Sunday, 4 September 2011

A thought experiment on the future of health care

Baroness Williams is arguing that a major flaw of the health bill is that it removes the obligation of the health secretary to provide a comprehensive health service ( ). Coupled with the decision to lift the cap on the amount of private work hospitals are allowed to do, she feels that we will achieve a health system in which private patients will dominate the agenda, and free health care will be truncated and relegated. She argues that this follows the example of the American health service, which is notoriously inequitable, and represents a backwards step for the UK.

Predicting the behaviour of individuals in times of ill-health can be tricky - I have no specific data on this matter, but I can call upon a wealth of personal experience which tells me that there is no such thing as odd behaviour when it come to ill-health: I have met a man in his 40s who spent three months lying in bed, unable to get up, before he sought medical help, and I have met a young woman who insisted on doing her own rectal exam in A and E, so that I wouldn’t have to. There is nowt as queer as folk.

What however is clear is that health care is important to people. Wealthy countries around the world spend billions on their health care. Per person, the expenditure on health care in the USA is two and a half times the European average, and yet 50 million Americans still have no health care cover, and the cost of medical treatment is the biggest single cause of bankruptcy. Overall the level of expenditure means that a lot of wealthy Americans are probably spending a lot of money on health care cover that they do not need.

We live in a country where the concept of not being able to access medical care, and spending all of our money on medical bills is unthinkable. We live in a country which spends less money per capita that any other major Western country, but still achieves similar health outcomes. The NHS is one of the most efficient health care systems in world, because of its economies of scale, and because of its lower administration costs: in countries where there are competing health care providers and insurers, they must each duplicate the administrative set-up themselves, rather than having the one set-up we have.

The price we pay for the kind of access that we have is that the people who contribute the most money to the NHS pot, are the people who tend to use it the least: there is a clear correlation between health and affluence. The way we fund our health service is a value judgement that we as a country made in 1946, and one to which many still adhere. But not everyone agrees.

If you are having trouble imagining how the NHS will change after the Health Bill, think about how you access dental care today. The concept of NHS dental care is often illusory, and where it does exist the level of care can be two tiered. I think dentistry serves as a really useful microcosm of how the NHS could change.

Given wider availability of private services, and lengthening waiting times for NHS services, an increasing number of people will take out private health cover, and no doubt businesses will increasingly offer health cover as an employment perk. Hospitals will compete for the higher tariffs they can charge to private patients, enticing them with better hotel services, fast access, preferential scheduling and a more personalised service. The NHS patients will wait longer, in poorer accommodation, and experience cancellations more frequently. As the level of service and experience (if not necessarily quality) plummets, more people will find the money to go private, perhaps risking bankruptcy (remember how much we value good health care). There will be an increasing clammer from those with health cover for tax rebates to reimburse them for the contributions they make to the NHS, and so the spiral starts.

Of course, I may be wrong, and the Health Bill may transform the quality and level of medical care in the NHS, but my mind cannot reach such lofty imaginative heights at the moment.


  1. A year ago at the trust AGM the chief executive was asked about private patients. He pointed out that the trust private income was 1% and that was pathology for local private providers; he said that there wasn't enough capacity at the hospital for private patients.

    So now I find that the trust is investigating taking private patients. What has happened? Well, a cut of 1.5% to the tariff helps focus minds - finance directors assume (it may not be true) that private patients will bring in much needed income. And the PCT restricting referrals makes the trust nervous - they are no longer guaranteed an income stream. Lifting the private patient income cap is the final nudge to get the policy going.

    The trust built two new wards two years ago. Single rooms, en suite. Clean, bright and modern. Lovely. My neighbour died in one in January - she was very ill and the single room provided the privacy and space for her family to be with her. This is why the rooms were provided.

    You can guarantee that private patients will not want to be on a ward or bay. They are paying, they will want a private room. It is a sure bet that those two new wards will be the private wing.

    The hospital was founded in 1839 as a workhouse, and in 1848 an infirmary was built: a hospital for the poor. A century later the rich and poor used the same hospital, free at the point of use. Now we are winding back the clock, where the NHS will be for the poor and the rich will pay to jump the queue. Sad days.

  2. Thanks for your comment Richard. Tomorrow and Wed is the last chance to lobby your MP before the Health Bill moves to the House of Lords. I will be highlighting my concerns to my MP once again - change is happening, and doctors need to ensure that they remain engaged in the process, from beginning to end.