London School of Hygiene & Tropical Medicine

“I wouldn’t be here today if it were not for the NHS”. This was Professor Steven Hawking’s response to an American newspaper which used him as an example to highlight the deficiencies of the NHS writing, ‘People such as scientist Stephen Hawking wouldn't have a chance in the UK, where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless’.

Over the past 150 years or so, people in the UK have seen tremendous increases in the number of years they could expect to live. In 1871, the average newborn girl was looking to live to around 45 years and by 2016, this had almost doubled to 83 years. For boys, these figures are a bit smaller, at 41 years in 1871 and 79 years in 2016. Much of this increase in life expectancy was, at least initially, due to public health improvements such as the provision of clean drinking water, safe sewage disposal, and improved food safety. Advances in medicine also played a role, albeit a smaller one. These included the development of antibiotics, along with improvements in surgery, anaesthesia and antenatal care since the 1930s.

Indeed here at the London School of Hygiene & Tropical Medicine (LSHTM), we showed how the decline in deaths from tuberculosis in England and Wales accelerated markedly following the introduction of chemotherapy in the late 1940s, with striking year on year reductions in death rates among young people in particular. This advance in treatment changed TB from a fatal disease to one that could be cured with drugs.

It was however only from the mid-20^th century when the impact of medicine and health care on people’s health became much more evident, with new interventions becoming increasingly available to treat conditions such as high blood pressure and some cancers. One example is death rates from heart disease, which halved between 1980 and 2000, with around 40% being attributable to improvements in access to treatment.

Women in the UK have also seen impressive reductions in deaths from breast cancer from the 1990s onwards, mostly as a result of better diagnostics and treatment. Work by LSHTM’s Professor Bernard Rachet and others has demonstrated consistent gains in survival from a number of treatable cancers since.

Then comes our work on amenable mortality, a term which describes deaths from a collection of diseases, for example diabetes and appendicitis, which are preventable with effective and timely health care. Amenable mortality can be used as a marker for the performance of health care systems.

Using this concept we have shown that between the early 1980s and late 1990s, improvements in access to timely and effective health care in the UK has added around 2.4 years to the lives of men under the age of 75. For women, these gains were smaller, at around 1.4 years. The difference between the two can be explained by higher levels of heart disease among men, which meant the potential to improve their life expectancy was greater. Importantly, these improvements have continued through the 2000s, although at a slower pace.

So we are doing well? The UK consistently ranks among the best performers in international comparisons of health systems, although this depends on the nature of comparison one choses to look at. Internationally, the UK does particularly well on measures such as prevention, safe care, coordination, and patient engagement, as well as equity. Yet, when it comes to outcomes, the picture is different.

While there have been considerable improvements in life expectancy and amenable mortality, some we have discussed here; internationally the UK continues to lag behind other comparable wealthy countries. This has been and remains a particular concern when looking at cancer survival, as highlighted by LSHTM’s Professor Michel Coleman and the Cancer Survival Group. They have shown that despite improvements, cancer survival has remained poorer in the UK. Likewise, while the UK now outperforms the US on the number of deaths that should be avoided through timely and effective health care, rates remain higher than those of its European neighbours.

The NHS today is under tremendous pressure to continue to deliver a service that is effective, accessible, equitable and sustainable. This remains a challenge, with recent work by Lucinda Hiam Professor Martin McKee noting that improvements in life expectancy at birth might be stalling for the first time since the introduction of the NHS in 1948. This is a matter of great concern, and although there may be many possible reasons for this, it highlights the important role of independent monitoring and academic scrutiny of trends and patterns in population health indicators. This is the work that can demonstrate and ensure the NHS continues to contribute to improving the health of people in the UK.