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June 2021

Commission reports on strengths and weaknesses of NHS



Although the NHS is held up internationallyas a leading example of universal health care, the health of the UK population lags behind that of other high-income countries, according to the authors of a new report.

In 2018, to mark the 70th anniversary of the NHS a major new Commission was established by The Lancet and London School of Economics and Political Science(LSE) to independently evaluate the NHS and its role in health in the UK.

Reporting after 3 years, this UK-wide 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 Commission highlights low funding for the health service, and the impact of poorly resourced social care and public health programmes on the health of the nation and its role in driving inequalities.

The report identified nine key priorities for action, including funding, workforce planning, pandemic preparedness, and improving population health, and it makes seven recommendations to address these priorities, including:

  • Immediately increase investment in the NHS, social care, and public health by 4% per year in real terms
  • Develop a sustainable, skilled and inclusive fit-for-purpose health and care workforce
  • Strengthen prevention of disease and disability and preparedness to protect against major threats to health
  • Develop and enhance diagnostics to improve treatment outcomes and reduce inequalities

Pandemic response

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 are complex and not yet fully understood, but elements of the UK Government response have been criticised, including delayed implementation of physical distancing measures, and a dysfunctional track and trace system. Testing capacity, availability of 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, the report says. 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 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.

Changing health needs

The demographics of the UK population are changing and so is the need for health care. Relative to other high-income countries, the UK is lagging on many health outcomes, such as life expectancy and infant mortality, and there is a growing burden of mental illness. The rise of multimorbidity, and persistent health inequalities, particularly for preventable illness, are issues that the NHS will face in the years to come. The immediate priority of the NHS will be to mitigate the wider and long-term health consequences of the COVID-19 pandemic, but it must also strengthen its resilience to reduce the impact of other threats to health, such as the UK leaving the EU, climate change, and antimicrobial resistance.

Workforce issues

Approximately 13% of the total UK workforce is employed in the health and care sector. Education, training, and workforce plans have typically considered each healthcare profession in isolation and have not adequately responded to changing health and care needs. The results are persistent vacancies, poor morale, and low retention.

Areas of particular concern include primary care, mental health, nursing, clinical and non-clinical support, and social care. Responses to workforce shortfalls have included a high reliance on foreign and temporary staff, small-scale changes in skill mix, and enhanced recruitment drives.

The report argues that to secure a sustainable and fit-for-purpose workforce, integrated approaches need to be developed alongside reforms to education and training that reflect changes in roles and skill mix, as well as the trend towards multidisciplinary working.

To sustain annual growth in the workforce at approximately 2·4%, increases in NHS expenditure of 4% annually in real terms will be required. Above all, a radical long-term strategic vision is needed to ensure that the future NHS workforce is fit for purpose.


LSE-Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19. Lancet 2021;397:1915-1978.

Practice Nurse 2021;51(05):8-11