The Barker commission has delivered a huge blow to the idea of charging for health and social care – perhaps this time it will stay floored, says Julian Le Grand

I have long opposed the idea of increasing the range of charges in the NHS. This is partly because of the obvious difficulties that charging for medical care at the point of use creates for the less well off, and the fact that means tests designed to deal with that problem never seem to work properly.

But there is also a more fundamental source of inequity or unfairness from charges. Most people become ill because of bad luck. Even those who might be considered to bear some responsibility for their condition, such as heavy smokers, are in part the victims of bad luck: not all smokers get lung cancer. People should not be held responsible for, or be made to pay for, situations that arise wholly or largely from factors beyond their control.

Julian Le Grand

‘People should not be made to pay for situations that arise wholly or largely from factors beyond their control’

However, when I started work as a member of The King’s Fund Commission on the Future of Health and Social Care in England, chaired by Kate Barker, I did wonder if I might have to change my mind. A number of well respected analysts had begun to question the sustainability of the free at the point of use model of healthcare in a time of fiscal crisis.

Ideas canvassed included charging for GP attendances, for appointment no shows, and for hospital care. It was also pointed out that social care dealing with people with long term conditions such as Alzheimer’s or Parkinson’s seemed indistinguishable in its aims from healthcare and was (heavily) means tested; was there not a case for creating greater alignment in the systems by means testing NHS care?

More fundamentally, was it not time for – in the words originally used by Chris Ham, the King’s Fund chief executive, when setting up the commission – a “new settlement” in health and social care?

Free at the point of use

In the event, my colleagues on the commission and I did not succumb to the calls for increasing charging within the NHS. We have called for a new settlement – one that better aligns the entitlements for health and social care.

‘The resources necessary to provide a decent level of health and social care would only take up around 11-12 per cent of GDP by 2025’

However, the settlement we endorse does not align a new means tested health care system with means tested social care but rather moves in the opposite direction: a progressive increase in the amount of social care that is free at the point of use and, with the small exception of some reductions in the exemptions for prescription charges, the preservation of NHS care free at the point of use.

Why? Partly because the claims of unaffordability did not stack up under examination. The resources necessary to provide a decent level of health and social care (and that would have to be found anyway, whether paid for privately or publicly) would only take up around 11-12 per cent of GDP by 2025: broadly in line with other European countries’ current expenditure just on healthcare.

It could be funded by a public-private partnership scheme that involved substantial public funding of social care as well as healthcare (this partly because of the continued failure of private insurers to offer products that cover social care costs). There is obviously a short term problem for the public purse, which is one of the reasons why the commission is recommending a staged introduction of its recommendations.

But we also recommend changes to, among other things, national insurance, which would help pay for the implementation of the recommendations – even in the shorter term.

Impractical charges

Then there were concerns about practicality. Charging for GP attendances, for instance, would encourage people to attend already overburdened accident and emergency departments; the only way to stop that would be also to charge for accident and emergency attendances, the difficulty of enforcing which is obvious.

Charging for no shows (apart from raising little money) also presents severe practical difficulties; the people who do not turn up for appointments are often precisely those who are difficult to track down to enforce debt collection. Hospital charges would be costly to administer.

Also, there is the problem for any charging system that it may discourage people who really need care. One of the reasons why The Commonwealth Fund judged the UK system to be the best out of 11 developed countries was because it had by far the lowest proportion of people who were deterred from seeking healthcare because of cost – an aspect of the system that would probably disappear if charging were significantly extended.

A zombie idea

However, the fundamental reason for the commission’s call for a new settlement arose from the prime purposes of any health and social care system: that of promoting fairness and of alleviating distress and suffering.

The commission was helped in its work by a group of “experts by experience”: people who, in trying to find care for themselves or members of their family with Alzheimer’s and other long term conditions, had been thrust into the almost impenetrable “system” of locally provided social care, NHS continuing care, and cash benefits such as attendance allowance.

‘In the telling phrase of the Canadian health economist Bob Evans, charging for healthcare is a “zombie idea”’

Quite aside from the distress in navigating this maze, neither experts by experience nor commission members could understand the logic behind the various divisions. Overall, the fairness case for providing most social care free at the point of use seemed just as compelling as that for healthcare: no one chooses to get Alzheimer’s, Parkinson’s or motor neurone disease.

The report’s proposals are not limited to identifying additional funding. It argues the case for a single pathway of care, with a single ringfenced budget and a single commissioner: proposals that will be challenging and complex to implement but reflect the fundamental reform needed.

In the telling phrase of the Canadian health economist Bob Evans, charging for healthcare is a “zombie idea”, one that always springs to life again after being dispatched and hence needs to be repeatedly killed.

The Barker commission has, I hope, delivered another blow to the idea in healthcare and extended this critique to that of excessive charging for social care. Perhaps this time the zombies will stay buried.

Julian Le Grand is Richard Titmuss professor of social policy at the London School of Economics

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