75 years of the NHS: how does it compare to international health systems?

Key:

JV:      Jo Vigor - host

DJ:        Danielle Jefferies

SA:      Siva Anandaciva

JV:        We're sure it's not escaped your notice that this month marked the 75^th anniversary of the founding of the NHS.  Commemorative coins have been minted, a special service was held at Westminster Abbey to mark the anniversary and there was even an episode of the Repair Shop dedicated to the occasion and while it's good and right to celebrate our National Health Service we all know that the challenges facing the NHS have never been greater.  Hello and welcome to the King's Fund Podcast where we explore the big issues and ideas in health and care.  I'm Jo Vigor and I'm delighted to be joined by two colleagues from the analyst team at the King's Fund, Danielle Jefferies and Siva Anandaciva.  Danielle, Siva, welcome to the podcast, delighted to be talking with you today.

DJ:         Thanks for having us Jo.

SA:         Hi Jo.

JV:        Hi both of you.  So we're going to start off the conversation today by looking back at the NHS in its 75 years and really starting to think about its origins and what was going on for it 75 or even 50 years ago and Danielle, you've recently dived into the King's Fund archive to take a look at what the Fund was saying in the early years of the NHS.  First of all, I want to know if you found anything bizarre or surprising in  your role as our historical sherlock.

DJ:         Yes, so a few surprising things, but I think the most surprising thing is just how many similarities you can pick out.  So despite how different the NHS, the King's Fund and society are and how much has changed in the last 75 years, you can still see some common themes and some common language.  So if you think about 75 years ago it's a very different context, we were recovering from World War II, we were thinking about infectious diseases when it came to health, so things like tuberculosis and fast forward today we're in a very different context, so recovering from a pandemic, we're thinking about heart disease, Alzheimer's, these kinds of things instead, but despite those differences if you look back on our archives we're talking about things like workforce shortages, waiting lists for elective care, supporting staff and their wellbeing and how we get people and support people moving out of hospital into the community.  So really surprising that we're still talking about similar things and actually it's almost bizarre you can look back into our archives and pick out quotes that could very easily just slot straight into one of our current publications, which is very interesting and very surprising to me but I guess when I thought about it a bit more it makes sense because these things are about staff, they're about patients, they're about patient care and ourselves at the King's Fund and the NHS are always going to care about these things and talk about these things.

SA:         I think Danielle is absolutely right that there are some fundamental issues that you'll always come back.  Is there enough money for the service?  Are there enough staff?  But when we look back, one of the things we really want to avoid is this sense of (inaudible 00:03:12), no matter what you do there will never be enough staff, there will never be enough money and 25 years ago these debates were in a completely different place, the fundamental issues remain, but the tone and tenor of where the service is at any given point in time can be radically different. 

JV:        Absolutely.  I was going to ask both of you actually about that because the themes are there, they translate, but is there anything specific that's come out for you as you were doing that research?  Is there something that you can just bring some of this to life that you were really surprised about?

DJ:         Yes, so for me the strongest example was about nursing retention and recruitment.  So in our archives we're talking about things like flexible working options, providing training opportunities, supporting the health and wellbeing of staff, and these are all things that feel very applicable today.  Even though we were talking about them 75 years ago the context is very different.  So I don't think many nurses today are thinking about gymnastics lessons for example or an x-ray on the first day to detect for TB, but the concepts and the ideas are still there, so that's very much saying that we need to listen to staff and what they need.  So what do they need as employees?  What do they need as people in the current context and their society and how do we listen to that and make sure we're catering to those needs even if the needs have changed a lot in the last 75 years?

JV:        Danielle I think that is really, really helpful to be outlining that, so it reminds me of some of the work that we're doing now today in terms of leadership work with clinicians and nurses and how it's rooted in some of the research of the 1950s and '60s which was looking at how do people deal with uncertainty and emergence in their roles, but the way that we talk about uncertainty and emergence today with our leaders and our managers is very different to how we've done that in the past.  So there's been a shift in that thinking, I think a very helpful shift, as we move towards different models of leadership in today's world around compassion and kindness and inclusion and away from some of that more command and control piece as well.  So I'm just going to go on to another question to both of you around the NHS has endured through some real major societal events, what do you think this tells us about the health service in terms of its ability to adapt and evolve?  Does this give you hope for the current challenges, because there's a lot of rhetoric around at the moment about things are broken, we've got to really do some mass transformational change and move to different models around this, but what's your reflections on that?  What would you say to our listeners?

