The “hard truth” in health is for politicians to say wat we cannot afford or what we cannot have..
BREAST CANCER SCREENING
Sir, We welcome the news that ineffective and outdated treatments are no longer to be funded by the NHS (report, June 30). What seemed a good idea at the time — whether cupping, bleeding or routine arthroscopies — should always be subject to scientific scrutiny, so as to protect patients from unnecessary, invasive and sometimes dangerous procedures. But one more thing should be added to the list: mass screening for breast cancer. There are so many false diagnoses that for every life saved some 250 women have terrible scares and unnecessary surgery. Mammograms are essential for women at high risk but more is not necessarily better. Universal screening results in over-diagnosis so that the very small number of breast cancer deaths avoided is matched by the number of rare cases dying from the toxic effects of treatment.
Nick Ross, president, HealthWatch; Michael Baum, professor emeritus of surgery, UCL; Susan Bewley, professor of complex obstetrics, KCL
If social care is means tested, why not medical care? NHSreality is a “heretic”. The NHS has become the greatest cult of our time. As a “holy relic” it is granted immunity from meaningful change..
This Thursday, a service of thanksgiving will be held at Westminster Abbey to celebrate the 70th anniversary of the creation of the National Health Service. This seems only appropriate. The British people no longer, as a collective, believe in God but they do retain a startling faith in the NHS. So much so, indeed, that it has become the greatest cult of our time.
No wonder its latest birthday is accompanied by a vast eruption of cant. The Guardian — never, bless it, knowingly undersold in this department — recently ran a feature asking contributors to consider and record all the ways in which they love the NHS. The answers were both revealing and unintentionally (I assume) amusing.
The novelist Mark Haddon, for instance, adores the NHS “because we pay for it with our taxes” and “the true worth of the NHS is that those of us who are lucky enough to pay tax can go to sleep at night knowing that we have helped make that radical kindness possible”. For Maggie O’Farrell, the NHS is “this country’s superpower”, and according to Gordon Brown the NHS is the “single idea” that defines Britain’s “character, its sense of itself, its purpose and direction”.
No one would refer to prisons or even schools in these terms yet these wonders of public safety and public improvement are also paid for by taxation. They are no more “free” than the NHS is free. Equally, it takes radical qualities of humbug to suppose there is something radically kind about the provision of public services of a sort common to almost every developed country.
We must cherish our myths, I suppose, and the idea of the NHS as the great shining centrepiece of the 1945 “peace dividend” is the most cherished of all our much cherished myths. The NHS stands as the peacetime corollary to the critical — and daring — summer months of 1940. Unlike in 1918, or so we have reimagined our history, the prizes of peace would this time be shared by everyone. In wartime we were all in it together; now we would all build together in peacetime. This is a romantic view of history but the kind of rosy-hued remembrance that’s irresistible.
All this guff and unctuous flattery has consequences. It is not just your usual brand of woolly-headed nonsense. Granting the NHS holy relic status unavoidably removes it from the arena of ordinary political debate. When the health service becomes a kind of sacred superstition it becomes something to be revered, not changed. Scepticism becomes sacrilege.
Yet if the health service were really the wonder of the world we’re so often told it is, you might think other countries would have noticed. But stubbornly, they have not. No other country thinks the NHS a blueprint for excellence. None have copied it. Perhaps they are all mistaken. Or perhaps they have appreciated some sensible truths we are blind to.
The NHS is only a system of providing healthcare. To hear nostalgists talk, you’d imagine no other country in the world provides healthcare for anyone. But look, NHS sentimentalists splutter, the alternative is an American system in which personal bankruptcy is always an option. Except, of course, the alternative is not an American system at all but rather any one of a number of European systems that — this may surprise some people — contrive to provide healthcare for all their citizens too.
Universal healthcare can be provided in many ways and it’s a peculiar conceit that imagines the NHS model is the only one that’s feasible. A peer country such as France manages a mixed system in which the private sector plays a significant role and yet, astonishingly, the French still manage to treat the sick and heal the broken.
