The BMJ Commission on the Future of the NHS

ANALYSIS

England, for example 26 ) to enable a period of catch-up for NHS infrastructure. Following these recommendations would ensure the stability of the NHS funding model, with ongoing independent analyses of population health outcomes and the healthcare system, and a five year strategic plan that would increase government accountability and facilitate healthcare planning. Recommendations • Continue funding the NHS primarily through taxation • Establish an independent Office for NHS Policy and Budgetary Responsibility for England to provide unbiased, robust reports on health and healthcare • Create a five year strategic plan for the NHS, with a detailed five year financial settlement and a provisional settlement over five to 10 years • Provide an immediate cash injection to start to recover a £32bn shortfall in funding over the decade to 2020 and to help to tackle the current NHS crisis, especially the surgery backlog and access to primary care Contributors and sources: JA is a health economist who has written and researched on healthcare funding and health policy more generally for over 40 years. GL is medically qualified, an international expert on evidence based practice, and the former chief executive of NICE. MM is the chair of the Nuffield Trust, a past chair of the Royal College of General Practitioners, and, until 2022, a general practitioner in Newham, East London; he has written and researched extensively on primary care and the quality of care more generally. All authors are members of the BMJ Commission. JA, GL, and MM conceived the paper. JA and GL wrote the paper, and MM commented on drafts. JA is the guarantor.

12 Licchetta M, Stelmach M. Fiscal sustainability analytical paper: Fiscal sustainability and public spending on health. 2016. https://obr.uk/docs/dlm_uploads/Health-FSAP.pdf. 13 Appleby J. Spending on health and social care over the next 50 years: Why think long term? 2013. https://www.kingsfund.org.uk/insight-and-analysis/reports/spending-health-social-next-50-years. 14 Appleby J, Harrison A. Spending on health care: How much is enough? 2006. https://www.kingsfund.org.uk/insight-and-analysis/reports/spending-health-care. 15 Office for Budget Responsibility. Economic and fiscal outlook – March 2023. https://obr.uk/efo/economic-and-fiscal-outlook-march-2023/. 16 Stein H. What I Think: Essays on Economics, Politics, and Life. 1998. https://www.aei.org/research- products/book/what-i-think/. 17 Wanless D. Securing our Future Health: Taking a Long-Term View. Final Report. 2002. https://www.yearofcare.co.uk/sites/default/files/images/Wanless.pdf. 18 Triggle N, Pym H. The key NHS targets that have never been met. 2024. https://www.bbc.co.uk/news/health-67884322. 19 HM Treasury. Spring Budget 2024. https://assets.publishing.service.gov.uk/me- dia/65e8578eb559930011ade2cb/E03057752_HMT_Spring_Budget_Mar_24_Web_Accessi- ble__2_.pdf . 20 National Institute for Health and Care Excellence. NICE Citizens Council Report on Age. Citizens Council Reports No. 2. 2023. https://www.ncbi.nlm.nih.gov/books/NBK401698/. 21 Involve. Citizens ’ Jury. 2024. https://www.involve.org.uk/resource/citizens-jury. 22 Centre for New Democratic Processes. How We Work: Citizens Juries. 2024. https://www.cndp.us/about-us/how-we-work/. 23 Coote A, Lenhaglan J. Citizens ’ Juries: From Theory to Practice. Institute for Public Policy Research, 1997. 24 Street J, Duszynski K, Krawczyk S, Braunack-Mayer A. The use of citizens ’ juries in health policy decision-making: a systematic review. SocSciMed 2014;109:-9. doi: 10.1016/j.socscimed.2014.03.005 pmid: 24657639 25 Nuffield Trust. NHS performance tracker. QualityWatch. 2024. https://www.nuffieldtrust.org.uk/qual- itywatch/nhs-performance-summary. 26 Appleby J. Chart of the week: The cost of NHS backlog maintenance hits an all-time high. 2022. https://www.nuffieldtrust.org.uk/resource/the-cost-of-nhs-backlog-maintenance-hits-an-all-time- high .

Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

Provenance and peer review: Commissioned; externally peer reviewed.

This article is part of The BMJ Commission on the Future of the NHS (https://www.bmj.com/nhs-com- mission). The purpose of the commission is to identify key areas for analysis, lay out a vision for a future NHS, and make recommendations as to how we get there. TheBMJ convened this commission, which was chaired independently by Victor Adebowale, Parveen Kumar, and Liam Smeeth. TheBMJ was responsible for the peer review, editing, and publication of the papers of the commission. The BMA, which owns TheBMJ , grants editorial freedom to the editor in chief of TheBMJ . Theviews expressed are those of the authors and may not necessarily comply with BMA policy. We thank all members of the BMJ Commission on the Future of the NHS for initial discussions that shaped the questions we tackled in this article. In addition, we thank Stella Vig, John Hall, Muir Gray, James Ebdon, Sally Gainsbury, Nicholas Mays, Bhash Naidoo, and David Hunter, who all contributed to a roundtable discussion. 1 Guillebaud CW. The Committee of Enquiry into the Cost of the National Health Service ( ‘ The Guillebaud Report ’ ). 1956. https://sochealth.co.uk/1956/01/10/guillebaud-report/. 2 Harker R. NHS Funding and Expenditure. Briefing Paper CBP0724. 2019. https://researchbriefin- gs.files.parliament.uk/documents/SN00724/SN00724.pdf. 3 Organisation for Economic Co-operation and Development. OECD Health Statistics 2023. https://www.oecd.org/health/health-data.htm. 4 Statista. Defense spending as share of GDP in the UK 1980-2021. 2024. https://www.statista.com/statistics/298527/defense-spending-as-share-of-gdp-united-kingdom- uk/. 5 Phillips D. Health spending planned to fall in England and Scotland in 2024-25, suggesting a top-up likely. 2024. https://ifs.org.uk/articles/health-spending-planned-fall-england-and-scotland- 2024-25-suggesting-top-likely . 6 Morris J, Schlepper L, Dayan M, et al. Public satisfaction with the NHS and social care in 2022: Results from the British Social Attitudes survey. 2023. https://www.nuffieldtrust.org.uk/re- search/public-satisfaction-with-the-nhs-and-social-care-in-2022-results-from-the-british-social- attitudes-survey. 7 Tempest M. Brown unveils tax hike to fund NHS. 2002. https://www.theguardian.com/poli- tics/2002/apr/17/economy.uk1 8 Wagstaff A. Social Health Insurance vs. Tax-Financed Health Systems — Evidence from the OECD. Policy Research Working Paper 4821. 2009. https://documents1.worldbank.org/curat- ed/en/545121468028868365/pdf/WPS4821.pdf 9 Adam S, Besley T, Blundell R, et al. Tax by design. 2011. https://ifs.org.uk/books/tax-design. 10 Giles C. UK tax system is more progressive than thought, says IFS. 2019. https://www.ft.com/content/505fc7ba-7e4b-11e9-81d2-f785092ab560. 11 HM Treasury. Public Expenditure Statistical Analyses 2023. https://www.gov.uk/government/statis- tics/public-expenditure-statistical-analyses-2023.

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