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.

Yeah. This doesn’t work. It’s ok for a utopia one off injury to one person where the family has savings to then opt to go a private pay route. But what about the second injury? Or third? Or what if their child breaks their arm? Or is diagnosed with leukaemia? Or the mother gets breast cancer? What then? What savings are left? And “Withdraw on the mortgage”- what if they are one of the millions of families that private rent because they are not even well enough off to own their home?

All you would be doing is creating more tiers of inequality with those least able to pay shut even more out. Right now private pay rich folks jump the queues and never even go into an NHS hospital. Your idea is to have the government subsidise less rich, middle class people to jump the queue in the NHS by paying copays.

Combine this with the fact that the sickest and the most chronically ill, most in need of healthcare (the disabled) are the most likely demographic to be in poverty and completely unable to do any “every day reach” like you envision. They’ll be quite simply left to die while on a waitlist that everyone not disabled and able to work a bit of overtime or have a pot of savings steams ahead of them in the NHS queue by paying their £20 or whatever. Keep in mind while a healthy person may need that £20 once or twice a year, this can quite often be several times a week when you are disabled and fighting numerous life limiting, chronic health conditions.

I'm confident that a part-pay system would cut the number of missed appointments. That's an advantage to everyone, including the doctors.

Other systems do work well. It’s worth looking at those to see how they do it

I think it would increase the % of missed appointments.

They’ve researched why people miss appointments it is often due to work or childcare, next is unable to afford cost of transport/or even get transport anc 10% never getting the notification they had an appointment.

If you had to pay for an appointment it would be payment after the appointment so, there wouldn’t be a situation where you’d pay £20 to book and then lose the money if you no show. That’s not how the model works. You pay when you attend the appointment. If you no show, you don’t pay.

So if we had copays, people would have an appointment and be forced to miss it due to not having the money for the copay as an additional reason to the known ones above.

There might be fewer appointments in total though as a recent survey showed that 1 in 4 Americans did not even make appointments because of the cost of the copay. They simply deferred seeking medical care. Which as you know can result in an increase in A&E due to conditions not being treated in time. So this idea of £20 to see the GP would actually cost more money in 3rd order impacts that it would generate.

They work well because they are better funded by their governments, there is no other cause/reason.

Are you basing your views only on the US system?

No.

@StefanosHill
’They’ve researched why people miss appointments it is often due to work or childcare, next is unable to afford cost of transport/or even get transport anc 10% never getting the notification they had an appointment.’
U.K. research on missed NHS appointments

‘If you had to pay for an appointment it would be payment after the appointment so, there wouldn’t be a situation where you’d pay £20 to book and then lose the money if you no show. That’s not how the model works. You pay when you attend the appointment. If you no show, you don’t pay.’
Every copay system in OECD for general practice

‘So if we had copays, people would have an appointment and be forced to miss it due to not having the money for the copay as an additional reason to the known ones above.’ logical outcome for U.K. when many are already missing appointments due to not having the money for transport to the appointment, plus cost of living crisis

’There might be fewer appointments in total though as a recent survey showed that 1 in 4 Americans did not even make appointments because of the cost of the copay. They simply deferred seeking medical care. Which as you know can result in an increase in A&E due to conditions not being treated in time. So this idea of £20 to see the GP would actually cost more money in 3rd order impacts that it would generate.’ What happens in the US due to human behaviour. Human behaviour that would apply to U.K. if we made GPs cost money to see. You would have people not seeking healthcare because they don’t have the £20. So we would end up with more A&E patients dependent on the NHS to step in because patients let mild conditions progress to serious/life threatening before seeking healthcare.

Which metric are you using?

% of GDP is slightly above OECD average

This is quite good, latest that came up

https://www.oecd.org/unitedkingdom/health-at-a-glance-UK-EN.pdf

% GDP is meaningless.
Funding on a per capita basis is very low. (US is an outlier)

You’d better let the people who included it as relevant.

People know at oecd.org

See this report on why Universal Health Care is the best model
https://www.oecd.org/els/health-systems/Universal-Health-Coverage-and-Health-Outcomes-OECD-G7-Health-Ministerial-2016.pdf

% GDP is only relevant to economists, it’s not a measure that is relevant to whether a healthcare system is adequately funded for the population it serves or how “good” a system it is.

