Health and care systems across the globe are under pressure. New technology and treatments create supplier induced demand. Consumer expectations and increasing numbers of people living with non-communicable disease only add to this demand. Health inequalities in countries like the United States[i] and England[ii] are widening.

So where would you put any extra money to make a difference? Into hard-pressed emergency departments, or perhaps investing in primary care? Or maybe social services or prevention programmes?

The truth is in most health systems a case could be made for investing in all these areas. However, the political reality is that most extra funding goes into acute services with the aim of managing demand in the short term. The Chancellor of the Exchequer in his 2017 autumn budget chose to put an additional £2.8bn into the NHS over the next three years but announced nothing for social care or prevention. Indeed the Public Health Grants received by local authorities in England will continue to suffer previously announced year on year cuts.

The various tribes in the health and social care system tend to add to the pressure on politicians to preference the immediate over the important. In England there has been an increase in hospital consultants whilst the number of GPs has declined, and social care and public health funding has been reduced. None of this makes sense when we face health and care challenges that are now very different from when the NHS was founded nearly 70 years ago.

So what is the answer? We know that ‘re-disorganisations’ of health and care are usually costly distractions with limited evidence that they improve outcomes. Such vast sums of public money are involved that some political oversight is mandatory. In any case, the public need to retain their right to express a view at the ballot box.

What seems to be missing is an authoritative, independent body to judge how much money is required and how it is best allocated. The Office of Budget Responsibility (OBR) does this for the UK’s economic forecasts and analysis of overall public finances. It has taken economic forecasting away from political influence and is one of a growing number of independent financial overseers around the world. Perhaps now is the time for an OBR for health and care.

So how would an OBR for health and care work? Like the OBR for public finances it would provide an independent forecast of health and care costs and an assessment of how government were planning for those costs. It would not dictate policy, or how services are delivered, but would independently scrutinise the government’s plans and, like the current OBR, give a view on the likelihood of hitting the financial targets. It would also, like the OBR, take both a short and long term view.

We’ve known about the looming social care crisis for at least 20 years but successive governments have failed to address it. The NHS has become a political football. Public health programmes, as have historically often been the case, are being cut to sustain funding elsewhere. This cannot continue. We desperately need a truly independent body to advise on how we make health and care sustainable.

Andrew Furber
Past President
Association of Directors of Public Health

[i] Dickman SL, Himmelstein DU, Woolhandler S. Inequality and the health-care system in the USA. 2017; 389: 1431–1441 DOI:

[ii] Buchan IE, Kontopantelis E, Sperrin M,   North-South disparities in English mortality 1965–2015: longitudinal population study.  2017;71:928-936 DOI:

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