What’s the prognosis? Patients' opinions on funding the NHS30 June 2013
With the National Health Service having celebrated its 65th birthday in a cloud of criticism and finger-pointing, what does the fiscal future hold for this grand old UK institution? The Department of Health’s Anna Dixon, and Amy Galea, Anastasia Knox and Dan Wellings of the King’s Fund asked those who arguably care most about the service – the patients – what should and should not be changed.
In the past 50 years, spending on the National Health Service (NHS) has increased from 3.4% to 8.2% of the UK's gross domestic product (GDP). If the next 50 years follow the same trajectory, the UK could be spending nearly a fifth of its entire GDP on the public provision of health and social care.
These statistics suggest a need for engaged and informed public debate about the level of future spending on health and social care, and how increased NHS spending might be funded. With this in mind, the King's Fund, in collaboration with Ipsos MORI, held two deliberative events with members of the public, one in London on 20 October 2012, and one in Leeds on 10 November 2012, to discuss how future healthcare will be paid for.
What do the public think about NHS funding?
Considering what polling can teach us about public attitudes to NHS spending, possible cuts and alternative funding models provide some context for the deliberative events' findings.
Figure 1 shows that most people think the NHS will face a severe funding problem in the future. What this data does not tell us, however, is whether people have a clear understanding of the scale of the challenge; the King's Fund was keen to explore this in the deliberative events.
Although two thirds of people think the NHS provides taxpayers with good value for money, fewer than half think it is doing all it can to reduce waste and inefficiency.
According to NatCen Social Research's 'British Social Attitudes 2012' report, 68% of people choose health as their first or second priority for extra government spending, placing it above education, housing, and police and prisons. Polling carried out for the Nuffield Trust in 2012 shows that 79% of people think public spending should be protected from cuts, even if that means bigger rises in taxation and/or deeper cuts in other areas of public spending. When asked which areas of public spending should be protected from any cuts, most people (79%) chose the NHS/healthcare.
What is clear, however, is that people have an unrealistic view about how much can be spent on the NHS. Figure 2 shows that about 40% of those surveyed believe there should be no limits on NHS spending. It is interesting to note, though, that this proportion was higher back in 2006, which suggests that more people are starting to accept that limits may be necessary and public spending is not infinite.
What are the challenges facing the NHS?
Funding was seen to be a challenge in two principal ways. Firstly, the issue of the cuts was raised at both events, with participants saying that, as a result, there is currently not enough money to maintain standards of care in the NHS. Secondly, the funding challenge was seen by some to be linked to the cost of drugs and medical technology. Some participants noted that the high cost of new treatments represents a considerable burden on the NHS, particularly given the general public's degree of expectation that these treatments should be available to all.
Participants also saw the UK's aging population and, less commonly, the increasing size of the population as a whole (partly as a result of immigration), as posing a considerable challenge to the NHS. Some participants explicitly linked this to funding pressures, as a result of both the cost of caring for older people, and the burden placed on resources by the sheer number of people using the NHS.
Although funding and demographic factors were seen as the greatest challenges, others were identified, including the inefficient use of resources leading to waste, problems attracting and retaining staff of sufficiently high quality, and rising expectations among those using the NHS.
What is patients' understanding of the issues?
All participants broadly understood the current NHS funding model and everyone was aware that healthcare is funded through taxation. It became clear, however, that there were a number of unanswered questions and less knowledge about specific details.
Most spontaneously mentioned National Insurance, but there was some confusion as to whether this is earmarked for healthcare and entitled people who had paid in all their lives to get services.
Services for which users were charged also came up. Some groups discussed what sort of services people have to pay for and also explored which types of people are exempt from paying charges.
There was quite a high level of awareness of charges being made for dental services and prescriptions. Fewer groups mentioned charges for optical services such as eye tests and spectacles, or car parking at hospitals. A number of services were mentioned that are not usually accessible on the NHS and must therefore be paid for privately, such as specialist physiotherapy, chiropractic, vaccinations for overseas travel and alternative medicine.
