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B,RITA.

lN'S

BIG'GE STENTE,RPRI
ideas

SE

for radical reform of the N H S

Oliver Letwin and John Redwood

1"1

.

"fiee£

2 . '95

I

l\;ote;,
wh:i;JI~

ILQIJD.ing 'l'ITI'!lcn h('!'~ ~Iw!l"ldl h(' taken

.~ ['.'pl'esenl:illljl" the> vi.'w

j~[ the Ccru'lFe f[lr PoUey Studi(,;;,.

U,i"""',

(,;;;~I'f'llSl>S ~. ::O~I}t-:lr3J.,t"o'~ji]iiun ini i~s 'p{lh!'ij~~di;l,n~, ,

page Intr,oduct ion 4

Wha t

is wrong

wi th

t he s'Yst em?

6

2.

How can

the

sys,tem be improv'ed'?

1'2

3,.

The need for ~ctjon now

20

RODUCTIO The It adu patie with
j

at"onal abs rb in

Health orne £

ervi
1

is

e big est e ter rOse a year -- a rno
0

in Brita"n" ro eve ho sa d rop ,
s

bil io
It

£500

the

ountry"

~eats almos ge t oyee

ndre
i
t

ts a d y. And
t

it is the 1 illio emp

mp oy -- a rna

w st r
twic

unde

on

as many

~n our A
a parat

n ire c enormous
s.

il service. am unt of hurna g eat majo
w

efta
0

t

goe ta_f

into ae

usta·ning

hOs

Th us
1

ity

the
y

ex raord-narily e sys em hat c gig. not be s

conscienti ut tamed.
I

rk·ng ~

nigh

and

to keep

e

sy te

a bu ea cra ic mo ster he in erest over ity
0

It negl cts
1,

pa ients, some

tre ts peop e an es

C

$es

de perately espons"bi

tretch s

do tors distr"bu

rs s, funds
in

Off ses

a d constant

-ncomp ehens"ble For bureaucra P t. many "c

ways. ears,

th
s ju

ashio
t

has bwen

to prete dad

d

ha much

hi loved

rna ster

a s "gh ly waywa

S ccessive

sup rf'ci new t·ers

1 reures' for its be
0

via ral new ri 1

'sord rs ers a posts, ib e.
t

-- introducing adm"nistration,
and

am

-stra "onl r mavin and new manag s ol"ti al y

installing be

new Bards reg r aim d ied fOr d
t

he

like -- hav
a1

ermis of

Bt
b a.s t
00

fundarne
,

change, lass' v
n

l~ r·ng s ~a

the nature
00"

e

hav

been e ough
b

Iy

AY

P litic' n
ideas as io as

hardy

to m nt"on
o

su h a ts

evo u ionary
by

imm diate y

su jecte ter

he

inte lig nt ia, un ompas "onat

a db·

ccusa

io s of be' g

nc rin

nd

4

Ii

he e

past

few w

ere consensus aimed
55

av
lS

be n che about res

.irst ,

f

n

ashionabl
rn

ac

ck

apart. by th

A

itici

as bee

a

ts ach'eved
0

.
,t

.

s be

('n the Pr

and in Parliarnen) funding Th-s's n

merely
by

ritualistic
J

ca Is for i cased
y te

but also no surpr

tacks on the

itself.

nce th
Ii

is bas'c _
i

ly well had to

sometim;

the

I•

ion was whe
'l h

irn of this paper the N, wide-ranging th t n
lS

o ensure

that the

ebate abou , becomes

he as

m ted by the new shift as is necessary_ provid
0

in moo

W

do not by any

means Our h

we

can

tantaneous worst forwa d

solutions. of

merely

'dentify th and to bring

deficiencies rOes of openly,

r ngements, c

options at he

re arm which
h

o be 'nvestigated
immediate uture.

evel ad'

5

L

WHAT

IS WRONG WITH THE SYSTEM?

