An NHS tax is needed to keep the NHS free to all at the point of need

Guest blog

This is the first in a series of guest blogs that we’ll be publishing in the run-up to the launch of the final report from the Commission on the Future of Health and Social Care in England.

Each blog will focus on one of the possible options for funding future health and social care considered in the commission’s interim report. Here, Nick Pearce of IPPR discusses how a dedicated NHS tax might work.

The commission will make its final recommendations on 4 September.

This is a guest blog post. The views expressed are the author’s own and do not necessarily represent the views of The King’s Fund.

The NHS is facing a serious funding gap if demand continues to increase and budgets remain frozen – up to £30 billion by 2021 according to NHS England. The independent Commission on the Future of Health and Social Care in England, set up by The King’s Fund, is a timely contribution to determining how to address the financial challenge.

As our population ages and increasing numbers of people have multiple long-term chronic conditions, pressure on our services increases. This government has more or less maintained the NHS budget in real terms, but this contrasts with the historical 4 per cent annual increases that until now have made the NHS able to respond to growing demand. 

If we are to avoid a financial crisis in health in the next few years, the NHS needs a cash injection to accelerate innovation and reform.

Health consistently comes out top in people’s priorities for extra government spending. But it is unrealistic to think extra funding could be found by cutting other Whitehall budgets more deeply – the ring-fencing of NHS funding has already meant disproportionately large cuts to unprotected departments.

A dedicated NHS tax or National Insurance increase would boost NHS revenue while not affecting other departments’ budgets. The public may be sceptical about tax increases in general, but is likely to be more supportive of those used to finance the NHS. A one percentage point increase in one of the National Insurance rates, ring-fenced for the NHS, would raise £4 billion and could be popular.

The government would, of course, need to be transparent that this funding was additional, not just filling gaps created elsewhere. It would also need to show that the new funding was having a measurable effect and not simply disappearing without trace into the NHS budget. 

Other approaches also need to be considered, as the commission’s interim report set out. 

For instance, we should look for more productivity gains in the way services are delivered. However, the NHS has already had to make fairly substantial efficiency savings over the past few years and there may be limited scope to do much more in the short term while maintaining quality of care. Also, not all of these savings will be cashable.

There is also the potential to reduce the predicted pressure on NHS spending by reducing demand for services, or at least stemming the increase. In health care this is surely an uncontroversial aim – we all want people to stay healthier for longer, which will in turn lead to lower demand on services. However, many of the possible solutions – integrating budgets and services, providing whole-person care, making greater use of community-based settings, encouraging healthier lifestyles, supporting patients to have greater control and so on – may take time to have a major financial impact.

Crucially, some of the measures to increase productivity and reduce demand would benefit from an upfront investment in cash. Using the invest-to-save principle, an NHS tax could be the catalyst that’s needed.

An NHS tax or increased National Insurance contribution would not generate the full £30 billion but it would be a significant contribution towards it. It could have a near-immediate effect in kick-starting a programme of innovation and reform to redesign health and social care services to better meet patient needs and reduce demand over time.

An NHS tax could play a significant – and immediate – role in reducing the funding gap while maintaining quality of care and keeping the NHS free at the point of need.

Nick Pearce is Director of IPPR. He rejoined the institute in September 2010 after two years as Head of the Policy Unit at No 10. An author and regular commentator on public policy in broadcast and print media, Nick writes on a wide range of issues, from social justice, public service reform and identity politics to the future of social democracy. 

This is a guest blog post. The views expressed are the author’s own and do not necessarily represent the views of The King’s Fund.

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Comments

#42368 stephen black
data scientist

There are two ideas in this blog I think are dangerous.

The first is the assumption, common among health economists who think about the NHS top-down, that there is no scope for significant improvement in productivity. Those who look at the problem bottom-up (that is they look at how the daily operations and processes of the NHS actually work) would beg to differ. There is a great deal about the NHS that could be done more efficiently if the way it worked was reformed significantly. Some of they change requires investment, but the major barrier is cultural: the NHS default assumption is that management just doesn't matter (which is why the system is so extraordinarily under managed). Politicians share this belief and have imposed management cuts to generate populist headlines about their "war on bureaucracy". But it is not hard to show that management (not perhaps traditional NHS management but good operational management) makes a big difference to the quality and cost-effectiveness of care.

