The NHS and its future

[PannickAtTheDisco]

I disagree with your series of posts philosophically. There's two issues that are a bone of contention to me:

• The NHS should be ran as a business entity rather than Government.
• Foreign nationals should be charged any more than us.

These are actually the same point expressed different ways but it comes down to whether the NHS is there to provide healthcare/wellness or whether the NHS should have larger constraints than that singular goal. Healthcare and economic considerations don't really mix, as much as we like to put them together. At some point there will always have to be a decision where it comes down "can we afford to save this person's life?". Currently that only really applies to elderly people whose lives as seen as inherently less valuable than a young person's life and there's a round "understanding" on this between everybody involved.

My problem is that the NHS should provide healthcare because it is the right thing to do and not because it acts as collective health insurance for the whole country. I don't like the idea of charging foreign nationals for this very reason - we're creating a situation whereby NHS services hold an economic value that we want people to fulfil based on their country of residence. That's a small step to judging the NHS as an economic value to the people in this country.

There's very few things that many people agree on are Good Things that we should do because they are Good Things rather than because there is a financial aspect to it. You can argue the economic benefits that having the NHS brings and that's obviously true but it's framing the argument incorrectly. The NHS should survive and be funded because it's the right thing to do rather than attempting to create efficiencies and financial savings. Knocking it out of Government can't really achieve this because any business cannot survive without being an efficient retailer and economic considerations will always override human considerations. That's the nature of a business. The NHS needs to be able to outweigh human considerations with money and it's only really Governments that have the financial power and ethics to achieve this.

I would argue the NHS is indispensable and therefore it's value to British society is so great that foreign nationals should absolutely pay as much as possible. Considering they pop over and don't pay their taxes here to contribute, they should have to fork out as much as we can get from them. If they want such a great service and think they can do it more affordably, go try in their own country, if not then they should accept they need to help prop up the service they want to use. The NHS is the right thing to do, but people need to pay for it, and in my view paying for it based on use against income is fairer than arbitrarily putting people's taxes up, particularly if they're young, healthy and don't use it.

 

[Chippy_boy]

I disagree with your series of posts philosophically. There's two issues that are a bone of contention to me:

• The NHS should be ran as a business entity rather than Government.
• Foreign nationals should be charged any more than us.

These are actually the same point expressed different ways but it comes down to whether the NHS is there to provide healthcare/wellness or whether the NHS should have larger constraints than that singular goal. Healthcare and economic considerations don't really mix, as much as we like to put them together. At some point there will always have to be a decision where it comes down "can we afford to save this person's life?". Currently that only really applies to elderly people whose lives as seen as inherently less valuable than a young person's life and there's a round "understanding" on this between everybody involved.

My problem is that the NHS should provide healthcare because it is the right thing to do and not because it acts as collective health insurance for the whole country. I don't like the idea of charging foreign nationals for this very reason - we're creating a situation whereby NHS services hold an economic value that we want people to fulfil based on their country of residence. That's a small step to judging the NHS as an economic value to the people in this country.

There's very few things that many people agree on are Good Things that we should do because they are Good Things rather than because there is a financial aspect to it. You can argue the economic benefits that having the NHS brings and that's obviously true but it's framing the argument incorrectly. The NHS should survive and be funded because it's the right thing to do rather than attempting to create efficiencies and financial savings. Knocking it out of Government can't really achieve this because any business cannot survive without being an efficient retailer and economic considerations will always override human considerations. That's the nature of a business. The NHS needs to be able to outweigh human considerations with money and it's only really Governments that have the financial power and ethics to achieve this.

If we were talking about a little institution costing only a few million - or even a few billion - a year, then I would agree wholeheartedly.

But the NHS budget for England for 2018 is I believe £122bn - a figure that pretty much everyone agrees is not enough, given the current demands, structures, levels of inefficiency etc. (We can debate what the fix is, either more money or greater efficiency, but that's a distraction: as it stands, £122bn is not enough.)

Even this sum equates to around £2,200 per person in England. So you average family of 4 is already paying nearly £10,000 per year, every year, for their healthcare. It's more money than some people pay for their home! Surely, at these astronomical levels already, we cannot simply just inexorably throw more and more money at it on the basis that it's a Good Thing?

