Tuesday, February 08, 2005

More on the NHS

In my previous post on the NHS I didn't propose anything positive of my own. My point in my previous post was to question the conclusions that the authors of the Reform Report arrive at: that a greater private sector involvement in cancer care would resolve the problems that cancer care faces in the UK: bureaucracy, lack of staff and lack of facilities. In this post I want to make a few remarks about funding the NHS.

Last night's Dispatches programme on Channel 4 was about the funding of the NHS. The presenter made the pretty sound case that the current funding increases for the service cannot credibly be sustained beyond 2008 and that costs are sure to rise, both because we'll have to pay back for PFI projects at high costs, because the costs of treatments are rising (I know that my own rather positive experience with NHS care probably set the country back at least £50,000) and because an ageing population will require more care. The presenter's suggestion was one that I totally support: that, given the political liability of tax increases, and if huge waiting lists are to be avoided, we'll have to move to a system of partial funding through compulsory private health insurance (paid for either by individuals or by employers) for the better off and universal, comprehensive and free-at-source care for the less well-off.

This is the system that's used across Europe, for example in France. And the French health service is marvellous. Still, the system of incentives that insurance would produce would have to be managed very carefully.

Legitimacy: First, I take it that higher income earners would have to be presented with some reason for taking on the extra burden of health insurance. Some set of incentives would have to be provided in order to make insurance worthwhile, assuming both that their taxes didn't fall and that the basic NHS care was still comprehensive. A very fine line would have to be struck. I fully support the idea that we should look at things like smaller ward sizes and, in some circumstances, faster turn-arounds for those who have assumed the costs of private insurance. Otherwise people might quite justifiably announce that they are being taxed twice for the same service.

Quality of basic provision: We'd have to be very careful, however, that we didn't head down the road the Ireland has taken: low quality basic provision, high personal costs for GP visits and costly insurance in order to be treated at a standard that's roughly equivalent to some of the services that the NHS provides now. There are unfortunate consequences at each stage of this system. The high GP costs mean that people might not present early with illnesses, meaning that they will receive less effective treatment at higher costs. The low quality basic provision is an injustice: healthcare should not be distributed based on ability to pay. And those who pay insurance should feel pretty resentful that they are not likely to see much of a return on their investment (beyond being a bit better off, in health terms, than their poorer neighbours.

I'm not sure how these pitfalls are to be avoided. I suppose the secret is that, provided the basic provision was sound, and there was real competition in the health insurance market, insurance companies might be provided with good reasons to extend a reasonable quality of care to their customers. But that would have to be achieved with a simultaneous reduction in insurance premiums, so that sufficient numbers could afford it.

What is certain is that the NHS, as is, will not last. As the presenter of Dispatches said, we have until 2008 to make up our minds. No debate on the issue means that we can expect bad decisions. Any bets?

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