Our NHS used to be the envy of the world. What went wrong?

‘We offer a late diagnosis service in this country, and that needs to be tackled urgently’ Prof Sir Mike Richards

Cancer treatment is catastrophically slow; the number of cataract and joint replacement operations has slumped disastrously; and access to the ‘universal’ system is blocked by huge waiting lists. It’s time for the health service to learn from other countries. Paul Nuki, Ben Butcher, Jörg Luyken and Henry Samuel report

Irina Meinel, a 56-year-old social worker from Heidenheim in southern Germany, needed a knee replacement at the height of the pandemic in 2021.

Her orthopaedist – who she booked an appointment with directly, rather than going through a GP – diagnosed her with arthritis and advised a complete replacement of the joint.

“He immediately did an MRI scan,” says Meinel, “then told me ‘your knee is so bust and your quality of life will get even worse if you don’t undergo surgery’.”

Meinel is insured by one of Germany’s statutory health insurers, known as “sickness funds”, but waiting was not an issue, even in the midst of Covid.

She spent four days in hospital, sharing a room with one other patient, then went to a rehabilitation clinic, in the lakeside town of Bad Waldsee, which offers thermal baths as part of its recovery programme. “I felt like Alice in Wonderland, they treated me well there,” she adds.

Meinel’s four-week stay in the rehabilitation clinic was paid for in full by her insurance, as was her operation and a fitness regime at a specialist gym once she returned home.

“I’m half Finnish, so I know what it’s like to have a state health system like the British one,” she says. “They have health centres there where you always have to wait, you never know which doctor you’re going to get, and the care is pretty anonymous. When I compare Germany with Finland I think we live in luxury.”

Meinel may be right about the German health system, which dates back to Chancellor Otto von Bismarck’s Health Insurance Act of 1883, but it’s a mistake to think the Finnish system is on a par with the NHS – a slur, even. Although the Finnish system is largely funded through direct taxation like our own, it remained open for normal business throughout most of the pandemic.

Indeed, the number of knee replacements it conducted between 2019 and 2020 was down just three per cent, according to OECD data published this week. In the UK, in contrast, knee replacement surgery fell by an agonising 68 per cent over the same period. The story for hip replacements and cataract surgery was the same: you were exceptionally unlikely to get one on the NHS.

Shutting up shop during the pandemic has had a terrible cost, with the number of people on NHS waiting lists in England now at 7.2million – 12 per cent of the population.

Not surprisingly, many are starting to vote with their feet.

The number of patients paying for private treatment in the UK is up 39 per cent over the past two years, while others are travelling abroad for care. This is despite most having paid into the system via the taxman all their lives.

Earlier this week, The Daily Telegraph told the story of Hazel Norbury, a 73-year-old retired teacher from Wales, who flew to Lithuania last year for a double hip replacement after being told she would have to put her life on hold and wait up to three years on the NHS.

The total cost of £16,000 was half the price quoted by private providers in the UK, and included flights, plus a two-week all-inclusive stay for her and her husband in a rehabilitation clinic for each of the two operations. “The way they looked after us was outstanding,” says Norbury.

Strikingly, on most capacity and outcome measures, the NHS now underperforms countries like France, Germany and Sweden by some margin.

For everything from cancer, where a paternalistic culture of “it’s probably nothing” still rules, to the treatment of heart attack and stroke, we sit at or close to the bottom of the G7 league.

In many areas, the performance of the NHS is now more typical of former Soviet bloc countries such as Poland and Hungary.

Across a range of diseases, but notable in cancer, the former Department of Health cancer tsar Prof Sir Mike Richards said recently, “We offer a late diagnosis service in this country, and that needs to be tackled urgently.”

The makings of the crisis were evident before the pandemic. According to a 2018 report, How Good is the NHS?, co-published by The Health Foundation, the Institute for Fiscal Studies, The King’s Fund and the Nuffield Trust, the main weakness of the NHS is healthcare outcomes. “The UK appears to perform less well than similar countries on the overall rate at which people die when successful medical care could have saved their lives,” it reports.

