And that’s all folks. A show of hands reveals that a majority of those in the room work in the NHS.
Certainly, there’s no shortage of passion if the questions and comment from those here are anything to go by.
Smallwood says that the trouble with marketisation is that it drives quality down as the cheapest provider will always be the one which is chosen.
The answer, he adds, is better planning. We need to move away from the myriad of small commissioning groups.
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Anita Charlesworth says that the future boils down to getting the right people with the right skills working together.
She adds: “We love playing with the structures. We absolutely adore it, but it’s a people based service and it’s having those people of the right skills working together that will be fundamentally important in terms of ensuring stability and sustainability.”
Stephen Dorrell addresses marketisation, saying that he remains of the view that “intelligent commissioning” is part of the way to address how services are funded.
“Commissioning that moves away from lawyers and focused on different options for the delivery of services and making more intelligent choices about the way that services are delivered seems to be the way to go.”
Another audience member wants the “marketisation” of the NHS to be halted.
She is backed up by another audience member who calls for the reversing of privatisation.
“We are also on the verge, sadly, of a full-scale NHS insurance system,” he adds.
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In a very unequal society, says Toynbee, the major challenge is about how to get one group of people to care more deeply about another group.
“It might not be them today, but it might be them in the future,” she adds.
Dorrell says that the “killer question” was about the division of health budgets and the difference between social care and health care.
The answer is, if you are an elderly person dependent on services supporting you at home, you are not remotely interested in whether it comes from the social care centre, the social housing department or from primary care, he says.
What is important is that you are benefitting from expenditure that will enable you to live a healthier and longer life.
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The way we compartmentalise public health budgets at the moment is a problem, replies Stephen Dorrell.
He advocates joining up place-based budgets so you can invest in them.
“How can you invest in paediatric budgets without involving the schools?”
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Some more questions. An issue which has not been dealt with is how to manage the health budget at the moment, says a man who says he was surprised that he could buy drugs overseas a lot cheaper than he could at home - provided he had the correct prescriptions.
A woman says we are emotional about the NHS in a way that we are not about social care. What can we do?
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PFI got hospitals built but it was a total disaster, replies Smallwood.
“What is inexplicable to anyone who knows anything about economics is why does the government borrow money for next to nothing, because interest rates are so low, and build what is needed,” he says.
“Also, why don’t we renegotiate the PFI, I mean use some strong arm.”
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Questions from the floor now. Tax evasion and tax avoidance is cited by one man, who suggests that everyone should pay similar rates, alongside a citizen’s wage.
Another question is about the impact of PFIs on day to day hospital finances.
The third one is about integration of health and social care. “Where do we decide that health and care are different?” asks a woman.
Stephen Dorrell sketches out a future in which resources for health care could be raised locally, and also be linked up better across authorities.
“Does anyone seriously think it makes sense to have a primary care bureaucracy and a social care bureaucracy?” asks Dorrell.
The idea of linking local services is fine but it is going to take a very, very long time, says Smallwood.
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Anita Charlesworth says there is a real challenge. The OECD concluded in a major study that no one system was better than the other. Really, he says, it was about how they were run.
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Polly Toynbee says it’s true: money has to be found, and ultimately from people’s pockets. “You can call it insurance, but it’s still tax,” she says. “It’s still going to be an amount or another which households are going to have to pay.”
The reason, she says, why other countries have insurance-based systems is historic.
The German one, for example, is linked to trade unions.
“I think you have to present people with choices. I think there are other ways of raising money.”
Toynbee: hypothecated tax is one option for funding the NHS #ThisIsTheNHS
— Guardian Healthcare (@GdnHealthcare) February 10, 2016
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Smallwood ventures the idea of “top-up” insurance. That might provide some of the extra revenue needed.
If not that, he asks, then what? He says he’s open to alternatives, but “ideology” shouldn’t be used to close down the argument.
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“Insurance” klaxon. Nobody in the Guardian agrees with him on it, says Christopher Smallwood, but his concern is that the NHS does not have enough money, and as we go forward standards are going to erode.
Tax revenues are not being produced quickly enough to make up what is needed to meet financial pressures, “So the question is: where does that money come from? There is a problem that it should come from tax revenues and it should all remain free.”
The result? If we are going to be financing out of tax revenues, the increasing demands on health taxes will have to “rise and rise and rise”.
“I don’t think any political party is going to find that an appealing pitch to the electorate. Therefore, if we want to finance the health service properly, we have to be open-minded enough to think if there are other alternative ways of financing it.”
Just look across the Channel, he adds.
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Charlesworth is optimistic about the NHS in 10 years. The health system is not a broken model, she says, even if we spend a lot on the free-at-point-of-delivery model.
“Assuming that we get economic growth, then we should have enough to spend more on it if we choose to do so. The problem is how we get from here to there. That’s obviously a political challenge, and it’s dependent on all of us wanting to spend more and agreeing how to spend more.”
Findings from the British Social Attitudes Survey pointed to “rock solid” support for the NHS as a free-at-point-of-delivery model. However, most people also felt that the NHS wasted money, and this feeling was particularly strong among those who had more contact with the service.
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One of the challenges here is that doing the right thing for “health” might not be the same thing as doing the right thing for “healthcare”, says Anita Charlesworth.
Giving an example of what she says is a positive development, she says that the rate of teenage pregnancy has fallen. However, she links this to developments in education. “This has to be holistic. One of the things is that you get more plaudits from raising the healthcare budget, but you get rather fewer plaudits by raising other budgets that may help.”
Loneliness is going to be a major challenge in the years to come, she adds, but again, it may not be the healthcare budget that addresses it.
