State of Health in the EU United Kingdom Country Health Profile 2019 The Country Health Profile series Contents

The State of Health in the EU’s Country Health Profiles 1. HIGHLIGHTS 3 provide a concise and policy-relevant overview of 2. HEALTH IN THE UNITED KINGDOM 4 health and health systems in the EU/European Economic 3. RISK FACTORS 7 Area. They emphasise the particular characteristics and challenges in each country against a backdrop of cross- 4. THE HEALTH SYSTEM 8 country comparisons. The aim is to support policymakers 5. PERFORMANCE OF THE HEALTH SYSTEM 12 and influencers with a means for mutual learning and 5.1. Effectiveness 12 voluntary exchange. 5.2. Accessibility 15 The profiles are the joint work of the OECD and the 5.3. Resilience 18 European Observatory on Health Systems and Policies, 6. KEY FINDINGS 22 in cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by the Health Systems and Policy Monitor network, the OECD Health Committee and the EU Expert Group on Health Information.

Data and information sources The calculated EU averages are weighted averages of the 28 Member States unless otherwise noted. These EU The data and information in the Country Health Profiles averages do not include Iceland and Norway. are based mainly on national official statistics provided to Eurostat and the OECD, which were validated to This profile was completed in August 2019, based on ensure the highest standards of data comparability. data available in July 2019. The sources and methods underlying these data are To download the Excel spreadsheet matching all the available in the Eurostat Database and the OECD health tables and graphs in this profile, just type the following database. Some additional data also come from the URL into your Internet browser: http://www.oecd.org/ Institute for Health Metrics and Evaluation (IHME), the health/Country-Health-Profiles-2019-UK.xls European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the World Health Organization (WHO), as well as other national sources.

Demographic and socioeconomic context in the United Kingdom, 2017

Demographic factors  United Kingdom EU Population size (mid-year estimates) 66 059 000 511 876 000 Share of population over age 65 (%) 18.1 19.4 Fertility rate¹ 1.7 1.6 Socioeconomic factors GDP per capita (EUR PPP²) 31 700 30 000 Relative poverty rate³ (%) 1 7.0 16.9 Unemployment rate (%) 4.4 7.6

1. Number of children born per woman aged 15-49. 2. Purchasing power parity (PPP) is defined as the rate of currency conversion that equalises the purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 60 % of median equivalised disposable income. Source: Eurostat Database.

Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD or of its member countries, or of the European Observatory on Health Systems and Policies or any of its Partners. The views expressed herein can in no way be taken to reflect the official opinion of the European Union.

This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area.

Additional disclaimers for WHO are visible at http://www.who.int/bulletin/disclaimer/en/

© OECD and World Health Organization (acting as the host organisation for, and secretariat of, the European Observatory on Health Systems and Policies) 2019

2 State of Health in the EU · United Kingdom · Country Health Profile 2019 83 79 75 81 77 Life expectancy at birth,years EUR 2000 remains achallenge. inequalities inhealthoutcomes improved inrecent years. Tackling EU countriesandhave not than inotherhigh-income and treatable causesare greater mortality rates from preventable Although below EUaverages, Effectiveness Per capita spending(EURPPP) % of adults policies. the role of primary andcommunity care in providing responsive, person-centred care hasbeenthefocusofrecent due toeffective gatekeeping at primary care level, althoughthislimitsthesystem’s surge capacity. Strengthening because average length ofstay ofhospitalservicesis25%lower andutilisation hasfallen thantheEUaverage and thescaleofincomeinequalities. Hospitalcapacity within theNationalHealthService(NHS)could bereduced The UnitedKingdom’s healthsystemdelivers good healthoutcomesrelative tothelevel ofhealthexpenditure 1 EUR 3000 per 100000population, 2016 Age-standardised mortality rate EUR 2500 Preventble UK UK UK mortl t mortl t Tretble 773 Highlights Obest Bne drnn Smon 78 2000 Bne drnn EU EU EU 2013 Smon Obest 17 21 22 90 2015 UK

154 15 17 19 20 21 % 2017 22 EU %

% 809 813 2017 EU Countr waiting timesand provider deficits. have notkept pace with growing demandforservices, leading toincreased average butlower than insimilarly wealthy countries. Since2008, budgets which isfree atthe point ofuse. Healthspending iscomparable totheEU Kingdom provide universal accesstoacomprehensive package ofservices, protection is good. Separate NHSsystemsinthefournationsofUnited The healthsystemisfundedfrom general taxationandfinancial Health system risk factorsmostaffectthose with lower incomeoreducation. which ishigherthaninmostotherEUcountries. As with healthstatus, above theEUaverage. More thanoneinfive adults were obesein2017, consumption hasbeenfalling, but particularly binge drinking remains consumption impacts thecurrent healthofthe population. Alcohol the lowest intheEU. However, thelegacy of previous heavy tobacco Smoking among adultshasdeclined rapidly andisnow 17%, among Risk factors lowest level. education canexpecttolive over four years longer thanthose with the socioeconomic inequalities. For example, people with ahigher level of increasingly common. Disparitiesinhealthstatushighlightimportant causes ofdeath, althoughdeathsfrom Alzheimer’s diseaseare at older ages. Ischaemic heartdiseaseandstroke remain theleading slowed since2011;mainly duetoaslowdown inmortalityimprovements Advancements inlifeexpectancy atbirth, currently at81.3 years, have Health status State of Healthin the EU ·United Kingdom ·Country Health Profile 2019 % reporting unmet medical needs, 2017 Accessibility EU UK of use. as itisnotalways free atthe point financial barrierstodentalcare, times have grown andthere are services is good. However, waiting of useandoverall accesstohealth Nearly care all isfree atthe point %01 0% Hh ncome %01 2% Countr EU EU Countr All 4% Low ncome 6% 8% access tocare anditsquality. could negatively affectboth doctors, nurses andcare workers Ongoing shortages of the healthsystem. of sustainability threaten the Workforce shortages Resilience 3

United Kingdom 2 Health in the United Kingdom

Gains in life expectancy have slowed to the slowdown in mortality improvements among older people. Between 2011 and 2017, there were United Kingdom markedly over the past decade no gains in life expectancy among women and the In 2017, average life expectancy at birth in the United life expectancy of men increased by just half a year, Kingdom was 81.3 years, slightly higher than the compared to over 1.7 years in the preceding five-year EU average (80.9 years). However, unlike male life period. This slowdown in life expectancy is not unique expectancy, female life expectancy was lower than to the United Kingdom, occurring in France, the the EU average (Figure 1). Increases in life expectancy Netherlands and some other EU countries too, but it have slowed markedly in recent years mainly due has been most marked in the United Kingdom.

Figure 1. Life expectancy of men in the United Kingdom is higher than the EU average, but lower for women

Gender gap: Yers Totl Men Women United Kingdom: 3.6 years EU: 5.2 years 90

85

80

75

70

65 83Ž4 83Ž1 82Ž7 82Ž7 82Ž6 82Ž5 82Ž4 82Ž2 82Ž2 82Ž1 81Ž8 81Ž7 81Ž7 81Ž6 81Ž6 81Ž4 81Ž3 81Ž2 81Ž1 81Ž1 80Ž9 79Ž1 78Ž4 78Ž0 7 7Ž8 77Ž3 76Ž0 75Ž8 75Ž3 74Ž9 74Ž8 60

EU Itl Spn Mlt Ltv Frnce Icelnd C prusIrelnd AustrFnlnd Greece EstonCrotPolnd Norw Sweden BelumPortul Sloven Czech SlovHunr Bulr Germn Denmr LthunRomn LuxembourNetherlnds Unted ndom

Source: Eurostat Database.

