A&E crisis highlights need for a more subsidiary healthcare system
Unsurprisingly, the opposition blames spending cuts and reorganisations, while the coalition points out that the situation in Labour-governed Wales is worse still. Be that as it may, it should not distract from the fact that overcrowded A&E departments are really just one manifestation of a more general long-term failure: a failure to organise healthcare in a more subsidiary manner. The health service lacks reliable mechanisms to direct patients to more cost-effective, low-cost tiers of provision. Too often, people are treated in hospital when an outpatient setting would be more appropriate, see a doctor when they should see a nurse, visit a surgery when they should visit a walk-in clinic, receive treatment when they should self-medicate, and so on.
This is both a supply-side and a demand-side problem. On the demand side, even where low-cost options exist, Clinical Commissioning Groups (CCGs) have no effective tools to redirect patients towards them. Rebates and differential tariffs could go a long way towards sorting that out. In this respect, a good example to learn from is the Swiss healthcare system. Switzerland operates a social insurance system, coupled with demand-side subsidies for low-earners to ensure universal coverage. People can choose a standard health insurance policy, but they can also opt for various sorts of saver tariffs, waiving certain entitlements in return for premium rebates. One of those is the ‘Telmed’ tariff, under which policyholders commit to having a telephone consultation first before they can book an appointment with a doctor. Phone consultations serve two functions. For routine cases, remote diagnosis can be a cheaper and quicker solution. And for cases that cannot be diagnosed from afar, a phone consultation can at least direct patients to the most appropriate provider, reducing the need for multiple appointments. Such solutions free up space in surgeries, which is especially relevant when people use A&E as a substitute for a GP appointment. The NHS 111 line is a small step in that direction, and GPs in the UK offer telephone consultations as well. But unlike in the Swiss system, there is no financial incentive for patients to use these options first.
In the Swiss system, people can also choose a deductible, again in return for a rebate, and pay for the full cost of medical care up to that level. People who choose that option are still protected from serious health-related financial risks (the highest deductible permitted is CHF 2,500), but as long as they only need run-of-the-mill treatments, they have every incentive to economise and search for low-cost options. Seeing a doctor with a routine ailment is probably not one of them.
Saver tariffs, coupled with tax rebates, could be introduced in the NHS as well. But to be effective, they would have to be coupled with changes on the supply side. The concept of the ‘prescription drug’ should be abolished. All drugs should be available on an over-the-counter basis, and prescriptions should only serve for reimbursement purposes. This would lead to an increase in self-medication, again taking pressure off surgeries and making it easier to get timely appointments.
The whole system of tying patients to surgeries should also be abolished. Doctors should be free to see patients who are not registered with their surgery, or to discard with the very concept of ‘registering’ altogether. That would allow demand to flow where the spare capacity is.
Finally, this is also an issue of market power. The UK has a lower density of physicians than most comparable countries, but British GPs are among the best-paid in the world, a strong hint at a guild-style system that aims to keep numbers low and prices high. Easing entry restrictions while localising pay negotiations would be a way to expand capacity, again reducing the need to use A&E departments as a substitute for the kind of medical attention that should be provided in clinics and surgeries.
During the current arms race of who professes greater ‘love’ for the NHS, such solutions are not to be expected. But there will come a point when the old mantra that the NHS is a wonderful service which is just ‘underfunded’ will lose its credibility. Supporters of fundamental reform should ensure that when that point arrives, the public is aware that there are indeed alternatives.
Kristian Niemietz is the author of the IEA Discussion Paper ‘Health check: The NHS and market reforms‘