To provide a sense of perspective (quoted in full).
https://www.telegraph.co.uk/business/
It’s not just the NHS: health services are imploding all over Europe
Waiting times are surging, staff are leaving and patients are dying across the continent
By Matt Oliver and Eir Nolsøe, 8 January 2023 • 6:00am
Sick patients flood in at the university hospital, filling up already overcrowded wards.
With doctors and nurses overwhelmed – and many struck down by illness themselves – planned surgeries have been cancelled to help cope with the influx of winter admissions.
“There is a perfect storm going on right now – and we lack staff,” one health leader complains on television.
To British ears, this will all sound familiar. Yet these scenes are unfolding in Sweden, where a winter crisis not dissimilar to our own is also wreaking havoc with the health service.
“The spread of respiratory viruses is at a high level and the burden on the healthcare system is great,” the Swedish Public Health Agency warned on Thursday.
“Staying home when sick is especially important.”
Swedish and UK hospitals are far from alone. Across most of Europe, healthcare systems – ravaged for three years by the pandemic – are struggling with huge backlogs while they simultaneously battle a “triple epidemic” of Covid, seasonal flu and the respiratory syncytial virus (RSV) this winter.
In Italy, medics have warned emergency departments are being “pushed to their limit” after flu cases hit their highest level for 15 years, while Spanish doctors have gone on strike over claims they are being chronically overworked. Authorities in France, meanwhile, have recommended people wear masks indoors again because of the rising number of infections.
As with Britain’s NHS, the crises are the result of short-term damage wrought by the coronavirus and long-term problems that have been stewing in the background for years.
After sidelining all but the most essential care during the pandemic, governments are now scrambling to reduce waiting lists. But they are juggling this priority with demands for greater funding to cope with older and sicker patients, while inflation eats away at their budgets.
The UK appears to have been hit harder by many of these challenges but their causes – from ageing populations to staff shortages – are common throughout the developed world.
But in interviews with the Telegraph, experts warned there are no easy or quick fixes for many of these issues. In the coming years, they will prompt searching questions about the provision of healthcare and how it should be managed without bankrupting the West.
“We get richer as a society in order to be able to invest and spend on innovations which allow us to live longer and enjoy more rewarding lives,” says Anita Charlesworth of the Health Foundation.
“What is challenging, when you fund the system through taxation, is that actually more and more of our taxes are going on the welfare state services that we value in our old age in particular.
“If we want these things over the medium to longer term, and it makes sense to provide them collectively, then the implications of that are that taxes as a share of GDP have to rise.
“Ensuring that's seen as fair, and that the public are happy to do that, is a challenge that all high-income countries are facing now.”
There were already signs that healthcare systems in the European Union were under strain before the pandemic, although performance across the bloc varied significantly.
In many countries this came after governments sought to repair their balance sheets in the wake of the financial crisis, trimming health spending or slowing increases.
According to data from the Organisation for Economic Co-operation and Development (OECD), this resulted in a fall in health spending as a proportion of GDP in the UK, France, Italy, Denmark, Ireland and Greece from 2009 to 2019.
Germany, Spain, the Netherlands, Norway, Austria and Finland managed to keep budgets flat or raise them slightly.
At the same time, EU populations continued to age, putting more pressure on health services. In the bloc’s 27 countries, the proportion of people aged 65 and above has risen from 17.5pc to 20.4pc.
Obesity surged as well, to about 60pc of the population in the European region – second only to the Americas – according to the World Health Organisation.
The rise of more complex health needs and flat or falling funding coincided with growing waiting times in many cases. They have climbed in Ireland, Portugal, Spain and the Netherlands in the decade following the financial crisis.
In 2018, the average waiting time for a knee replacement came in at 98 days in the UK, 152 days in Norway and 253 days in Poland, to give some examples.
Luigi Siciliani, a waiting times expert and professor of economics at the University of York, says this meant “health systems were already under stress pre-Covid”.
