The nhs is one of Britain's great institutions, touching the life of almost every citizen. The largest employer in the country, it delivers us into the world, protects children from once-fatal illnesses, maintains our bodies as parts wear out and helps us reach our three score years and ten. Now the health service is itself ageing: like many people at 50, time is beginning to take its toll.
The world in which the NHS now finds itself is different from that of its youth. Although we are oddly loath to admit it, Britain today is a much richer country. Per capita incomes have almost tripled during the lifetime of the NHS and many goods and services once beyond the reach of ordinary people are now part of their everyday lives.
When Bevan launched his free, state-financed health service, life was still a struggle for most people. Rationing was accepted because it provided better nutrition for the majority of the population than at any time in history; home ownership was for a minority; cars were owned by a privileged few; foreign holidays were unknown; most homes were devoid of the appliances now enjoyed by more than 90 per cent of households. Providing healthcare free at the point of use was then a good way to ensure that it reached most people. People were happy to queue for a service which offered them far better treatment than before.
Today, only the health service is rationed in Britain. Even those in the bottom 20 per cent of households enjoy standards of living that would seem luxurious to the average working class family of the late 1940s: central heating, washing machines, refrigerators, telephones, televisions and videos are to be found in more than 70 per cent of the homes of those in the bottom fifth of British income distribution.
Yet for most of our healthcare we continue to rely on a free state-provided service which ekes out its limited resources using a variety of techniques from lengthy queues to simple denial of treatment.
The quality of the medicine practised in the British health service is probably as high as any in the world. But many of the institutions through which it is provided are shabby and poorly organised to a degree that would be unacceptable in any other walk of life. The NHS has fallen behind health services in many other countries in terms of the treatment it offers and the quality of its service. You are more likely to get kidney dialysis in the US, where it has to be paid for, than in Britain. The same is true for other expensive forms of treatment.
People put up with a second-class health service because they have low expectations of it. A 1997 Which? report on hospital stays found a long list of complaints from a sample of 30 patients. Despite criticising delays in admission to hospital and their treatment once there, patients said they were "generally happy with the care" and "surprised that their stay in hospital turned out to be better than they had expected." This was because they perceived the NHS to be "run on a shoestring," with staff and bed shortages, long waiting lists and antiquated hospitals.
There are many obstacles to providing the healthcare people want, not least the belief that the NHS is the best in the world or that the only alternative is a US-type system which bankrupts patients and leaves millions without healthcare. Yet in most western countries, health services are available to all without queuing or other forms of rationing-and without creating unacceptable costs.
It is often claimed that the NHS is underfunded and that a modest increase in taxation could provide the resources it needs. Polls show that voters say they would pay more tax to improve the NHS. But in practice people are sceptical about whether higher taxes will provide better services.
Yet richer societies spend more on healthcare; people are, indeed, starting to spend their own money on treatment, from private practice for small operations to over-the-counter medicines. Some ?500m is spent every year on alternative therapies such as homeopathy and osteopathy. Walk-in clinics are also growing fast. Sinclair Montrose Healthcare opened its first two Medicentres in London in 1996, offering a 15-minute consultation for ?36 and a full check for up to ?250. These have been so successful that new clinics will shortly open in London and in other cities. It is revealing that the clinics are advertised by a poster which shows a nurse telling a doctor: "The patient is ready to see you now"-a reversal of NHS priorities.
Many people would like to spend more on basic health services, yet are unwilling to do so through a tax-financed NHS. A Mori poll carried out for the Social Market Foundation last year registered little support for further tax increases to finance the health service. But just over half said they would be prepared to find the money if it improved the service-for example, by guaranteeing access to the most up-to-date treatments.
People can certainly afford to pay more: the average household already spends more than ?700 a year on television, video, hi-fi and other forms of entertainment. More than 85 per cent of households with children have a video recorder-a figure which holds even for one-parent families. The average pet-owning household spends ?300 a year on pet food and related items-the bottom tenth spend half that figure.
