Public Involvement

In a personal piece reflecting on his own healthcare needs, Andrew challenges current thinking on ‘topping up’ and consults the welfare state’s urtext.

I have been back to the source for all things enlightened about the British welfare state - Sir William Beveridge’s magisterial and visionary 1942 report - produced in the darkest days of the second world war - entitled Social Insurance and Allied Services. I wanted to check on what he had said about people topping up their NHS care by paying a little bit extra on top of the what you get from the state as their entitlement. Did he predict that this would introduce the danger of a ‘two tier’ health service? Would Sir William agree with the modern day guardians of the NHS that “topping up” and “two-tierism” were heinous crimes to be discouraged at all costs? Far from it. The proponent of our universal and comprehensive welfare system did not say it had to be “all or nothing.” Quite the contrary. In fact what he did say on the subject sounds like it I could have heard it on Radio 4 only yesterday.

It only took the Beveridge Report until its ninth paragraph to state this as one of the “guiding principles” of the recommendations which led to universal social security and health care:

“social security must be achieved by co-operation between the State and the individual. The State should offer security for service and contribution. The State in organising security should not stifle incentive, opportunity, responsibility; in establishing a national minimum, it should leave room and encouragement for voluntary action by each individual to provide more than that minimum for himself and his family.” (ref. http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/19_07_05_beveridge.pdf )

Unsettling - but creative

I understand why some clinicians and NHS managers find this clearly stated principle of “voluntary action by each individual to provide more than that minimum for himself and his family” unsettling. But we have to realise that this is fundamental to the thinking which underpinned the creation of the welfare state - and it looks like this principle is moving closer to centre stage once again in our social policy thinking.

Respectable voices such as Chris Ham’s are calling for “a Beveridge Report for the 21st century” to guide the settlement between state and personal contributions in a new welfare dispensation and we are standing by for the Green Paper on social care funding which is expected late spring/early summer.

New health partnership with primary care needed

We have just seen the GPs grudgingly and grumpily accept the new contract about extra hours but what about the person over 60 – and I’m one - who would like to pay for lots more than the routine 10 minutes from one of the GPs in his own surgery? I would like to talk about what I would like by way of routine diagnostic tests so that I can establish a baseline to compare with five, ten and more years down the line. Should I not be able to do this if I want to stay in control of my own health and thereby help the NHS at the same time by spotting potential problems before they turn into acute needs?

The more organised among us do this sort of thing with solicitors when we get older, so why not with doctors (and a GP would be cheaper even adding in the costs for the tests I might decide on). BUPA will do this sort of thing, but why can’t we pay the NHS for it and talk to a GP who knows us and has all our records up on the screen? That’s a choice I would like available to me – and “choice” seems to be important these days in the NHS what with GP surgeries opening in a Greater Manchester Sainsbury’s leading the Guardian to declare that the future of British primary care is now “down past the deli counter and opposite the lipstick stand”.

Oliver Twist got better than this

But here’s the rub. The Government has a line against “co-payment” towards the cost of care which effectively nullifies one’s NHS entitlement and punishes you - should you foolishly persist in proffering money - so that the full cost of treatment falls on the hapless patient. The Department of Health justifies this with a spurious appeal to equity: “If those who can afford it start ‘topping up’ their care it will create a two tier NHS. What about those who can’t afford [insert name of current wonder drug or high tech treatment]?” Anyone who thinks that there has not been in effect a two, three or more tier NHS since 1948 hasn’t got out much lately. Even Oliver Twist got a better reception than this and he wasn’t offering to pay a groat for the extra gruel!

You can search the NHS Acts in vain for the prohibition on co-payment. That’s because it is a bureaucratic diktat and not law.

Incentivise responsibility and opportunity

As someone who can foresee himself as a social care consumer somewhere down the line, I welcome a more creative and flexible approach that does not betray the intentions of the begetters of the NHS but rather reflects them while taking account of how we live life now.

And so I also welcome the appearance of GP services in Sainsbury’s if they really do provide much more flexible access to primary care for more people. I think that Sir William would also approve of “docs in store” for one very good reason. If we are serious about getting many more people off benefits and back into paid work, then there are going to be even more capacity and access issues around conventional primary care sooner rather than later. What better way to incentivise people to take responsibility and the opportunity to consult the doctor - younger men in particular - than just after they visit the deli counter so they don’t have to skip work, have their pay docked or risk losing their hard won job?

The Moore Adamson Craig Partnership is committed to the widest possible debate about the health service with a particular interest in encouraging users to make their views known. We look forward to making a contribution to the new Beveridge Report for the 21st century in which the voice of the active citizen and service user will be prominent.