Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: By their budgets shall you know them

BMJ 2023; 382 doi: (Published 18 July 2023) Cite this as: BMJ 2023;382:p1639
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

“Show me your budget, and then I’ll know what you care about.”1 This quote is from Duncan Selbie, erstwhile head of Public Health England, when addressing the covid inquiry. It also applies more widely, and I was reminded of it this week as I read about the government’s plan to scrap inheritance tax.2 This proposal would benefit a small minority, as the tax is levied after only 3.76% of deaths in the UK, although many more people wrongly believe that they’ll be affected. Ending this tax would mean a £7bn reduction in government revenue.

If our economy has this amount of money to spare, there are surely other priorities that should be considered. The cost of meeting the demand for full pay restoration for doctors in training has been estimated at £1bn.3 While industrial action continues, with only urgent and emergency work happening on strike days, waiting lists for NHS treatment are inevitably growing.4 If we paid our doctors properly we could both stop the strikes and stem the haemorrhage of juniors leaving for sunnier climes with better pay and conditions. As well as being just and fair this would make economic sense, by simultaneously enabling patients on waiting lists to return to employment and stopping the export of our expensively trained doctors.

In thinking about the spare £7bn, perhaps we should also be focusing upstream on the wider social and commercial determinants of health. In the past week we’ve seen reports of rising hospital admissions with malnutrition, and the Office for National Statistics reported that one in 20 UK adults had run out of food in the past two weeks and couldn’t afford to buy more.56 The rate of this food insecurity is significantly higher in single parent families, affecting more than a quarter of such households. As the Joseph Rowntree Foundation points out, “the basic rates of benefits are inadequate and do not allow recipients to meet their essential needs.”7 The long term consequences of hunger and poor diet are shown in both physical and mental health, experienced by patients over many years and increasing the cost of healthcare.8

Clearly, we could all think of multiple ways of spending those billions that would improve the nation’s health, and we wouldn’t necessarily agree on which was most important. An investment in general practice—which might at last start to reverse the trend of GP surgery closures that have resulted in 650 000 patients losing their local surgery in the past five years—would be high on my list.9

It’s difficult to see how the government’s current proposal on inheritance tax would help, except by illustrating its priorities with great clarity.