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WHAT PRIORITIES FOR HEALTH ?
1306
professional ethics are maintained there is no reason why the peaks of efficiency in pluralism should and
be maintained while the gaps are eliminated in what has already become a common quest by politicians, public, and professionals to find a national answer to a national problem.4 The untreated sickness within the nation, which is the crux of the problem, is represented in no small measure by the sickness of those who still promote divisiveness in a national emergency. Medical science is nowhere more dynamic and inventive than in America-so much so that improved standards of health in most countries today are attributable in no small measure to American discoveries and techniques. It is therefore a paradox verging on absurdity that health care in America itself should be in a state of crisis.
TABLE
I-PLANNED
ACCELERATION-RATES
IN
PUBLIC SPENDING
not
REFERENCES 1. Public Law 89-749: 89th Congress S.3008, Nov. 3, 1966. (An Act to Amend the Public Health Service Act.) 2. Building a National Health Strategy. The President’s Message to Congress, Feb. 18, 1971. 3. Kennedy, E. M. Health Security for America. A Speech in the Senate of the United States—Proceedings and Debates of the 92nd Congress, 1st Session, Jan. 25, 1971. 4. Creative Federalism, Partnership in Health, Slogans or Solutions 1969 Annual Conference of the New York Academy of Medicine Bull. N.Y. Acad. Med. 1969, 45, 1135.
National Health Service WHAT PRIORITIES FOR HEALTH ? RUDOLF KLEIN Medical Care Research Unit, Department of Public Health, London School of Hygiene and Tropical Medicine, W.C.1
OVER the next five years, according to the Government’s latest projection of public expenditure,1 spending on health will go up by more than E400 million at constant prices. The budget for health and the related personal social services will rise from E2427 million in the current financial year to S2834 million in 1975-76. This includes the El 18 million bonus announced last month. It seems, on the face of it, a considerable increase. But is it enough ? Is health getting its fair share of resources ? No one has yet devised a way of calculating the right " amount to spend on health. International comparisons are notorilusly misleading II: for example, the fact that the United States devotes almost 50% more of its gross national product to health than Britain 11 may simply mean that the N.H.S. uses resources more efficiently rather than that Britain is
spending
too
little.
question of whether health is getting a fair share of national resources is more meaningful. For the Government’s expenditure projection is a measure of the priority attached by Ministers to spending on the various public services. And when the latest projection is compared with its two predecessors, it is clear that health has moved up in the pecking order of public expenditure. The first public-expenditure white-paper 4 was published by the Labour Government in 1969; until then the Treasury’s five-year projections of Government spending had been treated as official secrets. But the
Source: Cmnd. 4234, Cmnd. 4578, Cmnd. 4829.
in the
post-devaluation era, when the reducing the rate of increase in public spending that had taken place in the previous five years. The 1970 white-paperwas, because of the intervening general election, not published until the beginning of this year. It reflected the anxiety of the
This
was
stress was on
Conservative Government to carry out its election promises to reduce public spending still further. The 1971 white-paper, published last month, marks a shift of policy. The main concern is not so much with retrenchment as with the need for a boost to the economy to reduce the rise in unemployment. Against this background, tableI sets out the changing priorities given to health spending in the three policy documents. As the indicator of priorities, the average annual percentage increase in spending has been Since the used-i.e., the acceleration or growth-rate. " " are made on a constant Treasury projections price basis, this acceleration is unaffected by inflation. Admittedly, it is still not a wholly satisfactory measure of priorities; it leaves out of account that one service may have been starved of capital in the past while another may have been relatively well-provided fore.g., between 1960 and 1970 the N.H.S. was allowed only E935 million of capital investment as against S2475 million for education. Even so, it is still probably the best indicator available-though still incomplete. The main conclusion from tableI is that health, compared to other major Government programmes, has improved its priority position. The planned acceleration-rate has gone up quite considerably between the first and the second Conservative whitepapers from 3-3% to 3-9% a year. It is now very slightly above the Labour target of 3-8%. These figures, however, understate the relative improvement in the health budget. For health’s acceleration-rate has gone up, at a time when the growth-rate in other Government services has slowed down. Thus, for the first time, the acceleration-rate for health is now well ahead of education (3%) and social security (1-5%). The social-security growth-rate assumes that the present level of benefits will be maintained in real terms.