The second is that the best way to raise more for the NHS is a hypothecated increase in national insurance. The problem here is broader. The UK tax system is already an ineffective, inconsistent and badly designed mess. NI contributions are used by politicians to raise tax without admitting it. The notional income tax doesn't change, but the real amount of money taken out of salaries does. That's just dishonest and moreover complicates the tax system and makes it more costly to administer and less effective as the wealthy find more loopholes to avoid paying. It would be both more honest and more effective to put income tax up. Or, better, to completely redesign the system so it is simpler, fairer and more effective. we might find that the government's capacity to raise money would go up and the public's tolerance of taxation would improve. That would be a better solution for the NHS (and other public services) than a sneaky, complexity-inducing and potentially ineffective increase in NI.

#42369 Roger Steer
Director
Healthcare Audit Consultants

The best way to raise money is via general taxation.
The problem is stopping politicians spending it on sexier projects.
The only way is to increase the pain for misapplying resources.
That means making it easier for patients to sue, whistleblowers to blow, and for heads to roll when things go wrong.

#42370 Varsha Dodhia
Director

Patients cannot be treated as passive recipients of care. If patients were given access to their records and had some notion of how much it costs to provide care in various settings, then the vested interests would have much tougher job convincing that extra days in hospital is in patients interests or blame others for not providing the care needed.

We use the most expensive resource hospital care in a non transparent way. even the Commissioners do not really know what they are paying for. The quality of data provided by hospitals in the age of instant records is dismal. I was really taken back when I found that the discharge summary was audio recorded for someone to type a letter that was then sent to the GP, arriving 7 days after the discharge and then another person who keyed in the information on the GP system and there were significant errors.
Even though we talk about NHS, it is a fragmented system with some really perverse incentives so when people say increased tax will fund the NHS, we need to be mindful what transparency is there in terms of where the funding goes. The GP system which is what majority of people access is at breaking point and not funded properly.

#42371 David Dundas
Managing Director and NHS Trust Governor
Lion Industries UK Ltd

Increasing taxation further either through income tax, NIC or VAT is counter productive and leads to diminihing tax revenues. The way to raise more money for the NHS is to charge those who can afford it. Charging £ 10 a day for hospital meals would bring in a vaste amount, and charging £ 5 a visit to a GP would bring in more, exempting those on income support. If we charge for prescriptions, why not for these? Free at the point of need is an out-dated concept.

#42372 David Watson

There is nothing free about the NHS. Saying things like "free at the point of care" simply dis-intermediates payment from the service. Clinging to this notion, while politically convenient and makes for rocking good speeches, obscures the real issue which is to answer two questions: (1) How can we pay for the healthcare we want (re-introduce some responsibility for paying for services vs thinking they are free); and, (2) Is the NHS delivering services cost effectively and will appropriate clinical efficacy?

There is no free and economist understand the principle of the rationing behavior of price, although they seem loath to remind us that "price" has its place in the discussion. To say it another way, people will consume all of "free" they can get - and they will not value it.

The commission should address these points and I daresay they would get to a much more enlightened (and interesting) set of findings!

#42382 Elizabeth Roberts

Hear, hear to Mr Stephen Black. I too work in front line services and can attest to the huge amount of inefficiency and lack of incentives, even suspicion, to work differently. We are still paying Band 7 staff to type letters, for heavens sake!

#42387 Michael Tremblay
Health policy advisor
Cassis Limited

The proposed solution avoids the problem, as others have noted. There is a sense of deja-vu about it all.

If there are any hints as to what the future of healthcare and social care might look like, we likely need a system that is better integrated around the patient, uses clinical expertise better, and responds to patient preferences, is nimble, able to change and evolve locally better, deploy expertise and services that can changed quickly

So what funding model or options give us something that is flexible and sustainable for everyone? We know there will never be enough money so creating models to increase the pot of money is a deadend and seems to be the blog author's fantasy. If we briefly consider the impact of taxation funding on health system behaviours, what do we see: failure of financial discipline, failure of clinical quality, leadership failure to be tough on poor performance, inability to create and implement creative solutions, and we see a system that struggles (in the behaviourally relevant sense) to get patients to be more involved and responsible for their health and care.

