First off, a health warning to readers:  I am a fervent supporter of the NHS, so cannot claim to be unbiassed.  I’ve worked for the NHS since the late 1970s, in England and in Wales.  And of course I’ve been a patient too.

The NHS is unique in being 100% publicly funded.  It is also unique in the way in which it is politically managed.But listening to our politicians’ pronouncements in the run up to this election is worrying.  Both Cameron and Miliband continue speaking in vague generalities, when they can be pushed beyond platitudes.  Both parties box and shuffle around their proposed spending commitments. Jeremy Hunt spouts dogma-driven drivel while Andy Burnham talks of integration as though it will solve everything. I know that we haven’t had formal manifestos yet, but here are some of the issues we need to hear more about from each party before entrusting them with our votes.

Money:  The talk, so far, is all about the mythical magical figure of £8billion and who will/won’t commit to this level of funding.  This figure comes from  estimates produced by the new “NHS Czar”for England, Chief Executive…Stevens, who predicts that the NHS needs £8bn over inflation by the end of the next Parliament (2020/2021) to maintain its present level of services. 

Reports from leading health experts and think tanks suggest this figure is inadequate because:

• it relies on achieving efficiency savings of 2-3% per year
• The proportion of elderly people in the population will continue to grow during that period
• Elderly people, with growing rates of chronic disease, use more health and social care services than the rest of the population.

Efficiency savings in the NHS currently run at 1.5%, so expecting these to increase to 2% is a big ask, let alone expecting 3% per year.

Historically, costs in the NHS tend to rise faster than inflation because of the steadily increasing number of elderly people and because the costs of new medical technologies tend to rise faster than inflation.  Now we have an added factor, as cuts to Social Services budgets begin to hit the NHS. Therefore the supply of places providing rehabilitation facilities is falling.  This leads to back up in NHS acute hospitals and we have all seen the knock on effects of that this winter.

Resources  No place to discharge vulnerable patients to, means that beds in acute hospitals are full; so, no room for new patients, whether from A&E or scheduled admissions.  The whole system grinds to a halt, waiting times increase, staff are over-worked and pressured.  They get sick and are off work, so agency nurses and locum doctors are needed, adding increased and unanticipated spending on hiring short term staff.  And then the hospital emerges over-spent at the end of the financial year.

Performance  By this time with waiting times targets have been missed frequently, staff become stressed and demoralised while politicians wring their hands…

So is there a way out of this vicious cycle?

Funding:  The Health Foundation estimates that, expecting more realistic efficiency savings of 1.5% a year (the rate at which they are currently being achieved), the NHS still needs some £65 billion over and above inflation by 2030.  That means annual funding needs to increase to 2.9% a year, slightly higher than the predicted rise in GDP of 2.3% a year.

So far, spending on the NHS in England has risen by an average of 0.7% per year in real terms over this parliament (2009/10 to 2013/14). This is lower than the average rate of increase for the UK of 3.7% a year in real terms since the NHS was created in 1948. But it has enabled Coalition politicians to claim, rightly, that they have increased spending on the NHS:  from 2010-2013/14, spending on the NHS rose to £112, the highest amount since 1948. Spending increased by 1.1% in real terms in 2013/14. And planned spending is set to increase by 1.3% in real terms in 2015/16.  But the statement above still holds:  this is less than at any time since 1948.  And here are some effects:

• Spending by hospitals increased by 2% a year during this parliament (2010-15).  Now, 4 out of 5 hospitals are expected to be reporting deficits as this financial year ends.
• Meanwhile spending on general practice has fallen by 1.3% a year.  This is unfortunate because primary care is the bedrock of health systems, providing 80% of care. Care provided at primary care level can prevent more expensive care needing to be given at acute hospital level. And so. stresses on this part of the system have the sorts of knock-on effects we’ve all bemoaned this winter:  increased waiting times for GP appointments, A&E attendances up, bed shortages in hospitals and round we go again.

At the same time, NHS spending on care supplied by non-NHS providers (private, voluntary and local authority organisations) has risen by an average of 6.2% a year in real terms between 2009/10 and 2013/14. Services purchased by NHS commissioners (primary care trusts, NHS England and clinical commissioning groups) from non-NHS providers rose from £8.2bn in 2009/10 to £10.4bn in 2013/14 in real terms (see figure 5).www.health.org.uk/ fundingbriefing.

Spending on private providers is meant to bring in a more diverse range of services.  Introducing an element of competition can stimulate quality improvements.  But what it also does, much more inexorably and inevitably, is to increase transaction (administration) costs.  It may increase patient choice but, in my experience, this is a two-edged sword.  The patient also gets the burden of choice: s/he has to take on finding and selecting a provider, despite usually being in a vulnerable position (ill and anxious) when undertaking those roles.  And it makes it very hard to make judgements on relative quality because indicators are different in different systems, and commercial confidentiality concerns limit the information available to would-be service users.  Our system using GPs as gate-keepers provides both advocacy and monitoring of quality.

Miliband’s proposals, announced today, to cap profits made by private providers would ensure that some of the £18 million a day profit currently being made by private providers from the NHS budget (Patrick Wintour, http://www.theguardian.com/electionlive27.03.15) gets ploughed back into the NHS.  This would help to pay back the NHS for its investment in training, developing and employing those who may also work for the private sector…).  In addition his proposals to repeal the Health & Social Care Act, more aptly tagged as Lawnsley’s Disaster, perhaps, and remove the requirement on Commissioners to include private tenders, may also help the NHS to refocus on its core functions.  But more funding and more funding for social care have also got to be part of any package to ensure the NHS remains a viable free-at-the-point-of-access service, regardless of a patient’s locality, age,gender, or means!