Intended for healthcare professionals


Paying for the NHS

BMJ 2000; 321 doi: (Published 07 October 2000) Cite this as: BMJ 2000;321:897

This article has a correction. Please see:

Democratic control should not be dismissed

  1. Marcus Longley (, associate director
  1. Welsh Institute for Health and Social Care, University of Glamorgan, Pontypridd CF37 1DL
  2. ECOHOST, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  3. Barnsley Health Authority, Barnsley, South Yorkshire S75 2PY
  4. Department of Pathology and Microbiology, School of Medical Sciences, University of Bristol, Bristol BS8 1TD
  5. Manchester M20 1JA

    EDITOR—The editorial by Mossialos et al on the funding of the NHS effectively dismisses the false panaceas of private or state insurance.1 But their arguments against hypothecation are less convincing.

    Firstly, the comparative power of Britain's Treasury is set to decrease anyway, under the influence of British devolution and the growing power of the EU.

    Secondly, if hypothecation were to increase the demand for expenditure on the NHS, is that necessarily a bad development?

    Thirdly, it does not necessarily follow that increased expenditure on the NHS will reduce that on other (more beneficial) areas of public expenditure, such as transport and the environment.

    Finally, it is not clear why hypothecated tax should be more vulnerable to economic fluctuations than is the current system.

    The core issue here is one of democratic control, informed by “grown up” debate. Discussion in the United Kingdom on the future of the NHS seldom rises beyond the level of the nursery because politicians have not trusted the public with adult choices. Allowing the electorate to have a more direct say over how their taxes are spent—whether by hypothecation, referendums, or other methods—is a bit scary for control freaks and somehow seems “un-British.” But the experience of the past few years has shown that there is really no alternative. People will continue to moan about the NHS when they are excluded from any real decisions about it, and those who can afford to do so will eventually vote with their feet and take out private insurance, thereby creating a two tier service by default.

    Arguably the greatest change introduced by this government has been to devolve some of its power to Scotland and Wales. It should now keep faith with the electorate and trust people throughout the United Kingdom to make some of the big …

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