NHS funding for a secure future
BMJ 2024; 384 doi: https://doi.org/10.1136/bmj-2024-079341 (Published 20 March 2024) Cite this as: BMJ 2024;384:e079341Read the full series: The BMJ Commission on the Future of the NHS
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Dear Editor
https://www.bmj.com/content/bmj/384/bmj-2024-079341.full.pdf
The BMJ Commission set itself three fundamental questions about future funding of the NHS. How should we finance the NHS? How much do we want to spend? And how do we decide how much to spend? The commission agrees that NHS should be universal, free at the point of use and funded through tax. The commission looks to both 5 and 10 years with recommendations for an ongoing 5 to10 year process.
It is impossible to consider a secure future for the NHS without considering Social Services and Social Care.
• There is interdependence between social services and social care provision by local government and NHS. This requires debate and agreement.
• Adequate comprehensive social care facilities are essential. This will benefit both primary and secondary care. This may reduce the costs of the NHS.
• Care workers are as important as nurses and require a structured professional (non-university) path.
• Public health needs to straddle both local government and the NHS so that the social determinants of health can be addressed effectively.
• Primary care and public health need to be better integrated and expanded. This coupled with a national progressive extensive campaign on keeping well (exercise, good food, etc), directed at all parts of society.
The final four recommendations from the BMJ commission are very good and should be implemented as soon as possible to achieve the commissions goals within 5 – 10 years.
However these recommendations will not provide a secure future for the NHS and health, without adequate provision of social care, provided like the NHS free at the time of use and funded from taxation.
Competing interests: No competing interests
Dear Editor
£32 billion going to the NHS may be what the BMJ wants, but it is certainly not what the people of England need. As a matter of urgency, the people of England need the BMJ to work with the Department of Health and the NHS to identify and disinvest from areas where vast amounts of finite tax payer money is being wasted on unnecessary, and often times harmful, prescriptions, tests and treatments. In 2017, the OECD published a document which estimated that at least 20% of activity in healthcare services added no value, which is consistent with the DHSC publication Good for You, Good for Us, Good for Everybody: A plan to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions, which emphasised that at least 10% of prescribing was pointless.[1, 2]
It is also interesting to note that 20% of the current NHS budget is about £32 billion. To support this, the BMJ ought to revive the Too Much Medicine initiative which was last updated in 2018. Since this last update, the BMJ has publshed a number of articles about waste in healthcare [3, 4, 5, 6, 7] but more needs to be done to also actively work with all healthcare professionals to identify and disinvest from the wasteful activities and to reinvest the liberated resources to support higher value activities that can help to reduce the backlog, improve health and prevent disease. Linked to this, the people of England need the BMJ to advocate strongly for initiatives that will promote health and deliver primary prevention of disease like creating more spaces for the evidence-based and efffective diabetes prevention programme as well as providing healthy, delicious, sustainable school meals for all children in England.[8, 9]
The BMJ needs to look again inside the box of the NHS to reveal and reduce interventions of low or zero or negative value and recommend more high value options to promote population health. Even £1 billion can be used to improve health and prevent disease in a sustainable way for the people of England; for example, an additional £1 billion would be enough to provide all primary state school pupils in England with a free school meal and extending this to all secondary school pupils would be a additional £1.5 billion.
Funnelling ever more finite tax payer money into the NHS is not the best way to deliver population health given the state of the country right now.
Muir Gray, Anant Jani and Alf Collins
1. OECD (2017), Tackling Wasteful Spending on Health, OECD Publishing, Paris, https://doi.org/10.1787/9789264266414-en.
2. https://assets.publishing.service.gov.uk/media/614a10fed3bf7f05ab786551/...
3. BMJ 2022;379:o2614.
4. BMJ 2022;379:e069211
5. BMJ 2022;379:e070698
6. BMJ 2022;378:o2052
7. BMJ 2022;379:e070118
8. Nature. 2023 Dec;624(7990):138-144.
9. https://www.iser.essex.ac.uk/wp-content/uploads/files/misoc/reports/Impa...
10. https://ifs.org.uk/publications/policy-menu-school-lunches-options-and-t...
Competing interests: The Oxford value and Stewardship Programme promotes and provide professional and organisational development to help clinicians and healthcare organisations identify waste and shift resources to higher value healthcare www.ovsp.net
Re: NHS funding for a secure future - naming the elephant in the room
Dear Editor,
We are pleased to read that the an important elephant in the room is slowly being acknowledged in two articles that the BMJ has recently published.
In Appleby et al.’s analysis article, they make the point that to secure the future of the NHS policy and decision makers and the public need to make choices about what to spend the finite resources of the NHS on (1).
McCartney and Craig, this time referring to Scotland’s NHS, point out the same issue about choices but also remind us that these choices need to focus on helping us to reconcile the imbalances in supply and demand (2).
The elephant which is slowly coming out of the shadows has a name - rationing.
The choices that have to be made are difficult and with these choices some treatments and services will be prioritised and others not – i.e. rationed. It struck us as remarkable that this stark and uncomfortable consequence of these choices was never explicitly named in both articles.
Without acknowledging that rationing is one of the uncomfortable and difficult consequences of the balancing of supply and demand in the NHS, its financial security will always be in jeopardy. Without the willingness to acknowledge and embrace rationing as a possibility and reality of our choices, the NHS will be doomed to an endless cycles of: searches for the holy grail; reorganisations; reforms; different funding models; new technologies; AI and so on!
Geoff Wong
Mike Kelly
References:
1. Appleby J, Leng G, Marshall M. NHS funding for a secure future BMJ 2024; 384 :e079341 doi:10.1136/bmj-2024-079341
2. McCartney G, Craig N. Sobering assessment of Scotland’s NHS BMJ 2024; 384 :q602 doi:10.1136/bmj.q602
Competing interests: No competing interests