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.

Never understood why the NHS and schools aren't free to offer "private" services alongside the state services. They could actually make "profit" themselves which they could use to subsidise the "free" services to all.

Take hearing aids. On the NHS you get bog standard ones, that are fine for some people but pretty useless for some too! If you want better, you have to go private, and then some fat cat somewhere makes a few hundred pounds in profit for basically doing sod all. Why can't the NHS audiology dept "sell" those better hearing aids at a price between cost and private price, thus making a profit, albeit smaller, which would go into NHS coffers? What's worse is that you don't know the NHS ones are going to be pretty poor for you until you've gone through the NHS audiology consultations etc and issued with NHS hearing aids - if they're useless, that's NHS money wasted as they won't take them back. Then you go private, and you have another hearing test, consultation, etc., and get a better quality hearing aid, which IS on "sale or return" so if it works, you pay, if it doesn't, you hand it back and they "sell" it to someone else. No waste!

Same with, say, private rooms in NHS hospitals. OK, over-riding factor has to be patient in greatest "need" for a private room, i.e. mental or clinical or safeguarding "need". But when there's no one in particular "need", rather than it being a random free for all as to who gets a private room, why not make a charge for it, so that the NHS gets some income, all on the proviso, that you have to vacate (and get a refund) if someone else has a greater "need" for the room.

After all, look at dentists and opticians - you get "basic" NHS treatment/services at modest cost (or free if you qualify due to benefits, age, etc), but you can "trade up" to a better colour/quality of filling or dental bridge, or better quality of spectacle lens/frame, etc., by paying more.

In education, we already have "extras" paid for privately, such as musical instrument tuition, extracurricula sports, additional languages, etc., where parents pay for the casual/part time teachers but often still use the school's facilities such as classrooms, gym, hall, etc. Some schools charge third parties for facilities rental, i.e. gyms and halls for local dance clubs or sports clubs, etc.

I just don't think we, as a country, have properly explored letting and encouraging public service bodies such as schools, hospitals, etc to actually act more like businesses and make better use of their facilities, staffing, etc., to offer and charge for "extras" which can bring in valuable revenue used to supplement and subsidise their "free" public services. If people are going to pay privately, then far better for them to pay, say, your school or the NHS directly, so the school/NHS makes the profit!

Never understood why the NHS and schools aren't free to offer "private" services alongside the state services.

Because one of the basic tenets of the NHS is “free at the point of use”.

Our local hospital has a private wing used by its clinicians for their private patients. The profits from the hotel element are used to subsidise its main work. It’s a tiny amount though.

This is what the op is suggesting - a minimum level that effective and appropriate for all, but also options to ‘upgrade’.
No, what they're suggesting is that if current services are a 3/10 then it's acceptable for services to drop to 1/10 for those at the very bottom, those who are the poorest, those who are the most marginalised, those who are least likely to have the ability to fight for appropriate services.

Apparently that's fine and a price worth paying.

It’s always a price worth paying when other people have to pay it.

That doesn't stop "subsidised" services/treatments in dentists and opticians though, does it, nor does it stop GPs from charging for "extras" such as insurance letters, death certifications, etc. Allegedly, none of that affects the "free at point of use" services they also offer.

GPs also aren't shy about referrals to private healthcare providers, such as podiatry, consultants, physiotherapy etc.

It's just political ideology that "everything" has to be free at the point of use. I think if we want to save the NHS, we need to a move towards a system where the basics are free at point of use, but enhanced services (such as a private room or a standing/open MRI scan or hearing aids with more functions or a white filling or choice of convenient appointment times etc) are available at a cost to generate revenue into the NHS instead of private firms fat cat owners!

If more income = higher rate of tax, could you explain how the Prime Minister pays a lower rate of tax on his income than nurses and teachers do?

It’s always a price worth paying when other people have to pay it
Exactly this.

I'm not a fan of the politics of envy and think it's right that people have the option to make a range of choices for their own situations, but feel very very uncomfortable with any suggestion that basic services should be stripped back more and more in order to increase privatisation.

It has a nasty undertone of the undeserving poor attached to it.

And invariably comes from people who pay a lower proportion of their income in taxes than the underserving poor. See for example the current Prime Minister.

‘Other people’

Those that take the tax burden, that is true many posts offering up rises for other people.

They don't go, unless they are healthcare card holders and offered bulk billing so they don't have to pay. I imagine it would result in more people showing in to the emergency dept instead.

In Australia I used to go to a GP who took some bulk-billed patients (i.e. free) and some who paid extra. I paid extra (and got some conveniences like late appointments) but the money went to the overall practice which was used by people from a range of walks of life.

How long ago and where? I have family unable to find any surgery nearby that still offers bulk billing to adults without a healthcare card. Seeing a doctor is something they only do when desperate as they can't afford it.

