Charging for the NHS – another dam is to be breached


4:16 pm - April 16th 2013

by Natalie Bennett    


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Last month I was in Tremough, at the University of Exeter Cornwall branch, addressing a public meeting.

The subject of the NHS came up in the questions session, and I spoke about the Green Party’s belief in a publicly owned and publicly run system, and about how our current progression towards rapid privatisation was sending us in the direction of the American healthcare system, where obtaining most healthcare is dependent on your ability to pay (or to sustain insurance).

Having belonged for many years to an email list for mostly freelance copy editors with many American members, I know how worrying about health insurance shapes their lives. I know about horrors such as “drive-through” mastectomies, which I cited.

Some in the audience clearly thought this was not a fair comparison – we’d never see patients have to pay upfront in the NHS.

Then I remembered reading an article in the Financial Times (partial paywall), based on an interview with Malcolm Grant, chair of NHS England.

It notes that Professor Grant said he personally wouldn’t support charging for NHS services. But he is then quoted as going on to say:

It’s not my responsibility to introduce new charging systems but it’s something which a future government will wish to reflect [on], unless the economy has picked up sufficiently, because we can anticipate demand for NHS services rising by about 4 to 5 per cent per annum.

To say this looks like the start of a softening-up process is an understatement… a sense only magnified by today’s Financial Times editorial, which says in part:

There is room for serious debate about what role co-payment should play in healthcare. The NHS must continue to be a needs-blind system… but this does not preclude levying a charge to access the healthcare system. This would not only raise revenue but could serve to curb unnecessary demand.

All of this, as the Mid Staffs foundation trust is “declared bankrupt”, the second trust to meet this fate and the first of the supposed financial flagship foundation trusts to do so and as campaigners battle to see the NHS exempted from the US/EU Free Trade Agreement.

To say that the NHS and its “free at the point of use” principle is under attack is now surely beyond question. I’m also unsurprised that Professor Grant is at the centre of this.

I first encountered him in his still “main” job, the NHS one being only a sideline, as UCL provost. It was at a meeting to discuss the then proposed controversial UCL-sponsored academy secondary school in Camden, just opened after a troubled birth.

Like many others at the meeting, I left enraged by the professor’s arrogant certainty about the wisdom of the academy system, and at the idea that the university knew best about secondary education, rather than experienced teachers and parents. I encountered him next again in his UCL provost role resisting the finally successful Living age campaign for UCL cleaners.

He’s a representative of a special class – what you might call the privatariate – extremely well-rewarded proponents of privatisation who’ve moved seamlessly from serving New Labour’s neoliberalist agenda to lapping up posts promoting the Tory ideology of the small state. Another example is Lord Freud – now Tory Lord and Welfare Minister, formerly Labour “welfare reformer”, rightly targeted by UKUncut last weekend.

No surprise that Professor Grant is a standard bearing in threatening the very foundations of the much-loved NHS principle of “free at the point of use”.

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Natalie Bennett is leader of the Green Party of England and Wales
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Reader comments


You do know that this is how things work in Europe, don’t you?

You know, those systems which perform better than ours…

“publicly owned and publicly run”.

Paid for by me and the wealth generated by the Private Sector.

Brilliant.

The destruction of the NHS goes beyond the UK. The fact that the puppet politicians of tory, lib dem, and new labour are all involved shows how corrupt the political class has become. Many are getting very rich on doing the global 1% dirty work. The free market, privately owned system is now a religion. It is worshipped, and imposed with force if necessary. There will be no alternative, and no decent. You only have to see how the occupy movement has been brutally put down by the US govt. Meanwhile the real crooks and bandits, the bankers are given a free ride for their law breaking and destruction. Obama’s justice man Eric Holder, let the cat out of the bag when he said they can’t prosecute bankers because it might bring down the whole system. So bankers launder billions of drug money, and nothing happens. Yet if you or I take a few drugs we could do 20 years in the growing privatised prison complex.

Milton Freeman’s grandson recently said that democracy may have to be destroyed so that ultra free markets can be imposed. They don’t even pretend they want democracy anymore. And tomorrow they will put their queen in the ground, and no decent will be tolerated.

Democracy is finished. I hope you enjoyed it. Feudalism now awaits.

Private sector does not generate wealth. It steals wealth from the poor and gives to a small elite.

Still, glad you like being a butler serving your masters.

The cost of an average GP appointment is around £50 per patient. At the moment, that cost is paid for entirely out of general taxation.

