summary of written evidence
Healthcare funding review research report 3
August 2000
Introduction
As part of the review process, written evidence was invited from a wide range of organisations, including patients groups, academics, bodies representative of health professionals, and government. Evidence was also received from a number of individuals, particularly members of the medical profession.
Evidence was invited on the four questions to be addressed by the review, namely;
- What kind of healthcare does the public expect, want or need?
- What resources are required to provide this?
- Can these resources reasonably be expected to be provided under present or alternative funding arrangements?
- What mechanisms can be used to bridge any affordability gap that may emerge?
Responses were received from 62 individuals and organisations of which 27 addressed one or more of the questions posed. A list of those who provided a positive response for our request for evidence appears at appendix I. In general, most of these responses were stronger on the question of ‘what kind of healthcare does the public expect, want or need’ than on the questions which concerned resources.
This paper summarises the written evidence received. As noted above, it forms only part of the evidence to be considered by the funding review steering group and needs to be considered in conjunction with the other documentation produced.
What kind of healthcare does the public expect, want or need?
Definitions
In determining the wording of this first question, the steering group had some discussion itself about definitions of public expectations, wants and needs. It was felt that by including all these terms in the question, all aspects of the debate could be covered.
Some of the evidence commented on the importance of defining ‘expects’, ‘wants’ and ‘needs’. The submission from LSE Health commented that “Public expectations and the wishes and desires of individuals are not necessarily the same as the legitimate needs of the population” and suggested that whilst research to ascertain public expectations could help inform thinking about healthcare, an exercise such as a comprehensive needs assessment would be the most satisfactory way of answering the question. The Institute of Directors felt that an idea of what the public expects from healthcare could be gained from conducting a series of comprehensive surveys. ‘Wants’ could only truly be ascertained through a functioning market, and needs could be best assessed by specialists such as statisticians, economists and clinicians, ascertaining health needs on clear economic and clinical criteria.
The majority of the submissions received made similar points about public expectations, wants and needs which can be summarised as follows:
The public expects, wants or needs healthcare which :
- Is of high quality, offering up to date treatment to a high clinical standard,
- Is regulated and accountable to those using the service
- Offers the complete range of services, including primary and community care
- Provides equity of access, or equal levels of access for equal need
- Provides services which can be accessed free at the point of delivery
- Provides continuity of care
- Provides services which are tailored around individuals rather than organisational needs
- Allows individuals to be fully involved in decisions about their care and given information about treatment and choices available to them
- Offers fast access to hospital services and short waiting times.
The general tone of many of the submissions is exemplified by the evidence from Age Concern which stated that “The public continues to endorse the founding principles of the NHS, a service from the cradle to the grave, comprehensive and free at the time of need”. However, others argued that the public already accepts that some services are paid for.
A number of submissions raised the question of whether public expectations of the existing system and what it can deliver, fuelled by the media and politicians, are too high. It could be argued, however, that on the basis of evidence submitted by patient groups, the expectations of many of those using the service are not high enough, particularly in terms of the level of personalised service offered by the NHS. The Royal College of Physicians of Edinburgh commented that “over the life of the NHS there has evolved a growing gap between NHS ‘customer care’ and that of most UK customer experience. Waiting lists, queues, waiting rooms, uncertain appointments, arbitrary cancellations and the persistent shabbiness that characterises much of the NHS environment have now largely disappeared from the rest of British life, and direct experience of NHS care is now considerably at odds with public expectations and experience elsewhere”.
In its document ‘A Concerted Strategy for Modernising Social Protection’ (COM (1999) 347 final), submitted as part of its evidence to the review, the European Commission outlined four broad objectives, one of which is ‘to ensure high quality and sustainability of health care’. In order to do this member states should:
Contribute to improve the efficiency and effectiveness of health systems so that they achieve their objectives within available resources. To this end, ensure that medical knowledge is used in the most effective way possible and strengthen co-operation between Member States on evaluation of policies and techniques.