Perhaps, though, the French are a less moral people than the British. That is the obvious inference to be drawn from these endless panegyrics to the NHS’s values and glories; it is the last vestige, perhaps, of British exceptionalism. No wonder it had a starring role in Danny Boyle’s theatrical ceremony marking the opening of the London Olympics. It is not just a national health service, but a nationalist project too. As the writer Juno Dawson puts it: “The NHS is the last thing that makes our country brilliant.”
If so, it is a rum kind of brilliance. The metrics by which we judge success are revealing: if you are seen within four hours at A&E or if you need not wait more than four months to see a specialist then a box is ticked, a target met, and a job done. In other areas — such as mental health — waiting times of up to a year are far from uncommon. A stern critic might consider these generous timeframes but they are the way in which we ration care: not by any ability to pay, but by time. Like the A-Team, the NHS can help you but only if you can find it first.
As my colleague Matthew Parris has observed, by international standards we have a “second-rate service for the price of a third-rate one”. In terms of value, then, the NHS scores well. This is not a trivial concern. Equally, much of the care offered is indeed excellent because, in a wealthy and developed country, how could it not be? Here again, we sanctify banality and treat the ordinary as if it were extraordinary.
Nevertheless, an ageing population will require an ever greater share of the nation’s resources to be spent on health. The government’s plans to inject £20 billion into the system — funded by borrowing and taxation, not by the mythical Brexit “dividend” — may help to ease the strain but annual real-term increases in health spending of 3.4 per cent are some way behind the historical average uplift. In other words, it won’t be enough.
A second-rate service is not a terrible thing — after all, a second-rate ship is still a powerful fighting beast — but in the absence of new ways of working, more money will be spent on pumping to keep it afloat than on repairs to make it genuinely seaworthy. The risk is that we build a second-rate service for the price of a second-rate service.
None of this diminishes the value of the service or the dedication of its staff. The praise lavished on the NHS is often out of all proportion to its performance, however. In a better, less hysterical, political world it would not be controversial to say this. The principles underpinning the NHS may remain admirable but the sappy reverence in which the NHS is held has become a block to the reform and change it needs. It needs heretics and sceptics, not yet more devotional worshippers.
Update 5t July. Letters 4th July:
‘CULT’ OF THE NHS
Sir, In his article “NHS has become the greatest cult of our time” (July 2), Alex Massie explores our hysteria about “American” alternatives but omits to mention many more successful systems for universal healthcare provision in the West when judged by outcomes. The danger is that the cult-following neglects value for money.
The German healthcare system cares for about 80 million people, and the UK for about 60 million. Despite this, however, the NHS employs more staff than the entire German system, yet we know that Germany has significantly more doctors — 4.1 doctors per 1,000 patients compared with 2.8 per 1,000 in the UK.
Taxpayers fund the NHS and should be able to question whether support staff and managers give value for money. Questions like this can easily be overlooked in fervent support of a system seen as defining Britishness.
Adam P Fitzpatrick, FRCP
Consultant cardiologist, Mottram St Andrew, Cheshire
We have rationed drugs, doctors and nurses. It was appropriate to ration some drug treatments, and tis needs to happen. We could do much better with manpower planning, and te shortage we are facing in manpower is not due to Brexit, but to political expediency, short termism, denial, and mis-management by all political parties over 20 years.
Plans to ensure that Britain does not run out of medicine when it leaves the European Union are being drawn up, the head of the NHS has said.
Simon Stevens, chief executive of NHS England, said “significant planning” was under way to ensure that patients did not go without if drugs were held up by new border checks.
Hospitals were also being told to try to persuade European staff to stay so that the chronic shortage of doctors and nurses did not get worse.
Mr Stevens had previously said that he had not been asked to prepare for a no-deal Brexit, but said yesterday that he was now working with the government to protect medicine supplies.
Every month 37 million medicine packs arrive from the rest of the EU, with 45 million going the other way. The pharmaceutical industry has become increasingly concerned about interruptions to this and some companies have started to implement contingency plans. Worst-case scenarios drawn up by officials suggest that hospitals could run out of medicines with two weeks.
“There is immediate planning, which the health department, with other parts of government, is undertaking, around securing medicine supply and equipment under different scenarios. That will crystallise when it’s clear this autumn what the position will be,” Mr Stevens told the Andrew Marr Show. “Nobody’s in any doubt that top of the list in terms of ensuring continued supplies for all the things that we need has got to be those medical supplies.”