These, of course, are average rates for the whole five-year period. In practice, some of the largest increases-especially in spending on capital investment such as new hospital buildings-are planned to take place at the beginning of the period. Thus in the coming financial year, 1972-73, the increases will be 5-6% for the hospital service and 9% for the personal health and social services. As these figures indicate, the extra money will not be distributed equally between the different sectors. After 1972-73 it is planned to hold the acceleration-rate for the hospital
1307 TABLE II-PROPORTION OF TOTAL HEALTH EXPENDITURE AND CAPITAL) IN DIFFERENT SECTORS
(CURRENT
(%)
actual growth-rate of 3-9% achieved in the boom period of public expenditure in the first five years of the Labour Government.
Health expenditure is now getting a higher degree priority-as measured by its share of the extra resources becoming available-than at any time since 1964, and probably at any time since the early fifties. However, it should not be automatically assumed that this trend will continue. On present plans, health spending will increase almost twice as fast as public expenditure as a whole and considerably faster than the expected growth in the national income. There will therefore be a consequent shift of resourceswhether measured in terms of the proportion of public spending or of the gross national product devoted to health. But, as table i shows, this shift towards expenditure on health and other social services has been made politically easier by reductions in defence spending (under Labour) and aid to industry (under the Conservatives). These cuts have, as it were, created " spare capacity ". Given that these massive reductions are once-and-for-all exercises, and given that services such as social security will be pressing their claims, caution about the long-term financial prospects of health seems to be indicated. Government expenditure tends to follow a manic-depressive-cyclereflecting the state of the economy 8-and economy campaigns regularly follow bursts of spending. The extra money being made available should, therefore, be seen as a bonus, not as a sign that the present upward trend will continue indefinitely or as a signal to relax the drive for greater cost-effectiveness in health services. I thank Prof. R. F. L. Logan and Dr. J. S. A. Ashley for their of
Source: Cmnd. 4829. TABLE III-ACCELERATION-RATES IN PUBLIC SPENDING ALLOWING FOR THE RELATIVE PRICE EFFECT
Source: Cmnd. 4234, Cmnd. 4578, Cmnd. 4829.
sector
at 3-5% a year, while that for health and personal social services will be 6’8%. The result, as table 11 shows, will be a gradual shift in priorities within the health services-with hospitals and general practice (which is not capital intensive) getting a little less and the health and personal social services getting rather more of the resources available. Within the hospital sector the emphasis will be on reducing inequalities between different regions-i.e., most of the increase will be channelled to the worst-off regions 6 such as East Anglia and Sheffield-and on redistributing resources " to the mentally handicapped and mentally ill, the elderly and the younger chronic sick ". One of the questions left unanswered by these figures is the extent to which the increased funds will be available to improve standards as distinct from being needed to cope with extra demands. The professed intention is to use most of the extra money to raise standards; however, given the existing ignorance about how demand for medical services is generated, this could turn out to be an optimistic assumption. One of the few certainties is that the section of the population which makes the most demands on the health services-the over-65s, and even more the over-75swill be increasing over the next five years, and beyond.’7 The other question concerns the effect on the health services of movements in wages and salaries. This, however, is answered by the white-paper. The figures in table i do not allow for what is called the " relative price effect " -i.e., they leave out of account that labour costs change in different ways in different services. Thus the costs of social security (a staff of 64,000) are much less sensitive to wage-and-salary movements than those of health and welfare (a staff of 872,000). Table ill sets out the accelerator-rates amended to take the " relative price effect" into account. It leaves out the 1969 white-paper, which did not carry these figures, but includes, instead, the actual growth-rate of public expenditure under the Labour Government between 1964-65 and 1968-69. These revised figures show that the Health Services are, relative to most other Government activities, going to make even larger demands on the public purse than table I indicated. The true acceleration-rate for health is planned to be 5-1% a year, as against 4-5% for education and 2-7% for public expenditure as a whole. Most interestingly of all, the planned growth-rate for health is higher than the
helpful comments. REFERENCES 1. Public Expenditure to 1975/76. Cmnd. 4829. H.M. Stationery Office, 1971. 68p. 2. Abel-Smith, B. An International Study of Health Expenditure. World Health Organisation, 1967. 3. Office of Health Economics information sheet no. 9, September, 1970. 4. Public Expenditure 1968/9 to 1973/4. Cmnd. 4234. H.M. Stationery Office, 1969. 5. Public Expenditure 1969/70 to 1974/5. Cmnd. 4578. H.M. Stationery Office, 1971. 6. Griffiths, D. A. T. Hospital, 1971 (July), p. 310. 7. Ashley, J. S. A., Klein, R. E. Mod. Geriat. 1971, 1, 229. 8. Brittan, S. Steering the Economy. London, 1969.