“The mortality rate in the UK among people treated for some of the biggest causes of death, including cancer, heart attacks and stroke, is higher than average among comparable countries. The UK also has high rates of child mortality around birth.”

Like many before them, the report’s authors found the NHS to have a saving grace; a trump card so powerful you could theme an Olympics opening ceremony around it: the NHS offered better access to care than other health systems. It was more egalitarian.

“Among its strengths, the NHS does better than health systems in comparable countries at protecting people from heavy financial costs when they are ill,” said the report. “Waiting times for treatment in the UK [also] appear to be in line with those of similar countries.”

In short, the NHS had the moral high ground. Getting a scan for a suspected lump might be difficult and, sure, its waiting rooms were busy and draughty – but the NHS was there for everyone irrespective of their ability to pay. No one was ever turned away.

No more, alas.

The pandemic has not only made NHS outcomes worse, with excess deaths currently running at nearly 10 per cent above average, it has placed a question mark over that trump card, its raison d’être. Access to care in the UK now lags behind that of most comparable countries.

It’s not the money that’s the problem (the NHS remains free for the most part), but the queuing, with 411,000 patients now waiting more than a year for treatment.

Soaring waiting times for everything from GPS and ambulances to diagnostic scans and surgery mean the NHS – once a beacon of equality – is unable to meet taxpayers’ needs.

So why do the health systems of countries like Germany and France appear to be performing so much better than ours, and what might we borrow from them as we attempt to rebuild the NHS?

A good part of the answer revolves around healthcare capacity and the speed at which the population is ageing. Most of Europe has a similar problem – the populations of France, Germany and Italy are even older – but in Britain things have been aggravated by poor public health.

Rates of obesity and diabetes are higher, and average life expectancy is now a year or two shorter than in many comparable countries as a result. The same phenomena – poor population health fuelled by sedentary behaviour, junk food, alcohol and drugs – partly explains why death and hospital admission rates were so high in the UK during the pandemic.

The NHS, directly funded by general taxation as it is, has also been run lean compared with other Western health systems.

The mantra of efficiency, which has created “just-in-time” supply chains in many sectors, was imported to the NHS to a degree not seen in most other health systems – especially those with a competitive motive to keep things bright and shiny for their customers.

As a result, the NHS went into the pandemic with far fewer beds per head of population than most of its

‘In France you can see a GP in three or four days and get an MRI scan in four to six weeks’ Dr Patrick Vogt

competitors. The same is generally true not only of doctors and nurses, but also of vital equipment.

Without competition, capital spending in the NHS has been historically poor. We have just seven MRI scanners per million people in the UK, compared with 16 in France and 34 in both Italy and Germany, for example. In Japan, it’s 57.

Even now, after a big hike in spending, the per capita spending on health in the UK is only $5,387 (£4,383) per person. This compares with $7,382 in Germany, $6,114 in France and a whopping $12,318 in the US, according to the latest OECD data.

As the shadow health secretary Wes Streeting points out, UK health spending is also heavily skewed to hospital care rather than social care and other community services – one of the main reasons hospitals are now unable to release patients and free up beds and ambulances.

Streeting says: “When you compare the NHS to other OECD systems we’re kind of near the top of the table for spending on hospitals and acute services. But we’re either at the bottom or seriously lagging behind in terms of our investment in primary care, social care, mental health, community services, diagnostics and capital investment.

“That delivers the worst of all worlds … the challenge for the NHS isn’t simply a challenge of money. It’s how that money is best spent to deliver the best outcomes.”

It is not only greater capacity, more equal spending and better population health that explains why other

European health systems are outperforming us. There are structural differences in the way health services are organised.

Control tends to be more locally devolved and patients can choose from an array of providers. The role of government is more limited and the big pillars of any modern health system – primary care, hospital care and social care – better integrated.

In many countries, citizens also have a better idea of what they are paying for health as their taxes or insurance contributions are hypothecated. In Germany, for example, it is mandatory to pay into one of more than 100 different not-for-profit “sickness funds” for health and long-term care cover. The rate is just shy of 20 per cent of gross wages when all added up, and split equally between employer and employee.

