With the NHS facing the unedifying prospect of its worst A&E waiting times in a long time, and bed-blocking up by 52 per cent in three years, a quiet corner of the British Isles has employed a healthcare funding model that keeps its health service in fighting form.

Our healthcare system is in crisis. NHS performance is in decline. Last winter saw waiting times in A&E departments up and down the country soar to record highs. Meanwhile, sharp spikes have been recorded in the number of people waiting to begin treatment or to be transferred from hospital to social care. The demands imposed on the health service continue to exceed projected levels.

Two General Elections in as many years have helped amplify an ever-present national debate on the health service and its future, but, despite these, viable long-term solutions have been hard to come by. The only game in town is the status quo generously topped up with yet more public spending.

But, one possible solution to the country’s healthcare woes may come from a quiet corner of the British Isles. Situated within sight of the Normandy coast, but swearing allegiance to the Queen, lies the small Channel Island of Guernsey. Independent of Westminster, with its own system of government, and with no UK National Health Service to rely on, responsibility for the provision of healthcare to the island’s 63,000 strong population falls upon the island’s government, the States of Guernsey.

Under this system, primary healthcare for the island’s citizens is delivered by competing private primary care practices. Patients are charged around £60 to see their doctor. The island’s social security system sees this consultation fee reduced by £12 to £48 for all patients. Roughly half of all patients are covered by private health insurance (often provided through their employer). Insurance premium assessment criteria vary depending on provider and scheme.

For those with insurance, an automated system sees the primary care practices claim this fee back directly from insurers with no direct cost to the patient. Meanwhile, means-testing ensures those unable to afford the costs of their GP or nurse consultation (currently around 13 per cent of the island’s population) have their costs of treatment covered by the States of Guernsey at specially negotiated rates. Those who qualify for social security will see the costs of their consultation invoiced directly to the States of Guernsey.

Patients lacking primary care health insurance, and who do not qualify for social security support, pay as they go. Local competition law ensures each healthcare provider sets its own rates.

States social security funding ensures prescription charges are heavily subsidised at a cost to the patient of £3.90 per item (currently £8.60 in the UK). Those over the age of 65, or those receiving welfare support, are exempt from prescription charges.

Health & Social Care (HSC) is funded via the States of Guernsey and provides a community service, comprised of community nursing staff and a caring service, where short or long-term domestic support is required to give clients an acceptable quality of life at home and to avoid having to enter residential care. The costs associated with the provision of the Island’s long-term care system, including the costs of nursing and residential care, are funded in part via an additional social security levy, which is in turn used by the Social Security Authority to cover a portion of the patient’s costs.

Like in the UK, hospital care is provided free at the point of delivery by the state. All referrals to secondary care are made either by a GP or an emergency care clinician. But unlike the NHS, the Guernsey model is financed via what is in effect a compulsory insurance system: the Specialist Health Insurance Scheme. Funded via the Social Security Authority, the scheme is used to negotiate a contract with a group of specialist consultants, who then provide the core of the island’s secondary healthcare. Additional input to the costs of secondary care are made via general taxation in order to provide other services, such as nursing, psychiatry, pathology and radiology.

Patients have the option to be treated privately at the island’s main hospital, the Princess Elizabeth Hospital, offering a separate wing for private care. The revenue from the private wing subsidises patient care in other parts of the hospital, and includes a fee for service to the medical staff. The hospital offers islanders a comprehensive range of services from intensive and high dependency care to maternity care. Specialist consultant services are provided on Island by visiting specialists for haematology and rheumatology.  The only specialities not offered on the island are interventional cardiology and neurosurgery.

The hospital also provides a fully serviced emergency department, open all year round. Like its counterparts in the UK, the department accepts walk-in patients and ambulance emergencies and is the acute assessment point for all GP referrals both in and out of hours.  The service treats, stabilises and investigates all patients, from those with acute injuries to those with minor ailments. But, significantly, unlike emergency departments in the UK, all those patients presenting to the emergency department as their first contact and who have not been referred for secondary treatment by a GP, are charged a fee for service.

While the majority has this fee met through either their health insurance or welfare support, a significant proportion will be required to finance it themselves. Facing the prospect of more significant service fees at the emergency department, many patients opt instead for primary care treatment. This incentive helps ease the pressure on the island’s A&E department and avoids the type of patient congestion that has ground emergency care provision on the mainland to a halt.

Finally, a tertiary healthcare service is provided through contractual arrangements with specific UK NHS Trusts for specialist care (e.g. interventional cardiology) unavailable on the island.

So far, the evidence suggests the system works. Life expectancy on the Island continues to exceed that of the UK. The Island’s infant mortality rate is less than half that for England & Wales, and continues on a downward trajectory. Like the UK, circulatory diseases, cancers and respiratory diseases are some of the leading causes of death, accounting for 31 per cent, 29 per cent, and 13 per cent of deaths respectively. Furthermore, child immunisation rates are above those of the UK and continue to exceed World Health Organisation (WHO) target levels.

