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Government is right to question state-funded health care for all
31 January 2014 by Philip Booth

Bishop Pat Lynch is absolutely right to be concerned about whether migrants, asylum-seekers and those in great need will be able to get health care as a result of government reforms. The principles of the promotion of human dignity and the common good demand that all can access health care – and that includes migrants.

However, we should perhaps consider the wider issue. Should the state be the only financier and provider of health care? Should there be a responsibility on church institutions themselves in this regard? We share a health care system with Canada and Iceland that all other Western countries – including Catholic countries – have rejected. For example, 51 per cent of hospitals in Germany are not government-owned (and they provide much more than 51 per cent of the care) and 34 per cent in France. We do not have a health care system in which the state assists organisations that develop organically within the community, which is what Catholic Social Teaching demands. We have a health care system in which the state is dominant.

Before the war, the system was different. In 1939, charitable hospitals (the same names we know today – Great Ormond Street, St Bartholomew’s, and so on) took in 60 per cent of all patients requiring acute care, and local government provided places for many others. About 19 million people had health insurance and most of the rest of the population were members of Friendly Societies or made direct payments for their medical costs.

Less than 15 per cent relied on free services provided charitably, through the goodwill of doctors or funded by government. In the demands for reform it was that 15 per cent about which there was most concern.

But reform did not take the turn many expected. Neither did it take the turn Lord Beveridge would have hoped for. And we certainly took a different route from the Christian Democratic countries of continental Europe. Indeed, the creation of the NHS was not supported by the Catholic Church because it involved the complete compulsory nationalisation of almost all local, charitable, church and friendly society hospitals. The then-archbishop of Westminster, Cardinal Bernard Griffin, fought for and obtained exemptions, but only for the small number of Catholic hospitals. He argued that it would be a “sad day for England when charity became the affair of the state”.

There can be no objection in principle to people paying for health care any more than there can be an objection in principle to people paying for other things that the Catholic Church believes all need access to – food and shelter, for example. A system of provision and finance that combined mutual societies, insurance contributions, commercial entities, direct contributions, charity and church institutions, and government help where necessary and desirable, may well be more humane and serve families and the community well (the hospice movement has some of these features). That would also be a model that would enable people to obtain health care in a way that was compatible with their conscience. It is also worth noting that the thousands of friendly societies in pre-war UK, as well as the organisations that still exist today elsewhere in Europe, are often organised on the principle of reciprocity discussed with admiration by Pope Benedict XVI in Caritas in veritate.

Meanwhile, we are where we are. Bishop Lynch is right that all must have access to health care. It would also be wrong if the state monopolised the provision of health care and then pulled up the drawbridge so that some could not access a service of which the state had become the only provider. There is nothing intrinsically wrong, though, in asking migrants to pay for, or insure for, health care. However, this should not apply to those who are in no position to afford it (especially if they are asylum-seekers).

But, in the long run, perhaps we could have a less monolithic system in which Catholic hospitals and provident funds played an active part in providing health care for migrants in the same way that Catholic schools play an active part in educating their children – with or without state support, as is appropriate in the circumstances. Bishop Lynch is probably right. Certainly he is not wrong. But we need a wider debate too.

Philip Booth is the Editorial and Programme Director at the Institute of Economic Affairs

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Comment by: Mike M
Posted: 23/02/2014 14:49:19

To be clear about our definitions, by the economic “Ultra-right” I mean the those who support the presently dominant economic theories originating in the US, which led to Reagan/Thatcher economic thinking and continued with Blair & Cameron, which frees up all restraints on the rich & punishes the poor for being poor. I think the IEA does differentiate itself from the main group of the ultra-right but in providing support for Thatcherism brings about the same results.

On the subject of the Nobel prizes it is a special committee that selects the economics winner. But the prize for economic science (can there be such a thing) is awarded by the same overall body that awarded the Kissinger peace prize of which I was critical. See following from Wikipedia. The Nobel Prize is a set of annual international awards bestowed in a number of categories by Swedish and Norwegian committees in recognition of cultural and/or scientific advances. The will of the Swedish inventor Alfred Nobel established the prizes in 1895. The prizes in Physics, Chemistry, Physiology or Medicine, Literature, and Peace were first awarded in 1901. The related Nobel Memorial Prize in Economic Sciences was created in 1968.

Comment by: Joseph
Posted: 11/02/2014 22:18:43

The reality, though, is that there are also deep problems with efficiency.