For my part, I would be looking at how might supplementary insurance be used to part-fund some of the rationed care/medicines that are becoming increasingly evidence (think how we'll fund future oncology treatments if you think the current medicines are expensive). How to use co-payments effectively and when they don't work (US and France as examples). How co-payments enable pooled funding to integrate health and social care without the necessity of means-testing and enable patients to directly commission their needs (e.g. Korea). Why removing the hospital-based monopoly control of access to consultant specialists would be a good, rather than a bad, thing (think access to oncologists, neurologists and cardiologists, for instance where UK outcomes suffer and patient access is significantly delayed). Indeed, is the gatekeeper model fit for purpose, and is it possible that primary care seems to be now part of the problem. I think in part it is because of its inability to pull resources away from hospital monopolists.

Critical to future system flexibility and sustainability will be the need to rethink the current system of controlling access to training in the health professions (why does the UK have, e.g. so few neurologists, compared to other countries). Future healthcare requires greater flexibility in how clinical expertise is trained and deployed.

In my blogging, I've wondered why creative solutions fall on barren ground when transported to the UK from elsewhere -- think Evercare. Why haven't hospital managers addressed the challenges they face creatively on their own; that Virginia Mason, or InterMountain in the US (as breathlessly reported by the King's Fund) have successfully innovated and why haven't people here thought these thoughts independently?

From a policy perspective, the weakness in policy has always been the disconnect with implementation. There is the purity of the policy ideas (much loved by policy folk) and nonsense such as extra taxes (check out whether a similar tax in Ontario, Canada achieved its objectives or just made it easier to run over budget). Meanwhile the gritty real world remains.

#42388 David Oliver
Consultant Physician
ROyal Berkshire Hospital

For many of the range of interesting opinions expressed in response to this piece, there are alternative but I would suggest equally valid viewpoints for instance

1. It is absolutely the case that there are inefficiencices and unwarranted variations in the NHS (not least those caused by endless structural reorganisations), but we spend proportionately a lower percentage of GDP on healthcare than Canada, Australia, Germany, France, New Zealand, Holland, Nordic Countries etc and yet the Commonwealth fund comparison (and yes i know there are other comparisons out there) ranks our system highest on several indices - including value for money. So the assumption that underfunding isnt an issue is at least contestable

2. Co-payment based on ability to pay can work (notably in Singapore for instance). However, in my clinical job i frequently see the effects of means testing for social care - older people who would really benefit from home care are so scared of the means testing or the payment that they often end up refusing care which could help keep them at home. Given that the most intensive service users are frail older people with complex comorbidities, dementia etc or younger people with multiple long term conditions, social disadvantage and often chaotic lifestyles linked to drug or alchohol problems - do we reallly want to be asking the most needy groups of service users to be paying and thereby making them less likely to use services. Where its at these days isnt health literate educated professionals with a big interest in self care, contrary to the zeitgeist.

3. Central control of workforce planning. I totally understand that per capita we have a low number of neurologists or medical oncologists and that this could affect outcomes. However, in many other western countries, because a cardiologist or orthopaedic surgeon can earn 10 times what a GP or geriatrician or acute hospitalist can earn, medical graduated are drawn disproportionately into these high paying specialities partly to pay down debts for their courses which dwarf any similar debts here. What the population increasingly needs is good generalists in primary care and for hospitals, doctors specialising in acute medicine, geriatric medicine and general medicine - this is the biggest need. At least in the UK we are able to match workforce planning with need and because we have national salary scales for hospital doctors and GPs can earn similar money to hospital specialists, we dont have perverse incentives drawing too many doctors into single organ specialities, with big private practice earnings. Older people with complex co-morbidities dont want to be bounced around between lots of different docs based on organs - they want continuity of care and expert generalism.