Differences in life expectancy by socioeconomic Higher mortality rates for chronic diseases as well status are wider than the gender gap as a more significant stagnation in life expectancy occurs in more deprived areas, demonstrating the In 2011, the difference in life expectancy at age 30 extent of socioeconomic disparities across the country was four years between the lowest and the highest (Public Health England, 2018a). It also is an indication education groups in the United Kingdom, but of the significant poverty-related challenges facing the the gender gap was much narrower than the EU United Kingdom, particularly increasing child poverty average (Figure 2). As people with a higher level of rates and income inequalities (European Commission, education generally earn more, the education gap in 2019a). life expectancy reflects differences in income level and living standards1. In 2014–16, the gap in life expectancy at birth between the most deprived and least deprived decile reached 9.3 years for men and 7.4 years for women, up from 9.0 years and 6.9 years in 2011–13 (Office for National Statistics, 2018).

1: Inequalities by education may partially be attributed to the higher proportion of older people with lower educational levels; however, this alone does not account for all socioeconomic disparities.

4 State of Health in the EU · United Kingdom · Country Health Profile 2019 -100 2: ‘Healthy life years’ measuresthenumberof years atdifferentages. thatpeoplecanexpecttolivefreeofdisability of people aged 65 years andover inEngland report whole oftheUnitedKingdom, butmore than40% disability Just over halfofthese years (10.8) belivedwill without 20 years, to65-year-olds similar intheEUasa whole. British people atage 65could expecttolive another 55–75 years (the ‘baby-boomer’ generation). In2016, decades andtheageing ofthelarge cohortaged growing duetotheriseinlifeexpectancy in previous The share of people aged 65and over issteadily additional years arespent with healthproblems People areliving longer, but many of these Source: Eurostat Database. in diagnostic anddeath registration practices. Note: Thesize of thebubbles isproportional to themortality rates in2016. Theincrease inmortality rates from Alzheimer’s disease islargely dueto changes lead Figure 3. Alzheimer’s disease isincreasingly mortality common, butischaemic disease heart andstroke still Source: Murtinet al.,OECD Statistics Working Paper N°78 (2017). education (ISCED0-2). education isdefined aspeople whohave not completed theirsecondary people whohave completed atertiary education (ISCED5-8) whereas low Note: Data refer to life expectancy at age30. Higheducation isdefined as those withthelowest level of education education canexpect to live four years longer than Figure 2.Thirty-year-olds withahighlevel of EU21: 4.1 years United Kingdom: 4years Education gap inlife expectancy at age 30: % c educated -50 184 women 50 Lower ers 0 518 hn Prostte cncer e 2000-16(orner Brest cncer 2 (Figure 4). There are nodatacovering the Pncretc cncer educated women Higher

ers 558 est

er) Colorectl cncer educated EU21: 7.6 years United Kingdom: 4.4 years Lower ers men 49

Alzhemer’s dsese 40 State of Healthin the EU ·United Kingdom ·Country Health Profile 2019 Lun cncer Pneumon educated Higher ers men 534 60

diagnostic andcause ofdeathregistration practices. Alzheimer’s diseaseislargely due tochanges in seemingly rapid increase inmortalityrates from the biggestcauseofdeathalong with cancers. The (Figure 3). Nevertheless, cardiovascular diseaseis constant afterfalling steeply foranumber of years rates from ischaemic heartdiseasehave stayed cancer have increased, reductionswhile inmortality Deaths from Alzheimer’s diseaseand pancreatic the biggest causeofdeath Cardiovascular diseaseremains to 23%ofmeninthisage group. reported having symptoms ofdepression, compared addition, 34%ofEnglish women aged 65and over of daily living (ADL)such asdressing andeating. In over reported some limitationsinbasicactivities in old age, butaround oneinfive people aged 65and England are abletocontinue tolive independently slightly higherthantheEUaverage. Most people in rate of people with atleastonechronic condition is more than15%statedthatthey hadatleasttwo. The than 40%reported having onechronic diseaseand having nochronic disease. Among those who do, more Str Chronc obstructvepulmonr dsese Ae-stndrdsed mortlt rteper100000populton,2016 o€e 80 Isc hemc hertdsese 100 120

5

United Kingdom Figure 4. Britons aged 65 live just under half of the remaining years with some chronic diseases and disabilities

Lfe expectnc t e 65 Enlnd EU United Kingdom

200 92 199 10 99 108 ers ers

Yers wthout Yers wth dsblt dsblt

% of people ed 65+ reportn chronc dseses % of people ed 65+ reportn lmttons n ctvtes of dl lvn (ADL) Enlnd EU25 Enlnd EU25

16% 20% 22% 18%

40% 46%

44% 34% 78% 82%

No chronc One chronc At lest two No lmtton At lest one dsese dsese chronc dseses n ADL lmtton n ADL

% of people ed 65+ reportn depresson s mptoms3 Enlsh women Enlsh men

34 % 23 %

Note: 1. Chronic diseases include heart attack, stroke, diabetes, Parkinson disease, Alzheimer’s disease and rheumatoid arthritis or ostheoarthitis. 2. Basic activities of daily living include dressing, walking across a room, bathing or showering, eating, getting in or out of bed and using the toilet. 3. People are considered to have depression symptoms if they report more than three depression symptoms (out of eight possible variables). Source: Eurostat Database for life expectancy and healthy life years (data refer to 2017); ELSA survey for other indicators (data refer to 2016-17).

6 State of Health in the EU · United Kingdom · Country Health Profile 2019 4: The obesityrate isevenhigherbasedontheactualmeasurement ofheight and weight(26%in2016). amongadults 3: Bingedrinkingisdefinedasconsuming sixormorealcoholicdrinksonasingleoccasion foradults, andfiveormorealcoholdrinksfor children. regular heavy alcoholconsumption in2014, aslightly (2013¬–14). More thanonefifthofadults reported life compared to25%onaverage across EUcountries report having beendrunk more thanonce in their third (31%)of15-year-olds intheUnitedKingdom Alcohol consumption isalsodeclining, butalmostone significantly (seeBox 2inSection5.1). of smoking cessationserviceshasalsocontributed standardised packaging), but theincreased availability the requirement forcigarettes tobesold in plain, people’s exposure totobaccoadvertising (including due totheimplementation toreduce oflegislation EU countries(Figure 6). The declines are partly drastically andisnow lower thaninmostother Similarly, smoking among 15-year-olds hasfallen some 17%ofadultsbeing regular smokers in2017. in smoking rates forbothmenand women, with The UnitedKingdom hasseenasubstantialdecline consumption continues to be aproblem teenagers hasdeclined, alcohol harmful Although smoking anddrinking among Source: IHME(2018), GlobalHealth Data Exchange (estimates refer to 2017). beverage andsaltconsumption. can beattributed to more thanonefactor. Dietary risksinclude14components, suchaslow fruitandvegetable consumption andhighsugar-sweetened Note: Theoverall numberof deaths related to these riskfactors (205 190) islower thanthesumof each taken individually(218 645) because thesamedeath Figure 5. Tobacco anddietary risks are majorcontributors to mortality activity, deathsintheUnited accountfor34%ofall poor diet, alcoholconsumption andlow physical Behavioural riskfactors, including tobaccosmoking, to behavioural riskfactors United Kingdom can be attributed Over one deathsthird ofall in the 3 EU 17% U 16% Tobcco Riskfactors