“Extensive work” for a no-deal scenario was being done in collaboration with the pharmaceutical industry. “Nobody’s pretending this is desirable, but if that’s where we get to then it will not have been unforeseen,” he said.
Businesses have voiced increasing concern about the slow pace of Brexit talks. Airbus has said it would leave Britain, where it makes the wings for its passenger jets, if there was no transition deal. Carmakers have cut back on investment in Britain and BMW said it would close plants if it could not import components without disruption. Retailers are preparing to build stockpiles to manage potential border delays and banks have started to relocate some investment banking operations.
One in ten doctors and one in 14 nurses in the NHS come from other EU countries, and health chiefs have said hospitals cannot cope with an exodus. Recruitment of EU nurses has fallen more than 90 per cent since the referendum and departures have increased.
Mr Stevens said: “Every hospital has been written to asking them to reach out to their staff from the rest of the EU, providing that the home secretary has set a clear process by which people can apply to stay in this country, which we hope he will do.”
Last week the British Medical Association called for a referendum on the final Brexit deal, saying that leaving the EU would be “bad for Britain’s health”. Doctors called Brexit a “disastrous act of self-harm” because of its impact on research and medical regulation, as well as staff and drug supplies.
Mr Stevens also said that he expected to see a boost in social care spending. “The prime minister has been explicit that the settlement for social care will be such that there will not be extra pressure coming into the NHS,” he said, adding that the “obvious implication” was extra cash for councils.
The journal of the RCGP has a laudable edition with the 1948 Parliamentary White Paper and legislation on the front page. The leading article by a former chairperson, speaks of the sudden change in tone and funding with appreciation. But it is not enough…. the members are more in sympathy wit the BMA tan their academic college. We ALL need to worry. Its going to get worse, until we face up to reality. GPs are well paid, but it is not money that is the issue. It is the shape of the job…
For 70 years, general practice has been the foundation on which the NHS has been built. For 70 years general practice is where the vast majority of patient contacts have occurred, where generation after generation have been looked after by GPs and their teams, embedded within their community, providing care even before the cradle and often after the grave to those left behind grieving the loss of loved ones.
It’s been on this foundation of general practice, and the primary care we provide, that other NHS services have depended. We’ve managed demand, enabled efficient working elsewhere in the system, directed patients to the right specialist service, been innovative in care pathway design, and above all managed clinical risk on behalf of the NHS as a whole.
But when nearly 40% of GPs intend to quit direct patient care in the next five years, and over 90% of GPs are reporting considerable or high workload pressures, we know that the foundation of general practice has serious structural faults.
When instead of gaining an additional 5,000 GPs, we’ve lost over a 1,000, we know that the foundation of general practice is cracking.
When over a 1,000 GPs have referred themselves to the new GP Health Service in England because of stress and mental health problems, or when hundreds of practices have closed and over 1m patients have been forced to look for a new GP service, we know that the foundation of general practice is breaking down.
For far too long our service has been undervalued and taken for granted. GPs’ work ethic and dedication to their patients has been exploited through a decade of underfunding and soaring workload pressure, with the assumption that the GP practice will always be there to pick up the workload that others say they cannot or will not do.
The NHS fails to commission a specialist service, well don’t worry, the GP can do it; local authorities cut smoking cessation or weight management services, but don’t worry, just make an appointment with your GP and they’ll prescribe what you need; a new specialist care home or private hospital opens up in an area without any warning or planning, but don’t worry, the GP will pop around regularly to visit everyone; and then some bright spark comes up with a well-meaning idea that just requires the patient to get a letter from their doctor, but don’t worry because that’s what GPs are there to do, isn’t it?
Well let me make it clear, it is now time to worry. The foundation of general practice on which the NHS is built is seriously at risk of collapsing and if the NHS wants to survive in to old age we need urgent action now. If we cherish our NHS it’s time to save general practice.
In Scotland this has meant over two years of work that has led to the introduction of major new contract changes this year, aiming to reduce risk and workload for practices. In Wales a second QOF suspension helped practices struggling with workload pressures over the winter. In Northern Ireland, even without politicians being prepared to get back to their responsibilities in national government, NIGPC has secured agreement for additional funding for practices and pharmacists.
