Is the 1948 model of access to free healthcare still appropriate today?

The current model for the NHS

The current healthcare model in the United Kingdom sees the government provide universal health coverage to all citizens through the NHS and pays for this by general taxation. This single payer, single provider system ensures that healthcare is generally free at the point of use. In evaluating the model’s effectiveness, we must judge it against Beveridge’s aim for it to succeed in providing financial protection and equity of care. ² First, the current model is arguably most effective at achieving a strong breadth and depth of universal health coverage. There are next to no patient charges, and it stands out from nearly any other health system in the world in terms of coverage with minimal requirements while private spending remains low. ³ The depth of coverage is impressive from primary to secondary care, and from emergency care to chronic diseases. Second, this system is efficient and equitable. General taxation provides an efficient means of collecting funds whereas insurance-based systems require considerably more administrative burdens with significant costs associated with collecting payment and administering them. It is generally progressive with those at the top end of the income scale paying the most in. By having universal benefits, there can be no link to employment or other social status ensuring hard-to-reach groups are always included in the healthcare system. ⁴ A single payer also provides the government with collective bargaining power. Having a single payer allows negotiation of the best price with pharmaceutical companies and best value for money for patients. The National Institute of Health and Care Excellence (NICE) assesses new medicines against cost-effectiveness thresholds, ensuring that expensive new treatments have a strong evidence base. ³ Therefore, the charge that the NHS is ‘unaffordable’ is best countered by demonstrating that its public nature is what makes good value for money compared to alternatives. For example, UK health expenditure per capita in 2019 was US$4500 compared to the USA’s US$10,948 per capita, putting the UK around the OECD average. On the contrary, UK health outcomes, including life expectancy, infant mortality and maternal mortality, continue to outperform the USA. ⁵ Finally, the unitary system ensures high-quality care for all, with a national approach to evidence-based guidelines developed by NICE and strict clinical governance standards that should be implemented universally. ³ Considering alternative systems provides further support for Beveridge. The US system dominated by private insurance leaves it languishing in international league tables of health outcomes: life expectancy at birth in the USA lags behind OECD competitors and is comparable to the most deprived areas of England. Furthermore, the gap is most pronounced at lower social gradients. ⁶ Social insurance systems increasingly rely on taxation-based top-ups (blurring the distinction from a taxpayer-funded model), and multiple insurers can increase administrative costs and reduce efficiency. ⁷ Overall, there is a convincing argument that a general taxation funded free at the point of use health system creates the best healthcare system for a given number of resources.

A political choice

However, NHS resource allocation is fundamentally a political choice. But there can be no doubt that greater investment can improve health outcomes, and as envisaged by Beveridge, have positive knock-on impacts for the economy and wider society. ⁸ This is evidenced by the early 2000s period of high investment in the NHS being associated with improved outcomes in healthcare in terms of satisfaction. NHS satisfaction peaked in 2010 at 70% before a consistent reduction correlating with reduced year-on-year budget increases at this time. ⁹ A government seeking to allocate more resources to the NHS in 2023 should start with addressing key crises like waiting lists and workforce retention. ¹⁰ This essential, acute, initial investment should be followed by an investment in the NHS’ future. Digital and infrastructure improvements to create an NHS fit for the 21st century, rethinking models of care such as increased ambulation, home monitoring and virtual will be key to the future sustainability of the NHS. Demand-side pressures faced by the NHS also go hand in hand with social care provision, arguably a victim of the NHS’ success. The ageing population with multiple co-morbidities is driving to a large extent the pressures on the system previously discussed. ¹¹ There is undoubtedly a link between an ineffective social care system and Emergency Departments full of frailty and chronic diseases. ¹² Investment in a fair, Beveridge style settlement on social care, which should be brought fully into the NHS tent, will be key to securing the current model’s future. However, social care remains the great social policy issue that has flummoxed successive governments and this commentary does not pretend to offer any easy solutions. Instead, the next paragraphs will focus on how we should expand the offering of the 1948 model and its perceived purpose as simply to treat and manage illness.

