WITHOUT a major increase in real-terms investment in the health service over the coming decade the country faces “a continued deterioration in service provision, worsening health outcomes and inequalities, and an NHS that is poorly equipped to respond to future major threats to health”.

That was the message this week from experts tasked with evaluating the current state of the NHS and how to strengthen it by 2030.

The London School of Economics (LSE)-Lancet Commission brought together 33 healthcare academics in 2017 to mark the institution’s 70th birthday, and published its 123-page report on Friday as the UK emerges from its deadliest public health catastrophe since Spanish flu.

It is the first to provide a long-term analysis of the future of the NHS post-Covid, and urges policymakers to seize on the crisis as a “once-in-a-generation opportunity” for change analogous to the post-war era in which the national health service was born.

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They stress the pandemic has brought some of the best aspects of the NHS to fore: the national vaccination programme; its ability to recruit thousands of patients into clinical trials to fast-track the discovery or development of new coronavirus treatments and vaccines; and the founding principle of universal, tax-funded healthcare which means the UK has one of the world’s lowest incidences of “catastrophic expenditure” as a result of illness - that is, when out-of-pocket healthcare costs exceed 10 per cent of household income.

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“A major strength of the NHS is that it continues to provide citizens with a high level of protection from the financial consequences of ill health,” said Dr Michael Anderson, a primary care physician and expert in health policy at LSE who is one of the report’s lead authors.

“This is important because the UK has higher levels of income inequality than most other high income countries and this is even more important when you consider that the NHS can be seen as an island of universalism operating within a poorly functioning welfare state.”

This touches on one of the key messages of the Commission - that the UK’s comparatively low health spending compared to other G7 and EU15 nations, such as France and Germany, has been “compounded further by relatively low amounts of spending on social care”.

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It is not enough to increase investment in the NHS, they say; this must be matched by equal hikes in investment in social care and public health.

Some of the figures outlined in the report are stark.

The UK has the third lowest five-year survival rate for colon cancer of the EU15/G7 countries (the core EU member states plus Canada, Japan and the US).

Just 60 per cent of patients will be alive five years after diagnosis, compared to nearly 68% in Belgium

For lung cancer, the UK ranks fourth worst with around 13% survival compared to 33% in Japan.

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Deaths from heart disease and stroke are above average; infant mortality is 22% higher in the UK than in western Europe; and the UK has the highest hospital admissions rate for asthma across all 18 nations.

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The UK also scores low on resources. We have 2.5 hospital beds per 1000 people, second only to Sweden and compared to 13 per 1000 in Japan.

We have the fewest MRI and CT scanners per head, at 7.2 and 9.5 per million respectively.

Japan has seven times as many MRI scanners and more than 11 times as many CT scanners, but even within Europe alone the UK lags far behind.

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Germany has nearly five times as many MRI scanners per head, while the Danes have access to four times as many CT scanners than Britons.

On staffing, the UK ranks highest in a single category: the percentage of the nursing workforce who were trained abroad which, at 15.4%, is nearly twice as high as second-placed Germany with 8.7%.

The UK has lower than average levels of nurses, physicians, and dentists, and just a sixth of the physiotherapists that Germany does.

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Within the context of the UK, Scotland has the highest level of GPs and consultants per head and second highest level of nurses - but the highest rate of avoidable deaths, and lowest life expectancy.

HeraldScotland: Of the UK nations, Scotland has the highest levels of consultants and GPs per head; has the highest spending on healthcare and second highest spending on social care in the UK; but Scotland has the highest avoidable death rate and the lowest life expectancyOf the UK nations, Scotland has the highest levels of consultants and GPs per head; has the highest spending on healthcare and second highest spending on social care in the UK; but Scotland has the highest avoidable death rate and the lowest life expectancy

The remedy, according to the Commission, is not another “costly” NHS reorganisation or even to adopt a European-style tax plus insurance funding model (they “tend to have a much higher administration cost without any gain in terms of improving health outcomes” said Dr Anderson), but to simply bring UK investment in health closer in line with that of other high-income countries.

Excluding the US, the UK spends 13% less on health than the other G7 countries do on average.

“I think we have always believed that because we have a comprehensive NHS based on need that we spend money better, and I think that remains true,” said Professor Moira Whyte, head of medicine at Edinburgh University and a contributor to the Commission.

“But we haven’t seen the increases in health spending that there have been in other comparable countries and when you look at life expectancy stalling across all four nations of the UK, I think that does make the point.”

HeraldScotland: Public and private spending on health per person and as percentage of GDP in G7 and EU15 countries (2019) *USA data from 2013Public and private spending on health per person and as percentage of GDP in G7 and EU15 countries (2019) *USA data from 2013

The Commission recommends year-on-year increases in spending of at least 4% in real-terms up to 2030, not just for the NHS but for social care and public health too.

Since its inception, the NHS has averaged real-term annual uplifts in funding of 3.7%, but this has see-sawed between “periods of plenty and scarcity” with the financial instability “contributing towards the NHS being so vulnerable at the beginning of the pandemic”.

In total, the Commission’s funding recommendations would translate into an extra £102 billion for the NHS, social care and public health by 2030 (current UK spending is £162bn).

They outline a “broad-based and progressive taxation” model which would see an extra penny on income tax, national insurance and VAT by the middle of the decade, and an additional penny on income tax and VAT by the end of the decade.

HeraldScotland: Table shows UK's current position on tax:GDP ratio within G7/EU15 nations, and position by 2030 if Commission's recommendations were implementedTable shows UK's current position on tax:GDP ratio within G7/EU15 nations, and position by 2030 if Commission's recommendations were implemented

The UK would go from having the fourth lowest ratio of tax to GDP (after Ireland, the USA and Japan) to ninth out of the 18 nations by 2030 - higher than Spain, but lower than Germany and still well behind either France or Denmark.

In terms of costs to the individual, someone earning £15,000 annually would be £89 a year worse off by the middle of the decade while someone on a £500,000 salary would pay an extra £9,914 a year in tax - reducing their net income to £266,120.

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The plan - which also envisions some increases to to corporation tax and wealth taxes, such as capital gains - would accommodate a cap on social care costs of £75,000, with no one expected to pay towards their care once their assets or savings fell below £100,000.

HeraldScotland: Table shows current and projected tax contributions by 2025/26 based on Commission's recommendationsTable shows current and projected tax contributions by 2025/26 based on Commission's recommendations

Dr Emma Pitchforth, co-lead author and a public health expert who trained at Aberdeen University, said research showed widespread public support to pay more tax for health and social care.

She said: “Any decision not to increase funding risks the UK falling further behind other countries in terms of health outcomes.”

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Dr Anderson added that there was “very little capacity” to both pay staff fairly and grow the workforce without the 4% funding increases they recommend.

As well as increased staffing, the report envisages collaborative workforce planning between all four nations, more preventative health spending, targeted diagnostic services for at-risk groups, and one-stop-shop diagnostic centres (something the Scottish Government has pledged).

Ultimately, it is up to the UK Government to set the budget, with funding distributed via the Barnett formula.

Professor Whyte said serious investment in faster diagnosis would reap rewards not only in terms of improved survival, but by relieving pressure on NHS beds and budgets.

She said: “The earlier you diagnose a cancer the more easily it’s treated, which is good for the patient and cheaper for the NHS. That, over the longer term, would address some of these service capacity issues.

“People should look at those numbers and ask if they would be willing to pay that bit more for a better health and social care service.”