In England we have outlined what must be done, and made clear how any additional funding promised by the government as part of a long-term plan for the NHS must be spent. In our report Saving General Practice we highlighted the need for real investment that provides an additional £3.4bn recurrently each year.
We need to seriously step up our workforce plans to ensure every practice can recruit a GP when they need to and that existing GPs are properly supported to encourage them to stay in the service. We need to ensure every practice has the support of a pharmacist working in their team, to not only reduce GP workload, but to improve the safety of patient care and reduce medicine related adverse incidents.
We need to invest properly in premises, to reduce the risks for those potentially left last-person-standing and prevent bodies like NHS Property Services from pushing practices to the point of closure by their unacceptable and unjustified cost hikes. The deal in Scotland shows that something can be done about this and it is possible for the NHS to share some of the risk.
We need a step change in IT support, enabling every practice to have reliable demand-management systems and the technology to offer smartphone consultations when appropriate, without the need to exploit the out of area registration arrangements by cherry-picking young healthy patients as a provider in London is doing.
Primary care support
We need primary care support services that actually support practices and GPs, and don’t make our work harder and more difficult to deliver. The National Audit Office has forensically exposed the national scandal of NHS England’s abject failure over more than two years to sort out the shambles that they created when they privatised our back office service and left us with Capita’s Primary Care lack-of-service England. NHS England may have made over £60m savings on the deal but its practices, GPs and above all patients that have paid the price.
We need to protect, enhance and reinvigorate our independent contractor model of working and the partnership model that gives all GPs involved a voice in decision-making, which has delivered continuity of care for generations of patients and enables GPs to be positive advocates for their patients. It’s good therefore that the Jeremy Hunt has listened to us and set up a partnership review led by Nigel Watson.
And we also need to deal with the problem of indemnity. GPs effectively pay an indemnity tax of thousands of pounds just for the privilege of working. Securing commitments in England and now also in Wales to introduce a state-backed indemnity scheme by next April are important steps forward. All we ask is for equality with our colleagues in hospital. It cannot be acceptable for a GP to be working alongside a consultant colleague in the same community service, and for one to pay indemnity tax of thousands of pounds whilst the other has their indemnity covered by the NHS.
A comprehensive system, that covers all GPs – locums, salaried and partners – as well as the staff who work in our practices, has to be put in place, and we will work with government to make sure this happens.
I want to conclude by thanking the skilled BMA secretariat who support our work across the UK, the executive team and negotiating team members in the four GPCs who give up so much time to work on your behalf, and particularly to thank my colleague chairs, of GPC NI, Scotland and Wales.
However, this will be the last ARM at which Alan McDevitt and Tom Black chair their respective GPCs, and we owe a huge debt of gratitude to both of these giants of general practice, not only for the work they’ve done in Northern Ireland and Scotland but also for the huge impact they’ve had for GPs across the UK. Thank you to both of them.
Despite the challenges and the pressures, the government’s recent announcements show that we are winning the argument but there is much that still needs to be done. We will not give up on our vital task to save general practice, to rebuild the solid foundation on which the NHS has been built for 70 years and work with the whole BMA to ensure our patients get the best possible healthcare for generations to come.
NHSreality is worried that “a little nip and tuck” will certainly not work. In a world of open information, covertly rationing, and not being honest about what is not available, is not good enough. Being honest includes informing the populations of Wales, Scotland and N Ireland that, being in much smaller mutual organisations, they will get less choice, and usually lower standards in a world of large units and specialisation. Regions that do most of their surgery in DGHs (District General Hospitals) will be most affected. The BBC is a government organisation, and funds the Radio Times. It cannot be expected to give credence to rationing overtly.
The NHS may not need a full facelift but a little nip and tuck could work wonders, according to its leading experts
Henry Marsh – Neurosurgeon
What are the biggest changes you observed in your 40 years as a consultant?
The single biggest change has been the European working time directive and its shortened working week. It’s not all bad – it has meant less tiring hours and enabled more women to go into the surgical specialties – but it has also hugely diluted surgical training and fragmented continuity of care so that, their consultant aside, patients are now looked after by committees of junior doctors. Care has become dispersed.
