Feature

Low tax means no brass

As the government’s economic problems deepen, the question of how health services should be paid for is back on the political agenda. Allyson Pollock examines ‘expert opinion’ on the issue

Managers have thrown the government a lifeline in the debate on the future of NHS funding in two recent reports.^{1 2}

Both the National Association of Health Authorities and Trusts and the Institute of Health Service Managers use the time-honoured strategy of carrot and stick (the same ones, as it happens). The stick is a warning that NHS managers are no longer prepared to take sole responsibility for unpopular funding decisions; government must accept its share too. The carrot is an assurance that NHS managers’ thinking on the future of NHS funding is substantially in line with that of the Conservative party. The message is clear: we wish to implement your agenda, we can be a vital anchor for you in the battles to come but you must take the heat off us if we are to do so. It is a partnership that could contribute much to the demise of the NHS as we know it.³

The reports signal a regrettable sea-change in managers’ attitude to funding. NAHAT has jettisoned the commitment it made in 1987 to central taxation. Along with the IHSM it has come to believe that central taxation cannot provide sufficient health care funding any more and alternative sources of income and methods of delivering services must be examined.

So following the obligatory hymn of praise to the central tenets of the NHS - comprehensiveness, equity and equality of access to services - the reports launch straight into a review of alternative sources of funding and delivery of care. The financing options include a review of the hypothecated tax, social insurance and even local taxation using systems in other countries as illustrations. Although the policy-makers describe the advantages and disadvantages of each funding method, they omit to describe the political contexts in which these systems evolved and currently operate and, most importantly, whether systems used elsewhere conform as well or better to the principles laid down in the 1948 NHS Act.

It would have been useful if managers had evaluated the impact on service provision of the most significant experiment to date, the internal market, before proposing to give private enterprise an even bigger role. But the reports contain not a word on the internal market or its effects.

NAHAT and the IHSM are not alone in trying to anticipate government plans for the future funding and delivery of services. The management consultants Arthur Andersen and Burson-Marsteller have also produced a report on The Future of UK Health Care.⁴ Their stated aims were ‘to identify and predict the strategies which will be employed throughout Europe to balance quality and access to health care with cost control’. Beneath the icing these aims more readily translate as predicting just how quickly the NHS will deregulate and indicating to the commercial sector the areas for profit and the potential for controlling the workforce.

To make these predictions a survey of 10,000 health policy makers in 10 European countries was undertaken, with a 25 per cent weighted sample from the UK. They were then asked 180 questions. The report is careful not to trouble the reader with details of the questions or any description of the analysis or results. Perhaps management consultants are not constrained by issues of study design (claiming a response rate of 27. 5 per cent was excellent), confident that readers are more concerned with the conclusions than with how the conclusions were generated.

The expert panel has become a fashionable means of legitimising and endorsing findings and it is no surprise to find that the second part of the survey presents the response of an expert panel from each country for comment. It is the panel’s comments rather than the survey results which form the UK report. In spite of the fact that the latter survey purported to sample 2,500 policy makers in the UK, a common feature of all three reports is the domination of a few health policy analysts writing the discussion paper for one organisation,¹ the working papers for another² and then participating in the expert panel of yet another.⁴ How these policy makers are chosen and whose views they claim to represent is never made clear, but it is not surprising that the reports’ conclusions show striking similarities.

The panel’s statements read more like government policy than independent documents. Members forecast an increase in private health care driven by investment from purchasers and private insurance. This, they concede, will result in the emergence of a multi-tiered system based on ability to pay, at the expense of equity and equality of access. In fact, events have been moving steadily in this direction ever since responsibility for purchasing devolved to districts and fundholders.

The report spells out candidly the potential for profit in a system in which hospital trusts are unaccountable to the public and central planning has either been abolished or devolved far away from the provider. The panel forecasts hospital and bed closures. Between 1990-98 acute bed numbers will fall by 22.5 per cent. ‘Beds will disappear - the hospital authorities won’t consult anyone, they will just take them out of use.’ Trusts’ and fundholders’ lack of accountability has not escaped the management reports although this does not extend to a critique of the revised health authority boards.

Confusingly, the panel applies the government’s own rhetoric to describe the current reality of the NHS, a reality based on decreased resources and the consequent closures of beds and hospitals. In such circumstances it is hard to see how patients can act as ‘levers’ to increase choice and service standards (a central aspiration of the NHS reforms), although it is possible the panel is only concerned with a select group who can participate in a mixed economy of care, through health insurance for example. But where does this leave poor, elderly, disabled or chronically sick patients or even the average patient whose services are purchased by the average health authority struggling to maintain services?

Some panel members appear to be very selective about which people they would want to invest in. When asked to say why British survey respondents placed less emphasis on salary costs than did their continental counterparts, one recalled ‘the 20 per cent hike that nurses were given... with nothing in terms of return upon that investment’. Employees would do well to remember this the next time trust managers ask them to forego their 1.5 per cent annual increase, as happened recently in Ealing.

Far from challenging current government thinking on health care these reports aim to smooth the path in advance for government policy (apparently an increasingly important function of quangos). But managers should think twice. The alacrity with which so many of them embraced rationing and priority setting was tempered by the realisation that reductions in service provision are intensely unpopular with the public and the knowledge that complaints about the health service have never been higher.

The public may not understand the internal market but they can judge its effects on access to, and quality of, health services. If managers are set to take the lead in promoting greater freedom in the funding and delivery of health care at the expense of the core principles of the NHS, they may find themselves bearing the brunt of even greater public anger.