Shock horror! We do not all enjoy equal health
From time to time, the government bows to the view that, as we are not all equally healthy, the government should do something about it. According to the Department for Health and Social Care (DHSC), health inequalities cost the economy “around £100 billion a year”. Not unusually, the reasoning is fallacious: it is the ill health that costs the money, not the disparity. The NHS already focuses its resources on trying to make the sick healthy. If we were all equally unhealthy, the bill would be a great deal higher. The DHSC response, of course, is to set up yet another quango,The Office for Health Improvement and Disparities (OHID), which will tell us, yet again, not to smoke, to go easy on the booze, take more exercise and lose weight. There are no costs or performance measures. The OHID will have no effect but at least the government will be seen to have done something.
According to the WHO, the root causes of health disparities are “education, employment status, income level, gender and ethnicity”. The DHSC tells us that “health disparities across the nation [are] to be reduced by tackling [these] top risk factors for poor health”. That will be as transformative as four year-olds tackling the All Blacks.
The government needs to forget disparity and focus on improving the nation’s health overall. Has the DHSC considered, for example, whether the UK’s unique affection for the NHS is as much part of the problem as the solution? We can smoke, drink and get fat safe in the knowledge that the NHS will, mostly, protect us from the consequences at no cost to ourselves. Our GP may wave a warning finger and nanny state may run advertising to tell us to mend our wicked ways but the NHS will pick up the tab if we don’t.
In terms of healthcare quality, France and Italy come first and second with the UK 18th – not bad really. Italy is also the second healthiest country in the world (after Spain) with the UK 18th once again, but that does not tell us which countries have the lowest disparities. One would expect health and income disparities to correlate and on the latter the UK comes 104th [a high number means low disparity] out of 174 countries, next to Spain. The EU is comparable with the UK but the Nordic countries have slightly lower income disparity.
The French healthcare system expects some contribution, apart from taxes, from the unhealthy: “When you visit the doctor in France, the healthcare system will typically cover 70% of the fees and 80% of hospital costs. If you have a major illness, 100% of the expenses are covered………. the patient [pays] 1 EUR (1 USD), for example, per doctor visit.” Driving one’s car at excessive speed is not good for one’s life expectancy or that of others on the road but we are likely to pay a financial penalty for doing so. Irresponsible attention to one’s own health should attract penalties, not wholly free health care.
The disparity that does need attention is that between the NHS and social care. If one needs nursing due to a condition that’s no fault of one’s own, such as dementia, one is expected to pay for the care oneself or have one’s family do so. If, on the other hand, one occupies a hospital bed due to one’s own life choices, lung cancer for example, the state bears the cost. One’s life may be shortened but there is no financial penalty.
The nation’s social care problem will not be solved by giving more money to the NHS. Indeed, it may make both care and health worse. Social care “aggregate expenditure has declined in real terms by 8% between 2009/10 and 2015/16 in England” despite rising demand and huge increases for the NHS. We should use insurance to incentivise responsibility for our own healthcare and trim the NHS back to front line treatment and cure. It is astonishing that the insurance systems that have played such a big part in continental health and care systems barely exist here beyond BUPA-type health insurance that enables wealthier people, or those in high-level employment, to jump hospital waiting lists.
The Americans have given insurance too large a part; a balance between state (NHS and local authority) and private sector (insurance) health and care provision is needed. France and Germany have that roughly right; the UK does not.
As only about 20% of people used care homes at the last published census (2011), it is an ideal opportunity for insurance not least because the premium for those with healthy lifestyles would be lower than those for their more self indulgent cousins. “41% of residents in care homes fund themselves (self-funders) and 49% receive LA [local authority]-funding (around a quarter of these pay top-ups). Even for those receiving LA-funding, nearly all income, such as pensions, is offset against state contributions. The NHS also commissions nursing care services for people who have a primary health problem, around 10% of residents.” Of course, the problem would be that those who can least afford insurance are also those with the most need for it, i.e. the greatest health deprivation. Controversial as it would certainly be, the logical solution would be to increase social security benefits but then take the health and care premium from them. Practical solutions can be found on the continent.
Interestingly, whilst the care home population remained stable in the ten years to 2011 (290,000), the percentage dropped from 23% to 20%, possibly because of the funding difficulties.
The Association of British Insurers have talked with the government about this issue but, I was told, decided there was “no market for it.” In the 19th century there was no market for motor cars. A point which may have escaped them is that, far from being unfair, insurance is actually positive for reducing health disparities. If you are number 20 in the queue for a hip operation, and five people use private insurance to jump the queue, you are now number 15. Insurance is such a valuable tool to getting personal responsibility for one’s own health or late-in-life care that it should be tax deductible.
This blog makes four suggestions for reforming England’s health and care regimes:
The new disparities quango is either well intentioned, but muddled, thinking or a cynical application of political PR. Either way, it is an unhelpful distraction from the health and care reforms the country needs.
Private insurance already exists for health to a limited extent but not for late-in-life care. It should be encouraged for both, with tax deductibility, to incentivise healthier lifestyles through the premia.
The NHS does not need further large financial handouts but should be trimmed to front-line treatment and cure. Hospitals do not need layers of boards of different kinds nor should the NHS be allowed to take over social care via a mass of joint committees. The Centre for Policy Studies has found no evidence that integration improves outcomes.
Social care, per contra, does indeed need substantially more funding as well as a rise in status to rank alongside the NHS. That would also reduce the pressures on the NHS.