There is also the loss of authority of senior doctors. When I became a consultant there was one pyramid, one hierarchy, and senior doctors sat at the top of it. Now there are all kinds of pyramids – doctors, nurses and management among others – and nobody is in overall charge. The result is chaos. Patients are better informed, which is a good thing, but that, too, has a flip side: greater patient autonomy has resulted in one per cent of the NHS budget – more than £1 billion a year – now going on legal expenses.
What are the most significant issues facing the NHS?
The simple fact is that an ageing population and advances in medical technology mean more expense for the NHS. For instance, if you make operations simpler and safer you end up operating on more people. There are no easy answers, and many of the suggested solutions, be it rationing healthcare, or eliminating some procedures, aren’t really solutions at all.
The reality is that we already have a degree of rationing in the form of waiting lists, which act to some extent as a filter. And while it’s reasonable to question whether procedures like cosmetic surgery should be funded, I don’t think it would make a big difference to the NHS budget if they weren’t. Similarly, while I am an advocate of assisted dying, I don’t think it would make any difference to costs were it to be introduced. Ultimately, most of us cling to life for as long as possible.
So where does the nub of the problem lie?
One of the factors making medicine more expensive is cancer. It’s essentially a disease of old age, and one that has become more treatable with developments such as immunotherapy. But the critical thing is that a lot of cancers don’t need treating – earlier this month immensely important research was reported that showed that a large number of women with breast cancer do not require chemotherapy. A similar study has been done on prostate cancer sufferers, which showed that 25 per cent of those diagnosed did not go on to progress beyond the early stages of the disease. At the moment we can’t ascertain who will and won’t progress – but my hope is that advances in molecular genetic studies will help us get better at selecting who needs treatment. That’s where we should be putting our money – and it might actually save money.
Is there cause for optimism?
Absolutely. I passionately believe that the principle behind the NHS is still the best one. We may have to accept, though, that this is a model that needs to be tweaked, whether it’s by supplementing with insurance or paying for some aspects of our medical care. I’m in favour of a Royal Commission being set up to discuss how this could be done, so the public have some say in what should happen.
Henry Marsh’s book Admissions: A Life in Brain Surgery is now available in paperback
Professor Magdi Yacoub – Cardiothoracic Surgeon
Do you still believe in the NHS?
Absolutely. I have worked for it all my life and I would do the same again. I travel to some of the world’s poorest countries with my charity the Chain of Hope, which works to establish sustainable centres for cardiology, and it’s a continual reminder that what we have is the best healthcare delivery system in the world. Every patient who comes is welcomed and given the best without discrimination, and that is a wonderful thing. But we have to be continually critical and not just congratulate ourselves on what has happened in the past.
What do you think are the main problems we face today?
The very large number of administrators in the NHS and the urge to keep changing things has bedevilled the system. Its effects trickle right through the system: at the coalface workers wake up wanting to do something good and then find there are new regulations and new rules.
What needs to happen?
Doctors have only two masters: patients and science. To my way of thinking we need to spend more on integrating science instead of on new administrators and managers. Allowing for innovation is very important. We also have to encourage the public to work in partnership with the NHS, to be part of the whole system, because they own it. The idea that there is somehow a competition between prevention and hi-tech medicine is a fallacy – it’s a continuum. The drop in the rates of heart disease, for example, is due both to better prevention and better medicine.
You favour changing organ donor laws so that people have to opt out, rather than opt in. Can the NHS afford increasing numbers of transplants?
Organ donation is a gift: when you have seen someone dying in the middle of the night and then you meet them again 30 years later after they have received a transplant – you cannot put a price tag on that. What people forget is that the process of learning about and perfecting transplantation benefits so many other branches of medicine too.
Professor Farah Bhatti – Consultant Cardiac Surgeon
What has changed in the service since you qualified in 1990?
The medical advances have been phenomenal. When I qualified, cardiac surgery was just an emerging field, and now people talk about open-heart surgery as if it were commonplace – which in some ways it is. We’ve got technological advances in all areas of medicine and surgery is no exception. There’s also been a shift towards greater team-working. Today it’s not a hierarchy of doctors and nurses, but a wealth of paramedical and support staff working together.
So what are the challenges?