State of Healthin the EU ·United Kingdom ·Country Health Profile 2019 EU 18% U 15% Detr rss combined (3%and2respectively). and low physical exercise accountfor5%ofdeaths deaths.for about15%ofall Alcohol consumption sugar andsaltconsumption) are estimatedtoaccount second-hand smoking). Dietaryrisks(including high totobaccosmokingattributed alone(bothdirect and (Figure 5). Around deathsin2017canbe 16 %ofall Kingdom, compared to39%fortheEUasa whole with 16%among 15-year-old boys. moderately active each day in2013–14, compared only 9%of15-year-old reportgirls being atleast This proportionis particularlylowamong girls: exercise (thisislower thantheEUaverage of15%). with only 13%reporting daily moderate physical Physical activity among 15-year-olds isrelatively low, overweight orobese in2013–14(EUaverage 17%). 15 %);however, only 15%ofBritish15-year-olds were in mostotherEUcountries data onheightand weight. This isahigherrate than Kingdom were obesein2017based onself-reported More thanoneinfive adults(21%)intheUnited but few teenagers arephysically active Obesity levels inchildren arerelatively low that nation. sales have totheirlowest fallen level ever recorded in of minimum unit pricing policy inScotland, alcohol among menas women. Following theintroduction (Figure 6). Regular binge drinking higher proportion thaninmostotherEUcountries 4 (theEUaverage was 3 istwiceasfrequent EU 6% U 3% Alcohol EU 3% U 2% ctvt Low phscl 7

United Kingdom Figure 6. Obesity, heavy alcohol consumption and lack of physical activity are major public health concerns

Smon (chldren)

Veetble consumpton (dults) 6 Smon (dults) United Kingdom

Frut consumpton (dults) Drunenness (chldren)

Phscl ctvt (dults) Bne drnn (dults)

Phscl ctvt (chldren) Overweht nd obest (chldren)

Obest (dults)

Note: The closer the dot is to the centre, the better the country performs compared to other EU countries. No country is in the white ‘target area’ as there is room for progress in all countries in all areas. Source: OECD calculations based on ESPAD survey 2015 and HBSC survey 2013–14 for children indicators; and EU-SILC 2017, EHIS 2014 and OECD Health Statistics for adults indicators. Select dots + Effect > Trnsform scle 130%

Socioeconomic inequalities have a completed their secondary education smoked daily, negative impact on health risks compared to only 7 % among those with a tertiary education. Similarly, in 2017 almost one quarter of As in other EU countries, many behavioural risk people without a secondary education were obese factors in the United Kingdom are more common (24 %), compared to 18 % among those with a higher among people with lower education or income. education. In 2014, one fifth of adults (19 %) who had not

4 The health system

The NHS provides universal access to Health spending is comparable to comprehensive services free at the point of use the EU average but budgets have not kept pace with growing demand Since 1999, health care has become a devolved responsibility in the four nations of the United In 2017, health expenditure in the United Kingdom Kingdom and the way in which services are organised was slightly higher than the EU average per person and paid for have diverged as devolved governments – EUR 2 900 (adjusted for differences in purchasing have chosen different ways of addressing the issues power) compared to EUR 2 884, and slightly lower they faced. However, all home nations have retained as a proportion of GDP (9.6 % compared with 9.8 % the tax-funded NHS model. Each nation has its own for the EU). However, as shown in Figure 7, health planning and monitoring frameworks and their own expenditure is considerably lower than similarly public health agencies, resulting in clear differences wealthy countries such as Germany (EUR 4 300 per across some policy areas. However, the systems capita, 11.2 % GDP) and France (EUR 3 626, 11.3 %). face very similar challenges and have sometimes This level of spending has been relatively stable over independently proposed similar solutions (Box 1). time, but it has not kept pace with growing demand With over 80 % of the United Kingdom’s population for health services (European Commission, 2019a) (see living in England, the English NHS is the largest health Section 5.2). service.

8 State of Health in the EU · United Kingdom · Country Health Profile 2019 to dentalcare and prescription pharmaceuticals legal residents (Section5.2). Fixedcharges are applied as mostNHSservicesare free atthe point ofusefor United Kingdom thaninmany otherEUcountries, countries. Financial protection isstronger in the spending islow (16%)compared tomostotherEU of totalhealthexpenditure) andout-of-pocket (OOP) marginal, supplementaryrole inthesystem(3.1% public sources. Voluntary HealthInsurance plays a 2017, 78.8%oftotalhealthexpenditure camefrom predominantly financedfrom general taxationandin In line with theEUaverage, healthservicesare taxation andfinancialprotection isensured The healthsystemisfundedfrom general Source: OECD Health Statistics 2019 (data refer to 2017). Figure 7. Healthexpenditure isclose to theEU average butless thansimilarsized economies 4 000 EUR PPPpercpt 2 000 5 000 3 000 1 000 Plan for England (2019), theaimisto create primary meet thechallenges outlinedintheNHSLong Term addressing staff shortages andcontrolling costs. To those withmultipleco-morbidities, whilealso of patients withchronic conditions, particularly teams. These changes seek to better meet theneeds model for thedelivery of primarycare services by features; for example, moving towards asimilar implemented separately, butthere are some common IrelandNorthern have beendeveloped and NHS reforms inEngland, Scotland, Wales and Box 1.Primary care reforms are converging across theUnited Kingdom Government &compulsor nsurnce 0 Norw

Germn

Austr

Sweden Netherlnds

Denmr

Luxembour„Frnce

Bel„um

Irelnd Voluntr schemes &household out-of-pocet pments

Icelnd State of Healthin the EU ·United Kingdom ·Country Health Profile 2019 Unted ‰n„dom Fnlnd

EU Mlt

Itl system approach to healthandsocial care. ‘A HealthierWales‘ (2018), sets outavisionof awhole The Welsh longterm planfor healthandsocial care, ‘teams’ have beenestablished to achieve these ends. Irelandand Northern multidisciplinary ‘clusters’ or to provide person-centred high-quality care. InWales effective relationships withsecondary andsocial care practices to work inpartnerships andto develop care services. InScotland, thevisionisfor general between General Practitioners (GPs) andwithsocial care networks that encourage more collaboration EU countries). of healthspending in2017, compared with 3%across services thaninothercountries (EUR165orover 5% considerablywhile more isspent on preventive pharmaceutical spending ison generics (Section5.3), EU-wide average (Figure 8)asa greater share of person, pharmaceutical expenditure liesbelow the both of which are comparable toEUaverages. Per is closely followed by inpatient services(29%), outpatient (orambulatory)care (31%)butthis Most spending onhealthservices goes towards and others)are exempted (seeSection5.2). children, pregnant women, people onlow incomes (in England only), althoughseveral groups (such as Spn

Czech

Sloven

Portu„l

Cprus

Greece

Slov

Lthun

Eston

Polnd

Hun„r

Bul„r

Crot

Ltv Shre of GDP Romn % of GDP 00 25 50 5 7 100 125 9

United Kingdom Figure 8. Spending on pharmaceuticals is lower than other EU countries

EUR PPP per cp t Un ted  n dom EU

1000 31% of totl spend n 29% of totl United Kingdom 888 spend n 800 858 827 835

19% 600 of totl spend n 14% 543 of totl spend n 522 400 471 416 5% of totl 200 spend n 152 89 0 Outpt ent0 creƒ Inpt ent0 cre€ Lon -term0 cre Phrmceut cls0 Prevent on0 nd med cl dev ces

Note: Administration costs are not included. 1. Includes home care; 2. Includes curative-rehabilitative care in hospital and other settings; 3. Includes only the health component; 4. Includes only the outpatient market. . Sources: OECD Health Statistics 2019, Eurostat Database (data refer to 2017).