Consider the elderly lady who has a small problem with haemorrhoids. She has the option of going to buy some ointment at a cost of £3 or going to her GP where she will have her problem examined by a nice young doctor and will be given a free prescription for the cream.

In her position, what would you do? The choice is obvious.

Now consider what she would do if it cost her £10 for the doctor’s appointment? Unless she had any other concerns regarding her symptoms, she may well go to the chemist.

Now consider what she would do if she had to pay the full cost of the appointment herself.

The above illustrates what is wrong, in principle, with a health service that is allegedly “free” at the point of delivery.

Because it is not free at all, it is just not paid for at the point of delivery. And when it is paid for it is, in all likelihood, paid for by someone other than the user.

And what is the opportunity cost of the £50 the old lady has consumed? A care workers salary for a day? Meals on wheels for someone for a week?

And before somebody mentions it, the old lady above is my fiction and, I can tell you, she does not have bowel cancer….

We’ve had a form of co-payment in the NHS since 1949: prescription charges.

I look forward to seeing all these selfish tories get ill and die when they can’t pay for their treatment.

Of course it won’t be the tory elite, but the morons who vote for them. The number of people in the US who are forced into bankruptcy because they can’t pay their health bills is frightening.

But that is what the 1% want. People are to work until they drop. Ill people and old people will be exterminated. And this way they don’t even have to build death camps. Lovely.

@Sally

Do tell, where does the wealth come from to pay for things?

9. George Hallam

“Consider the elderly lady who has a small problem with haemorrhoids. She has the option of going to buy some ointment at a cost of £3 or going to her GP”

Consider a man who has a problem with his bowels. He has the option of doing a self-diagnosis and buying some ointment or tablets at a cost of, say, £3 or he can go to his GP.

Self- diagnosis is fine, if you have a minor problem. But what if it isn’t minor?

10. George Hallam

“And before somebody mentions it, the old lady above is my fiction and, I can tell you, she does not have bowel cancer….”

Which proves conclusively that in your fictional world, a private medical system is better than a publically-funded medical system.

Unfortunately, we have to live in the real world.

11. George Hallam

@Tim J

“We’ve had a form of co-payment in the NHS since 1949: prescription charges.”

Get the history right.

The power to make charges was included in the 1949 NHS Amendment Act, but this was not done until 1952. There were exemptions for people in receipt of National Assistance, War Disability Pension, children under 16 or at school, and venereal disease patients.
Prescription charges are abolished in 1965 and prescriptions remain free until June 1968, when the charges are reintroduced.

“In 1949 there wasn’t much effective medication. Prescription charges were seen mainly as a way of reducing the quantity of medicine pouring down the nation’s throat. But now there is a lot of very effective medication which, when taken, reduces the need for more expensive hospital treatment. So it doesn’t make much sense to discourage poor people from taking their medicine.”
http://www.sochealth.co.uk/national-health-service/access-to-health-care-and-charges/prescription-charges/

This issue is for real. In the FT, dated 15 April 2013:

Health chief suggests NHS may have to charge patients

Malcolm Grant, chairman of NHS England, told us that he thinks a future government will have to consider more widespread user charges in the health service unless the economy picks up.
http://blogs.ft.com/westminster/2013/04/nhs-chief-suggests-charging-patients/

Besides the news report, the FT also has an editorial mildly endorsing what the editorial calls: “co-payment”, but without explainiung how that co-payment might be determined.

13. Churm Rincewind

The Financial Times piece also notes that “…on past trends of growth the NHS will cost the equivalent of one-fifth of GDP in less than ten years…a funding gap of about £20 billion a year if the current funding settlement continues…”

In short, if the economy doesn’t pick up sufficiently the NHS will simply become unaffordable and have to be cut back.

That’s quite a big problem and is, I think, worthy of serious debate now, before the problem becomes a crisis. No wonder Professor Grant raised the point, and I don’t believe that a personal attack is a useful response to his remarks.

George Hallam

You assume that the NHS is actually good at spotting and treating serious conditions in reasonable time, comparison with other countries suggests this may be optimistic. Anyway the old lady is surplus to requirements in the modern NHS, off to Mid – Staffs with her.

This scare-mongering extrapolation is, as the OP suggests, designed to soften us up. After all, what’s the alternative? Put up taxes for those who can afford to pay more? Actually do something about corporate tax avoidance?

16. Churm Rincewind

Oh, and @ George Hallam (11): You report that “In 1949 there wasn’t much effective medication.”

I’m sorry, but this is nonsense. The most effective medication ever introduced (except perhaps from aspirin) is antibiotics, which were widely available by 1949.