Ensure access for all to high quality health services and reduce health inequalities.
Strengthen support for long-term care of frail elderly people by providing appropriate care facilities and reviewing social protection cover of care and providers.
Focus on illness prevention and health protection as the best way to tackle health problems, reduce costs and promote healthier life.
Although this does not directly address the review’s questions it gives an idea of the priorities which healthcare systems should be addressing in meeting the expectations, wants and needs of their populations.
What resources are required to provide this?
On the basis of the above, it can be seen immediately that many of the points raised in the evidence on what the public ‘expects, wants or needs’ are not explicit funding issues, but call for changes in the way the healthcare system, and more specifically the NHS is organised. Much of the evidence received reflected this and concentrated on how to make better use of existing financial and workforce resources. (see below)
As expected, the evidence that was provided on estimating the optimum level of resources required, came mainly from the perspective of international comparisons of health expenditure and the position of the UK in terms of percentage of GDP spent on healthcare. A number of submissions commented on the desirability of bringing UK levels of expenditure closer to European counterparts. However the debate following the Prime Minister’s commitment in January 2000 to doing exactly this illustrates that the issues are by no means clear cut. Adrian Towse and Jon Sussex of the Office of Health Economics, in their article ‘“Getting UK healthcare expenditure up to the European Union mean” – what does that mean?’ (BMJ 2000, 320:640-2), comment that “Tony Blair’s statement that the United Kingdom should increase the share of gross domestic product (GDP) that it spends on health care to the average of the European Union (EU) raises several questions. Firstly, will the proposed increases in NHS spending of 5% in real terms (after accounting for inflation) each year to 2006 raise the UK figure from the 6.7% of GDP spent in 1998 to the 8% that the prime minister identified as the EU average? Secondly, is 8% the current EU average, and will it still be in 2006, seeing that the average is a moving target dependent on health spending and economic growth in the 15 countries of the EU? Thirdly, is this a sensible target to aim for?”.
Further caveats include the doubts raised by many about the relative efficiency of many of the systems held out as examples to the UK.
The submission from the European Commission also made the important point that the different social protection systems of each member state in Europe reflect their own traditions and values, highlighting one of the drawbacks of making comparisons between health systems, ie their lack of transferability from one country to another.
A number of the submissions commented favourably on the extra resources to be made available to the NHS and some suggested that the review should be concentrating on how best to use these. In his Budget speech in March the Chancellor announced that for the current financial year (2000/01) the NHS would receive a £2 billion supplement to current plans, taking planned UK NHS spending to £54.2 billion and the cash increase from 5.9% to 9.9%. He also said that this increase will be followed by cash increases of £4.4, £4.9 and £5.2 billion in each of the next three years, representing real growth of 5.6% in each year on current forecast for inflation. The new plans are summarised in the table below. These planned increases stem from an interview the Prime Minister, Mr Tony Blair gave in January on the television programme Breakfast with Frost in which he said the government wished to raise UK spending on health to the EU average over the next five years. Subsequently, in July, the government published its National Plan for the NHS detailing areas in which it intends to concentrate resources.
NHS Expenditure planned and actual 1998/99 to 2003/04 (UK cash)
| 1998/9 | 1999/2000 | 2000/1 | 2001/2 | 2002/3 | 2003/4 | |
| Allocations (£bn) | 45.1 | 49.3 | 54.2 | 58.6 | 63.5 | 68.7 |
| Cash growth (£bn) | 4.2 | 4.9 | 4.4 | 4.9 | 5.2 | |
| Cash growth (%) | 9.3 | 9.9 | 8.25 | 8.25 | 8.25 | |
| Real growth (%) | 6.9 | 7.4 | 5.6 | 5.6 | 5.6 |
Other submissions pointed to the desirability of the longer term strategy of investing in improving the public health through wider measures to improve housing etc and personal responsibility for the maintenance of good health through the adoption of healthier lifestyles. Commenting on the unlikely prospect of funding being available to meet the full range of public expectations, the University of Edinburgh Faculty of Medicine suggested that “there would appear to be an argument in favour of maintaining intervention services at a level of adequacy with professional manpower suitably trained and rewarded to attract an adequate level of staffing, allowing there to be some shift towards the delivery of the appropriate social infrastructure to encourage better health states for future years and future generations.”
