The future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19

The UK's response to the pandemic The UK has recorded one of the highest death rates associated with COVID-19 globally, whether measured as deaths that are directly attributable to COVID-19 or by excess mortality. The reasons for this high rate are complex and not yet fully understood, but elements of the UK Government response have been criticised, including delayed implementation of physical distancing measures, poor coordination with local authorities and public health teams, a dysfunctional track and trace system, and an absence of consultation with devolved nations. The role of the National Health Service (NHS) and relevant national executive agencies in relation to testing capacity, availability of personal protective equipment (PPE), the cancellation and postponement of many aspects of routine care, and decisions around discharge from hospital to care homes should also be critically examined. Conversely, aspects of the response by the NHS and relevant national executive agencies deserve recognition. In only a few weeks, capacity for critical care was massively expanded, many thousands of staff were reallocated, and services were reorganised to reduce transmission of SARS-CoV-2. The NHS also collaborated with academic institutions to share knowledge about clinical characteristics of the disease and to establish world-leading clinical trials on vaccines and treatments. The response to COVID-19 brings to attention some of the chronic weaknesses and strengths of the UK's health and care systems and real challenges in society to health. Failures in leadership, an absence of transparency, poor integration between the NHS and social care, chronic underfunding of social care, a fragmented and disempowered public health service, ongoing staffing shortfalls, and challenges in getting data to flow in real time were all important barriers to coordinating a comprehensive and effective response to the pandemic. More positively, the high amount of financial protection that was provided by the NHS and an allocation of resources that explicitly accounted for differing geographical needs have, to some extent, mitigated the already substantial effect of the pandemic on health inequalities. The London School of Economics and Political Science–Lancet Commission on the future of the NHS This UK-wide London School of Economics and Political Science (LSE)–Lancet Commission on the future of the NHS provides the first analysis of the initial phases of the COVID-19 response as part of a uniquely comprehensive assessment of the fundamental strengths of and challenges that are faced by the NHS. The NHS has long been regarded as one of the UK's greatest achievements, providing free care at the point of delivery for over 66 million people from birth to death. Against this backdrop, and considering international evidence, this Commission sets out a long-term vision for the NHS: working together for a publicly funded, integrated, and innovative service that improves health and reduces inequalities for all. This Commission makes seven recommendations, and associated subrecommendations, for both the short term and long term, with a 10-year timeline. First, increase investment in the NHS, social care, and public health. This Commission proposes that yearly increases in funding of at least 4%, in real terms, are needed for health, social care, and public health. Second, improve resource management across health and care at national, local, and treatment levels. Third, develop a sustainable, skilled, and fit for purpose health and care workforce to meet changing health and care needs. Fourth, strengthen prevention of disease and disability and preparedness to protect against major threats to health. Fifth, optimise diagnosis to improve outcomes and reduce inequalities. Sixth, develop the culture, capacity, and capability to become a so-called learning health and care system (ie, in which data-enabled infrastructures are routinely used to support policy and planning, public health, and personalisation of care). Finally, improve integration between health care, social care, and public health and across different providers, including the third sector (ie, charity and voluntary organisations). Central to the argument of this Commission is that an ongoing increase in funding for the NHS, social care, and public health is essential to ensure that the health and care system can meet demand, rebuild after the pandemic, and develop resilience against further acute shocks and major threats to health. This funding should be targeted towards increased investment in capital, workforce, preparedness, prevention, diagnosis, health information technology (HIT), and research and development. Furthermore, the NHS should develop new ways of working with patients and citizens. This Commission sets a vision of transformation to meet changing health and care needs of the UK population but rejects any calls for reorganisation of the NHS on a large scale. Past experiences have taught us that reorganisation on a large scale is often a disruptive process without any evidence of benefit.1 We argue instead that the foundations of the NHS can be strengthened through further investment and integration of pre-existing operational institutions. The COVID-19 pandemic has reinforced the economic case to invest in health, which is crucial for fiscal sustainability and enhancing societal wellbeing.2 However, we acknowledge that committing to increased investment in the NHS, social care, and public health will be challenging in economically and geopolitically uncertain times. To implement the funding recommendations, this Commission estimates that total expenditure would need to increase by around £102 billion in real terms, or 3·1% of gross domestic product (GDP) in 2030–31. Taxation reforms would be required to increase funding and we provide an indicative analysis of the amount of potential change that would be required to personal income tax, national insurance contributions, and value-added tax. This Commission serves as a call to action. We argue that, similar to the establishment of the NHS after World War 2, after the COVID-19 pandemic and leaving the EU, the UK faces a once-in-a-generation opportunity to invest in the health of all its population and secure the long-term future of the NHS. Failure to re-lay the foundations of the NHS (ie, strengthen through increased investment and commitment to its founding principles) risks 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.