Our

present

National

Health

Service

was designed sta,ndard PI"iva te

as

a

V-b~ic

sector safety net~
wbo had inade~:I111ate

to provide
I",esources
tQ

a, basic pay
'foOl'"

of' care
doctors.

for
n

~•. ,ose
th'iili!

na t Lona.Lf.sa t ion after the war,

proposals many ,features

put of

forward by the ,Labour the ,alr,~ady
flourishIng

Govern:cent PI"j'vat,e

&ector
carryon,

were preserved.
with private

Consultants
in
a,:$

in hospitals
to their

were allowed
,NHSjobs,

to
and

practice

addition

GFs

wer~ al1o~ed
proi V~ tie fees

to remain with

free

en.t:erpris,~

partners,

oft,en

mixing

NBS work.

MilKS pat i ent s th.. os,e in the The

were

not

meant to

imag in,e that to

they receive stoic

(u nI ik,e luxury queueing.

private spirit

sector)

were entitled of

treatment.

was that briskly

wartime:

spartan surroundings~ because
had gone

efficient

doctoring. het ter of a tban

Neverthele~s,
anything a that huge

it

was -befo~ei

foOl' many pe-op le--

it bad the appearance
adm.ittedly pub I ie

miracle,

stride

tow.al'd.~ (an S.incEl the

som,ewhat purt tat:p) Utopia.

war,

e.xpectations. noOt.

have

changed ~

the

attitu.des

built

into the NHS have e~ample

The most glaring

of the gap between

the 1940$ system lo·f waiting reliable NRS
two

and our 19S.0s~'xp~ctations lists.
f igure,g waiting

is the

corrt inned exi.stencle

At

th~

end of 1986 (the lat~st

date

fer

whicb

a:re ava i 1ab 1e) , lists; of thesefhal

there Wer8 almost
f

700,000 people on toOwai t more than for mDre
than

were destined

months

for

treatment,

and one in fifty

a

year.

6

he pro aganda
11f

of La

0

r politician, -n 1979,

this wa wa

no hOng

w.
t•

r

ct, ighe

w

n La

r Ie t offic

-ng lists we bid-g their

wit

over 750,000 p ople

q iet y

1

In and

the Sov - t ortages of
h

U

- n and other

anned'

econom

s,

wa-ting in no the

of supply
19405.

are stil - y, th Br

norm,

s they were
0

Brita-n er
I

Luc

. ain

1988

accustomed that p

to

ch p e omena. to b yor
t

Our shops

ar

ull of re f
1

d

Ie want

our car s lerooms vel agents of

of th

peop e want housand go s
'x

buy; to fa Brit

their customers pr~c s. Everywher demand

trips

way plac s a supply Service. -se tha

bargain

modern Na impo

qu- kly matches

in th t sed
d,

'onal HaIth

is by
if

ant to r cog
m

NHS

w

-ting lack

lists of han well be -n

re

he syst fu ~ng
y ars
J

elf ra her t

n by any

funds. has
a

were the
I ,

to -ncrease even long for m effect xamp wou d b
J

aster might

ing

ecent

crease wa ng nt ct year,

-ng lists. the first

funding he fast

do

led

a of

ffec

expan

ion

acilities, would

which

m-ght w 11 cut queue. and in reviously llat-on'of ft uncur

But the

n xt s

e the discovery s tha were all

new techniqu d. Once
th

curing w cur
(

disea became
0

ava-lable, cour wo want

hose suffert.

g from the re evant -- probab h long
y

ase would
ui

treatm

At some sage supply, and 9

sao
arced

demand ba

d aga-n exce

NBS wo Id waiting

into ra -oning

pply by creat-

ts.

7

Put si ply, the el0

th

pOl

t

h n

t

a system
0

-n which queu
health
i ti i r

y

ethod of rat-o

the amoun Ii y

cares

cannot ng. tha

n

e wait'ng

-- without
0

ally em

porters queu ing to

h

presen
0

sometimes

good method give prie
y

ra

~ng s pply
n medica

s

it enab es

octors than erl th t ut of Servic

0

those most

ra her
h

to those most able to pay. ng honest, wait'ng a proble with since

h-s argumen

at least has

its propane an -n rinsic

re thereby tea u

adm-tting the NHS. ffects in th

co stitute tear

m nt is that on the atti

"t n glects of those who work

onlng by queues . by queu

Rationing a
I

s one can see liS -- turn bit w0

nywhere

b

-nd

the

curtain,
I •

or in th
E

c demand

omers

or patien be coming of the

s into a met
0

nuisance

extra

needs

by

lengthening h nds inevitably the priv aspects One

some queue, the tend to prov-ders. become ch

hout any more money The adm istrators 9 as

the

se v space
a

die atorial, new patient a attitude

o sly allotting
'f

q e es gee of And h

dmission o

wer

this gen service.

q ickly sprea

other

cl ssic tim

x mp e
for do

is the practice of individuals u ional

setting attend-ng

a

common

pointment

outpatient dams ours have be n of

c

nOes.
-ecting

What

kind

of ins nd cons

ind is it tha to
0

patients while
m

the"r

m-lies

needless h who

sitti

g,

ltant deals with

invit d for the

ime?