Decentralised purchasing of services The United Kingdom relies on allows coverage inequalities for international recruitment to maintain some high-cost services adequate health workforce numbers

The central government directly allocates money Although it has been steadily increasing, the number for health care in England and provides block grants of doctors per 1 000 population is low (2.8, compared to the home nations (Scotland, Wales and Northern with an EU average of 3.6 in 2017). In contrast, the Ireland), which then set their own health budgets, number of nurses per 1 000 population has been determining how the block grants will be used. Local declining since 2005, going from 9.2 to 7.8 in 2017, commissioning bodies in England make decisions while the EU average steadily increased from 7.3 in about primary care and the routine services to be 2005 to 8.5 in 2017. This has shifted the ratio of nurses provided, considering budgetary constraints and to doctors in the United Kingdom (Figure 9). In 2018, national guidelines. High-cost specialist services are there were 39 000 unfilled nursing vacancies in the commissioned at national or regional level and should English NHS (11 % of the nursing workforce); 80 % follow recommendations from the National Institute of these vacancies were filled by temporary staff. for Health and Care Excellence (NICE); however, some The government response has been to increase the services are still subject to variation in coverage. number of nurse training places, but as of September Waiting lists for elective surgeries also vary between 2018, the intake of new student nurses has remained regions and nations depending on the pressures the steady. Shortages are driving innovation in changing respective services have faced. workforce roles and career paths, but also affect access to services and waiting times (Section 5.2).

10 State of Health in the EU · United Kingdom · Country Health Profile 2019 Prctcn nurses per1000populton EU average (172 per 1000 population), indicating 131 per 1000 population) were 25%lower thanthe common conditions. Hospitaldischarges in2016(at provide thefirst point ofcontactandtreatment for health sometimes otherallied professionals who Primary care is provided by teamsofGPs, nurses and due to problems insocialcareprovision is increasingly important but challenging The integration ofcommunity-based services system’s toabsorbshocks ability (Section5.3). increasing demandforinpatient care haslimitedthe hospital bednumbers, highoccupancy rates and outpatient care andday surgery. However, low in part, to a greater focusonmore cost-effective average of7.9days. These trends canbeattributed, steadily, to6.9days in2017, compared with theEU Average length ofstay (ALOS)hasalsodeclined 2016 (well below theEUaverage of5.0 per 1000). lowest intheEU(afterSweden) at2.5 per 1000in The number ofacutehospitalbedsisthe second capacity foritspopulationhospital The UnitedKingdom hasasmall Source: Eurostat Database (data refer to 2017 ornearest year). around 30%inPortugal). InAustria andGreece, thenumberof nurses isunderestimated asitonlyincludes those workinginhospital. Note: InPortugal andGreece, data refer to alldoctors licensed to practise, resulting inalarge overestimation of thenumberof practising doctors (e.g. of Figure 9. TheUnited Kingdom hasrelatively few doctors andnurses perperson 20 10 18 14 16 12 0 8 4 6 2 2 Nurses Low Doctors Low Nurses H h Doctors Low 25 PL RO LU U SI 3 LV HU IE BE FR FI HR S EE State of Healthin the EU ·United Kingdom ·Country Health Profile 2019 35 CZ NL EU EU vere 36 CY ES IS 4 MT IT D SE as they were nolonger financially viable(Section 5.3). the long-term care sector, with many providers closing workers put great strain onthesocialcare branch of budgetsandshortagescuts tolocalcouncil ofcare care benefits, itcanbe privately funded. InEngland, outside thissystemor wish tosupplementtheirsocial and fundedby local governments. For those who fall Publicly fundedadultsocialcare ismeans-tested care intofewer centres asa way ofimproving quality. schools. The trend hasbeen toconcentrate specialised tend tobelarger teaching hospitalslinked tomedical care forthemostcomplex casesandrarer diseases, Tertiary care services, which offerhighly specialised Most secondarycare is provided inNHShospitals. to shape future services. NHS, hence revising theircontract isakey policy tool independent andcontracted to provide servicesinthe for people with chronic conditions(Box 1). GPsare the focusof policies toimprove thequalityofcare providing responsive, person-centred care hasbeen GPs. Strengthening therole of primary care teamsin the importance ofthe gatekeeping role played by BG DE 45 LT NO PT 5 Prctcn doctors per1000populton AT 55

EU vere 85 Doctors H h Doctors H h 6 Nurses H h Nurses Low EL 65 11

United Kingdom 5 Performance of the health system

slightly below the average for the EU, but noticeably 5.1. Effectiveness higher than in the Netherlands or Sweden, suggesting United Kingdom Preventable mortality rates are below room for improvement (Figure 10). Also, there has the EU average but higher compared been little progress in reducing preventable mortality since 2011. Smoking rates have fallen as a result of to other high-income EU countries concerted policy efforts for tobacco control and the Preventable mortality rates indicate how effective increased availability of smoking cessation services public health and primary prevention interventions (Box 2). However, the impact of historically high are at preventing and controlling disease. In the smoking rates is still visible as one in five preventable United Kingdom, preventable mortality rates are deaths is due to lung cancer.

Figure 10. Mortality from preventable and treatable causes in the United Kingdom is just below European averages

Preventble cuses of mortlt Tretble cuses of mortlt

Cprus 100 Icelnd 62 Itl 110 Norw 62 Mlt 115 Frnce 63 Spn 118 Itl 67 Sweden 121 Spn 67 Norw 129 Sweden 68 Frnce 133 Netherlnds 69 Netherlnds 134 Luxembour 71 Irelnd 138 Cprus 71 Icelnd 139 Belum 71 Luxembour 140 Denmr 76 Portul 140 Fnlnd 77 Greece 141 Austr 78 Unted ­ndom 154 Sloven 80 Belum 155 Irelnd 80 Germn 158 Germn 87 Denmr 161 Mlt 87 Austr 161 Portul 89 EU 161 Unted ­ndom 90 Fnlnd 166 EU 93 Sloven 184 Greece 95 Czech 195 Czech 128 Polnd 218 Polnd 130 Crot 232 Crot 140 Bulr 232 Eston 143 Slov 244 Slov 168 Eston 262 Hunr 176 Romn 310 Bulr 194 Hunr 325 Ltv 203 Ltv 332 Lthun 206 Lthun 336 Romn 208 0 50 100 150 200 250 300 350 0 50 100 150 200 250 Ae-stndrdsed mortlt rtes per 100 000 populton Ae-stndrdsed mortlt rtes per 100 000 populton

Lun cncer Alcohol-relted dseses Ischemc hert dseses Pneumon Ischemc hert dseses Accdents (trnsport nd others) Colorectl cncer Stroe Chronc lŽ respŽ dseses Others Brest cncer Others

Note: Preventable mortality is defined as death that can be mainly avoided through public health and primary prevention interventions. Mortality from treatable (or amenable) causes is defined as death that can be mainly avoided through health care interventions, including screening and treatment. Both indicators refer to premature mortality (under age 75). The data are based on the revised OECD/Eurostat lists. Source: Eurostat Database (data refer to 2016).

