Don't scrap the NHS, but do reform it radically, and that includes charging

A starting point would be charges to walking-wounded who appear in Casualty at the weekend with injuries from drunkenness, brawling and other anti-social behaviour

by Robin Mitchinson on 27 August 2013 10:24

My experience of the NHS compels me to think more kindly of it than do many of its critics. In 1948, shortly after the NHS began, my elder brother was diagnosed with TB/ meningitis. If the NHS had started just a while later he would have died. As it was, he spent two years in hospital and was one of the first patients to be treated with streptomycin.

He was also a cripple from birth as a result of a congenital dislocated hip (for which under private medicine he would not have been insured as a preexisting condition). So he was a lifetime patient of the NHS. As a successful businessman, he also paid his dues.

In those early days the NHS was regarded as a wonder of the world, which it was. But that was then and this is now. Society has changed out of all recognition in the past 65 years, and social attitudes have changed with it. We now have an entitlement culture in which services are regarded as a right rather than a boon.

One manifestation of this is that the NHS has been taking a lot of flak in recent years, both from people and press and from grandstanding politicians. How justified is it? ‘Not very’ is my reply.

The Red Tops are constantly accusing it of being run by too many fat-cats in suits. Not true. Only 2.8 percent of the staff establishment is classified as ‘management’.

They also say that it costs too much, and yet we spend £300 per person per year less on health care than the European average. The cost to the nation is just over 6 percent of GDP. In Germany it is 10 percent. France spends 25 percent more than Britain.

A recent independent survey comparing the  British experience with Australia, Canada, New Zealand The Netherlands, and the US has shown an average patient-satisfaction rating of over 80 percent. The NHS came second overall. It fell down in one major area – cleanliness, where it came it sixth, a consequence of ‘lowest tender’ privatization, perhaps.

That we get many complaints and a few major scandals must be set against the fact that it treats 1 million patients every 36 hours. In a perverse sense, the fact that scandals are of such rarity that they make the front page for days is a success measure.

And yet...

Things cannot go on the way they are. God knows how many ‘reforms’ have been started, going all the way back to the ‘prescription charges’ row that split the Labour Party. The truth that politicians do not have the moral courage to face is that the NHS has two basic structural faults that will not respond to minor surgery.

The first is its founding principle of free delivery at the point of service, regardless of ability to pay.

It is simple economics that if you provide a free good, the demand will be insatiable, inexhaustible, and ultimately unaffordable. This is precisely the NHS predicament. Over the years, science has provided exponential improvements in health care, but this involves ever-more expensive technology, treatment and drugs.

It has also played its part in extending average lifespan to around 80, almost a doubling in a century. This has been accompanied by higher expectations and an entitlement-culture that leads people to seeing the doctor for the most trivial reasons.

The second is that the NHS is simply too big. It is almost impossible to manage an organization that employs 1.4 million staff, especially when officials and Ministers in Whitehall insist on micro-managing from the centre. Only Indian Railways and Wal-Mart are this size.

Without fundamental change, the NHS will collapse under the weight of its own contradictions. The free-good philosophy must be abandoned and charges levied for certain categories of patient and treatment.

We hear much about the overburdening of A&E departments. A starting point would be charges to walking-wounded who appear in Casualty at the weekend with injuries from drunkenness, brawling and other anti-social behaviour. The outcome might be fewer patients and higher revenue.

All patients with a family income of £24,000 should be required to make a contribution to their treatment, beginning with a fee for each consultation. This might reduce time-wasting for trivial matters, cut waiting times, and do away with the hated appointments-ritual. In return, GPs would be expected to restore weekend surgery hours.

But changes of this kind are simply nibbling around the edges. The NHS can’t be ‘reformed’; it must be reconstructed. How?

The German system has its attractions. Health care is the responsibility of the Lander together with mostly not-for-profit independent hospitals and private practitioners. The Federal Government is a regulatory body and funding source but has no management role.

The budget is 72 percent from taxes and 23 percent from private contributions. This creates a system that has a degree of democratic accountability and transparency, to which patients must make a financial contribution, and with a bottom-upwards management philosophy in which decisions are made at the lowest appropriate level.

This is well suited to a Federal system; could something similar work in the UK? One solution might be to revert to the basic structure pre-1974, when hospitals and clinical services were the responsibility of Regional Health Authorities, with community health being run by local authorities. But it was frustrated and restricted by the dead hand of Whitehall.

There would need to be substantial differences. The Ministry of Health should play the same role as the Federal Government in Germany. The RHA should have some democratic presence. In particular, the head of service should be elected, on a similar basis as the new Police Authorities. The prospect of being turfed-out by the voters at the end of 4 years would concentrate the mind considerably.

It should have its own taxation powers, so that voters could see exactly how much of taxpayers’ money was being spent and where. This is well-nigh impossible under the present regime. (The overall cost of the NHS is currently £109 billion, which by my reckoning is about £1,500 per person). On the basis of ‘he who pays the piper’,  it would also severely limit the ability of Whitehall to put its oar in.

So there it is, Jeremy Hunt. Now get on with it!

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