How should we pay for the NHS?
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j682 (Published 09 February 2017) Cite this as: BMJ 2017;356:j682
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Was National Insurance not brought in to pay for the NHS when it was founded in 1948? We don't ever hear any mention of it either from medical leaders or politicians. I don't know whether it is still used to pay for the NHS or whether it is being used for other things like old age pensions or whether it could cover the cost of the NHS but surely that would be a good place to start to look at everyone's National Insurance contribution as a means to pay for the NHS?
The second thing of course would be to cut out some of the bureaucracy and save a lot of time and money that way!! When I was a junior hospital doctor if I saw someone in A&E who needed a specialist opinion or an investigation I referred them for it. Now as a GP I get those patients sent back to me from the A&E doctor for me to refer, wasting both time and money! Ands that's just one small example of how stupid some of the NHS procedures have become.
Competing interests: No competing interests
I am surprised that the Government did not seek to apportion a specific part of each taxpayer’s contribution to the NHS years ago. The 2011 Health and Care bill required all trusts to become foundation trusts - independently managed and responsible for their own finances.
If the aim of having all care provided by independent foundation trusts or independent sector providers had been realised, then the previously separated funding stream could have been privatised like so many other national services, and the NHS would have become a privately funded and delivered service. At the time, I thought that this was a deliberate plan that Andrew Lansley was working towards.
Of course the foundation hospital target has quietly gone away as it became clear that few organisations could reach and sustain the criteria required, and I cannot imagine any for-profit organisation wishing to take on the disaster that the NHS has now become.
Competing interests: No competing interests
A policy on health service spending is meaningless without a policy on health creation. Most disease is not random. Our chances of getting ill or dying are greatly increased by social and psychological adversity, some of which is preventable by early intervention. This means we need massive public investment in comprehensive perinatal health (Kraemer 2015), in paid parental leave (Tanaka 2005), children’s centres and early years education. But also the recognition that insecurity – especially in housing and employment – damages health through the physical stress it causes. Michael Marmot’s book The Health Gap (2015) chronicles this data in scientific and accessible detail.
NHS funding cannot be taken out of politics because its costs depend so much on the impact of other policies, especially those that aggravate inequalities.
Kraemer S Mental health: needs go beyond RCTs Lancet 2015 385: 9980;1831–1832 DOI: http://dx.doi.org/10.1016/S0140-6736(15)60922-9
Tanaka S. Parental Leave and child health across OECD countries The Economic Journal 2005; 115, F7-F27
Marmot M. The Health Gap, Bloomsbury, 2015
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Re: How should we pay for the NHS?
Re: How should we pay for the NHS? Fiona Godlee. 356:doi 10.1136/bmj.j682
No one could disagree with the letter written to the prime minister by the president and council of the Royal College of Physicians; it would, I suggest, have been summarized by Richard Asher in a sentence: the NHS is failing, and physicians can improve the situation, but please give us more money to do it. This is not happening.
Surely it is time for the political parties and the leaders of our professions to have the courage to agree that no amount of increased funding, endless committees designed to produce trivial and obstructive changes, and fatuous statements about increased efficiency are going to fix the situation. We need a wholesale redesign.
Too few doctors? Then tie in the ones the taxpayer has trained, as the armed services do, for X years before the age of, say, forty, which would allow for starting a family, but would not lose a precious investment.
Too complicated to finance? Make GPs salaried like their consultant colleagues, and abolish clinical excellence awards and all payments for extras (e.g. diagnosing dementia). Find a way to finance home and hospital care from the same budget.
Poor continuity of care? Base general practices on hospital sites, with GPs encouraged to act as their patients’ primary physician in hospital, calling in a specialist as needed. This gives the specialist more time to use their specialist skills. Place“Doc-in-a-box” mini surgeries in more distant towns and villages.
No time for GPs to do that? Employ physicians’ assistants widely as a first port of call, but not nurses, as they are needed as nurses, not as untrained diagnosticians. And go back to training nurses by apprenticeship, selecting kindness, empathy, common sense and intelligence not a university degree.
Too much paper work? Introduce universal no fault personal injury cover as in New Zealand with the Accident Compensation Corporation. Use managers specifically to cut down, for example, the number of times a patient is checked before a procedure, inappropriate mandatory training, and unnecessary and repetitive forms and obsessional use of computers etc.; trusting staff to do the right thing may be self-fulfilling.
Drugs too expensive? Nice could invite drug companies to bid to supply the whole NHS, accepting that all medications and technologies will not be available.
Still too little money? A modest fee to see a doctor for those who can afford it. It works well in Sweden and New Zealand. The Times (11/02/2017) states that the NHS is paying locum doctors up to 4000 pounds for a day’s work, a problem which could surely be solved by a price cap legally binding on all purchasers for all locums.
This leads to the biggest challenges: how to persuade us all that we are responsible for our own health, that it is not appropriate to sue whenever something goes wrong, and that the tax payer simply cannot afford to support ongoing stupidity or buy the latest monoclonal antibody or technical advance unless the benefits are substantial. Secondly, to remind the medical and nursing professions of the word “vocation”, which doesn’t seem to be used much these days. Greedy people with a slight interest in medicine should not be part of our professions.
Dr Richard Best
Consultant Physician,
Yorkshire.
Competing interests: No competing interests