Can we afford the NHS in future?BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4321 (Published 12 July 2011) Cite this as: BMJ 2011;343:d4321
All rapid responses
I love John Appleby's demolition of the overly simple statements
politicians make to justify what they do, but I'm not always sure he
reaches the right conclusion at the end of his arguments. In this case he
also makes some dubious assumptions.
The government (and other politicians) have reasons to hold back from
being honest about why NHS reform is necessary. Criticism of the NHS, no
matter how justified by data or fact, tends to provoke a firestorm of
criticism from outside and inside the service. This makes getting the
people you've just criticized to change a lot harder.
In this case our political classes (even the Conservatives) have
chosen to measure the value of the NHS by how much we spend on it rather
than by how good the output is compared to how good it should be. So it
gets a little embarrassing when you need to have the productivity or the
But on the significant point about affordability are John's arguments
solid? Well it depends where you start. He doesn't extrapolate the last
decade of growth but the long run average which is much lower. And he
doesn't address productivity which seems to decline sharply as we spend
more. The UK government faces severe constraints on its ability to spend
in the next 5 years if we want to avoid ending up like Greece. So, in
practice, if we gave the NHS 4% real terms increases we would have to cut
something else by even more (as, if I remember rightly, he argued in the
Kings Fund report on NHS funding in a cold climate). Would the voting
population accept maybe 10% annual cuts to the police force, or education?
That is what affordability is really about.
Moreover he uses dubious stats to illustrate the benefit of
increasing NHS spending. The chart showing % GDP spent on health vs Life
Expectancy (showing a positive relationship) can be criticized on several
grounds. He doesn't label the countries, so it is hard to judge whether
the selection is representative (the USA is clearly not there, for
example). % GDP is probably a less useful metric than absolute spend per
head at PPP exchange rates which should allow better comparisons when GDP
is very different. I did a quick attempt to replicate his result using
gapminder numbers (www.gapminder.org) and for a comparison of western
economies I don't find a strong relationship at all (though including the
USA is bound to lower the relationship).
Since we know from internal metrics that both productivity and
quality could be improved a lot and that spending too much may harm
patients (it is clear in the Dartmouth Atlas work in the USA) I'm not sure
that affordability is the right ground for debate anyway.
Competing interests: I have worked for PA Consulting for more than a decade. Clients of this global management consulting firm, headquartered in the UK, have included the Department of Health, NHS providers and NHS commissioners. The views expressed here are personal opinions and not those of PA Consulting.
When doubt is raised about whether we can afford the NHS, the motives
of those asking the question should be scrutinised.
Think through the logic very carefully.
Unaffordable to who?
If to the Country as a whole , one is claiming one of the riches
nations on earth cannot look after the health of it's citizens.
If unaffordable to the Exchequer you are exposing your philosophy and
priorities as to what tax is spent on, as healthcare through general
taxation is the fairest, most effective and cheapest way
--all other systems would be even less affordable
You would be agreeing that we abandon universality and the
comprehensive nature of the NHS, and we accept 2 tiers of healthcare in
If unaffordable to the citizen we go back to the dark ages , pre-NHS
,with the state leaving people to their own devices. This then becomes a 3
tier system like in the USA
The way a society delivers it's healthcare defines the values and
nature of that society.
That's why I'm glad I'm British and not America.
If we can't afford the NHS in it's current form or any other form, we
will need an additional system. Add the cost of that, whether it be
insurance based or whatever and the citizen ends up paying alot more .
The total will be far greater than the cost of even the most comprehensive
Those who have never liked the NHS have peddled this "we can't afford
it" nonsense since 1948. What they really mean is they don't want to pay
for it. As Appleby states , spending on health is a matter of choice, not
affordability. Yet again, Lansley inadvertently exposes his hand.
Of course we can afford the NHS
We cannot afford NOT to have the NHS
Dr Paul Hobday
Competing interests: No competing interests
Publication of this feature on line has fascinating timing, being the
day that the Office of budget responsibility also comes out(1)and says:
"Our central projections, and several of the variants we calculate,
show that on current policy we would expect the budget deficit to widen
sufficiently over the long-term to put public sector net debt on a
continuously rising trajectory as a
share of national income. This is clearly unsustainable."
"Under our central projections, the government would need to increase
taxes and/or cut spending permanently by a little over 3 per cent of GDP
(?45 billion in today's terms) from 2016-17 onwards to satisfy the inter-
temporal budget constraint through an immediate and permanent adjustment."
"Under our central projections, the government would need to implement a
permanent tax increase or spending cut of 1.5 per cent of GDP (?22 billion
in today's terms) in 2016-17 to get debt back to 40 per cent and 0.8 per
cent of GDP (?12 billion in today's terms) to get it back to 70 per cent."
"There is considerable uncertainty surrounding the scale of the fiscal
challenge that confronts future governments, but the fact there is such a
challenge is not in doubt. Neither is this a challenge confined to the UK.
As the International Monetary Fund argued in their Fiscal Monitor in
April: "Although substantial
fiscal consolidation remains in the pipeline, adjustment will need to be
stepped up in most advanced economies, especially to offset the impact of
age-related spending... From an even longer-term perspective, spending on
pensions - and
especially, health care - constitutes a key challenge to fiscal
So, although John's analysis is interesting, it is not the whole
picture. However I would agree that the question will be: do we spend on
health housing, food or education?
Step up the first person to decide whether we take from our children
or our parents?
The argument really is a choice of what we spend our money on.
However I don't see any country in our fiscal state aiming to increase
overall public funding, the impact on escalating debt would be too great.
Any one care to advocate higher taxes- I suspect not?
1. Fiscal sustainability Report July 11 Office of budget
Competing interests: Director of foundation trust