This uproar about the government charging for the NHS and not telling anyone

This article has been shared a lot on social media today:

https://opendemocracy.net/ournhs/richard-grimes/government-moves-to-consider-nhs-user-charges

It says the government has launched an inquiry into whether the NHS should have an upfront cost, or user charge, at the « point of delivery », which is where it is currently free. It also says this was decided in the House of Lords, making it completely undemocratic.

If this was true, I’d be outraged. As it is, the fact that it has even been mentioned is fairly outrageous, along with the concept that the unelected Lords can have any say in anything. (Although a lot of them have a lot more expertise than many politicians, though they also have no concept of real life for a lot of people. And it’s not democratic).

What actually happened, if you refer to the Parliamentary transcript, is a bit different. I appreciate that not everyone wants to spend their morning reading through pages of Parliamentary transcript and the supporting notes, so I am going to do a brief summary here. I’m not telling you not to care about this, just asking you to be a bit more informed about exactly what was said as the article being shared is a bit loaded…

The initial debate was one requested by a Lord to look at the sustainability of the NHS as a free service at the point of need, so yes, whether the NHS should remain free to users was asked to be debated at the House of Lords. Depending on how much influence the outcome of the debate was allowed to have (and I’m fairly openly anti-Tory so I think far too much), this is pretty poor from the government.

A note was issued to members, available here: http://researchbriefings.parliament.uk/ResearchBriefing/Summary/LLN-2015-0019

which refers to an NHS report, also available through a reference in the document, stating the following:
« Preserving the values that underpin a universal health service, free at the point of use, will mean fundamental changes to how we deliver and use health and care services….[W]ithout bold and transformative change to how services are delivered, a high quality yet free at the point of use health service will not be available to future generations. Not only will the NHS become financially unsustainable, the safety and quality of patient care will decline ».

This is where the reference to free at the point of use comes from. The report (and note provided to Lords) does not say that the answer is to stop it being free; it is more in the way of a threat, that unless we get our act together we can’t go on as we are. To me, the intention to keep it free is maintained, at least in the NHS report and subsequent Library note.

Then onto the Lords debate. In a very quick summary, I will outline exactly who spoke on the issue and what they said about user charges in particular – there are 17 participants so it isn’t incredibly brief but it’s a lot shorter than the original transcript.

1. Lord Patel (CB): Lord Patel introduced the issue, outlined issues with the increasing use of the NHS, and then with regards cost to users had the following to say
« If we persist in the same way as we have done for the last 20 years we will see a gradual shift to a two-tier system: those who can pay will get care; those who cannot will not. The variations in care will get wider. »

(Obviously I am now doing what I criticised the original article for and only giving a part of what was said and giving it out of context, but I’m trying to be a bit more balanced and give exactly what was actually said on user charges).

2. Lord Fowler (Con) then spoke also acknowledging the increasing demand on the NHS. He has a bit of a push for charging at the point of service:
« what is required at the start of the new Parliament is a thorough, independent and authoritative review of the financial pressures that the health service will come under, and at the same time to set out the options for financing healthcare. We may find that funding it out of general taxation is the best and most cost-effective method—I certainly argued that it was a cost-effective service when I was Secretary of State—but we cannot have a sensible debate on the way forward without examining the other issues. We could have a ring-fenced health tax, or look at a potential system of health insurance. We should explore the part that charges could play: I always found it extraordinary that, for example, prescription charges caused so much upset, given that about 70% were prescribed absolutely free. »
This acknowledges the idea of it, and could be a sneaky way to bring it in. Or it could just be not ignoring the elephant in the room. It certainly doesn’t seem to be fully in favour of it without more information, but again it depends how that information is obtained.

3. Next was Lord Turnberg (Lab), who backed up suggestions for a Royal Commission to look into the issue. He gave a few examples of inefficiencies in the current NHS system, particularly around Acute Trusts and middle management, but argued the NHS should be sustainable with some reform. He made a bit of a dig at the government for reducing NHS spending in the name of austerity measures, argued for better integration within the NHS, and ended with « The question is not whether we can afford a health service free at the point of delivery but whether we can afford one that is hidebound by disincentives in the way I have described. »

4. Baroness Emerton (CB) defended the work of nurses and midwives, hailing them as heroes and heroines. She stressed the importance of high quality nursing, then had this to say about costs « If the outcome is unaffordable then difficult decisions have to be made as to the level of service that can be provided, or money found to meet the costs. »

5. Baroness Gardner (Con) was big on dentistry and, unrelated to the costs debate, had this to say which I took a bit to heart:
« I want to make one other point about Manchester. When the city gets all these new powers, I hope that it also gets a bit of sense. »
But back on topic: the only comment made about costs was still linked to dentistry:
« I would like to have retained free dental examinations. In your Lordships’ House, I won a vote on an amendment on that which then went to the Commons, where they attached financial privilege and we were not allowed to debate it again. »
This also highlights that the House of Commons may still ignore recommendations from the House of Lords, though of course it depends on if they say what they want to hear.

6. Baroness Masham (CB) listed a lot of things that could be done to save money and said it was important to sustain the NHS but made no mention of up front fees or anything that could have been disguised as such.

7. Lord Warner (Lab) says mass NHS reform is needed before more money is « pumped » into it, but then says the following:
« If the NHS fails, as I think it will, do the Government increase borrowing, cut other public services further or raise taxes? Without any of these, they will have to face up to finding new streams of revenue or reducing the NHS service offer. Those are the hard facts of economic life. »
This could be taken as a nod to the need for upfront costs, or it could be a simple statement of fact, though the former seems more likely given a later quote: « Our tax-funded, largely free at the point of clinical need NHS is rapidly approaching an existential moment ».