Most groups included people who were well informed about co-payments and exemptions policy in the NHS; for example, most knew that those who are unemployed or on benefits are exempt from paying charges. Some participants were also aware that patients with certain conditions, such as diabetes and cancer, and people in full-time education are exempt. Others mentioned pregnant women and pensioners as being exempt, and a couple of people were aware that people who use a lot of prescriptions are able to pre-pay on an annual basis.
Most groups were aware that people can choose to pay for healthcare themselves or through private health insurance, but not everyone was clear about whether or not this takes pressure off the NHS.
How did patients react to the case for change?
Although many participants felt removed from the decision-making process at present, there was a sense among some that the public should have more influence on how the government allocates funding.
Participants wanted to know more about where the money goes, including what the NHS spends money on, how much NHS staff are paid, and what proportion of the taxes they pay are allocated to different areas of government spending. While many people were surprised by how much the government spends on the NHS, others found it hard to imagine what else public money is spent on.
Participants felt that there needed to be more information about the cost of different areas of public expenditure, and a more open debate about how to prioritise spending between these competing areas.
Some felt that the quality of the services is not good despite the large amount being spent, while others thought it justifiable to spend that proportion of the country's wealth on health.
Some participants resisted the idea that rising healthcare spending will mean people having to pay more taxes to cover it, with a figure of as much as £570 a year for every household being suggested in the presentation.
The fact that £1,500 is spent on average per person per year made a strong impact. Most participants recognised that this is not distributed evenly across the population because some people have greater needs than others. There was also recognition that some people, such as the unemployed, are not contributing, raising the 'bill' for others.
When informed that they might have to pay more for healthcare, however, participants were concerned that the amounts discussed would be unaffordable for individuals and households.
Should the fundamental principles of the NHS be upheld?
Participants were asked to think about the three fundamental principles upon which the NHS was founded to gauge their reactions when these were challenged.
Those three principles were:
- comprehensive - access is based on need and not the ability to pay
- universal - it is there for everyone
- high quality - care that is safe, effective and personalised.
Charging for services
Participants were told that, although access to most NHS services is currently free at the point of use, if funding pressures should become worse or the electorate decides against paying more in tax in order to continue to ensure that all NHS services remain free, one option would be to charge people for some services.
This could simply mean providing a more narrowly defined package of benefits under the NHS, but it could also involve more widespread co-payments for services that are currently free of charge.
Group discussions followed, and then participants were taken through an exercise in which they were shown a number of lists of different types of health services (see Figure 3, below right) and were asked which three they would be most willing to pay for. Once they had chosen, they were given the estimated cost of the services and were asked if this changed their previous decision.
Willingness to pay: priority-setting
As many participants had previously noted, there are already charges for some services within the NHS. While many reluctantly accepted charges for some services, some participants argued that 'everything should be free' because charging is 'ethically wrong' and runs counter to the principles of the NHS. Overall, there was considerable surprise that the current charges contribute only 1% of the NHS budget.
It emerged that participants' decisions about charging were guided by a number of principles. These included whether services were perceived as necessities or luxuries, whether the service being used was elective or an emergency, whether the person could be said to be responsible for their ill health, and whether providing a service free now might prevent higher costs later.
There was a general view that the NHS should be able to charge for procedures that are not medically necessary.
For many participants, cosmetic surgery was initially seen as a chargeable area as it was widely viewed as a choice, rather than a medical necessity. As discussions progressed, however, it became clear that this issue is not as straightforward as participants had initially thought.
Many participants felt that breast augmentation surgery and gastric bands should not be free on the NHS, but others argued that in some cases these interventions could be a necessity.
This would be the case if, for example, a cancer patient required breast reconstruction following a mastectomy, or if an obese patient had unsuccessfully tried every other avenue to lose weight. Most participants also argued for cosmetic surgery to be allowed on the NHS for someone who has had an accident and requires reconstructive surgery, or where some aspect of their appearance is making them so unhappy that they are unable to lead a normal, productive life.
