Thursday, 2 June 2011

Caring for each other, caring for ourselves

Michael Moore: [to a British couple in hospital] What'd they charge you for that baby?
British mother: [confused] I'm sorry?
Michael Moore: You gotta pay before you get out of here, right?
British mother: No.
British father: Na na na. Everything's on...
British mother: This is NHS.
British father: So no. It's not - it's not America.
("Sicko", Michael Moore documentary)

We remain the only country in the western world without free, universal health care. (Michael Moore on the USA insurance based scheme of healthcare)

The Jersey health department have just launched a consultation, entitled "Caring for each other, Caring for ourselves". They outline the possible future options:

Scenario 1: "Business as Usual" - We should keep the same structure for providing services as we have today, and significantly increase spending so that services can be provided to meet growing demand.

Scenario 2: "A small increase in funding" - We should keep funding almost the same, provide what services we can within this budget and accept that many services will be subject to restriction or may no longer be available free.

Scenario 3: "A new model for health and social care" - We should change the way services are provided, so patients see the right health or social care professional at the right time and in the right place. Changes will affect the way that health and social care works in the island; there will be some cost

What has struck me with the way these options are presented in the paper is that it is very much a forced card, like a magicians trick, in which the individual has to take a particular card because they are given no choice, despite the appearance choice.

Two major factors are costs, and the demographic time bomb, of an increasingly elderly population in proportion to the working population supporting them. But the time bomb is consistently treated as a continuing situation, whereas while more people are living longer, part of the demographic skew is also due to the baby boomer generation becoming older, and may be a "hump" to be navigated over rather than a permanent fixture. This doesn't effect the medium term strategy, but it may mean that in the long term the situation may need revising again.

Scenario 1 is presented as pretty much ruled out completely. It is simply not viable with increasing numbers of elderly population to sustain business as usual, however much we would like it, because of the sheer element of costs involved. So it is ruled out.

Scenario 2 is presented as the same at present, but with cut-backs to services to contain costs. So while it may be a painful option, no one is going to want it if possible.

Scenario 3 is the card of choice. A completely rethought idea of the health service. Now this is not bad in itself, and insofar as functions provided directly can be delegated at less cost - for instance, blood pressure or diabetes checks being done at the pharmacist rather than at a doctor's practice, there are some good suggestions being made. But the meat of the proposal comes with the funding suggestions which are tucked away at the back, and I was struck in particular by:

Insurance - A social insurance scheme, whereby people pay into a fund that specifically raises money for health and social services. This is already planned for long term care from 2013.

As a universal method, I still think this is wrong, and Aneurin Bevan summed up the main arguments against it in his book "In Place of Fear", in the chapter on the NHS.

Bevan notes that such a scheme unless it is very simple, is liable to all kinds of complications, and notably it will increase the bureaucracy needed for its administration. But it will not be a simple scheme, for at the very least, it will need to tie in with income support, and it will have to account for people who do not work, who have chosen, for example, to bring up their children at home, or equally the unemployed, those taking early retirement, those who cannot work because of health or handicap. How will the scheme deal with children, too, is another question for an insurance scheme, as they will either be exempt, or an insurance levy will need to be placed on an individual basis like a poll tax.

It had always seemed to me that a personal contributory basis was peculiarly inappropriate to a national health service. There is, for example, the question of the qualifying period. That is to say, so many contributions for this benefit, and so many more for additional benefits, until enough contributions are eventually paid to qualify the contributor for the full range of benefits. In the case of health treatment this would give rise to endless anomalies, quite apart from the administrative jungle which would be created. This is already the case in countries where people insure privately for operations as distinct from hospital or vice versa.

And the move away from taking the budget from taxation also means that the burden of double taxation will rise. At present, an individual is taxed on their gross income, less the contributions to social security. But, however one dresses it up, the contributions to social security are none the less, a form of taxation by the state, which is also subject to the 20% tax before it is taken!We may appear to keep up the appearance of a 20% tax rate, but increasing the amount taken by the State in the form of contributions, while subjecting that difference to taxation, is effectively increasing taxation by more than 20% on earned income. Wouldn't increasing direct taxation be a fairer and more transparent mechanism, rather than taking more by stealth and pretending that 20% is the tax rate.

Bevan points out that an insurance scheme invariably leads to means testing for health, and while this may be a way off the American system whereby health is not provided until it is known that the patient can pay for it, it is still a slippery slope:

Whatever may be said for it in private insurance, it would be out of place in a national scheme. Imagine a patient lying in hospital after an operation and ruefully reflecting that if the operation had been delayed another month he would have qualified for the operation benefit. Limited benefits for limited contributions ignore the overriding consideration that the full range of health machinery must be there in any case, independent of the patient's right of free access to it. Where a patient claimed he could not afford treatment, an investigation would have to be made into his means, with all the personal humiliation and vexation involved. This scarcely provides the relaxed mental condition needed for a quick and full recovery. Of course there is always the right to refuse treatment to a person who cannot afford it. You can always 'pass by on the other side'. That may be sound economics. It could not be worse morals.

And Bevan also considers those who would be exempt from such a scheme:

Some American friends tried hard to persuade me that one way out of the alleged dilemma of providing free health treatment for people able to afford to pay for it would be to 'fix an income limit below which treatment would be free while those above, must pay. This makes the worst of all worlds. It still involves proof, with disadvantages I have already described.

The really objectionable feature is the creation of a two-standard health service, one below and one above the salt. It is merely the old British Poor Law system over again. Even if the service given is the same in both categories there will always be the suspicion in the mind of the patient that it is not so, and this again is not a healthy mental state.

And the litmus test of any system of healthcare, he states as follows:

The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged.

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