How to convert NHS (and social care) in England to a (Dutch-style) NHSS (National Health and Social Service)
Key Points
- The NHS is performing poorly – in almost all parts of its work, despite record levels of funding. Minor change will no longer make any difference
- More money, staff and beds will make no difference. CKDEx proposes a depoliticised Dutch-style social insurance system in England that would still be free at the point of delivery
- It will require 3-4 Acts of Parliament (described below) to bring in
- There will be no overall increase in cost. NHS England (and regions) and ICBs (eventually) will be disbanded
- Public health will be funded by the NHSS and no longer be independent of the NHS
- Social care will be funded by (and be fully part of) the NHSS
- A compulsory NHSS Health Tax – will pay for normal NHS care, with an appropriate reduction in income tax
- A compulsory NHSS Social Tax – will pay for NHS social care, with an appropriate reduction (or replacement) of National Insurance. Social care will pass to the NHSS in this model
- Modern working practices – will be needed. This includes hospital doctors, GPs, a 7 day NHS, and disbanding specialised commissioning.
Background
Most people are critical of the NHS at present. But few have put forward any workable suggestions to improve it. So what is the argument for change? The NHS is currently performing very poorly. We know it. The public knows it. The media knows it. The government and both main parties know it. Neither seem to have a plan to sort it out. There is no hint of significant reform or new ideas from either major party, with a general election looming.
The evidence for poor performance is all around us, including 7.6 million people waiting for an operation in July 2024 in the UK.
Hence private practice is thriving. Private GPs are forming every day. But most of our citizens do not have enough money to pay for private practice. Most people do not love the NHS any more. So what’s the solution? MyHSN thinks the NHS should ‘go Dutch’. Why?
The Netherlands has arguably one of the best healthcare systems in the world. Its cost is similar to ours (10% of your taxes) and if you need an operation it almost always happens within 6 weeks of GP referral. So it useful to look at it to find out why it works so well. If a business is not working, its normal to look at businesses that do work.
More money, staff and beds is not the solution. We have tried that. Another reorganisation? We have tried that as well.
Interestingly the NHS formed out of 4 major friendly societies, which were 4 very large functioning SIOs.
What caused the NHS to perform so poorly?
It is not known for certain. The NHS’s Tipping Point, when all major target performance dipped significantly, was in 2017 – long before COVID-19. COVID-19 was just the final nail in the coffin. We think its a lethal combination of three factors:
- Rapidly growing population– especially of the frail elderly with multiple co-morbidities – leading to a health/social care need outstripping demand
- Brexit– for 5 years both major parties ignored the NHS, focussing on Brexit. For the NHS to deal with population growth (see above) it needs to constantly improve its productivity
- Long-term social care– neither major party are willing to deal with the tax implications of the state providing long-term social care for the frail elderly. Hence many people have to sell their houses to pay for it at the end of life.
Whatever the cause, we all have a story – my Mum, your Uncle, her neighbour – that ‘cannot get out of hospital’ for lack of social care, or who are waiting in pain for an operation for over a year.
So, solutions not problems. How can a Dutch-style system be brought to the UK? Here goes. Breathe in.
NHS name. This changes to NHSS (National Health and Social Service) in England.
1. Social insurance organisations (SIOs; Requires Act of Parliament)
We propose an open tendering system for no more than 15 (10 later) companies, to apply to become a social insurance organisations. They should be given 5 year contracts, which are nationally (not regionally) based.
No more than 6 can be based in the UK, 3 from USA, 3 from Europe, 3 from other countries. No more than 50% can be profit-based (with a profit limit negotiated yearly). SIOs cannot refuse any patient.
All parts of NHSS (except for non walk-in GPs) will provide equal care 7 day a week; including all aspects of elective, non-elective, mental health (and similar, e.g. learning difficulties), social and other care.
NHS England (and its regions) will be disbanded as well as specialised commissioning. ICBs will be disbanded within a year of the SIO system starting. PCNs will continue to exist and each align with a single SIO.
All GPs become paid employees of NHSS, and the current model of GP disbanded. All GP properties bought by DHSS. There with increased national system of GP-run walkin centres (8am-8pm, 7 days a week), with all fulltime GPs working in one for at least 5 weekends a year.
All current hospitals, NHS and private, will become part of the NHSS. DHSC will buy all private hospitals. NHS will stay being owned and maintained by the NHSS.
Prescriptions will become free in England, bringing them into line with Scotland, Wales and Northern Ireland.
