Intended for healthcare professionals

Analysis NHS at 70

What models of funding are best for a healthy and just society?

BMJ 2018; 361 doi: (Published 14 June 2018) Cite this as: BMJ 2018;361:k2566
  1. Mark Hellowell, senior lecturer1,
  2. John Appleby, director of research and chief economist2,
  3. Mark Taylor, academic visitor3
  1. 1Global Health Policy Unit, University of Edinburgh, Edinburgh, UK
  2. 2Nuffield Trust, London, UK
  3. 3Radcliffe Department of Medicine, University of Oxford, Oxford, UK
  1. Correspondence to: M Hellowell mark.hellowell{at}

Mark Hellowell and colleagues assess the options for achieving an adequately funded NHS

The National Health Service was created in 1948 with the aim of ensuring that access to healthcare would depend on need and not ability to pay. “The essence of a satisfactory health service” wrote the health minister Aneurin Bevan, “is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged.”1 In Bevan’s view, this required a healthcare system paid for out of general taxation rather than, say, a ringfenced tax or insurance with contributions tied to benefits. From the beginning, then, the link between payment for and consumption of healthcare was deliberately broken. Equality of access was to be accompanied by inequality in financing, with contributions based on people’s ability to pay.

And there, you could argue, the story ends. Apart from some minor adjustments, the source of funding for the NHS has remained the general pot of taxes, with a small amount of additional revenue from patient charges. But there is now a growing sense that things might have to change.

Current funding gap

After eight years of historically low funding growth for the NHS (with per capita increases slowing from 4.4% to just 0.1% a year since 2009-10),2 coupled with unabaiting demand pressures, the NHS is finding it increasingly difficult to maintain performance on several high profile targets.3 This is despite a fifth consecutive year of substantial overspending by trusts in the English NHS.4

The immediate prospects on funding do not look good either. The extra money announced last autumn amounts to a per capita boost of 0.7% next year, with next to nothing thereafter, and is offset by cuts elsewhere, including the public health budget.5 Against this background, the prime minister, Theresa …

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