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.

Your proposed approach will increase the number of people who can buy their way better but it will decrease the resources for those with low incomes. So it would, overall increase inequality.

Because the people who pay for private schools also pay the tax? But sorry, I forgot - this is MN, so cannot possibly have the ‘rich’ people benefitting from any of the tax they pay….

Bluntly, I'm solving for "stable and fair society", not "society with the lowest absolute inequality".

As it happens I believe that very high levels of inequality, combined with a sense that one's personal situation is impossible to change within the existing system, does contribute to instability in society (if people feel the only way out is riots & revolution).

So I don't want to increase inequality just to be a bitch.

But I do want to increase mobility up the scale (and yes, this does imply the possibility of slides down). That is how to address the italic part of the statement above. Which is just as important as the first.

No one is suggesting we get rid of private schools or private hospitals & not everyone who uses private schools pay tax in the UK either, my brother never did, yet his wife and family benefitted greatly from what other tax payers here in the UK paid.

In the UK you can top up state education with paid tuition or move close to a very good school or pay for 11+ tuition.

PFI being used to pay for all those shiny new schools and hospitals that our children will be paying for.

Most of them are 30 year contracts so unlikely.

Best way and its widely acknowledged to do so, is to improve educational attainment for all & that means spending the sorts of money on state as is spent in the private sector.

Even now, the most likely to missing out on an education are the kids on free school meals.

Thank God we have them, imagine the state the NHS would be in now, if they d never been built?

Is this based on outcomes from other countries?

Quite a few have mixed systems does it move them towards higher inequality?

Also if you’re going to do private and state mix you’re probably better off not lumbering people for decades with increased costs as PFI did

From what I recall of my economics courses, though I can’t quote the papers etc. - In general, where state provision allows people to add on or where it only covers a minority of people, the base provision by the state goes down over time.

Of course there are also lots of other things that can influence state provision and wealth inequality. If you want to tackle those things you need to look at the whole system. But since we are only talking about this one lever, it is not likely to decrease inequality.

...as does all Govt borrowing, Blair faced the choice of adding to national debt, increased taxes, PFI or not making up for the lack of investment in health by the previous Tory govt... which is what the current lot have done too, underfunded the NHS.

Imagine how much more there would be to spend on the NHS without the costs of PFI.

https://www.nao.org.uk/press-releases/investigation-into-the-rescue-of-carillions-pfi-hospital-contracts/

Thanks for this. I know a few countries used a mixed system and charge varying amounts. They also have a variety of levels in inequality.

People seem ok with state plus private if in PFI form, I do t think that’s coming back for good reason. But a mixed model has been used.

As a way to get more disposable income into the system I’d look at other countries. The biggest issue is even if they were better parties likely won’t propose it and people won’t vote for it.

Don’t think..

Look up Benenden.

“Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.”

A two or three tier system would deepen inequality and simply allow those with financial advantage to put themselves first. It already happens but any further attack on the free at point of use principle is unforgivable and must not be allowed to happen.

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

The trouble with this though is you're back to it screwing over the poor.

If you and person A both need a knee replacement. You have 2k so you get yours done in 2 months instead of 2 years. Person A can't afford that. They also have a manual job where they're on their feet all day. They end up having to take time off such, increasing their financial instability. Maybe they have to leave the workforce - their job would have sucked up their being ill for a month or two but not for two years.

Obviously that's an imaginary example, but can you see how what you're proposing is likely to increase the health inequalities experienced by those members of the population who are already suffering the most deprivation?

@Augend23 but in your example, the less fortunate person has a 2 year wait in any case - all the negative consequences are STILL true under our current system. At the moment you can get it done on demand privately for a cost of £10k.

Healthcare is not a finite resource, it responds to the forces of supply and demand. More people paying higher prices would increase the supply, as well as general investment in facilities, tech and staff that benefits all. State resources can then be focused on the smaller subset that really need it.

what the OP suggests doesn’t make it worse in the absolute sense for the poorest, and in fact proper policy would ensure improvements for all, even the poorest. So the person with no financial means gets surgery in 12 months instead to 24, and a whole bunch of others get surgery within 3 months instead of 24, and the wealthy continue to schedule surgery at their convenience with a surgeon and hospital of their choosing.

