ANALYSIS
THE BMJ COMMISSION ON THE FUTURE OF THE NHS NHS funding for a secure future Demands on the NHS continue to increase, and difficult decisions have to be made on how much we want to spend and how to finance that spending to ensure its stability
1 City University and Imperial College London, London, UK 2 Nuffield Trust, London, UK 3 Royal Society of Medicine, London, UK 4 University College London, London, UK Correspondence to: J Appleby jappleby999@gmail.com Cite this as: BMJ 2024;384:e079341 http://dx.doi.org/10.1136/bmj-2024-079341 Published: 20 March 2024
John Appleby, 1 , 2 Gillian Leng, 3 Martin Marshall 4 Worries about the sustainability of NHS funding have a long history. Just five years after the NHS opened its doors, amid concern about escalating spending on the NHS, the then Conservative government set up an independent commission led by Claude Guillebaud to examine the costs of the NHS. That inquiry found that spending remained sustainable even though it had increased, and actually recommended that extra investment was needed in hospitals and community services. 1 At the time of the Guillebaud inquiry, NHS spending represented 3.2% of gross domestic product (GDP). 2 More than seven decades later, spending has outstripped the growth in GDP so that by 2022 we spent around 9.3% of GDP on the NHS. 3 This growth has been driven in part by additional demand (the UK population has increased by around a fifth since the 1950s, for example) and also by supply. Medical technology has developed, creating new opportunities for treatment and care. Higher price inflation in healthcare relative to the economy as a whole has also contributed pressure to spend more than the growth in the country ’ s economic wealth. Growth in the past few years has also included
exceptional funding as a result of covid-19 measures of course, although these are now starting to unwind. The willingness to spend more on healthcare is not unique to the UK. Internationally, over time, virtually all countries have increased spending as a share of national wealth. That willingness has been enabled by a combination of higher taxes, of one sort or another, and reprioritisation of public spending. For example, in the UK, defence spending in the 1980s was around 5.5% of GDP. It is now around 2.3%. 4 Annual spending on the NHS has increased on average by around 3.4% in real terms, but budgets have not increased smoothly from year to year (fig 1). Annual increases averaged 6.2% over the decade from 2000 to 2010 but just 1.2% between 2010 and 2020. This represents a significant financial gap in funding that has had a direct impact on the performance of the NHS and the quality of care it has been able to deliver. Prospects for the financial year 2024-25 look bleak, with the Institute for Fiscal Studies analysis of planned day-to-day spending in England suggesting a real cut in funding of 1.2% — equivalent to £2bn — plus a 0.75% real cut for the Scottish NHS and only a modest real rise in Wales of 0.7%. 5
Fig 1 | Annual real changes in UK NHS spending 1950-51 to 2022-23. Data source: 1950-2018, British Social Attitudes survey 2 ; 2019-22, authors ’ estimates based on UK health departments ’ annual accounts
The slowdown in funding has shown itself in worsening NHS performance on headline measures
such as waiting lists and waiting times. The exigencies of the covid-19 pandemic had an
the bmj |BMJ 2024;384:e079341 | doi: 10.1136/bmj-2024-079341
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