ANALYSIS
• No systematic approach exists for calculating additional funding for areas such as service transformation or potential savings such as from reduction in waste or improved productivity. • Capital funding is ring fenced, but in practice this budget has been raided by the NHS to bolster revenue spending, so new developments may not be prioritised leading to a lack of investment in the future. Taking all these factors into account, we propose a future process for determining national NHS funding that would rely on a new independent body, an Office for NHS Policy and Budgetary Responsibility (OPBR) to inform this process. This body would produce regular independent reports on the state of the nation ’ s health, on healthcare, and on medium term (five to 10 years) and long term (50 years) modelled funding projections for the NHS (including the local authority public health grant). At the start of the term of a new government, this report would trigger a public response from government with a firm NHS funding settlement for five years and a provisional settlement over the medium term period (fig7).
public service agreements, defines the key improvements that the public can expect from these resources. Spending reviews usually take place every two to four years. Challenges with the current process for funding NHS healthcare are well recognised, and include the following: • Year-on-year funding shows significant volatility, which makes long and medium term planning a challenge for healthcare managers. This volatility is partly related to the political cycle, but it is also influenced by other external factors, such as the pandemic or the overall financial outlook. • Public engagement in the decision making process is limited, meaning that little opportunity has been available for determining public priorities or taking them into account. One example where the public has contributed is through the decisions on funding taken by the National Institute for Health and Care Excellence (NICE). NICE includes lay members on all its committees and has used a representative citizens ’ council to answer strategic questions on priorities — for example, should we prioritise spending on the treatment of younger people over that of older people. 20
Fig 7 | Overview of a transparent, accountable approach to NHS funding. ICS=integrated care system
The aims of this approach would be to link the funding settlement to the cycle of new governments and improve planning by including a forward prediction for the next 10 years. It would increase government accountability by requiring a response to the independent report and lengthen the funding settlement period to 10years.
To ensure the government response on what can and cannot be funded, we need a process for taking public opinion into account. This might follow a model similar to a citizens ’ council or jury, whereby representative members of the public are randomly selected to debate a particular question or problem in depth. This provides a useful mechanism to distil informed public opinion and ensure
the bmj | BMJ 2024;384:e079341 | doi: 10.1136/bmj-2024-079341
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