Sunday, 16 October 2016

Could private top-up insurance help fund the NHS?

This article first appeared in the BMJ

Current tax revenues cannot maintain healthcare standards, writes Christopher Smallwood, but David Wrigley worries that introducing inequity sounds the death knell of a service free for all who need it

Yes—Christopher Smallwood

It is hardly controversial to suggest that standards of healthcare in the NHS are declining. A stream of recent reports has shown the strain the NHS is under, drawing attention to a near universal failure to meet the target of four hours’ waiting time in emergency departments,1 the longest waiting times for operations since 2007, and unprecedented staff shortages. 
The principal cause of this lamentable state of affairs is unquestionably underfinancing of the system. In 2012-13, few trusts were in deficit but by 2015-16 the proportion had reached 85%.2 As the King’s Fund has said, we are “facing a health system buckling under the strain of huge financial pressures.”2
Current problems are set to intensify at an alarming rate. The budget for NHS England is planned to rise by 1.4% next year, then by 0.4% and 0.7% in the following two years, compared with an expected rise in demand and cost pressures of between 4% and 5% a year.3

Muddling through

If we try to go on “muddling through,” a steady erosion of standards is inescapable. Trusts under ferocious pressure to balance the books leave vacancies unfilled, cut the ratio of staff to patients, slash capital spending, defer operations, increase waiting times, cut training, and restrict the treatments they are prepared to offer.
The only hope of reversing this process is properly to debate how to bring more money into the NHS. The NHS will not be adequately financed as long as it relies exclusively on tax revenues. Given budgetary constraints, it is inconceivable that the government will approve NHS budgets rising more rapidly than gross domestic product to match rising demand.
The choice is stark: either we find new sources of finance to supplement tax revenues or we accept the prospect of declining standards for years ahead.

French model

Lessons can be learnt from some other European countries that provide excellent healthcare and are financed differently from our system. If we moved towards the French model, for example, mainstream healthcare could continue to be mainly financed from public funds, but the proportion of treatment costs covered would vary depending on the service provided.4 Treatment for catastrophic events would be paid for entirely by the state, with more minor treatments requiring a contribution from individuals. People on benefits would be exempt from such charges so that everyone could receive the care they needed.
The government could negotiate with insurance companies the premiums chargeable to provide cover for this menu of charges, as in Switzerland and the Netherlands, and also for the treatments which the NHS is likely to withdraw from as the financial squeeze continues. Without such a scheme, poorer people may lose access to these treatments.

Far lower premiums

A French style scheme would make top-up insurance readily affordable for most people. The premiums would be far lower than for private insurance at present because the bulk of costs would remain covered by the state.
The French experience is that people opt for top-up insurance in large numbers—95.5% of people have it and the rest have their healthcare paid for from social funds5—so it is not easy to describe this as a two tier service. Over time, it is possible to envisage that a quarter of healthcare in the UK would be paid for from these supplementary funds, as it is in France, enabling us once again to deliver international standards.
People on low incomes would be treated for free, with better-off people making contributions well within their means. We’re rich enough to drop the “free at the point of use” principle for the pragmatic “no one should be denied the healthcare they need for financial reasons.” How else can we reverse the decline in standards that now looks inevitable?

No—David Wrigley

The NHS is going through one of the toughest periods of its life.6 Every day we hear of general practices closing,7hospitals at full capacity,8 patients waiting in pain in emergency department corridors, ambulances queuing up with patients outside hospitals, and a social care system cut to the bone.
Politicians, commentators, and think tanks often say that we need a serious conversation about NHS funding.9 This usually means, “Let’s start making patients pay.” And because of the huge pressures the NHS is under some of them think that soon this will happen10: private companies will offer “fee-for-service” appointments or care, and private insurance companies will help write new “NHS policies” to give patients access to their GP or to pay for some operations or procedures.
Any appointments above a threshold, or more complex procedures, would be funded by patients “topping up.” This is common in the United States, which has one of the best healthcare systems—if you can afford it—but also some of the most iniquitous healthcare in the world.