In Ireland, the government had been battling unsuccessfully to bring down waiting lists for years, with doctors’ associations blaming the problem on a lack of beds and trained staff.
The number of patients waiting for some form of hospital treatment stood at about 553,000 at the end of 2019 – well over target. But the pandemic has caused the figure to balloon even further to 897,300, almost one fifth of the population.
Likewise, the NHS waiting list in the UK stood at 2.3 million in 2009 but by early 2020 had increased to 4.3 million. Today, the figure is about 7 million – equivalent to more than a tenth of the population.
The coronavirus pandemic then dealt a devastating blow to all health services, as it forced them to prioritise urgent care for the huge influx of Covid patients and put off non-emergency procedures as they grappled with the crisis. Later efforts to ensure populations were vaccinated also sucked up time and resources.
During that period, many people avoided visits to the doctor or missed appointments, for fear of becoming infected or contributing to strain on the system.
According to the OECD, the true impact of these delays to care may not come to light for years. Those who missed cancer screenings could now be diagnosed at a later stage, for example, requiring more substantial and costlier treatment. Mental health problems that may have built up during lockdowns are also expected to have a lasting effect, adding to demand.
Overall, survey company Eurofound reported that more than one in five people in EU countries had foregone medical care, including examinations and treatments, during the first year of the pandemic – with a similar number reporting they still had unmet needs in spring 2022.
“We know that we've almost certainly missed a lot of serious illness during the pandemic,” says Anita Charlesworth, director of research at the Health Foundation and a former top civil servant.
“And being able to have a timely diagnosis is really important. Early diagnosis tends to be associated with better outcomes and it tends to mean that you need less complex healthcare intervention, which is more costly in the end.
“So early detection and diagnosis is in the patient's interest and it's also in the taxpayer’s interests.”
But the return of patients seeking care again, coupled with more limited availability as health services still grapple with Covid and other respiratory diseases this winter, is putting further upward pressure on waiting lists. It means more patients could see their conditions worsen.
And as with the initial shock of the pandemic, some countries are dealing with the resumption of normal services better than others.
“Most countries experienced increases in waiting times,” York’s Siciliani explains. “The size of the problem, the backlog and the waiting list seems more prominent in England than in several other European countries, such France, Germany and Italy, though not all of them.
"For example, Ireland, Portugal, Poland have similar or longer waiting times.”
There were differences in how health systems coped with the initial impact of the pandemic as well. Between 2019 and 2020, the volume of hip replacements dropped by at least 45pc in England but only by 20pc in Italy and Spain and less than 5pc in Finland and Denmark, the OECD found.
Part of this is down to the spare capacity they had pre-pandemic and the state of their workforces, including how stretched they are, experts say.
Charlesworth argues this is why the NHS in England has been hit harder than other countries.
“Going into Covid, we were already struggling to meet our performance standards, we had less capacity, so we had to delay more treatments,” she says.
“We have very high levels of bed occupancy, fewer staff and fewer beds, which means our resilience to peaks in demand is lower than countries like Germany and France.”
Pandemic hangover
Like in the UK, the aftermath of the pandemic has piled pressure on healthcare systems across Europe as well.
Flu and other respiratory diseases have come roaring back as life returns to normal, while looming under more acute issues is the structural shift towards a more elderly population suffering from more chronic conditions.
Meanwhile, many healthcare staff – exhausted from the pandemic – are eyeing the exit.
Alessandra Taraschi, a GP in Rome and spokesman for the Italian Federation of General Practicioners, says these challenges are just as familiar in Italy as they are in Britain.
During the pandemic she and her colleagues had to work around the clock to help Covid patients despite great uncertainty around how to diagnose and treat them.
Then came the drive to vaccinate most of the Italian population. And now? A massive care backlog and growing anxiety among sickly patients.
“We’re really tired,” she says. “Many of us worked with burnout due to this workload. And now we have to manage all these examinations that haven't been done [during Covid].”
Taraschi has also noticed that since Covid, patients have become more anxious about minor health issues which they could easily manage themselves at home, such as colds and flu, and are seeking appointments with GPs.
