The article by Alex Scott-Samuel was a wonderful vision of how a health service ought to be. A care system wholly publicly owned, entirely free, funded out of progressive general taxation, publicly provided and publicly accountable. Maybe it was a bit light on accountability and on the role for shared decision making and community development. But who could disagree and still claim to be a Socialist?
But sadly the issue in not – can we conceive of a system we would like to see but – how far can we go towards getting one? So to move to Alex’s model what would be necessary?
We would have to elect a government committed to making the necessary changes. Given the other changes necessary this does not appear likely.
We would have to have a re-disorganisation on a scale which makes the Health & Social Care Act changes look like tinkering. Would be massively unpopular with a great number of the people who would have to make it happen – even more than now!
We would have to confront what defines the boundary for “publicly provided” – is it only clinical services or every part of care service delivery? Does anyone care that hospitals are build by private companies or that we use MICROSOFT, or SERCO for facilities management – so where is the boundary?
We would have to leave the EU and GATT. Which could have major macro economic consequences.
We would have to completely redefine our system of contract law. There are hundreds of thousands of existing contracts which would have to be broken – at huge cost or with huge economic dislocation.
We would have to nationalise a lot of providers who currently provide service to, but are outside of, the NHS. Up to 30% of mental health and almost all of social care are only provided by non public organisation – they would have to be nationalised. So too would Pharmacy? GPs? Dentists? Ophthalmology?
We would have to totally redefine what we think of as social care. Once it is free the level and pattern of demand for services will radically change and clarity over assessment and prescription would be necessary.
We would have to go against the consumerist trend which seeks choice and wants plurality. This may not be a bad thing but would require major changes in attitudes.
We would have to raise a great deal more in taxation to pay for the changes. Not just Defence cuts but probably most of education and welfare. It is not unreasonable to think of doubling the % of GDP required.
So how much would the changes “cost”, what level of funding is required (%GDP), what taxes would go up, how long would the changes take, who would manage the change process? Anyway I am sure that Alex and those in KONP and NHAP who advocate similar changes can set out their answers.
The SHA has set out its own approach to change which falls well short of the aspirations of fully publicly owned and provided; partly through ideological considerations (we see a role for choice and some non public provision) but also because we think you have to advocate changes which have at least some credibility.
This debate is an important one. Can we move further in the direction we would all like to go in – but retain credibility?