The Blog

It is Time to Think the Unthinkable on the NHS

It will require political leaders who can effectively communicate the benefits of different healthcare systems around the world, and explain compellingly why change is required. It will be hard going, but the rewards for patients and for the public purse could be very great indeed.

It would be sheerest utopian folly to expect the government to attempt further serious NHS reform before 2020. Even with a distracted and disunited left, there are plenty of other issues -the future of the Union, Britain's EU membership, Syria, the economy and the Tory leadership transition- to provide grist to the political mill. If the Tories simply manage to keep the NHS financially and clinically afloat until the election, that will be an achievement in itself.

But far-sighted policymakers should be considering the NHS's long term future as well as staving off immediate crisis. We know that Simon Stevens, NHS Chief Executive, has a 2020 road map, but what happens after that? What should the NHS look like in 2030, with the sophisticated healthcare and demographic predictions we have available?

It is clear that the system needs further profound reform to become sustainable, but every time a politician proposes change on any scale, anguished voices rally to stop them. The most recent reforms, conducted when Andrew Lansley was Health Secretary, were a classic case in point, as is the current threat by junior doctors to strike this coming winter. So it is vital that, as policymakers look ahead into the future, they also consider how to shape public opinion around essential reform.

Long-term thinking should give policymakers the chance to ask radical questions and put basic principles under the microscope. The current model of healthcare provided free at the point of use is one of the great post-war achievements but a disaster in terms of healthcare funding. Cool heads on all sides of the argument would admit that, were we designing the system in today's environment, it would not look anything like it currently does.

So it is worth looking around the world to see where instructive comparisons can be made. Typically, when serious NHS reform is put on the table, the immediate counter argument is a comparison with the highly marketised American system. America, as everyone knows, delivers significantly worse healthcare outcomes for a significantly higher proportion of GDP. Warning that the NHS could move towards an American model is a misleading straw man; surely not even the most free market Tory would want to bring in an American system to the UK.

Instead, those who treasure the NHS should make the argument that there are non-American systems which offer a fundamentally better patient experience for less money while not leaving the poorest behind.

Take, for example, the universal Australian system, known as Medicare. Medicare provides free treatment in public hospitals and primary care which is subsidised to varying degrees via a rebate system. On top, the government encourages higher earners to take out private health insurance via the tax system.

This comes with a number of positive ramifications. Much care is still provided free at the point of use, as surgeries are able to bill Medicare directly for any treatment provided. For those that aren't, patients in the public system can take a picture of their receipt on a phone and get electronically reimbursed via an app, so nobody is left out of pocket for any amount of time. For each interaction with a healthcare professional, a form of receipt is provided, which comes as a healthy reminder that healthcare is not free, even if no money immediately changes hands.

The NHS establishment warns darkly of the appearance of credit card readers in GPs' surgeries - but this is precisely what has happened in Australia without shutting the poorest out of receiving care and while offering patients a higher quality experience than in the UK. Of course, charging in the UK already exists for prescriptions, glasses and the like anyway. There is no reason why a wider co-payment system as exists in Australia would be bad for patients in the UK.

Better too is the basic geographic model of primary care in Australia. There is no need to see a GP within a certain radius of your home; any citizen can go to any primary doctor and be covered by their insurance or Medicare. This negates the undignified and pointless scramble for places in a local surgery in the UK.

Furthermore, for most people, the rebate from the government covers most but not all of the cost of treatment - so a missed appointment will cost them money directly and acts as a deterrent to not turning up. The flip-side is that appointments can be cancelled at up to two hours' notice at no charge, giving the system more flexibility for other patients to take advantage of.

That in turn means that pressure on GPs is significantly lower, and it's possible to get an appointment almost immediately. Australian patients only to present at A&E in a genuine emergency, rather than because they can't get in to see the GP; moreover, the sorry lines of patients outside surgeries for a walk-in clinic appointment have no place here.

Surely these issues of fundamentally better patient experience should be at the heart of long-term thinking on NHS reform. Sadly, the British healthcare debate remains blinkered to the narrow confines of a system designed for a different age, and politicians are cowed by the angry, hell-bent guardians of the status quo.

Australia is no utopia, of course. Its issues of health inequality don't just run on class or financial lines, but are complicated greatly by indigenous issues. It is battling a major epidemic of methamphetamines, or 'ice' as it's known. Skin cancer is a huge problem and the population is ageing. But for all its complexities, the system provides a thought-provoking model of how healthcare in the UK could function. For that to happen, it will require long-term, radical thinking and brave politicians willing to face down the inevitable howls. It will require political leaders who can effectively communicate the benefits of different healthcare systems around the world, and explain compellingly why change is required. It will be hard going, but the rewards for patients and for the public purse could be very great indeed.