12 State of Health in the EU · United Kingdom · Country Health Profile 2019 Database for people aged 65 andover (data refer to 2018 ornearest year). children (data refer to 2018); OECD Health Statistics 2019 andEurostat Source: WHO/UNICEF GlobalHealth Observatory Data Repository for and thefirst dose for measles. Note: Data refer to thethird dose for diphtheria, tetanus andpertussis, the EU Figure 11.Vaccination for influenza isthehighest in vaccines forolder people (Box 3). Child vaccination for children’s vaccinations and75%forinfluenza WHO recommended targets for vaccination –95% Extra effortshave beenrequired totrymeet proportion oftotalhealthexpenditure (Section4). the UnitedKingdom is thehighestinEUasa England, overall spending on preventive servicesin had anegative impact on public healthfunding in Although cutstolocal government budgetshave is the highestin the EU Investment inpreventive services Amon peopleed65ndover Influenz Amon chldrened2 Mesles Amon chldrened2 Dphther, tetnus,pertusss access to medicalrecords orout-of-hours care. The explore thepotential of digitaltechnologies to give There are also pilot public–private partnerships to to enablemore flexible working patterns for doctors. care isdelivered andreimbursed withthepotential challenged policymakers to re-evaluate how primary health care companies. Thearrival of GPapps has general healthmonitoring services offered by private available apps to give fast-track access to aGPor of thehealthcare landscape. There are many widely Digital technologies are anincreasingly evident part Box 2.Digitaltransformation andprevention intheUnited Kingdom

Unted n dom 94 92 73 % % % State of Healthin the EU ·United Kingdom ·Country Health Profile 2019 EU 44 % 94 % 94 % run vaccinationprogrammes. available asGP practices and community pharmacies vaccination free ofcharge and vaccines are widely including thoseaged 65andover, are for eligible (the EUaverage was 44%)(Figure 11). Priority groups, and over was thehighestinEUat73%2017 influenzawhile vaccination for people aged 65 years rates are slightly still below recommended levels, been approved assafe andeffective. Apps Library lists apps anddigitaltools that have and drinks to access nutritionalinformation. TheNHS enables users to scan thebarcodes of popularfoods as part of awidercampaign) isalso available that proven itself effective. AChange4Life app(launched a 28-day smokingcessation programme that has NHS Smokefree, whichisafree appthat provides already widelyadopted. Themost established is use of mHealth (mobile health) for prevention is Strategy (Rechel, Richardson &McKee, 2018). United Kingdom Measles and Rubella Elimination of thenations committed to implementingthe threaten herd immunity. InJanuary 2019, allfour vaccination coverage rates. These gaps continue to geography, withLondon having particularly low in vaccine uptake by ethnicity, deprivation and vaccine free of charge. There are also inequalities children andadults are eligibleto receive theMMR immunisation rates inthelate 1990s. Older in olderage groups asaresult of adrop in Nevertheless, under-immunised cohorts persist and rubella(MMR)vaccine by theirfifth birthday. received thefirst dose of themeasles, mumps status inAugust 2019. In2017, 92 %of children and theUnited Kingdom lost itsmeasles-free due to outbreaks arisingfrom imported cases, cases was reported thefollowing year mainly interrupted for three consecutive years, arise in 2017, that is, endemictransmission had been elimination of measles for thefirst timein are relatively good. WhileWHOdeclared the Current vaccination rates intheUnited Kingdom from vaccine hesitancy Box 3. Measles vaccination rates are recovering 13

United Kingdom Cancer survival rates are low compared indicators such as infant mortality (Public Health to other high-income countries England, 2018b). However, the determinants of these inequalities lie largely outside the health system. Five-year cancer survival rates are worse in the United Kingdom compared to other high-income countries in Figure 12. Five-year net cancer survivals have the EU (Figure 12). However, 25 years ago the gap was

United Kingdom improved, but remain around the average much wider and a strong policy focus on improving the effectiveness of cancer services has led to rapid Lun cncer Unted n dom 13 % improvements in the five-year net survival rates for Prostte cncer EU26 15 % the most common cancers. Three quarters of eligible Unted n dom 89 %

women participated in breast cancer and cervical EU26 87 %

cancer screening programmes in 2016. Brest cncer Unted n dom 86 % Tackling health inequalities in avoidable Colon cncer EU26 83 % deaths is a core challenge Unted n dom 60 % EU26 60 % Population health in the United Kingdom, and the Note: Data refer to people diagnosed between 2010 and 2014. risk factors that influence it, are strongly shaped Source: CONCORD programme, London School of Hygiene and Tropical by health inequalities according to socioeconomic Medicine. status (Section 2, Section 3). The amenable mortality gap between more and less affluent areas narrowed Quality of care is of major policy importance, between 2001 and 2010, as improvements in deprived and key indicators show it is improving areas were greater. However, the gap is still wide and follows a clear socioeconomic gradient. The Lower in-hospital case fatality for stroke and heart rate of mortality amenable to health care in the attack (myocardial infarction) within 30 days of most deprived areas of England in 2010 was more admission suggests that quality of acute care than double that in the least deprived areas. This is above EU averages (Figure 13), and there has means that although mortality from preventable been considerable improvement over time. The and treatable causes is on aggregate similar to concentration of cardiology services into fewer more the EU average, it is noticeably higher in lower specialist providers has been influential in improving income groups. These patterns of inequality hold outcomes (Section 4). true for cancer survival rates, but also for basic

Figure 13. Survival after heart attack or stroke is better than the EU average

Acute Mocrdl Infrcton Stro e

2007 (or nerest er) 2017 (or nerest er) 2007 (or nerest er) 2017 (or nerest er) 30-d mortl t rte per 100 hosp tl st ons 30-d mortl t rte per 100 hosp tl st ons 20 30 25 15 20 10 15 10 5 5 0 0

EU13 Itl Sp n EU11 Sp n Itl Ltv  Polnd Ltv  Eston  Czech  F nlnd SwedenIcelnd Norw Czech  Icelnd Sweden F nlndNorw L thun  Denmr Sloven  L thun Sloven  Denmr Luxembour Luxembour Un ted  ndom Un ted  ndom Note: Figures are based on patient data and have been age–sex standardised to the 2010 OECD population aged 45+ admitted to hospital for AMI and stroke. Source: OECD Health Statistics 2019.

The quality of primary care is reflected in the levels (COPD) are above the EU average, which may be a of avoidable admissions to hospital for diabetes and legacy of previously high smoking rates and current congestive heart failure, which are much lower than exposure to air pollution, which is a growing concern the EU average (Figure 14). Avoidable admissions for (European Commission, 2019a). asthma and chronic obstructive pulmonary disease

14 State of Health in the EU · United Kingdom · Country Health Profile 2019 pressure onemergency care andattendancerates Barriers toaccessinthis part ofthesystemincrease problems inaccessing out-of-hoursurgent care. Kingdom foundthat49%ofrespondents reported standards. A recent survey across theUnited for waiting times thatexceedcentrally determined To maintainaccess, providers are held accountable outstrips resources available, waiting listsare used. rationed by to ability pay. Instead, where demand is provided free atthe point ofuse, accessisnot those onhighandlow incomes(Figure 15). As care time ordistance, with arelatively small gap between unmet needsformedicalcare duetocost, waiting On average, around 3%ofthe population reported Waitingaccess barrier to main are the times 5.2. in January 2019(Department ofHealth, 2019). work isneeded;thenext 20-year vision was launched primary care considered still inappropriate, further However, antibiotic with 20%ofall prescriptions in by 40%andhumanuse falling by 7.3%by 2017. to 2018resulting falling inanimaluseofantibiotics The firstintegrated OneHealthstrategy ran from 2013 national strategy andaction plan in place since2000. has long beenanadvocate foractionon AMR, with a resistance (AMR). The UnitedKingdom government of public healthonissuessuch asanti-microbial but thenationsall work togetherintheinterests Quality assurance inthesystemisadevolved matter, continues with anew 20-year strategy Action to addressanti-microbial resistance Source: OECD Health Statistics 2019 (data refer to 2017 ornearest year). among thehighest the EU, whileadmissions for asthma andCOPD are congestive failure heart are amongthelowest in Figure 14. Avoidable admissions for diabetes and 600 400 200 per 100000populton Ae-stndrdsed rte of vodble dmssons 500 300 100 0 Asthm ndCOPD Accessibility EU21 U Dbetes U EU21 Conestve flure hert State of Healthin the EU ·United Kingdom ·Country Health Profile 2019