I am glad that an NHS hospital helped get my appendix out - but I am not so happy that I had very bad stomachache for many days beforehand, with my local surgery nurse telling me to drink peppermint tea and the sort. In the end, the surgeon told me that my appendix burst, and it was rather messy: what should have been a routine operation of a few minutes took two hours. A big scar is now apparent on my tummy. My wife was pregnant with our first child, and I could quite easily have never had a chance to see the baby.

I sometimes wonder if private money can be invited to invest in the system, to train up medical professionals, and bring business discipline into the system. Clearly a lot of regulation needs to be done in such a system.

But then and again, this is not really such a big thing. I cannot think of any government run supermarkets - but yet, food is so very important for sustenance. We have the Food Standard Agency who helps to ensure the food does not become unsafe, even if produced, packaged and marketed by private companies.

I sometimes fall into the temptation of assuming that business people are not ethical, and driven solely by the profit motive. However, I usually would rather imagine that many business people are proud to provide a service to the community. Some MBA programmes have business ethics as options. Some large corporations also hire business ethic consultants.

Comment by: philip
Posted: 11/02/2014 20:34:47

we should probably draw things to a close so this will be my last word. Regarding the Nobel Prize winners I mentioned them specifically in relation to the jibe "academic sounding", but I accept that you may not be impressed by those who have won the prize (which is, in fact, given by a completely different institution from the peace prize so it is not the same Nobel institution, I am afraid). There is also more complexity to economics and the arguments we make than you give credit for as perhaps is illustrated by the report on the last-but-one Nobel Prize winner to write for us in the Guardian at the time she won the Prize. The arguments to do with the delivery of healthcare are also more complex than perhaps you give credit for which is why nearly all other OECD countries have chosen different routes to the delivery of care from the UK even if the state ensures through its system of finance that all have their care financed. If you wish to use terms such as "ultra right", I think you should define them as the IEA was established for amongst other reasons precisely to fight what is commonly understood to be "ultra right" national socialist thinking and, as I have said, has had many prominent members of the Liberal Party and its successors as authors or staff. Much better to play the ball than the man.

Comment by: Mike M
Posted: 11/02/2014 16:02:47

Of course I am aware that the rise of the right leaning & ultra-right economic “think tanks” occurred before Thatcher/Reagan. Money from the very rich, who saw their huge advantages slipping as inequality slowly decreased, poured into these organisations to produce propaganda in all the media. However they were the first fully be influenced by this propaganda and set the UK & USA on a course to once again allow inequality to increase
I am not particularly impressed by the number of Nobel prize-winners who have written for you. A quick look at those who have won the prizes for economics reveals that most have been supporters of the destructive type of economics that has brought about the rise in inequality since the mid-seventies. And is not the Nobel institution the one that gave a peace prize to the monstrous Henry Kissinger responsible for uncounted thousands (maybe millions) of deaths in Chile, East Timor and Vietnam (See documented evidence in The Trial of Henry Kissinger by Christopher Hitchens).
Still no proper response to the main point – since 1948 we have had a health service which served the majority of the population very well, the first in the world to make health available to all and as such envied by many. Since the mid seventies we have had governments, influenced by organisation like yours, looking to cut back or privatise health services to the detriment of users and the benefit of private companies like Virgin Health Care which I am sure you will agree is not non-profit making. And despite what you say, in practice we have never had the nationalisation of the whole system. From the start there has always been a private system of hospitals for the rich – I have two with four miles of my home. As Bevan, who against his better judgement, allowed private healthcare said of the doctors at the time “I had to stuff their mouths with money to get them to co-operate”.
Mike M

Comment by: philip
Posted: 10/02/2014 10:34:12

well funded? - The IEA has a turnover considerably less than that of the average school

Thatcher era? - The IEA was founded in 1955 to counter concerns about authoritarian central planning policies of both left AND right

Academic sounding? - we have 12 Nobel Prize winners as authors

Making the matter personal? - it was you who made the gratuitous comments

Owned by hedge funds - really. On the whole, non-state institutions that provide health care are not profit making (even today in the niche provision in the UK)

The US, private/charitable mix? - The state spends as much on healthcare in the US as it does in the UK, covering the poor and old badly (and 50% of all health care is provided in the last couple of years of life, so the coverage of the old is substantial). It was for this reason that I deliberately avoided comparisons with the US: the problems in that system are well debated, complex and as much to do with regulation and legal systems as anything else. You could choose about 20 other OECD countries with which to make comparisons.

