Blair's billions: where will he find the money for the NHS?
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7238.865 (Published 25 March 2000) Cite this as: BMJ 2000;320:865
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Dear Sir,
"How is the public to be persuaded to spend over three times more on
private health care than it does at present?"
Well, fear and desperation will do for a start. In the absence of a
coherent strategy and with the sole debate being conducted in journals and
at times when most of the public are not involved,the politicians can
afford to fling back at us what is ours to be spent anyway. The reality is
that we have a form of means-testing now - by attrition and with minimal
debate.
As professionals with experience leave the system, unable to deliver
the level of care they would like to, in a system that so often frustrates
them, the public will experience the realities of underfunding,
discontinuity of care (in areas where it matters),cramping of quality
time, and crushing top-down agendas on spending and clinical creativity.
Those who can afford to will simply jump off the state trampoline and
into the arms of more and more private providers - sorry, partners in
care.
This is all part of the "third way" - the policy that dares to speak its
name, but not its substance.
New Labour cannot afford to let this cat out of the bag, since it is
a sure-fire vote loser, according both to them and the authors of this
article - so we will have desperately needed moneys fanfared, often more
than once,and released with all manner of strings attached. The
politicians will take the credit for any successes and the clinicians will
be blamed for the failures.
Yours
Dr. Chris Manning
Conflict of Interest; Personal View
Competing interests: No competing interests
Sir,
In reading Appleby and Boyle's very clear analysis of the options
open for financing the Prime Minister's pledge to increase total
healthcare spending to the EU average, I was struck by the rather
different emphasis evident in the "Summary points" box when compared to
the main text.
In the text, Appleby and Boyle make it clear that increasing
government spending to 56% of GDP would only occur if spending by all
departments increased at the same 9.7% annual rate required to achieve the
NHS spending pledge. As they immediately note, this option is almost
certainly unacceptable, and one senses that it is something of an Aunt
Sally. They then describe a scenario which, I would suggest, is far
closer to a position in which "other government spending is not to be
affected by extra spending on the NHS" - i.e. non-health government
spending rises at planned levels of 2.25% p.a., while only NHS spending
increases at 9.7% - and it is on the latter scenario that their ensuing
consideration of additional taxation needs is conducted.
Unfortunately, it seems to be Aunt Sally who makes it to the Summary
Points box, where the dread prospect of public spending consuming 56% of
GDP is headlined, rather than the distinctly more modest 41% to which the
tax calculations appear to refer. Needless to say, heroic efforts would
undoubtedly be made to spread any required tax increase across a number of
different tax bases - so that "10p on the pound" income tax hikes are
probably not round the corner either.
Soundbites matter on a subject like this. The paper cuts to the
heart of the debate - the need for increased taxation to deliver the
services which taxpayers seem to want. Let's avoid accidentally handing
ammunition to the briefers and the reporters whose deadline means they
only read the summary box...
Even if a clever device is found by which the "pledge" only covers an
increase to the original offer of 8% of EU spending, let's be clear that
this would still be, as Appleby and Boyle point out, an awful lot of extra
money. With the first instalment already in the Budget, and signs that
Government will openly accept modest increases in the overall tax burden,
we can be pretty confident that big real increases are genuinely coming.
Let's therefore open the debate on how best to spend that money as a
matter of urgency. The more extra cash the NHS receives, the greater the
chance that some of it will be poorly spent - and the stronger the
imperative that this once-in-a-generation opportunity be properly planned
and executed.
Competing interests:
No longer a UK taxpayer
Competing interests: No competing interests
Response from authors
Sir
In reply to Martin Hensher we agree that the summary box point about
the possibility of total government spending rising to 56% of GDP in order
to preserve the relative share of NHS spending at around 14.4% of total
government spend was something of an Aunt Sally. But we included it to
emphasise the sheer scale of the increases in spending needed to reach the
true EU average while not impinging on other spending departments.
We also accept that soundbites matter. But there is a difficult line
to tread here - as illustrated by Chris Manning's response. We would
emphasise that we believe there are not only strong ethical reasons for
supporting a health service funded from a progressive taxation system
(funding for the NHS is the most equitable in Europe) and provided
universally to those in need regardless of ability to pay, but also
significant economic arguments.
We do not advocate increases in private health care spending; it's an
inefficient way of investing in health, it's inequitable, and if linked to
opting out of paying tax, it would kill the NHS. Apart from that, it's
fine.
But none of this makes the NHS or those who control the purse strings
immune from criticism.
Chris Manning answers what we originally felt was a rather rhetorical
question about how the public are to be persuaded to spend over three
times more on private health care with his belief that the public's
knowledge of the desperate straits in which the NHS finds itself, the loss
of top professionals and other problems will simply drive them away. Our
point was that most NHS spend goes on those least capable of funding their
own care, and hence least able to choose that option.
There's no doubt the NHS could find uses for more money, and the
Government has made a good start, but care needs to be taken by respected
NHS professionals when shroud waving. Any supporter of the NHS needs to
separate out perception and reality about the performance of the NHS,
which in itself is no mean task.
John Appleby
Sean Boyle
Competing interests: No competing interests