The National Association of Primary Care answered the question as follows:
Human resources of all types – well trained, kept up-to date and flexibly employed. Shortages of nurses and doctors are likely to continue or worsen in the short to medium term.
A significant investment is required in the capital estate and in a range of state-of-the-art equipment.
Litigation costs are rising – resources for these must not impede the development of a modern NHS.
The Medical and Dental Defence Union of Scotland also expressed concern at the amount of money which the NHS was having to spend on ‘disciplinary’ matters involving clinicians, increasing medical negligence claims and the potential costs involved in clinical governance, and felt that these trends need to be examined in any review of healthcare funding.
LSE Health pointed out that resource requirements depend ‘not only on need and demand but on the ability of the system to maximise technical efficiency … and control costs’. Some of the evidence equated efficiency with refocusing services to make them more patient centred, whilst others called for greater use of guidelines and service frameworks, or emphasised the role of management information in identifying and promoting good practice. The Royal College of Physicians of Edinburgh, for example, welcomed the increasing use of systematic evaluation (eg NICE and SIGN) and also commended the clinical guideline approach as a method which ‘ensures independence, patient involvement, a respect for complexity and a product that enjoys wide esteem’. Age Concern suggested that national standards should be set and good quality health services costed, and for there to be transparency regarding the means of funding these.
In addition to a substantial increase in the workforce, there were also calls for more effective use of staff and changes to skill mix, and for greater investment in staff training and salary levels to help maximise the contribution they could make to the service. For example the RCN (Scotland) noted that “There is a lot of duplication of effort and this should be stopped………there does not appear to be enough nurses to allow the quality of care to be delivered that patients deserve and that staff want to deliver. If you were to ask nurses what are the most important factors involved in overcoming nurse shortages and allowing nurses to give the highest quality of care they would say: that it is important to get the right numbers and types of nurses, there should be better employee friendly policies, well funded and supported professional development, more student places and access to better clinical placements, expand resources for clinical supervision, tackle student nurse hardship and widen nurse leadership programmes.”
The Scottish Council for Postgraduate Medical and Dental Education also wished to highlight “the crucial importance of having a well-trained workforce in the NHS if we are to achieve the high standards of care rightly expected by our patients. Although considerable resources are devoted to the basic training of people intending to work in the NHS, until now little attention or resources has been targeted on the educational needs of the NHS workforce itself.”
The submission from Lloyds Pharmacy called for “the re-engineering and refocus of existing systems”, using pharmacists to help reduce wastage of prescribed medicines and to undertake screening programmes which would reduce health expenditure in the long term. The University of Edinburgh Faculty of Medicine also commented favourably on using the workforce more efficiently by substituting doctors with nurses as had already taken place successfully in a number of areas. The Proprietary Association of Great Britain, in its paper ‘Managing demand and meeting expectations’ (2000), argues that to ease the pressure of demand patients with minor ailments should be encouraged to see pharmacists or nurses, rather than doctors, and to use over the counter remedies rather than prescription medicines.
Can these resources reasonably be expected to be provided under present or alternative funding arrangements?
As noted earlier, many of the submissions received clearly supported the continuation of the NHS and the principles upon which it was founded. They also expressed a continuing aspiration that the present system of funding the service should be retained and a belief that with increased levels of public funding the NHS could provide the level of service required by the public. The Long Term Medical Conditions Alliance expressed the view that “All our lives are affected by chronic illness, either personally, as carers, as family members or as employers. We feel that the increased public spending on health care is one which is supported by society and will continue to be so.”
