Alan Maynard is professor of health economics, University of York

Monday 1 September 2008

Time to "screw" the NHS?

The Blair-Brown axis has increased the funding of the NHS in an unprecedented manner, with an additional £50 billion and total expenditure now of £105 billion. Soon we will be spending ten per cent of gross domestic product (GDP) on the NHS. What are we getting for our money?

There have been undoubted improvements in service delivery, with waiting times for elective surgery falling, better delivery of care for chronically-ill patients following the filling of GPs' mouths with gold with the 2004 GP contract and improvements in areas covered by National Service Frameworks.

'Whatever the fiscal situation, the case for increased spending on the NHS is weak'

Variations on a measurement theme
However as Comrade Darzi has noted in his flood of reports over the last year, we have yet to sort out clinical practice variations and the absence of outcome measures. These long standing issues have - at long last - permeated the brains of mandarins in the Department of Health. Well done, chaps!

Efficient policymaking should have started back in 2000, at the point to which Darzi has now led us in 2008. Now we have the absence of an implementation policy of substance, and a plethora of exhortation. In the best traditions of Whitehall, it was decided in 2000 that the problems of the NHS were to be soaked in taxpayers’ hard-earned money.

Now even Ministers have discovered that they have put the cart before the horse. Still, they can console themselves by recalling that this is a fine tradition shared by decision-makers in both political parties when they are in power!

Ministers now appear to believe that the NHS exists to improve patient care. This is a welcome development after 60 years of confusion, during which you could have concluded that the NHS is a social security system for its workforce.

Ministers now appear to believe that the NHS exists to improve patient care. This is a welcome development after 60 years of confusion, during which you could have concluded that the NHS is a social security system for its workforce.

With the economy curling up at the edges like an old lettuce, the pressure on public spending is increasing as is questioning of value for money in the public and private sectors.

Cold economic winds
Prudence Brown has given us a massive public sector deficit, which may worsen as unemployment increases and tax revenues fall and social security payments rise. If inflation moderates, Brown may seek to spend his way out of his economic difficulties to affect his election chances.

If inflation does not moderate, fiscal pressures will increase and spending will have to be constrained with some vigour.

Whatever the fiscal situation, the case for increased spending on the NHS is weak. There is all too little indication of improved health outcomes resulting from NHS spending increases.

Furthermore, given the failure to manage clinical practice variations, the time has now come to say to managers and clinicians, “no more” until you can demonstrate an evidence based case for reducing the taxpayers’ income with increased funding of the NHS!

Will hard and static NHS budgets bring change and greater efficiency more swiftly than the currently sexy policy virus of financial incentives and competition from private sector providers - and perhaps commissioners? Is such a policy electorally viable in the run up to the next election?

The evidence base for hard budgets encouraging change is as good as (if not better than) that for incentives and increasing private sector activity. However it is all rather “evidence-lite”.

'The “rediscovery” of ubiquitous healthcare rationing looks likely to dominate public debate. '

However the economy’s woes may drag the Government into such policies: the electoral consequences will be noisy! The “rediscovery” of ubiquitous healthcare rationing looks likely to dominate public debate.

This competitive struggle for control over resources is ever-present, but veiled. Shredding this veil will reveal whether or not particular clinical emperors are naked or can defend their budgets with evidence that their interventions provide cost-effective care for patients.

Confronting the inevitability of rationing and the universal problem of prioritising competing patients will involve rivers of tabloid-fanned emotion, as we all try to believe we are immortal and that the NHS will always be there - whatever our ailment and despite the inevitability of our demise.

This clamour about the denial of immortality will be unpopular for Government politicians, who desire to be seen as always giving and never depriving patients of care. Their emergence from cloud-cuckoo land into the land of hard and cash limited budgets and rationing will be painful, but it is about time they earned their salaries and generous allowances to buy goodies at John Lewis!