Since the population of the country is ageing there is bound to be an increasing cost burden on the NHS. On top of this technology is improving and when we are ill we all want access to the most up to date equipment and the most appropriate drugs. This also adds to costs.
Either we increase the amount of funding going to the NHS faster than the rate of inflation or hospitals cut back on services or they get massively more efficient. Those are the only three alternatives.
It would be nice to think that we could fund the extra costs by making the service more efficient. But you don't cut bureaucracy by cutting funding. You cut bureaucracy by simplifying and streamlining procedures. One of the best ways to do this is to stop constantly reforming and re-organising the NHS so that the staff can focus on providing a good service rather than on wasting their time trying to understand and implement the latest top down re-organisation. Another good way to do it is to simplify the funding system and reduce the number of targets that are monitored. No target ever treated a patient. Every target requires time and expense to monitor and introduces a culture of target chasing rather than patient care.
The worst way to cut bureaucracy is to require more and more services to be put out to competitive contract. Every contract has to be drawn up, put out for tender, awarded and then monitored. This adds cost and bureaucracy. Those winning the contract have to cover their costs and make a profit. They can only do this by delivering a cheaper service. The impact of this has been clearly seen in cleaning. When this was contracted out it looked at first that the new private providers were cheaper than the old in-house cleaning teams. But the service they provided was so poor that we ended up with MRSA and other superbugs spreading across our hospitals. Leaving aside the massive health risks this has created, the cost to the NHS has been enormous. Similarly the cost of contracting out hospital building programmes via the Private Finance Initiative has proved crippling. Instead of steadily building good quality hospitals at cost some NHS trusts were forced into 20 year maintenance contracts which are now placing crippling costs on the service.
The idea that we can deal with all the extra costs via cuts to bureaucracy is a dangerous illusion. Ultimately increased costs require increased expenditure. If we want a better service then we are going to have to pay for it. One way of doing this is to increase the waiting lists to such lengths that more people will pay to go private. In the end this will result in us all paying twice. Once for the basic service and once when we are really ill via spending whatever savings we may have in a desperate effort to help those we care about pay for rapid treatment when the NHS lets them down. Very few people think this would be a good idea. But that is the system we are stumbling towards by default.
Far better to admit we need to put more money in. And the source of that money? Firstly as the economy grows and expands it creates the opportunity for NHS funding to grow at the same rate. Secondly progressive income tax charged efficiently at higher rates for the wealthy is the only seriously sustainable way to provide enough cash to ensure that the whole population remains healthy. Thirdly it is a matter of priorities. It is something of a cliche but if the choice is spending on Trident missiles that are irrelevant to modern warfare or investing in better equipment for the NHS and selling some of that technology around the world then I know which I regard as better value and as more productive for the economy. Equally if I had £370 billion to spend that had come from quantitative easing I wouldn't choose to give it to the banks - I might choose to invest some of it on new hospitals free of PFI.
We also can't get away from the fact that we need enough young tax payers to cover the costs of integrated health and care services for the elderly. Given the recent birthrate, this means we need a sensible sustainable amount of immigration so that we don't end up like Japan where there is an ageing population, a national debt greater than 200% of everything the country earns in a year and not enough young people to look after or pay for the older generation's care.
There are some interesting and useful ideas being put forward by other parties about how to run the NHS. For example the idea of giving local control to Manchester and of combining the care and the health services there could prove to be a rare good idea from the Conservatives. Local control - overseen by local users who know who to complain to could prove much better and simpler than remote Whitehall control. Provided that it doesn't prove to be yet another top down re-organisation done as a pre-election sound-bite. Provided that it doesn't result in money going to favoured areas and being taken from others. Provided that it is accompanied by increases in cash not assumptions that we can fix the local council's reduced care budget by raiding the NHS budget.
And this need for hard cash is the most important point. You cannot fund the health service properly by re-organising it again. The illusion that just one more administrative change or just one more clever target or scheme thought up by a politician will fix things is deeply dangerous.
In the end there is no alternative. We need to come up with the cash and we need to be prepared to pay the taxes to cover it.