It is a very slippery slope. The result would be that the current quality would be available at the co-paid level, and the free level would turn to be much worse than now.

That not necessarily true as the NHS is so regulated by government with no share holders. The government could allow the NHS to offer upgraded service such as out of hours routine appointments with a set premium for staff providing them like now that comes out of the money and the rest invested back into free services. It's also things like minor cosmetic services I got two moles removed but GP isn't allowed remove the skin tag within the same area at the same time as it's cosmetic. I got it removed privately for £450 most of which would be profit that could have been fed back into the system.

Longer term you could look at things like hotel services and for non cancer/life saving surgery the option to run two lists side by side so if it's a 24 month wait for X you could say charge a set fee of maybe 2k to go on the fast track list from which 2 patient are on the theatre list per day vs 1 from the standard list. Those small amounts soon add up to money that can be reinvested back into services.

Our dentist now offers both NHS and private services. I rang for an appointment for DS first one she offered was in school hours 7 weeks from now or I could pay £55 for one on a Saturday 8 days later saving me a mornings annual leave and him missing school so was happy to pay. They never used to be open on a Saturday when I was a kid as it was a total NHS practice so no one is losing out.

Schools is the same they already largely select by house price so allowing top ups or allowing parents to use the money that would have been sent to that outstanding school as a part payment on fees only enhances the experience of poor pupils. They either benefit from the investment of wealthier parents or get a place they wouldn't have been in catchment for if like Harry who is now off to private went to that outstanding school down the road from his parents house.

Paying more for better seems perfectly fine to me when it comes to transport, leisure, housing etc. For health and education? No thanks. Just entrenches inequality imo.

Can we all stop and pause a moment to consider whether the cost to us and generally to taxpayers of various privatised industries is better or worse than before privatisation? Is the quality of service better or worse?

Water?
Gas?
Electricity?
Railways?

What does history tell us will be the result of privatising healthcare?

Railways is an outsider with that list as pre-privatisation, we had a very old "fleet" of trains which needed replacement as not only were they old, they were non compliant with health & safety, and disability laws. Had it not been privatised, the taxpayer would have had to pay for the modern stock with wider/sliding doors, larger toilets, on board display screens, etc., which costs millions per carriage. Privatising it all was a way to get that cost off the Govt balance sheet and paid for using private monies. It was basically similar to the PFI for schools and hospitals - just smoke and mirrors to get debt of the govt's balance sheet to make our huge borrowing deficit to look better than it really is.

The taxpayer did pay for the trains though, but in addition also paid billions in dividends to private companies that could have been further invested in the UK railways, rather than being a subsidy to the Italian and German railways.

I can’t compare old state services but to other countries that do different models, they can benefit from extra money pumped in to the overall system via incentives like tax rebates

The opposite to trying to burden the state system more by making private more inaccessible.

The whole idea of public health and education is not just for the education and health part, it is for the social benefit. Inclusive, well-funded services benefit everybody, leading to stable, productive, peaceful societies. Division within society is what creates discontent. The most volatile countries in the world are where inequality is highest - this can be money, but also opportunity, power etc.

Ideally, education, health, water and transport would be properly funded, serving the population and leaving no real incentive to opt for private except for vanity.

Yes I think that would be a good system , we've taken out private health care because I truly believe you cannot rely on the NHS anymore.

These things in the main are not publicly funded though.

Wealthy folk can already by-pass the state systems and these private concerns contribute little/nothing towards the costs of the staff the state sector has trained and given experience too.

All a bit one sided, lets see the private sector fund the training of their own staff and then see if their economic model is sustainable?

Inequality is there because the average person has to wait 2 years for new hip, give up work and go on benefits because the wealthy simply do not pay enough tax or in the case of companies, decent wages, favouring the shareholder instead.

Yes, but the costs are spread out over many years, so basically kicking the can down the road instead of paying up front and thus avoiding the costs adding to the national debt. As I say, like PFI being used to pay for all those shiny new schools and hospitals that our children will be paying for.

I am glad we are in agreement that the poster who said that the taxpayer didn't pay for modern stock of trains is mistaken.

@Chocolatefreak Division within society is what creates discontent. The most volatile countries in the world are where inequality is highest - this can be money, but also opportunity, power etc.

My point is that we already have this division and are simply entrenching it even further by insisting that the two systems stay worlds apart from each other.

They are not worlds apart, the private insurance sector leach off the NHS for staff and experience and take the easiest and most profitable treatments, they don't do AE, wont treat chronic conditions and stay well away from majority of cancers... and when they screw up, its the local NHS they send their patients to be fixed, in our local Nuffield's case, they don't even have their own MRI scanners, using the NHS ones instead.