ANALYSIS
Fig 6 | 2002 Wanless review: UK total (public+private) healthcare spending scenariose. 17 GDP=gross domestic product
Notably, the Wanless review postulated an initial “ catchup ” and then a subsequent “ keepup ” funding path, which, in the most optimistic scenario, implied a flattening of spending growth at around 10.6% of GDP, with the NHS accounting for around 9.2% of GDP. So, spending would grow in real terms each year but at the same rate as the growth in GDP. By 2019 total health spending had reached 10.2% of GDP and was pretty much on track to meet his lower spending scenario, even allowing for the slightly miscalculated starting point in 2002. Unfortunately, the future was a bit more uncertain than anticipated. Although spending did, more or less, hit Wanless ’ s lower suggestion (in total and for the NHS), the figure depended on significant and sustained increases in productivity each year that the NHS did not achieve and a well behaved public who stopped smoking, ate their greens, and generally looked after themselves. The NHS was spending more, but whether it was delivering “ high quality services to the UK population ” is debatable. Funding was on the fully engaged scenario trajectory, but performance was more like slow uptake. 18 A key conclusion of the 2002 Wanless review was that a similar exercise should be carried out every few years to take account of changes in the population (its size, demography, and epidemiology), as well as changes on the supply side (advances in medical technology, etc). We support this recommendation but would emphasise two things. The first is a more explicit acknowledgment of the need to find and justify a sustainable long term future funding path that recognises Stein ’ s law and the opportunity costs of healthcare spending. The second is the need to actively promote and support efforts to ensure the best and most productive use of NHS resources.
Finally, a strong case can be made for immediate financial intervention in the NHS to boost funding. Even allowing for the large jump in spending in 2020-21 as a result of covid-19 related measures, if spending had increased at the long term average from 2010-11 to 2022-23, UK NHS spending by 2022-23 would have been around £32bn (15%) higher than actual spend. In the recent spring budget, the government has pledged a further £2.5bn for the NHS in England in 2024-25 to keep up day-to-day funding of the health service, with a further £3.4bn investment over three years to improve productivity through digital transformation. These figures, although a start, certainly will not make up the significant shortfall that the NHS now faces. 19 Catching up on this shortfall in revenue and capital spending would, realistically, take time. But a start could be made with a real increase of 4% for 2024/25, equivalent to around £8.5bn at 2022-23 prices. Similar increases over the subsequent four years would make up the shortfall. With the proviso that it will be up to the NHS to decide the detail of how best to spend additional funds, it is clear that immediate priority should be given to investment that will sustainably reduce elective, mental health, and cancer waiting times; improve access to primary care; and address the workforce and capital investment challenges that the NHS is currently facing. We would note that given current economic conditions and financial pressures across public services in general, no easy short term fixes to public finances are available. Future governments will need to grapple with difficult decisions, including the probability of raising more money from general taxation. How do we decide how much to spend? In broad terms, the current approach to setting public spending involves a spending review led by HM Treasury and, through various
the bmj | BMJ 2024;384:e079341 | doi: 10.1136/bmj-2024-079341
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