Elsewhere, the situation in Italian hospitals will also sound familiar to Brits.
“There are huge waiting lists,” she says. “So people in hospitals have to work longer hours to get them down.
“There is also great demand due to flu and respiratory viruses.
“We don’t have enough beds for patients, so they have to wait a lot in the emergency department. But it’s not a problem of furniture. There aren’t enough doctors.”
Another long-running problem that continues to affect many health services is the state of their poorer cousin: social care.
Often, valuable hospital beds are being occupied by patients who should be discharged but are waiting for services in the community or a care home place. Being able to promptly discharge patients is vital, as otherwise they occupy beds needed by others.
“What do you do after the hospitals? It's a huge problem,” Taraschi says.
The social care system is struggling in the UK too.
“A lot of the problems that we're experiencing at the moment are the perfect storm of this pressure from infectious disease and Covid combined with problems of not being able to discharge patients,” Charlesworth says.
“Whereas in the past 20 years we've seen the amount of time patients stay in hospital fall, we are now seeing the amount of time that patients stay in hospital increase.
“The social care system was very, very fragile going into Covid.”
Rising demand for doctors
A key issue behind capacity problems in both the health and social care systems is staffing.
In fact, a shortage of doctors and nurses is “a problem in virtually all developed countries”, according to Gaetan Lafortune, an economist at the OECD.
And although these concerns are not new, they have taken on a new importance after the pandemic.
“There are more doctors and nurses now in virtually all EU and OECD countries than there were 10 years ago, both on an absolute level and relative to the population,” Lafortune says.
“But this doesn't mean that the shortages have become smaller because the demand has increased more rapidly.”
In Rome, Taraschi says many doctors are retiring early because they feel depleted and worried about their personal health.
This is adding to existing staff shortages, while not enough young people are going into training.
It means that although Italy currently enjoys slightly more doctors per head than most of the EU – four per 1,000 people compared to 3.9 across the bloc – the number working in public hospitals and GP surgeries is declining.
With many of those remaining tending to be older and approaching retirement, the European Commission predicts a “significant shortage in the years to come, especially in some specialties and general practice” as they continue to leave the workforce.
On top of this, Italy employs fewer nurses than nearly all western European countries, with roughly 6.2 per 1,000 people, and the number of nursing graduates has been in decline since 2014.
In the UK, there were 8.7 nurses and 3.2 doctors per 1,000 people last year, according to OECD data.
British doctors tend to retire earlier than in other countries, with the UK retaining the lowest share of doctors above the age of 55 among OECD countries. The British Medical Association has warned that the way the NHS pension scheme and national taxation policies interact means the “most sensible course of action” for many doctors is to reduce their work or stop working altogether.
Exhaustion from the pandemic and inflationary pressures are also causing many staff to consider quitting their jobs across Europe, Lafortune warns, with discontent evident in the widespread strikes plaguing the continent.
In Spain, thousands of healthcare workers walked out in November. In France, the same happened in June. German doctors held strikes in March. Over the past two years, Danish nurses have been on strikes multiple times.
Ana Giménez, a representative of the State Confederation of Medical Unions in Spain, told local media that many hospitals were having to compete with private companies and other countries for trained personnel.
“It is a long and tiring career and the new generations are less and less willing to let their vocation take over,” she told newspaper El País in November.
“Instead of working in Leganés in the evenings in exchange for €35,000 a year to see 60 patients a day, they go to France to see 20 for €90,000.”
The story is similar in social care, where British providers are battling with supermarkets for potential recruits – and losing.
Dr Carolyn Downs, a researcher at Lancaster University, told MPs on a parliamentary committee that many social care workers are stressed by the lack of time they have to do essential tasks and travel between clients and complain of poor pay and “low status” in society.
The issue is so bad that even the opening of a new shop near a care home can trigger an exodus.
“We have had care managers saying, ‘I dread hearing Aldi is opening up nearby, as I know I will lose staff’,” Downs said in a written submission to the Health and Social Care select committee.