Unrestrained markets? - Nobody believes in unrestrained markets, the question is whether the first mechanism of restraint should be the state

Prof. Berridge? - I did respond to that by saying that neither Beveridge nor almost any other country believed it was necessary to respond to the problem by nationalising the whole system

The state is not the community, it exists to serve the community

Comment by: Mike M
Posted: 07/02/2014 17:25:06

I am afraid that it is necessary for readers to know the basis of articles in these days when apparently disinterested opinions expressed in the media are actually often backed up by one or other of the well funded right leaning organisations, with academic sounding names, that abound since the Thatcher/Reagan era. I only said, “here we go again”, because previously we disagreed over Pope Francis’ comments on poverty when State provision as against unrestrained market provision was the bogey.

Is State provision not communal. Surely we are all members of our state? You and I have some hand in directing the state whereas we have no say in the market controlled by large companies and often nowadays those most undemocratic organisations, hedge funds.

In making the matter personal you managed to avoid the main point, which was backed up by the quote from Professor Berridge, under the pre-NHS system many including most of those in the communities into which I was born could not afford treatment even if it was “non-profit making”.
Now everyone in this country is treated. This is in contrast to the disgraceful situation in the USA where under the private/charity regime many millions have no health care at all in what is still the most wealthy country in the world. And into the bargain the US regime, as far as I can discover, achieves this terrible outcome by also being the most costly in the world.
Mike M

Comment by: Jim McCrea
Posted: 06/02/2014 22:43:20

mhopwood. I think that you will find that MANY people, including practicing Christians of many stripes, will find that contraception and, in some cases, abortion are "medically necessary" and far, indeed, from being "unethical."

Comment by: Joseph
Posted: 06/02/2014 18:01:10

I remember from my R.E. that "owning all thing in common" was more an experiment of the early Christian community in the Palestine (as described in Acts), and some people conjecture that it all went wrong, and Paul was having to ask other communities to give financial resources to "rescue" it.

I suppose whether this conjecture was right or not, it seems difficult to separate the Good News away from being financially fluent. I do remember it says in the Gospel somewhere that we need to be as cunning as foxes but as pure as sheep (or something like this)...?

I think I am beginning to like there being a choice of hospitals and styles of care. With this, it might be good to also have some kind of rating system of the hospitals, so that the patients would know what they are getting themselves in for. Unlike food, where I have many opportunities to try different brands of bread, I may well only have one large visit to a hospital!!

Comment by: M Shrewsbury
Posted: 05/02/2014 23:51:59

It would be great to see public-funded health provision run by a range of providers which might include Catholic organisations.
My only concern is that we aren't much good at finance.
Just ask your diocese where it is possible to access the most recently audited accounts.
Then don't hold your breath.
The culture of secrecy reflects badly on the church.
I say this, with regret, as a lay person who feels his contribution to church thinking is regarded as 'unhelpful' and whose duty is to be passive and obedient.
A 'Citizen Dividend' as Joseph advocates sounds very reasonable but the language of the market can't beat 'owning all things in common' to use the language of the Gospel.

Comment by: philip
Posted: 05/02/2014 17:56:23

"Here we go again – Private always better than state (of course it is the job of IEA to press that point)".

I am interested too in the intellectual generosity of commenters on the blog. I don't begin my articles by "Here we go again, bishop complaining about spending cuts but I guess he thinks that is his job" or "here we go again, the Tablet peddling its usual social democratic line" or "here we go again, Mike M justifying the most state-centered health system in the world". Why not respect contributions to debate for what they are - a useful attempt to inform, critique and improve understanding even if you don't agree with them? It is a matter of fact that, in Catholic social teaching, nowhere does it say that the state should be a monopoly supplier and financier of healthcare (and finance the termination through abortion of one in six pregnancies and a lot of other things we would disagree with morally). There is nothing that strictly rules out monopoly state provision of healthcare in Catholic social teaching (though there is when it comes to state monopoly provision of education) but it is not the way generally favoured. There might be a good reason for the Church's view on these matters. It is not just the IEA you know...The arguments stand and fall on their own merit.

Comment by: philip
Posted: 05/02/2014 17:47:24

"Private always better than state (of course it is the job of IEA to press that point)" - of course, I did not say that. I asked what the respective roles of different providers and financiers of healthcare should be. Should the state finance and provide all healthcare and, if so, why is it only the chosen model in the UK and Canada?

"In short, Britain’s health care system, pre-1948, did not work well. It was a patchwork of institutions which were not accessible according to need." I addressed that as did Beveridge of course (I think you exaggerate the point but that is a matter of degree). However, the idea of nationalising all hospitals and having only the state providing finance was not the option most people expected or most other countries followed. There are ways of helping systems work better without smashing them up entirely.

