Whither our UK NHS ?

The NHS is 75 years old, and one of our most prized institutions. As you'll see from the analysis below, it is now  sorely in need of medical assistance itself. How can we save it from its terminal decline ?

Editors note: This blog was first published in August 2022 - in view of the steady deterioration in the service since then, which has now reached crisis point, not least because of the ongoing industrial action, I've  updated it to reflect the changes. The Election result has finally introduced some real soul-searching amongst politicians as to why the current funding and organisational model of the NHS is failing...unfortunately this is likely to be a tough nut to crack without a radical change in its funding model - which any Labour government will find difficult to square with its ideology. We shouldn't therefore expect much progress in this direction, despite Labour's large majority.

Nevertheless, I stand by the original recommendation of a radical funding model revamp with significant structural integration - only this will achieve adequate efficiency and funding to run a fit-for-purpose service  - and pay (and hopefully therefore retain) all its workers adequately. As you'll see from the arguments below, it's also essential that we integrate adult social care fully within the NHS system to make this work. 

With public confidence in the NHS now at an all-time low (24% in 2024 down from ca 70% in 2010), surely even our politicians must now sit up and take notice. It's no coincidence that they are actually doing so now that the election has passed and real responsibility is now in the hands of a new government.  We need to 'hold their feet to the fire' to prevent it confining itself to expensive sticking plaster...at our expense.

I’ve also included some quite revealing comparisons with our EU neighbours in this edition. Read on for more details...and comprehensive suggestions for the politicians to consider.

* * * 

I have to admit to some trepidation in attempting to tackle a subject as potentially controversial as this one.....

However…..needs must.

In my view, we’ve now got to the point where we have a nationwide health system that’s nearing collapse, and is manifestly unfit for purpose. This view has already gained wide acceptance, as recent surveys suggest, not least amongst hard-pressed NHS workers themselves. As a nation, we really can’t turn a ‘blind eye’ to what’s being allowed to happen any longer.

By way of a disclaimer, I do not profess to be in any way expert in the organisation or funding of global healthcare systems. The ideas presented here are my own, and are based on my experience of working both within the NHS, and subsequently in the pharmaceutical industry, over a 35-year working lifetime. As such, my views may well not agree with the opinions of others. They are designed merely to stimulate discussion at a time when a serious re-think appears vital to our future health and well-being in these islands.

How and why have we reached the current woeful state of affairs ?

There are three key underlying issues which have brought matters to a head:

a) Funding derived from taxation alone is insufficient to 'power' a modern 21st century health system that meets the needs and expectations of nearly 70 million people with the current demographic distribution. Moreover, our population is still growing  and is forecast to reach 74 million within the next 10 years. It is also ageing rapidly, and the numbers of working age chronic sick requiring treatment is also increasing. This has major implications for the productivity of the economy and the benefits bill.

b) The adult social care system is not integrated with the rest of the system, and is itself based on a failing funding model. This has led to an acute mismatch between demand and supply, resulting in inadequate elderly care in the home, thus forcing unnecessary hospital admissions and bed-blocking.

c)  Our GP practices are overloaded and inadequately resourced, both financially and in terms of available medically-qualified staff. The resulting lack of available GP appointments is forcing patients, who could otherwise be treated locally, to turn to A&E departments; these in turn have become chronically overwhelmed and thus themselves forced to ration care by availability. NHS dentistry is also in steep decline, due largely to unfavourable contract terms, driving more people to the private sector....or even to DIY 'treatment' measures in extremis.

Population control: Our UK population has expanded continuously since the NHS was founded in the late 1940s, and continues to grow, due largely to the continued high levels of net immigration and reduced death rates. Since Brexit, immigration has increased rather than declined (we were, of course, promised it would decline substantially by the Brexiteers; at the time, a little thought regarding demographics would have made it obvious that Brexit would simply transfer the source of immigrants from eastern Europe to other less wealthy countries, rather than remove it as they suggested). 

The bulk of UK immigrants are now indeed economic migrants from the third world, rather than from EU, and are increasingly entering UK via illegal means (as the burgeoning daily totals of channel ‘hoppers’ arriving on our southern beaches from France in small boats will confirm). Although the France is deemed a 'safe' country, and the French authorities are making some efforts to stem the tide, the favourable economic model  and lax policing against the people-smugglers on both sides of the channel has ensured the crossings continue. In particular, Macron's steadfast refusal to agree a rapid return arrangement for illegals is hampering progress towards a viable solution. The Home Office 'threat' to deport some migrants to Rwanda was always going to be an ineffective deterrent, given the vanishingly small chance of an illegal migrant ending up there (see previous blog on immigration for more details) and is now, quite rightly, history. 