U EU21 remain’. Visitors who have European HealthInsurance theyuntil have beenawarded ‘indefinite leave to care asthey are notconsidered ordinarily resident when processing their visa toentitlethemNHS Economic Area are required to pay anNHS premium migrants who have comefrom outside theEuropean when accessing NHS services. Since 2015,April such asrefugees andasylumseekers are notcharged provided inemergency care departments. Groups compulsory mental healthtreatments andcare treatment fora defined listofcommunicable diseases, resident (such asirregular migrants) thatcover benefit package forthose whoare notordinarily to pay isacore value oftheNHS. There isalimited Access toservicesbasedonneedrather thanability comprehensive National HealthServicecare in the UnitedKingdom areentitled to people All who areordinarily resident appointment. are mainly experiencedduetodelays in getting aGP in July 2015. Difficultiesinaccessing primarycare but thetarget was 95%. The standard was lastmet four hoursfortreatment inemergency departments, that 84.4%of patients were waiting nomore than are increasing. InJanuary 2018, NHSEngland found & Doran, 2018). patients orthrough theEHICscheme (Bradshaw, Bloor canberecouped400 (EUR455)million directly from a at GBP1.8(EUR2.05)billion year, of which GBP to theNHSoftreating non-residents all isestimated in place toinvoice patients directly (Box 4). The cost provided and providers increasingly have mechanisms Other visitors must pay costoftreatment thefull the statutoryscheme inthe patient’s homecountry. the NHScanclaim thecostoftreatment back from Cards (EHICs)donot pay outof pocket forcare, but treatment orbilled inappropriately. the rightpaperwork to prove it,have beendenied long-term legal residents, butwhodonot have to theUnited Kingdom asBritishcitizens andare high-profile cases where peoplewho migrated in theUnited Kingdom. There have beensome those deemedto beirregular migrants living trend hasbeento restrict access to services for visas are beingdeniedcare. Theunderlyingpolicy patients who, for example, have overstayed their bill for thecost of hospital care upfront and Since 2017, new regulations require providers to is increasingly limited Box 4. Access to services for irregular migrants 15

United Kingdom Figure 15. Unmet needs are reasonably low and access to care is equitable across income groups

% reportn unmet medcl needs Hh ncome Totl populton Low ncome 20 United Kingdom 15

10

5

0

EU Itl
Spn Greece Ltv Polnd Irelnd C
prus Frnce Mlt Eston Fnlnd Icelnd BelumBulr Crot SwedenNorw
Czech Austr Romn Sloven Slov­Portul Lthun Denmr­Hunr
Germn
Luxembour Netherlnds Unted ‡ndom

Note: Data refer to unmet needs for a medical examination or treatment due to costs, distance to travel or waiting times. Caution is required in comparing the data across countries as there are some variations in the survey instrument used. Source: Eurostat Database, based on EU-SILC (data refer to 2017).

There is no explicit list of benefits and all apply for prescribed outpatient medicines in England, necessary health services are covered although 90 % of those prescribed annually are dispensed free of charge. The largest gap in coverage There is a legal requirement for the NHS to deliver is for long-term care, which dominates OOP spending necessary health services and a commitment to (Figure 16). In England, spending on social care is patients’ rights. However, commissioning decisions are means-tested and not automatically funded by the most often made at the local level. This means that government. Personal social care is only considered a the provision of certain services which are considered universal benefit in Scotland. high-cost but non-essential (such as some fertility treatments) are more readily accessible in some parts Spending on outpatient medical care is often private of the United Kingdom than in others (Section 4). spending to access services that are formally available Dental care is included in the benefit package, but with the NHS, but which have long waiting lists, such patients pay fixed charges for NHS dental care unless as physiotherapy. Patients circumvent waiting lists they are exempt (e.g. children aged under 18 years, to receive quicker treatment by paying out of pocket pregnant and postpartum women, low-income to access private services, but not all households can households and other groups). Fixed charges also afford to do this.

Figure 16. Out-of-pocket expenditure is relatively low and dominated by spending on long-term care

Overll shre of Dstrbuton of OOP spendn Overll shre of Dstrbuton of OOP spendn helth spendn b tpe of ctvtes helth spendn b tpe of ctvtes

Unted ndom EU Inptent 05% Inptent 14% Outptent Outptent medcl cre 30% medcl cre 31% Phrmceutcls 41% OOP OOP Phrmceutcls 55% 16% 158% Lon-term cre 58% Dentl cre 25% Lon-term cre 24% Others 26% Others 09%

Source: OECD Health Statistics 2019 (data refer to 2017).

16 State of Health in the EU · United Kingdom · Country Health Profile 2019

Others

Lon-term cre

Dentl cre

Not OOP OOP Not OOP OOP phrmceutcls

Outptent medcl cre

Inptent utilities). 5: Catastrophic needs(i.e. expenditure isdefinedashouseholdOOPspendingexceeding40%of totalhouseholdspending netofsubsistence food, housingand private dentistsare expensive. and abletotreat NHS patients canbechallenging and dental care free ofcharge butfinding adentist willing Formally, low-income households canaccessNHS needs is greater fordentalcare thanformedicalcare. have beenincreasing. Income inequalityinunmet relative toEUaverages, butsince2008, unmetneeds Overall, self-reported unmetneedsare alsolow 90 %reported waiting timesasthemainreason. aged over 16reporting unmetneedsforhealthcare, financial reasons. Survey results show thatofthose are generally dueto waiting timesrather thanfor Unmet needsforhealthcare intheUnitedKingdom Source: WHORegional Office for Europe 2018; OECD Health Statistics 2019. Figure 17. Catastrophic spendingandout-of-pocket spendingare both low United Kingdom –1.1 million people –experienced standards, in2014, 1.4%ofhouseholds inthe (Figure 17). catastrophic spending compared totheEUaverage reflected inthe low percentage ofhouseholds facing OOP spending oninpatient care islow, andthisis household healthspending anissue isstill low levels ofunmetneeds, catastrophic Despite good financial coverage and % of households w thc t stroph c spend n 10 14 16 12 0 8 4 6 2 0 5 Although very low by international 5 FR 10 HR SI IE DE 15 CZ U€ SE State of Healthin the EU ·United Kingdom ·Country Health Profile 2019 S€ 20 AT EU18 EE PL 25 Kumpunen &Holder, 2018). on over-the-counter medicines(Cooke O’Dowd, prescription charges. This could reflect spending quintile, despiteincome-basedexemptions from of financialburden forhouseholds inthe poorest population, they are themostsignificantsource does notleadtofinancialhardship inthe general quintile. Although spending onoutpatientmedicines thirds ofthesehouseholds are inthe poorest income catastrophic spending onhealthservices;over two improve productivity were alsosuggested(Box 6). Term PlanfortheNHSinEngland, solutionsto digital operational efficiency (Box 5). As partofthenew Long mixofthehealthcarethe skill workforce tomaximise develop innovative solutionstocopesuch aschanging and Section5.3). This has pushed some providers to the extra servicesbeing commissioned(Section4 unspent becausethere are insufficientstaffto provide waiting timesandmeeting targets could beleft investments inthehealthsystemaimedatreducing Workforce shortages are such thatrecent extra times, reducing access to healthcare a factorindetermining longer waiting Health workforce shortages areincreasingly % of out-of-pocet p ments s sh re of he lthspend n HU PT 30 LT 35 EL 40 LV 45 CY 50 17

United Kingdom 6 Box 5. Skill mix is changing to cope with 5.3. Resilience shortages The health system faces increasing Periodic shortages of professional staff have demand with historical underfunding fostered skill mix innovation and change. A and recruitment deficits