Envy of the world

That is why the model of the NHS from 1948 onwards has been the envy of the world. It is paid for from general taxation, free at the point of use, and available to all no matter what your background, bank balance, or location in the UK. 
We must ask why we are in such a dire financial situation when in 2010 the NHS had the highest ever satisfaction rating and shortest ever waiting times.11 Since 2009 funding has increased by just 0.9% on average a year,12 and this is set to continue until 2020. Many economists think that the NHS needs a 3%-4% increase a year just to keep pace with demand.13
This 0.9% increase has allowed governments to say, “We have increased NHS funding year on year,” because inflation has been low.14 However, it does not make up the 3%-4% shortfall and has led to this disastrous financial situation throughout the NHS.

Cuts in funding

An explicit decision was made at the highest political levels to offer the NHS these paltry amounts. The economic policies of the 2010 and 2015 administrations have led to many cuts in funding for public services. The NHS was “protected” but only against inflation. The blame for the current state of the NHS lies firmly at the door of our politicians. This allows talk of “top-up insurance” as the answer to the NHS’s woes.
Having a budget for a package of care, say for one year’s treatment for diabetes, sounds attractive. But what happens when that money runs out? People who could afford it could top this up for extras such as diabetic retinopathy. But people with no insurance or savings would be unable to do this and lose out. We should be working hard to ensure that everyone has equal access to all the care they need.
Politicians could decide to fund the NHS adequately if they were to end their obsession with cutting public services. Governments can borrow at all-time low interest rates, and investment in healthcare has been proved good for the economy.15

Exorbitant interest payments

We should be investing in front line staff instead of “management consultants” of dubious value.16 And we should find a way to end the exorbitant £2bn a year interest payments for private finance initiatives that could be spent on caring for patients.17
Without more money we are just a short step away from the introduction of NHS health insurance or demands that the public supplement out of their own pockets. That would be a sad day for patients, and the NHS as envisaged—free for all at point of need—will be gone.


  • Competing interests: Both authors have read and understood BMJ policy on declaration of interests and declare that DW is deputy chair of BMA Council.

Saturday, 9 July 2016

A Quiet Time for the NHS

400 doctors recently gathered in Belfast for their annual meeting to discuss issues affecting the whole profession. It is a 4 day event and a very busy week discussing issues affecting everyone from medical students up to retired doctors covering medical politics as well as the professional, scientific aspects affecting our day to day work.

GPs were angry this year. Angry at how their branch of practice has seen yet more cuts to their budgets and angry with politicians who make out things are OK when those of us working on the front line of the NHS know it isn’t.

GP surgeries are closing across the country now. GPs can no longer keep going and are handing their keys back to NHS England. What a shocking indictment on our politicians when their policies and funding cuts bring about the closure of much loved and well respected community surgeries. Patients are the ones who lose out and once a surgery closes it will never come back again.

The workload in intolerable with upwards of 60-70 patient contacts a day, 30-40 blood results a day, 20-30 hospital letters to deal with, numerous telephone consultations and a few home visits thrown in for terminally ill patients whom we increasingly care for at home now in their dying days.

Much of this was discussed in Belfast and the profession has demanded a rescue package that will go some way to save our profession from collapse. If nothing comes about by the autumn, then the BMA has been given the go ahead to ask GPs whether they will consider industrial action. This is how bad things have got. General practice used to get around 12% of the NHS pie to fund its work and this has been gradually eroded by our politicians to around 7% now. That is nearly a 50% cut when workload has rocketed and the complexity of the work we do has increased significantly. We now see patients with up to 8 co-morbidities such as diabetes, heart failure, renal disease, hypertension and COPD. Often they are on 10-15 different medications and juggling all of this in a 10 minute appointment is nigh on impossible. The chair of GPC, Dr Chaand Nagpaul, said in his conference speech this was ‘not possible, not sustainable, not safe’.

Dr Napgpaul went on to say how shameful it was that when we are the worlds 6th richest economy that we have some of the lowest number of hospital beds in Europe and very low numbers of doctors and nurses. He accused politicians of ‘savagely slashing NHS funds under self-proclaimed austerity’.