It is only bilateral agreements with countries that are UK immigration 'hot spots' that hold out any hope of stemming the human tide into the EU and thence to our shores. The new 'command' structure introduced by Labour aimed at tackling the gangs is likely to be just as ineffectual as the Rwanda policy as long as their are enough desperate people willing to make people-smuggling  activities profitable. New smugglers will always emerge when any existing ones are taken down by the authorities, and the resulting 'whack-a-mole' strategy simply won't stop the trade.

We should remember also that although illegal migration continues to be a thorn in the flesh of government, its contribution to our population excess is dwarfed by the levels of legal migration approved by government. It is this that we must reduce radically going forward if we are to improve, or even just maintain, our standard of living and reduce the overwhelming demand on our healthcare system and infrastructure.

Demographics: Our indigenous population is also ageing rapidly. In this respect, the NHS is a ‘victim of its own success’. By keeping elderly patients alive beyond their natural span through medical advances, without, of course, being able to hold back the natural ageing process, we have unwittingly created a demographic 'time bomb' for both pension and healthcare provision. 

Inevitably, the majority of our pensioners in their 80s and 90s, (many of whom would never have survived to such a great age without modern medicine and universal free healthcare) will need medical intervention more frequently than their younger peers. Far from seeing them as a burden, we should remember that these people effectively created and nurtured our society, and have contributed to  financially to it through National Insurance (NI) throughout their working lives. Their combined efforts have supported later generations steadfastly through their development. As a society, we thus owe it to them to provide the respect, care and assistance they have undoubtedly earned from us in their declining years. 

The need for a fully functioning and integrated health service with the capacity to cope with the numbers is now therefore even more urgent than ever if we are to avoid continued suffering and unacceptably large increases in the death rate due to a lack of appropriate care. Planning must include a complete rethink on Adult Social Care provision and its integration, the serious shortcomings of which are now actively inhibiting hospital admissions.

A brief look at the NHS's history may help put things in context here. The NHS was originally designed as a basic safety net in the period immediately after the second world war, at a time when the UK population was still under 50 million, and average life expectancy was in the low- to mid-70s. It revolutionised medical care in UK by providing access for everyone which was free at the point of need, and it served us well throughout the last half of the 20th century. Things started to go seriously down hill in the early 2010s following the wave of EU immigration in 2004 and the 2008 financial crash. With ca 70 million plus inhabitants now ‘crammed’ into this small island and many living into their 80s and 90s with the associated multiple chronic health problems, it simply cannot cope. Indeed, we should never have expected it to…..

Inflationary pressures: The sheer cost of modern medicine in itself, and the rapid inflationary spiral, have added to the funding burden, presenting a virtually 'bottomless pit' of healthcare funding needs, which is impossible to satisfy via tax revenues alone. The recent onset of a cost-of -living crisis and the resulting rapid rise in interest rates engineered by the failed monetary policies of central banks in response to the 2008 financial crisis have merely served to exacerbate the funding  problem.

Consequences: 

Effects on patients: Instead of our healthcare system meeting the increased levels of need, we are now effectively all subject to rationing by availability across the board, from the chronic non-availability of GP appointments right through to ambulances queuing outside hospitals, patients languishing  in corridors for days on end (and, sadly, even dying there!), and severe rationing of hospital beds of any description. This more recent calamity has been exacerbated by the appallingly run-down state of the adult care sector, such that elderly patients are effectively ‘trapped’ in hospital beds due to the lack of anywhere else for them to go, even though they would otherwise be healthy enough to leave the hospital.

We cannot go on like this……apart from any consideration of patient welfare, or the morality of denying them their treatment ‘at the point of need’  that was promised under their National Insurance contracts, if this situation continues, the NHS will continue to ‘haemorrhage’ staff to other professions,  and the system will just collapse.

This state of affairs should not be tolerated in a western European nation which is still relatively prosperous, and retains its place as the 6^th richest economy in the world.

Effects on staff: As a former NHS clinical scientist myself (many years ago now), I’m well aware of how dedicated the majority of staff in our NHS are, often working punishingly long hours under difficult conditions. Burnout is now common amongst front-liners, and many have already left the service as a result of the Covid pandemic, if only to preserve their own health and sanity.

