Why the Tories will have to consider NHS charges after 2015

With George Osborne determined to avoid further tax rises, patient charges will be the only way to solve the health funding crisis.

Another Spending Review has been settled with the NHS again protected from cuts. But the longer austerity continues, the harder it will be for the government to justify special treatment for some departments. As last week's Resolution Foundation report showed, if the current ring-fences around health, international development and schools are maintained, some departments will have had their budgets more than halved by 2018, with a 64% cut to the Foreign Office, a 46% cut to the Home Office and a 36% cut to defence. Something will have to give. And with the Tories reportedly planning to rule out further tax rises, it will be even harder for any area to escape Osborne's axe (should he still be in the Treasury after May 2015). 

There is a strong case for making an exception for the NHS. Polls show that it is the most popular spending area with voters and the above-average rate of inflation in the health service means it requires real-terms rises just to stand still. As today's SMF paper on the Spending Review notes, "A ‘flat real’ settlement for the NHS is therefore not what it sounds like since it is defined with reference to an irrelevant price index. To keep up with rising input costs, growing demand, and the public’s expectations for an adequate healthcare system, growth in spending on health has historically outstripped GDP growth." 

By historic standards, the NHS is undergoing austerity. Since 1950, health spending has grown at an average annual rate of 4%, but over the current Spending Review it will rise by an average of just 0.5%. As a result, in the words of the SMF, there has been "an effective cut of £16bn from the health budget in terms of what patients expect the NHS to deliver". Should the NHS receive flat real settlements for the three years from 2015-16 (as seems probable), this cut will increase to £34bn or 23%.

Without further tax rises, the inevitable result will be a significant fall in the quality and quantity of services. But with the Tories seemingly determined to avoid these, another option rears its head: patient charges. At today's British Medical Association conference, that it is precisely what doctors will propose. Gordon Matthews, a member of the BMA consultants’ committee, will say: "A publicly funded and free-at-the-point-of- delivery NHS cannot afford all available diagnostics and treatments." Outlining the funding crisis that I've just described, he will add: "Everyone recognises that we’re in times of austerity, there isn’t a lot of money around, while public expectations have gone up and up, medical treatments have become more expensive and there isn’t an easy way to square the circle."

Matthew will propose drawing up a list of core services that will be provided for free, with charges introduced for others. If this seems heretical, it's worth remembering that our "free" health service hasn't been truly free since Labour chancellor Hugh Gaitskell introduced prescription charges for glasses and dentures in his 1951 Budget (although they have been abolished in Scotland, Wales and Northern Ireland). Morally speaking, there is no difference between these fees and co-payments. There is also growing public recognition that a high-quality NHS will need to be paid for. A recent Ipsos MORI poll for The King's Fund found that there is support for introducing charges for treatments that are not perceived as "clinically necessary" (such as cosmetic surgery and elective caesarean sections), for people thought to "misuse services" (e.g. missing appointments or arriving drunk at A&E), for patients requiring treatment as a result of "lifestyle choices" (e.g. smoking and obesity) and for 'top-ups' to non-clinical aspects of care (e.g. private rooms and other 'hotel' services). 

For now, the Tories insist that they will not go down this road. After Malcolm Grant, the chair of the NHS Commissioning Board warned last month that the next government would have to consider introducing "new charging systems" unless "the economy has picked up sufficiently", Jeremy Hunt told MPs: "Professor Malcolm Grant did not say that. What he actually said was that if the NHS considered charging, he would oppose it. I agree with him; I would oppose it, too." But just as pensioner benefits, once considered untouchable, are now being targeted by all parties for cuts, it seems increasingly unlikely that a "free NHS" will survive the age of austerity. 

Consultant Gynaecologist Ertan Saridogan gives Health Secretary Jeremy Hunt a demonstration of a laparoscopy system during a tour of University College Hospital. Photograph: Getty Images.

George Eaton is political editor of the New Statesman.

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Why hasn’t British Asian entertainment built on the Goodness Gracious Me golden age?

It is 20 years since the original radio series of Goodness Gracious Me aired. Over two decades, the UK media portrayal of Asians hasn’t used its success to evolve.

Save for a handful of special one-off episodes, Goodness Gracious Me hasn’t occupied a primetime TV slot for nearly two decades. Yet still it remains the measuring stick for British Asian comedy.

