If Beveridge were alive today he might introduce NHS charges

Nick Timmins in The Guardian reports and opines 1st July 2016: If Beveridge were alive today he might introduce NHS charges  (When he produced In Place of Fear A Free Health Service 1952 and in particular Chapter 5 In Place of Fear, Beveridge and Bevan were both aware of the discouragement of autonomy and encouragement of dependency. State paternalism is now accepted to be a worse long term solution, by health staff but not by politicians.. Timmins is recommending rationing..

It is nearly 75 years since Sir William Beveridge’s mighty report on Social insurance and allied services, which is widely seen to have founded the modern welfare state and to have played a key part in creating the national health service. The world has changed immensely since then, so what Beveridge would say today can only be a parlour game.

It has, however, to be incredibly short odds that he would look at the current NHS and at England’s social care system and conclude that the two were just not working well together.

He would note the many more older patients with multiple conditions, and that modern medicine has long been able to rescue many with lasting conditions who would have died in earlier decades. Helping both to live well can depend as much on social care as health.

He’d look back to Stephen Dorrell’s tentative plans for social care reform in the 1990s, to the million pamphlets written since then, to the Royal Commission on Long Term Care (accepted in Scotland, rejected in England) to the (now parked, and quite possibly canned) Dilnot report, to the King’s Fund’s Barker commission and much else. And he’d decide it was time for action.

He’d conclude that no one is well served by having two separate systems run on two decidedly different sets of principles, and he’d recommend that the two become one. Not that he would find it easy to marry free at the point of use healthcare with heavily needs and means tested social care.

For many people, free at the point of use healthcare is sacred – even if there are in fact some charges, for prescriptions and dental treatment for example. It remains so despite the history of the past 30 years which has seen significant parts of what was NHS activity – billions of pounds worth of it – shifted across to the means-tested social care sector. For example, a significant percentage of those now in nursing homes used to be cared for on NHS long stay wards.

Beveridge, if his report is anything to go by, might well look for a national insurance, or social insurance, solution. He believed firmly in “benefit in return for contributions”. But he might recoil from that idea.

These days a full switch to classic social insurance is an unappealing answer. General taxation provides the widest possible tax base and is cheap to collect. Classic social insurance involves contributions from employees and employers, with some additional contribution from the state. But that has the effect of switching the whole cost of health (and of social care in a merged system) on to the working age population thus raising the cost of employment.

In an increasingly global economy, the aim should be to make jobs as cheap as possible to create and then to tax the income and wealth they produce. It is for precisely that reason that, in so far as there has been a shift in mainland Europe’s social insurance systems, it has been to introduce more general taxation.

And even if Beveridge managed to sort the funding out, there remains the immensely important question of how to organise the newly integrated service. You only have to read his chapter on how a national health service might work – it bears very little relation to what Aneurin Bevan eventually did – to know that in areas such as this he was better at finding funding answers than organisational ones.

It might be heresy to say it, but he might find it all too difficult. There are sections in his report where he sort of gives up – for example, over “the problem of rent” (a fair way to help people with housing costs). A problem with which we still live.

But he might just conclude that to get to a fully integrated health and care system requires a painful trade off. Namely that if English politicians and their electorate are not willing fully to fund a jointly free health and social care system, then some new NHS charges may be needed in return for a better funded but fully integrated health and social care approach. Given his love of insurance, he’d probably seek to devise those charges (for a GP visit or out-patient attendance, or hospital stay, for example) in a way that made them insurable.

He would not be as popular as he was when his original report was launched – queues formed down Kingsway in central London to buy it. But he might decide that was the best way to sort out a bad job. What is certain as certain can be at this distance in time, is that he would see it as an issue that had to be tackled.

This is an edited version of an article published by the King’s Fund as part of a series of short essays exploring a range of hypothetical scenarios for the future of health and care. Tweet your thoughts using the hashtag #nhsif

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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