It is important to appreciate that every trained staff member that leaves the service in this way takes with them a wealth of training and experience which is then lost to the profession. We owe it to those who remain to create a system which they feel confident will give them a decent working environment and prospects for the future. The problem is not the people manning the NHS… it’s the nature of the outmoded healthcare model they are desperately attempting to prop up.

Legal implications

One aspect of the failure of NHS provision outlined above that doesn't seem to have been publicised is the legal obligation of government to provide healthcare under the terms of the agreement we all undertake with it when we start paying National Insurance contributions. Since this is effectively a compulsory deduction from earned income, and is predicated to 'buy' lifetime healthcare services, I would expect failure on the part of the provider (i.e. HMG) to deliver healthcare to an acceptable standard would render it liable to legal penalties. 

Although I'm no expert on these matters, given the obvious NHS service provision failings we see daily, surely it can only be a matter of time before an individual sues HMG for breach of contract ? If their claim were to be upheld, I suspect class actions would quickly follow...with potentially disastrous effects on government budgets.

What then needs to be done ?

Possible solutions: The previous PM, like his many predecessors, certainly had an unenviable task, given the results of Covid and all the other woes that had befallen us after the 2019 election. The new incumbent will suffer the same problem if he continues to 'kick the can down the road' by failing to implement radical reform, including of the funding model. Assuming he has any time to raise his head from the even more acute problem of how to avoid half the population being bankrupted by increased taxation, benefit means testing, cost of living increases, sky-high mortgage rates and increases in their electricity and gas bills this winter, there is no obvious ‘silver bullet’ which can offer a solution for our healthcare system in its present form.

The first and most important thing the new PM needs to do is to cast aside any preconceptions about the inviolability of the current system and start thinking ‘outside the box’.

This is of course inherently difficult for any politician to do in a democracy, and is arguably one of its failings, since it promotes discontinuity. For any elected government, looking towards the next election is always the first priority, and in our political system this is never more than 4-5 years away, and applies however large their majority. Any radical change risks raising the ire of voters, particularly the more conservatively-minded ones (with a small 'c', of course!), especially when it comes to a subject as controversial as interfering in any way with the structure of ‘our NHS’.

Because of this, I personally do not hold out much hope that anything sufficiently radical to make a real difference will happen immediately following the election, or indeed for a substantial period thereafter.  That said, its current majority of 179 makes it the best-placed in recent times to achieve radical change. 

By the end of 2024, the process of collapse may be well nigh complete if no action is taken. The NHS is teetering on the brink now, and the relatively hard 2023-4 'healthcare winter', coupled with a predicted bad flu season this autumn and winter, the continued periodic  resurgences of Covid and abandonment of regular Covid top-up vaccination campaigns,  and all the economic stresses we already know are coming our way, could well tip it over the edge sometime during 2025. Neither is there much likelihood that the new Labour regime will be any more disposed to 'bite the bullet' - if anything their 'probationary' position and their political ideology, which normally espouses nationalisation in all things, would make this even less likely. Their super-majority might may them a little less cautious generally, but this is not to be wished for, given the lack of any restraint on wayward policies it would cause.

Assuming at some point government, of whatever ideological hue, will actually be forced into taking radical action, how could we reform the system….and how quickly could this be done ?

First, an important pre-requisite. Whatever scheme is proposed, it must cater for the government’s existing financial commitments to those who have already spent a working lifetime paying into National Insurance. This has always been a compulsory deduction, and was designed to provide both a pension and free healthcare at the point of need for all contributors. Government is therefore doubly obligated to provide lifetime free healthcare ‘cover’ to every paid-up pensioner under any new scheme, based on their lifetime contributions. This guarantee should also be extended at least pro-rata to anyone who is yet to retire and still contributing to the existing scheme. This assumption must be ‘set in stone’ within any plan, and cannot be up for negotiation. As an electorate, we should not, and must not, agree to anything less.

Can we still hope for a fully state-funded system provided for entirely out of tax receipts ?

The answer, regrettably, is almost certainly – no.

The main reason for this is that our population is just too large, and arguably now too elderly and unhealthy, for effective healthcare support to be fundable solely through taxation at a level of overall tax burden that the UK electorate would be prepared to tolerate. Covid has also taken its toll on the health of younger age-groups, with long-Covid sufferers in the hundreds of thousands no longer able to work, and many suffering from untreated mental health problems. The expanding legions of other long-term sick unable to get the treatment they require to get them back to work are also adding to the demand. All of them requiring benefit support, thus adding to the DWP's budget requirement. 