United Kingdom key feature has been to allow lower level staff Since 2008, the focus shifted onto achieving to perform roles or tasks previously done by efficiency savings in the health system by increasing professionally qualified staff in order to fill gaps. productivity. A funding gap has emerged between In hospitals, a shortage of junior doctors triggered meeting the increasing health needs of the population a growth in extended roles for registered nurses. and the limited resources that have been made Similarly, there has been an increase in the number available to achieve this. Some of the increasing of clinical support roles to perform more routine demand is the result of natural demographic changes, aspects of patient care to reduce the workload of such as the large cohort of ‘baby boomers’ ageing, but registered nurses. Many such changes are locally technological and medical advances and increased organised by employers or have been issued by patient expectations have also played a role. Reduced professional bodies. This has led to an increase in access to long-term care has also added pressure on variety and thus challenges to ensure consistency hospital services. Demographic changes are projected and transferability of recognition for these to increase spending on long-term care from 1.5 % of competencies. GDP in 2020 to 2.7 % in 2070, while public spending on health care would increase from 8.1 % GDP in 2020 to 9.4 % in 2070, which contributes to the identification of fiscal sustainability risks in the medium and in the Box 6. Digital-first primary care in the Long long-term (European Commission, 2019b). Term Plan In 2017, analysis of projected demand and historical As part of the Long Term Plan for the NHS in funding growth rates suggested that at least GBP England, digital-first primary care will become 4 billion more for the NHS was needed in 2018/19 a new option for every patient to enable fast to stop patient care deteriorating. Spending was and convenient access to primary care by 2021. projected to fall by 0.3 % in 2018/19 without It is hoped that similar remote consultations for considerable investment. The government announced outpatient services will reduce the number of an increase in NHS spending (March 2018) and in-person visits by up to one third (avoiding up published the Long Term Plan for the NHS in England to 30 million outpatient visits a year). There are (January 2019). It sets out how an increase of GBP still concerns about monitoring and regulating 33.9 billion by 2023 (a 3.4 % annual increase in real the quality of care provided using these digital terms) should be spent. Most of the new spending tools (such as apps), as the doctors seeing is for clinical care, while new spending on capital, patients could be based anywhere – practices can public health and staff training are not included. subcontract this service to an online provider. This This injection of funds allowed hospitals to reduce has already happened as a pilot project in some or overcome their deficits, but access to the new areas of London for out-of-hours care. Data are funds was conditional on providers making further collected through these apps to train algorithms efficiency gains, and it is not clear how this can be that improve diagnostics and suggestions. It is achieved. Providers are still overspending because therefore important that data storage and use by of increased demand – particularly in urgent and these private companies is adequately regulated emergency care. to ensure that any big data generated serves the Reforms to commissioning and primary care seek to public good (Castle-Clarke & Imison, 2016). As improve the resilience of the system by integrating new models of digital primary care services are care at the local level, but also by addressing health developed, unintended issues they may present workforce shortages. However, commitments to are being examined to support innovation, while expand the health workforce, by providing more safeguarding patients, general practice and the undergraduate places and improving retention of wider system. existing staff, are probably insufficient to address the short-term shortages of staff (Section 4).

6: Resilience refers to health systems’ capacity to adapt effectively to changing environments, sudden shocks or crises.

18 State of Health in the EU · United Kingdom · Country Health Profile 2019 Source: Eurostat Database (data refer to 2017 ornearest year). average Figure 18. Both average lengthof stay andthenumberof hospital bedsare substantially lower thantheEU Foundation, King’s Fund&Nuffield Trust, 2018). care duetosubstantial staffing shortages (Health has the potential tocause great pressure insocial cause forconcern. A drop ininternationalrecruitment which hamper internationalrecruitment are also nurses leaving the workforce early. Migration policies of domestichealth workers as well asdoctorsand Workforce shortages are duetotheinsufficientsupply vacancies, sickness/absence andstaffturnover. of increased unplanned demands, highlevels of staff are usedtomanage workload intheface is theincrease intemporary staffing. Temporary A key driver oftheoverspending against budgets risk to the sustainability of the healthsystem Workforce challenges now present the greatest 0 4 6 2 Beds per1000popul
t on 5 3 7 1 2000 2001 2002 2003 2004 2005 State of Healthin the EU ·United Kingdom ·Country Health Profile 2019 2006 2007 Un ted  ndom 2008 2009 and more spending cutsare planned (Bradshaw, Bloor budget hasbeenseverely cutinreal termssince2015 advocacy for prevention, inEngland the public health care over preventive care servicesand, despitestrong However, aselsewhere, thesystemfavours acute growth inday surgery hasalsobeenrapid (Figure 19). hospitals andintoambulatorycare (Section4). The This reflects thedrive tomove more care outof in theEUat84.3%, secondonly toIreland in2016. Estimated bedoccupancy rates are among thehighest shocks. capacitythe small limitsthesystem’s toabsorb ability low ALOS compared totheEUaverage (Figure 18), but Kingdom is very efficient, withlow bed numbers and indicators suggestthathospitalcare intheUnited access toservicesorqualityofcare. Hospital future efficiencies are achieved withoutsacrificing caution isnow neededtoensure thatany possible more thanithas intherest oftheeconomy, and decade, productivity inthehealthsystemhas grown available by ‘doing more with less’. Over the past a given level butcreate savings toincrease funds The aimhasbeento protect healthspending at allocates resourcesefficiently Indicators suggest the healthsystem & Doran, 2018). 2010 Beds 2011 2012 ALOS 2013 2014 EU 2015 Beds 2016 ALOS (d
s) 2017 ALOS 0 2 4 6 8 10 12 19

United Kingdom Figure 19. The share of surgical operations and procedures performed as day surgery has increased more rapidly than the EU average

% of d sur eres 2006 2016 100

United Kingdom 90 80 70 60 50 40 30 20 10 0 Unted n dom EU Unted n dom EU Unted n dom EU Ctrct In unl hern Tonsllectom

Source: OECD Health Statistics 2018; Eurostat Database (data refer to 2006 and 2016, or nearest year).

Prescribing by active principle is widespread and leads to the high Box 7. Embedding health technology penetration of generic medicines assessment ensures efficient access to effective medicines Prescribing by international non-proprietary name NICE is a specialist health technology assessment (INN) is an important driver of efficiency. The generics (HTA) agency for the NHS in England, Wales market share has been consistently growing since and Northern Ireland, and it works closely with 2000 with the United Kingdom having the highest Healthcare Improvement Scotland. These agencies proportion by volume in the EU at 85.2 % for the assess the affordability of new treatments in publicly funded pharmaceutical market (Figure 20). By addition to their cost–effectiveness (through a value, 37.6 % of the publicly funded pharmaceutical ‘budget impact threshold’). Their recommendations market is made up of generics, which is the second are advisory but are generally considered in highest in the EU behind Austria. This is due, at decisions about which services to commission. least in part, to the implementation of prescribing Both are partners in the EUnetHTA Network. guidelines for GPs (European Commission, 2019c). All four nations collate evidence of cost–effectiveness Their analysis is also used when negotiating down and the affordability of new treatments to inform the high cost of innovative medicines, which policymaking and make the best use of available are purchased centrally. From January 2019, a resources (Box 7). voluntary scheme to introduce a more streamlined and flexible approval process fast-tracks the best value innovative medicines. This will give patients access to new medicines up to six months earlier, as well as potentially saving the NHS nearly GBP 1 billion in the next year.

