What you pay for

Like the unwelcome rumble of thunder, from distant hills, on a summer’s day… something’s coming.

Like a call, on a landline, in the middle of the night… never good news.

Harbingers of nothing-good.

So it is, with the press. Behind paywalls, like a secret society, editors plant their seeds of doubt…

…the NHS is failing, we need to try something else. Anything’s better than this.

The Times and the Telegraph, both £walled, have writers telling us the NHS is done-for. Comes their clarion call; we must change the system.

Rumours abound; Kamikwazi has to balance the books and will cut public spending.

I’ve been at this game for long enough to have seen ideas come and go. Reforms, changes, lunatics like Lansley, zealots like Milburn and the seriously dozy, like Nick Clegg.

The NHS has seen them off. This time? Mmmm…

The social insurance stone is being pushed up the hill. If they can get it to the top, the momentum, as it rolls down the other side, might be unstoppable.

What’s the problem?

It is true, there are huge waiting lists, an exodus of staff, wages are poor, working in health and care is unattractive.

Would a social insurance system, fix it? No.

It is true, we don’t have enough health professionals nor enough beds.

Would a social insurance system fix it? No.

It is true, there are some outcomes that are better elsewhere… but it depends on what comparator you pick. 

Would a social insurance system fix it? No… 

… but we must ask, why are we asking these questions?

From the world banking crisis, in 2009, the NHS experienced a decade of, pretty much, flat-line-funding.

The historic annual, uplift in funding, since the NHS started in 1948, has been just under 4%. The austerity, funding famine brought consequences… 

… we haven’t trained enough people, built enough capacity, repaired enough, modernised enough. 

It’s easy to forget, we went into the Covid debacle with 40,000 nursing vacancies and waiting lists already at an historic, 4.5m.

Now, the sky is dark, with chickens coming home to roost. A bow-wave of 7m people waiting, coupled with a bad winter, if the NHS loses momentum it could overwhelm it.

Would a social insurance system fix this? No?

Would a social insurance system have stopped any of this happening?

There is no ‘one-system’ of funding across the EU, or the OECD. Some; state-funded like ours, some social insurance, some are substantially private and some reimbursed.

Government schemes provided the financing for nearly a third of all healthcare expenditure in the EU in 2019. 

Compulsory contributory health insurance schemes and compulsory medical-saving-accounts accounted for just over half. 

These two, primary sources accounted for 79.7 % of all financing. The rest is ‘out of pocket’ expenditure. The user pays.

There is a further complication. The OECD definition of what constitutes healthcare spending changed. As the Health Foundation explain; 

‘…Compared to the old definition, what now constitutes spending on ‘health’… includes much more of what in the UK has traditionally been thought of as ‘social care’…

…as well as … the NHS and preventative care… it excludes ‘capital spending’.

This has meant a large accounting switch from social care spending to health care spending …’

Apples and lightbulbs…

It’s a mix and too complicated to unpick, here. However, there’s a common theme. Almost all of the healthcare systems, we compare with the NHS, funded their health systems better, during the ten years following the banking crisis.

The upshot… 

• in 2010, in funding-ranking, we were behind Germany and France. 
• In 2011 we plummeted behind Germany, Sweden, Japan and France. 
• In 2012, Belgium joined those in front of us. 
• We stayed 5th, until 2020 when the share of UK GDP spent on health improved to 9.92%, 
• Still behind Germany 10.91% and France 10.34%.

The moral to the story?

You can fund the NHS out of your left-hand pocket for taxation, or your right-hand pocket for insurance premiums… but it’s still your trousers…

… somehow you have to pay and if you take less money, from either pocket, you’ll get less healthcare.

If we demolish what we have;

… created competition, insurance legislation, fixed the problems of training, regulation, emergency care, equity and access…

…or…

… committed to long-term funding for the NHS around 4% of GDP, invested in training and created stability… 

… it’s still about the money…

… you’ll still get what you pay for.

News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.