Moreover, it was also observed that withholding certain treatments might simply result in higher costs for the NHS in the future; for example, if someone were refused a gastric band, was unable to lose weight and subsequently required joint replacements and/or treatment for diabetes resulting from their obesity.
Many participants felt that it would be appropriate to charge for elective caesarean sections, but that emergency caesareans, or those arising from medical need, should be free. As in the initial discussion about cosmetic surgery, choice was felt to be a key factor in determining whether or not someone ought to pay.
A few participants argued that walk-in centres are a 'luxury' and should be paid for; they offer a service that has more accommodating hours and quicker access, and people should pay for such a 'commodity'.
Some participants suggested that services that are not directly related to healthcare should be paid for - for example, meals on wheels, ambulance trips for planned hospital appointments and hospital food were seen as 'extras'.
When it came to routine health checks, there were mixed views. A number of participants argued that, as they are preventive services, they should remain free as they save costs in the long term; others thought that taking care of yourself is 'your responsibility'. When it came to routine health checks for those with chronic conditions, many agreed that these should be free, as they represent a recurring expense.
Misuse of health services
When thinking about who should pay, and for what, many participants discussed discouraging or penalising those perceived to 'abuse' the system. Almost all groups mentioned drunks in A&E departments at weekends.
Another category of people mentioned was those whose illnesses are self-inflicted, such as those who do not exercise or control their diet and, as a consequence, are obese, or those who smoke and have lung cancer. Many thought these people should be responsible for the consequences of their decisions.
Others mentioned people who miss planned hospital and GP appointments, and those who do not make good use of the system - for example, those who go to the A&E department when they should be going to their GP first. To prevent this from happening, some thought investing time and effort in educating people on how to use the health service appropriately would save money in the long term.
How much do NHS services cost?
During this part of the exercise, participants were presented with rough estimates of how much services cost (see Figure 3).
Participants were clearly unaware of these costs; many expressed shock when the sums were revealed, both because they were higher and lower than expected. Those who had health insurance were less surprised by the costs, although in some instances participants with health insurance observed that they had paid more for certain services privately than the costs set out in the exercise.
The widespread surprise at the cost of services affected discussions in two ways. Firstly, there was agreement that more widespread awareness of these costs would lead to more discriminating use of services. It was suggested that this could be promoted by putting up a list of costs in doctors' surgeries, or sending patients itemised bills of services they had used.
Secondly, the cost of an individual service had an impact on whether participants were willing to consider paying for it. Lower-cost services, such as health checks and GP appointments, were seen as something patients could pay for, but when the costs were very high, for example a surgical procedure costing thousands of pounds, participants were less willing to countenance charges, often because they themselves would not be able to afford them.
The cost examples also made some participants reconsider the principles of charging. For example, preventive services, which cost relatively little, were seen as appropriate to charge for, while having to pay for a GP appointment, for instance, might result in some people delaying seeking help, which could potentially cost the NHS more in the long term Other participants suggested that, rather than covering the full cost of services, people could pay a contributory charge. A maximum charge or how much of a contribution should be made was not settled on, but £10-30 was mooted.
The idea of introducing means-testing into the NHS was very unpopular among participants, and they struggled to envisage scenarios in which they would be able to accept it.
Some objected on the grounds that means-testing is contrary to the core principles of the NHS - the idea that the NHS is universally free at the point of use was frequently referred to as one of its most important foundations. Means-testing was felt to undermine this by placing people's economic circumstances above their need, and it was suggested that it might prevent them from seeking help when they needed it.
Moreover, some participants thought that anyone with a high income who pays tax and National Insurance already contributes financially to the NHS, so means-testing would, in effect, result in some people paying twice.
Other objections were also raised. There was a widespread view that it would add to the financial burden on middle-earners, who would be required to pay more for the same services. Many participants also felt that those who could afford to pay more were likely to access private healthcare and would therefore bring only a limited amount of additional money into the NHS.