Were we to fund it to the levels your post would imply (where tough choices about "can we afford to save this person's life?" don't come in to play) I cannot imagine how much that would cost, but I am sure it's not a marginal top up. Inevitably, and at all practical levels of funding, I think there will always be constraints and tough choices.

I've posted earlier that I don't know what the answer is, and that's true. But it seems to me that there's some "sacred cows" that we need to revisit. Is it right that everything the NHS does for us, has to be free? Perhaps we should be looking at a smaller core of free services and charges for more things? Perhaps we should even contemplate NHS cover not being free at all for people beyond certain income levels (like £150k / year perhaps). I know these sorts of things are contentious, but we cannot carry on as we are and some radical new thinking is needed I believe.

 

[PannickAtTheDisco]

If we were talking about a little institution costing only a few million - or even a few billion - a year, then I would agree wholeheartedly.

But the NHS budget for England for 2,018 is I believe £122bn - a figure that pretty much everyone agrees is not enough, given the current demands, structures, levels of inefficiency etc. (We can debate what the fix is, either more money or greater efficiency, but that's a distraction: as it stands, £122bn is not enough.)

Even this sum equates to around £2,200 per person in England. So you average family of 4 is already paying nearly £10,000 per year, every year, for their healthcare. It's more money than some people pay for their home! Surely, at these astronomical levels already, we cannot simply just inexorably throw more and more money at it on the basis that it's a Good Thing?

Were we to fund it to the levels your post would imply (where tough choices about "can we afford to save this person's life?" don't come in to play) I cannot imagine how much that would cost, but I am sure it's not a marginal top up. Inevitably, and at all practical levels of funding, I think there will always be constraints and tough choices.

I've posted earlier that I don't know what the answer is, and that's true. But it seems to me that there's some "sacred cows" that we need to revisit. Is it right that everything the NHS does for us, has to be free? Perhaps we should be looking at a smaller core of free services and charges for more things? Perhaps we should even contemplate NHS cover not being free at all for people beyond certain income levels (like £150k / year perhaps). I know these sorts of things are contentious, but we cannot carry on as we are and some radical new thinking is needed I believe.

"2,018" - lol.

 

[grunge]

I would argue the NHS is indispensable and therefore it's value to British society is so great that foreign nationals should absolutely pay as much as possible. Considering they pop over and don't pay their taxes here to contribute, they should have to fork out as much as we can get from them. If they want such a great service and think they can do it more affordably, go try in their own country, if not then they should accept they need to help prop up the service they want to use. The NHS is the right thing to do, but people need to pay for it, and in my view paying for it based on use against income is fairer than arbitrarily putting people's taxes up, particularly if they're young, healthy and don't use it.

This is the thing, while its really difficult to gauge correctly, the estimated cost per year of people "tourists" using the NHS like the way you describe is about £15-20m a year, the estimated cost of chasing the payments... £18m a year. so its debatable if its even worth the effort of tracking them down to make them pay or just absorb the hit. This includes xpats who come home to go to the hospitals.

 

[Chippy_boy]

"2,018" - lol.

Don't know what happened there??? :-) Fixed!

 

[PannickAtTheDisco]

This is the thing, while its really difficult to gauge correctly, the estimated cost per year of people "tourists" using the NHS like the way you describe is about £15-20m a year, the estimated cost of chasing the payments... £18m a year. so its debatable if its even worth the effort of tracking them down to make them pay or just absorb the hit. This includes xpats who come home to go to the hospitals.

why chase the "cost"? Chase more, you know...don't let them leave the country till they've paid up, that kind of thing.

 

[grunge]

why chase the "cost"? Chase more, you know...don't let them leave the country till they've paid up, that kind of thing.

so you think the NHS should potentially lose money chasing them?

 

[PannickAtTheDisco]

so you think the NHS should potentially lose money chasing them?

don't need to chase. Foreign national comes to hospital, provides ID, and the charges are logged on the system against their ID and shared with immigration. When they decide to leave the country without paying, they're stopped at passport control and either pay up or are banned from coming back into the country till they've paid up. No "chasing" at all. Charges logged at source.

