WHEN the NHS was born 75 years ago, there was an expectation that healthcare spending would gradually reduce over time.

That made sense in a Britain where life expectancy was around 65 for men and 70 for women, and medicine was primarily concerned with treating infections and injuries.

As it turned out, we did start living longer - adding roughly 15 years to life expectancy by the time austerity hit in 2010 - but we now spend a much larger proportion of our lives unwell.

By 2019-21, males in Scotland could expect to live in good health only until the age of 60 - or just 45 if they lived in the most deprived areas.

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The Herald: Healthy life expectancy has declined in Scotland over the past decade, and is significantly worst in the poorest neighbourhoodsHealthy life expectancy has declined in Scotland over the past decade, and is significantly worst in the poorest neighbourhoods (Image: NRS)

The poorest Scots spend a third of their life in ill health, but even the most affluent - living into their 80s on average - will spend their final 11 to 13 years in poor health, much of it linked to obesity, excess alcohol consumption, and smoking. 

And old age brings its own problems, of course, such an increased risk of dementia and cancers.

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This is not a problem that is unique to the UK: all over the developed world healthcare systems are buckling under the pressure of an ageing population living longer with multiple chronic conditions, while the pool of taxpaying workers able to fund it becomes proportionately smaller.

There is no magic bullet, and no perfect alternative funding model to escape that conundrum.

As a recent report by health think tank, the King's Fund, noted when comparing UK performance against 18 other rich countries including France, Germany, the US, Australia, and Japan, there is "little evidence that one individual country or model of health care system performs better than another across the board".

It added: "Countries improve health care for their populations mainly by reforming their existing model of health care rather than adopting an alternative.

"Rather than unwinding the NHS, we should seek to improve it, and there is a lot to learn from other countries when doing so."

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There is probably nothing that would benefit the NHS more in the long-run than if the population as a whole became considerably fitter: less overweight, more active, and consuming diets much lower in sugar, salt, and saturated fats than we do now.

According to the Bloomberg Global Health Index, Spain was the healthiest country in the world in 2023 (the UK was 19th, sandwiched between New Zealand and Ireland).

It is projected to have the longest life expectancy of any nation by 2040, at 85.8 years on average.

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Its success is attributed to a combination of exercise (37% of Spaniards walk to work), a Mediterranean-style diet that is comparatively low in red meat and processed foods, and a universal healthcare system funded by the state and residents' public health insurance payments.

Not all procedures are included under state healthcare, however; some have to be paid for directly or through private insurance. Roughly a quarter of Spaniards have private health cover.

Nonetheless, Spain is well ahead of the UK for avoidable mortality rates - defined as deaths from illnesses or injuries that were either preventable or treatable.

This is a key marker of a population's overall health (by preventing sickness in the first place), and how well its healthcare system is functioning (to respond effectively once disease is diagnosed).

According to the King's Fund report, Spain had an avoidable mortality rate of 51 deaths per 100,000 as of 2019 versus 69 per 100,000 in the UK.

Of the 19 countries studied, this was exceeded only by the United States on 88 per 100,000.

The Herald: Spain has been ranked the healthiest country in the world in 2023Spain has been ranked the healthiest country in the world in 2023 (Image: Getty)

That is a fairly clear signal that things were going wrong in the UK well before Covid.

Some of it can be blamed on healthcare resources - for example Spain has more than twice as many CT and MRI scanners per head as the UK, and 50% more doctors - but much of it is also down to how we live in the UK.

Without concerted government leadership to reduce inequalities and drive a seachange in lifestyles we will continue to flounder at the bottom of such league tables.

Keeping the NHS affordable into the future will also depend on a radical shift in resources from hospitals to the community.

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Denmark, with a population of less than six million, offers an interesting blueprint. Since 2007, it has halved the number of hospitals while increasing outpatient appointments by a fifth and ploughing money into social care.

In superhospitals such as the 850-bed facility in Aarhus, fewer than 3% of beds are occupied by patients ready for discharge compared to more than 10% in Scotland despite both countries having almost identical bed numbers: 2.6 per 1000 people in Denmark versus 2.5 per 1000 in Scotland.

The goal is for more people to stay well at home for longer, and local authorities in Denmark have a legal obligation to provide social care to any patient fit to leave hospital. If they do not, they have to pay for the hospital bed.

Patient satisfaction is high, cancer outcomes have improved, and waiting times are low.

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Here, health and social care integration continues to move at a glacial pace, with care homes closing and home care providers struggling to recruit and retain the staff they need while GP numbers decline in real-terms and over 10% of district nurse posts are unfilled - a vacancy rate which has more than trebled since 2015.

None of that helps to get, or keep, patients out of hospitals.

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There is also a debate to be had on end-of-life care.

Professor Sir David Haslam, the former chair of NICE - the body which evaluates the cost-effectiveness of medicines for the NHS in England - is among those backing a redistribution of spending towards services which promote good health rather than on drugs and medical interventions which simply extend life at the end, especially among the frail elderly.

This was "not about rationing care, it is about providing rational care", he added.

Fundamentally, NHS reform should be less about reinventing the wheel, and more about what can keep the wheels turning.