Democracy, we are all told and mostly believe, is “the least bad form of government.” Sadly and ironically that belief is hardest to sustain during elections when we are deluged in slogans (“strong and stable”) and wild promises, long term issues are largely ignored, and complex issues are simplified to the point where meaning is lost. Health is both a long term and a complex issue. In Britain the independent Institute of Fiscal Studies is one body that tries to inject some reality into the elections, and it has said that neither of the UK’s two main political parties has presented an “honest set of choices.” I was thus disappointed by the institute’s spokesman speaking on the radio about health.

He pointed out that expenditure on the NHS has increased by about 4% a year for years and implied that that was the amount needed to sustain the NHS. All parties are promising an increase, but the biggest promised increase (from Labour) is just over 2%. The British people, he concluded, had a stark choice of agreeing to a 4% increase (with the implications of increased taxes) or accepting that the NHS could offer less than now.

He did mention that the causes of the need for an increased spend were ageing of the population, increasing demand, and health professionals being able to do more, but he didn’t give any idea of relative importance. In fact the main driver is health professionals being able to do more. Nor did he mention that much of that “more” offers little value, fending off death by weeks, undertaking heroic operations, and keeping people alive in a state that many might regard as inferior to death. Even if there is value to the individuals, which is debatable, it doesn’t offer value to society when education, housing, benefits, the environment, security, the arts, infrastructure investment, and much else have to be raided to pay for healthcare.

Nor did he spell out that a 4% increase year on year, which includes, like compound interest, a 4% increase on the 4% increase of the previous years, rapidly becomes unsustainable.

But his biggest failure was not even to mention the third way forward—to use the resources very differently. I don’t mean the marginal gains that come from trying to do the same more efficiently, but major changes—more nurses and other community health workers; fewer doctors (particularly specialists); greater investment in primary, community, and social care; less investment in hospitals; better use of information technology; radical pruning of low value interventions (as judged by patients and citizens); encouragement of self-care; much better end of life care; more creating of health and less healthcare; and a boosting of public health. With such radical changes we could produce both much more value from the expenditure on health and a sustainable system.

I can see, however, that the Institute of Fiscal Studies may not mention such an alternative because they see it as politically unachievable. The weakness of democratic government may mean that they are right, but simple mathematics means we will have to come to such changes eventually, perhaps too late to save the NHS.

Richard Smith was the editor of The BMJ until 2004.

Competing interests: None declared.