This question is as relevant today as it was in the 1940’s when Labour gave us our NHS within a welfare state. Welfare now has bad connotations, social care is chronically underfunded and our NHS is in deep financial trouble. It is not helpful that we have a care system designed for the 1940’s, but total opposition to reorganisation!
We mostly agree that we want our NHS to be universal, comprehensive and free at the point of need. Mostly we agree to a tax funded system. Many now argue that social care should be the same and the Care Bill has made some tentative steps in that direction. Many are calling for better standards of social and health care or at least that the highest standards achieved in parts of the system should apply generally.
We all accept strains are placed on the care system by demographic changes, improving technologies, therapies and drugs, and changes in our expectations. All ensure costs of care rise faster than inflation.
But
If current trends continue then by 2020 the gap between the level of funding required and that expected will be of the order of at least £30bn (almost a third of current funding). It may well be more; it could be less, but not a lot less. On all projections we will have fallen back in the international league table of health funding to be below the level of 1997.
We are often asked to believe that this gap can be closed by accounting tricks and by efficiency gains or by “magic” policies like integration. This is nonsense and we can’t use this to avoid the need to make fundamental decisions as a society. It’s time for a more grown up debate.
We can make the NHS more efficient, especially around things like the use of the estate, procurement and IT infrastructure. Of course this should be done but claims about this have been made many times and never really delivered.
We can, it is claimed move care “out of hospital” with major savings but few believe this. It is right for patients but change on any scale would take some time and would require considerable investment in the short term. Shutting acute capacity is not exactly popular.
In social care costs reduction has led to poor care and a race to the bottom for terms and conditions of staff. Entitlements have been restricted – it is hard to see how much worse provision could get.
We can remove some of the worst features of the competition and market model foisted on the NHS and we should do that, as Labour has pledged, but potential savings are nowhere near the exaggerated claims sometimes made.
It is claimed that “integration” will save money, but the evidence is at best mixed and it is far from clear what flavour of integration allows these savings. Better working between NHS and local authorities, sharing services, collocating staff, avoiding unnecessary duplication is good but may not save much money.
So what do we do?
If we want a universal, comprehensive system which is free then taxes have to be raised. It is as simple as that. Most would accept higher taxes on other people – especially the “rich” or “bankers”. More could be raised through a higher rate income tax on high earners, mansion tax and some additional inheritance taxation but not enough.
But there is a precedent when national insurance rates were increased to fund a better NHS (or at least that was the rhetoric at the time). This happened and the world did not end.
And one obvious alternative is to re-invent national insurance. The old idea that you paid in when you could and got “benefits” when you needed them is still a strong concept in an advanced democracy. Only on the far right does anyone argue for moving to private insurance and market based models for care.
First we have to decide what kind of society we want. If we want to care for those in need, pool the risks of devastating costs that are not insurable and give everyone peace of mind then we have to pay for it. Do we want to bring in means testing for health care? Do we accept a minimum service for emergencies which is free and the rest is charged for in some way? Should we require everyone who can to take out insurance? Do we want top ups and co-payments and charges for GP visits?
Most don’t. But most don’t yet accept the need to pay for better care through taxation.
It’s up to us and its time we had the debate and stopped the pretence that somehow markets or efficiency can avoid tough decisions.