There should be more partial-private options in health and education

[Middlelanehogger]

People often say that for social mobility reasons we should abolish private schools or private hospitals as it's unfair that there's "one system for the rich, one for the poor".

However I think this thinking is backward. We should encourage more gradual step-ups that enable people to slowly inject more of their own personal money into the system as they move up the income ladder and become able to do so.

For example, currently I have the choice to go to my underfunded, busy NHS GP, or a completely private GP and pay the full costs. Likewise I could send my kids to state school or go completely private.

Great if you can afford the "completely private" option.

But there isn't an intermediate option. In Australia for example, you get a govt rebate of say $30 for every GP appt. This covers a basic GP, or you could apply it towards a more expensive GP with a nicer waiting room or late operating hours etc that costs say $50 (i.e. you only pay the $20 difference, vs $0 in the free option).

In the UK you either pay £0 or £50. There's no £20 option.

In the Australian system, the health system overall gets an extra $20 that wasn't there before (from the extra top-up), and more people are able to access the nicer services (because more people can afford $20 than $50).

There's a similar argument to be made for private education. Why can you not "move" your state school funding to a private school to offset the costs? It would allow a smoother mixing along income levels instead of the harsh cutoff/separation we have today.

Eliminating inequality is completely impossible due to human nature, but keeping a harsh separation between "the rich" and "the poors" also isn't the answer. It just keeps "the rich" even more in their bubble.

I like that idea - you get my vote

Yep, I agree that it shouldn’t be either / or.

Australia does this in education. Not sure it's an ideal solution.

in most situations when countries tackle social issues in this way what happens is you get an underclass that’s completely neglected as the base level of state paid provision falls further and further away from average provision.

Because all the GPs and teachers want to work in nice consulting rooms or in private schools where they can expel bullies and not deal with problem children, and so the free option becomes under staffed, the patients struggle to get appointments and the care suffers from being late, and delivered by inexperienced staff.

It ends up with unacceptable quality of care/education for those who cannot pay, and their families.

Why should taxpayers fund private schools? They're not for the benefit of everyone.

Agree, if people can afford to pay they are not burdening the NHS, so appointments are available for those who can’t pay. The current system is not sustainable

All that would happen is middle becomes default and gets overcrowded and unmanageable. No better than current state education but with a some kids who get very poor provision. And rich people still paying for better education for their kids.

This

I’m not sure what I think about education but I agree about healthcare. I think the only way to improve the NHS is for users to start putting money in - I’m in Scotland and I think those who can should pay for prescriptions. I’d also love the option to pay £20/£30 for a gp appt rather than the call at 9/wait for triage callback pantomime I currently have to go through.

This has been suggested a number of times for education over the years. It's called a voucher system.

Regarding health, that option does exist. Look into health insurance. There are brokers who will help you find the most suitable policy. Not so good if you have anything chronic though.

The down side of partial funding, as we can see with the badly functioning "free" nursery hours system, is that cheapskating on the part of the govt causes more problems than it solves.

That doesn't exist for health Weve dabbled in and out. We use the Livi health app we found through Boots, I paid for a private GP appt before my honeymoon as I thought I needed antibiotics. I agree it's probably the only realistic option

Eliminating inequality is completely impossible due to human nature, but keeping a harsh separation between "the rich" and "the poors" also isn't the answer. It just keeps "the rich" even more in their bubble.

I have no idea what the situation in Australia is as I’ve never been, not being rich enough: but in the U.K. environment that is a total cop-out. It is not acceptable that some of us work hard all our lives to end up with nothing because all of our money goes to fund idle rich landlords and their even more idle feckless families. For the scale of inequality in the U.K. you can look at https://equalitytrust.org.uk/scale-economic-inequality-uk or remember that poverty kills people in the U.K.

I really don’t agree, the completely free options would become worse and the class divide would get wider.

This seems like a recipe to entrench an underclass who have to make do with the absolute minimum service level, or more likely, minimum service level with limited staff and availability.

In Australia I paid $99.50 for a GP appointment this week (2 week wait as non urgent) I only get $41 back from the government. But have to pay the full amount and the refund comes back 24-48 hours later.
No GPs in my area offer bilk billing (fully funded) to new patients.
I can afford it -- but I wonder what happens to the patients who can't.

I think whenever you have state subsidies into the private sector, a price adjustment take place in the system to account for it. See: the car scrappage scheme in the last recession, stamp duty holidays after COVID, eat out to help out etc.

The additional money is just subsumed into the profit margin as state funding is not impacted by the usual supply-demand dynamic.

Absolutely this.

We could improve the service provided by the nhs by changing people's expectations, and making them take more responsibility for basic care.

60% of people in a&e don't need to be there.

