Matthew Parris

To reform the NHS, use the politics of envy

We need a populist argument — one that will appeal to the masses — for charging some people for access

7 February 2015

9:00 AM

7 February 2015

9:00 AM

‘Let’s make the rich pay more.’ Does that sound so right-wing? To me it has a positively socialist ring. It should appeal to egalitarians: to those who call themselves socially concerned and seek new ways to redistribute wealth.

So why not apply it for the NHS? Let’s make the rich pay more for health care.

I’m no health policy wonk. I chip in with just this one small suggestion, which is not really about market-based reform of our health service, but about how to sell the idea to a deeply reactionary electorate.

The British are positively neuralgic on health. They shudder at the use of words like ‘profit’. Expressions such as ‘privatise’, ‘charge’ or ‘insurance’ are incendiary in our health politics. As a result, both major parties are paralysed. The Tories are paralysed by fear of being thought to threaten the NHS; Labour’s paralysis is born of the stupefying knowledge that all they need do to show they care is promise to protect the institution from change.

How, then, to break this political stasis? We need a populist argument — something that will appeal to the masses — for charging some people for access to our health service. What better approach than the cry that the rich are hitching a free ride on an already overcrowded wagon? Instead of talking about how to protect the poor, why don’t we talk about how to sting the rich?

In a public service for which swelling demand exceeds supply, the richer among us (who tend to be older) are hogging scarce resources, crowding out younger, poorer patients while demanding that we the better-off should carry on getting our health care ‘free at the point of use’. Why should it be seen flintily right-wing to find this objectionable?

Whatever else may be its demerits, the proposal for a ‘mansion tax’ is hardly thought to be an assault on the poor. So how about a mansion-tax equivalent for health? If we could reframe the argument as an argument for making the rich pay extra, we might begin to crack the ice that has formed across this issue, freezing debate. We might begin to free up thinking.

I get free travel on all public transport in London at all times. This is a pensioner benefit that’s worth more than £2,000 a year to me, even if I earn ten times as much as the fare-paying poor. I also get a winter fuel allowance. My literary agent jokes that his buys just enough fuel to fill the Bentley. The argument that it’s a disgrace to shower benefits like these on the rich comes typically from the left — the socially concerned — not the right.

If anything, the case is stronger when we turn to health provision. My winter heating is not making anyone else colder, nor my travel concessions depriving anyone else of a ride: but in health, where resources are overstretched, the better off are adding to queues and waiting times and degrading the quality of provision by hoovering up a free public service.

The most cogent objection to my line of reasoning is, of course, that the rich already do pay — and pay more — for health care because health care is funded through general taxation. I acknowledge this, but simply take the moral reasoning forward by proposing another way for the rich to pay, and relating it, this time, to their actual call on the service. We do need to put more money into health. It will have to come disproportionately from the better off. The only question is by what means we extract it from them — general taxation alone, or charges for use too?

The advantage of the latter approach is that charging will have a secondary effect of reducing richer people’s demand on the NHS. Not only will these citizens think harder about whether and when they need to call on the health service, but some of them — being obliged to pay for provision, whether state or private — will go private. Here would be an impost that conferred a double benefit on the NHS, simultaneously reducing demand and increasing funding.

My case is strong, my argument obvious. Others have been advancing it since the NHS was founded. Except as regards prescription charges (which were fiercely fought) the argument has made no progress; so we have to conclude that the national mind is set against it. The way to change a nation’s mind is either by catastrophe — which God spare us in the case of the NHS — or by stealth.

Stealth requires politicians not to be greedy or impatient, and to think long-term. The poll tax, a sound idea in principle, was sunk by the Treasury’s refusal to underwrite the only strategy by which it could have been sneaked in: to make the charge small to the point of being derisory at first. Later, once the principle had been accepted, it could have been steadily hiked up. Another sound idea, electronic road-pricing, will only ever be accepted by offering motorists a huge cut in vehicle or fuel tax in return for relatively light charges on road use. Later, all three could be hiked up — but only once the principle of road charging had been accepted and the idea normalised.

So it will be for health charges. To sneak the idea in, they will have to be imposed only on a small minority: the seriously well off — perhaps those paying the very top rate of taxation — and tapered. The change may even cost more than at first it yields. Later…

In health, ‘make the rich pay’ would be the thin end of the wedge. But it is the right wedge, and if thin enough, and if hammered in with the assistance of a little good old British class hatred, the idea would in time become normalised. Only thus, and very gradually, could we sneak reason back into health policy.


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Show comments
  • Terence Wilkinson

    Interesting idea but I think it is flawed. What happens when the rich demand a better service for their extra money? If I had to pay I would demand to be seen at the stated time not 10-20 minutes later, I would want to see a specialist when it suited me not when it suited him/her/them (after reading Rod’s article I am confused on the gender issue) and if I had to stay in hospital I would want a private room. So an idea that starts out with the best of intentions might lead to a health apartheid. It would be far better to introduce top insurance for all as this would raise more money and remind the NHS of whom pays for their services.

    • Andrew Smith

      This could work. A statutory health insurance for all graded accorded to earnings. Additional health insurance for the added extras like a private room or consultant treatment.
      It works elsewhere.

      • Matt Sharp

        Although it does work elsewhere, does it improve cost-effectiveness? It would very likely increase administration costs. And would it really be worth such a massive reorganisation?

        Other places that rely on health insurance tend to pay more per capita.

  • annewareham

    Lucky man, to not be aware that this is already the case if not proclaimed. If you need treatment of a variety of kinds within your lifetime you’ll have to pay for it. At least in Wales. Ordinary, isn’t it?

