How do we fix the NHS?

Sometimes an ongoing news event is like watching an earthquake. The story veers in one direction, then another, all the while wreaking damage. It’s not until the shaking stops that you can see the new landscape and give a considered opinion. The story in this case is that of Ashya King, the five year old boy with a brain tumour. When the story first broke, the parents were being criticised for being irresponsible by running off out of the country with him. Then more information comes to light and what do you know; now it’s the turn of the police for some criticism. A little more news and now the hospital are getting criticised. As this article is being published, Ashya is in Prague for the Proton Beam therapy his parents hope will help him recover. The thing is though, even if he makes a full recovery, there will be no happy ending to this story.

This case however has done something which is unlikely to be diminished by subsequent news, which is to cast a bright light on the poor state of advanced cancer care in this country, and by association, the NHS as a whole. This is nothing that hasn’t been said a million times before. The difference is that usually when someone is denied a potentially lifesaving treatment on the NHS, it makes page five of the papers and perhaps a thirty second spot on the news, but only if the person makes a big enough fuss. What Ashya and his parents have done is put the issue centre stage, on the 24-hour rolling news and the front pages of the papers. Perhaps then, we can now have the conversation that has been needed for many decades. The NHS no longer works and should be scrapped. Knowing that practically free healthcare is available any time day or night is quite a comfort, and perhaps this is why nobody, certainly not the politicians we elect will countenance a debate on the long-term future of healthcare in the UK.

Since its foundation in 1948, the NHS has been a broken system operating on a kind of giant Ponzi scheme where the new taxpayers funded the treatment of the elderly. When the NHS first began offering treatment, the range of treatment options was limited while the life expectancy for a man was 65.8 years. For a woman it was a fair bit longer at 70.1 years. Skip forwards to today and we find a figure of 79.5 years for men and 82.5 years for women. Putting this into a little context helps to drive home the issue.

  • People are living longer than ever before
  • Later life illnesses such are dementia are becoming more prevalent as a result of people living longer. Managing these conditions is expensive
  • People are living longer after they stop contributing to direct taxation revenues
  • The range of treatable illnesses is expanding and are ever more expensive to treat
  • The population as a whole is aging. Salaries for those entering work are lower, again resulting in lower tax receipts

So far, so good. While it doesn’t make for particularly pleasant reading, there’s nothing especially controversial about the above assessment. So let’s set the Cat amongst the Pigeons and make three suggestions for what to do with the NHS.

Option 1: Do Nothing

This is the non-option. As it stands, a person earning £30,000 per year will contribute £1230 per year to healthcare through their taxes. If nothing is done to acknowledge the realities of the current situation then this amount will need to increase. Ultimately the UK would become a healthcare system with a government on the side. At the same time, the increased spending on healthcare would not result in an improvement in standards, merely maintain the status quo. You can find out how much of your tax is spent on healthcare using the HMRC Tax Calculator.

Option 2: Fix the NHS

This option could also be titled “The economics of healthcare”. It involves taking a list of the services that the NHS offers and squaring that against the healthcare budget made available to the NHS. This would involve difficult and painful choices. For instance, if you have a heart attack, then the NHS will stabilise you, but not offer corrective surgery. Maternity services would be abolished except for in emergency cases. In short, the NHS would be there to stop people dying, but not necessarily to make them healthy. The benefit of this option is that the NHS is now sustainable over the long-term and it can still provide a public service. Compared to the current system, this would be an improvement since you would know what treatments are available, regardless of where you are in the country, rather than having to play the postcode lottery. Additionally, within the set budget, the range of treatments that can be offered will increase as the cost of providing these treatments falls.

This is a good time for private medical insurance to make an entry. The current full-service policies that are offered direct to individuals and through many employers could be supplemented by NHS top-up policies. One problem though, how do the poorest in society pay for these policies? If the government funds them then we’re back to option 1, but it’s even less efficient. The alternative is to say “Tough Luck”, but a three-tier health system isn’t really a vote winner, no matter how well it works. It is sage to conclude then, that over the long-term, the NHS is broken beyond repair – The numbers no longer add up and there is too much baggage, both physical and emotional. This brings us to our last option.

Option 3: Scrap the NHS and replace it

This is by far the most difficult option, how do you scrap a system held dear by millions and replace it with a healthcare system fit for the 21st century. Importantly, everybody must still be able to access it and it should be relatively free at the point of use. This would suggest that some form of insurance scheme will be needed. The universal access requirement would suggest that the insurance system would need to be government supported, like national insurance, but not another way of saying “Additional Income Tax”. How about this then? Everybody must have one for of health insurance or another. Children are covered by their guardian’s policy, but adults must buy their policies. People will have a choice where they buy their policies, either on the open market, at the market price, or at a fixed rate from the government insurer. The government insurer will use the funds in the same way as a commercial insurer – Investing them to make an additional return. Those receiving a pension, benefits, or paying tax will automatically be charged for a government insurance policy unless they choose to buy a private one. Tourists will need to show proof of medical insurance on entry. Those who cannot be automatically insured will be compelled by law to buy a policy.

Now that the healthcare system is being properly funded, we can sort out the delivery of treatment. In the UK we have a system of horizontally stratified healthcare with GP’s on the front line, followed by A&E and full hospital treatment. Why not turn that thinking on its head though. If you need an eye test then you don’t go to see your doctor, you go to an optician, any optician, and for roughly the same price, get an eye test. Dental care should work in the same way, yet it is a reminded of the fact that the NHS is broken. In a vertical model, clinics with a particular speciality take over from GPs and basic hospital outpatient care. A&E still exists, as does complex outpatient, and inpatient care in hospitals. The clinics and hospitals are private and are set up where the demand exists. Since long waiting lists signify missed business opportunities, this should increase the level of access to healthcare. A small charge is made for each new appointment which covers some of the cost, with the new insurance system picking up the remainder of the cost.

Like the large private health insurers, the government would be able to open private hospitals through its insurance scheme and compete for patients. In addition, it would probably need to provide some treatment services which are in the national interest such as isolation treatment for the highly infectious diseases such as Ebola. This model also means that bad treatment is punished directly. If a hospital gets a reputation for being poorly run, then patients can simply choose to take their treatment elsewhere. Finally because the treatment is funded by the insurer at a national rather than local level, it doesn’t matter where in the country you are, you are still able to access the same level of healthcare.

Given that there is no political will for wholesale reform of the NHS, it’s likely that at some point, economics will force us into an unhappy compromise position somewhere between doing noting and scrapping the NHS. Indeed we are seeing this already in the closure and downgrading of hospital services across the country. If and when this happens, nobody wins and the pain it causes will outweigh anything that would come from an orderly transition. How this issue is likely to end is still unclear. However, what Ashya’s case has brought to the fore is that things most certainly need to change, down to the doctors who allegedly threatened his parents with a court order if they tried removing him from the hospital’s care. Such behaviour can never be acceptable. If such behaviour is commonplace then the NHS is in an even worse state than previously imagined. The call to everybody has to be not to tolerate it, but to acknowledge the reality of the situation and demand change.


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