DJ:         So for me it definitely gives me hope, so yes the NHS is not in a good place at the moment for staff or for patients or the system, but if we think about the last 75 years and how far the NHS has come, at the moment it's still delivering a lot of amazing care and it's helping millions of people every day.  It's contributed to an increase in life expectancy over that time, almost a decade, and we're no longer thinking about tuberculosis and infectious disease we've changed the picture of health over the last 75 years which should be encouraging in some sense because the NHS has supported and survived for the last 75 years despite how much has changed.  At the moment it's about how do we support the NHS in this next phase?  How do we support it so it continues on for another 75 years? 

SA:         Yes I agree and for me it's one of these classic we overestimate how much change is possible in two years but underestimate how much change is possible in ten years kind of scenarios where to be honest any time I'm getting down over the health service and how bad things are, I think back to something Don Berwick, this eminent professor from the States said, because he's a consultant paediatrician, and it was just a throwaway remark in one of his speeches he was giving, where he said "When I was training as a paediatrician all the kids I saw with leukaemia died and now most of them live," and it's that sort of thing where shared decision making, safety, all of these things even in my lifetime I've seen progress.  So yes I'm not for one minute denying the reality of how bad it is but there is still hope.

JV:        Thank you, I mean I think that's a great message for listeners and let's just stop a moment, we've been talking about the NHS here and its 75 years, but of course the health of the nation is not all about the National Health Service.  Social care plays a huge role in supporting the health and care of the nation, as do carers, as do other agencies.  So just picking up on one of those areas, what impact has the crisis in social care have on today's NHS?

DJ:         So the NHS and social care are completely dependent on one another and I think it's no coincidence that we're also celebrating the 75^th anniversary of the start of the social care system in this country because we can't have one without the other.  So we've been thinking about how do we support people in the community not necessarily in hospital for actually the last 75 years and we're still talking about it because we haven't quite sorted how social care supports the NHS and vice versa.  So we need social care in order to help care for people in the community rather than in a hospital bed and that problem has increased over the last 75 years.  We've got an aging population and looking forward the problem is only going to increase even more, so by 2045 we're expected to have double the population over 85 which is going to put a huge pressure on both the NHS and social care.  So when we think about these two things we need to think about them together and how do we support and grow both of them together.

SA:         Just on the need for optimism, I know social care has not been fixed, I know there have been repeated promises, but again honestly when I started my career … actually literally when I started my career in the Department of Health I had my (s.l info 00:09:38) meeting with my director and I was with another newbie at the same time and we were asking about the Department of Health because it was still called the Department of Health back then, it's priorities, and at one point in the conversation she said, "And how much analytical work do we get to do on social care?" and I'm not exaggerating, I didn't know what the word social care meant and now there is no chance I would have got that job and be in that room if I didn't know it.  So I think definitely the awareness of the interdependency that Danielle's talked about has gone up and it feels like we're on the precipice.  I honestly cannot think how a government over the next ten years could come into power without a reasonable plan for tackling adult social care and the crisis that is going on there.

JV:        So we've talked about our NHS in England and the UK and its last 75 years but I think there's some opportunity now to really look across the globe and across and into other countries.  Siva, you've recently authored a report comparing the NHS to other health systems across the world, what did you learn and why do you think this type of analysis often appears around major anniversaries of a health and care system?

