International comparisons of health care systems have their limitations, but even accepting the caveats on the availability, comparability and interpretation of data, a general picture emerges from this report that suggests the NHS is under-resourced.

Workforce

The NHS spends 65 per cent of its budget on staff and is one of the largest employers in the world, but its health and care workforce is under unprecedented pressure. Compared to other countries, the UK remains stubbornly below average in the number of nurses and doctors per head of population. This is despite previous increases in nursing numbers following the reports into the care failings at Stafford Hospital and current efforts to increase medical and nursing training places.

There are approximately 100,000 vacancies for clinical staff in the English NHS, and nearly half (49 per cent) of nurses do not think there are sufficient staff to let them do their job effectively. Given the long training times for clinical professions there

growing concerns over whether the UK health service can recruit and retain sufficient numbers of staff to keep pace with rising activity levels in the short and long term.

Staff shortages also affect the ability of the UK’s health system to use its other resources efficiently. For example, a shortage of radiologists in the UK coupled with a shortage of medical imaging equipment will have a knock-on impact for timely diagnosis and treatment of conditions such as cancer. Hospitals have also temporarily closed hospital beds due to staff shortages – with one estimate suggesting that the number of beds that were closed in September 2017 due to a lack of staff was the equivalent of two entire hospitals.

The government is currently developing its first strategic health and care workforce plan in a generation. It is vital that this strategy provides the much-needed direction and practical support to address current and future staffing pressures.

Physical resources

Looking at physical resources such as hospital beds, residential care beds and MRI and CT scanners, the UK is one of the leanest health care systems in this basket of countries.

A comparatively low level of health care resources can, in some cases, reflect efficient health care services. For example, the UK spends less on medicines than many other comparable countries but is still above average in its consumption of medicines such as anti-hypertensives and cholesterol-lowering drugs, in part because of national efforts to improve the value for money of medicines expenditure. The UK is one of the most effective health systems in adopting cheaper generic medicines as they become available, and in the UK a voluntary pricing agreement between the government and the pharmaceutical industry aims to improve access to innovative medicines and ensure the cost of branded medicines stays within affordable limits.

A similar example of effective use of resources is the use of hospital beds. The UK was an early adopter of attempts to lower average lengths of stay in hospital by introducing day-case surgery and investing in community care to reduce the time older people remain in hospital after they are medically fit for discharge. These measures have led to more efficient use of hospital bed capacity and as a result, as our previous work has noted, the number of hospital beds in England has more than halved over the past 30 years.

However, there are limits to how much advances in care or prudent management of health care systems can mitigate the impact of a low level of resources, and there are clear signs of a growing shortage of beds in the NHS. This has been recognised by Simon Stevens, NHS England’s Chief Executive, who announced new guidelines for assessing proposals for closing hospital beds, noting ‘there can no longer be an automatic assumption that it’s OK to slash many thousands of extra hospital beds – unless and until there really are better alternatives in place for patients’.

A consequence of the low number of available beds has been increasing levels of hospital bed occupancy, which puts pressure on patient flow and waiting times as demands for emergency and planned treatment continue to increase. The Care Quality Commission has said the NHS is now ‘straining at the seams’ with more than 90 per cent of hospital beds occupied – far higher than the 85 per cent level recommended for safe and efficient care. Hospital bed occupancy remained high throughout March and April 2018 and was associated with a substantial increase in the time patients waited for both urgent and planned hospital care.

The pressure on hospital beds in the UK is closely mirrored in services that provide care out of hospital. The reduction in the number of residential care beds in the UK reflects the impact of funding pressures in the adult social care sector over the past few years where budgets were cut by 8 per cent in real terms between 2009/10 and 2015/16.

As with hospital beds, fewer residential care beds may not necessarily be a marker of poor care or overstretched services. In recent years some parts of the UK, and other countries such as the Netherlands, have increasingly tried to support people through providing more non-residential care, such as domiciliary care (where a care worker visits an individual at home to help with everyday tasks). However, both domiciliary care provision and bed capacity outside of hospital have been affected by budget pressures in the UK and this has had a knock-on effect on pressures within hospital – the number of medically fit patients who experience delays in leaving hospital has increased substantially in recent years.

The government has committed to a Green Paper on the funding of social care for 2018, but there is little indication that the pressure on residential care facilities in the UK will ease in the short term.

Health care funding

Successive governments in the UK have prioritised health care spending and provided real-terms growth in health care budgets despite continued austerity and significant cuts to other public services. The British public similarly continue to prioritise health care – 86 per cent of respondents to the 2017 British Social Attitudes survey say the NHS faces a major or severe funding problem, and 61 per cent support tax rises to increase NHS funding.

Despite the desire to protect health spending, the English NHS continues to face huge financial and operational pressures. Hospitals and other providers of health care services now routinely report significant annual financial deficits, and cuts to social care services have increased demands and pressures on health care services. It has been estimated that by the end of the current parliament there will be a £20 billion funding gap facing the NHS.

The recent changes to how health care spending is classified and measured internationally means the UK has moved up the funding league table and now has broadly average levels of health care spending compared to other countries. Moving to a more consistent measure of health care spending is to be welcomed and provides greater clarity for future international comparisons of funding. However, this change in accounting conventions does not mean health services in the UK have any more tangible resources to cope with the challenges they face.



As this report demonstrates, the UK lags well behind other nations in a number of key areas that materially affect a country’s ability improve the health of its population. In these circumstances, the question should perhaps not be why doesn’t the NHS perform better compared to other health systems, but how does it manage to perform so well compared to other countries on delivering accessible and equitable care when it is so clearly under-resourced.