In return you are guaranteed comprehensive health and social care cover, including mental health, dentistry and long-term nursing care. Those earning more than $68,000 can opt for fully substitutive private health insurance instead.

“In theory, choice is one of the central strengths of the German health system,” says Berlin-based reporter Jörg Luyken. “Doctors are generally self-employed, while patients are free to shop around for doctors, hospitals and health insurance providers that suit their needs.”

Germany’s GPS must also survive on their own merits. You are not forced to go to one to get an appointment with a specialist and you are not tied to a particular practice.

Luyken explains: “If you are seeking a consultation with an orthopaedic surgeon in Berlin, you can choose online between close to 300 specialists and have an appointment within a week.”

France, too, has long been proud of its public health service, and it is easy to make favourable comparisons with the ailing NHS. When told that people who have suffered a stroke or another category-two accident wait on average more than 60 minutes for an ambulance to turn up, some French experts are shocked.

“Theoretically, you should reach A&E within 20 minutes and I would say that in 90 per cent of cases, this limit is still respected when it comes to strokes or sepsis,” says Dr Patrick Vogt, a GP in Mulhouse, eastern France. “That’s partly because we have a network of firemen who plug the gaps if ambulances can’t get there quick enough and there is a queue-jumping system when you arrive in such cases.”

As for GPS, Vogt says, “you can get an appointment within three or four days, an MRI scan within four to six weeks and other scans within a fortnight.”

Ludovic Fournel, an associate professor in thoracic surgery at Cochin Paris University Hospital, agrees that “looking at the UK figures, all the health indicators are in the red”.

He adds, “My brother-in-law and sister-in-law, who live in London, when they have simple health issues, such as needing an epidural to give birth, they are tempted to come back to France because either the UK state hospitals don’t want to do it or you pay through the nose in private maternity clinics.”

The big difference, adds Gérald Kierzek, a casualty doctor at Paris’s Hôtel Dieu, is that “in your system there is a low number of specialists. We still have one specialist to one GP in France.”

In Europe, it is not only hypothecated contribution systems that do well. Denmark and Sweden have stable health systems which, like the NHS, are largely funded through direct taxation.

There is, however, much greater devolution of power: both systems are “nationally regulated but locally administered”, say experts.

A huge difference between the “social insurance” systems of the sort pioneered by Germany and systems which are based on “private insurance” like the US is not just equality of access but control over costs.

US GDP spending of $12,318 per capita is more than double what we pay in the UK and more than three times what Italy puts into its health system. It is, by almost all accounts, one of the least efficient on the planet in terms of bang for your buck.

Observing the merits of other systems is one thing, importing them into the NHS is quite another. For example, devolution of health administration works better in Europe because the governments there tend to be less centralised generally.

Also, running a German-style health insurance system in the UK with multiple providers would provide a cultural challenge. They only work where contributions are mandatory and they demand first class governance and regulation.

The German system – the oldest in the world – has evolved this expertise over 139 years. Our own regulators, meanwhile, are still struggling with the basics of clean river water and getting energy firms to keep the lights on.

So what’s likely to happen in the UK – will the NHS survive and, if so, how might politicians rebuild it?

“While the NHS is implementing similar strategies to other countries to clear care backlogs, its path to recovery may be longer than many other systems,” concludes a recent report from the Nuffield Trust. “Countries with greater pre-existing capacity and that have more effectively contained coronavirus are likely to be in a better position to cope with care backlogs arising from the pandemic and recover from its consequences.”

The same authors think the pandemic has provided “a narrow window of opportunity” for reform where previously there has been a lack of political will or funding – something that is already being grasped overseas.

But this Government is busy firefighting and is likely to be doing so from now until the next election. Meanwhile Streeting is plotting a new “10-year plan for the NHS” and says there will be “evolution not counter-evolution” if Labour win the next election.

“We can’t have a something-fornothing culture where we put money into the system,” he says, “but patients don’t get better standards and access in return.”