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.

private schools get charitable tax relief.

I pay in to Benedon, £12.95 a month, which means if I need a common operation other than joint replacement or heart surgery & have to wait longer than 5 weeks on the NHS, I can go private.

I think the insight missing from this thread is that you can have a public commitment to e.g. universal access to healthcare without it having to be provided directly by a government funded monopoly. There are examples of this round the world that we could adapt.

I think the previous poster(s) nailed it though when they said the UK is now too poor to make such a change.

We have got too many people who wouldn't be able to pay anything at all into e.g. a social insurance system and without the time or skills to handle a system where you need to shop around a bit, so we are stuck with what we've got. Especially as politicians don't dare touch it.

My daughter was a patient in the UK in a hybrid cardiac operating theatre 11 years ago. Spain's first similar operating theatre opened in 2020 (Barcelona) Israel's 2022.

I will ask you again which countries (noting there are some of our near neighbours who don't have the facilities at all) have such theatres that are usable on demand by a paying customer, without the need for clinicians to make a choice between patients?

@jgw1 as you have paid the baby goes first on the morning list but your 10k is used to staff the operating theatre out of core hours with the ST8 performing one or more of the surgeries from that day.

To get the PICU bed you can look to bring in extra staff to either step down one the patients that isn't ready for a normal ward ratio but could say go to PHDU if more staff were available. If you can't do that offer out a locum shift to run one of the recovery beds as a ITU or if you have an adult bed free someone goes to ITU with appropriate staffing cover from the 10k.

The NHS is the master of doing more with less resources, doing more with more resources would be a walk in the park.

@sleepyscientist could you just help me with a few details. Who is going to staff the operating theatre outside of core hours?

The surgical team has been operating on the patient for 7 hours. The lead surgeon and consultant anaesthetist started work around 7am, they were able to hand over to PICU at 4.30pm. Around 7pm they spend some time with the family of the patient explaining what they have and haven't been able to achieve. Are you suggesting that at this point they start surgery on the next patient on the list?

Where are you finding the extra PICU staff from?

Unfortunately the theatres and hence recovery room is on a different floor from PICU, so using the recovery room as an auxillary PICU, would not just require two additional suitably qualified nurses, but also an additional consultant intensivist. So that is non starter.

There is a spare suitable adult ICU bed in the next city 70 miles away. When is there a KIDS/NTS ambulance available for the transfer? Presumably you have to move a non-paying patient, they will then need to be returned to the children's hospital for futher ongoing care on the ward as their condition improves.

@jgw1 i am not going to join you in your rabbit hole. The reality acknowledged by pretty much everyone is that the nhs is pretty chronically underfunded, has crumbling infrastructure and outside of a few flagship investments, is massively behind its neighbours when it comes to innovative medicine being available to those that would benefit.

The question is how to fix this. Some of us believe better integration of public and private, alongside active revenue generation in the form of nominal fees and an ability to purchase benefits that matter to you (like a gp appointment you can put in your work diary or a private room or a better knee replacement) is going to be a critical element in addressing the funding gap. It doesn’t have to be any more unfair than the current setup - loads of people would have access to better care instead of just the top 10% and state resources could be prioritised for the truly vulnerable.

The reality is the UK is well on the road to privatisation - increasing numbers are taking up private health insurance or paying full whack when they realise how dire things are. The real question is whether the public system can take advantage of an increasing willingness to pay for healthcare.

In my proposed universe more people stay as doctors because they actually have a chance of earning a decent salary in a private system.

"The private system would steal all the NHS-trained doctors"

Sorry, but where do you think NHS-trained doctors go today? Not into the NHS, they all quit after 2 years and go work for bloody management consultancies. I know, because I work with them! At least if they got poached by a private hospital, they'd still be available to do surgeries for people, relieving pressure off the waiting lists!

Its not a pretty train of thought to follow is it, because allowing someone to pay for surgery has meant that a newborn whose clinical need was greater died when they could have survived and led a fulfilling life. Such though is the world that those who advocate private healthcare aspire to.

But yes, essentially we come to the core ethical dilemma which is

A) treat more people, but you have an unequal chance of being the one to receive treatment

B) treat fewer people, but everyone equally has the chance to be the one to receive it

Which one is preferable depends on the actual hard difference in numbers. We all lean one way or the other based on gut instinct. But I'd argue the NHS can adequately treat so few people now that we need to move the system more towards A, even if that does mean an increase in absolute inequality at the boundaries.

One way to look at is there’s an amount of money sloshing around that people spend on holidays, food, going out whatever

And a healthcare budget which is via the state

Incentives that pull more money from those with disposable income to health care can work, other countries do it. Not really impacting on inequality

People are more resistant here as we’re not used to it, but successful approaches from o/s can be emulated without full reform

Actually replace food with restaurants etc

No. Any system that requires the sick & disabled to contribute more to the costs of their healthcare is unacceptable. These are the ones least likely to be able to afford the additional costs of a private-public mix. And we know from the excess deaths rates in other countries solely do to being unable to afford healthcare that such a system literally means condemning innocent children, women and men to a painful and lingering death due to their illness/disabilities.