8

Anotbe:r,

even

more

grotesqu.e

example
by

of

the system

atti is

tudes:

in
II

the
casualty

adm~nlnst~ators departments.

the

i'

II

I'll

sat 10n of

Often patients post. with

are made to injuries
1 ike h;ft

and
Illnr;oming ever

pushed

from pillar
They

to
are

their

more painful. station,

registered (again

and docketed .ilik!€!'parcels}

IltU"cels
In

in

a railway

and

then

i'iIoulder quaet 1y on some hard
when

bench ,.

'The eventual

qu.all ty

of

111'1Medica,l help. "nl}) -rob --

it comes troln an individua.l
is by then

doctor. aware

may be that the

but

th~

pat ient

only

to.r,wel1

hYGtem regards him as 'another caser, Tbe wards themselves i~-,]day resort i
111M
I

not as a valued

customer.

tell the sam@ story. cheap" tha t Looke.d
little as

Who would go to a as uninv it ing as an
to the simplest

however

ward?

Little

or no privacy, such

access

ort'lloaern

technology

re l,ephon.es and

te lev i s ions,

ce~y restrictive visiting
on could run

hours, poeI' food with
It is fare

little choice. No whether
10n.g

a 1"'e501"t on t na t bas is.

dpub't flll

_,_ ly prisoners Not that
Lit

in

max Lmum secur.:ity
the

gaols m.edical

much worse., an easy th,e life

thls means that
of th~lr'

sta,f f: have contrary,

the

expense

p.atients.
rCl';!:l!I:ost

On the «).f

system

up rates

quite as badly

them.. They too

are

shoved Junior
not ]be

round
d, ctorsf

and lined up like p~rcels by the
ind by any themse!\Tes
periaI

administration.
which would

worl~ing

hour's liv.ing

porm.itted , hl_ Y

institution;

.in a da.z.e of' overwork,

aretorced

to change

jobs

every

few months, to

suit
that

some
they to

The fact
provide
their

such decent

med~cal

services

as they do is a tribute

dedication.

It

need

be

n.o surprise

that,

in a

sys;tem

dOll1l.inated by

administrators, the
alive

tbe Report
and

responsibility pointed ont,

for the mess
if F'lorenc~ with ou
t

if diffuse.

As were

Griffiths
today

Night lng-ale .Lamp, was she

walking

th.€! corridors Ln ord,e:r to find
the

a who

'Wou.1d

undoubt.ed I y be do ing, so

in charge.

At t.he apex: Qof the P¥rami.d sits
a I so
runs,

Secretary

of State
soc ial

(who

as

a. harmless

a LdI lue ,our

.£40. b iII ion

seCUl"ity

system). none

He is ably supported is

by a rrumb~t'of junior
mOl',e

m.inistel's-three
to

o.fwhom.

1LkeI y toO spend
the job

than

two or

years

learning

and doing T'here

before being
100
I

transf,err.ed

some o t her their

departm.ent.

area.lm:ost

0.0000 civ.:i 1 servant

dividing the

t,ilfiie between. health Health
dlepu.ty

and$.lo,cial

services

.

