I blog partly because I like to write, partly because I’m arrogant enough to believe people will read what I write and like it, and partly for interactivity. I’m not a professional writer (no cheap cracks please…), so I like to play around with writing and words without being too constrained by any conventions of particular media. This post is a bit experimental, and I’m focussing on the interactivity aspect of blogging. Part of the reason that The Sharpener was set up was to create a forum for proper debate between lots of people who disagree, whether it stems from party political tribalism, from genuinely differing axioms / prejudices / Bayesian priors / fundamental views, or from different logical paths stemming from those priors. In view of that, I thought I’d set out my views on healthcare in the UK, a subject which both interests me ideologically and academically, and which affects me personally, as my wife works deep within the bowels of the NHS. What I want you to do is to read it, disagree, and tell me why you think I’m wrong. Then, I’ll tell you why you’re mistaken.
First, though, a description of the current system, and why it doesn’t work. The NHS, I believe, is unique in that it is a state-run system that both pays for and also, critically, provides healthcare services. Most other Western nations that provide some form of healthcare for their citizens just pay for it – they don’t provide it. Historically, the NHS was put together just after the second world war, in 1948. Prior to this, healthcare in the UK was privately provided. There is some dispute over how comprehensive and effective this all was, and it tends to be overplayed and highlighted by champions of the NHS on the left that anyone poor couldn’t get healthcare and was left to die, on the street, of some terrible, but easily cured affliction. People like me point to the large amounts of charity, the fact that consultants often gave their time for free to those who couldn’t afford it, the building of hospitals purely to provide free healthcare to those who couldn’t afford it (like the Royal Free), and so on. As with all political statistickery, the truth is probably somewhere in between. It is probably fair to say that provision was patchy, and that quality varied. That said, you could make the same statement today. Provision is now rationed, rather than patchy, but if you’ve got 3 months to live and you’re at the end of a 6 month waiting list, the difference is almost completely academic.
The founding principles of the NHS were that it should be:
i) free at the point of delivery,
ii) funded from general taxation,
iii) available to all, regardless of status (including visitors to the country, incidentally).
and these principles have largely held, although charges were introduced for prescriptions and glasses in the 50’s, the dental service has been de facto privatised, and the provision of optician’s services has been actually privatised, over time. The third principle has also been watered down slightly, and now you have to be a citizen to qualify for free healthcare, or your country of origin has to have a reciprocal agreement with the UK for tourists.
So, what’s wrong with all this? It all sounds great, doesn’t it? Healthcare is free, available to all, and paid for by everyone in society. It’s a kind of social insurance policy. Wonderful. Except that it doesn’t really work that well. Like all things that are ‘free’, healthcare in the UK is heavily in demand, which means that the only sensible thing the provider with a fixed budget can do is to limit supply by rationing. This is achieved in all kinds of ways, but none of them are good for patients – restriction procedures by waiting list, restricting funding for certain procedures, restricting funding for expensive drugs, etc. I don’t particularly want to go through a list of measures for the overall quality of the NHS and give it a good kicking in the post, but feel free to raise them in the comments, and we’ll have a knockabout debate about it. It also isn’t good for the staff who work within it, although this is partly an argument against the strength of the unions in a monopoly provider. Broadly, compensation bears very little relation to actual performance, so there is little incentive to excel beyond that oft-quoted, and rapidly disappearing, phenomenon of public-sector pride and professionalism.
Bizarrely, and somewhat irritatingly to someone of my political persuasion, I think New Labour are making some decent steps on the long road of reform. Introducing, or rather, expanding, the purchasing of healthcare from the private sector, is necessary to introduce competition, to shake up established bureaucracy, and to make the political climate favourable to independent provision. I’m amazed that it is a Labour government who are doing it, but I guess only Nixon could go to China, and only Tony could start to seriously dismantle the NHS. Let’s face it – we can’t afford to pay for universal healthcare for all. We’re all living longer, getting sicker, and getting more demanding in terms of our lifestyles. We have got to the point where Viagra, IVF, and even cosmetic surgery are available on the NHS. This is, frankly, ridiculous.
Where I would like to get to is a system where the state pays for a minimal safety net level of healthcare, which is completely provided by the private sector. The rest should be covered either by direct payment, or by health insurance, but universal safety net coverage would be available to all from general taxation. I think this retains the best intentions of the founding principles of the NHS, while acknowledging the failings of a centralised, bureaucratised system that will run out of funding at some point in the near, but not-so-near, future.
Over to you, commenters – let’s flesh out a healthcare policy. Why, where and how am I wrong?