Besides, we should be looking at G7, not OECD for our comparators.

No point looking at the very recent post Covid funding settlements when analysing issues with the NHS.

The long term underfunding of the NHS is very well researched, compared to the best funded EU health systems, the NHS suffered an approx real terms £40bn per year shortfall in the first few years after 2010, there is a very clear reason why we have so few staff/equipment/scanners.

Now what we are having is throwing money at the problems with no long term plan, hard of course for the Tories as they may well be in their last year of office.

Yes @Kazzyhoward Some stupid decisions on funding made in the Blair years, money wasn't always well spent, as it often isn't who ever is in power... i see that now in defence.

we only pay for what we can afford, it is the same all over the world, no matter the labels put on any given system

even very great professionals who charge thousands lose patients, so there is no a recipee for success in any human made system.

And this
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/articles/howdoesukhealthcarespendingcomparewithothercountries/2019-08-29

• “However, of the G7 group of large, developed economies, UK healthcare spending per person was the second-lowest, with the highest spenders being France (£3,737), Germany (£4,432) and the United States (£7,736).”

I found that link pretty good actually at setting out where we sit against OECD

If we’re spending OECD average for % of GDP where’s the issue?

Our GDP is lower per capita overall?

In which case trying to get more money from people for healthcare will be tough. Real healthcare spending has gone up over the last decade or so but our needs outstrip it.

Ageing population will mean we need higher than real terms funding. Who will you tax more?

There is this analysis of spending vs performance
https://www.taxresearch.org.uk/Blog/2021/08/05/the-nhs-is-suffering-from-underfunding-and-its-showing/

“The NHS has little spent on it, but delivers above average performance for that, still. This is highlighted in this chart:”

”So what to conclude? First, the NHS remains good at very many levels.
Second, it is not as good as it was. A decade of underfunding is now showing.
Third, we are paying a price in health care outcomes for not spending enough on healthcare. The absence of slack in our system; the absence of a culture of caring in government and the failure to act in preventative healthcare, so apparent during the Covid crisis, all impose a considerable cost on the U.K.
And, quietly unspoken behind all this is the fact that the U.K. has pockets of dense poverty and pervasive inequality throughout the country which in reality denies access to healthcare. That may be because people cannot afford time off to attend a surgery. But it also impacts through many aspects of lifestyle, including diet as well as decent housing. Fuel poverty is another issue: people do not die of flu in the U.K. any more than they do elsewhere, which is almost not at all. They die from pneumonia, most of it linked to poorly heated houses. This is the scandal behind this data.
Covid has revealed the underfunding of the NHS, as well as government refusal to do anything about it. But the bigger issue is that we tolerate poverty in the U.K. in a wholly unacceptable way, condemning many to poor health and early death. Government indifference to that is now beginning to show in the data. The Labour investment in the NHS has worn off. What is left is a sorry shadow of what we need.
It would be really good to have new commitments to the NHS, and the commitment to fund them. Investment in health care by government is known to have a rate of return well in excess of the sums spent. Why won't this government spend in the NHS in that case?”

Thats simply not correct, Govt's have choices to make, so an obvious one would be "Build a railway to save 20mins on a 3hr journey or buy new scanners, build more hospitals and train more staff"

Another, Have Austerity for 10 plus years or have it for 5 years and then borrow (at almost 0% rates) to improve growth and productivity" which is what almost all european countries did.

The issue is that GDP measures the gross domestic product of a nation. It has nothing to do with how many people are in the country or how much healthcare is needed.

If you are a poor country with 100m people you will have a lower GDP and so need to spend a higher % of GDP to get the same level of healthcare as a rich country with 50m people and a higher GDP. Healthcare is relatively inelastic except that poor people tend to need more of it than rich people due to the health impacts of poverty.

The stat is mostly for economists to measure the financial stability of a country. It’s not meant to be used to ascertain how healthy the populace is.

Who will you tax more?

The corporations and wealthy.

Ok sounds easy, if people are static and comparative attractiveness doesn’t matter.

R of Ireland is doing incredibly well from lower corporation tax. Starting to talk about a sovereign fund from those wealthy US multinationals.

Please do tell where the extra money is going to come from to just fund more from taxes.

It's always "someone richer than me".