SA:         I'll start with the second bit, why do we do it?  I think to be honest it can be quite habit forming every five years another birthday or anniversary comes round and you think well let's update what's happened before, because I think you do … think tanks do one of two things, they either commission lots of interviews from the great and the good to give a perspective on the health system as it is at the moment and where it's going or they update the analysis of how do we compare to other countries.  And I think we do it for not just because it's habit forming but partly because there's this constant need to calibrate how good the system is.  So you look over your shoulder at another country and see how are they doing?  Is there anything we can learn from?  The other thing is tied to what Danielle was saying about data from the past, it's actually surprising how little comparable data we have over the long history of the NHS.  We can tell how much we've spent on it, but it's very hard to say are you in a relatively good place or a relatively bad place?  We look across more than we look back sometimes.  But the first thing you've asked was what did we learn?  I  know it sounds a bit counterintuitive, but the first thing I learned was to be really, really cautious when you do the types of international comparisons and think anyone who does it, and Danielle saw this as well, you look at something like the number of MRIs, CTs canners we have, and you think well that's pretty easy you just go round every country and count how many MRI or CT scanners there are, and that's when you get into the real detail of have you captured all the resource in the private care sector?  How big is the private care sector?  Is your account up to date?  And all of these things can really make you very cautious when you make comparisons, but overall I would say having done the work a few things really did stick out.  The first is that our health care system is broadly middle of the pack compared to our peers, compared to France, Germany, the Netherlands, some of the countries that we would consider as higher income European nations.  We have fewer resources, I think this is one of the things that really came through, staff, equipment, anything basically that you fundamentally need to run a health care service we're either at the bottom or towards the bottom of the league table.  We have really poor health care outcomes.  So yes there are things that are affected by wider society like life expectancy, but even if you look at things that are within the gift of a health care service like recovery from stroke and heart attacks, we do poorly, we do poorly compared to our neighbours.  But it wasn't all bad, there were some things that we do really well like our performance on some measure of efficiency and some things that are in all honesty harder to evidence but come through more in the qualitative data where we really do have a nationalised health care system.  So whether it's something like the (s.l recovery charger 00:13:33) in COVID or when ICU capacity is reaching a real breaking point, the benefits of having a system where you can get all the leaders basically on one WhatsApp group and try and coordinate things is probably not to be underestimated. 

JV:        Thanks Siva, I mean there is a lot to unpick there, isn't there?  A lot to think though.

SA:         Yes, sorry, very long answer.

JV:        No, no, no, I think it's all really, really interesting and that whole piece around being cautious about what we're measuring and how we're measuring that is a really good lesson as well.

SA:         On that Jo, can I tell you about the limoncello model of comparative health policy which is not actually a model, I'm trying to introduce it, but the idea is you go to Sorrento or somewhere on the Amalfi Coast and you have this wonderful meal in the cool balmy evening and then at the end they bring over this chilled shot of limoncello and this is clearly a personal story, I tried it and thought it was amazing, refreshing, crisp and so me and my wife bought this massive bottle of limoncello in duty free on the way back home and then when we cracked it open in our rainy February evening in Bethnal Green and we were thinking what?  This is awful, why have we done this?  We do the same thing with other health care systems, so we look at how they deliver care in Alaska, in Nuka multidisciplinary teams and we just think let's import it, or you look at the Buurtzorg model of nursing care in the Netherlands and say, "Let's bring that over," and all the work that colleagues like Jo Maybin here have done have shown it's not impossible but there's a reason why it's so embedded these health care improvements in the culture of that host country.  So  you need to be aware of that before you try and import something.

JV:        Absolutely and we've certainly found through our work that you really need to understand your own context well and taking the international piece there's no cookie cutter approach to this, you have to think about why does that work?  How long has that taken for them to do that and why is working in their context and then what's the translation into ours?  So I really, really like the parallel with the limoncello experience there Siva, that's great, thank you.  The report itself how has that been received and what have people said to you in conversations that you've had since?  What's stood out to them?

SA:         Good question.  I would say there are different responses from different types of people.  I'd say there's one group of people where the international comparisons of the NHS was new info that they found interesting and informative and were just glad to have it.  I'd say there were some people where it was … they broadly had an idea of what the issues were but it was helpful to have it all collated.  So I'd say that was the … it wasn't interesting but it was convenient, and then I'd say there was a group of people where it's we knew all this, why have you done it again?  So there was a split there but I'd say most people fell into that first bucket which was interesting in and of itself of this is new interesting info.  The other thing I'd say is it's been interesting how the same information or statistic can be used equally to further the arguments of people either on the left or the right of politics or whether you're pro or anti the current model of the NHS.  So the same figure about health care outcomes I've seen used as we have a fundamentally good model of health care it just needs more resources and I've seen it used as look what our model of health care produces we need a completely different model of health care.  So I think it can be used … once it leaves the building it can be used by other people in any way they want. 

JV:        Yes, and maybe the important thing here is that we're doing work that stimulates conversation and knowledge gathering and awareness and stimulates that dialogue around what does this mean in terms of our context as well.

