NHS charges - the Zombie policies walking into Downing Street?

Reform - the think tank that provided David Cameron with his lead health advisor - is trying to resuscitate discredited policies on NHS charging in England and introduce some dangerous new ideas to boot.

caroline m.jpg
Caroline Molloy
20 November 2013

Image: Flickr / Gianlua Misiti

Reform has produced a series of proposals to ‘plug the NHS funding gap’.

Charges for GP visits. Charges for overnight stays in hospital. Big hikes to prescription charges. Means-testing of NHS ‘end of life’ care.

Worried about equity? Well, this is “fairer for young people”, Reform suggest (perhaps forgetting that young people tend to get older, and might want a decent healthcare system left when they do).

Means-tested dentistry and social care are held up as models for the NHS to follow.

Reform admit that the evidence shows such measures hurt people who are “poor and in ill health”. They admit too that charging for GPs could just drive more people into already over-stretched A&E departments.  

But such concerns receive short shrift compared to the upsides Reform see - that charging will “limit… the role of the State”, “allow individuals to self-fund additional services”, “encourage patients to self-medicate” and “create the clarity needed to encourage private spending and create a market for supplementary insurance”.

Why should we worry? Aren’t Reform just a wild-eyed bunch of private health and insurance-industry funded hard right-wingers that no-one takes seriously?

In fact, Reform’s influence reaches into the heart of Downing Street. It was from this think tank that David Cameron recently recruited his chief health policy advisor, Nick Seddon - who himself has mooted charges for GP visits.

The Department of Health issues robust-sounding disavowals, saying “We have been absolutely clear that the NHS should be free at the point of use”.

But Reform suggest that the government could simply redefine what “the NHS” means, suggesting government “move the boundary between health and care to broaden the definition of social care” (something that has already been pushed too far, many would say).

They add “This would enable more services currently provided free at the point of use by the NHS to be funded through (individual contribution) such as equity release and long term care insurance”.

Keen perhaps to gloss over their suggestion that people should be made to sell or re-mortgage their homes to pay for medical care, too, Reform tell us their report “focuses on reforms to prescription charges, which they see as more politically acceptable”.

Indeed, both social care charging and prescription charging have long been seen as a Trojan horses to other healthcare charging, both by its advocates and its opponents. Prescription charges were minimal until the Thatcher and Major governments hiked them from 20 pence to £5.65, a real terms 11-fold increase. Already, around 800,000 patients a year fail to get all or part of their prescriptions dispensed because they cannot afford the cost, adding to healthcare costs further down the line, according to a MORI poll for Citizens Advice. But at least currently 62% of the population and 90% of prescriptions are exempt from charges - something Reform wants to change.


Reform acknowledge that the last major review of NHS funding found that charges were “inefficient and inequitable” and that taxation was the most effective way of paying for healthcare, just as NHS founder Nye Bevan insisted when he dismissed means-testing, charging and insurance, saying:

“The means of collecting the revenues for the health service are already in the possession of most modern states, and that is the normal system of taxation.” 

Taxation is - Reform admit - still the model of NHS funding “preferred by the public”.

But these days it’s surprisingly rare to hear a politician explicitly defending this core principle of the NHS. Cameron’s appointee as new NHS Chief Executive, former United Health chief Simon Stevens, wrote an essay for Reform last year that appeared to problematise the “the NHS’ tax-funding mechanism”. 

Heavy lifting 

There are other think tanks prepared to help Reform do the political dirty work - or ‘heavy lifting’ as it’s now known - to try and shift the public away from their commitment to a tax-funded comprehensive NHS towards one based on charges and insurance.

Reform cite a recent Kings Fund report to back their assertion that “attitudes to charging have begun to shift in recent years”. In fact the Kings Fund’s focus group strongly rejected NHS charging and preferred increased taxation if necessary. Only after two days of being brow-beaten with the “inevitability” of the NHS’s financial “crisis”, did attendees reluctantly concede that if they absolutely had to accept charging, they would prefer it applied to less vital procedures and to more irresponsible patients.

Reform also try to claim that GPs and the British Medical Association are shifting towards supporting charging - an attempt at co-option roundly rejected by both the BMA and the Royal College of GPs. Dr Chaand Nagpaul, chair of the BMA's GP Committee said yesterday:

"This proposal undermines the core value of our NHS: universal access based on need, not ability to pay. If a charging system is introduced there's a risk it would deter patients from seeing a doctor and getting the treatment they desperately need." 

Think tanks like Reform are useful for politicians. They can advocate unpopular policies at enough distance to allow plausible deniability - at least until after an election when there could be sorrowful acceptance of what the ‘experts’ are saying.

Shirley Williams - from a generation of politicians that did its own dirty work - forgot the script a bit. Having claimed last year that she had saved the principle of free NHS care, she said this year that it might after all be necessary to introduce payments for GP visits and to end free prescriptions for all pensioners.

‘Demographic timebomb’, ‘funding gap’, ‘NHS crisis’

The groundwork is being laid in other ways, too.