Another big issue at the moment is the junior doctor dispute. We recently saw a ballot of junior doctors and medical students reject the contract by 58% to 42% on a 68% turnout. On the day this was announced the chair of JDC Dr Johann Malawana resigned as he had recommended the contract to his colleagues and given they had rejected it he felt he had to leave. Dr Ellen McCourt was elected chair the next day. Ellen is an A&E trainee from Hull and has a lot of work ahead of her. JDC have decided to survey its membership over what steps they might be prepared to take next. You will have seen that Mr Hunt got up in Parliament days after the result was announced and announced he would be imposing the contract. This has led to a group of junior doctors (Justice 4 Health) consider legal action against the actions of Mr Hunt. We will have to see where all this gets us over the summer.

All this is at a time when the major political parties in turmoil and the country has voted to leave the EU. It is hard to think of a time when so many momentous events have come together at once like this.

One thing we must remember is that our patients must come first in all we do. Despite the savage cuts to the NHS and the dwindling workforce we must do all we can to ensure patients receive safe, high quality care. We must hold to account those who put this aim of ours at risk and speak out on behalf of our patients when we believe we see injustice occurring.

No doubt there will be many more interesting times ahead of us!

Wednesday, 13 April 2016

Thoughts from the Picket Line

I arrived at the picket line at Royal Lancaster Infirmary at 8am on Wednesday just as the photographer was arriving to take some pictures for his latest story. There is still significant media interest in the strikes - which are the first set of doctors strikes in 40 years.

The junior doctors had arrived and were getting their banners ready and it was fantastic to see some local teachers turn up to support our doctors. The rain didn’t dent our spirits and we spoke to many passers by who supported us and hundreds of cars honked their horns in support as they drive by.

As a GP I support our junior colleagues 100% in this fight for a safe and fair contract and what is in effect a fight for the NHS. I know they don’t want to be on strike but they have been forced into this by Cameron and Hunt who now see doctors as their enemy and are trying to crush them.
A consultant came out to the picket line and brought coffee for us and I had a chat with him. He said the consultants were showing huge support for the junior doctors and would continue to do so during the next escalation to a full walk out in late April.

In most democracies if a Health Secretary had handled the situation so badly that junior doctors had gone on strike he would have ben sacked. But not in this country. We have a government prepared to bully doctors and force through and implement a contract that is manifestly unsafe, unfair and what we have recently seen is actually discriminatory – to women on the whole.
Junior doctors have been left with no choice as Cameron and Hunt refuse to talk. The doctors are livid at how they have been publicly vilified by politicians prepared to lie about statistics in order to justify their misplaced ideology.

It made me think once more how GPs have it bad at the moment too. With a crushing workload, no time to think or take stock of the 50-60 patients we see at 10 minute intervals each day, the GP profession is on its knees and many are walking away because they can’t continue. 12-14 hour non stop days are the norm and it is killing my specialty. I am so angry at what is being done to what was once the jewel in the crown of the NHS. Many GPs say they no longer feel safe in their day to day work given all the government has piled on us.

In a way I would like GPs to be on strike side by side with our junior colleagues to show the dreadful state the NHS is in due to the neglect of this government. Year on year real cuts to the NHS budget has left the service close to collapse. When the NHS needs 4% increases each year to keep up with the care needed it has been getting 0.9% for the past 6 years.

When the junior doctors change jobs in August (as they do each year) there will be huge gaps in rotas as doctors will have gone abroad or just left medicine. Their morale is so low they do not want to work under this imposed contract.  I think some hospitals will seriously struggle to fill rotas leaving doctors to care for ever increasing numbers of patients overnight and making it less and less safe.
The government should be ashamed of itself having brought the service to its knees but they continue to ply us with their lies about the NHS doing well and care improving – when every NHS staff member knows the exact opposite is true.

It is a national scandal. It should see a government fall. It should see millions of us on the streets.
The only way to stop what is happening is to get angry and get active. Join campaigning groups, get family & friends to write to their MPs, write to the local press, oh and above all support your junior doctors and tell them you stand shoulder to shoulder with them.

They are fighting for your NHS. An NHS that might not be around much longer.