20 State of Health in the EU · United Kingdom · Country Health Profile 2019 higher education, as well asmany non-government NHS. There isalsoenormousresearch capacity in the evidence baseto guide decision-making inthe care research intheUKanditsrole isto provide Research isthelargest funderofhealthandsocial performance. The NationalInstituteforHealth evidence, as well asformonitoring andevaluating The healthsystemhas good capacity for generating policymaking evidenceguide to Effective knowledge-generation provides Source: OECD Health Statistics 2019. Note: Data refer to theshare of genericsinvolume. Figure 20. Theshare of thegenerics market isoneof thehighest inEurope 80% 60% 90% 40% 20% 50% 30% 70% 10% 0% 2005 Un ted  ndom 2006 2007 2008 Frnce

State of Healthin the EU ·United Kingdom ·Country Health Profile 2019 2009 2010 2011 generally takes tobearfruit(Edwards, 2018). of reforming healthsystemsandhow long change which are oftenover-optimistic given thecomplexity results from bigchanges over very tighttimescales, Policymakers are under pressure toachieve positive does notalways filterthrough to potentialsolutions. implementation ofnew strategies and policies, butit used by policymakers toassessandinformthe health system. The evidence generated isregularly organisations which analyse developments inthe Germn 2012 2013 2014 EU17 2015 2016 2017 21

United Kingdom 6 Key findings

• The population of the United Kingdom enjoys • The health system has been a site of policy

United Kingdom high life expectancy, and the overall health innovation as decision makers have sought status of the population is good. However, to meet increasing health demands with these average figures mask wide disparities limited resources. Innovations in workforce in health by socioeconomic status. The gap policies have focused on greater team in life expectancy at birth between the most working and task shifting in both primary affluent and most deprived is 9.3 years for and specialist care. Increasingly, the use of men and 7.4 years for women. Improvements remote consultations relying on modern in life expectancy have slowed since 2011, communications technologies have become mainly due to the slowdown in mortality a reform target for both primary and hospital improvements at older ages. outpatient (ambulatory) care. While these innovations may improve accessibility and integration, it is not clear that they will • Although the proportion of deaths attributed automatically contain costs. to behavioural risk factors is below average for the EU, over one third of all deaths in the United Kingdom can be attributed to tobacco • In 2018, an injection of funding for the many smoking, dietary risks, alcohol consumption English National Health Service providers and low physical activity. The United Kingdom in deficit relieved some of the financial spends considerably more on preventive pressure in the system as it cut deficits, but services than other countries, yet there has disbursements were conditional on providers been little progress in reducing preventable achieving even more efficiency gains. mortality since 2011. Hospitals are already working at near full capacity with high occupancy rates and short lengths of stay. It is unlikely that additional • The four nations of the United Kingdom all efficiency gains alone can be sufficient to have tax-funded health systems that provide reduce health spending. The system is already universal access to a comprehensive benefit efficient, and overspending is driven by the package. Overall, there are low levels of unmet need to meet increasing demand for services. needs, low out-of-pocket spending and good In social care, funding cuts have pushed many financial protection. This is achieved with providers to the brink of financial insolvency. average levels of health spending.

• Beyond underfunding, shortages in the health • Waiting times are the main barrier to workforce are a key challenge. The United access and are used to ration care in the Kingdom relies on migration to sustain its face of resource constraints and increasing health system. International recruitment is demand. Waiting times are increasing, but hampered by restrictive migration policies, are similar across socioeconomic groups. As uncertainties around the United Kingdom’s in other countries, increasing demand in the position vis-à-vis the EU and the rights of United Kingdom is largely due to population EU nationals living there. In turn, staffing ageing; while people are surviving previously shortages make the working environment untreatable conditions, they are living longer more stressful and difficult. with chronic diseases and multimorbidity.

22 State of Health in the EU · United Kingdom · Country Health Profile 2019 Key sources

Cylus J et al. (2015), United Kingdom: Health System OECD/EU (2018), Health at a Glance: Europe 2018 – Review. Health Systems in Transition, 17(5): 1–125. State of Health in the EU Cycle, OECD Publishing, Paris, https://www.oecd.org/health/health-at-a-glance- europe-23056088.htm

References

Bradshaw J, Bloor K, Doran T (2018), ESPN Thematic Health Foundation, King’s Fund, Nuffield Trust (2018), Report on inequalities in access to healthcare UK. The health care workforce in England: make or break? European Commission, Brussels. Nuffield Trust, London.

Castle-Clarke S, Imison C (2016), The digital patient: Office for National Statistics (2018), Health state life transforming primary care? Nuffield Trust, London. expectancies by national deprivation deciles, England and Wales: 2014. Statistical bulletin, 1 March 2018. London. Cooke O’Dowd N, Kumpunen S, Holder H (2018), Can people afford to pay for health care? New evidence Public Health England (2018a), A review of recent trends on financial protection in the United Kingdom. WHO in mortality in England, PHE publication gateway Regional Office for Europe, Copenhagen. reference 2018655. Public Health England, London.

Department of Health, United Kingdom (2019), Public Health England (2018b), Health profile for Contained and controlled: the UK’s 20-year vision for England: 2018. Public Health England, London. antimicrobial resistance. HM Government, London. Rechel B, Richardson E, McKee M, eds. (2018), The Edwards N (2018), Lesson 1: Avoid the temptations of the organization and delivery of vaccination services in grand plan. Nuffield Trust, London. the European Union. European Observatory on Health Systems and Policies and European Commission, European Commission (2019a), Country Report United Brussels, http://www.euro.who.int/__data/assets/pdf_ Kingdom 2019. 2019 European Semester. Brussels, https:// file/0008/386684/vaccination-report-eng.pdf?ua=1 ec.europa.eu/info/sites/info/files/file_import/2019- european-semester-country-report-united-kingdom_ en.pdf

European Commission (2019b), Fiscal Sustainability Report 2018. Institutional Paper 094. Brussels.

European Commission (2019c), Joint report on health care and long-term care systems and fiscal sustainability – Country documents 2019 update. Institutional Paper 105. Brussels, https://ec.europa.eu/info/sites/info/files/ economy-finance/ip105_en.pdf

Country abbreviations

Austria AT Denmark DK Hungary HU Luxembourg LU Romania RO Belgium BE Estonia EE Iceland IS Malta MT Slovakia SK Bulgaria BG Finland FI Ireland IE Netherlands NL Slovenia SI Croatia HR France FR Italy IT Norway NO Spain ES Cyprus CY Germany DE Latvia LV Poland PL Sweden SE Czechia CZ Greece EL Lithuania LT Portugal PT United Kingdom UK

State of Health in the EU · United Kingdom · Country Health Profile 2019 23 State of Health in the EU Country Health Profile 2019

The Country Health Profiles are an important step in Each country profile provides a short synthesis of: the European Commission’s ongoing State of Health in the EU cycle of knowledge brokering, produced with the ·· health status in the country financial assistance of the European Union. The profiles ·· the determinants of health, focussing on behavioural are the result of joint work between the Organisation risk factors for Economic Co-operation and Development (OECD) and the European Observatory on Health Systems and ·· the organisation of the health system Policies, in cooperation with the European Commission. ·· the effectiveness, accessibility and resilience of the The concise, policy-relevant profiles are based on health system a transparent, consistent methodology, using both quantitative and qualitative data, yet flexibly adapted The Commission is complementing the key findings of to the context of each EU/EEA country. The aim is these country profiles with a Companion Report. to create a means for mutual learning and voluntary For more information see: ec.europa.eu/health/state exchange that can be used by policymakers and policy influencers alike.

Please cite this publication as: OECD/European Observatory on Health Systems and Policies (2019), United Kingdom: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.

ISBN 9789264578661 (PDF) Series: State of Health in the EU SSN 25227041 (online)