The Island’s healthcare model may present some alluring solutions to the challenges facing the NHS. But at the very least, it can provide a fresh perspective as the debate over the NHS’s future rumbles on.

8 thoughts on “Healthcare: Lessons from Guernsey?”

  1. Posted 10/08/2017 at 02:42 | Permalink

    All primary care is provided on a private basis whilst some secondary care and specialist services are free. Specialist (secondary care) services are only accessed via a referral from a GP. There is no reciprocal health agreement between Guernsey and the UK so it is advised that prospective residents consider taking out health insurance

  2. Posted 11/08/2017 at 17:52 | Permalink

    The Guernsey system sound great and bears many similarities with the australian system. The UK needs to reconsider some of the basic principles of the NHS if we are to get worldwide class care and shorter waiting lists

  3. Posted 12/08/2017 at 08:54 | Permalink

    I have just experienced Guernsey healthcare. I had to go to A&E in Guernsey I was seen by a Doctor in five minutes and was out within an hour.
    The charge for seeing the Doctor was £55 and an X-Ray cost £85. Because people have to pay there is never the situation of time wasters and without doubt the UK should seriously look at some form of payment as the situation is now critical.

  4. Posted 13/08/2017 at 09:35 | Permalink

    There are many islanders who don’t qualify for free treatment and can’t afford the insurance premiums. Many fall into this category when they retire and insurance via work ceases but age related premiums rise. Paying for GP visits, flu immunisation, blood tests etc means many people put off going to the doctor until it is an emergency. Also there is no real competition in the system. They all charge the same high rates and changing practice is complicated and carries a cost so it isn’t as good a system as the article suggests.

  5. Posted 13/08/2017 at 12:56 | Permalink

    Living in Guernsey I can confirm that this article is full of opinions of someone who hasn’t a clue what our health service is like. We would much prefer a different health service. This article has been written with information only from government or healthcare sources. If you want to know how it really works, ask the people.

    Every day I hear people complain of ailments that they cannot afford to go to the dr about. Every day many wonder if their ailments will turn out to be something more sinister but if you cannot pay for your appointment immediately, many dr surgeries will not allow you to be seen or will keep you waiting for hours while those who can afford it get treated first. And while we know our children need treatment for serious injuries, we treat them as best we can at home because a visit to a and e now carries up to £500 charges depending on what time you go and what treatment is needed. This is simply unaffordable for those who struggle to find the money to put food on the table each week. The 13% that “cannot afford it” are on benefit and quite rightly should have help but what about those who aren’t on benefit but a low income? Well, they have to find the money or not attend the dr. There is no help for working families.

    If you are referred to a specialist for x-rays, specialist screenings or more serious treatment etc most of it is then free but osteopaths, blood tests or minor surgeries done in the Drs office are all charged for and can run into hundreds if not thousands of pounds.

    This article claims it works. I can promise you it does, but as with everything else, only for the rich. The working class are left to suffer because they cannot afford a visit to the dr.

    The mental health service is appalling, rehab is non-existent, even smear tests which are free in the UK cost us £80+. Our hospital and maternity ward are excellent, albeit with limited facilities which sees patients sent off island for major surgeries or screenings. Personally, I’ve always found the Drs and nurses to be wonderful but a carefully worded article that suggests our system works is an insult to their hard work and dedication.

  6. Posted 14/08/2017 at 08:51 | Permalink

    Also a Guernsey resident, can I just point out that when Amy says “We would much prefer a different health service”, she is not speaking for everyone in Guernsey (in fact, I’d suggest very few). Our health service does not have the waiting times and many other maladies of the NHS in the UK. There is support available for islanders who genuinely cannot afford the GP bills, while secondary healthcare is free at the point of delivery.

  7. Posted 14/08/2017 at 14:41 | Permalink

    As President of the Committee for Health & Social Care in Guernsey I can advise that there was no input from us into this article, as suggested by Amy. What I would add is that whilst there may be lessons to be learnt from Guernsey by the NHS, and I am sure there are, the model of health and care in the Bailiwick (ie not just the island of Guernsey) is not sustainable. Like the UK, we have an ageing demographic which is putting more pressures on a reactive demand-based system. We are currently redesigning the model to be more pro-active, joined up and community focused because of that.
    We also need to tackle the issue of equity of access. The article talks about a £60 GP fee, subsidised by government. Whilst this worked well when the system was brought in and the subsidy was around half the fee, that is not the case now and means it is a barrier to those just about managing. Again, we are looking at this as part of our focus on prevention and early intervention.
    One advantage we have is that health and social care is the responsibility of one government department. We need to improve how we integrate that care, and funding sources are more complicated, but at least we have the political responsibility in one place.

  8. Posted 14/08/2017 at 18:02 | Permalink

    Guernsey trains no doctors it is parasitic to the NHS training programs and makes no financial contribution. Doctors therefore have no training comitments. There is social support for the poorest in society however a large number are caught with marginal incomes.

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