There

is

National
a

Service Management chairman
s

Board,

with a ministerial
.ach,i·~fmedi cal

chairman.
of f i eel'

a c.h.iefexecu

t i ve •

,a

There are the inter-regjan~l
the Regions.
and

coordinating

committees.
The poor

There

are

There are the

the Districts.
bot t OlD,

little hospitals
we i ght of

GPs s1 t d.own at

try ing

to suppor t the
t hem.

this

massive Each of

adminIstrative

s,trutCture

above,

the administrative ·of autonomy~' --

tiers has what a ,euphem,ism wi.th one
I

civil

servants that they making· service'; Regions; '\Ioes
.. a.

call
spend

~a degree

meaning another

theit' t:i.rne points.

quarrelling

and

polltical the
and

The M.a~n.a.gement Boardflghts the Districts

the civil fight the

RegioDs

fight the ceDt~e;
f igh t

everybody
+he buck

s the Sec];'e tary of' State. wi th

I 'f sQmeth ing

wrong;

i so pas;sed around
NHS"

br:i} 1 ian t legerdemain costs £:21 billion

This ,employs

is

tbe

a ;$ystem tha' has

yea.r,

a milli.on

peop Je ,

no clear

lines

of responsibility"

10

I' J!

I

Lons by queue nothing the more

1ike than

a war t i.me government. a new prob 1em. and administrators·

treats leaves .

each Junior

patient
ffi@dical

, !'~

1.1f it

mercy of

unseen

Radical ~hange

is

11

2.

:HOW CA.N THE

SYSTEM

BE

.IMPROVED?

The debate

need

t,Ol"'

change right

is

now wide ly accepted. cha,nge. There

But there is the no hope defects

is that of

much it the that The

.a.bou.t the

kindo,f

can

be resolved

in in a few easy sentences:
the importance of

sy'stem sus tained range for 1. '2.

a.re s'o bas.t c and thinking opt ions

he aI th .is is

so grea.t. required.
i tsel

and f'urrdamerrta.I reappraisal which. needs de bat.e , It of the of to be considered

ot

f a ma.tt~r

consid,erable
Establishment Incr,eased

shou.ld

Lnc Lude , as aminilllum::
independent between trust. the N1IS and the

NBS as an ventures

use

joint

p:ri.va.t,e secb:!:t" ,. :3. Extending th,e principle of charging.

4.
5,.

A system
.A n.ational

of

'health creditsfi.
health insurance

scbeme.

1. Establi;shm_ent
Some
0t

of

th~ llia_!5

~

independe.nt
in the

trust
system o,verhaul mj ght be

the by

mos t obv j nus a

de,f ect s

current

remedied

thorough.-going proposals

administrative

which The

carried
NRS could.

the Griffiths
for example,

to their logical
entirely

cCDcluson.

be separated

'f'rom the its With

DHSS and

be

matte Lrrt.o a,n independent
by

trust.

publishing
Board.

own
such

accounts
in

and governed place. the

.1 ts

'own,

apo 1 it leal.

a Board

politicaJ
the regional

elements
authorities

of
--

the

present be

system
rEmoved. with

particula.r"ly

could

.12

~'l

"i

j',

Lorra.L hoesp I tal

and

district

manage'!!;"$ taking

their

place.

tIH·lf'l· , ','1,

suchan
be

arr,an.gement.
squar,ely with

responsibility
on the shoulders

for
of

the whole
the

system
and

Id

placed

Chairman.

Ex,~cu ive • t
l

subordinate
respectivle

managers
of

having
ope r-atLon,

IJpf:;inslbili,

y for

their

;sectioll.s

the

Administrative
III

changes

on this scale would b€ aI tel"ations of the NHS
of

~n

entirely
have

r r i ,or'

nt

affair

from the

m.any minor

which

taken from.
of

pi

J,l:n ver the
poiitica,l

last few
sphere

years.
arrd the

Removal

management clear lines

I il~,'

e$tablishment

would have great effects
dmin1strative

on the system.

But, when fundamental

change

is con$idered,

two

two

lieW will it alter the t ,w .rds p,a, t Len t 51 and .1 •

basic

attitudes

of

administrators
or

Moww i 11 it e 1imina te gueue:s (w i thou t Lnf inite fundi.n.g) ,"prove the present conditions in NBS haspi tals,?

There may perhaps be good answerS to these
t bey

questions;

but,

do ex.i.st.
unlikely

they are by no means obvious.
that attitudes towar~s patients

It seems, prima.
(for

example)

1 II

be

much

impro'V!f!'d m~rely by

altering

the

administrative

~. !ncreased us'!;, NHSipriVate 01'
l'll~

sector cooperation, on the
involvement ability in

Gov'ernm.entha.s:t',ecent
NMS

ly :f'ocused attention.

ot
m.any

II",
<i

to
its

benef

it

from privat@slect()l"

qn c t:6! of

work ..

