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Editorial Monday 15 April 2013: Accounting for Chairman Mal's incursion on the NHS future funding debate

One of the major philosophical aims of the NHS reforms newly-born to a proud albeit defenestrated Anderew Lansley (saviour, liberator) was to liberate the NHS from day-to-day political interference by passing the operational power to the national commissioning board, NHS England.

His successor, Jeremy 'Bellflinger' Hunt, may be wondering if the non-interference deal should have gone both ways, in the light of comments to the Financial Times by NHS England's Chairman Mal, Professor Malcolm Grant.

Chairman Mal told FT public policy editor Sarah Neville that "it’s not my responsibility to introduce new charging systems but it’s something which a future government will wish to reflect [on], unless the economy has picked up sufficiently, because we can anticipate demand for NHS services rising by about 4 to 5 per cent per annum”.

Mmmm. Remind me whether there's a spending review of some kind being planned?

The FT piece reports that Chairman Mal 'indicated he would not support such a move, describing a free-at-the-point-of-use health service as “the defining value of the NHS because it’s not just a health system; it’s a social support system”.'

Getting into the realm of how the NHS is funded is an interesting choice for the chair of NHS England. It gets into the territory of national and international macro-economics - and it's intensely political.

Tax funding for the vast majority of NHS services has the merit of being efficient, and of not creating incentives to provide unnecessary healthcare.

Making care free at the point of use, without direct user co-payment (save for prescriptions and dentistry), has the merit of likewise being administratively efficient and of not deterring those on low incomes from seeking care early, when it should be cheaper.

Furthermore, the current funding system seems to be popular with the general public, to judge by the new findings from the Kings Fund / Ipsos MORI research.

The art of the possible
Otto von Bismarck said, "politics is the art of the possible". He knew a fair bit about politics and power, did Otto.

Otto has a lesson for Chairman Mal here.

Otto's lesson is not a lesson about macro-economic clairvoyance. It is instead the point that, as the iridescent Professor John Appleby of the Kings Fund has often pointed out, what we choose to spend on NHS healthcare is a political decision.

Chairman Mal is a political figure, but not one elected by taxpayers.

Clearly, he remains entitled to his opinion.

Equally clearly, he needs to be mindful that as chair of NHS England, his role is governance rather than executive - and his opinions should be expressed accordingly.

It was, after all, at his pre-confirmation hearing with the Commons Health Select Committee that Chairman Mal said "there is a big difference between interference and accountability".

He also told the committee that "it is going to be messy as we go through a very complex transitional programme. What we hope for is a sharper, more transparent and more accountable system at the end".


Chairman Mal also said that "it’s absolutely critical to be clear about the difference between governance and management. David Nicholson will have responsibility for managing the Board. The board will have responsibility for governing".

It is disputed wither it was von Bismarck's fellow-19th century powerbrokers Talleyrand or Metternich who, on hearing of a person's demise, said "I wonder what he meant by that?"

Chairman Mal should be mindful that Kremlinology of NHS leaders is a well-established tradition, and that many will be asking that same question of him over his intervention on the pointed politics of future funding of the NHS.