 

[inbetween]

Agree with some of that mate - especially the stuff about pay. There's plenty of people in the public sector who are over-holidayed, over-sick-day'd, over-pensioned and generally over-paid.

But the quality comments you responded to are I believe valid. The public sector as a whole - not just the NHS - has been brow-beaten for so long about the need for cost control, that its procurement inevitably gravitates to the cheapest option - and this is the critical point - even when the cheapest option is not up to the job. Disposable gloves was one such example I heard of where they were getting through 3x as many because the product was simply too crap for the purpose it was procured for. So not in fact saving any money at all.

My beef about the public sector more generally is that as you, I believe there is still enormous inefficiency and waste, but the institutions themselves - the NHS being one - are so entrenched in their ways and ways of thinking, they simply cannot see it. And if they can, they are too large or too bureaucratic or whatever it may be for them to do anything about it.

You do not need to be an expert to recognise this. Anyone who's been unfortunate enough to have a loved one in hospital for any length of time, will have seen it for themselves. People stuck on wards for weeks, with little or no imperative to get things done for them. "The consultant will be around on Tuesday" - when it's Thursday today. "We'll take you down for your x-ray tomorrow" - when you were there only 2 hours ago for something else and with a bit of foresight they could have done both together. Drugs are still given out like sweets to people who don't need them or don't take them. My aged mother-in-law could open a pharmacy with the boxes and boxes of wasted drugs stuffed in various draws and this is not at all uncommon.

I don't know what the solution is - I wish I did. But it's clear it's not working at all efficiently even now after all the efforts to make it more efficient. Something needs to change and throwing ever more money at it is not a solution unless we want a 35% basic tax rate.

To be fair even a 35% tax rate will not solve anything, I can guarantee that if £10bn was made available tomorrow it would just disappear and nothing whatsoever would change. Hospitals are finite places and if they are full then it doesn't matter how much money you give them, we could always burn the money to heat them but I am guessing we are already doing enough of that..

 

[I'm With Stupid]

Even this sum equates to around £2,200 per person in England. So you average family of 4 is already paying nearly £10,000 per year, every year, for their healthcare. It's more money than some people pay for their home! Surely, at these astronomical levels already, we cannot simply just inexorably throw more and more money at it on the basis that it's a Good Thing?

Are they really astronomical levels though? Compared to other countries? The UK puts in just over $3k per year per person. If you combine government funding and compulsory health insurance (which is effectively another tax, since it's compulsory) in other countries, you'll find that most of Western Europe is paying more than that. In France and Japan (2014), it's approaching $3.5k, and Belgium and Ireland are both around that too. Austria is in the high $3,000s. In Sweden, Germany, Denmark and the Netherlands, it's over $4k. The only difference is that a lot of these countries have an insurance company in the middle making profits, and none of them see significantly better results than the UK and all of them come below the UK in terms of efficiency of their health services. In terms of GDP percentage, the UK also doesn't spend as much as lots of other countries. We spend 9.7% of GDP on healthcare, compared to Austria, Denmark and Belgium (all 10.4%), Norway and the Netherlands (10.5%), Canada (10.6%), Japan (10.9%), France and Sweden (11%), Germany (11.4%) and Switzerland (12.4%). It's worth mention that the USA spends 17.2% of their GDP on healthcare, so government funding isn't everything, especially if it's being used to subsidize the profits of huge corporations.

In the Netherlands, you have to pay around €100 a month out of your salary for health insurance, but as you might imagine, poorer people get that subsidized. On top of that, you have to pay the first €385 per year of healthcare costs. The government just sets and enforces the rules, but everything else is privately run. And people who say that private companies run everything better would presumably argue that they do better, but is this the case? What do they get for their extra 33% funding? Is it 33% better services, or just a nice profit for the insurance companies? Every comparison I've ever read seems to put the UK as better in some areas and worse in others, but crucially, always better at the efficiency we're always told that only private businesses can offer (just like they have on the trains). Here's an unbiased comparison. It's quite amazing how well the NHS does when it's probably dealing with the most unhealthy population in Western Europe.