Making the model better

The first step up the ladder is to upscale secondary prevention. The benefits of secondary prevention can be widespread and impact on multiple conditions. Initiatives to promote ‘Making Every Contact Count’ ¹³ should be accelerated, cognisant of time pressures on clinicians in the current stretched environment. A call from the chief medical officers in the BMJ to make secondary prevention the purview of all clinicians ¹⁴ is therefore welcome but must be matched by addressing investment and workforce factors discussed above. However, an NHS future where every consultation has the time and space to address secondary prevention like good blood pressure control, weight loss and exercise promotion is a healthy aspiration. Crucially, if we are to fulfil Beveridge’s goal of making health gains more equitable, we must improve uptake for interventions like statins, anti-hypertensives and screening programmes across the social gradient. For example, people from lower socioeconomic backgrounds are more likely to smoke and less likely to quit ¹⁵ while the healthcare costs associated with this inequality have been estimated at £4.8 billion. ¹⁶ We should therefore draw inspiration from the coronavirus disease 2019 era initiatives to encourage uptake of vaccinations in hard-to-reach groups. These lessons can be adopted to ensure that secondary prevention uptake is increased across the social gradient. ¹⁴ The untapped potential of advances in secondary prevention to improve healthcare outcomes and make savings for the public purse highlights once again the benefits of retaining a free at the point of use health service. Preventative measures are a key opportunity to prevent costly complications and further healthcare encounters. This incentive exists because it is the public purse that will ultimately pay for downstream costs; the incentives are not necessarily the same in a different healthcare model. For example, providing financial incentives in primary care through the Quality Outcomes Framework to proactively manage chronic disease and vaccinations is best achieved in the single payer, single provider system. ³

Next, we should see Public Health as part of the health system and determinants as part of a wider health system. We should not deliver healthcare in isolation from the causes of ill health and should aspire to an NHS that sees addressing all five of Beveridge’s Giants as part of its responsibility. Unfortunately, while great strides have been made in tackling social determinants of health, all of Beveridge’s Giants still contribute significantly to health inequalities today: squalor (homelessness); idleness (poor working conditions); ignorance (education); and want (poverty and current cost-of-living crisis). ⁸ We should therefore promote and develop initiatives addressing these Giants. For example, ensuring good-quality healthcare for homeless people; ‘Pathway’ is an integrated approach to improving healthcare for homeless people, using hospital admission as a key moment for ensuring that both medical and social care are delivered. ¹⁷ Other initiatives can target healthy eating, or in the case of ‘Live Well’ coaches, the interplay between health and employment. ¹⁸ NHS trusts can also be role models in tackling social determinants of health. One example is the East London Foundation Trust, which aspires to become the first ‘Marmott trust’, by committing itself to the eight principles identified in the Marmott report. Initiatives include ensuring it is a living wage employer, promoting access to training and employment for young people and increasing social prescribing. ¹⁹ These ideas may seem to overstretch the boundaries of what the healthcare model should provide. However, healthcare is a small contributor to population health. Beveridge himself envisaged the NHS as a service to ‘diminish disease by prevention and cure’. ⁸ However, viewing these issues through the prism of health and the putative savings for healthcare has the potential to focus minds to deliver social change. A Beveridge model health system therefore provides significant advantages to taking this public health-based approach: publicly delivered healthcare ensures that the needs of the population are foremost as opposed to profits.

Broader determinants

To go one rung further would be for the NHS to tackle head on the commercial determinants of health. Four industries are now responsible for one-third of global deaths ²⁰ and integrating a response to the commercial determinants of health into the healthcare system is therefore common sense. At the government level, the introduction of Pigouvian taxes and regulating advertising to tackle the harmful product industries should be promoted, but at the level of healthcare organisations, action can still be taken. NHS trusts should be educating patients and staff on commercial determinants of health, and at an organisational level, the NHS should divest from fossil fuels and reduce links to harmful product industries. ²¹ The ‘Delivering a Net Zero National Health Service’ report ²² in October 2020 is a welcome start on air pollution but we must go further and faster with air pollution responsible for 36,000 UK deaths a year. ²³ It is crucial to highlight the distinctive advantages a single payer and provider affords to these issues. If the same conglomerates that controlled these industries also had investments in our hospitals, it would be even harder to address commercial determinants of health. Ultimately, a publicly owned health service is more accountable to the public than one with multiple private providers and can speak out with one voice against the commercial determinants of health.

Still good but still unfinished

Overall, the depth of services and benefits the current model can provide as well as an unrivalled breadth of coverage mean it keeps its place as a system to be rivalled. However, we need not only access to free healthcare for all, but also a health system for all, and one that sees the benefits distributed in a proportionately universal way. Crucially, a prevention-based system that aims to improve outcomes in the long term is not as easily achieved in insurance-based/for-profit systems. There would undoubtedly be resistance in some quarters to the expansion of the health service playing field. However, the public support for the institution of the NHS and the potential gains to health outcomes and society give hope for the aspiration to a health system that comprehensively addresses Beveridge’s five Giants. Ultimately, the conclusion is that the 1948 model is still appropriate but there is still unfinished business.