"... Science is one thing and wisdom is another ... If you look at the results which science has brought in its train, you will find them to consist almost wholly in elements of mischief. See how much belongs to the word Explosion alone, of which the ancients knew nothing. Explosions of powder-mills and powdermagazines ; of coal-gas in mines and in houses; of high-pressure engines in ships and boats and factories. See the complications and refinements of modes of destruction, in revolvers and rifles and shells and rockets and cannon. See collisions and wrecks and every mode of disaster by land and by sea, resulting chiefly from the insanity for speed, in those who for the most part have nothing to do at the end of the race ... Look at our scientific drainage, which turns refuse into poison. Look at the subsoil of London, whenever it is turned up to the air, converted by gas leakage into one mass of pestilent blackness, in which no vegetation can flourish, and above which, with the rapid growth of the evergrowing nuisance, no living thing will breathe with impunity. Look at our scientific machinery, which has destroyed domestic manufacture, which has substituted rottenness for strength in the thing made, and physical degradation in crowded towns for healthy and comfortable country life in the makers ... I almost think it is the ultimate destiny of science to exterminate the human race."—THOMAS LovE PEACoCK, Gryll Grange, 1861. (Pp. 127-128 in Penguin reprint of 1949.)
professional ethics are maintained there is no reason why the peaks of efficiency in pluralism should and
be maintained while the gaps are eliminated in what has already become a common quest by politicians, public, and professionals to find a national answer to a national problem.4 The untreated sickness within the nation, which is the crux of the problem, is represented in no small measure by the sickness of those who still promote divisiveness in a national emergency. Medical science is nowhere more dynamic and inventive than in America-so much so that improved standards of health in most countries today are attributable in no small measure to American discoveries and techniques. It is therefore a paradox verging on absurdity that health care in America itself should be in a state of crisis.
TABLE
I-PLANNED
ACCELERATION-RATES
IN
PUBLIC SPENDING
not
REFERENCES 1. Public Law 89-749: 89th Congress S.3008, Nov. 3, 1966. (An Act to Amend the Public Health Service Act.) 2. Building a National Health Strategy. The President’s Message to Congress, Feb. 18, 1971. 3. Kennedy, E. M. Health Security for America. A Speech in the Senate of the United States—Proceedings and Debates of the 92nd Congress, 1st Session, Jan. 25, 1971. 4. Creative Federalism, Partnership in Health, Slogans or Solutions 1969 Annual Conference of the New York Academy of Medicine Bull. N.Y. Acad. Med. 1969, 45, 1135.
National Health Service WHAT PRIORITIES FOR HEALTH ? RUDOLF KLEIN Medical Care Research Unit, Department of Public Health, London School of Hygiene and Tropical Medicine, W.C.1
OVER the next five years, according to the Government’s latest projection of public expenditure,1 spending on health will go up by more than E400 million at constant prices. The budget for health and the related personal social services will rise from E2427 million in the current financial year to S2834 million in 1975-76. This includes the El 18 million bonus announced last month. It seems, on the face of it, a considerable increase. But is it enough ? Is health getting its fair share of resources ? No one has yet devised a way of calculating the right " amount to spend on health. International comparisons are notorilusly misleading II: for example, the fact that the United States devotes almost 50% more of its gross national product to health than Britain 11 may simply mean that the N.H.S. uses resources more efficiently rather than that Britain is
spending
too
little.
