Political commentary

Replacing the NHS

Colin Welch

FOT A PRISONER OF RIGHT': gullible as ever, I doze happily off again, fondly dreaming of that aged firebrand held in durance vile by reliable chaps such as Gen. Pinochet, Mr Norman Tebbit, Col. Tejero and Dr Andries Treurnicht. Friends tell me that it is not exactly so, except in the minds of headline writers, who presumably find the real facts hard to fit in. 'EXTREME LEFT FOOT A PRISONER OF EXTREME LEFT RATHER THAN OF EXTREME EXTREME LEFT' — a bit of a mouthful, isn't it?

The by-elections have left all three or four main parties with nothing in the bag but something to hope for. So, with Parlia- ment, as I write, in abeyance and Foot seemingly safe in custody, may I return to last week's problem — how to curb the potentially infinite growth of expenditure on health? I promised to examine alterna- tives to the National Health Service. First, let's look at Graham Turner's proposals, not so much an alternative as the present NHS radically streamlined and souped up, removed from the control of the DHSS, and turned into a corporation under a 'supremo' of first-class ability, backed up by a board of able businessmen and medical professionals and by administrators of 'much higher managerial calibre'.

A shake-up of this order might take 20 years to effect. By that time the initial im- petus would be flagging. Supremos too grow old, lose their supremacy; able businessmen become less able, remember other interests; good doctors are not always good at admin; the high calibre of managers may be lowered by wrestling with un- manageable reality. It has all happened before.

The NHS reminds me of Taine's descrip- tion of French administration under the an- cien regime: 'The machine, through its complexity, irregularity and dimensions, escapes from the King's grasp. A Frederick II, rising at four o'clock in the morning, a Napoleon dictating half the night in his bath and working 18 hours a day, would scarcely suffice for its needs. Such a regime cannot operate without constant strain, without indefatigable energy, without in- fallible discernment, without military rigidi- ty, without superior genius.' It defeats or- dinary mortals as it defeated Louis XVI: after brave but feeble efforts at reform, 'his hands fall by his side weary and powerless'.

High calibre management can achieve much for a time, perhaps even the 20-40 per cent increase in productivity hoped for by Mr Turner. But it is rendered impotent in the long run if it is doomed to operate in a system basically misconceived. What is un- soundly financed cannot for long be well- managed. Wherever, as in the NHS, scarce resources are treated as though they were infinite and free, wherever they are used and consumed without regard to cost, there will also be missing all the indicators, dials and data essential to good management. Unless the supremo is given the power to change all this, he too will find himself still managing in the dark, with waste and gross inefficiency still eluding his grip.

The Tories rightly seek to restore market disciplines in health. They have been sniff- ing cautiously round various ideas for health insurance. It is an explosive subject, as the think-tank must have reminded them, almost impossible to mention, let alone, discuss, without provoking the most appalling uproar.

This is a pity. Yet there do seem drawbacks to whatever health insurance schemes I have bumped into. If com- pulsory, the premiums are indistinguishable from just another tax. If run by the state, insurance is commonly bogus, either through perpetual insolvency kept at bay by frequent write-offs and Exchequer subven- tions, or through being raided by the Ex- chequer in the unlikely event of a surplus turning up. If privately run, the poor will not be able to afford the premiums. If these are subsidised, waste and extravagance will reappear in a new form by a different door. All of us know from experience how lax in- surance companies are about checking costs. Take yout dented car to the garage: you are quoted £100, say. 'Not on in- surance? That's different, squire: let's say £20.'

Mrs Thatcher has declared the NHS safe in her hands. So perhaps it should be, unless she has something better to offer. May I suggest something which seems better to me? And if it isn't, I would be grateful to know why.

My modest proposal is this. That all doc- tors, hospitals and all forms of medical care should cease to draw their incomes from the state. They would rely instead solely on pa- tients' fees. In other words every patient, and not just a relatively privileged few as now, would enjoy the benefits of private medicine — and that they are benefits is proved by the number ready even now to pay twice over to get them. But the poor cannot possibly afford private medicine? Very well: the state pays a proportion of medical bills, the percentage to be based on the patient's income or tax coding, that is, on figures already easily available. As a result, the rich would pay their own bills unaided (though they could insure), middl-

ing people would pay middling amounts, the poor would pay ten or five per cent, the very poor nothing at all. (In other cases ton the state could reasonably pick up the entire bill: for the bedridden old, for instance, for certain chronic illnesses, for treatments or investigations costing more than s° much.) What have we so far achieved? First the NHS, with all its cumbersome bureaucrat)'' its tiers upon tiers of non-managil managers and paper-pushers (who' i,e understand, now actually outnumber IP, medical profession), its inflated and disat- fected workforce, has, like Marx's stele's simply withered away. In its place rises d simple, 'relatively cheap accounting art, disbursement exercise: could it not — handled by existing state institutions; modestly reinforced? Secondly, we 118„:1. given to the poor two dignities they ne': had before. One is equality with the ricn the doctor no longer cares, may not even know, whether his patient is rich or P°r'r his fee being anyway the same. The nthe„ dignity is of being no longer dependent 01`_ the doctor, no longer ordered about, shown the door, refused home visits, told to cornea back tomorrow, treated like dirt, like ts child or an inferior: fee -paying patients command respect. Thirdly, we have found decide for himself how much health we'

expenditure on brake for runaway health ex

put the lever in the hands of the only persej fit to use it — the patient. I have mendonto exceptions, which should not add trP h more than ten per cent of total state he i'd" expenditure. For the rest the patient woal:is himself bear a proportion of his and ilid family's medical bills. In this light he vitt , want and can afford. Decisions for gr°,virbi; up people, to be sure, which conic' agonising; yet the state's help would tentPe' them and make them tolerable for all. ,;5 :),In effect we have made every patient l' own Minister of Health, his own supreillhe his own high-calibre manager. He is hethe boss. He says to the doctor come and Ae cometh, go and he goeth. We have 1118',5 the individual greater and the state le' great. in cid' In what I suggest a means test is embed .. idleness, earning nothing or nothing t's,

arises. Poe ed. And from this a possible snag

we all know (and, if not, Mrs Her Parker gives the facts and figures in her Int'il pressive pamphlet, The Moral Nazar(' 61 Social Benefits, IEA, £3.00), the contbalets effect of taxation and means-tested bete° r is to put anything between 17 and 2°2.):h cent of our workforce into a trap in vi,j:Ibie they are better off without any v's",nt means whatever, in idleness or apParZat has to be declared. To devise more meanre tested benefits would surely be to lure 51° d citizens into that trap. I see the danger; fe, what I propose, desirable as it seems t°1.,:rt should certainly not precede but form Pty of, or follow, that immense reform of and and benefits which is so long '— disastrously overdue.