Experts debate government's decision to ring fence NHS funding

Head to head: Should the NHS budget be ring fenced?

Is the government's decision to ring fence NHS funding fair? Two experts debate the issue on bmj.com today.

John Appleby, Chief Economist at the King's Fund argues that the alternative to ring fencing is too painful. "If the NHS were not protected it would have to find cuts amounting to around 14% of its budget (equivalent to -18bn) over the next few years," he writes.

He suggests the NHS could achieve this by cutting staff pay by 30%, sacking all consultants and general practitioners, or abolishing the NHS in Scotland and Wales. "None of these is very appealing, but it underlines just how hard it is going to be for non-protected services - and what spreading the pain would actually entail," he writes.

Even protected, the NHS will have to make considerable improvements in its efficiency and productivity over the next few years if it is to stretch its budget to meet growing demands and costs, he warns.

A more fundamental argument for protecting the NHS is that this is what the public wants, says Appleby. In a recent poll, 82% said the NHS should not be cut, with just 2% saying it should be. "In this dismal world, spreading the pain would not be efficient given the values the public hold," he concludes.

On the other side of the debate, David Hunter, Professor of Health Policy and Management at Durham University argues that, far from improving the public's health, ring fencing may have the opposite effect.

He believes that, "instead of ploughing resources into rescuing growing numbers of people who are leading unhealthy lives, we need to shift the focus upstream to prevent lifestyle illnesses from becoming a drain on NHS budgets."

"If the NHS budget was not ring fenced we could take public health and health inequalities seriously and ensure that resources are directed to where the pay off will be highest," says Hunter. "Protecting the NHS sends a perverse signal that being unhealthy may be preferable to remaining healthy."

Securing integrated care across the health and social care interface is also likely to get worse in future as a result of the public spending cuts and a ring fenced NHS budget, he adds.

By contrast, an integrated commissioning model for health and wellbeing, embracing the NHS, social care, and other local authority services, provides one way forward. "Investing in health will reduce the long term cost of delivering health care, " he concludes.