The sketch show, which transitioned seamlessly from radio to screen (it started as a BBC Radio 4 series in 1996), has stood the test of time and is as much a staple of modern British Asian culture as Tupperware or turning up an hour late.

What Goodness Gracious Me did so expertly was to take a set of serious issues facing first, second and now, I suppose, third generation migrants, and turn them on their heads. 

In making light of the pressures of academic expectation or family drama, Goodness Gracious Me wasn’t playing down the poignancy of such concerns; it was raising awareness and combatting their uglier side with humour.

It offered resonance and reassurance in equal measure; it was ok to have an embarrassing uncle who insisted he could get you anything much cheaper, including a new kidney, because other people like you did too.

That Goodness Gracious Me was broadcast on a mainstream channel was also a victory for minorities; it made us feel integrated and, perhaps more importantly, accepted. Against the backdrop of Brexit, what wouldn’t we give for that treatment now?

Really, though, the jewel in Goodness Gracious Me’s crown was its willingness to recognise diversity within diversity. It is a relic of a departed era when discourse on TV around Asians was different, when the broad church of that term was truly represented, rather than reduced to one catchall perception of British Muslims.

Goodness Gracious Me offered insight into the experiences and idiosyncrasies – religious or otherwise – of Indians, Pakistanis, Bangladeshis, Sri Lankans and even English people. It’s what made it so accessible and, in answering why subsequent programmes have failed to reach similar heights, this is a good starting point.

Without the flexible sketch format, the modern Asian sitcom Citizen Khan has struggled to cover multiple topics, and, by being specifically about a Muslim family, it leaves many non-Muslim Asians wondering: where’s ours?

I hasten to add that I feel plenty of sympathy for the British Muslim community, hounded by tabloid headlines that attack their faith, but it would be disingenuous to suggest that non-Muslim Asians are sitting pretty in 2016 and don’t need a similar level of support in terms of positive public perception.

The current volume of British Asian media products is fairly good. The BBC has its dedicated network, The Good Immigrant essay collection was one of the outstanding reads of the year, and we still have champions of comedy in Romesh Ranganathan and Nish Kumar.

But I think ultimately it comes down to the broadness of appeal, rather than the quantity of products. Goodness Gracious Me was not only able to engage the full spectrum of British Asia; it transcended its target audience and was on terrestrial TV.

The British Asian media on offer now is up against it, released as the country’s attitude towards foreigners completes a full circle back to the same suspicion my grandfather encountered in the Sixties.

Fewer outlets are willing to explore the stretch of what it means to be Asian, either by denying it due consideration in mainstream shows or by peddling their own monolithic observations. The BBC Asian Network, for example, is laudable in its existence, but does little to engage the young Asians who aren’t into techno spliced with Bhangra.

The mainstream representations of Asians in Western film and television that are commissioned, meanwhile, are irritatingly limited and sometimes inaccurate. In an article for the Guardian last year, Sara Abassi lamented the disproportionate appetite for “gritty post-9/11 films about conservative Pakistani families”, and that the researchers of American series Homeland failed to realise that the national language of Pakistan isn’t Arabic.

When I interviewed the actor Himesh Patel for the No Country for Brown Men podcast, he suggested that the answer to re-establishing Asians in mainstream media, both here and in America, was three-fold. The first challenge to overcome was for outlets to acknowledge that not all Asians fit the same religious or cultural profile; the second was to be open to placing Asians in non-Asian specific products to better reflect their presence in society.

Patel, who is best known for his portrayal of Tamwar Masood in the soap opera EastEnders, made his third recommendation based on this role. He felt that characters should be written with only their personality in mind, making the ethnicity of the actor who plays them incidental. Tamwar’s awkwardness but underlying kindness, Patel said, was what defined him – not his skin colour.

Goodness Gracious Me, though a primarily Asian show and a comedy at that, actually taught some salient lessons about representation. It succeeded in providing a window into a multiplicity of cultures, but at the same time wasn’t a total slave to the politics of identity – several of the 100-plus characters needn’t have been Asian at all. It was reflexive to the times we lived in and a perfect advertisement for empathy. That is why we still talk about it today.

Rohan Banerjee is a Special Projects Writer at the New Statesman. He co-hosts the No Country For Brown Men podcast.