The British government has been talking darkly about the exploding demands on the National Health Service, which will rapidly make it unaffordable if it is not reformed. This has recently been challenged by Professor John Appleby, at the health think tank King's Fund. This was in a recent article in the British Medical Journal, behind a paywall, but summarised by the BBC here. This question goes to the heart of health policy in the UK, but politicians dare not discuss it - because it puts the very principles of the sacred NHS in question. But the problem will not go away.
According to some figures on Wikipedia Britian spent an unremarkable 8% of its national income on health, compared to over 16% in the US, before the financial crisis struck. Those figures will be higher now, since our income has shrunk, but the relativities will be much the same. The comparison between the two countries is usually held up to show how ineffective US health spending is, since health outcomes look generally pretty poor there. But the comparison can be looked at the other way. The US can afford to spend more than 16% of its national income on health and still remain one of the most prosperous countries on the planet. There is nothing mysterious about this. Developed countries are long past the level where basic human needs of food and shelter are met; how we choose to spend the surplus is up to us, and there is no reason why we can't choose health care over cars, designer clothes or big holidays. It's not as if it requires massive imports to sustain it.
You can take this line of reasoning further. The basic proposition of health care is to reduce pain and prolong life; these are consumer propositions to, well, die for. Suppose we lived in the economist's free market utopia, where health spending was a matter of individual choice in a perfectly competitive free market with no information asymmetries. There is no reason to think that health expenditure would not be higher than the 8% or so we currently spend in Britain, or indeed as high the US figure. We can perfectly easily afford it.
That's not the problem. The problem is paying for it almost entirely through unspecific taxes, the core design principle of the NHS. And here the government is on much stronger ground. There is an upper limit to how much tax we can raise for health care. Up to a certain point, of course, the NHS model works perfectly well. Look on the taxes as an insurance premium and it helps spread risk in a way that people like. But the more you spend, the more the weaknesses of the model are exposed.
- There is no direct line of sight between what you pay and what you get. How on earth are you supposed to decide whether you are getting value for money?
- You have no choice in the level of service you get. One size fits all.
- People who are better off may feel that they are paying too much relative to what they get. This may not be quite as strong an argument as it first appears, since the less well off pay a lot of tax through cigarettes, alcohol, petrol and VAT - but the perception is still a problem.
- Taxes create a drag on the rest of the economy, reducing incentives to work and therefore shrinking the resources available.
America is able to get away with much higher levels of health expenditure because so much of it comes from private insurance premiums and direct private payments for treatment. But even there a battle royal is developing over how to balance taxes and government support.
Of course, to some putting up taxes is the right way to go. France and Sweden get away with higher tax burdens than the UK after all. But this is very fraught. Some think you can go after big companies and very rich people and leave everybody else. This is not as easy as it sounds though, since this wealth is very mobile. Property is not mobile, of course, but raising taxes on property is probably as politically toxic in Britain as taxing fuel is in the US. There is also a problem if too much tax revenue comes from the very rich or corporations - these start to acquire more political weight. Which leaves the not-so-rich. But these people are under pressure and feel over-taxed - Ed Miliband's "squeezed middle".
So I think the government is right. We have hit the limit of what the country can afford for tax-funded free-at-the-point-of-use health system. But we have not hit the limit of what people are prepared to spend if it's their own money and for their own benefit. The risk to the NHS is that the more affluent middle classes start to opt out of NHS services, depriving them of critical mass and undermining the principle of social solidarity. This has already happened to NHS dentistry.
Nasty. In the last years of the previous government the issue of co-payments was quite high up the political agenda: the possibility of NHS patients topping up their treatments with their own money to get things not on the basic menu. This had become politically charged because of the costs of some rather questionable cancer treatments which the NHS were denying but which people were prepared to pay for. The Conservatives clearly considered the topic politically toxic, since they have fudged the issue of cancer treatments with a bit of extra funding. Labour and the Lib Dems were inching towards accepting co-payments, though I expect both parties are now bouncing back.
But in my view co-payments is the best way to relieve the pressure. The NHS should define a basic menu of treatments that everybody is entitled to, but accept payments for anything outside this. This undermines one of the sacred founding ideas of the NHS, that everybody gets the same, no matter how wealthy. But it is better than the alternatives. It's the debate we should be having.