Jennifer Dixon considers the choices for the NHS given the current and projected future financial climate, and argues for a broad, two-way dialogue with the public as a channel for discovering solutions.  

The gloom continues. The pressure on public finances is not just a 10 year problem, but will be here for the longer term mainly because of an ageing population. That is what recent projections from the Office for Budget Responsibility suggest, even before the International Monetary Fund last week downgraded the previously meagre forecast for GDP growth in the UK economy – to 0.2 per cent this year and 1.4 per cent next.

So the 10 year pinch for the NHS and social care we showed in our recent analysis with the Institute for Fiscal Studies (IFS) is the new normal. (Look out for more from our research programme on the financial challenge facing the NHS and social care services over the autumn.)

In this climate, will public support for solidarity – collective financing and universal benefits in the NHS – hold up? So far so good. But how to use that support? For the NHS the broad choices are few: raise productivity; cut the NHS offer; or find more money. Raising productivity is likely to need massive change – much of the type that public action resists. Surely the lessons from successful reconfigurations include dialogue and more dialogue with all involved?

Cutting the NHS offer (as in part explored in our recent report: Rationing health care: is it time to set out more clearly what is funded by the NHS?) will happen because big efficiencies won’t happen overnight (understatement). One way is to reduce services, another is to stop them and make people pay privately. Do the latter and these services will be permanently off the NHS menu – gone after 65 years – with large numbers of people going without care. If this is the choice, surely it would be better to reduce, even if it drives some (hopefully temporarily) into insurance?

Could there be dialogue with the public to gauge support for this – reduced access to some services now but a NHS for the next generation? This is hard! But who better should make this decision? How about finding more money for the NHS? Within the current budget envelope for the public sector, dream on. As David Willetts made clear at our debate on universalism last week, no spending increases in the public sector without tax rises.

But what about a tax rise? Also at last week’s debate Frank Field noted the public distrust of letting the Government have more of its money with few strings attached (i.e. taxation). But he thought hypothecation was worth another look (witness the one per cent successfully added on to national insurance for health care by Gordon Brown). Would public support for this help to unblock the traditional Treasury views on the subject?

But there are no real conversations with the public save ad hoc polling at national level and public consultations of varying quality around local reconfigurations. This is dangerous for the politicians perhaps, but the alternatives may be costlier. The very slow process of reforming social care is a case in point. It seems there is a lack of political will rather than lack of money (or lack of ideas for solutions) – the bill as outlined by Dilnot was modest.

If it is now time to sweat the assets of the NHS, why not sweat the public support productively. Not through one-off pieces of market research, listening exercises or referenda, but perhaps through an ongoing two-way exchange to find solutions?

What do you think?

This article first appeared on the Nuffield Trust website.

Note:  This article gives the views of the author, and not the position of the British Politics and Policy blog, nor of the London School of Economics. Please read our comments policy before posting.

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