4. With regard to the Gatekeeper role played by primary care, it is a powerful bulwark against people "doctor shopping" and going straight ot secondary care experts even if in many cases they dont require this input - in turn under a more marketised model, those same specialistss are perversely incentivised to over-investigate and over-treat and people end up with fragmented, poorly co-ordinated care with too many cooks involved. Even now, it seems to be the case that people want quick access to a familiar GP and if they are actually able to get that they often wont default to hospital at all, but primary and communty health services are underfunded.

5. We have to stop recycling the myth that there is no clinically led innovation and quality improvement coming from within the NHS and our "cultural cringe" to all things coming from overseas - yes of course we should be open minded and receptive to good practice examples, but there are examples of innovation in the UK (across the whole service and not just among selected provider chains who can pick and choose which population they look after) which when i speak about overseas, people wish they could import from us. Check out for instance the work of the national hip fracture database, hip fracture best practice tariff etc on driving up quality and improving outcomes for people with hip fracture across the whole NHS - not just in one or two rolls royce providers. Oh and the reason Evercare didnt work isnt because of some kind of resistance to quality improvement in the NHS - its that the politicians of that time tried to drop in a model into a very different context, railroad through a report on effectiveness before it had a chance to bed in and actually the intervention bore little resemblance to the Evercare model.

I could go on, but i think its a perfectly defensible proposition that we need to increase NHS funding to c 11% of GDP and to do this out of general taxation (though the draconian cuts in social care which impact so much on individuals and on the use of health services) need to be reversed and we do need to move towards more integrated care models and a greater focus on prevention.

The US service is designed to enable world class provision and choice to a few service users in a few services who can decide which business line to be in. The NHS is designed to provide universal coverage to whole populations at a half decent standard at a low cost - and this is what it generally does despite all the caveats

David Oliver

#42481 Rob Brittlebank
Lecturer in Health Policy and Leadership
Staffordshire University Faculty of Health Sciences

As a semi-retired, lower-middle level tax payer with a significant career in the NHS, I agree wholeheartedly with Nick Pearce's view. It's clear that the demand for and expectation of the health care sytem is not being matched by the amount of money put into the system. Apart from the wholesale privatisation of the NHS, which I abhor as 1) it's unethical to make a profit out of people who are sick and needy, and 2) it's just not profitable anyway (look at the problems Circle et al have experienced trying to run health care privately), the only way is to fund it through income tax. Whilst no politician will accept this as it will lose them votes, the 'sweetener' will be matching this to a rise in the taxability threshold so that only people who can afford to will pay the extra tax to ensure sustainability of the service - Simples!

#545692 susan shaw
retired

I do not see why there should be a debate at all & I reject the notion.
If tax was collected as it ought to befrom the tax dodgers there would be no need to even consider increasing taxes for the rest of us.

#545695 Dom Ramos
artist

There is an long-standing intransigence to address the establishment in the NHS put there by a whole managerial class of two govermments - managerial posts which hugely, and daily suck revenue out of patient care without great benefit to anybody but themselves.

Whistleblowers are constantly, and in the absence of undertakings to the contrary, put out of a workable discussion for improvement of the system: all those I talk to identify managers as being at the heart of the problem against an atmosphere where the lack of transparency means we cannot know how much of the NHS is being sweated in contracts to Virgin Healthcare and other wholly shadowed contractors with the worst possible record in healthcare when brought under a proper spotlight . It is now obvious why.

The entire austerity narrative by Hunt and Osborne is being used as a blind to the multifarious vested interests, over 35 MPs from the Conservative benches alone are invested or represent these, and the hideous veil of 'non-speech', and outrageous disregard of the reality of what is going on behind the scenes should fool no acerbic or perspicacious observer of the piecemeal trashing of this vastly popular mainstay of British civilisation.

It is now incumbent, as never before, for people to gather round and defend the principle as well as the practice of the NHS. Social engineering has gone so far. We will stop it going further together.

#545696 anthony jones
teacher
none

what if solar pannels were fitted on all hospital roofs that could have them a social club that i belong to from jan to june 2014 was paid over £4,000 from an energy company for the power that we gave to the grid

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