question of whether health is getting a fair share of national resources is more meaningful. For the Government’s expenditure projection is a measure of the priority attached by Ministers to spending on the various public services. And when the latest projection is compared with its two predecessors, it is clear that health has moved up in the pecking order of public expenditure. The first public-expenditure white-paper 4 was published by the Labour Government in 1969; until then the Treasury’s five-year projections of Government spending had been treated as official secrets. But the
Source: Cmnd. 4234, Cmnd. 4578, Cmnd. 4829.
in the
post-devaluation era, when the reducing the rate of increase in public spending that had taken place in the previous five years. The 1970 white-paperwas, because of the intervening general election, not published until the beginning of this year. It reflected the anxiety of the
This
was
stress was on
Conservative Government to carry out its election promises to reduce public spending still further. The 1971 white-paper, published last month, marks a shift of policy. The main concern is not so much with retrenchment as with the need for a boost to the economy to reduce the rise in unemployment. Against this background, tableI sets out the changing priorities given to health spending in the three policy documents. As the indicator of priorities, the average annual percentage increase in spending has been Since the used-i.e., the acceleration or growth-rate. " " are made on a constant Treasury projections price basis, this acceleration is unaffected by inflation. Admittedly, it is still not a wholly satisfactory measure of priorities; it leaves out of account that one service may have been starved of capital in the past while another may have been relatively well-provided fore.g., between 1960 and 1970 the N.H.S. was allowed only E935 million of capital investment as against S2475 million for education. Even so, it is still probably the best indicator available-though still incomplete. The main conclusion from tableI is that health, compared to other major Government programmes, has improved its priority position. The planned acceleration-rate has gone up quite considerably between the first and the second Conservative whitepapers from 3-3% to 3-9% a year. It is now very slightly above the Labour target of 3-8%. These figures, however, understate the relative improvement in the health budget. For health’s acceleration-rate has gone up, at a time when the growth-rate in other Government services has slowed down. Thus, for the first time, the acceleration-rate for health is now well ahead of education (3%) and social security (1-5%). The social-security growth-rate assumes that the present level of benefits will be maintained in real terms.
These, of course, are average rates for the whole five-year period. In practice, some of the largest increases-especially in spending on capital investment such as new hospital buildings-are planned to take place at the beginning of the period. Thus in the coming financial year, 1972-73, the increases will be 5-6% for the hospital service and 9% for the personal health and social services. As these figures indicate, the extra money will not be distributed equally between the different sectors. After 1972-73 it is planned to hold the acceleration-rate for the hospital
1307 TABLE II-PROPORTION OF TOTAL HEALTH EXPENDITURE AND CAPITAL) IN DIFFERENT SECTORS
(CURRENT
(%)
actual growth-rate of 3-9% achieved in the boom period of public expenditure in the first five years of the Labour Government.
Health expenditure is now getting a higher degree priority-as measured by its share of the extra resources becoming available-than at any time since 1964, and probably at any time since the early fifties. However, it should not be automatically assumed that this trend will continue. On present plans, health spending will increase almost twice as fast as public expenditure as a whole and considerably faster than the expected growth in the national income. There will therefore be a consequent shift of resourceswhether measured in terms of the proportion of public spending or of the gross national product devoted to health. But, as table i shows, this shift towards expenditure on health and other social services has been made politically easier by reductions in defence spending (under Labour) and aid to industry (under the Conservatives). These cuts have, as it were, created " spare capacity ". Given that these massive reductions are once-and-for-all exercises, and given that services such as social security will be pressing their claims, caution about the long-term financial prospects of health seems to be indicated. Government expenditure tends to follow a manic-depressive-cyclereflecting the state of the economy 8-and economy campaigns regularly follow bursts of spending. The extra money being made available should, therefore, be seen as a bonus, not as a sign that the present upward trend will continue indefinitely or as a signal to relax the drive for greater cost-effectiveness in health services. I thank Prof. R. F. L. Logan and Dr. J. S. A. Ashley for their of
Source: Cmnd. 4829. TABLE III-ACCELERATION-RATES IN PUBLIC SPENDING ALLOWING FOR THE RELATIVE PRICE EFFECT
Source: Cmnd. 4234, Cmnd. 4578, Cmnd. 4829.