These systems are only better for those who are blessed with good health and a good income.

Sounds like a strong arguement to me for taxing wealth.

Why is that the Prime Minister pays a lower rate of tax on his income than an NHS nurse?

A= pay £££ to skip to the head of the queue and fuck the poor, sick and disabled.

No thanks, I’d rather we all agree to pay a bit more tax and not just we individuals but also businesses so that the NHS were properly funded.

Can you say which countries you mean?

I don’t think all private plus state systems are as such, are they

It depends on your point of view. I'd see a part pay system as pulling up the experience and standards for everyone, including those that can't pay.

A lot of people already have this option through work group health plans.

Through a, free to me, plan I can access private GP appointments, physio, annual health checks ups, scans, private rooms. It is not designed to replace NHS treatment but supplement it, although I can choose to pay more for an enhanced plan.

I think a scheme that makes that kind of stuff more accessible to individuals would be good. I love the NHS but it is generally very shit at minor or preventstive stuff. I have had persistent but manageable lower back pain but manage since lockdown. I could not access my NHS GP to talk about it. I spoke to a private doctor through work, was referred the next day to a physio and was diagnosed with a spasming piriformis muscle and I have a course of physio exercises.

It is now getting better

@jgw1 i think you need to work on either reading comprehension or critical thinking. The scenario you describe is a fever dream of your own creation.

No. Your are still ignoring the issue of costs proportion. Current going private doesn't cover full care with it's full costs. It's just a glorified copay for jumping the queue.

Let's make a model here. Let's take large dog's veterinary medicine as a good approximation of the real commercial costs of health care.
Simple consultation is about 60£.
Any actual treatment starts at higher hundreds for minor things.

Private human GP appointment costs about 60£ as well. Any actual trearmenent costs more and unless it is something easy and easy to profit on, it goes back to the NHS.
If the treatment costs 1200£, saving NHS 60£ for the initial consultation means getting better (more timely) care with your costs 95% publicly funded. Your suggestion you should be able it get it with your meagre 20£, meaning 2,5% of the costs is absurd.

What I'm trying to propose is a system that allows and enables "small reaches" for everyday people, to avoid some of the situations in this thread.

For example take someone who works as a manual labourer, i.e. someone working class but not on the bones of their arse. He injures his knee and is told it's a 2 year wait on the NHS, no physio etc. 2 years without income (or significantly reduced for him as he needs a working knee for his job) would be devastating for his family.

He doesn't have full-scale private insurance and can't afford the full-freight price of his treatment. He has a bit of savings and could withdraw a bit on the mortgage, and treating this is a major priority for him and his family so they're prepared to pay what they can.

I want to live in a system where he has options. There are many many more people in this category than people who literally have nothing. If these people had an avenue to put in what money they can, yes for a bit of advantage to themselves, state support could be directed to the people who really don't have anything.

The system where he gets full perfect treatment immediately on the NHS completely for free doesn't exist, so stop talking about a dream world

It’s a situation that could easily occur. And does. Check this out.

http://digitaleditions.telegraph.co.uk/data/1397/reader/reader.html?social#!preferred/0/package/1397/pub/1397/page/67/article/NaN

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

You think the Tories would have been spending the difference on the NHS ? really???

If Blair had not used PFI, the borrowing would have gone to national debt or it would never have been done and we'd have an even worse NHS.

The cock up was in negotiating the contracts, not PFI itself, borrowing for improvements is a common way of funding.

But what options?
The copay system called private care works only because only a small proportion of the population enters it. The moment majority would, it would transform a simple queue to a queue of "jump the queue ticket holders".

Previously you suggested 20£, now we are getting to withdrawing from the mortgage, which can be more substantial sum.
Won't it be better to slightly increase the taxes and rise the money together, than to deplete all savings and equity from the working class guy from you example, so when his child needs treatment for allergies two years after that, they would be in the bones of their arse situation?

To an extent, yes, but some of the spending wasn't actually "necessary". Such as the huge 3 story building which replaced a small GP surgery near us. The idea was for it to be a "health centre" with out patients, x-rays, audiology, podiatry, etc. The top two floors have never been used and are basically empty. Half the ground floor is barriered off and never used. It's basically just the same number of GP treatment rooms as the tiny building it replaced, and none of the promised extra services have even happened. It's a monumental cost that simply wasn't needed - a sheer waste of taxpayers' money. A replacement "like for like" size of GP surgery would have been a fraction of the cost. I think a lot of the "shiny" new hospitals and schools was because they could, rather than because of need - all down to vanity rather than necessity.