There is general agreement that the National Health Service (NHS) in the United Kingdom is currently facing unprecedented challenges. Many of these challenges face all health services: increasing demand for healthcare arising from technological developments, demographic changes, rising expectations, and the increase in chronic diseases that require long-term coordinated care.
In terms of public spending, the United Kingdom has entered a period of austerity. Under the Coalition government (2010-2015), spending increased by 0.8% but growth in demand was 3-4%, resulting in a shortfall in funding. According to the 2015 Kings Fund verdict, although ‘[t]he coalition government met its commitment to increase NHS funding in real terms over the course of the parliament, […] this was less than the growth required to meet demand.’ The Kings Fund “Deficits in the NHS 2016” report found that ‘NHS providers and commissioners ended 2015/16 with an aggregate deficit of £1.85 billion, […] the largest aggregate deficit in NHS history.’ It has been estimated that by 2020/21 there will be a gap of £22 billion between patient need and NHS resources. The suggested solution to this shortfall is for the NHS to make efficiency savings rather than to expect more funding.
However, as Chris Ham has noted, money designated for transforming the NHS and priming new care models, as set out in the Five Year Forward View (2014), is being used for sustainability and deficit reduction rather than improvements that could lead to more efficiency. These pressures are set to continue, with Brexit bringing financial uncertainty and the current government’s statement in October 2016 that no more money will be forthcoming for the NHS.
The response to this ‘funding crisis’ in the NHS has been fascinating and illustrates how choices that would not have been seriously discussed 20-30 years ago are now being considered as possible policy options. User charges are on the agenda and professional bodies such as the BMA have discussed whether patients should be charged for GP visits. Examining the NHS in Wales, the Nuffield Trust commented: ‘it is difficult to see how the NHS as we know it can be sustained without significant change in public spending policy or the approach to its financing.’ The House of Lords has recently appointed a Select Committee in June 2016 to look at the long-term financial sustainability of the NHS and will consider, among other things, ‘alternative types of funding (eg. charging for some services, encouraging greater private spending, limiting what the NHS provides)’. This all indicates that the parameters of the debate over how healthcare is funded are changing.
Alongside financial pressures, the NHS has also undergone significant organisational changes with the 2012 Health and Social Care Act. This was the culmination of policy measures over last 30 years that questioned state provision of welfare and goods. These twin elements have resulted in a heated debate over the very future of the NHS. This debate has become crystallised over the big issue of whether we can afford to continue with the NHS, as it is now a, more or less, publicly funded body – or if we need some form of radical change such as introducing insurance models of funding or moving away from the principle of ‘free at the point of delivery’.
These debates have been focussed very much at the economic level – what can we afford, how can we get more from the money we do spend, how can we get extra resources into the system (i.e. through top-up charges or more private spending). However, this is a debate that needs to be based on a consideration of what type of health service we want. As Nick Black has noted in his evidence to the House of Lords Committee, there is a political question of ‘how much we want to spend on health and social care as a society […and] how fair we want the distribution of those services to be.’ The kinds of social values and type of society we want to promulgate are key (yet often neglected) areas that should be central to this debate. As the eminent health economist Alan Maynard says, ‘ensuring that people don’t have to pay out of their own pockets in times of ill health and enshrining the principle of collective responsibility for each other’s healthcare, remains essential.’
At root, much of this discussion is driven by ideological or political considerations: do we want a more free-market approach to welfare provision, underpinned by a conception of negative rights, or should certain goods be provided by the state and ‘social rights’ safeguarded and given priority? Health care funding and financing raises important philosophical and ethical questions which are, at root, about the role of the state in the provision of key resources and the extent of state responsibility to individual citizens. The answers to these questions have implications for the public-private mix in health and social care financing and provision.
There is now a pressing need for public debate over these issues – a renewed consideration of what type of health service and, ultimately, society we want. To my mind, a commitment to healthcare as a societal good and collective responsibility for healthcare (coupled with a greater reliance on evidence of what works) should frame the policy agenda so that healthcare in England remains globally respected and can continue to improve and develop in the 21st century.
Feature image: Medical by Darko Stojanovic. CC0 Public Domain via Pixabay.