To fund the current NHS system at the level of care that was available in 2003 before the start of the main EEC-driven immigration 'wave', government borrowing would have to soar to levels which would be completely unsustainable, given the high levels of interest rates we're now experiencing. It is now likely that rates will remain historically relatively high for at least the next 2 years, and will, hopefully, never return to the abnormally (and dangerously) low levels we saw over the last decade. We saw in the summer of 2022 what happens if a chancellor even thinks about un-costed borrowing, so no government, particularly this one, will try that again. We must therefore accept that a significant financial input from the private sector will be required just to make ends meet, let alone fund radical reform.

Looking at those existing systems still working ‘state-funded only’ models, only the Scandinavian countries have systems that until recently still appear to be working reasonably well. The snag with all of them is that the average tax burden on individuals required to fund them is almost twice as high as our own, and likely to increase even further as costs increase. This would clearly be unacceptable in UK. 

Moreover, the Scandinavian healthcare systems are by no means perfect and have themselves struggled with both the natural ageing of their populations and the large influxes of economic migrants the Shengen agreement has imposed on them over recent years. The ‘death knell’ to the possibility of adopting a similar system for UK is that the current government has already committed to a promise of no basic tax increases, and will be unlikely to renege on that, even to keep healthcare afloat. Although the Labour regime will be more ideologically prone to raise general taxation to fund increased spending, and could invoke a 'get out clause' by raising thresholds (remember they have cleverly only promised not to increase tax rates), a Starmer cabinet with Reeves as chancellor will be likely to aim for political capital by continuing restraint in this area, given the last government's failure to honour its own promise of lowering the overall tax burden. Whether their manifesto promises will be honoured by labour after any possible internal 'regime change' to a hard left scenario is of course another matter.

What can we learn from some of the other existing models ?

The US healthcare system is entirely based on private insurance with only a very basic ‘safety net’. We must on no account attempt to emulate this system in the UK - it would be disastrous. Even with Obama’s hard-won 'safety net' reforms, which are still in place despite Trump's best efforts during his presidency,  its divisiveness and manifest social inequalities would not, and indeed should not, be tolerated here. The US system is also incredibly expensive per capita, based as it is on unfettered private health insurance charges and the predominance of high-tech ‘all or nothing’ medicine, and whopping unrestricted proprietary drugs bills.

The Scandinavian state-funded systems might, at first sight, appear quite attractive as a template for a hybrid system here. As discussed, they do still appear to be working reasonably well despite the recent challenges of Covid and the various mass immigration ‘events’ of the 2010s. They all, however, have a hidden disadvantage from the UK point of view in that the populations they serve are much smaller than ours – Denmark, for example, of whose healthcare system I do have some past working experience,  has a population of only ca 8 million, half of whom live in the greater Copenhagen area. If their per-capita healthcare cost were applied in UK, it would literally bankrupt us within a few years.  Little prospect, then, of things going that direction, even if a future government regime were to be of a more leftward-leaning disposition and therefore be more likely to adopt their usual 'tax and spend' strategy.

How then do larger northern EU countries, with more comparable populations to our own, do it ?

As our closest neighbours in NW Europe, Germany and France are arguably the nations most comparable in terms of population size & demographics and their GDP, so let’s take a brief look at their systems for possible pointers.

Germany, which is widely accepted as having a more resilient system than ours, and has a comparable population size, uses a model which we might do well to consider emulating. See link for more details.  It is largely supported through a publicly-funded health insurance scheme, which is jointly financed by employer and employee contributions via the tax system. The scheme allows opt-outs for those above a certain level of income, who then must arrange their own private cover for everything. All German citizens are required by law to have health insurance in one or other category. Pensions are organised and funded separately, so the Health scheme is dedicated solely to healthcare provision. Approx. 85% of the population are opted-in, with the remainder going private. The opt-in covers GP and outpatient visits, and most forms of hospital treatment, but not some investigational tests. An important difference between the German insurance-based scheme and our taxation-funded NHS is that in addition to basic healthcare, it also covers accidents/emergencies and long-term adult social care needs, and these are both fully integrated within the system.

Although the German system is certainly struggling with the rapidly increasing costs of all aspects of healthcare under the increasingly unpopular Scholz regime, and was also hit quite hard by the vast wave of immigration resulting from Merkel’s reckless ‘open door’ policy during the Syrian conflict, it has so far managed to avoid the chaos that characterises the UK NHS. It also coped relatively well with the Covid pandemic fallout, once the initial teething problems with vaccine availability in EU were sorted out. Its overall integration strategy and the inclusion of social care as an obligate part of the system, along with a high level of federal government support, may well explain part of its resilience.