  • Mc

    ” Let’s make the rich pay more for health care.”

    Another wet argument from Parris. The fundamental flaw to the demand for more NHS spending is that there is no limit to how much money the NHS can swallow, based on what treatments are permitted on the NHS.

    The only mystery for me is how Thatcher tolerated having Parris in her vicinity. I would have expected Thatcher to have hurled him out of a window within 5 minutes of being in his presence.

    • AQ42

      “I get free travel on all public transport in London at all times. This is a pensioner benefit that’s worth more than £2,000 a year to me, even if I earn ten times as much as the fare-paying poor. I also get a winter fuel allowance.”

      There is nothing stopping him leaving his pensioner’s pass at home and paying full fare like anybody else. In any case, the ‘benefit’ goes to the public transport providers and is in effect a subsidy to them, because it enables them to provide more services for the paying passengers. Were pensioner’s passes abolished, the elderly would not travel to the same extent and the providers would have a lower income.

      • Mc

        “Were pensioner’s passes abolished, the elderly would not travel to the same extent and the providers would have a lower income.”

        Tough. There are many things that I’d like others to buy for me. Just because a benefit is handed to the old, young or vulnerable doesn’t negate the fact that it may not actually be essential to survival.

  • Miss Darkside

    I know how horrendously middle class this seems, but my two non-negotiables should our income drop are our private healthcare insurance and our child’s private school fees. I’d sell the car, downsize the house, stop eating out, turn down – or off – the heating and never have another holiday before I’d sacrifice either of them. Both the NHS and education system are so broken that I need my back-up systems in place more than I need a fortnight in France.

  • trace9

    Perhaps Andrew Lansley could be charged £3 Bil. for the damage he did. His Cabinet pals could pony up a little under Collective Responsibility if it’s any bother to him.. Stopping mass immigration – weeell…

  • Joe

    Public health services are not reformable.
    Leave the money in peoples hands and let them chose where to spend it.

  • vanLomborg

    I believe it will take the British public another decade or two until they realise that their current healthcare provision and funding of it just does not cut the mustard.

    They will talk about charging foreigners for another three to four years, then they will start looking at HOW to charge foreigners, then they will discover this only brings in 0.05% of additional NHS revenue, so around 2025 the British public will be ready to bite the bullet and just go for what the French, Germans and Danes have been doing all along for over a century.

    • Mc

      I’d like to think that you’re correct, but I can’t see the British giving up their precious NHS. I do have a smidgen of sympathy for their stupidity in that you can be guaranteed that the politicians implementing a changed NHS funding model will almost certainly not drop the tax rate By the amount of the cost of funding the new model. I.e. The tax payer will be paying their old tax rate plus the cost of the new funding fee.

    • Matt Sharp

      What are the advantages and disadvantages of what the French, Germans and Danes have been doing?

      A quick google and it seems like Denmark has a tax-funded universal healthcare system, like the NHS. France and Germany use health insurance. All 3 countries appear to spend a fair bit more per capita on health than in the UK.

  • Mike Howard
  • Mike Howard
  • This would mean that higher earners would be paying twice for a service they may not even use.

    The NHS will always want more money. Even when Tony and Gordon were throwing billions at it, there was still a ‘funding criris’. Look back through headlines online from over a decade ago and you’ll see we’re still having the same debate, just pointing the finger at different people.

    As long as it remains “free”, it will perpetually be in a crisis. There is no incentive for personal responsibility in the current system. I have private insurance, it’s cheaper than I thought it would be and I resent proposed tax increases to pay for other people’s care. My insurance is £22 a month and covers everything I need. Any working person could afford that. My income is less than £20k a year too, so I’m not rich by any stretch of the imagination, for what it’s worth.

  • mikewaller

    I am starting to get worried about Matthew. First we had that nonsense several weeks ago about “page 3” representing the high point of British libertarianism whereas it was actually the thin edge of a wedge that has now yielded freely available pornography of diamond hardness; and now we have this. A health service is not just another consumer facility; one provided free at the point of delivery is the hallmark of a civilised society, something I am never slow in pointing out to our American cousins. Start making the rich pay, and you will be in a two tiers service in no time. Worse, without the rich around to kick up about their treatment, the lowest tier would be bloody awful in very short order.

    A much more sensible idea would be to slap full VAT on confectionery, fizzy drinks and any other “luxury” foodstuffs that do more harm than good and direct the entire proceeds to the NHS. It would also make a lot of sense for the Devon model in which the NHS and social service for the elderly are run as a single entity to be followed throughout the country. Above all, someone needs to be very brave and explain that as we head into an era when well over one third of the population will be above pensionable age, getting a substantial inheritance from mum and dad is going to be very much the exception. To put it very bluntly, the comparatively modest sums middle of the road guys like me paid in taxation over the years is laughably small in relation to the possible demands we could place on the system as we get towards the end of our very much extended lives. Something, somewhere, has got to give.

  • rtj1211

    To reform the NHS, use the cost-benefit evidence of medicine……

    I know that’s too hard to understand, it being Politics 101 for Primary School children, but really: you will have the best health service, given the budgetary constraints available at the time, if you apply the rigours of cost to the nation vs benefit to the nation in all medical procedures, medical technology investments, medical infrastructure design- and builds etc etc.

  • Edward1

    The real problem with the NHS is the huge variation in quality. I have twice had to pay for private treatment as I was getting a second class service at my local hospital. The NHS has had to set aside £25 billion for claims for mal treatment.