It’s common knowledge that we are dealing with an increasingly elderly population, with quite complex medical needs, with limited resources: we need an uplift of four percent in spending just to stand still. Everyone within the NHS from doctors to domestics is working incredibly hard to cover shortages, working extra shifts and filling in rota gaps. They do it out of goodwill, but it has implications for the health of the staff and patient outcomes. We also need to think about the best use of the resources we do have – we have patients in hospital who are medically well enough to go home but there is no one to care for them. We desperately need more joined-up health and social care.
Should we be looking at rationing resources?
I don’t think the words healthcare and rationing should be in the same sentence. The focus needs to be resourcing the NHS properly and then using what we have sensibly and logically. That starts with evidence-based medicine – everything I do as a cardiac surgeon I do with that and the patient in mind: ie, is surgery the right choice in terms of survival and quality of life?
I think if you go down the insurance route, the result will be that there are people in need of medical attention who would not seek it. I think where the money conversation should be happening is around how all our taxes are spent, and the proportion going into healthcare. Seventy years ago if you were unwell and you weren’t wealthy, you could die. The landscape has changed immeasurably since then but we can’t lose sight of all we have achieved and what we have created.
Dr Michael Mosley – Writer/broadcaster
What are the most pressing problems faced by the NHS?
The scale of staff shortages is unprecedented. The number of unfulfilled nursing posts is horrendous, and a huge number of qualified doctors are moving abroad. We’ve had crises before – when I qualified in the 80s it was also quite grim – but it’s as bad as it’s ever been.
Does it need more money?
It clearly does, but we are already spending, in real terms, four times more money than when I qualified. So the amount going into it has increased enormously – but so has demand. We’re living longer, getting fatter and people now have more chronic and complicated diseases.
What should we do?
If the primary problem is demand, then that needs to be tackled. The NHS as a system actually works very well – it’s lifestyles that are causing many of the problems. We are getting fatter, and rates of Type 2 diabetes have doubled, which leads to an increased risk of heart disease and kidney failure, and possibly dementia. The rise in obesity is also linked to an increased risk of cancer. All these problems are related. I think the Government needs to focus on getting people healthier earlier and for longer.
How do they do that?
The sugar tax is a good start, but we need to think more imaginatively, such as redesigning cities to encourage people to walk more.
Michael Mosley appears in Celebrities on the NHS frontline, Thursday 28th June at 9pm on BBC1 (BBC2 in Wales)
Professor Robert Winston – Fertility Expert
What angers you most about the current state of the NHS?
It has become a political football, with different parties clamouring to style themselves as the service’s saviour. This has led to a constant restructuring of the service, which is unhelpful. We should be collectively deciding the percentage of GDP we’re prepared to spend on it, which should be agreed by all the main parties.
NHSreality is surprised that the Guardian still refers to the NHS. There is no NHS. The goodwill that was once there is much reduced, and what remains is spilling away.
Zara Aziz in the Guardian Tuesday 5th June opines: Long waits, cut and rationing, happy birthday NHS. It’s getting harder for doctors to provide good care. But the NHS would be lost without the goodwill of those who work there
The NHS (2018)
They opened the NHS
Seventy years ago
Markets and gain have undone it again (and again)
And now you would never guess
There was once a fair NHS
Before the performance targets
It is within the patient’s and staff
And the overworked nurses
Only the GP sees
That where inequity thrives
And managers count their beans
There was once an NHS
Yet, if you enter the service
On a weekend evening late
Where alcohol fuels casualty duels
When the surgeon dreads his mistake
(They fear the managers more
Because of their powers)
You will hear an aside, as philosophies collide
And post code dice rattle on embers
Consistently blinded to
The covert rationing
As though they perfectly knew
My old lost, fair, NHS
But there is no NHS.
After Rudyard Kipling – The Way Through The Woods.
The only part of this article that I disagree with is “…in a service based on the principle of equal treatment for equal need, financial status should impose no restrictions on access. This rules out a system reliant on out-of-pocket payments or private insurance since both link access to the ability to pay.” This is not true, as Germany and Holland systems work well enough under insurance, and New Zealand works with payments and subsequent reimbursement. The Canadian system is different by state, but each state covers the poorest for free. The “Hard truth” is that a soundly financially founded health care system will always seem tough on some. Australians pay up and can choose between basic state access, or paying a bit more for enhanced choice. No other country has chosen our system, even after 70 years and our Olympic boasting. The public need to be led into realising why not.
