“The state is or can be master of money, but in a free society it is master of very little else.”
What was launched on 5th July 1948 and still faces insatiable demand today? Which public body has increased spending from £11.4 billion (at 2010/11 prices) in its first year of operation 70 years ago, to £147.1 billion in 2015 - and still commands the almost unanimous support of the British public?
Yes, that's right - it’s the NHS: now to be presented with a “birthday present” of £20 billion per year, and still to be run out of general taxation.
So the spotlight is on this welfare leviathan, which may have been designed with the above quotation in mind but has certainly developed on the socialist principle of “government knows best”.
Notwithstanding the crippling increase in the National Debt caused by universal welfare provision over the past 70 years, the British love affair with the NHS continues, still based on its original three core principles:
- that it meets the needs of everyone;
- that it be free at the point of delivery; and
- that it be based on clinical need, not ability to pay.
I don’t take issue with any of these three principles, and we should all applaud the dedication and amazing service provided to over one million patients every 36 hours: that’s 243 million patients each year, and equivalent to each citizen being an NHS patient on average 3.7 times each year. Here are some of the other extraordinary statistics from the NHS Confederation:
- In 2015/16 there were 40% more operations (excluding diagnostic testing) completed by the NHS compared to 2005/06, with an increase from 7.215m to 10.119m.
- There were 16.252m total hospital admissions in 2015/16, 28% more than a decade earlier (12.679m).
- The total number of outpatient attendances in 2015/16 was 89.436m, an increase of 4.4% on the previous year (85.632m).
- In 2016, 507,784 NHS patients were admitted to independent providers for their elective inpatient care. There were 891,717 referrals made by GPs to independent providers for outpatient care during the same period.
- There were 1.826m people in contact with specialist mental health services in 2015/16. 103,027 (5.6%) spent time in hospital.
- There were 21.034m outpatient and community contacts arranged for mental health service users in 2014/15.
- At the end of April 2017, there were 3.783 million patients on the waiting list for treatment.
- At the end of April 2017, 885,876 patients were on the waiting list for a diagnostic test.
No, it’s the funding of the National Health Service which causes the real problem: somehow we need to wean ourselves off the idea that “free at the point of delivery” has to mean “wholly tax-funded”.
Four days after the NHS’s 70th birthday the General Synod of the Church of England will debate a motion from the diocese of Carlisle on “The Long-Term Sustainability of the National Health Service” (click here for the two background papers: GS2089A & GS2089B). Its focus will be on a House of Lords Select Committee report in April 2017, which looked at health and social care - now both combined under Jeremy Hunt’s leadership. The interesting aspect of this report is the contrast it makes between recommendations for funding health (paragraph 170 of the report) and for funding social care (paragraph 239). It says health should continue to be tax-funded, whereas social care should be underpinned by a means-tested system of insurance.
What logic is there for this dual approach? I would suggest, none. It’s just that the British public is deeply addicted to the socialist mantra of paying from the public purse for our state-driven health system, whereas for social care means-testing has been accepted as the norm.
However, the need-risk profile is very similar: in fact, for health there is arguably more prospect of people taking action to restrain their need for service by keeping fit, not becoming obese, and not taking unnecessary risks. Social care for the elderly is much more involuntary than health, as old age limits the scope for mind and body to take measures to avoid the need. On this basis, health would be a much stronger candidate for payment by an element of mandatory individual insurance.
The question is therefore: should both health and social care only be paid out of general taxation for those who cannot afford the cost of that mandatory insurance, leaving everyone else to pay their premiums as they do for their food and housing?
And in case anyone should say “what about National Insurance?”, it’s important to remember that, unless an insurance premium bears some relevance to cost of claims, it’s not really insurance: just part of the taxation system.
When you consider how the pressure will increase for health and social care, you soon appreciate that this is a really big issue for long-term sustainability, not just of the NHS but also for the National Debt:
- The UK population is projected to increase from 65.6 million in 2016 to 69.0 million by 2024 and 72.7 million by 2034.
- The UK population is expected to continue ageing, with the average age rising from 40.0 in 2014 to 42.9 by 2039.
- The number of people aged 60 and over is projected to increase from 14.9m in 2014 to 21.9m by 2039. As part of this growth, the number of over-85s is estimated to more than double from 1.5 million in 2014 to 3.6 million by 2039.
- There are an estimated 3.0 million people with diabetes in England (2016).
- In England, the proportion of men classified as obese increased from 13.2% in 1993 to 26.9% in 2015 - and from 16.4% to 26.8% for women over the same timescale
It will be interesting to see how the General Synod responds to this dilemma, for the Bible teaches us that Christian focus should be on the poor and most disadvantaged, not those well able to pay for themselves. I suspect, however, that the almost unconscious addiction to socialism that is assumed in the phrase “The Common Good” will hold sway (see our commentary – ‘Power and Paternalism”).
However, let’s hope the Government sees the fundamental inconsistency in the House of Lords Select Committee recommendations, and starts gradually to wean payment for the health service off “100% tax-funded”.