SA:         Yes, I think you're absolutely right and I think it goes back to this, why do we do this type of work?  There is something absolutely normal about being curious about how other health care systems are performing.  Why wouldn't you look at other countries and see how they're doing?  And just to be clear, sorry, I think the report was unequivocal, our current mode of health care is not the issue to address, we've performed well with this model of health care in the past, I'd say look at the resources, do more on the health care outcomes but don't try and fundamentally change how the NHS is organised and structured and funded.     

JV:        This just takes me on to the next question, so we've talked about how we're looking at other health system around the world, but you've spoken to experts in various different countries, what did you learn about their system?

SA:         So we spoke to people from Singapore and from Germany and I think one of the things was just how … I was glad we did the qualitative interviews because that's where you really understand the different approaches people take to health care and just how fundamentally different cultures are.  Actually maybe I'll start with Germany, one of the things that really came through was this issue of pride, we were talking about how in the UK the NHS routinely tops polls of what you makes proudest to be British and I remember the person I was speaking to saying, "Pride can be a really dangerous emotion and do I have high expectations of my health care system in Germany?  Absolutely.  But they're expectations, I'm not proud of it, I'm proud of the grades my kids get in school, I'm proud of them doing well at piano lessons, but pride can hold you back sometimes from changing your health care system."  So that was one thing that came through strongly.  The other thing that came through was this sense of the national bit of the health service we have in this country and I know it doesn't sound like a big deal, but I think it is a big deal that he was saying things like clinical audit.  You can have one database that pulls in information on fractured neck of femurs from across every bit of the NHS and use that to further whether it's research or improving how services are delivered.  When you've got more atomised health care systems  out there it is just so much harder.  So I think we sometimes take the NHS for granted in that regard.  And from Singapore I guess it was interesting to see different approaches to things that I would say are more cultural rather than operational.  So data sharing, obviously they have safeguards in place for sharing health care data, but one of the people from Singapore said, "If I'm a citizen I presume that my health care system knows about me and that information is shared appropriately so that I'm not telling my story over and over again," and I was thinking that feels about ten years ahead. 

JV:        Danielle listening to Siva and working alongside him on this work, is there anything you want to add from your perspective?

DJ:         So I think what was most interesting to hear about the interview Siva did is just how differently we think about health care in different countries.  So just some of the examples of hearing how technologically forward other countries are and how they see that as normal whereas here in the NHS you can describe things and it would be a dream come true for some of the things that Siva described and heard in places like Singapore.  So just how different we are to other countries was quite surprising and quite interesting and especially if we start thinking about what makes us proud to have an NHS and why we are proud of that and what aspects should we be proud about and what aspects should we be thinking more closely and thinking more closely about changing.

SA:         Yes, that's really a good point.  Do you know what?  Both Singapore and Germany representatives were embarrassed at points I would say.  So at one point the person from Singapore said, "We're not really that good.  Don't big us up," and then went on to describe exactly as Danielle has said, how technologically they were streets ahead of us and from Germany their capacity, their bed capacity in hospitals, was so much higher than ours and they were talking about how their experience of COVID was so different and again it was oh yes but we do spend a lot on our health care system.  I was just thinking as a citizen rather than a policy analyst I'd love to be in the position where I'm embarrassed at how well my health care system is performing.   

JV:        I'm curious as well, because of the space that I work in in the King's Fund is around workforce and people and leaders, when you were talking to people from Germany and Singapore were they coming up with some of the same workforce challenges that we're experiencing here in the UK?  Were there some similarities there?

SA:         Not really to be honest.  I mean it was stunning in that sense that obviously a lot of the workforce problems and staffing shortages are a global issue, but in terms of where they were in the priority list I'd say that acute staffing shortages in the health and social care workforce and things like tackling backlogs of care that have built up during the pandemic are two things that are right up at the top of the policy agenda in this country that are just not given the same prominence.  And I think partly it's where their system is, but also how they think about their system because everything seemed to be on a much longer horizon.  Singapore was thinking about ... they were saying things like, "Well we're really thinking about where primary care should be over the next 15 to 20 years," so it felt less like how do get through the current crisis and more where do we want our system to evolve to.