The National Health Service was created in 1948 with the aim of ensuring that access to healthcare would depend on need and not ability to pay. “The essence of a satisfactory health service” wrote the health minister Aneurin Bevan, “is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged.”1 In Bevan’s view, this required a healthcare system paid for out of general taxation rather than, say, a ringfenced tax or insurance with contributions tied to benefits. From the beginning, then, the link between payment for and consumption of healthcare was deliberately broken. Equality of access was to be accompanied by inequality in financing, with contributions based on people’s ability to pay.
And there, you could argue, the story ends. Apart from some minor adjustments, the source of funding for the NHS has remained the general pot of taxes, with a small amount of additional revenue from patient charges. But there is now a growing sense that things might have to change.
Current funding gap
After eight years of historically low funding growth for the NHS (with per capita increases slowing from 4.4% to just 0.1% a year since 2009-10),2 coupled with unabating demand pressures, the NHS is finding it increasingly difficult to maintain performance on several high profile targets.3 This is despite a fifth consecutive year of substantial overspending by trusts in the English NHS.4
The immediate prospects on funding do not look good either. The extra money announced last autumn amounts to a per capita boost of 0.7% next year, with next to nothing thereafter, and is offset by cuts elsewhere, including the public health budget.5 Against this background, the prime minister, Theresa May, has promised more money,6 but with the government intent on continuing its deficit and debt reduction path, and Brexit posing uncertainty for economic growth, it is unclear how any extra spending can be financed.
Principles of fair funding
This raises a fundamental question: what do we want the funding system to achieve?
Fortunately, there are some principles to guide us. Firstly, in a service based on the principle of equal treatment for equal need, financial status should impose no restrictions on access. This rules out a system reliant on out-of-pocket payments or private insurance since both link access to the ability to pay. The problem is aggravated by the inverse relation between socioeconomic status and health, making healthcare costs or insurance premiums highest for those with the least.
About 10.6% of the UK population have private health insurance, usually as a benefit provided by an employer. Being insured is strongly related to income, so that 38% of the top fifth of earners have insurance compared with only 8% of the bottom fifth.7 All countries recognise the inequalities associated with private finance. Even in the US, taxpayer funding in one form (Medicare and Medicaid) or another (subsidies and tax breaks for insurance costs) is substantial, accounting for about half of total health expenditure in 2016.8 Funding sources are also always and everywhere diverse: general taxation, forms of compulsory social insurance, and combinations of direct payments and subsidies to protect particular groups are the norm in most comparable countries, including France, Germany, and the Netherlands.
A question therefore is what might be the right balance between different sources of funding? Are there some benefits in, for example, expanding user charges—not just to raise funds but to reduce “frivolous” or unnecessary demand?
Charges do raise money, of course, and they reduce demand. The problem is that charges can only play a modest role in raising money otherwise they erode the goal of equity of access. As well as deterring overuse, the famous RAND Health Insurance experiments in the 1980s found that charging deters legitimate use, particularly among the poorest, eldest and sickest patients.9 Consistent with this, the UK—with its limited charging regime—has much lower shares of the population that do not pick up prescriptions, do not visit the doctor, and do not get recommended for care compared to most other countries.2
A second principle to underpin any funding system is that it is fair. But what do we mean by fair?
This could mean that the wealthy should pay more than the less wealthy. Is the sum of taxes and revenues currently raised by government fair in this sense? If we look at income tax alone, the tax system is strikingly progressive, with the top 10% of earners contributing 59% of revenues in 2015-16.10 However, the NHS is funded by all taxes, not just income tax, and the other major sources of income—VAT and national insurance—are regressive.
Across all taxes, the top 10% of earners paid 27% of tax in 2015-16, which is in line with their gross income. Indeed, every decile pays tax almost exactly in line with gross income, so that the burden as a whole is neither progressive nor regressive but proportional to income.10
However, when the social gradient in the use of services is considered, the overall incidence of costs and benefits is redistributive. Poorer people die at a younger age but use NHS services more, and cost the NHS more, over their lifetimes than richer people.11 Reflecting this, the formula for resource allocation to specific geographical areas has always been adjusted to account for area deprivation.12 This is a feature (not a bug) of a collective system that seeks to diminish financial barriers to access and insure against the costs of care.