sector
at 3-5% a year, while that for health and personal social services will be 6’8%. The result, as table 11 shows, will be a gradual shift in priorities within the health services-with hospitals and general practice (which is not capital intensive) getting a little less and the health and personal social services getting rather more of the resources available. Within the hospital sector the emphasis will be on reducing inequalities between different regions-i.e., most of the increase will be channelled to the worst-off regions 6 such as East Anglia and Sheffield-and on redistributing resources " to the mentally handicapped and mentally ill, the elderly and the younger chronic sick ". One of the questions left unanswered by these figures is the extent to which the increased funds will be available to improve standards as distinct from being needed to cope with extra demands. The professed intention is to use most of the extra money to raise standards; however, given the existing ignorance about how demand for medical services is generated, this could turn out to be an optimistic assumption. One of the few certainties is that the section of the population which makes the most demands on the health services-the over-65s, and even more the over-75swill be increasing over the next five years, and beyond.’7 The other question concerns the effect on the health services of movements in wages and salaries. This, however, is answered by the white-paper. The figures in table i do not allow for what is called the " relative price effect " -i.e., they leave out of account that labour costs change in different ways in different services. Thus the costs of social security (a staff of 64,000) are much less sensitive to wage-and-salary movements than those of health and welfare (a staff of 872,000). Table ill sets out the accelerator-rates amended to take the " relative price effect" into account. It leaves out the 1969 white-paper, which did not carry these figures, but includes, instead, the actual growth-rate of public expenditure under the Labour Government between 1964-65 and 1968-69. These revised figures show that the Health Services are, relative to most other Government activities, going to make even larger demands on the public purse than table I indicated. The true acceleration-rate for health is planned to be 5-1% a year, as against 4-5% for education and 2-7% for public expenditure as a whole. Most interestingly of all, the planned growth-rate for health is higher than the
helpful comments. REFERENCES 1. Public Expenditure to 1975/76. Cmnd. 4829. H.M. Stationery Office, 1971. 68p. 2. Abel-Smith, B. An International Study of Health Expenditure. World Health Organisation, 1967. 3. Office of Health Economics information sheet no. 9, September, 1970. 4. Public Expenditure 1968/9 to 1973/4. Cmnd. 4234. H.M. Stationery Office, 1969. 5. Public Expenditure 1969/70 to 1974/5. Cmnd. 4578. H.M. Stationery Office, 1971. 6. Griffiths, D. A. T. Hospital, 1971 (July), p. 310. 7. Ashley, J. S. A., Klein, R. E. Mod. Geriat. 1971, 1, 229. 8. Brittan, S. Steering the Economy. London, 1969.
"... Science is one thing and wisdom is another ... If you look at the results which science has brought in its train, you will find them to consist almost wholly in elements of mischief. See how much belongs to the word Explosion alone, of which the ancients knew nothing. Explosions of powder-mills and powdermagazines ; of coal-gas in mines and in houses; of high-pressure engines in ships and boats and factories. See the complications and refinements of modes of destruction, in revolvers and rifles and shells and rockets and cannon. See collisions and wrecks and every mode of disaster by land and by sea, resulting chiefly from the insanity for speed, in those who for the most part have nothing to do at the end of the race ... Look at our scientific drainage, which turns refuse into poison. Look at the subsoil of London, whenever it is turned up to the air, converted by gas leakage into one mass of pestilent blackness, in which no vegetation can flourish, and above which, with the rapid growth of the evergrowing nuisance, no living thing will breathe with impunity. Look at our scientific machinery, which has destroyed domestic manufacture, which has substituted rottenness for strength in the thing made, and physical degradation in crowded towns for healthy and comfortable country life in the makers ... I almost think it is the ultimate destiny of science to exterminate the human race."—THOMAS LovE PEACoCK, Gryll Grange, 1861. (Pp. 127-128 in Penguin reprint of 1949.)