The French healthcare system is similar, in that it is largely funded by a state-sponsored insurance scheme (PUMA). This, however, only covers ca 70% of the cost of routine appointments and residual cost to the patient also depends on the ‘category’ of healthcare professional involved. Any costs not covered by state-backed insurance are generally covered by additional private insurance paid for by the individual. The state provides this additional cover free for those earning below a certain threshold (currently for a single person living alone it is ca 9,000 euros p.a.). Everyone else pays in via social premiums based on their level of income. Social care, as in Germany, is closely integrated with the rest of the healthcare system, and is funded by means-tested government subsidy, with different levels of government contribution for both residential and home-care. Pensions are again treated and funded separately.

But how much do citizens of our nearest EU neighbours actually pay towards their Healthcare and Pensions ?

Although their tax systems are different, and taxation levels of course do vary depending on individual circumstances, it’s quite instructive to compare ballpark figures on tax levels. I’ve obtained figures for France, Germany & UK based on an 'average' mid-level pre-tax EU salary of 60k euros (see Table 1):

 

Table 1:   Salary, Tax & National Insurance  comparison Germany, France & UK
Country	Gross Salary	Income tax	Social security	Residual	Tax Burden (%)	Pension*
Germany (Euro)	60,000	9847	11595	38,558		18600
%		16.4	19.3	64.3	35.7
France (Euro)	60,000	7731	12703	39,566		22000**
%		12.9	21.2	65.9	34.1
UK(£)	53,240	9959	4959	38,322		9700
%		18.7	9.3	72.0	28.0
(Single person, working age with no children, standard tax allowances, Tax Class 1)
* pensions are contributory and depend on the individual's record; average values for a full 35 years.
** France has a guaranteed minimum of Eu 8200 p.a. regardless of contributions.

 As we can see from the figures, our EU neighbours do pay more (ca 25% burden for a mid-range salary of  60k Euro) overall in tax, but interestingly they actually both pay less income tax. The big difference is in Social Security taxation, where the UK NI contributions amount to only ca 9% of gross income, whereas both our neighbours pay more than twice this. What do they actually get for their extra cash, though ? The answer is:

 1) A much better pension – the average single person pension for someone with a full contribution record is more than twice the UK figure. Pensionable age is significantly lower also – In France it is still as low as 60 for both sexes. Macron is currently engaged in a battle with his electorate, just to raise this to 65.  

2) Their healthcare provision is also far superior to the NHS in its current state, and is fully integrated with adult social care, which is much more generously funded and effective. 

The message, to both electorate and government, is a clear one – you get what you pay for….

What sort of model might work for us ?

Viable UK models: If (or is it when ?) the present UK NHS system actually collapses or (perhaps less likely) some form of pre-emptive radical reform is initiated by government, it would seem the most likely outcome will be a model with funding contributions from both state and private coffers. 

This is de facto the current arrangement in all but name. Because of the impossibly long NHS waiting lists for elective surgery, distressed patients who have the resources to do so are already turning to the private sector in droves. Private medical insurance companies are already taking advantage of the public dissatisfaction with NHS performance and are now actively campaigning for new subscribers.  Dental treatment has been particularly badly affected during the past year, now that so few UK dentists are accepting new NHS patients due to their unfavourable contract terms. Those who can afford it have already 'gone private'. The electioneers 'to a man' are all lamenting the now notorious 'dental deserts' which have sprung up throughout the UK. We risk losing NHS dental care altogether if something isn't done to entice dentists back into the NHS fold....and soon.

Some may argue that we should just let ‘nature and the free market take its course’ when it comes to healthcare, and allow a new system to evolve naturally from the wreckage of the old. Given the demographics of our current population, however,  and the likelihood that the cost of living 'crisis' will persist for some time, this could, unfortunately, result in a level of  suffering and excess deaths comparable to or even greater than our pandemic losses.

 Perhaps more to the point, it would consign any presiding government and its party to the dustbin of electoral history, however large their majority. 

The end result would probably be something akin to the two-tier US system, with a private insurance 'free for all' but without any form of effective safety net. It would also be subject to the vagaries and exploitation of the open market. We must beware of falling into this ‘trap of inactivity’, and continue to press for active, and well thought out, change.

Assuming we do manage to avoid just ‘kicking the can down the road’ beyond the 2024 election, the only real solution with any chance of success is an integrated hybrid private-public model, funded jointly by private- and government-sponsored health insurance, but with a robust safety net to ensure everyone still gets treated at the point of need, whatever their means. 

