How should we pay for the NHS?

The question of how much we should spend on the NHS, and by what means, seems to have reached new urgency. Over the past week the BBC’s NHS Health Check series of special reports has given graphic form to a rising tide of concern, as waiting lists lengthen, increasingly sick and elderly patients queue inside and outside emergency departments, and overburdened doctors and nurses speak openly about their fears for patients’ safety. Patients and relatives are asked what’s to be done. Their simple reply: “We need more beds, more staff.” In the heat of this current crisis, might we imagine a different world, in which most NHS care has been shifted to the community, and the need for hospital beds is falling? Sue Brown, winner of the King’s Fund “the NHS if” essay competition, does just that (doi:10.1136/bmj.j602). A new government persuades a sceptical public that it must temporarily increase taxes to invest in the alternative to hospital care: health and wellbeing and, initially, an oversupply of home care. Once community services are established, money is withdrawn from hospitals, despite doctors’ strikes. Finally, means testing for social care is stopped for all but the very rich, at last allowing full integration with healthcare. Only two things are missing to realise this beautiful vision, says Brown: money and political will. Would a dedicated NHS tax be the answer? As part of a series entitled “If I ruled the NHS” that The BMJ ran during the last general election campaign, Henry Marsh saw a hypothecated tax as one way to depoliticise the NHS and rescue it from the vagaries of electioneering (doi:10.1136/bmj.h1483). In our Head to Head article this week Richard Layard extends the argument (doi:10.1136/bmj.j471). A dedicated tax would make it easier to translate public demand for a better health service into action, he says, and would avoid the uncertainty of alternating periods of famine and plenty. But John Appleby thinks this would give only the illusion of certainty. He says that we will still need a conversation between politicians and the public about what we want to spend on healthcare and the trade-offs with other things. This and other important conversations now have a new home within The BMJ. Our revamped blog site, BMJ Opinion (blogs. bmj.com/bmj), is a place to find superb writing on health and healthcare from the UK and around the world. Take a look and do send us your comments and contributions.