8. Lord Kakkar (CB) pointed out contradictions between different sources of information, and with regards funding, questioned « What analysis have Her Majesty’s Government made of other healthcare systems that are committed to equity of access and universal coverage—such as those in Germany and the Netherlands—but which use different models of funding that care, and what can we learn from those models? Have they addressed similar challenges in a more effective fashion? ».

9. Lord Mawhinney (Con) starts with « Anyone who has been through what I have has to be an NHS fan. Secondly, for the record, apart from the years when I lived and worked in the United States, I have never had any private health insurance; I have been an NHS man all my life. » then goes on to say « It is time for an independent national commission to recommend how we should move from unsustainability to sustainability ».

10. Lord Crisp (CB)’s views can be summarised with « I will not talk about co-payments—that is, getting people to pay as well—other than to say that all the studies show that if they are to be big enough, they will affect both the poor and the rich: they affect the behaviour of the rich, who then go elsewhere, while the poor cannot afford to pay for services. You can have small co-payments, but large ones have those impacts ».

11. Lord Cormack (Con) worryingly said « Whether the extra funding comes from compulsory insurances or certain charges matters not, but it has to come » which is the main alarm bell being rung in the article I’m disparaging, along with « Let us now, freed from the constraints of coalition government, have the sort of boldness that the Chancellor expressed in the Budget speech yesterday. »

12. Lord Desai (Lab) suggested « He is quite right to say that there ought to be a royal commission, but I expect that the Government will pour cold water on that. » which is perhaps more reassuring as a reminder that the House of Lords can make recommendations but they can be ignored. He made an interesting suggestion of « There is no reason why the Chancellor should not tax sugar and salt and link the tax quite explicitly to the health service—even though it would finance only a very small proportion of the costs. »
It was also in his speech that the « Oyster card » idea was raised. This is not a suggestion to charge for the NHS via an oyster card. It is in line with the suggestion to put the price of prescription drugs on the boxes to raise awareness of the costs of the NHS and to try to challenge behaviours in people who are perceived as unnecessarily costing the NHS money (I am not saying whether that is true, just that it is a perception). Regardless of whether it is a good idea or not, it isn’t a suggestion to charge for the NHS. The full context is as follows:
« Another suggestion that I have made before in your Lordships’ House is that, although we do not want anyone to feel that they are being charged for using the health service, we ought to make clear to people the cost of providing it. People think that because it is free, it is costless—but it is not. »

13. Lord Ramsbotham (CB) makes no reference to introducing charges but instead asks to reduce inefficiencies in the NHS, summarised as follows: « My first point is that affordability requires the ruthless elimination of anything unnecessary or wasteful, such as silo working when more than one ministry is involved. »… »[M]y second wish, in the interests of stability and sustainability, is that in addition to the independent commission called for by my noble friend and many others, the future of the NHS should be subject to cross-party consensus. »

14. Viscount Bridgeman (Con) gets straight to the point with « I suggest that its brief should address, among other things, the question of free at the point of delivery…[T]here appears to me to be a once in a lifetime opportunity to address this issue. I suggest to your Lordships that such a commission would have the unbiased authority that would enable it to address the unthinkable of some form of selective contribution by patients for treatment »
This isn’t great.

15. Lord Reid of Cardowan (Lab): « I do not believe that the solution lies in an insurance-based system. » Again, he outlines several examples of inefficiencies and argues for tackling these to improve the funding gap.

16. Baroness Walmsley (LD) fairly crucially says « The principle that it is free at the point of need is something that all political parties continue rightly to support. ». Then as a bonus adds « I start by asking the Minister whether he will work to persuade the Home Secretary that her determination to send home some foreign nurses who earn less than £35,000 per year is unjust and detrimental to the NHS and the people of this country. » She also lists several inefficiencies to be tackled.

17. Lord Hunt of King’s Heath (Lab) refers to previous research done on the topic which states « the claimed advantages of insurance, finance or substantial increases in charges—or co-payments, as we now call them—would outweigh the disadvantages in terms of equity and administrative cost ».
Then, a point that is positive for fears of user charges but negative for hopes of actual improvements if the Lords recommendations are followed: « My experience of the NHS is that the moment you set up a committee of inquiry, it is always used as an excuse to put off difficult decisions. »

Finally, Lord Prior, the Under-Secretary of State in the Department for Health responsible for the area, responds. He quotes research with the following findings
« Private funding mechanisms tend to be inequitable, regressive … have weak incentives for cost control, high administration costs and can deter appropriate use »
« There is at least no evidence to suggest that a tax-funded system is less effective or efficient than any other system. Indeed, tax funding allows the collective pooling of financial risk across the whole population for collective benefit. »
Accusations of him being overly pro-marketisation seem quashed by his quote « The market does not work so well in healthcare—in any country—because there is information asymmetry in the market: the patient will always be less well-informed than the professionals in the system. »
He addresses the charges debate as follows: « It is one of the only institutions we have that provides the same care—or service—to rich and poor, the lucky and the unlucky, to people born with a good genetic inheritance and those who are not. It is part of the glue that holds our society together, and I would not wish to be responsible for weakening those links…I am personally convinced, having looked at many other funding systems around the world, that a tax-funded system is the right one. »
He agrees some form of review is needed, which may or may not be heeded by the House of Commons.

Finally, it is worth noting that this was initiated by Lords, so Jeremy Hunt saying there are no Conservative plans to charge for the NHS could well be true as this hasn’t come from him or from Cameron etc. But equally, never trust a Tory 😉

In conclusion, I’m not saying whether I think the House of Lords was overwhelmingly for or against user charges. I’m not saying whether their recommendations will be accepted. I’m just trying to offer a slightly more comprehensive but readable summary than the article referenced at the start.