POLITICIANS looking for cheap applause, which is not uncommon, can usually rely on three small letters.
No SAS. That was Michael Portillo in a rather curious speech at a Conservative Party conference.
No, those praised letters are NHS. Frequently delivered as “our wonderful NHS” or “our wonderful NHS”.
Suitably cajoled, the usual response from the audience is to whoop and, indeed, cheer.
Meanwhile, our enthusiastic viewers are silently wondering: “Is our NHS really wonderful or wonderful?”
The answer, of course, is no. He is in critical condition. Covid, of course, made things much worse, but there are also longer-term structural issues.
I have nothing but the highest praise for those who care for patients and their anxious families.
However, we need to lose the atmosphere of wonder. The NHS just isn’t working, north or south of the border. We need to face that squarely, without in any way belittling those who strive to make it work.
Such, presumably, was the motivation of NHS managers who indicated, in minutes leaked to the BBC, that they had a “green light” to examine ideas previously considered off-limits, such as charging for wealthier patients.
The universal political response? How dare they?! Even with this we are not going to put. Our NHS is wonderful. Wonderful, in fact.
My own answer? I’m not sure it will work, but thank goodness someone is prepared to consider reform.
Or do we just accept a system where ambulances are delayed, where A&E units are packed to overflowing, where patients are lounging in corridors for hours, and where one in seven Scots is on a waiting list of some kind?
As The Herald revealed, a group of Scottish GPs suggested at a medical conference that there could be a fixed consultation fee for wealthier patients “in a bid to reduce demand”.
I’m not sure such ideas save much unless the charges for the rich are prohibitively punitive.
This could be seen as something unfair, endangering the very social and fiscal solidarity on which the health service depends.
In essence, we have two options. We may change the method by which health care is funded or we may try to lessen or divert demand.
Generally speaking, there are four methods of financing. Britain’s NHS, where the cash comes from general taxes; mandatory deductions from pay stubs to cover medical care; universal insurance where care can be provided by the private sector; and pay as you go.
I discussed this with Mark Hellowell, the Director of the Global Health Policy Unit at the University of Edinburgh.
He said co-funding, or charging some patients, could have an impact, but would likely be limited, in part because such systems were often accompanied by multiple waivers.
Furthermore, he noted that systems that do in fact discourage patients from seeking primary care could end up causing problems, and costing more money, if these patients later presented to hospital with more serious problems.
Dr. Hellowell said that overall, he might be in favor of a system that earmarks or mortgages the funds raised for health care.
This is because international evidence suggested that people were more inclined to tolerate such levies if they knew the money was going directly to health care. However, he admitted that he was probably in the minority within the academic community on that.
In essence, there are problems with all financing systems. For example, employment deductions will require an additional system of coverage for those who are not employed.
I also believe that there is a structural political problem in changing our method of financing. Out of habit and utility, we are understandably drawn into the universal provision system.
However, it has its own problems. Chief among them is that we can tend to undervalue, and overuse, something that doesn’t come with an obvious price tag.
We can turn to NHS care all too easily. Hence, the current Scottish Government appeals to people to consider whether they really need to go to the emergency room.
If we don’t charge for access, could we charge for ancillary services? There are still prescription charges in England, although they have been removed in Scotland.
Two points. The reintroduction of prescription charges in Scotland would be politically damaging to any party that made the attempt. In addition, the exemptions and the corresponding red tape could mean that relatively little would be saved.
So could we reduce costs in other ways? Perhaps by restricting the availability of new drugs? There are clear limits to the fairness, or effectiveness, of such a move. Although, in practice, drugs are already evaluated, with a balance between cost and likely clinical value.
What about another idea from the leaked article? Send patients home faster?
Actually, that brings us directly to another big issue that came to the fore at Holyrood this week. The issue of social care.
It is universally recognized that one way to ease blockages in the hospital system would be to free up more beds by discharging patients. That would also ease the strain on A&E, and would be beneficial to the entire system.
However, to do that, we need a much better system of social care. This week Holyrood’s finance committee warned sharply that plans for a National Care Service lacked cost precision.
As I’ve noted here before, some also fear that the new service could enhance management without necessarily improving service where it’s needed, on the ground.
Another point. Let’s say we divert more money to the NHS. What would we spend it on? More staff and more skills would be welcome.
But recruiting is already facing problems, partly due to poor workforce planning in the past. And Brexit hardly helped. Just this week, Anas Sarwar of the Labor Party highlighted staff shortages at Tayside’s oncology service.
Splurging cash now won’t work right away. That will require better training, effective recruitment, and a period of years.
Ideally, we need more investment in exchange for efficiency, savings, and reform. We need better social care. We need restrictions on demand, where possible. And we need to improve recruitment.
For all this, we will have to wait. But then, in the health service, we should already be good at it.