Does this offer a long-term

solution

to the

eel' ta.i:nl y ,
i •

private
in,creas ing
t he

sector
~f:r iendl

could in,ess
I

make

a

great
,and

n~ r j bu t Lon l

to

of hospi tals

13

t

a ients wi h tele isi n
0 0

more

comfort

be

cond"tions.
t

Fo s

example, an video

r n al camp ni s cud
1 pa

re t ot

lev"sio nd wit p ovid

ind"vidu cont
0

"en s,

wi h r mot el com
0

co tro s could ~
from

h adset telephones n ighbours, Cateri suppli ~o e d
hai

a se, who

ritish

for

pat'

wis

kee

ouc

with

fr"e ds, re ativ s and businesses co d provide osp·tal
g,
0

thelr bed ide.

fOrms

alt rna iv those who wis

ood to the b sic mea s to xerci echoic be mad

by

he

dress' and

cosmet"c variety of

a d beau y s rvic s cou d n ert or h ·nm nts could riv-leg
0

vai able, th ough h spital bringing

a

be

s ppli d to

priv te

en erprise.

u ply-ng

, f rms could in much n ede

make ren al or royalty unds. In add-tion,

payment s J hn ee

to the NH ugges s

in his CPS pamphlet

'H althy Com eti ion·, to ove no jus

co petitive services al

tender"ng ut also

c uld surgery as So thi

be

extende
t

upport

fac" it·es s a ready ar
0

pima he

y care s rvice
f

and hospi it in. remain:

bui ding

ase in some pa ts B
t t

good.

s rio s quest'ons e p obI ms? esponsibility Cou

wou d any of
t

gtt

th

root of ines of

it do any hing

establ'sh

clear

in the
by queu

HS? s be al e e ? answers.are
i th

a tit des tow rds pa ien s and rationing Thes easy wi 1
t

ques ion an were

do not seem to have posit"ve pr'vate In eed, as an i
i

not N th

Iner ase s.

sector even

invo vement
if
t

ot

do

miracl

combin
t

d

wi h give

es abl'shment ines of

of the NH

"nde endent
is mos

t

(0

e

ar
bou

esp nsibility), chang

unlik

ly to

bring

ap-d a d w"d s read wait-ng
is s.

bas'c

ttit d s,

or to

eliminate

14

:3. Extendin_g Another

the

pr.inc::iple which has

of

charging been

avenue

tentatively

explored

by

the

Government is ch~rging. th~
could basic enough

In p:r'incipl~. this could be extended -- a charge
the problems

to

point

of universality
solve

tor every
ofwaitin9

service.
lists

That
of

permanently att i tudes for each

and

towards
service

pat: iemt.sto ensure

- .sinc,e the
that

NBS could matched br inging of

charge'

demand

supplYf
funds to an

~Very pa,t i en twould
the system... If

become

a valuable
th the

cu s tom~r,

combinedw.i this

establ.ishment in ,ef f'ectturn

the NHS as toa

independent
nationalised private

trust,

would

th~ NHSin terms

non~prof'its,ervice and at

comp~ting

on level

w.ith

th.e

sector,
j

arms-length ope
Dvel"whe

fram the Government. lm,ing' de fee t in
this

There How Some

e , however,

a:PP'I'oach., afford it? of The

would
might

those in need of health care be able be abLe
but

to to

to

ta,l':.e out

,eiM,)ugh insurance

cove-r most .great.
care

their n.eeds
is.ignal

.for many the

expE~mse would be too
i tsabi 1 i ty

advantag'e

of the

NBS --

to

take

o:f those

most in n~ed, regardless
of

of their
w.i th
the

income -- would be lost: a case
bath water. by 'Th,e

th:r,owing the

baby

out

introduction

of

universal

charg iug

oou J d not, to the defects

therefore,
of the

i ts,elf

ccns t i tute an

adequate re$ponse

p~esent system.

