Howard Lyons offers a personal viewpoint

For many years now, successive British governments have been accused of trying to sell off or privatise the National Health Service. The Lansley Reforms introduced by the Coalition Government in 2012 were felt by some to be preparing the way for greater involvement of the private sector in both the commissioning and the delivery of healthcare services. But the Five Year Forward View for NHS England, published in October 2014, (1) put more emphasis on partnership and innovation in raising standards and transforming the provision of healthcare to meet the needs of the 21st century. The role of the private sector was noticeable by its absence.

Nevertheless, there is considerable scope for selling NHS services to an international clientele which has long been eager to access the knowledge and expertise acquired over the past 68 years of operating the world's largest universal healthcare system. Showcasing the NHS and Great Ormond Street Hospital in the opening ceremony of the London Olympic Games reminded the world how highly we British regard our tax-funded health system, free at the point of need, and how integral it is to our social identity as a nation. It also elicited a barrage of requests for help in improving their health systems from a wide range of countries, most notably those emerging nations with increasing economic success, such as India, China, Brazil and the Middle East.

Many shortcomings

As citizens of the UK - and even more so for those of us who work inside the NHS - we are uncomfortably aware of its shortcomings, whether they be the mounting pressures on GP services, the heavy reliance on agency nursing staff, the deficiencies in mental health provision, overcrowding in Accident and Emergency Departments, and the lack of integration between health and social care, to name just a few. The Forward View seeks to address the perceived widening gaps in health and wellbeing, care and quality, and funding and efficiency through the creation of new partnerships and 'the right investments'; so there is no complacency about the challenges we are facing. But in an international context, we have much to be proud of - and grateful for - compared with most other countries. Perhaps Jesus' summing up of the parable of the talents is relevant here: 'From everyone who has been given much, much will be demanded; and from the one who has been entrusted with much, much more will be asked.' (2) What is certain is that as part of a global community we cannot simply live to ourselves.

An ageing population

The oft-quoted report by researchers at the New York-based Commonwealth Fund published in 2014 bears testimony to the high regard in which our health system is held when compared with countries like France, Switzerland, Germany, Sweden, the Netherlands, Australia, Canada and the United States (see chart on next page). The UK comes out top on access, quality of care and efficiency, and second on equity. But of greatest interest to emerging nations, struggling to know how best to provide acceptable standards of healthcare to their burgeoning populations, is the expenditure per capita figure where the UK is lower than all the other countries, apart from New Zealand, and less than half the cost per head of the United States. (3)

However, the latest OECD Report (4) demonstrated that the UK, at 8.5% of GDP, is still below the OECD average of 8.9% and is also below the UK level for 2009 when figures are adjusted for inflation. Understandably, most people would agree with the OECD's conclusion (and the Economist Intelligence Unit's analysis of the same figures) that the UK needs to spend more of its GDP on healthcare if we are to cope with the rising demands of an ageing population. (5) But since 2009, Britain has been trying to tackle unprecedented levels of national debt and a growing budget deficit. So where is the muchneeded extra money going to come from?

Sharing expertise

One contribution could come from income generated by sharing expertise with the international community, especially in emerging markets where growth in expenditure on healthcare in countries like China is expected to double in the decade up to 2020. And so, following the Olympic Games in 2012, the Department of Health, NHS England, and UK Trade & Investment jointly agreed to establish a new organisation to facilitate the export of British healthcare knowledge and experience to generate revenues for the UK economy.

This new organisation, called Healthcare UK, was launched at Arab Health in Dubai in January 2013 with a mandate to encourage suitably-qualified public and private sector healthcare organisations to maximise their export potential. Targeting the high growth countries in Asia, the Middle East and Latin America, Healthcare UK (6) was tasked with identifying the biggest opportunities for British organisations to work with overseas governments to help them improve their healthcare delivery through major infrastructure projects, training and education partnerships, application of digital technology, advice on health systems development and sharing expertise in genomics, clinical services and personalised medicine.

Partnerships

In each of these areas, Healthcare UK has facilitated engagement for NHS Trusts, arms-length bodies like Public Health England, Royal Colleges and Universities. Many of these already had international experience but often lacked the commercial knowledge to take best advantage of the opportunities that were being identified. Overseas governments were keen to engage with the most wellknown institutions such as Great Ormond Street Hospital but, above all, they wanted access to the knowledge and expertise which they associated with the NHS brand. By creating consortia of NHS, private and educational institutions to respond to specific needs, Healthcare UK has been able to provide tailored solutions where risks are mitigated for the public not-for-profit organisations and revenues are maximised for all parties.

Not only does this generate much-needed revenues for NHS Trusts but often it will expose NHS staff to other health delivery systems and offer invaluable learning opportunities through working on international projects. Examples include one North London Trust sharing their world-class research and experience in community-based mental health delivery with the Mongolian Centre for Mental Health. NHS Tayside has customised their model for delivering improved outcomes for diabetes patients with the Kuwait Health Network. Leeds University Teaching Hospitals has developed a partnership with the King Hussein Cancer Centre in Jordan for research and clinical services support. Portsmouth has franchised a programme used in more than eight countries teaching staff to anticipate, recognise and prevent critical illness at an early stage. King's College Hospital has agreed to help establish a teaching hospital and medical school in Punjab. And this selection of projects is just the tip of the iceberg. Many UK-based clinicians have developed associations and partnerships with clinicians working in other countries which have significant revenue-generating potential if properly addressed. The key is to develop the right business model to minimise risk and any potential impact on home services, whilst maximising the returns for the NHS Trust.

Healthcare UK focuses on projects that will generate revenues for the UK economy, but it also helps organisations who want to share their expertise on a philanthropic basis. Many NHS Trusts have set up partnerships to work with overseas hospitals that are less well-resourced.

Income generation

The Tropical Health & Education Trust (THET) has been a facilitator of such partnerships for the past 25 years. (7) THET has been appointed by the Department for International Development to administer the Health Partnership Scheme, which helps UK health institutions and professionals to establish partnerships with counterparts in developing countries to strengthen health systems in some of the poorest countries through skills transfer and capacity development. A typical example is the partnership between Northumbria NHS Trust and Kilimanjaro Christian Medical Centre in Tanzania to support the launch of a National Burns Unit.

Given that nearly half of all hospitals in Africa are operated by Christian charities, links and exchanges between NHS Trusts and African hospitals can be a fruitful way of sharing knowledge gained in our resource-rich NHS with those who have learned to make do with much less - and being a blessing to each other!

Back in the 1980s, there was an outcry when hospitals started to generate income from on-site banks, shopping malls and Starbucks coffee shops (replacing the tea-stands run on a shoe-string by the Red Cross or League of Friends). Now income generation of many different kinds is an acceptable feature of NHS Trusts, and a vital contribution to balancing the books.

In its first three years of operation, Healthcare UK has succeeded in helping over 100 organisations in both the NHS and private sector to win contracts valued at just under £5 billion as well as introducing more than 750 organisations to export opportunities in the target markets. Compared with the projected deficit of £30 billion, this is still a relatively small amount. But if every NHS Trust maximises its potential for international work - without compromising the focus on delivering high-quality services to the local population - the chances of safeguarding a sustainable, publicly-funded NHS, free at the point of need, will increase significantly.

Howard Lyons was managing director of Healthcare UK 2013-16, an enterprise helping UK healthcare providers to do more business overseas. He was CMF Treasurer 2010-14. Howard was awarded the CBE in the 2016 Queen's Birthday Honours.