The NHS crisis that none of the parties will discuss: how to pay for it

With a £30bn funding gap, all parties need to decide whether they would raise taxes, cut spending elsewhere, or impose patient charges. But don't expect them to tell us.

If there's one NHS issue that none of the parties are prepared to confront, it's that of funding. The common view is that the health service has been shielded from austerity by having its budget ring-fenced, but in reality the reverse is the case. Owing to the above-average rate of inflation in the service, the NHS requires real-terms rises just to stand still. As a recent Social Market Foundation paper noted, "A ‘flat real’ settlement for the NHS is mot 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%.

If they wish to avoid a significant fall in the quality and quantity of services, this government and future ones are left with three choices: to raise taxes, to cut spending elsewhere, or to impose patient charges. The third of these is proposed by the think-tank Reform today, which calls for a £10 charge for GP consultations, £10 fines for missed appointments, the introduction of a means-tested system for end of life care and an increase in prescription charges from £7.85 to £10 (with exemptions for those on low-incomes). It estimates that these measures would raise around £3bn a year, with research director Thomas Cawston commenting: "Few will want to debate higher NHS charges but the funding outlook for the service makes it unavoidable. Prescription charges are the easiest route to new revenue, with exemptions for people on low incomes built in." 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 now been abolished in Scotland, Wales and Northern Ireland).

But perhaps unsurprisingly, the Department of Health has responded by dismissing the idea out of hand. A spokesman said: "We have been absolutely clear that the NHS should be free at the point of use, with access based on need. That is why we have increased health spending in real terms alongside £20bn of efficiency savings to make sure the NHS continues to provide excellent care."

Labour, meanwhile, spying an opportunity to cause political mischief, has commented: "Patients will be alarmed that friends of Number 10 want to see charges for GP appointments and hospital care.

"Labour froze prescription charges before the election, but they have increased year on year under David Cameron. They are now creeping towards £10, as these plans want, and are adding to the cost of living crisis.

"The Government must come clean on any plans to charge for NHS care. They have already lost people’s trust over the crisis in A&E and thousands of axed nursing jobs – this will only add to it."

But this merely defers the question of how we will ultimately pay for a health service of the standard the public both expect and deserve. Will any party grasp this nettle before 2015? Don't count on it. 

Jeremy Hunt delivers a speech during his visit with David Cameron to the Evelina London Children's Hospital on July 5, 2013 in London. Photograph: Getty Images.

George Eaton is political editor of the New Statesman.

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Remain voters must ditch party differences to gain a voice in Brexit Britain

It's time for politicians and activists to put aside their tribal loyalties.

The status quo has broken. British politics lies shattered into pieces, and even Brexiteers look stunned. We are in a new landscape. Anyone who tells you they have the measure of it is lying; but anyone reaching for old certainties is most likely to be wrong.
 
Through this fog, we can already glimpse some signposts. There will be a leadership election in the Tory Party within three months. While it is still unclear who will win, the smart money is on a champion of Brexit. The Leave camp are in the ascendancy, and have captured the hearts of most Tory members and voters.
 
The next Conservative prime minister will lack a clear mandate from voters, but will need one to successfully negotiate our exit from the EU. They will also see a golden opportunity to capture the working-class Leave vote from Labour – and to forge an even more dominant Conservative electoral coalition. UKIP too would fancy their chances of dismembering Labour in the north; their financier Arron Banks now has almost a million new registered supporters signed up through Leave.EU.
 
In this context, it seems inevitable that there will be another general election within six to twelve months. Could Labour win this election? Split, demoralised and flailing, it has barely begun to renew, and now faces a massive undertow from its heartlands. In this time of crisis, a party divided will find it difficult to prevail – no matter who leads it. And amidst all today’s talk of coups against Corbyn, it is currently tough to envisage a leader who could unite Labour to beat the Brexiteers.  
 
From opposite ends of the political spectrum, I and my Crowdpac co-founder Steve Hilton have been testing the possibilities of new politics for years. In this referendum I supported Another Europe Is Possible’s call to vote In and change Europe. But it is crystal clear that the Leave campaigns learnt many of the lessons of new politics, and are well positioned to apply them in the months and years to come. I expect them to make significant use of our platform for crowdfunding and candidate selection.

Time to build a progressive alliance

On the other side, the best or only prospect for victory in the onrushing general election could be a broad progressive alliance or national unity platform of citizens and parties from the centre to the left. Such an idea has been floated before, and usually founders on the rocks of party tribalism. But the stakes have never been this high, and the Achilles heels of the status quo parties have never been so spotlit.
 
Such an alliance could only succeed if it embraces the lessons of new politics and establishes itself on open principles. A coalition of sore losers from Westminster is unlikely to appeal. But if an open primary was held in every constituency to select the best progressive candidate, that would provide unprecedented democratic legitimacy and channel a wave of bottom-up energy into this new alliance as well as its constituent parties.
 
In England, such an alliance could gather together many of those who have campaigned together for Remain in this referendum and opposed Tory policies, from Labour to Greens and Liberal Democrats. It might even appeal to Conservative voters or politicians who are disenchanted with the Leave movement. In Scotland and Wales too, some form of engagement with the SNP or Plaid Cymru might be possible.
 
An electoral alliance built on open and democratic foundations would provide a new entry point to politics for the millions of young people who voted to stay in the EU and today feel despairing and unheard. Vitally, it could also make a fresh offer to Labour heartland voters, enabling them to elect candidates who are free to speak to their concerns on immigration as well as economic insecurity. I believe it could win a thumping majority.

A one-off renegotiation force

A central goal of this alliance would be to re-negotiate our relationship with Europe on terms which protect our economy, workers’ rights, and the interests of citizens and communities across the country. Work would be needed to forge a common agenda on economic strategy, public services and democratic reform, but that looks more achievable than ever as of today. On more divisive issues like immigration, alliance MPs could be given flexibility to decide their own position, while sticking to some vital common principles.
 
This idea has bubbled to the surface again and again today in conversations with campaigners and politicians of different parties and of none. What’s more, only a new alliance of this kind has any prospect of securing support from the new network movements which I helped to build, and which now have many more members than the parties. So this is no idle thought experiment; and it surely holds out greater hope than another rearranging of the deckchairs in the Parliamentary Labour Party.
 
The alliance would probably not last in this form beyond one parliamentary term. But during that time it could navigate us safely through these turbulent referendum seas, and lay foundations for a better country and a better politics in the coming decades. Food for thought, perhaps.
 
Paul Hilder is co-founder of Crowdpac, 38 Degrees and openDemocracy. He has played leadership roles at Change.org, Avaaz and Oxfam, and was a candidate for general secretary of Labour in 2011. 

Paul Hilder is an expert on new politics and social change. He is the Executive Director of Here Now, a movement lab working with partners around the world. He co-founded 38 Degrees and openDemocracy, helped launch Avaaz.org and served as Vice-President of Global Campaigns at Change.org. He has worked on social change in the UK and around the world, including in the political arena and with Oxfam and the Young Foundation.