17. George Hallam

“You assume that the NHS is actually good at spotting and treating serious conditions in reasonable time”

“Pagar’s” fictional comparison was between a diagnosis by a GP and self-diagnosis.

http://books.google.co.uk/books?id=WocLstyO8LwC&pg=PR15&lpg=PR15&dq=professor-anita-Ghatak&source=bl&ots=5hi7KMerBc&sig=vdJO55UQtVHIX3zCl6lzrwoeeIw&hl=en&sa=X&ei=qJNtUc7tDaTT0QW5uIDQCQ&ved=0CEcQ6AEwBA#v=onepage&q=professor-anita-Ghatak&f=false

http://www.moveon.org/share/72e232/hollywood-legend-ed-asner-has-outraged-republicans?rc=share-4e4670

Watch this. It says it all, and is pissing off the Republicans. They hate the truth.

16

“I’m sorry, but this is nonsense. The most effective medication ever introduced (except perhaps from aspirin) is antibiotics, which were widely available by 1949.”

Absolutely. Even before Aspirin, which is surely a wonder drug, there was vaccination against Smallpox, a killer disease which has become globally extinct. Polio is very close to global extinction because of vaccination. Every winter, I have an anti-flu jab which is usually very effective.

There have been great leaps and bounds in advances in medical treatments during the last 50 years with anti-virals, transplant surgery, treatments for cardiovascular events such as heart attacks and strokes. But note this:

“Between 1990 and 2010 life expectancy in the UK increased by an average of 4.2 years to 79.9 years. But the trend masks worrying declines when matched against other nations with similar levels of health care, it is claimed. In 1990 the UK ranked 10th in a league table of 19 countries showing years of life lost (YLL) per 100,000 members of the population. YLL is a standard method of measuring levels of premature death. Twenty years later Britain had slipped to 14th in the table, with only five countries showing worse figures.
http://www.independent.co.uk/life-style/health-and-families/health-news/uk-falls-behind-europe-for-healthy-life-expectancy-8520199.html

@George Hallam

Sorry what’s the purpose of that link ?

21. Nan Parkinson

Natalie,
Your post makes me very sad. What can we do to stop the privatariate running roughshod over us all?
And who is there to call a halt to the activities of GPs who, although there is a blatant conflict of interest, are going to continue to shepherd patients to the private companies in which they have an interest?

As several have mentioned, many of the European health care systems have copayments. Small charges to see a doctor etc. All of which are capped: some fairly minimal sum per year is the most that can be paid in such charges.

As to the NHS inflation being 4-5% a year. Well, yes. It’s there.

It’s called Baumol’s Cost Disease. It’s simply an inevitable effect of the difference between services and manufacturing.

Average wages in an economy are set by the average productivity in that economy. It’s easier to increase productivity in manufacturing (as it was in farming before that) than in services. Thus services will become more expensive relative to manufactures over time.

This is inevitable: except.

One can try to increase productivity in services. How does one do that? Well, we’ve found (from Baumol’s work again) that market based systems increase productivity better than centrally planned ones.

So, to recap. Yes, the NHS has a higher than national average inflation rate. Because it’s a service. A solution to some, part, all of this problem is to make it a market based system which should increase productivity more than it being a non-market based system which will thus reduce that higher inflation rate.

Note that market based does not mean US style. French, Swedish, Danish, they are all market based to a much greater extent than the NHS is.

But to say that the 4-5% inflation rate is a problem for a market based NHS is nonsense. The market based NHS is a solution to the 4-5% inflation rate.

23. George Hallam

“Oh, and @ George Hallam (11): You report that “In 1949 there wasn’t much effective medication.”

I’m sorry, but this is nonsense. The most effective medication ever introduced (except perhaps from aspirin) is antibiotics, which were widely available by 1949.”

But not so effective that it did any good for George Orwell. This was because he was allergic to the only variety available.

Things have moved on since then. There has been a massive in growth in the pharmaceutical industry over the last sixty years.

You mentioned antibiotics.

“First-Generation antibiotics is penicillin. It has a narrow spectrum of clinical use, but are good for Gram positive bacteria. Some bacteries produces beta-lactamase which inactivates penicillins.

Second generation antibiotics is ampicillin and amoxicillin. They have an extended or broad spectrum of clinical use, and the Gram negative bacteries is more sensitve to 2nd generation.

Third generation (i.e. carbenicillin and ticarcillin) has broader spectrum of use than the second-generation penicillins, and is in use for serious infections.

Fourth generation (i.e. mezlocillin sodium, piperacillin) is even more potent.

