Can we really tackle waiting lists in the NHS?

Could a new UK government make rationing fairer by changing the way healthcare services are paid for?

As we wait today with bated breath for the results of today’s UK General Election, I thought we should turn our thoughts to the nearly 8 million people in England who are waiting for NHS treatment.

Source: British Medical Association

[Note for our American friends: this blog is about funding the NHS in the UK. What follows will make almost no sense to you. Anyway, you should be outside somewhere eating hotdogs and celebrating throwing-off the yoke of monarchy]

Can the next government solve this enormous waiting list problem without adding hundreds of billions to the NHS budget?

I believe it is.

To do so, my assertion is that we need to follow the money and then work out how to ration care more fairly.

I think we should “Give the Patients the Money”

[this link is to a peer-reviewed white paper that I wrote about 10 years ago, published by the University of Southampton]

Here’s a brief summary:

1. Health funding is becoming unsustainable, especially if - like the NHS - you promise an unlimited supply.

2. Demand for healthcare is increasing unsustainably due to ageing, chronic disease, new treatments and cultural changes in expectations

3. Supply of healthcare is limited and is falling in real terms due to budgetary constraints, the cost of Covid and is made worse by staff shortages,

4. Healthcare provision must therefore be rationed. Anyone who thinks that healthcare need not be rationed should revisit the previous three points.

5. The NHS rations healthcare through waiting. I wrote this 10 years ago. It is as true today as it was then. Waiting lists are a very effective - but blunt - form of rationing.

6. ‘Rationing by waiting’ is neither fair nor rational. Some people on the waiting list suffer more than others (their symptoms may be objectively or subjectively worse). Different parts of the country have different waiting times.

7. There is a fairer way to ration care by changing the way that we pay for services. Here’s my suggestion:

   1. Recognise that there are two ‘types’ of healthcare. Those that are not chosen by the patient (e.g. emergencies, cancer treatment) and those that are chosen (e.g. most GP appointments, elective orthopaedics)

   2. Call these Type 1 and Type 2 respectively.

   3. Now pay for these through different funding streams which allows the patient to determine how much they want to pay or wait.

8. Type 1 healthcare is the treatment you never want for you or your family: cancer, emergencies, ICU, the horrors of serious ill-health. This is paid for and provided by a nationwide insurance scheme and a network of providers paid for out of central government funds. This structure is familiar because is what we already have at the moment. Free at the point of service with the risk shared equally among the entire population.

9. Type 2 healthcare is the treatment you might spend time thinking about. It is also - crucially - treatment over which you might want to exercise some agency: where and how you have your baby, which GP or family doctor you see, how and when you have your knee replacement. This type of healthcare should be paid for using a government-managed Health Savings Account (HSA).

10. Health savings accounts (HSAs) have already been used to great effect in the NHS - but only for long term conditions - and with great success. They are called “Personal Health Budgets” but they ‘re the same thing. They have demonstrated significant advantages:

    1. They empower patients

    2. They make the cost of care objective and highly visible.

    3. They incentivise innovation and efficiency

    4. They encourage cost-effectiveness through the exercise of patient choice

11. Regulation of HSAs is important. Some things that would be necessary:

    1. Money from HSAs could only be spent on regulated providers on appropriate care (i.e. no aesthetic or unproven technologies).

    2. Providers would be required to advertise and publish prices to create a true market.

    3. Education and support for HSA holders would be essential

    4. Minors and people lacking capacity would need to be excluded

    5. For those who overspend or underspend, a form of protection would be needed

I recognise that there are many reasonable objections to HSAs - some of which are outlined and rebutted in the paper. The most emotional charge is that HSAs would represent ‘privatisation by the back door’. Given that all of this is still paid for by government, I would reject that.

Instead, I would ask this question: would a two-tier system such as this, which increases patient choice, agency and directly addresses the way in which care is rationed be more expensive, more unfair, or otherwise worse for patients than the backlog that exists at the moment? I would suggest not.

Of course, I actually don’t know whether this would work. What I do suggest is that the next government explore this as a possibility and perhaps run some experiments to find whether such a plan would work.

The evidence from Personal Health Budgets remains convincing