One

way

of

preserving

the'advant:ages

of

charging

(while a

Dvercoming
system Hourston of in

its

ove:rwhelmLng disadvantage)

would be to instal
by

'credit:sl
hLa Aims

(similar to the sch.eme advocated
of

Jam.es

Industry pamphlet ...A Health Alternative)"

15

Each
no te",

iDd~v1dual paXisnt would rece±ve,
ent.itl.in.g him to t:re,atment for

from

hi$ GP,

a

I

credit Th.is

a speci.f Lc complaint.

c~.dit
treatment

note
in

would cove~ the cbarge
question.. If the patient

levied by the
chose

NBS

for

the
a

instead to go. to to carry
erut each of

private
wit.h

sector hospital,
hLm making 0[" through

he would be entitled
.in cost Since

the credit
h.is

up any d I f ferenoe prJ va te insurance.

own.

resources

NBS nO$p.i ta 1

would patients make

be
r

funded

so LeI y through

the

rece ipto,f

~ red.:l t5 ~ c ir.ii.'centive

from. to

al1admlrlist:t'atol's hospi ta.l attract

:would ha.ve a direct
i ve
1

the.lr

welcoming

to

patlent$

and
be also

medically
crea,ted
between

successful.
not only

In short,

increased competition would private
such the

b~twee!n the

NBS and the
another.

sector
an

but

one

MRS ho~pi ta 1 and to

Under than
Oll:'

a.rrangemen.t.

it m1.gh be pos~ ible t
the en t .ire NHS
a.S

go even furth,e~
t
It'U$t

est:a.b 1i.shmen:t of

,an .independent

company:

hospital or district could be separately
na t ional fundingau.thori
ty Le it a 1:: the

established, with only a cent r-e toaamjn.ish~l' the

payment of credits.
Unfortunately, nothing t,o guaran.tee that t.he
I

.it
r igh't
I

does::
be

:amount of

m.on~y

wi 11

avai.labJ e fol' sp6nd.ing
governm.ent in the

on heal t h ca.l"'@'. As now,

it would 1,eave thEl'
choiG~
j

awkwa.rd positi.on

of ·having to, mak,ea

year-by-year, without

about the proportion method of bringing

of GDP ~o be spent on the RES, the amount

any

ho.me to individu.als

th~.t. they are spend.ing

on the:i.r hea.l th ..

]6

I.

B.

na.tional

health

insuranc,e the

schem'e of a pur-e c r e d i t s' scheme is a

1\
,i

Illu,thod of

overco.ming

drawba.ck health

T

lly it to a national
m, everyadul to
t;

insurance

system.

Under

such

W:{~ t
!H~(.J

would

contribute insur,an,c,e

a fix'ed fund.

insurance

premium be to

b year

ana,t i orie I be-a 1th by ind~pe:nden,t

'The fund would

idminister,ed

tru$,te,es.

who 'would have that 1 ike 1y to f,or a be

a, duty
sufficient issued

i),l:nce
p ~'1Ji
!

its

books
to

each year,
cove
l'

by ensur~ng
I

- urn

was set year are

all

the

credi

ts

l'

by

l'

in

that

(and

to

c re a t e a,surplus;

contin.genci,es).

There
'1'1re

$e~reral

ways in which

such a system

could
r

opera te ,

i nSuranG'~

prem i um cou l d be

a.ctuar Ily risks though

adj us ted

like

car

lnurance,
I'U

to

reflect

the

varying

ass,ociated tb.is not would w,ell

with

different to be were

"go,riesot anced

contributor to or those in a

need

by subsid1es

who were high

'off,

and

~jther
'lOSS

already

ill

risk

ca.tegory..

Anoth,er where

.i bi J i t.ywould would

be to

ret Gl..i:n a fully wi.th

means- te;sted and

sys tern,

Pl"-wd.,ums
bm1US@S

C9rI:'E!la,te

incomes; of tor these

where

no-clai,ms
absent

and ath.!ll!l' tradi this would insurance

t .iona 1 features

insurancEpeople
two

were to limit

-llll

though
,0 f

remove
Gover.

in(>entives Between

the

the i r

pas! b i Ii tie's,

1:1,s a spectru.m
One

of

feasible

combin,ations.
lat premium
f

val' .ian t wOll.l d be af

whichwou.l,d,

not

vary

··1ther with the income of the indiVidual
ot ill-health. Toavai.d average this b~ing

insured

or with his ri~k
cO~Jr'esponding in th,e

~egl:"es~dve"a

reduction
1",<. X

in the
for those

income tax rate, taxpayer's

and. st eepen1n.g

rates

hIgher-rate
on.

would

be

r-equt r-ed ,
given

in.
an

-iddi t ion,

;SH)'cial security

w,ouldneed

t.o be

11

immediate

inrease

to

cover

the!

