Observations Future of the NHS

It’s time to be honest about NHS funding for the next five years

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1978 (Published 16 April 2015) Cite this as: BMJ 2015;350:h1978
  1. Rob Webster, chief executive, NHS Confederation
  1. Rob.Webster{at}nhsconfed.org

If we had all the money in the world we would still need to change the NHS

Whoever wins the UK general election in May, funding for health is expected to stay below the long term NHS average. Even where a new government is willing to commit to additional funding—and there has been much debate this week, some of it acrimonious, over the various political pledges1—it is likely that unprecedented savings will still be required from the NHS, in line with figures set out in the Five Year Forward View.2

Politicians may experience déjà vu. Before the 2010 election the former NHS chief executive David Nicholson wrote to set out the efficiency challenge over the next parliament, stating, “We need to look at 2010-11 as the first year of this new five-year strategy, not just the final year of growth.”3 Despite this notice, a debate on funding was absent from the political campaign, and NHS finances were barely mentioned in the main parties’ manifestos.

The NHS met the challenge and has delivered around £19bn (€26bn; $28bn) of efficiency savings. In doing so it has continued to increase its productivity by 1.5% a year, from a longstanding annual average of 1%.4 These savings filled the gap left by a flat funding settlement and helped the service meet a relentless increase in demand.

Most savings were driven by cuts in staff costs and punishing reductions in the prices paid to NHS trusts. These types of saving are less likely to carry weight over the years ahead. Of course, they still have some part to play. The Labour peer Patrick Carter’s review of procurement, for example, is important for supporting “less efficient” providers in “catching up” with the performance of the best through improvements in technical efficiency.5 Nonetheless, the bulk of savings must now come from new and better ways of working to improve efficiency.

Savings will need to be hard fought across the next five years, and productivity is expected to rise even further. The Five Year Forward View’s ambitious target of delivering productivity increases of 2-3%—three times the average and a further acceleration of the enhanced rate realised in recent years—presents a daunting challenge.

Importance of collaboration

But the health service has a good idea how it might achieve these savings. We know that bringing clinical and financial colleagues together can have a big effect on value, and both sides will want the freedom locally to establish and build on these relationships.6

We also want to do more across whole systems, on the basis of the notion that value doesn’t exist in an organisational vacuum and needs to operate at volume. The potential is demonstrated by the good work being done to integrate care through the new vanguard sites and integrated care pioneers announced in March.7 Evidence is still emerging on the outcomes, and a degree of risk remains.

Politicians have a role in setting the financial context and creating the political will to support change. With a focus on funding, the NHS needs four things from the government in the next parliament:

  • A degree of stability is needed, with a clear funding settlement for at least five years and no top-down reorganisation. This would allow arguments about the amounts of money to be “taken off the table” and help to build the local relationships needed to make savings.

  • The funding gap identified in the Five Year Forward View of at least £8bn by 2020 needs to be filled by the Treasury. This should include filling a further hole emerging in finances for 2015-16. Without this additional money, efforts to find up to £22bn efficiency savings will not be enough.

  • One-off transformation funding should be made available to invest in new models of care. This would give the whole system the potential to make savings.

  • Social care funding must be stabilised. If this does not happen, the NHS will continue to feel the cost pressure this creates and have little control over the effect that social care has on NHS services.

A new government must commit to these critical conditions, and the public must be given the chance to debate them during these last few weeks of the election campaign. The House of Commons Health Committee’s decision not to publish an important report on NHS finances indicates an eagerness to avoid an informed debate on this much needed discussion.8 9 Instead we have a political row and conflicting messages from the political parties, with varying claims as to staffing levels and productivity changes.

The 2015 Challenge

The 2015 Challenge, signed by the NHS Confederation and 22 other influential health and care organisations, has tried to force the debate.10 We saw progress last September when we launched our manifesto: each political party responded with initial funding commitments. But progress must continue from the campaign trail into the new parliament.

It’s time to bring clarity on what is needed in the NHS—the money is one challenge, transforming care is an even greater one. If we had all the money in the world we would still need to change the NHS. We do not have the right NHS for 21st century patients, with their levels of frailty and multiple morbidity.

We have a simple task: we need to ensure that any person who needs help will be put in touch with someone who can deliver it to them. In the past this would have been a doctor. Increasingly, patients will self care, work together as peers, or see other professionals. The obsession with changing the administration of the NHS and increasing the staff needs to be replaced by an obsession with improvements in care delivery. Patients, doctors, and wider care teams will need to develop proposals to deliver this improvement locally—in a climate of financial certainty.


Cite this as: BMJ 2015;350:h1978


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • For more from The BMJ on the UK general election go to bmj.co/election.


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