Some participants felt that means-testing would be socially divisive. They argued that those who were being asked to pay would resent others receiving the service for free, and, because they were being asked to pay, they would demand a higher standard of service, raising the possibility of a two-tier health service.
Some participants also queried the financial viability of means-testing, questioning how much the administrative costs would be and how effective current means-testing schemes were.
Participants considered that 'the wealthy' were most likely to be able to contribute; however, the point at which individuals were felt to qualify as wealthy was set very high.
Participants discussed people such as Richard Branson or Wayne Rooney, and, even when the bar was lower, it still excluded the majority of society (one group discussed an annual income of £150,000; in another it was £70,000).
In addition, the arguments against means-testing for people on very high incomes were generally seen as
One group of older participants suggested that it would be more acceptable to means-test the young than the old. It was argued that older people are used to the current situation and would find a shift to means-testing very difficult, particularly as they have been contributing to the NHS for most of their lives on the understanding that they would have access to care, free at the point of use, when they needed it.
This group asserted that younger people are not only less emotionally attached to the NHS, but also have not contributed to it financially to the same extent, and would therefore find it easier to accept means-testing.
Finally, there was some suspicion that the introduction of means-testing might be the 'thin end of the wedge' - that, while it might be limited at first, the number of people required to pay would continually increase until everyone was required to pay for their healthcare.
Resistance to means-testing was not universal, and in some instances participants suggested practical ways to make it work. One idea was that means-testing could be based on the level of general taxation being paid, with people in higher bands paying for a certain proportion of the cost of their care.
For most participants, however, the concept of means-testing was unpalatable and raised serious questions regarding fairness and its practical application. For these reasons, most participants rejected it as a potential solution.
If funding became tighter, one option presented to participants for discussion was that the NHS would offer only a basic standard of care and anything above that would have to be paid for by individuals. Patients, for example, might have to pay to be seen more quickly, for a better drug or prosthesis, for a private room, or for a bed on a single-sex ward.
Many participants found this a very difficult concept, and thought that lowering the standard of care to a basic package was not acceptable - nearly everyone taking part, both young and older, thought that the NHS is already offering standards of care that are too low.
Despite strong initial resistance to variations in levels of care, some attitudes shifted during the course of the discussion - for example, older groups recognised that a two-tier system already exists.
Many were worried that implementing a basic standard of care would be socially divisive and does not fit with the ethos of the NHS. Some participants questioned how this would work in practice - how would varying levels of service be offered in the same hospital, for example? There were others who accepted the idea.
When challenged, many conceded that a two-tier system would be acceptable as long as the baseline provided an appropriate clinical service. A 'good' and 'better' model was less controversial, although the principle of universalism remained strong, with a desire that safety and fairness should not be compromised.
Some believed the lowering of standards would lead to a slippery slope, resulting in the complete fragmentation and privatisation of the NHS.
Next, moderators asked participants to discuss three aspects of quality:
- speed of service
- hotel facilities
- clinical care.
The idea that patients might be able to pay to move up a waiting list was 'shocking' to some participants. It was felt that allowing 'queue jumping' would cause suffering to patients who could not afford to pay, and that those with the money should go to a private hospital, which would not have negative consequences for patients within the NHS. It was argued that speed of treatment should depend on the severity of illness and not the ability to pay.
Not all participants shared these objections, however, and a minority were willing to accept the idea of paying to avoid waiting lists (with some suggesting that this is exactly the role currently filled by the private sector).
Waiting times have gone down, but participants had a sense that it still takes a long time to get an appointment for certain services, and others mentioned that it is difficult to get an appointment with their GP, which sometimes forces them to seek private healthcare.
Almost all participants felt that they would be willing to pay for what was termed 'hotel facilities', which included: finer-quality bed linen, a private room, better food, a television and the availability of other 'premium' choices that were clearly distinct from clinical need.
Some participants felt strongly that the NHS is already 'running to stand still', and that the standard of care could not get any lower. This idea was supported by personal experiences of poor clinical care and reports in the press.
