings”…
It’s failings is correct. It’s also means the possessive of it i.e. The failings of the NHS.
Thorough article.
There are more important things to discuss – but you’re wrong. The only possessive form of “its” is “its”. See http://www.its-not-its.info/
Thanks!
Good article, thanks. There is a fourth option though, however unpalatable it may be to many. At present just over half of the population take more money from other taxpayers over their lifetime, than they give back. Arguably the post-WWII social security system is failing: provision of welfare and healthcare to everyone, regardless of their contribution to society, becomes unsustainable when there are more people taking out than there are contributing. (We know that there is no support for increasing the taxes further to fund either the NHS or social care: the proposed referendum by Surrey County Council was widely expected to result in a refusal by their electorate to allow them to increase council tax to do just that.)
The fourth option is therefore effectively ‘rolling back the NHS’; reducing it to providing the bare minimum of core services, including ED etc, and relying on private insurance for the remainder. Those unable to pay for expensive care would have to do without. This would be market forces in action: those most able to contribute to society would be remunerated accordingly, while those making the least contribution would be least able to draw on the resources of other taxpayers. This model would also allow punitive charges to be levied on smokers, drinkers and the overweight, via insurance premiums, reducing the moral hazard of forcing other people to subsidise the consequences of poor life choices, and thus incentivising better choices (or not; either way though, not imposing unfair costs on those who choose more wisely). We can not continue to demand infinite output from the NHS, with finite resources.
I certainly hope we adopt this course of action. I am doing my best to ensure that if necessary, however, I can follow friends and colleagues who have gone to work in places like Dubai and the Cayman Islands, where people are allowed to keep what they earn, rather than have it taken from them to fund the social and health care of an ageing generation who seek to impose on younger people the adverse consequences of their failure to save for their retirement, health and care needs.
I assume the friends off to Dubai and Cayman are not these folks http://www.news.com.au/travel/world-travel/middle-east/dubai-migrant-workers-the-hidden-slaves-behind-glamour-city/news-story/b3997ed5b013870424e84d78a561946c. Nor are they the on the receiving end of this http://bitingants.blogspot.co.uk/2010/11/are-we-racist.html
What kind of world do you want? Apparently not one which is based on simple values of humanity, decency, respect for others, or understanding of the political and social circumstances which lead to behaviour you find distasteful.
Keep what you earn? Earn by exploiting others? You’re welcome to it. It will help you sleep easy in your hammock.
Dear Incognito, I hope you get to Dubai, the sooner the better.
Hear, hear garyrowl, I’m sure he will love the excellent slave society that capitalism built in Dubai
I’ve adapted the letter
“Dear Sir,
I want this government to prioritise and fund the NHS. I hold Jeremy Hunt personally responsible for it’s under funding and mismanagement advocating privatisation and will vote accordingly at the next general election. Please bring him to account for his actions or lose my vote.”
Yours faithfully
Dear Incognito aka I’m alright Jack, What a unconscionable view of humanity you have.
this is so clear. thank you.
Saw your very effective recent animated video about the NHS, its history and use. I work as a Clinical Psychologist and was hoping to make something similar to demonstrate the impact of cuts on other services. Is the video something you made yourself ? Thanks
I used a programme called VideoScribe which was very easy. I would recommend.
[…] Is the NHS really over? Just the facts. […]
Your NHS virtual essay is brilliant. I am secretary/chair of ‘South Warwickshire Keep our NHS Public’ group and would like to use some of the graphics in the video (freeze framed) in a local NHS leaflet. Is this OK??
Of course!