Is it time for a dedicated tax to fund the NHS?
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j471 (Published 08 February 2017) Cite this as: BMJ 2017;356:j471
All rapid responses
This is answering the wrong question. We should be discussing health and healthcare not just the NHS.
Health and healthcare is about ensuring that everyone has the best health to enable them to fullfill their potential, and then caring for them when they are sick, in the most socially acceptable, effective and cost-effective way within the resources available.
Concentrating discussions solely on the NHS and healthcare services misses out the first half of the issue, where many of the solutions may be found.
When we start looking at the big picture, which is wider than just health and healthcare, we may start coming up with more imaginative, sustainable and effective solutions.
Think bigger if you want solutions.
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Dear Editor
I have been a patient for almost 70 years since the age of 8 in 1948 when the NHS was born and worked as a hospital doctor and then as a GP for 30 years. Having had about 20 operations and several stays in hospital, the last being 25 years ago, I recently found myself back in hospital for 2 weeks and how things have changed.
Of course I received much kind and efficient care but being seen by 16 different doctors and looked after by about 30 different nurses and nursing assistants I longed for a key doctor and a key nurse. Lack of continuity of care can lead to failures of communication and compartmentalisation which can also be exacerbated by poor communication between specialities.
The rota system for nurses with long shifts and then days off is not good for them or for patients. Only 2 nurses and 1 assistant were British and some were not fluent in English or had difficult accents but where would the NHS be without them?
It so happened that the ward and then the unit that I was treated on were where I was a Houseman and then a SHO 50 years ago. We lived in the hospital and had 1 evening, 1half day and alternate weekends off. While not wishing a return to such a regime, current consultant and junior doctor rotas are not conducive to good team medical care as under the old firm system. How can junior doctors be adequately trained when they are prevented from getting to know patients and from following them through an illness?
I am a passionate supporter of the NHS and well aware of the financial and other pressures on it. It is rare to see patients wearing dressing gowns now. How much money could be saved if every hospital in the country turned its heating down by 1 degree? One does not need many calories while lying in bed or sitting in a chair all day. How much could be saved and maybe waistlines reduced by omitting the unnecessary biscuits and cakes at coffee and tea time?
Perhaps someone could start up crowd funding for the NHS. The response might surprise the government into increasing NHS funding in some appropriate manner.
Dr Margaret Charlton BM BCH MA Oxon
mcharltontextiles@yahoo.co.uk
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Polarised positions are rarely the whole story and the truth lies somewhere in the middle. Richard is correct to the extent that the politics of the NHS needs avoiding, and John is right that we do need to address the perverse impact of macroeconomic vagaries.
Richard proposes a solution through National Insurance, as if there was anything so misnamed as this. Indeed, it was supposed to be hypothecation, but grasping governments have turned it into just another income tax. NI needs unbundling from the general revenue pot and handed back to the individual taxpayer, who can use it for co-payments for healthcare. The value of this is two fold: the patient has a direct financial interest in the bill they get for the care they receive and will be more likely to be a more critical partner in their care, while providers have a reason to pay attention to their costs and to patient preferences, by improving their performance which is directly linked to the choices patients make and not to proxy decisions by bureaucrats. Patients need to be engaged in order to align behaviour with prevention, for instance.
With John's position we are still left with the imponderable of how much of national general taxation to commit to this. Transparency is hardly rampant in NHS funding, with layers of administration, merging and demerging funding streams, and the separate funding for health and social care. So much for transparency. As for goodwill, the politics of evasion by governments wrapping themselves in the NHS flag and then doing direct policy damage hardly builds confidence. The problem here is the behaviour of political decision making of funding, not transparency and certainly not money as such.
Both approaches disenfranchise patients from direct financial and clinical interest in their care, both assume a beneficent political ethos, neither solves the problem of the structural discontinuity of health and social care and neither has a ratchet to increase and redistribute funding. Neither, too, deals with the private care elephant in the room where the middle ground would be agnostic to how care is provided -- something patients would value. One benefit would be to knit together healthcare and social care without having to encourage it through failed policy such as the Better Care Fund. [1]
[1] National Audit Office, Health and Social Care Integration, February 2017.
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Securing adequate funding for the NHS is of utmost importance, and as can be seen throughout hospitals nationwide at present, an inability to do this can have severe consequences. However, the plan that has been outlined in this article is fundamentally flawed.
Tying NHS spending to government manifesto promises creates problems of its own. If we look at the most recent UK General Election we can see a majority government elected with only a 36.9% share of the vote. Thus, a suggestion that a party winning a majority means the voting public has reached a consensus on NHS funding is incorrect.
Furthermore, following the recent EU membership referendum we can see the effects of headline promises on voting behaviour and the potential for misleading, headline-grabbing statements to appear attractive to voters.
Finally, handcuffing governments with five-year spending plans does not allow for changes in circumstances to influence budgetary decisions. For example, a large financial crisis similar to 2008, or less dramatically, the Liberal Democrats finding that their plans to scrap tuition fees were unaffordable after the 2010 election.
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With just under 75% of this week's poll being in favour, so far, and with the suggestion also made that working pensioners should start paying NI contributions, the time has come for HMT to take hypothecation seriously, and not to oppose as a matter of principle. For many years since its inception, there was an assumption by most people that the NI stamp contained an element of National Health Insurance intended to be for the NHS, though that money in reality went into the consolidated fund, as with all tax revenue, and was never dedicated to the NHS. In this era of transparency and a widespread perception of under-funding of the NHS, there has to be a better debate, though not a referendum, please. But including adult social care will have to remain in the 'too difficult' and pending tray. The fundamental difference between a means-tested system and - for the most part - a system free at the point of use cannot be reconciled.
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Re: Is it time for a dedicated tax to fund the NHS? Absolutely- from a German perspective.
I lecture on the differences between the German and UK systems. When all is said and done, one of the biggest differences between the two systems is the earmarked (hypothecated) funding for health that the German Social Health Insurance provides.
It does not simply stop the fluctuations in health funding levels, but it prevents these fluctuations resulting in such dips that it then takes years to resolve through hugely increased funding levels just to return to the status quo.
This is entirely cost-inefficient, and hypothecated funding would have the potential to reduce the problem significantly...leaving other meddling restructuring "initiatives" as another topic for a Head to Head!
Competing interests: No competing interests