Funding cuts to local authorities – which are responsible for running the vast majority of social care – are partly responsible.
Per person spending on social care for over-65s fell by 31pc to £391 between 2009 and 2018, according to the Institute for Fiscal Studies (IFS).
The funding squeeze has left councils unable to pay social care workers competitive wages, making it harder to attract recruits and exacerbating the staff shortages.
Britain’s exit from the EU, which has made it harder for European workers to get jobs here, leading to a drop in the overall size of the workforce, according to recent research by the Nuffield Trust.
But the shortages in social care have also had a more direct impact on hospitals, piling extra pressure on them and creating a toxic feedback loop.
The IFS estimates that as social care funding has declined, admissions of over-65s to A&E have increased by about 30pc. As much of half of that increase was probably attributable to the cuts, the think tank said.
But while many health services across Europe are all dealing with similar issues, the tighter situation in the UK health meant it entered the pandemic with very little spare capacity - making it more vulnerable to shocks.
“During normal times, we're running a very efficient system,” says Icaro Rebolledo, another economist at the Health Foundation.
“But once something gets out of control that is not normal, then because you running the system with less capacity then you're not able to cope with those unexpected shocks.
“That is one of the things that left the system less able to cope.”
More worryingly, research by the IFS recently warned that the coronavirus pandemic appears to have left the NHS able to treat fewer patients despite having more resources.
The Government has announced an extra £3.3bn of funding for the NHS in each of the next two years, meaning that by 2024/25 the budget will be 2.9pc higher than under pre-pandemic plans.
Overall, annual NHS funding is currently 11.1pc higher than pre-pandemic levels and the health service has 8pc more nurses and health visitors than before, at 22,700.
But the IFS said the NHS was still struggling to treat more people than it was in 2019.
No one really knows why, says researcher Max Warner, but it may be a combination of factors, from staff burnout to more complicated health conditions and even possibly a lack of managers who can look at things strategically.
York University’s Siciliani says there are tried and tested ways to bring waiting lists down, many of which were pioneered by the NHS in England in the 2000s.
They involve ploughing in extra funding, setting guarantees for maximum wait times and bringing in the private sector.
But the staffing shortages – not to mention widespread exhaustion – will make this much harder.
“The health workforce is exhausted, sickness and leave absences are high and recruiting or retaining personnel is more difficult, which slows down the recovery,” he says.
The call for yet more resources are also unlikely to go down well with ministers, who have already funnelled more cash towards the NHS at the expense of swinging cuts in other areas of government spending.
The Health Foundation’s Charlesworth says there is no clear evidence that one particular model of health funding works better than others. The NHS is funded entirely by taxes, like its equivalents in Sweden, Italy and elsewhere.
In France and Germany, patients must make compulsory payments towards a social insurance system. But this is little more functionally than a tax – and one that only targets working people, meaning that they bear all the higher costs when premiums have to rise.
Another alternative is to means-test provision, as is done in Ireland. There, only medical card holders qualify for entirely free healthcare and these are given out based on family income – making the system essentially a safety net.
Non-card holders must fund their own GP consultations and prescribed medicines, although they may access hospital care for free or at reduced rates.
Partly as a result of this, Irish government spending on healthcare is just 6.7pc of GDP, compared to 11.9pc in the UK.
But Charlesworth argues that the best way to better fund the NHS is to simply grow the economy, rather than necessarily adopt new funding mechanisms.
“In a decade where one of the biggest challenges we face is economic growth, putting more of the cost of our health care on to workers and employers, which is what social insurance systems do, does not seem to me to be intuitively attractive,” she adds.
“The biggest problem we've got really in affording our healthcare system is the lack of economic growth. So we want a flourishing economy that in the end, will help us to afford a flourishing NHS.”
As hospital wards across the Continent continue to fill up, and waiting lists elongate, coping with these new challenges is only going to become harder – whether it is in Sweden, Italy, Britain or elsewhere.