A third principle to guide us is that the system should raise “enough” funds to enable the provision of services at the quality and quantity that society, taken as a whole, has the willingness and ability to pay for. Over the past 70 years NHS spending has grown 10-fold in real terms and doubled the share of gross domestic product it accounts for (fig 1). Has this been enough?
International comparisons suggest the UK is a relatively low healthcare spender. A recent analysis found that per capita spending was, at $3377 a year (£2500; €2800) in 2016, lower than that of the 10 comparable countries (Canada, Germany, Australia, Japan, Sweden, France, Denmark, the Netherlands, Switzerland, and the United States), and over a third lower than the mean among these countries.15 Consistent with this, the UK employs fewer nurses (8.2 per 1000 population) than the European Union average (9.0) and fewer doctors (2.8 v 3.7), and has fewer computed tomography scanners (8.0 per million population v 31.5).16
In this context, do the last eight years of strict financial control tell us that our reliance on government funding is letting us down? Some think so. Especially in an era of growing public distrust of government, some have argued for an earmarked (or hypothecated) tax that can help bolster public support for higher levels of funding by clearly linking new or increased taxes to the NHS. The idea has strong support compared with most other areas of publicly funded activity.2
Potential for hypothecation
In one sense this would bring the UK into line with its European neighbours. Many countries fund healthcare through compulsory social health insurance premiums—in effect, a hypothecated tax on wages and employers. However, with the introduction of extensive government subsidies to address gaps in coverage, most of these systems have actually been converging towards the UK model.18 It is not at all clear what advantage is to be gained from the UK’s moving in the opposite direction. In addition, governments here have tended to balk at the curtailment of budget flexibility that earmarking requires. With “pure” earmarking, in which the amount spent on a service is determined by the amount of money raised from a particular tax, the resulting unpredictability of funding is clearly impractical (although note the effect of economic recessions on NHS spending in fig 1).
An alternative proposal is to set an NHS budget based on independent forecasts of demand and set a tax rate that is expected to raise enough to cover the cost. If it turns out to raise more, or less, then the Treasury keeps the surplus or pays the extra from borrowing or general taxation.17 There are rumours that the health and social care secretary, Jeremy Hunt, supports the idea of ringfencing national insurance contributions for a similar purpose. But the fact that hypothecation tends to be premised on increases to regressive forms of taxation—such as National Insurance contributions—should give us pause for thought.
A different argument could be made for earmarked taxes on health damaging products such as tobacco, alcohol, or sugar sweetened drinks. In these cases, taxes help to address the behavioural causes of ill health and reduce healthcare demand, as well as raising money. And while the tax burden may be regressive, the distribution of benefits in terms of improvements to health is skewed towards those on lower incomes.
Hypothecation in this sense may help to persuade a sceptical public that an addition to its tax bills is worth paying, in terms of a better and more sustainable NHS. But it is not so clear that such a radical approach—one that, in the form proposed, goes against the grain of recent health system reform in Europe—is needed to persuade the public. Perhaps people are already convinced. Last year, some 61% of respondents to the British Social Attitudes Survey said they would be prepared to pay more tax to fund NHS services.2 This may be a good time to take them at their word.
Consensus is growing that the NHS needs more money. The debate about how this might be paid for—from increasing user charges to creating a specific NHS tax—is worth having. But it is hard to see that the benefits claimed for such changes outweigh the costs of moving away from the current source of general taxation. Nonetheless we are clearly at a critical juncture in the history of the health service. The 10-fold increase in funding since 1948 has largely been financed from changes in government spending priorities—notably much reduced spending on defence, housing, and what were previously nationalised industries. There is now much less room for this sort of reallocation. Other areas of public service—including housing, welfare, and education, which are important determinants of health—have already been cut to the bone; extra money will inevitably have to come from new, or higher, taxes. More than ever before, higher taxes are an inevitable consequence of a desire to spend more. The choice, as they say, is ours.