The importance of new generations is when bacterias are developing resistance against earlier generations of penicillins.”

http://en.wikipedia.org/wiki/Pharmaceutical_industry

http://www.pedaily.cn/Item.aspx?id=194137

24. Charlieman

@21. Nan Parkinson: “Your post makes me very sad. What can we do to stop the privatariate running roughshod over us all?”

I weep too that few people think such things.

“And who is there to call a halt to the activities of GPs who, although there is a blatant conflict of interest, are going to continue to shepherd patients to the private companies in which they have an interest?”

GPs run as a private business. You know, like since the NHS was invented. The NHS is based on private GPs who spend a lot (most?) of the face to face contact time with patients. If they did not exist, you would be running to the A&E for every ailment.

If you don’t like the way that GPs operate, that’s fine. Government has had nearly fifty years to find something better; if you have a good idea, I welcome it.

Natalie Bennett presents a horror story. It is just a story.

25. Churm Rincewind

@23 George Hallam: Thanks for your thoughtful reply.

However, the fact that medical treatment has moved on during the last fifty years is not evidence that there was no effective medication available in 1949. I still think that this is a daft claim, and what’s even more bonkers is the argument in the article you quote that prescription charges were introduced in order to restrict access to medication which the article also claims were ineffective in the first place.

As for George Orwell, it’s true that he reacted badly to streptomycin. At the time this was costly and relatively hard to come by, and as result its use was strictly rationed by the NHS. Not that this mattered to Orwell, who had no compunction in calling in favours from his wealthy aristocratic chums in order to get privileged access to the drug free from the NHS. These days I think it’s called queue-jumping. Not very fair, not very egalitarian, and perhaps not the best example you could have quoted.

“At the time this was costly and relatively hard to come by, and as result its use was strictly rationed by the NHS. Not that this mattered to Orwell, who had no compunction in calling in favours from his wealthy aristocratic chums in order to get privileged access to the drug free from the NHS. These days I think it’s called queue-jumping. Not very fair, not very egalitarian, and perhaps not the best example you could have quoted.”

That isn’t actually what Orwell did.

He used his own money to buy the drug in the US. He had US book royalties in dollars and that’s what he used.

He did have to get permission to do so under the exchange regulations of the time. Something that I’ve always thought pretty shitty. That you’re not allowed to use your own money as you like. But that’s what the system was.

27. the a&e charge nurse

[26] ‘That you’re not allowed to use your own money as you like’ – as a corollary did you think that it’s pretty shitty when people DON’T get treatment because they can’t afford it, or end being bankrupt due to unpaid medical bills (like in the USA)?

If you want to put buying power at the heart of our health system then at least admit this ‘freedom’ cuts both ways – in other words it may have certain advantages for those with deep pockets while those at the other end of the spectrum will just have to make do with the health service equivalent of the pound store?
http://l2.yimg.com/bt/api/res/1.2/YuIQOiOW7HMp5yjDuDPGWQ–/YXBwaWQ9eW5ld3M7cT04NTt3PTYyOQ–/http://l.yimg.com/os/650/2012/04/12/Poundland-PA-6731842-jpg_163332.jpg

Nan asks: “Your post makes me very sad. What can we do to stop the privatariate running roughshod over us all?”

I think the starting point is to speak up loudly and often. And to stress that this is a failed model – an emperor without clothes who needs to be exposed. Talk to the general public and everyone knows that privatisation results in poorer services, lower pay and profits being taken from public funds, all too often into tax havens, but that general understanding hasn’t got enough attention in the media and the politicians haven’t felt the need to rein in the privatariate – indeed all too often they are the same people.

29. the a&e charge nurse

[28] well said – we all know how things pan out once corporations gain sufficient leverage.

Once upon a time water used to be free, but nowadays execs have received over a billion in dividends (after fleecing Joe Bloggs) – of course execs need their billions but curiously the product seems much the same as it always did
http://www.guardian.co.uk/business/2012/nov/10/water-companies-tax

30. George Hallam

@ “the fact that medical treatment has moved on during the last fifty years is not evidence that there was no effective medication available in 1949.”

Look at the context.

In 1949 there wasn’t much effective medication, that is, compared with today.
..now there is a lot of very effective medication

31. George Hallam

@28 “I think the starting point is to speak up loudly and often. ”

This is what we are doing in Lewisham.

For example see our ‘letter to a Lord’ scheme.

http://www.savelewishamhospital.com/write-letters-to-lords-now/

32. Planeshift

“Now consider what she would do if she had to pay the full cost of the appointment herself.”

