Spending on and availability of health care resources

The recent announcement by the Prime Minister to bring forward a new long-term funding settlement for the NHS means it is timely to look at how health spending in the UK compares to other countries and how the NHS measures up on some of the key resources this spending pays for. 

Although it can be difficult to find data on health care resources on a comparable basis across countries, international comparisons can still provide useful context for the debate about how much funding the NHS might need in future. There is also precedent for this approach – for example, when Tony Blair famously pledged on the ‘Breakfast with Frost’ programme in 2000 to get health spending up to the European Union average.

Various organisations undertake analysis to compare different health systems around the world. For example, the US-based think tank the Commonwealth Fund compares the performance of health systems in a number of developed countries using a wide range of indicators, finding that the UK scores very highly on measures of administrative efficiency and delivering equitable and timely access to care but performs poorly on health outcomes.

In this long read, we focus specifically on a small number of key resources – staff, beds, equipment and medicines – using data from the Organisation for Economic Co-operation and Development (OECD). We also update our analysis of how much the UK spends on health care under the new System of Health Accounts 2011 methodology, which has led to substantial changes in what is classed as ‘health care spending’.

Key messages

• Although data limitations mean that comparisons between countries should be treated with caution, international data provides valuable insight into key areas of expenditure and useful context for the debate about NHS funding.

• Our analysis of health care spending in 21 countries shows that the UK has fewer doctors and nurses per head of population than almost all the other countries we looked at. Only Poland has fewer of both.

• The UK has fewer magnetic resonance imaging (MRI) and computed tomography (CT) scanners in relation to its population than any of the countries we analysed. Although this data should be treated with particular caution, it is clear that the UK lags a long way behind other high-performing health systems in investing in these important technologies.

• Of the countries we looked at, only Denmark and Sweden have fewer hospital beds per head of population than the UK, while the UK also has fewer beds in residential care settings than comparator countries. While lower numbers of hospital beds can be a sign of efficiency, the growing shortage of beds in UK hospitals indicates that bed reductions in the NHS may have gone too far.

• Although costs are rising, the UK spends less on medicines than most of the countries we analysed. A key reason for this is the success of initiatives to improve the value of expenditure on medicines, such as encouraging the use of generic drugs.

• Under the Organisation for Economic Co-operation and Development (OECD)’s new definition of health spending, the UK spends 9.7 per cent of gross domestic product (GDP) on health care. This in line with the average among the countries we looked at but is significantly less than countries such as Germany, France and Sweden, which spend at least 11 per cent of their GDP on health care.

• The picture that emerges from this analysis is that the NHS is under-resourced compared to other countries and lags a long way behind other high-performing health systems in many key areas of health care resources.

Workforce

The most important resource, and often the largest area of cost, in any health care system is its workforce. However, comparable international data is readily available for only a relatively small number of staff groups, such as doctors and nurses.

Even comparisons of these groups should be interpreted with caution, as comparing the number of clinical staff in each country does not tell us how these clinicians work, whether or not their expertise and skill-mix is comparable, and how health and care services are organised around them.

Doctors

The UK has 2.8 doctors per 1,000 population, which is below the average of 3.6 for our basket of countries (Figure 1).

Nurses

The UK also has fewer nurses per 1,000 population (7.9) than average (Figure 2), positioning the UK next to the Czech Republic and Austria and far behind Germany (13.3 nurses per 1,000 population) or Switzerland (18 nurses per 1,000 population).

Bed capacity

Pressure on bed capacity in NHS hospitals has grown in recent years, and high levels of bed occupancy are now common. The number of hospital beds is not the only factor behind these pressures, and fewer hospital beds can be a marker of high-quality care where this reflects greater efficiency and shorter lengths of stay in hospital or where more care is being delivered outside of hospital when this is clinically appropriate.

Hospital beds

It is striking that the number of hospital beds in the UK (2.6 beds per 1,000 population) is substantially lower than the average of 4.4 beds for our basket of countries (Figure 3). Bed levels in the UK are similar to those in Canada and New Zealand and far below those in Germany and Austria.

Beds in residential long-term care facilities

The pressure on hospital beds in the UK is mirrored in services that provide care out of hospital, and the UK also has fewer residential beds for long-term care than comparator countries (Figure 4). Most of the other measures in this report, such as the number of doctors and nurses, predominantly reflect the resources of the NHS. However, in the UK residential long-term nursing and care home beds are largely provided by the private sector.

Medical technology

Investing in modern medical technology is essential to improve the diagnosis and treatment of disease and is associated with cost savings and improved efficiency in health care provision. Despite the wide range of available technologies, comparative international data is limited to a small range of medical imaging technologies such as magnetic resonance imaging (MRI) units and computed tomography (CT) scanners. Data for the UK only includes MRI and CT units in the public sector, so these comparisons should be treated with particular caution.

Medicines

Health care systems face pressures in controlling growing spending on medicines while maintaining access to medicines and supporting the pharmaceutical industry to develop new medicines. Spending on pharmaceutical medicines accounts for more than one-sixth (16 per cent) of total health expenditure across our basket of countries in 2015 (this excludes spending on pharmaceuticals in hospitals). A lower level of medicines spending can also be a marker of efficiency in a health care system, such as greater use of cheaper generic forms of drugs.

Comprehensive data on use or consumption of pharmaceuticals is not available so we have used spending on medicines as our main measure for comparing countries. The UK spends just under £500 per head of population on medicines, which is below the average for comparator countries (Figure 6).

Funding

The most obvious limit on the physical resources (workforce, beds, equipment, medicines) of a health care system is the level of its financial resources.

Different countries use very different approaches for financing health systems, though no country relies on a single source of funding for health care. Eighty per cent of health care spending in the UK is financed through government expenditure, with the remainder coming from out-of-pocket expenditure, voluntary health insurance or other financing schemes. Australia, Canada and New Zealand use a similar approach for funding health care. This contrasts with countries, such as Germany and France, which fund health spending largely through compulsory health insurance. Since the 2008 global financial crisis, most countries, regardless of their method for financing health care, have had a common aim of containing growth in health care expenditure.

Recently, there has been a major change in how health care expenditure is measured for the purposes of international comparisons (see box below). This accounting change has had a significant effect on the UK’s standing relative to other countries – though it is important to emphasise that this does not mean the UK is actually spending more or less on health care as a result. It is also important to note that different countries adopted the revised health spending methodology at different times, which affects our ability to draw meaningful long-term comparisons.

The UK spends 9.7 per cent of its GDP or national wealth on health care under the new definition of health care spending. This is about average for the basket of countries in this report. The UK has a similar level of health spending as a proportion of GDP to Austria and Australia but falls behind other high-income countries in our basket such as Germany, France and Sweden, who spend 11 per cent or more of their GDP on health care.

The impact of adopting the new methodology can be seen clearly in Figure 8, with a sharp increase in the reported level of health care spending when the new definition of health care spending was adopted in 2013.

Discussion

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](http://www.health.org.uk/sites/health/files/Workforce pressure points 2017 FINAL_0.pdf) 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.