Intended for healthcare professionals


The election debate on the NHS

BMJ 2009; 339 doi: (Published 23 September 2009) Cite this as: BMJ 2009;339:b3917
  1. Chris Ham, professor of health policy and management
  1. 1Policy and Management, Health Services Management Centre, University of Birmingham, Birmingham B15 2RT
  1. c.j.ham{at}

    The future of health spending will be a key battleground

    If the headlines told the story of patients being offered a wider choice of GP, then the real message of the English health secretary’s recent speech at the King’s Fund was that the election debate on the future of the NHS starts now.

    In a wide ranging analysis of the state of the NHS and options for its development, Andy Burnham set out the government’s stall and threw down the gauntlet to his opponents.1

    At the heart of his speech was the argument that the performance of the NHS has improved in the past decade and needs to progress further in the next. This means holding on to gains such as shorter waiting times for treatment, and giving more attention to improving the quality of care and prevention.

    Echoing his predecessors, the health secretary reiterated that future improvements need to be brought about from the bottom up rather than imposed from the top down. To this end, he emphasised that the programme of work on measuring and rewarding the quality of care set out in Lord Darzi’s NHS Next Stage Review2 will be given priority, with hospitals being paid more for better patient experiences.

    In a subtle but important shift in policy, the speech also signalled that the use of independent sector providers will only be considered if the NHS is not providing high quality care to patients. The implication is that competition between a mixed economy of healthcare providers will proceed more slowly than expected, with the NHS being seen as “our preferred provider”.1 This opens up the prospect of clear red water between the two main political parties in the light of the Conservatives’ plans to give independent sector providers a bigger role in the healthcare market.

    The health secretary highlighted two other areas where Labour’s approach differs from that of the Conservatives. The first concerns its continuing commitment to explicit rights for patients to access services within defined periods of time, compared with the Conservatives’ policy of abandoning these targets in favour of improving population health outcomes. The second relates to David Cameron’s aim of establishing an independent board to run the NHS at arm’s length from politicians, criticised in Burnham’s speech as “plans to create the world’s largest quango out of our NHS”.

    Alongside these differences, many similarities exist between the Conservative and Labour parties, not least the common concern to increase patients’ choice of GP that drew the speech to the attention of the headline writers. The suspicion here is that the health secretary is taking on board policies favoured by other parties to limit their freedom of manoeuvre. This is a textbook example of triangulation—New Labour’s tactic of positioning itself in the middle ground by adopting ideas more usually associated with its opponents.

    The government’s eagerness to start a debate about the NHS so far ahead of the next general election can be explained by survey evidence indicating that more people now believe the Conservatives would do a better job than Labour of improving the NHS,3 despite the fact that public attitudes towards the NHS are more positive now than at any time in the past decade.4 This discrepancy may be the result of the explicit commitment given by David Cameron to increasing the NHS budget in real terms even if this means major cuts in other areas of public spending.

    If this interpretation is correct, the future of NHS spending is likely to be a key battleground in the election campaign. With Gordon Brown and Alistair Darling gearing up for a review of public spending plans, the results of which are expected to be announced in the autumn pre-budget report, the pressure will be on the government to be clear as to whether it will match the Conservatives’ commitment on NHS funding or face the prospect of reductions in services.

    The health secretary gave only an oblique indication of the government’s thinking in noting that better services will have to be funded in future “from taking on a bigger efficiency and productivity challenge”.1 Translated into plain English, this means that NHS organisations are likely to have to find cash releasing efficiency savings of around 5% for a number of years, a target that is much more demanding than any that has been achieved in its history.

    In an organisation currently spending more than £100 billion (€111 billion, $163 billion) a year, the scope for reducing waste and improving efficiency is of course considerable. The government will drive improvements in efficiency by reducing the prices paid to providers under the payment by results tariff, including paying for some services on the basis of best practice rather than average costs. While price controls will contribute to the savings that need to be made, other measures will be needed to bring spending into line with available resources.

    Of critical importance will be the approach of the next government, Labour or Conservative, to public sector pay and pensions. This area of spending matters because of the high proportion of funding—typically over 70% in an NHS trust—that goes on staff. Tight controls of pay and pensions will help to minimise the impact on jobs but politicians are likely to steer clear of making specific commitments until the election is over.

    Equally important is the willingness of politicians to support the merger of hospitals and the rationalisation of services to improve quality and reduce costs. The auguries on this front are not promising, with the public strongly attached to local services and politicians seemingly willing to lend their support to campaigns to protect these services almost regardless of the clinical or financial consequences.

    In this context, the health secretary’s recent speech let the cat out of the bag in warning NHS leaders against trying to predict the future and carrying out their own spending reviews leading to proposed service changes. While the political logic behind this warning is impeccable with an election only nine months away, the consequence of it being followed is to delay the sensible and necessary analysis of options for the future.

    Fortunately, Burnham’s advice is being heeded more in the breach than the observance with managers taking their cue from David Nicholson, the NHS chief executive, who warned back in June that £20 billion needs to be saved between now and 2014, and whose leadership managers are already following. Just as ministers find it difficult in an organisation as big and complex as the NHS to stop things going wrong, so too they are not well placed to prevent managers doing the right thing.

    The rebellious thought this prompts is whether the NHS needs to be led by an independent board if its top leaders are already taking the initiative to plan for a much more difficult future. David Cameron please note.


    Cite this as: BMJ 2009;339:b3917


    • Competing interests: None declared.

    • Provenance and peer review: Not commissioned, not externally peer reviewed.


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