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We have inherited a commitment that the NHS should be tax-funded and free at the point of delivery, says Stephen Dorrell. Rather than promoting and sustaining the ability of people to lead healthy lives, this means that the service ends up being focused largely on treatment.
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The discussion moves on to international comparisons. A story we published today on that issue was the third most read piece on the Guardian site today.
Anita Charlesworth says that undoubtedly the NHS does very well in the measurements of the Commonwealth Fund.
However, we are bottom of the tables in terms of obesity and poor diet, which is a major driver of many of the poor outcomes, she adds. The OECD, she says, also notes that the NHS is quite a low spender.
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Stephen Dorrell says that what the CQC has been doing is to focus on a local health economy and the experience of care for those living in that community, rather than a “tick box” system of the past.
Declining health standards are a certainty over the next few years in the current circumstances, says Smallwood. “It comes down to more money,” he adds.
Christopher Smallwood: we are exploiting the professionalism and dedication of people to save money #ThisIsTheNHS
— Guardian Healthcare (@GdnHealthcare) February 10, 2016
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Anita Charlesworth says that what Britain is trying to do is make sure that it does not spend any more per head of population in health in 2020 than it did in 2010. She adds: “What we are trying to do in 10 years is not spend any more money, once we have allowed for inflation. We have never done that before. No other country has done it either.”
Christopher Smallwood says that so many hospitals are in deficit that finance comes to dominate every consideration. “You leave vacancies unfilled, you relax the nurse patient ratios,” he says.
“And most importantly, capital spending virtually stops. But you need it because it’s spending on x-ray machines, wards and so much else. If you do not invest in these things, then the whole system runs down.”
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Stephen Dorrell says that at a time when the economy is in recovery mode, planning on the basis that the public service will compete in a market where prices are uncompetitive just does not work.
In terms of staffing, he says that it should not just be about bringing people in through the door, but also about creating an environment which is conducive to keeping people. Public sector pay policy is broadly sustainable, he adds.
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How do we keep nurses in the system? Polly Toynbee says that many are leaving because of the unbearable hours.
She adds: “It isn’t just the money. You just needs lots more of them. And of course we are draining poorer countries of their doctors and nurses, which is not a very good thing either.”
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“What’s the morale like in Tooting?” asks Paul Johnson.
St George’s University Hospitals NHS Foundation Trust chair Christopher Smallwood says that it varies a lot.
In a way, he sees the doctors dispute as not so much about the individual items but through the prism of a bridge too far.
He adds, about low recruitment of nurses, that there has been a haemorrhage of staff.
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Anita Charlesworth opens the debate by addressing the background to the latest doctor’s strike. We’re facing another five years of very tight funding more broadly, she says, and expectations are that wages will pick up. However, morale has been rock bottom in the NHS, which she says should be a number one priority.
“One of the things that has been driving overspends is the reliance on agency staff,” she adds, to murmurs from many in the audience. “You need people who are feeling positive … whether or not we can bring staff with us will be a deal-breaker in the next few years.”
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Introducing the debate, Paul Johnson says that much reporting of the NHS has been done in a reflex way, and so the Guardian’s series has been a concerted attempt to tell the story of the service through the voices of those who work in the service and are touched by it.
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How do we pay for the NHS we want?
Welcome to live coverage of a debate that seeks to provide answers to that question as part of the Guardian’s This is the NHS series, which has sought to tell the story of the service through the voices of those on the frontline.
The debate, which is being chaired at the Guardian by the Guardian’s deputy editor, Paul Johnson, brings together:
- Former Conservative health secretary and chair of the NHS Confederation Stephen Dorrell.
- Chief economist at the Health Foundation Anita Charlesworth.
- St George’s University Hospitals NHS Foundation Trust chair Christopher Smallwood.
- Guardian leader writer Polly Toynbee.
“Health and high quality care for all, now and for future generations,” announces NHS England as its mission statement. Few would disagree with this vision, yet the reality of funding an ever sprawling NHS is increasingly the focus of heated political debate.
With NHS England boss Simon Stevens expected to make £20bn in efficiency savings by 2020 and the UK falling behind Finland and Slovenia in terms of healthcare spend, how will the NHS continue to strive for and deliver high-quality care?
John Appleby of the Kings Fund warns that Britain’s status as an increasingly low spender” might mean the NHS cannot deliver improvements in quality of care patients want.
The aging population and a creaking social care system reeling from local council cuts is putting even more pressure on NHS resources and frontline staff.
Is it time for radical rethink of how we pay for the care we expect? Our panel of experts debate their vision for the future.
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We’ve also been comparing the systems in some of the world’s leading countries for healthcare to examine who gets the best value for money, and who the best outcomes.
Read on here:
Before the debate gets under way, here’s a report by health editor Sarah Boseley that goes to the heart of some of the issues being discussed.
She’s been speaking to a leading expert on international health systems who says that, while the NHS has been the envy of the world for its fairness, good outcomes and value for money, it needs more funds and the dismantling of recent changes if it is to be so again.
Healthcare in the UK still takes first place in the rankings of 11 wealthy nations put together by the Commonwealth Fund in the US. But Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, says the real glory days of the NHS were in the 1980s. Other countries, such as Spain, Italy and Portugal, modelled their own systems on it.
“The NHS was envied because it was very effective, low cost, and delivered good outcomes,” he said. But it was always underfunded. “It needs more money and it needs to dismantle some of the more recent changes,” he said.
PFI – the private finance initiative, which was used to raise money to build new hospitals – has left a huge legacy of debt. The financial troubles of the Barts trust in London, heading for a £135m deficit, the largest in NHS history, are largely a result of PFI, said McKee. That, together with the reorganisation imposed by the Health and Social Care Act and issues around the pay and performance of the workforce including junior doctors, had created “a perfect storm”, he said.
Here’s the article in full:
