Debate: The NHS

This resolution is central to many, if not most, items discussed at Congress. What is the role of a health service and how should it be funded? When it was founded in 1948 the NHS was based on the founding principles that it would: meet the needs of everyone; be free at the point of delivery; be based on clinical need, not ability to pay; be funded by general taxation.

In England, the NHS Constitution states that NHS services should be free at the point of use, except where charges are provided for in legislation (for example, prescription charging and dentistry).

In Wales, the Government is committed to the NHS as the provider of the health care free at the point of delivery funded by government. There is a national delivery framework and performance mechanism for services, along with a national process for workforce planning and education commissioning.

The Scottish Government is committed to a “publicly owned, publicly delivered” NHS, “free at the point of need”, but integration of health and social care is challenging perceptions of “health care”. With different funding criteria applied in the NHS (free at the point of need) and social care (eligibility by criteria), integration raises tensions around “fairness”. Few services classed as “health” are charged for in Scotland, but there is a mixed market of commissioned care providers. NHS spending on using the private sector increased from £69.5 million in 2010-11 to £81.8 million in 2015-16.

In Northern Ireland, the integrated health and social care service [HSC] is based upon an Executive commitment to “the principle of universal health care, free at the point of delivery to those in need”. All of the major Northern Ireland political parties share a fundamental belief in the founding values of the NHS. The service is based upon five integrated health and social care trusts covering Northern Ireland geographically, with a regional commissioning and performance management function undertaken by the Health and Social Care Board and supported by the Public Health Agency.

Given its size and budget, some have argued that the NHS is costly, slow to adapt, and therefore not suited to the 21st century. Public spending on health care in the UK has increased to 7.2% in 2016-17, in response to a combination of factors, including medical advances and increasing cost pressures from a growing and ageing population. Such a rise in health spending is in line with most high-income OECD countries, and the NHS system has the advantage that people are not deterred from seeking care because of concerns about cost.

The majority of the public in England, Wales and Scotland (78% in 2015) consistently rate health spending as one of their top two priorities for government, and surveys have indicated that an increasing proportion of the population support boosting NHS spending. In Northern Ireland, an opinion poll conducted in advance of the Assembly election in March 2017 confirmed that the health service is seen as the top priority by the electorate.

Increasingly, what is currently NHS-funded is discussed in conjunction with other care needs, for example, social care. For instance, issues with the effective delivery of urgent care are often linked to delays in discharging patients, partly due to availability of social care. There is increasing mixed-economy in NHS services: for example, £1 in £8 of local budgets in England is spent on care provided by non-NHS organisations. It should also be noted that around 30% of RCN members work in the independent sector.

It is hoped that this item will stimulate a debate regarding the fundamentals of what a health care system should look like, how it should be funded and what role the private sector should play within it.