There was a general consensus that people's wealth should not influence their treatment. If that were to happen, then many more would opt for health insurance. But some argued that it is acceptable to pay for certain extras, such as a titanium hip or a branded drug, because this would help the NHS to stretch the money available to it. These participants felt that the NHS is not there to provide the best available products or treatments.
Which changes would patients support in principle?
Groups were reluctant to support any of the fundamental changes to the NHS under discussion. It was clear that, given a choice, participants wanted to retain the NHS as a service that is universal, comprehensive and high quality.
The NHS was often referred to as a 'national treasure', and some people saw the NHS as bound up with their identity as Britons - as something they were proud of and that should be defended. There was a clear belief that, because of these fundamental principles, the NHS is better than the health system in other countries.
Some participants recognised that there might need to be trade-offs or compromises in order to retain the
system as a whole. Most resisted this idea, however, and only when pushed hard were they able to express any views on what was the least worst option.
Some groups had a more in-depth debate about the distributional impacts of different changes. When discussing the pros and cons of the three scenarios for funding the NHS in future (means-testing, taking away some services and all services being available but only with a basic level of care), participants identified that poorer people would be at a disadvantage in the latter two because some services would no longer be available free of charge, and care would be provided at a lower standard unless you could afford to go private or 'top up'.
This led them, albeit reluctantly, to support means-testing.
Bias towards the status quo
Participants' views appeared to be shaped to some extent by comparing the proposed change under discussion with their understanding of the present system. For example, some participants felt that we already pay for some types of care so extending this would not be a big change. Others recognised that people with money can already go private to get better care. This suggests that the public support the status quo and may therefore be more prepared to accept incremental changes.
Across many of the groups, there was some acceptance of charges for treatment if people's own lifestyle choices are to blame for their ill health. Participants thought charges could encourage people to make better decisions and take more responsibility for their well-being - what one person called 'tough love'.
What else should be done to improve the NHS?
Better use of new technologies was mentioned by some participants - for example, using Skype for certain clinical consultations could be more effective than face-to-face interactions. One participant mentioned the wastage of drugs, suggesting that leftover drugs should not simply be thrown away.
Another idea that came up in a few groups was that the NHS should be more proactive in earning money. Some participants mentioned that the NHS should start collecting donations from people, and others suggested that pharmaceutical companies should 'pay a fee' in order to access and trial their products on patients in the NHS. Another idea was that local businesses could sponsor their local NHS.
Many argued that if people are living longer, then they should also work for longer and, in turn, pay taxes for longer. This view was more strongly expressed by older participants, a few of whom felt that this would generate significant revenue.
A few of those in London argued that National Insurance could be increased, and one or two others expressed some appetite for increasing taxation but ring-fencing the additional revenue for health. This idea was not universally accepted. There was, however, a sense that companies that are promoting unhealthy behaviour, including cigarette manufacturers and fast-food chains, should be taxed.
The idea of mandatory health insurance for companies was also considered as an option. This would work like current pension schemes, where the employee makes a contribution and the employer matches it. Some participants thought that the allocation of resources within government should be revisited.
The public's view
When presented with facts and clear information, participants started to understand the size of the funding challenge. They expressed an interest in having more information on how the health system is funded and were willing to discuss the issues.
Most accepted that the NHS is under pressure, but few accepted that this is on a scale to justify changing the fundamental principles on which the NHS is based. It is interesting that, despite the wider economic situation and the cuts being applied to other public services, there was a lack of urgency about the financial challenges facing the NHS. The numbers are so large that it may be difficult for the public to engage with this issue in a meaningful way. People greatly value the system as it operates at present and are conservative about change.
Although we might not need to face these issues and dilemmas immediately, the NHS is currently facing the most challenging financial period in its history and it is likely that the fundamental principles underpinning the NHS will be challenged at some point. Preparing the public for this debate and understanding how to communicate these issues will be vital if they are to be engaged in that decision-making process.