(I’m playing devil’s advocate here)

Probably not go. But then the major problem with the UK is that it is too focused on secondary care and dealing with problems a long time after they start. Partly down to the fact we still seperate the social care and health service, a seperation that no longer makes sense but persists because one is free at the point of delivery and one isn’t generally speaking.

The debate on co-payment misses the point entirely. Lets consider how the English system operates:

Co-payment in prescription charges.
Co-payment in non-residential forms of social care for the majority.
Co-payment for residential care, but where means testing and squeezed budget means the state is only effectively paying for non-home owners.
Secondary care in hospitals free at the point of delivery
“Medical” care (drugs, use of expensive technology etc) effectively free at the point of delivery ( a prescription charge when the drugs costs thousands is neglible).

Now lets examine where the pressure on costs is going to come from:

(1) Elderly population with chronic conditions needing expensive and frequent hospital care before ending up in residential care.
(2) New drugs and medical technologies that effectively costs thousands for just one course of treatment. As companies develop targeted drugs (stuff that only works on people with certain gene codes) and more treatments for rare diseases (recent breakthroughs in cysic fybrosis for example) this cost will only grow and before long treatments for one person could cost in the hundreds of thousands.We already have an issue with patients with rare diseases being denied access to medicines on grounds of (opportunity) cost.

Lets also consider that primary care and non-residential social care has been under-invested in for years. Lets also consider that the main problem – particularly with the later – is also lack of take up because some people percieve it to be unnecesssary and it costs them money.

So why the hell are we only talking about co-payment in the areas where we need more of it?

Isn’t the most sensible solution here – at least if we accept no significant new injection of cash – to reverse the situation?

By this I mean what we need to do is extend free at the point of delivery to those services that keep people out of hospital and out of residential care for longer. Introduce free prescriptions, keep GPs appointments free and eliminate charges for non-residential care.

Then to cover the cost of medical technology we introduce co-payment for hospital care, expensive drugs and technology. Now obviously these are expensive and most people won’t have the thousands of pounds lying around to do this. So we then create insurance markets to cover this – based on the european system rather than the US system to ensure the entire population has cover. That way we solve the problem of the NHS having to deny patients with rare diseases access to expensive course of drugs. It is a problem that an insurance market is almost designed for.

We also solve the problem of un-necessary attendence at A+E. Going to A+E will get you hit with a bill (albeit covered by insurance), going to your GP is a zero cost. (we keep out of hours GPs free). For planned surgery that requires hospital stay, a more market system gets created and drives standards up (We ensure that the tarrif system is the same for each hospital to prevent individuals/companies choosing cheap but unsafe units).

Obviously back of a fag packet stuff above. Thoughts?

(again, devils advocate here)

33. George Hallam

“we then create insurance markets to cover this .. to ensure the entire population has cover.”

Bad idea.

The underlying problem is inequality. The poor (most people) won’t be able to aford full insurance cover.

34. Planeshift

European style not american.

i.e. everyone gets covered in some way.

The NHS will always be free at the point of use, apart from a few loons on the extreme right wing fringe of politics, no-one serious wants to introduce an insurance based system into the NHS, the public outcry would be massive, it would be political suicide for any party to do such a thing. If this was a serious risk, I would expect the Labour Party to be making a big thing out of it.

36. Derek Hattons Tailor

@ 2 “Paid for by me and the wealth generated by the Private Sector”.

What wealth ? The entire banking industry and therefore the entire private sector is being bankrolled by taxpayers money. My kids will be paying off the bankers debts and they haven’t even left school yet.
Gotta love these people who think that because they work in the private sector and pay a few grand a year in tax they are somehow paying for the entire public sector. If you stopped paying tax tomorrow, no one would even notice. And what about the huge swathes of the “private sector” that are wholly or largely dependent on government contracts – are they “generating wealth” too ?

Seriously, help me out here. Where does the money that Governments spend come from? If it isn’t from tax receipts (yes, and borrowing and investment income and licensing), then where?

38. Charlieman

7. Stuart: “Seriously, help me out here. Where does the money that Governments spend come from?”

Magic monkeys. If you don’t believe in MM you are a bit daft.

39. Planeshift

“The NHS will always be free at the point of use, apart from a few loons on the extreme right wing fringe of politics, no-one serious wants to introduce an insurance based system into the NHS, the public outcry would be massive”

Can’t quite remember the public outcry over dental charges – which are significant. Plus the public outcry over elderly people selling their home to pay for residential care costs – something the public still thinks is the NHS rather than local authorities – has not cost a single politician their jobs. Meaning it is less important than expenses fiddling.


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