The fundamental objection expressed by several organisations, for example, MIND, to providing resources under alternative arrangements, was the inappropriateness of insurance based systems for many including those suffering long term conditions and mental health problems. These groups would either find it difficult to obtain cover, or needed healthcare which was comprehensive, integrated and multidisciplinary. Age Concern also made the point that even those who are able to access private healthcare frequently do not do so when their healthcare requirements are immediate or are particularly complex. The Royal College of Paediatrics and Child Health also argued that a PMI based system would be inappropriate for children “…there is very little private practice in paediatrics when compared with other branches of medicine in the UK, partly because most paediatricians are more comfortable practising in the context of a multi-disciplinary team and partly because by the nature of things people with young children are often those who are least able to afford private health insurance, apart from the most prosperous sector of the community………There is also the difficult question that much paediatric health care these days is related to conditions which are chronic and long term and continue into adult life, so that changes in the health insurance system would present particular problems for that group of patients.”
Others noted that there already existed in the UK a mixed economy of healthcare, tacitly accepted by the public, by which much dental and optical care and long term care which had originally been part of the health/social care package is paid for by individuals. They saw no reason why this system should not continue to exist, with a publicly funded system supplemented by individuals through some degree of co-payment or PMI if required. The submission from PPP questioned whether the public would accept the increase in general taxation needed to bring expenditure up to French or German levels. It suggested that the overall expenditure on healthcare must come from increased personal expenditure. Also that “There is no reason why the current system of paying for state funded health care from funds raised through general taxation should not continue to be at the core of the way in which health care is funded in this country. Nor is there any reason why additional private funding could not be achieved through appropriate judicious introduction of co-payment for some government funded services.”
PPP also argued the point (later supported in discussion at the first review seminar) that the funding system (ie general taxation) was efficient but the system of delivery was not. “…the key issue that this review should address is that the NHS and Department of Health will never achieve the maximum value from money spent while the role of funding health care is so completely aligned with the direct provision of services.”
What mechanisms can be used to bridge any affordability gap that may emerge?
The main issues which arose from the evidence submitted on this question was some (mostly quite limited) exploration of alternative funding methods and opinions on the suitability of these.
Age Concern suggested that “successive opinion polls have demonstrated that whilst the public is usually resistant to paying higher levels of (especially direct) taxation, they are usually sympathetic to the philosophy of paying more for good quality healthcare, available at the time of need. This view from the public indicates the possibility of levying a hypothecated tax for healthcare.”
PPP suggested that “New mechanisms to be considered within the context of the healthcare funding system fundamentally continuing as it is would include:
(a) co-payment for some government funded services (for example, hotel charges for in-patient treatment, charges for a GP appointment, etc)
(b) a review of the tax system to remove the disincentives that limit the scope of corporate funded medical insurance, and to introduce fiscal incentives for individuals to set up medical savings accounts should they wish to do so.”
The Association of Surgeons of Great Britain and Ireland suggested that “it is debatable in the field of general surgery whether conditions such as asymptomatic hernae, asymptomatic varicose veins, asymptomatic skin lesions (bar those likely to be malignant), vasectomy and reversal should be freely available on the National Health Service.”, and that the public should be encouraged to seek treatment privately for such conditions.
The RCN (Scotland) suggested that the ‘tobacco tax’ announced in November 1999 should be used for initiatives to support staff, allowing other funds to be spent on patient services and equipment.
Two blueprints for completely new systems were submitted by the Institute of Directors (‘Healthcare in the UK: the need for reform’) and the Institute for the Study of Civil Society (‘Stakeholder health insurance: a submission to the BMA inquiry into NHS funding’).
The other key issue to come out of the evidence on this question was that of rationing and the need for an open public debate about this.
