What can the NHS afford? Every week one pressure group after another protests at rationed treatments, as the NHS suffers its greatest funding shortfall since it was founded.
Today, it’s Breast Cancer Now – and its case is exceptional. Usually rows over cancer drugs involve extraordinarily expensive new treatments, often not properly proven, offering a few months’ extension at the end of life. But here is a cheap drug – bisphosphonates to be taken for three years at a cost of just 43p a day – that would prevent one in 10 deaths if given to all eligible breast cancer patients. A study in the Lancet shows it cuts the risk of cancer returning by 28% and the risk of death within 10 years by 18% – a significant effect. But it has been caught in a money row that is a typical symptom of the fragmented, competing service created by the 2012 NHS Act, where everyone offloads costs on to everyone else: should it be paid for locally (yes, says NHS England), or funded nationally (yes, say local clinical commissioning groups – CCGs – and providers). The National Institute for Health and Care Excellence (Nice) – excellent but often too slow due to lack of resources – will not adjudicate until 2018.
And what of IVF? It’s constantly picked on as if it were a mere lifestyle choice, like cosmetic surgery. But Nice decrees that every woman who needs it should get three free cycles of infertility treatment on the NHS. A survey shows only one in four areas in Britain offers all three cycles: who gets a baby is a postcode lottery as arbitrary as delivery by stork. Instantly on the Today programme, IVF campaigners were grilled as to whether desire to have a baby should really be a priority compared with, say, cancer treatments?
That’s the way it always goes – one lot of NHS needs pitted against another, when the answer of course, is both. The pain of childlessness – a health malfunction – can be a lifelong agony, far worse than minor ailments that are treated unquestioningly. Nice recognises it and it is the best judge we have of value for money treatments when even a well-funded NHS always has to prioritise. Rationing is inbuilt in every health system – and it’s far more brutal under US private insurance plans. The only question is only how much are we willing to pay for what? The RNIB reported this week that people are waiting up to 15 months for cataract treatment, as cash-strapped CCGs, ordered to cut their debts, ration non-life-threatening treatments, even if delay may be life-crippling.
What can we afford? A strong report emerged on Wednesday from the Office for Budget Responsibility – the government’s getting and spending arbiter. Yes, it concludes, the NHS will still be affordable in 2030 and it could increase its share of GDP by almost a fifth. Just as growing numbers of politicians thrash around for new ways to pay – insurance or top-up fees – here come the official budgeteers saying the growth the NHS needs is affordable. Leading health economist Professor John Appleby, of the Nuffield Trust, says the OBR report shows the NHS can comfortably be paid for through general taxation.
We spend 7.4% of GDP on the NHS, but that’s due to fall to just 6.9% by 2020: can that be kept to in the current crisis? Though Theresa May has told top health officials that there will be no more money, she may be forced to relent. The OBR says spending could rise to 8.8% by 2030, an annual real-terms increase of 3.5% a year, still less than the NHS’s 4% average increase since 1948. Appleby says: “The real debate the UK needs to have is over how much more we want to spend on the NHS, not whether we need to change the way the health service is funded.” The OBR figure for 2030 simply puts us in line with most equivalent countries – such as France, Japan, Germany and the Netherlands.
The House of Lords long-term sustainability of the NHS committee will report in March. This is a never-ending story, as the cost of the NHS has caused untold anguish to one government after another. Only five years after its foundation, the Tory government set up a commission to look into whether its long-term funding would meet future demand, though it only cost 3% of GDP then.
The NHS always had enemies – and its affordability is a 1950s question very like grammar schools. However often the evidence shows that the cheapest and most efficient way to pay for health is collectively through general taxation, there are some who imagine private insurance, or some kind of complex semi-private system, or top-up fees would magically see us all pay less for more. Year after year the US Commonwealth Fund points to the UK system as being the best bang for the buck – but mere evidence seems to count for less and less.
The one big question is how much tax we will pay for what standard of treatment. The NHS tops public concerns right now, and so it should. What politicians should really be asking themselves is how best to put this honest question to voters – what will you pay?
We can afford the NHS. The question is whether we are willing to pay for it | Polly Toynbee
