Charges are acceptable – at last the ideology of 1948 is challenged

It seems charges are acceptable for non-EU foreign visitors. At last the ideology of the original 1948 NHS is being challenged. This sets the tone of reality necessary for a pragmatic debate on the future of our health care funding. Pensioners included, co-payments will be necessary, in addition to charging foreigners. So why not make it a condition of a visa that visitors have insurance cover, or deposit a bond for future payments which can be returned electronically?

For that matter why not have identity cards for all citizens, so that their right to the NHS is evident and valued. Absence of a card could lead to a charge, and co-payments will become the routine. Of curse, if the majority of cheap and cheerful goods and services, say under the cost of two pints of beer and a packet of 20 cigarettes, are policy exclusions, then we will be able to afford the things we fear getting and being unable to pay for.

The Health Services are competing for money from the same non-existent pot as state pensions. Something has to give.. Overt rationing, exclusions and co-payments seems a pragmatic way forward.

The Times leader 31st October is “Charging ahead” and claims that the health secretary has lit the touch paper for change:

For the first time in the history of the National Health Service emergency care will soon cease to be free for all patients in all circumstances.

Foreigners, who are defined in this case as people without British residency, are to be charged for ambulance and accident and emergency services under plans put forward by Jeremy Hunt, the health secretary. If the care is not urgent they may have to pay before receiving it.

The health secretary has lit the proverbial blue touch paper. His initiative will dismay NHS admirers overseas who see the service, often without ever having experienced it, as a beacon of civilised socialism. Within Britain, Mr Hunt’s proposals are attacked as half-baked and a misguided attempt to turn doctors into border guards.

Such concerns are overblown. Under the new arrangements no one who needs urgent care will be denied it. But those who do not may be deterred from demanding it. The knock-on effects will be positive, not just for NHS finances but also for queues at A&E departments.

Critics of charging for NHS services tend to focus on the unacceptable scenario of gravely ill patients being turned away by a hospital or failing to seek care for fear of being presented with bills they cannot pay. They should focus instead on the health service’s current reality. Its promise of care for all, free at the point of delivery, is unique because no other country has found a way to fund it. The principle that care should be based on clinical need rather than ability to pay is noble, but it is unrealistic unless substantial savings can be made when care is not essential.

Figures from 2013 show that roughly half of all patients who attend A&E departments need no treatment at all, yet visits cost an average of £111 a time. When every public service is under intense pressure from the Treasury to deliver more for less, it is unfair to expect British taxpayers to subsidise free care for visitors, especially when the care turns out not to have been urgent. Mr Hunt is right to make a stand on behalf of those who fund the NHS, however unpopular it makes him with those who do not.

The criticism that the new charging proposals are half-baked is at least half right. It is not yet clear who will decide which patients should be charged, or when, or how. Nor will charging foreigners for care make a substantial difference to NHS finances. A 2013 study by the Department of Health estimated that the service was used by 2.6 million migrants a year at a cost of up to £2 billion, of which £500 million was realistically recoverable. These numbers did not include the cost of so-called health tourism (often women coming to Britain to have babies) which has been put at anywhere from £70 million to £300 million a year.

Since that study, charging foreign users of non-emergency NHS care has begun in earnest, but with limited effect. Less than a sixth of the money that could be recouped under existing rules is actually recovered. This is largely because the system for charging consists of sending letters to the overseas address supplied by the patient, with little or no follow-up when they go unanswered.

Practical hurdles, however, are no reason not to persevere with a policy that is fair and stands to strengthen the NHS. The American experience of charging for emergency care is instructive.

Contrary to myth, with very few exceptions US ambulance and emergency medical services deliver world-class care first and charge later, when patients or their insurers can afford to pay.

The roughly £70 million recouped each year from foreigners using the NHS does not include savings from sending the important signal that the service is not free to all-comers. Mr Hunt’s initiative will amplify that signal and the health service will be stronger as a result.

Robin Ash and Chris Smyth In another article on the same day in The Times report Baby boomers will send pension costs to £128bn:The expected huge rise in the number of pensioners over the next 25 years will add almost £32 billion to the state pension bill, experts said yesterday.

This week’s forecast by the Office for National Statistics suggests that a demographic time bomb is looming as the number of workers climbs slowly, while those of pensionable age surge to unprecedented numbers.

As the postwar baby-boomer generation hits retirement age, the number of people at state pension age and older is projected to grow by almost a third, from 12.4 million last year to 16.5 million by 2039.

The number aged 75 and over will almost double to 9.9 million. The number of centenarians is projected to increase from 14,000 to 83,000.

Alongside the basic increase in the cost of providing state pensions are the hard-to-quantify costs of public sector pension schemes as well as increased pressure on healthcare services. NHS England has already projected a £30 billion funding gap by 2020.

Today there are 31 people of pensionable age for every 100 of working age, but by 2039 this will increase to 37.

“Over time, everyone will be entitled to the full new single state pension which is expected to be around £151.25 per week when introduced next year, or £7,865 per year,” Steven Cameron, a director at the pensions company Aegon, said yesterday.

“So for every extra million pensioners over state pension age, there’s a cost of £7.8 billion even before allowing for inflation increases. If there are 16.5 million pensioners over state pension age in 2039, that’s a yearly cost of £128 billion.”

Actuaries were unable to quantify the impact the ONS projections would have on the pension bill for the civil service, teachers and others in the public sector. MyCSP, which administers the principal Civil Service pension scheme, is paying 670,000 pensioners £4.2 billion annually.

The increasing number of pensioners will put such pressure on pension and health spending that the chancellor will have to break his rule to run a surplus in “normal times” by 2023, research by the Office for Budget Responsibility has predicted.

According to the Intergenerational Foundation think tank, the UK’s public sector and state pension liabilities are so high that the amount that future generations will have to pay off through their taxes is several times larger than the national debt.

Angus Hanton, the co-founder, says: “Unless urgent action is taken, the increasing take-out of state, public sector and private sector pensions will bankrupt the young. The triple lock must go, retirement ages must rise more rapidly and those already retired need to accept that they will have to take less, for longer.”

With demand for NHS services rising at 4 per cent a year, mainly because the population is becoming older and sicker, alongside the cost of new drugs, NHS England has already warned of major financial shortfalls.

It has a projected an annual £30 billion funding gap by 2020, of which the government has promised to contribute £8 billion, leaving the rest to be found through efficiency savings.

The Health Foundation think tank, predicts that the gap will grow to £65 billion by 2030 and could even top £100 billion if no efficiencies are made.


This entry was posted in A Personal View, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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