The Chartered Society of Physiotherapy suggested that “the issue of ‘affordability gaps’ should be openly discussed. Rationing is already in evidence in a number of guises within the NHS.” The Royal College of Physicians of Edinburgh saw the need for a broad societal debate with patients and public, concerning the goals and limitations of modern healthcare, covering such issues as “the social roots of much UK ill-health; the medicalisation of distress; expectations of greater direct public access to life-style pharmaceuticals (eg Viagra); the role of medicine and the pharmaceutical industry in focussing on the late manifestations of lifestyle related and possibly preventable illness; and the limitations of medicine towards the end of life.”
Patients’ Concern suggested that there may be an ‘acceptability gap’ on the public’s part when it came to meeting the cost of healthcare rather than an ‘affordability gap’. If this is the case, reductions in levels of service must apply across the country and not be at the discretion of local health bodies.
The lack of transparency and inequities in current approaches to NHS rationing were raised by a number of organisations. For example, MIND cited evidence of individuals with severe mental health problems being refused more effective drugs on cost grounds. Age Concern suggested that “the experience of recent years has been one of increasingly abandoning older people.”
Conclusion
The written evidence submitted, although not completely comprehensive in the range of issues it covers, has provided some useful information and also insights into the views of a range of organisations and representative groups. It is clear that there remains a lot of support for what might be called the founding principles of the NHS and that few of those submitting evidence would wish to argue for a wholesale move from general taxation as the principal method of funding UK healthcare.
What did come out of the evidence was acknowledgement that the issue of rationing needs to be tackled more openly. This in turn raises the question of whether a more open approach to rationing will inevitably lead to the exclusion of certain ‘non-core’ services from the NHS and how individuals should be encouraged to pay for these if they wish.
Contributors
Mr Walter J Ablett
Age Concern
Mr W Aitken
Association of Surgeons of Great Britain and Ireland
Mr A D Bacon
Barnsley Local Medical Committee
Dr Michael Blackmore
Mr Edward Bramley-Harker, National Economic Research Associates
Mr J Brightman
Mr Ken Buck
The Chartered Society of Physiotherapy
Common Services Agency for the NHS in Scotland
Mr M Davey
Derbyshire Local Medical Committees
The European Commission
European Observatory on Health Care Systems/LSE Health
Faculty of Occupational Medicine of the Royal College of Physicians
Faculty of Public Health Medicine of the Royal Colleges of the UK
Dr R Fitzgerald, consultant radiologist
The Healthcare Improvement Network
Herefordshire Local Medical Committee
Professor A T Hill
Institute of Directors
Institute of Directors Scotland
The Institute of Economic Affairs
Institute for Public Policy Research
Institute for the Study of Civil Society
Dr Vincent Kielty
Mr P Lawrence
Ms Vera Leathart, Vera Leathart and associates
Dr C O Lister
Lloyds Pharmacy
The Long-Term Medical Conditions Alliance
Dr C G Male, chairman, district medical staff council, Hartshill Royal Infirmary
Mr Stuart Marples, Institute of Healthcare Management
The Medical and Dental Defence Union of Scotland
Mental Welfare Commission for Scotland
MIND
The National Association of Primary Care
Mr William J Newlands, consultant ENT surgeon
Dr Keith Nightingale
Office of Health Economics
Patient Concern
Mr B T Pearce
PPP Healthcare
The Proprietary Association of Great Britain
Royal College of Nursing Scotland
Royal College of Obstetricians & Gynaecologists
Royal College of Paediatrics and Child Health
The Royal College of Physicians of Edinburgh
Dr Rosemary Rue
Scottish Association for Mental Health
Scottish Council for Postgraduate Medical and Dental Education
Dr Barrie S Smith
Suffolk Local Medical Committee
Mr Peter Sugden
Dr A M Till
University of Edinburgh
University of Glasgow
Dr Michael Wilks, chairman, BMA ethics committee
Mr Peter D Williamson
Dr Linda Winkley, consultant child and adolescent psychiatrist