Weekend drunks and brawlers should be handled by city centre drunk tanks.

That’s not really how it works in Australia though. If a GP charges you nothing, that money comes out of their wages. It makes no difference to the government
And in education yes you can go private (fancy) religious (cheap but less fancy) or public. The government heavily subsidise private so it’s not great for the country at all

60%? How do you come to that figure? If GPs were entirely available on same day then some people would go there yes. Or if there was easy access then some chronic problems would be better controlled and present less. The answer is not that people are silly. It’s that GP is underfunded and underavailable.
And having worked in a city with a “drunk tank” there are still plenty of people that need to come to ED. But they aren’t the ones causing the issue to be honest.

We have a partial private / public healthcare service in France and I think it's great. Those of us that can afford to pay a bit more for healthcare have reasonable options to do so, which relieves the pressure on the public services.It's not all or nothing - NHS or hugely expensive private providers.

DH and I are not wealthy (teachers). We are in the French healthcare system, so have all the rights and benefits that every French taxpayer does. We also pay a mutuelle through our work - not insurance as such, more a top up system that bridges the gap btw what the health providers charge and the government will reimburse. This costs about €200 per month, taken straight from our salaries.

DS broke his arm really badly last year. Because we have a good mutuelle and because there's a great private clinic / hospital round the corner from us with a walk-in trauma clinic open all day, we went there instead of the public hospital A&E. No queues, seen straight away. Long story short, it couldn't be reset and after 3 x-rays and several attempts to reset, the ortho dr sent us away with a next day appointment with a private ortho surgeon. DS had surgery, then wound care from a nurse coming to the house for 3 weeks, then 12 weeks of physio plus rdvs with the surgeon. The care he received was absolutely faultless. No queues. All rdvs made at our convenience.

So what did this cost? Some examples.

X-rays at the trauma clinic.
Clinic charges €52
Govt reinburses €19,52
Mutuelle reimburses €32,48
I pay €0,00

Surgery - 2 hours surgery, top level surgeon, private hospital, private room.
Surgeon charges €598,50
Govt reimburses €148,50
Mutuelle reimburses €148,50
I pay €301,50

Anaesthetist - GA during operation, including pre-op rdv with anaesthetist
Anaesthetist charges €201,22
Govt reimburses €61,22
Mutuelle reimburses €61,22
I pay €78,78

RDV with surgeon
Surgeon charges €65
Govt reimburses €16,10
Mutuelle reimburses €29,90
I pay €19,00

Private physio - 12 weeks, 2 rdv per week.
Physio charges €16,13 per rdv
Govt reimburses €9,58
Mutuelle reimburses €6,45
I pay €0

So yes, we had to pay out for the care. But the prices of private healthcare here are nothing compared to similar services provided privately in the US or the UK. The quality of care was so good, and because we are able to access it at a reasonable (to us) cost, it took us completely out of the public system. We're still paying all our taxes etc, so are still paying into the system and it's there for anyone that needs to use it.

Another important point: mutuelles are not like private health insurance in the UK/US - no such thing as pre-existing conditions (everything is covered).

Another point: because the govt funds this partial private / public system, it means that private providers are able to create facilities - clinics, hospitals, practices etc - throughout the city. I live city centre and I am surrounded by private physios, nurses, doctors, gynaecologists, dermatologists, opthamologists etc. Yes there are shortages, but I can still find them and make rdv at my convenience really easily. Pretty much every part of our city has private clinics and hospitals that supplement the bigger public hospitals.

Just adding to clarify that our mutuelle is €200 for the whole family (2 adults, 2 children) - not individual.

Am I just being cynical, or would private practices just up their prices to make any top up from the govt negligible?

I know it works in other countries but we have a real culture of greed here it seems.

@BodegaSushi There are different levels of ‘private’ providers here. Lowest are ‘conventionné’ which means they charge what the govt will reimburse. Most GPS, physios, nurses - all the day to day services - are this level, so there’s nothing left to pay. Beyond that, there are two levels where the providers can charge more than the govt up to set limits, then there is ‘outside the convention’ - the latter providers charging whatever they want. so you always know in advance where your provider has positioned themselves and how much you are likely to be reimbursed. In 15 years and two kids, I’ve never had to resort to the top level, and we have always used private providers rather than public hospitals for treatment. I gave birth to DS2 in a private hospital. stayed there for 5 nights (was a bit of a long process) and all I paid for in the end was €20 per night for my private room - the govt and the mutuelle picked up the tab for everything else.

The thing is, if every provider went ‘outside’ ie charged top dollar, they would very quickly run out of clients as they would exclude all the middle-income earners like me, who can afford to pay a reasonable amount but not outrageous, non-reimbursed prices. As it is they can make a very nice living by focusing on this group - and take the pressure off the public system.