Lr s t yea.r

prem.ium

(with

this

amount

thereaft.er being

indexed as part of the general

indexation

of social securjty y·~t State another

payments). vat' ian t would be to mode·l t.he scheme Pension. Everyone but people would p~y an on the

EarniDgs~Relat~d

incomemake

CQuld decid@ to

their own alternative Under full coet

provision,

and to receive NIlS hospitals

a modest rebate. woul·d charge the the
be in

any of these schemes.. of each treatment
fund (via
I

and would

r·eceive credi t s from
Queues would no

insurance out of

GPs) t.o Gover since the

the·SA= cos ts . have

the

quest ion

NHS would

intierest
rath.~l"

~eceiving sooner.

its Supply

credits w.cmld
out

(and hence its cash)

la.ter

than heal th

match demand at whatev'€.l' of the prem.lum set

lev·el of

cal',e· was fundable the private

(just a.s i.t now dCH;$ in

sector).

The not.
Indeed, scheme

existence course!
under eou.Id

ot a natIonal health insurance
be to the detrlmen~ of
vaI'.ia.nt.s, l"ights to

scheme

would
sector.

of

the

prlva~e

at.ny ot the be given

contributors

to the national
Dr

carry some
either

a Ll

ot
form
I

the of

insurance rebates

cover

to t.he privat.e $ector~

in the

for private

insurance o~ in the form of •credits

usable

in private

sector hospitals.

The adm~ni$t.rators of the insu~ance and would be
whe·ther

scheme would be at: arms happy to

length from the NBS itself,
the

s,ee pat Lent s gett jng

tr·e.atment

they

.needed,

in. a pub1 Lc -or in a PI' iva h~· sector hasp i tal. the divisioDS between the public and private

To a great degree. sector would fade.

:1.8

A

system

of this sort would b@ fraught And it would be foolhardy leap.

with

transitional

difficulties. present
Might sys;tem

to move so far from the leap?
presen.t for

one in a single rather,
01.

But need there be just one
to work slowly scheme? from. the

it not,
towards

be possible

national

in;:;.urance

One could

begin,

example, trust
r

with
1;0.1 i

the

e$tablishm~nt
j 0 iut ven

of the t'ures

NHSasan

ind'epend'fmt
the

th

.inGnlH~lSed

be tw·een the NHSand
U5'e

pr ivate
standard

sect·o.r;

move
bya

on next central

to the

of

!

credits

I

to

meet
for

chal"Q,es set

NHS funding

admi:nis t rat i on

independently
last stage

managed
crea~e

hospitals

or districts; insurance

and only at
scheme

the

a national

health

separate

from the taK system.

J!.9

3.

THE NEED FOR ACTION

NOW

W,e ha.v~ sketched to the

no more of

than

the

beginning's (which

of

ideas,

rest:t'.ict,ed of the

management

hospitals huge

form only one part huge detects.

;$'ervie,e) .Th,~ will have

NHS isa

system

with

Remedies in of

to

be

on the

same

scale. will need

Attitudes to

ingrained None

administrators this can happen

and politicians un1ess the

be alteTed. a

Government
operating hear ings

comnli s,s.ions
like but

fundament.a.1l
of Social

t'll?vi'ew

ot the entire
he I ding

system, pubi c Such

+he review to
the

s ecur i ty , within

coming bu i ldon
4,

cone lusioll.s,
m~.nagernen t

a few months.

a review

should

changes
Medicine NHS
be,tw,een agenda

now being implemented
Bill.
an the I t should

and on Clause methods of

of

the

Health

and the

.investigate trust and

of legtabl.ishing

i.ndependen.t NHS a.nd the

in.creasing
It

co-operation open

Pit" iva te

sec tor.

sh.ou.ld have an
and any
0t

on he-a1th cr ed i ts , i n.suranceschemes

her

ser ions

and

rad.ie-al

suggestions.

Abov~

all.

it

should

be

started

i.mmediately.

20