A sensible package of charges would introduce a fee for seeing a doctor, whether general practitioner or hospital physician. A fee of ?10 would raise ?3.3 billion before exemptions. Next, a charge for using hospitals at, say, ?25 for day surgery and ?50 for a longer stay. This would raise ?300m a year. Only one charge might be levied in any 12-month period, to avoid overtaxing the sick or disabled. Hospitals would be encouraged to offer value-added services for a fee, such as single rooms, guaranteed treatment dates and choice over time and date. Publishing tariffs for common operations such as hip replacements would make it easier for people to go private rather than wait-releasing resources for those unable to pay.
Overall, this package could add up to ?5 billion to the NHS budget: an increase of 10 per cent. This would be reduced if there was an extensive system of exemptions. Restricting exemptions to those on means-tested benefits would have the advantage of simplicity.
Ensuring that no one loses out from the introduction of charges is impossible. Therefore it will be important to remember that one aim of asking patients to pay is to produce resources to remedy health inequalities which are higher in Britain than in many other European countries where charging is routine. For example, free eye tests and dental check-ups could be targeted towards those on inner city housing estates who might be reluctant to pay.
But the argument in favour of asking people to pay is not simply to bring in more money. It is about recognising that people can afford to pay towards their own healthcare and will increasingly do so. The reason is that they want more choice, diversity and control over their healthcare spending than is possible with a state-financed system free at the point of use and where the patient is the passive recipient of care.
All patients have similar needs at the onset of life-threatening conditions. But much healthcare, including recovery after such episodes, does not fall into this category. Some patients will rate convenience, speed and pleasant surroundings as more important than others. As in other parts of life, we all have different priorities-and some people are happy to pay to have them met.
It is perfectly plausible that the NHS will continue to exist in much its present form, particularly if the government succeeds in finding savings elsewhere in public spending to allow a boost in the share of GDP which goes into the NHS. But it is equally plausible that the NHS will have become, by then, what its supporters have always opposed: a second-class service for those who cannot afford to pay. Private insurance now covers 13 per cent of the population, twice the proportion in 1980. At this rate of growth, it will be a long time before half the population is covered. Yet the likelihood is that, as with goods such as cars and personal computers, the rate of growth will accelerate as private insurance moves from being seen as a luxury to a necessity.
Introducing charges would raise more money and perhaps also reduce waste-diminishing the need for rationing. It could extend choice to all by increasing the resources available and spreading them more wide-ly. It would also change relationships in the NHS, putting pressure on doctors and hospitals to respond more to patients' individual needs.
Would paying lead to greater inequality? One country where people are expected to make a contribution is Sweden, the epitome of European social democracy. Swedes pay between ?15 and ?23 to see a doctor, up to a maximum of ?200 per patient per year. Yet Sweden has greater equality in health outcomes than Britain. Most European countries expect patients to pay to see a doctor, even if the charge is waived or refunded for those on low incomes.
Introducing charges need not undermine the collective provision of health services to pay for the sort of treatment which none but the wealthiest have the means to afford. The risk of serious illness, catastrophic accidents and epidemics needs to be pooled in some way. That can be organised through an NHS, social insurance funds such as are found in continental Europe, or private insurance with state help for low income people to pay the premiums.
Given the history of the NHS, it would be foolish to swap to one of these alternatives. The NHS remains an efficient organisation for pooling risk, a job that it can do so long as it retains "membership" of most of the population. But that is the danger for the NHS: that its membership is eroded by people drifting into private insurance. Those people will inevitably be the most affluent and healthy in society; leaving the NHS as a rump insurer for people who are too poor or unhealthy to take out private cover. The challenge for the NHS is to adapt its service to maintain its role in the job it does best: pooling the health risks for the entire British population. The hardest part will be to realise that preserving one of the NHS's fundamental values-a universal service-can be achieved only by sacrificing ano-ther-free at the point of use.
A free service was essential in the peculiar circumstances of postwar reconstruction. Today it looks anachronistic. But a universal health service which retains the membership of most of the population remains as valuable for social cohesion today as it was 50 years ago. It is worth fighting for.