JV:        I think there are some lessons there, isn't there, Siva and Danielle about some of the long term strategic planning and getting people from our NHS and social care system involved in that thinking as well?  So thank you.  Thank you for that.  The report also predominantly looks at performance.  Is there anything else you'd want to learn from the health systems of other countries and I've just picked up the piece about workforce, but is there anything else that you'd want to share with our listeners today? 

SA:         Gosh, yes, loads.  I mean I suppose you're right the report focused on performance and I'd say how do we do against other countries.  So one of the things is why do we differ to other countries and how they've improved in some of the big areas that makes sense to look at at a country level at a national level.  So I know people talk about it a lot in health policy but what Estonia has done on its digital policy, things like adult social care reform in Germany and Japan, that's the sort of thing where it's really interesting to see how they've had that bug national conversation with the public, that makes sense to do that at a national level.  So more on the how of where change happens.  I suppose the second area is I'd say not national but international learning of individual health care systems and we do it from time to time at the King's Fund, but the work you're potentially doing on RUSH Medical, the work we've done before with the Montefiore system in the Bronx, I think that's really helpful because you can see how a hospital system or an integrated care board in this country can look across and say, "I can see how I can take some of these principles and apply them to my work," but it's international comparison below the national level.  And I guess two final ones, one is about countries that weren't in our basket.  Because we were trying to compare things like average length of stay and spending, we picked as close as we could to a homogenous basket.  I think some of the work that's been done in other continents that we don't normally look at including Asia, East Asia, Africa, what they're doing on primary care reform in Brazil, Costa Rica, all of the countries that are not normally included in our basket I think are great examples of learning.  And the final one is I've just got a niche interest in things that are really hard to measure, like you a bit Jo, of clinical leadership and management, almost every secretary of state I've lived through has said at some point, "We need to get more clinicians into management." The approach to clinicians in management in countries like the US and Canada is so completely different.  Here I still run into medical directors where people have said, "It's your turn, do it for a couple of years and then you can be released," while in other countries it's a prize, you want to move into a management career.  So I'm always interested in learning more about how other countries do on leadership as well. 

JV:        Absolutely Siva.  I mean a passion for me as well and you're so right, lots of the stories that we hear from our own system are about it's almost like you're on rotation and really you've got the poisoned chalice for the next couple of years please get on with it, whereas actually we should be celebrating those skills as something that you need to master and that you should be doing that earlier on in your career.  So I think we'll be really pushing and talking to some of the universities about how they include that in their curricula, how do we change the education approach to clinical professions as well.  So I think we've got a lot of work to do here and a lot of things we can draw on again from across the globe.  So thank you for that.  Thank you for picking that up.  Danielle is there anything else as we just come to a close that you want to add at this stage that you think would be helpful for people? 

DJ:         So I think the final thing I'd pick up on is in the report we talk a lot about international recruitment, and I found it interesting linking that back with the history of the NHS and also that we're also at the 75^th anniversary of Windrush and our long history of international recruitment, how we bring people into this country and support them and support them in the NHS and the work they do and I think it was just interesting to see in the report how other countries approach international recruitment and how that differed quite a lot.  So we would take quite a lot of international recruits compared to other countries and I thought it was interesting to be able to see those numbers and see how those other countries are approaching it too and maybe there's a different way to think about it.

JV:        I think that would be really, really helpful, Danielle.  Again I think there's … we're hearing anecdotal stories of 50% of some of our clinical gaps have been filled by overseas recruitment, how are those people being treated?  How are we ensuring and helping people when they're bringing their families over to be integrated within their local communities?  And I think there's a lot of work to be done there as well as some of the discussion around the ethics of some of that from a sustainable point of view.  So lots to go at there and lots to maybe look back over that 75 years in relation to what's happened and what's worked well and what could be better if from that point of view. 

SA:         See you in five years I guess.

JV:        Yes, let's see what the future brings.  Thanks Siva, thanks Danielle and thanks for your stories around hope as well.  So that's all we've got time for today.  Thank you to Danielle and Siva for joining me and you can read the report we've been discussing on our website www.kingsfund.org.uk.  The show notes for this episode and all our episodes can be found at www.kingsfund.org.uk/kfpodcast and you can get in touch with us via Twitter our account is @thekingsfund.   The producer for this episode was Emma Sheffield and it has been edited by Bespoken Media.  Don't forget to subscribe, share, rate and review this episode wherever you get your podcasts and of course thank you for listening.  We hope you can join us next time.