How Do We Most Fairly Ration the 110 Billion?

A special debate on the current state of the NHS. Recorded in front of an audience at the BBC Radio Theatre London.

The last few months have seen the service creaking under unprecedented demand, and there is likely to be worse to come. Something needs to give. Is it simply a matter of more resources, or do we also need to change our expectations of what the NHS provides? Is rationalisation and rationing the way forward?

Dr Mark Porter discusses the issues with a panel including Clare Marx, president of the Royal College of Surgeons, Chris Hopson, chief executive of NHS Providers, David Haslam, chair of NICE, Prof Sir Nick Black, London School of Hygiene and Tropical Medicine and regular contributor Margaret McCartney GP. Issues discussed include whether the NHS should continue to be free at the point of use. Is there too much bureaucracy with too many bosses? Was the internal market evidence based, has it worked and was it fair? Rationing of treatments. And can the NHS be taken out of politics? Inside Health listeners set the agenda by emailing the programme - some of whom joined the audience - so thank you for all your input.

Margaret McCartney writes: The NHS is never far from the headlines, but the last few months have depicted a service in crisis. It's been made clear that there will be no more money from central government - so what needs to give?

Clare Marx, explained the angst of her members who wanted to operate on people but had been forbidden to. Nick Black, discussed the types of surgery that were now being placed off limits - like hip replacement surgery - even though they were very cost effective. Because of the way hospitals are funded, it is these useful operations that are being stopped rather than the much less cost effective prescription of some very expensive cancer drugs. Chris Hopson described tensions between the expectations being placed on the NHS to provide excellent care despite the funding gap to actually provide it. And David Haslam, chief executive of NICE, expressed his disquiet that patients could no longer expect a consistent service across the NHS. Instead, different Clinical Commissioning Groups decided themselves how many rounds of IVF to fund, for example. The result was a patchwork of provision, and was inherently unfair.

Is rationing therefore the way forward? Some listeners had emailed in suggesting that the NHS shouldn't fund treatments for 'smokers, drinkers and the obese'. Others that people should pay for hospital meals, or there should be a charge made for GP consultations. We already have charges for some things - for example, prescriptions in England, or dental check ups for many people - but as Clare Marx pointed out, removal of teeth is the commonest childhood operation, so can we really say this policy has been successful? I don't believe that we have the evidence to show this is safe: the bureaucracy would be sizeable - I had to sign 12 bits of paper for a routine check when my kids and I last went to the dentist - and then there are unintended consequences. Paying for appointments turns us in to consumers - would doctors feel obliged to give us treatments that people want, even when they don't work well, aren't cost effective or do net harm?

Listeners wanted to know if the NHS was over managed - and had strong opinions on how much could be saved if we got rid of middle managers in particular. But Chris Hopson pointed out that we spend less than the very efficient Germany on hospital managers, and Clare Marx said that hospitals are highly complex places needing a huge amount of organisation to run smoothly. For me it is a question of what managers are doing - is it of value to patients, or is it a waste of time?

Nick Black argued that there was a great deal of waste still in the NHS - and suggested that the internal NHS market may have had some advantages to start off with, but now, the 4.5 billion a year estimated to be spent on it could be better used elsewhere. There is no doubt that the process of bidding and judging for commissioning costs time and money, but how to stop the problem of bad and wasteful policy in the first place? Could politics be taken out of the NHS? I was on my own, arguing that party politics had done avoidable harm to the NHS and that cross party working - as we see in the Health Select Committee and the National Audit Office - was possible. My fellow panellists argued that since the budget of the NHS was such a large amount of money it would be impossible to disentangle it from politics: but Chris Hopson pointed out that defence spending, for example, was ring fenced. The audience overwhelmingly voted to be taxed more to pay for the NHS. If we were sure that extra money would go on human level care, and not wasteful, non evidence based policy making, I would support it completely. But we are not, as a population, being given that option.