Figure. Summary of initiatives being implemented to improve quality of care while better utilizing resources.

Health care in the UK is provided through the publicly funded National Health Service (NHS), established in 1948.¹ Services are generally accessed free at the point of care, with the fundamental principle of equitable health care based on clinical need and irrespective of the ability to pay. Funded through general taxation, most services are provided at no cost to residents, though charges may apply for some services such as prescriptions and dental treatment. No medical insurance is required to use these services. The NHS is admired for its many achievements, having a strong emphasis on prevention, public health, and tackling health inequalities, and providing comprehensive coverage while being relatively cost-effective; in 2021, the UK spent $5,387 per person on health care compared to the United States expenditure of $12,318 per person.²

Though a principal strength of the NHS is protecting people from financial barriers to seeking medical care, the NHS is facing significant challenges as demand exceeds capacity.³ Foremost among these are funding issues due to an aging population, increasing chronic disease burden, and the rising costs of modern health care. This is in addition to variability in health care outcomes, workforce shortages, and lengthy wait times. With over 750,000 episodes of care each year and a 20% rise in referrals to secondary care over the last 20 years, urology as a specialty is confronted with unprecedented demand.⁴ Urology is in the top 10 specialties for the greatest outpatient attendances, with almost 3 million appointments per year.⁵ The COVID pandemic has considerably intensified this pressure with 43.4% of patients waiting longer than 18 weeks for treatment.⁶

Despite this context, the recent years have demonstrated the ability of urological services to develop and adapt, with urology at the forefront of innovative and high-quality care. The NHS, being a coordinated national service, has the unique advantage of representing multiple providers in implementing national guidance as well as procurement of medicines and equipment. Using wide-ranging data analysis, in-depth reviews of services, and benchmarking against national standards, a number of initiatives have been implemented with the objective of improving quality while better utilizing resources.^4,7,8 The Figure summarizes several of these proposals that aim to increase capacity and provide effective pathways for all aspects of the patient journey along a clinical pathway. Elements of this framework can be adopted at a national, hospital, and individual surgeon level. For example, on a national level, moving toward a system-based approach with the establishment of formal Urology Area Networks facilitates collaboration, enabling the support of multiple subspecialist services, mutual aid, resource efficiency, and opportunities for workforce development (see Figure). For urology departments, the introduction of electronic advice and guidance has reduced unnecessary referrals into secondary care and the formation of Urology Investigation Units has enabled the specialty to deliver increased efficiency and greater patient throughput. The development of high-volume low-complexity surgical hubs has similarly improved productivity while reducing the backlog of less urgent surgery. Individual urologists are encouraged to ensure that patients are reviewed remotely where appropriate, booked for an outpatient or day-case procedure if suitable, and given sufficient information when placed on a waiting list. National organizations such as the British Association of Urological Surgeons have been proactive in developing strategies for workforce development, well-being, and retention for all staff groups, in addition to urology departments focusing on integrating service delivery and training recovery.

The NHS is highly regarded for its remarkable strengths, ensuring that all residents have access to urological services regardless of socioeconomic status and eliminating financial barriers to care. Nevertheless, it is essential to acknowledge the challenges faced by a health care system which is held accountable for achieving value for public spending while maintaining high-quality services. The NHS is proactively working toward finding solutions to successfully rationalize urological services, presenting opportunities for an efficient, collaborative, and patient-centered health care system that continues to deliver high-quality urological care to the UK population.