Politicians love to remind us of the ‘demographic time bomb’ of our ageing population (with Health Secretary Jeremy Hunt saying recently it was a "challenge more serious than the economic crisis…potentially even as serious as global warning").

Such alarming pronouncements ignore the fact that a number of doctors, academics, economists and even the Royal Commission on Long Term Care have argued that the ‘ageing population’ actually makes very little difference - as people don’t just live longer, but stay healthier for longer, it adds as little as 1% in real terms growth in costs. Other academics have criticised the “discourse of apocalyptic demography” as serving a neoliberal agenda, concluding “People seeking a future that includes a well-functioning safety net, beware.”

But the ‘demographic timebomb’ message is worked into the ‘funding gap’ narrative. The 'funding gap', first coined by McKinsey in 2009, has been pushed since by other management consultants, by right wing think tanks like Reform, and even by once highly respected and independent experts like Nuffield and the Kings Fund, whose boards now include people with a background in private health or its satellites - people like the infamous Penny Dash and Simon Stevens himself, both also former advisors to ultra-New Labour Health Secretary Alan Milburn.

The same 'unaffordability' and 'inevitability' messages is drummed in by government appointees from Monitor, NHS England, by men at the top of various bodies that rather dubiously claim to represent NHS interests, and by the luckless local hospital bosses and GP-turned managers left carrying the can. They queue up to warn of the unpalatable medicine we must swallow - whilst surprisingly silent on the government policies that are starving the NHS of funds whilst loading it with unnecessary costs.

The vice-chair of Conservative Health Dr Paul Charlson comments  “I think charging is a good idea in principle (but) it would be political suicide for a party to introduce this. They could only really do it if there was a feeling in the country that health services were falling apart.”

Meanwhile Health Secretary Jeremy Hunt, absolved of responsibility to secure a comprehensive health service since last year’s Health Act, loses no opportunity to imply the NHS is broken, as he regretfully suggests that the NHS is "scandalously" inefficient and calls for a "profound transformation".

Behind the language of ‘NHS crisis’, ‘funding gap’ and ‘demographic time bomb’ is the inconvenient truth that most of the bitter pills being proffered - not just user charges - are likely to cost us more, not less, in both financial and human terms, somewhere along the line.

Lessons from abroad

Study after study has shown that less marketised healthcare systems - like the British - are cheaper to run. But Reform merely suggest that extra administrative costs will be countered by “innovations in payment systems” such as “electronic, wireless and online payment”.

Reform acknowledge that the OECD has found that the British currently spend a much lower than average proportion of our income on healthcare costs (both personal spending and tax paid), and benefit from an “especially high level of financial protection from the consequences of illness”.

Are these differences to be celebrated as a source of national pride, and cherished as a vital safety net all the more important in the cost of living crisis?

Reform identify them as simply anomalies to be eliminated.

The Canadians ditched attempts to introduce GP charges after finding it resulted in sicker patients who require more expensive care in the end. Germany abandoned such charges in 2013 having also found them to be ineffective and hugely unpopular.

A beautiful debunking of user charging by Dr Morris Barer and colleagues at the University of Texas Health Policy Institute again showed that user fees are as likely to deter necessary treatment, as unnecessary treatment.

In the words of Canadian Doctors for Medicare, user charges “merely transfer the burden for payment of health care from the 'healthy and wealthy' to the 'sick and poor'”.

Courage or cowardice?

There are more effective and fairer ways to address the NHS ‘funding gap’, if we had a government with the courage to stand by ordinary people in hard times.

We could reverse the shift to a wasteful market based system that has increased NHS admin costs hugely - already up from 5% to 14% of the whole NHS budget and rapidly rising to the 33% US level.

We could take on the corporations driving the bulk of NHS inflation - the ever more expensive but not necessarily superior ‘solutions’ heavily marketed by big Pharma and big technology, not to mention the food and tobacco lobbies contributing to making us ill in the first place. And, ever present, the big finance that helped create this mess we're in.

What we have instead is a government secretively negotiating away our ability to reject corporate behaviour that harms our health and healthcare. A government publicly hiding behind useful idiots like Reform, advocating the steady destruction of universal, tax-funded healthcare, free at the point of need.

Dr Barer and his Texas colleagues argued that fees tended to be advocated by spokespeople for vested interests like private healthcare providers and insurers who anticipated (correctly) that such fees would raise costs overall. They dubbed it a classic “zombie policy”- one which is “intellectually dead”, but just keeps on coming back, however many times we kill it.

As Reform say, “While user charging in the NHS has historically been resisted, in light of the current financial environment, advances in technology and changing policy priorities, it is possible to reassess the case for reform”.

In other words, why waste a good global financial crisis if it lets you reanimate your favourite zombies?


Like this piece? Could you donate to OurNHS here to help keep us producing the NHS stories that matter? Thank you.

Had enough of ‘alternative facts’? openDemocracy is different Join the conversation: get our weekly email


We encourage anyone to comment, please consult the oD commenting guidelines if you have any questions.
Audio available Bookmark Check Language Close Comments Download Facebook Link Email Newsletter Newsletter Play Print Share Twitter Youtube Search Instagram WhatsApp yourData