A birthday presents go, this one is hardly a secret. There have been stories for weeks about whether the government will give the National Health Service extra funding to mark the 70th anniversary of its creation in July – or leave this until the Budget in November. The greater uncertainty was about how much. A figure of £20bn by 2023 has just emerged, following a tussle between those advocating new funds – including the prime minister – and the chancellor, concerned about maintaining control on spending just as public finances are getting back into the black.
There are good reasons to put in more funds now. Key elements of the health service are showing severe strain, judged by waiting times in A&E, pressure on beds and time waiting for operations. The causes are well known. There have indeed been improvements to efficiency, and digital health techniques are being developed, but their impact has been overtaken by pressure on budgets and the ageing of the population. What is more, sharp cuts to local authority funding since 2010 have undermined the funding for social care, particularly care for elderly people, many with dementia. The knock-on effect on hospitals and GPs has been clear.
“The case for steadier funding is clear but both main parties have found the debate about how to fund this too hot to handle”
As government problems go, health is in a special category. Many of the pressures causing today’s predicament have been foreseen for years, if not decades in the case of demographic trends. Social and technological trends are also fairly steady. But that has not made solutions easier to find, and to retain once devised. Instead, the political heat around everything to do with health and its funding has made many of the possible solutions politically inaccessible to both main parties. The answer at this point (as the Institute for Government argues in a report this month, supported by the Health Foundation) is more money for health and for social care, more consistency of funding and agreement on where this money is to come from. The latter is the most controversial, with the prime minister’s latest announcement no exception. Theresa May hasn’t explained exactly where the £20bn will come from, but hinted at both possible tax rises and using the “Brexit dividend”.
Since 1955, funding for health has gyrated from real increases of 8% a year to real cuts. In social care, since the mid-2000s, the rolling five-year average of real terms expenditure has been consistently falling, aside from the injection of the Better Care Fund in 2015-16. Social care has been the poor relation of health; aside from recurrent scandals in residential homes, there has been comparatively little attention given to the strains on it.
The case for steadier funding is clear. It takes three years to train an initially qualified nurse, 10 years to train a fully qualified GP and usually a minimum of 12 for a hospital consultant. Decisions on drugs and on purchase of technical equipment need to be planned in advance to get the best from them.
But both main parties have found the parts of the debate about how to fund this too hot to handle. For Labour, anything that departs from an NHS that is free at the point of use is generally taboo (even though there are precedents for payment in prescriptions for some people and dentistry, these raise very little). The Conservatives’ attempt to require elderly people with significant equity in their homes to draw down more of it to pay for their care rebounded on them. That part of the 2017 manifesto was promptly labelled a “dementia tax”; although the elderly with more than £23,000 in assets are already required to pay, the sharp public reaction to the proposals appeared to rest on a lack of widespread understanding of this.
So what should be done? The government’s decision to increase NHS funding may go some way to alleviate immediate problems. A plan to tackle its pressures along with those on social care would help considerably too; that is clearly what Jeremy Hunt intended in asking for his job to be expanded to secretary of state for health and social care.
But this one announcement from the prime minister is unlikely to do the job. The best answer would be for the government to launch a thorough investigation into the future needs of the health service and of care for the elderly, and into the possible sources of this funding. That would need to comment on the extent to which greater efficiency and improved public health might alleviate the pressures; the desired level of health and social care services – an inescapable political decision; the funding needed and the best way to raise it.
There might be attractions to doing this through a cross party parliamentary inquiry, if there were sufficient support. More than 100 MPs, including 21 select committee chairs, have already called for one. There could be some appeal, too, in asking the Office for Budget Responsibility to extend its work to comment on the sustainability of health plans and funding. There are different routes to the same goal. That goal is clear, though: to avoid the cycles of crisis and emergency funding in health, and to make the planning and funding for its future much more predictable.