We must also integrate social care into the overall package and ensure it is adequately funded for any viable model to work. This will avoid perpetuating the ‘bed blocking’ crisis which is rife in our UK hospitals, and is effectively paralysing their operation, and those of the associated emergency services. Neither can we risk a model akin to that of the US, where people are turned away by hospitals through lack of funds, and die as a result.

We must also aim for a more holistic model of social support, based on the 'cradle to grave' approach adopted by the scandinavian countries. Although arguably more intrusive, it is much more effective in encouraging and maintaining a healthy lifestyle throughout life, and ensuring the individual receives the care they really need in later life when they need it. 

Although this might appear a more expensive approach in the short term, the savings generated by preventing chronic illness, and thereby minimising hospital attendance, will make it much more economical in the long run. The social benefits would also be considerable, particularly for those nearing the end of their lives, who would overwhemingly prefer to die in their own homes rather than on a gurney (if they can find one!) in a hospital corridor. Interestingly, many of the more enlightened GP practices in UK are now turning to this type of model for the management of their ageing population lists.

Last but certainly not least, we must train more doctors - and these must be from within our UK population. The combination of woefully small place allocations at our medical schools, and their tendency to favour foreign students because of the £9k fee cap on home students, has led to the current crisis in GP and hospital doctor recruitment, and driven the need to import staff from abroad. We need to outlaw discrimination against home students by our universities. 

All this will certainly not be an easy one for government to 'sell' – or indeed fund. Devising a funding model which takes account of legacy NI contributions will in itself be a major challenge for the policy makers, never mind actually making it all happen. And this will be the case whoever happens to be in power.

Could any UK government hope to sell this type of reformed package to the public, and what would it need to include ?

Selling the change: The financial cost implications for the individual will be a paramount consideration. Introducing up-front charges for GP appointments, as per the French system, would 'stick in the craw' for most, and should be avoided. Given the unfairness of what is happening now, extending NHS funding for the private healthcare currently contracted in as an ‘overflow’ mechanism to cover the current NHS shortfalls and its vast waiting lists might be an acceptable first step. To some extent this is already happening behind the scenes. An optional uplift in employee NI contributions for those still contributing could be used to fund this extra provision, and would entitle the payer to faster access to treatment as an incentive to contribute. How would government best ‘sell’ this concept to the electorate ?

Many firms already include private healthcare insurance premiums in their employee remuneration packages, and these are currently taxed as benefits in kind at the employee's marginal rate by HMRC. Employers could instead use these ‘incentive’ funds (and a corresponding reduction in their employer NI contributions) to provide enhanced contributions to the uplift scheme for the individual. As contributions to UK taxation, they would then cease to be a direct benefit in kind for the employee, thus saving them marginal-rate tax, which would provide a small but significant further incentive for individual employees to agree to sign up.

Since Hunt reversed Sunak’s original substantial uplift in both employee and employer NI contributions, and then reduced NI even further, a voluntary uplift in contributions could be achieved by Reeves without any ‘extra’ cost for those prepared to continue paying in at their original level. The extra revenue generated for the treasury could then be used to set up and subsidise an insurance scheme involving the private sector, which would fund enhanced treatment for new participants. Those who opted out would still receive the basic healthcare package currently provided under the current scheme, which should itself in time be significantly improved by the re-resourcing process I’ve described. 

Existing pensioners should, of course, receive the fully-enhanced package as of right, given they will already have fulfilled their existing (and compulsory!) NI 'contract' with the government.  As the system 'bedded-in' and things improved, the majority of younger workers would accept the need for enhanced NI payments in return for better healthcare, and any initial divisions in the level of provision could be ironed out in the interests of fairness.

This is probably the only recipe for getting a government-sponsored private insurance element 'over the line' in the short term, given the public’s current resistance to privatising anything, let alone our ‘precious’ NHS. 

We must however ensure that the taxpayer isn't saddled with an additional burden as a result.  Maintaining the contributory principle of NI deductions from salary to ensure a worker's future healthcare provision is essential to avoid this….what happens when a government tries to abolish the contributory principle which NI embodies, and dump part of the financial 'black hole' back onto its key pensioner demographic, was decisively demonstrated by the 2024 election result....they really did deserve to lose.

I hope this blog will stimulate further discussion on this important topic – please feel free to comment, but please don’t ‘shoot the messenger’, electronically or otherwise !

First published: 19.8.22; Revised 22.10.24