Another healthcare funding review
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7282.312 (Published 10 February 2001) Cite this as: BMJ 2001;322:312All rapid responses
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I read with great interest the Editorial by Jennifer Dixon on NHS
funding. Like many doctors I fear for the future of the NHS and if the
organisation is to have any future then some hard political decisions have
to be made. The NHS was founded on the principle of " the greatest good
for the greatest number". This has served the UK well and many other
countries have been envious of our system. However society has changed and
now the expectation is "the best possible care for every individual". This
is an understandable aspiration but it is not clear if society is willing
to bear the cost of such a health care system or accept the concept that
health is primarily the responsibility of the individual.
The NHS might be compared to public transport, good value for money
and an efficient use of resources but at times uncomfortable and
inconvenient. If the population were asked to choose any type of transport
at no personal cost then then the choices would be diverse. Some public
spitited individuals might still opt for public transport or even a
bicycle, those wishing greater individual freedom but still recognising
the need for cost restraint in a publically funded system might opt for an
old mini. However in a society dominated by consumer values, many would
want a BMW, Porsche or a top of the range 4x4. In addition, some would
want an immediate replacement if something went wrong, even if this was
due to lack of maintainance or subjecting it to regular abuse.
Paradoxically the evidence is that in large towns with so many cars on the
road, travel is less efficient than by public transport.
As increasing numbers of patients demand their "rights" the NHS
struggles to meet all these demands. Staff feel they are running faster
and faster but cannot keep up with rising expectations. In the past the
NHS has used covert rationing through waiting lists, limitations on
certain types of treatment or variation in standards of care. The NHS is
increasingly centrally driven and these methods of demand control are not
tolerated.
The choice facing the UK Government and media is stark (the "silent
majority " of the population probably accept this), either engage in
meaningful debate over the scope of NHS or the organisation will crumple.
It will crumple gradually and painfully. If this happens then it is likely
that health insurance will play an increasing role in health funding and
the greatest strength of the NHS of free health care for all will be lost.
Those that want the luxury model will be able to afford it but for those
that cannot will have a long and painful walk in search of treatment.
Conflict of interest None. (I ride a bike to work and own an eight
year old Rover 214!)
Competing interests: No competing interests
In Jennfier Dixons useful review of the so called health funding
gap there is a signficant issue which the NHS traditionally pushes
under the table ( preferring instead to blame the publics lack of
appet ite for taxation .) I refer of course to the NHS's gross
managerial and business inefficiecncy . Take for example the
procurement bill for supplies and equipment currently running
close to £10 billion. A recent PASA statement estimated that the
NHS could save close to £2 B PA if a fully functional -e
procurement system was implemented . Signficantly Lord hunt
has agreed with them.
see.
http://www.pasa.doh.gov.uk/whatsnew/
If you add in the signficant costs to the service of general
bureacracy ( escalting rapidly with PCT's ,surely there are far to
many of these in the pipeline ) poor finacial and administrative
management and of course the clinical issue of funding services
with no proven benefit what does that leave us? £ 4 or £5b at
least.
We cannot go on blaming the public and the politicans for not
funding the NHS when its in our hands to bring us up to 21
century standards of business and clinical practice.
Julian Fifield
Competing interests: No competing interests
Another healthcare funding review
The BMA has, in its Healthcare Funding Review, essentially
agreed with the governments own position - that the fairest,
most efficient and cost effective way to deliver healthcare
is through direct and indirect taxation with resources
subsequently allocated according to need. Few doctors would
argue with this and that the most important principle of the
NHS - equality of access, must be preserved.
Unfortunately the tax based model can only be maintained if
certain "ideals" may be met. Firstly there must be a
general realisation of the cost of good healthcare and a
willingness on the part of the public for progressive tax
rises to match medical advances, an increasingly aged and
medically dependant poulation and increasing affluence and
expectations in society at large. Secondly it must be
apparent to the public that their money is being well spent.
Finally, such funds must be ring fenced and spent according
to need, as assessed by the public and healthcare
professions such that the NHS is freed from the kind of
"conditional funding" and wasteful political interventions
that come when funds are "granted" by politicians determined
to be seen to reform, change and claim ownership of new
initiatives in the name of electoral popularity.
Unfortunately these ideals are not currently being met and
as a consequence the public will continue to be resistant to
the kind of taxation levels required to fund the NHS our
country deserves. Rather than emphasising "rationing" and
the need to define essential services the BMA should have
grasped the nettle and stated what we all know - that the
affluent do not pay enough, for the reasons stated, into
health care provision in this country. As a consequence many
families will spend more on car insurance per annum than on
NHS contributions.
In creating a core service available to all which is so
degraded that the better off are given an incentive to pay
for extra services we will replicate the situation in our
schools. Forcing the well off in society to cover themselves
with insurance by means testing, rather than because the NHS
is so run down, would be a far fairer option. As a
consequence the less well off would still be protected and
have access to a much better funded and potentially first
class service. Extra funds aquired through insurance would
be in fact "hypothecated" and the affluent may resent paying
this less than tax.
Such radical reform would be inferior to a totally tax-based
system, but only one which existed in an ideal world of
trust in government and egalitarian spirit which we do not
currently inhabit. It would, however, shake government
popularity not in the lower, but in the middle classes and this will be avoided at all cost.
Competing interests: No competing interests