I asked this earlier in the thread, but no one answered, perhaps you would be so good as to give it a go.

My daughter needs heart surgery. There is a waiting list. Currently those in greatest need get treated first.

If the system proposed existed I could pay for her to have surgery sooner. Lets say I have booked the surgery for next Thursday. The surgeons are booked, the multi-million pound operating theatre, the team of medical professionals, the PICU bed she will be in afterwards is reserved, everything is ready.

On Tuesday of next week a baby is born with a heart defect that needs life saving treatment. Since I have paid for the surgery next Thursday, do they operate on my daughter, or on the newborn?

On the way to school on the Thursday of the surgery there is a bad car accident and a couple of children need intensive care. I have paid for a bed, so presumably my daughter still gets it and her surgery goes ahead? So which of the other two children who need an ICU bed does not get one?

@schooloflostsocks we already have a two tier system. I had a minor foot surgery done privately (via insurance paid by my employers). If I went NHS I would have had to wait YEARS, and it would have had to degrade significantly, with long term impact on my mobility, restrictions on ability to exercise, and significant pain.

instead I went private and had it done within weeks, scheduled at my convenience around work commitments with a surgeon I chose. It was done in a private hospital where I had a private room, catering on demand and concierge services available. Follow up visits and physiotherapy (which NHS would not have offered) were also readily available and scheduled at my convenience. I missed a couple days of work, but otherwise no disruption- definitely worth it for my employer.

the NHS option is absolutely unacceptable for anyone, but what 90% of people in my situation would have had to accept. Not everyone needs (or wants) the platinum option that I received (I didn’t either really), but increasing the number of people getting adequate care surely is a good thing?

@jgw1 you see it as a fixed pie of healthcare, which makes sense in a state monopoly like the UK, but there are plenty of other countries where there is enough slack in the system to treat everyone in an emergency health crisis. The slack comes from some people paying more for luxury elements (choice of physician vs. assigned, scheduling at convenience vs assigned, choice of implant, extra rehab, on demand access to consultations, etc) which means there are always extra beds, surgeons, surgical theatres, nurses, diagnostic equipment, etc. you don’t choose between the child who needs heart surgery, the newborn or the car accident victim because you can treat them all. Some might have private rooms, some might have better rehab packages, or better aftercare follow up, but all receive critical treatment when they need it.

at the moment we have stroke victims waiting hours for ambulances when every minute counts

A paedicatic cardiac hybrid operating theatre costs millions of pounds to build.

You seem to be proposing having several spare, with the associated surgical teams so that people can choose when they have their operation. This would be close to doubling the current capacity in the UK.

I would be interested to learn which countries you think have such spare capacity?

The issue is, that the health care is very expensive to set up, operate, scale and keep ready even when noone needs it. We can speak about costs of having the health care ready and cost of using it at the specific moment.

At veterinary medicine it is clearer. In human medicine lots of the "going private" is in reality only about bribing the doctor for jumping the queue, using the very same resources as everyone else, when the base costs for having them are already paid from the shared pot.

I understand that current state of NHS is terrifying and people would like to find a way how to get something better, but the only way which would really lead to something better is pressuring government to get something better for everyone.

@jgw1 the exact stats you are looking for are difficult to collect, which I suspect is the straw man behind your argument. Can’t precisely prove you wrong, so maybe you are right?

But then most developed countries are better resourced than the uk. The UK has one of the lowest ratios of cardiologists per million population amongst developed countries. Getting basic diagnostics done in the uk takes weeks or months, while in other countries it is more typically weeks or days. Other countries operate with far more slack in the system than the UK - we can quibble over exactly how to measure paediatric cardiac capacity, but in most developed countries there wouldn’t have to be a choice between patients in need.