Is the health service in danger of intergenerational unfairness?

With an ageing population there is now a danger that scarce resources are being sucked up the older generations and spent disproportionately on the elderly.  There are reasons to fear this: we know that health costs for older people are increasing and the NHS’ projections show that over the next 30 years spending on the over 60s is expected to go from 47% of the total budget to 66%.  That’s a huge change – from about half to two-thirds.  It’s also been seen in other sectors, such as housing and pensions, that the baby-boomers as a cohort have few qualms about demanding resources without enough regard for the needs of younger and future generations.  We are in a new world where we need to be alert to fairness not just between social classes but also between age cohorts, as the Intergenerational Foundation (www.if.org.uk) argues.

The best way to counter this danger is certainly not to deny its possibility: rather we should be measuring, projecting and discussing it out in the open.  No one wants older people suffering from lack of resources but equally we don’t want to drift into a situation where young people are disadvantaged because of unreasonable commitments we’ve made to older cohorts.  This is exactly what has happened in public transport – older people are guaranteed free public transport by statute whereas younger people’s discount fares have usually been at the discretion of the local authorities.  The result is that when there is a financial squeeze, as there has been since 2009, young people’s discounts are cut while free bus passes for the over 60s are protected by law.  To its credit the NHS recognises this to some extent and the National Institute of Health and Care Excellence (“NICE”) assesses new medicines and treatments taking into account the number of extra worthwhile years of life that will be enabled, or “quality-adjusted life years” – which is what they calculate. Efforts to recognise fairness between generations are also evident in the recent decisions to put more resources into midwifery and neonatal care. In putting more money into birth-related care the NHS explicitly recognises its duty to future generations:

https://www.england.nhs.uk/2016/02/maternity-review-2/

There are some specific areas where intergenerational fairness is in short supply because of the historical leanings of the service.  For example, mental health is most likely to affect younger people: most mental health conditions (apart from dementia) become apparent between the ages of 15 and 25.  This can include stress-related conditions, anxiety, schizophrenia, and depression.  Spending on mental health has always been a poor relation to spending on physical conditions so here there is unintentional but real discrimination against the needs of younger people.  Simon Stephens, who heads NHS England, points out that one in four of the population will experience a mental health problem at some point and mental health is more likely to cause a visit to A&E.  Yet, he says, only 10% of A&E departments have 24 hour specialist mental health expertise.   Actually, since taking over as chief of NHS England Simon Stevens has raised the question of intergenerational fairness quite explicitly and asks, “Would intergenerational fairness support a further increase in the share of public spending on retirees, at the expense of children and working-age people?”

There are other dangers to future generations in how the NHS operates.  One of these is its pensions system for health workers which, like other public sector schemes, creates pension commitments on the basis that these will be paid by younger and future generations.  As life expectancies increase so does the likely future cost of these pensions and this burden is increasing.  Another example of a surprisingly large burden created for future generations – but unmatched by any resources – is the commitment to pay for the NHS’s medical negligence.  According to the latest Whole of Government Accounts this is now £14 billion and has been rising quite rapidly (by over £2bn a year in recent years so equivalent to almost 2% of NHS annual spending).  Most of these liabilities are for hospital errors around birth and represent a commitment to pay for care for a disabled person for the rest of their life, so the NHS is clearly creating these liabilities for the next generation without providing any funding to cover these costs.

In summary there are three distinct areas where the NHS is in danger of committing serious intergenerational unfairness:

– allocating resources too heavily on the older generation’s physical needs as shown by the projected shift in resources;

– systemically giving inadequate resources to whole areas that affect younger citizens more than the old, such as mental health;

– building up liabilities for future generations to pay such as for pensions and medical negligence.

It’s always been the case that the NHS has been more of a service for the old than the young (just as education is the reverse) but the risk is that it is becoming increasingly a service for the old at the expense of the younger generation.