"I would like to understand why you believe that, after having deducted insurance company fees..." First of all, I would not expect most providers to be profit making. They are not in many OECD countries, they were not in 1948 and, even in the marginal and rather commercial world of what remains of the private sector in the UK, the biggest provider is not profit making. Secondly, individuals are different and have different preferences for different services (we should respect this). Also, in any system, capital has to be provided, risks taken and a return provided (that is true when church or state providers - but they bear the risks).

Comment by: MIKE M
Posted: 05/02/2014 11:59:25

Here we go again – Private always better than state (of course it is the job of IEA to press that point) – You really do have rose tinted spectacles when you look at health provision before the NHS – I come from the generation that was very young at the time of the introduction of the NHS and can assure you that the previous generation regarded it as the greatest piece of legislation ever passed and it contributed in a huge way to providing a feeling of security most of them had never had. See the short piece from an article by Professor Virginia Berridge director of the Centre for History in Public Health at the London School of Hygiene and Tropical Medicine:-
In short, Britain’s health care system, pre-1948, did not work well. It was a patchwork of institutions which were not accessible according to need. The two primary deficiencies were lack of access to hospital care and lack of access to health care for dependants – the families of working men. Many of these had no formal health cover and had to use self-medication or medicines bought over the counter from the local pharmacist. As a result, an illness, or paying for medical attendance at a birth, could cause major financial problems for families across the country
I would like to understand why you believe that, after having deducted insurance company fees, shareholder dividends and no doubt many other amounts from the money available, we could improve health care provision. It would seem difficult in health care to apply the usual methods used by private firms to reduce costs i.e. reducing the quality of provision or reducing the wages of the workforce
Mike M

Comment by: mhopwood
Posted: 05/02/2014 10:20:14

I would love to see the UK allow its taxpayers to opt out of all the unscientific (e.g. homeopathy), extraneous (e.g. voluntary cosmetic surgery) and downright unethical (e.g. contraception and abortion) "services", and just pay for medically necessary treatments.

It's particularly scandalous to read about mental health care struggling for cash while pseudoscientific "alternatives" get State funding.

Would "market forces" really allow reasonable alternatives though? Here in Germany we officially have a choice of health providers (actually just insurance pots), and apparently all of them offer a bunch of (at best) useless "alternative" extras.

Comment by: mhopwood
Posted: 05/02/2014 10:20:10

I would love to see the UK allow its taxpayers to opt out of all the unscientific (e.g. homeopathy), extraneous (e.g. voluntary cosmetic surgery) and downright unethical (e.g. contraception and abortion) "services", and just pay for medically necessary treatments.

It's particularly scandalous to read about mental health care struggling for cash while pseudoscientific "alternatives" get State funding.

Would "market forces" really allow reasonable alternatives though? Here in Germany we officially have a choice of health providers (actually just insurance pots), and apparently all of them offer a bunch of (at best) useless "alternative" extras.

Comment by: philip
Posted: 03/02/2014 10:22:48

very fair point, Joseph. There are lots of ways of doing this and one approach I think you definitely don't follow is the approach in the US (where there are effectively three systems, an incredible amount of both state and private money spent, artificial encouragement for short-term and employer-based schemes and a defective legal system and, arguably, very high costs because of the various vested interests in the system - both professions and drug companies: both sides of the political argument accept that though they have different solutions and a big "I would not start from here" problem). In fact, some people have recently suggested what you suggest below. Separating finance and provision is important, I think (and nearly all other countries do that). And there are lots of ways to provide finance to the less well off without making them feel as if they belong to a separate system. That is also the way to respect differences in preferences. People tend to think of healthcare as a uniform service but it isn't - I might want to "belong" (and I use the word "belong" advisedly) to a - possibly Catholic - healthcare provider that did not provide abortion and contraception, perhaps had a reputation that was not as good as London teaching hospitals for cutting edge acute provision but really put the manpower into caring for me in a dignified way. Others may have different preferences.

Comment by: Joseph
Posted: 02/02/2014 18:23:32

Thanks for the blog. Just one immediate feeling.

I understand the logic. Under this system, there will inevitably (and rightly so) it will inevitably that "those who can" will have to pay, and "those who cannot" can still get healthcare for free.

The more I look at this the less I feel I am part of the society, though. It feels as though the society is so making use of me and it feels as though I get nothing in return. Am I not part of this society? Come on - please give me if just a little token to remind me that society loves me, and not treat me as some kind of money making tree.

I think getting rid of means testing in many areas could be a very good thing. It makes society more integrated. How about some kind of "citizen dividend" - an unconditional sum payable to all citizens, in recognition that everyone is equally having a share in society - to replace all kinds of means-tested benefits (including healthcare insurance as kind of suggested by Mr Booth here)?