Joining NHSS scheme
It will be compulsory for all adults in UK who are 18 years and over (UK citizen, or non-citizens, both to be defined) to be a member of the UK’s DHSS, and join a SIO. Payments starts at aged 18 years. Most people will register at birth, or on arrival in the UK. All people, when registered, will rejoin yearly.
The only exceptions will be the armed services (with >3y contracts) and prisoners (over 3 month sentences).
Medical consequences of continued non-membership
Only emergency and maternity care is provided. Emergency care is defined as: 1. A&E, or 2. walkin centre – with no more than 1 contact per month, and no follow-up appointments will be provided.
Regarding prescriptions, the cost of only one course (of upto 2 weeks) of emergency drugs is free. Other drugs have to be paid for by private prescription.
Financial consequences of non-membership
If a citizen or non-citizen (to be defined) does not join scheme for >3 months from 18th birthday (or 3 months from first arrival (or re-arrival) in UK), when they do apply to join, a 20% higher cost of monthly basic (and extra) level care for their first year will be charged – after which they revert to normal payment.
2. NHSS Health Tax (NHTx; requires Act of Parliament)
This is equivalent the ZVW (Zorgverzekeringswet), which requires all residents in the Netherlands to purchase a basic national medical insurance.
Basic Care. This is compulsory and incudes GP, hospital, mental health and maternity care – costing approximately £120/month (for example). These services would be free at the point of delivery.
Extra care. This is voluntary and includes dentistry, audiometry, physiotherapy/OT, dietetics, podiatry, optometry, counselling, menopause care – costing approximately £80/month. Again, these would be free at the point of delivery.
Choice of health provider. People will not be normally be able to choose their health provider (e.g. GP or consultant) – unless a monthly top up is paid to enable them to choose a different doctor in that SIO.
Note. The cost of all three levels of care is decided upon by the government (in the form of a new DHSC-based regulator) yearly, i.e. a regulator will be needed to make the system work as a carefully managed market.
Reduced rate. There will be a reduced rate (25%) for certain groups – e.g. £30/month for Basic Care Care (and £45/month for Basic and Extra Care).
Reduced rate NHSS care will apply if your total yearly income is less than £12k, you are on longterm disability (physical or mental) benefits, or unemployed (for over 3 months), or a full time student.
Visitors to the UK for over 3 months, will need to apply for NHSS care, join an SIO, and pay (in advance) a standard monthly for a minimum of 6 months – after which they can apply for a yearly membership.
Note. The reduced rates are also set by the new ‘DHSC regulator’ yearly.
SIO ‘end of year reward scheme’. A person will receive a £480 (i.e. 4 months basic level NHSS care) reward (taken off the next years payments), if they have had no more than 3 contacts with their GP, or hospital OP appointments, procedures or operations (see Public Health later).
Tax adjustment. Income tax is reduced by 2% (or what is needed). Hence the SIO contribution becomes a hypothecated tax that cannot be used for anything else.
There will be consequences for DNAs (DNA = ‘did not attend’). These are defined as not attending (without valid reason) an SIO-run service – appointment, procedure or operation. If someone DNAs 3 or more arranged contacts per year, they will pay a higher rate for basic and extra level care, in the following year (e.g. £150 and £100 a month respectively). This will occur even if they move to a new SIO provider the following year.
3. NHSS Social Tax (NSTx; requires Act of Parliament; can be linked to (or same as) NHTx)
This is equivalent to the WLZ (Wet langdurige Zorg) system (REF), which covers long-term nursing care (e.g. for people with dementia) and other long-term mental and physical problems.
This will be a compulsory tax paid equally by the employee (upto 5% of salary, for e.g.) and employer (upto 5% of salary). The self-employed will pay 5% of their income as well.
All aspects of longterm social care are transferred to the responsibility of NHSS, who pays for all (state) short and longterm care (e.g. disabled, domicillary care, nursing or residential care)
In other words, councils will lose responsibility for social care and that funding is transferred to NHSS.
Short and longterm care is free for all members of DHSS scheme, if have been in scheme for a minimum of 2 consecutive years or more.
There will need to be a tax adjustment. We propose National Insurance is reduced (proportionately, e.g. 2 pence in the pound). The NSTx will be a hypothecated tax that cannot be used for anything else. This could form a stimulus for removing NI from the UK; and focusing its replacement on social care, that we all may need one day.
This system will remove the need for families to sell their parents’ property (or use their investments) to fund the care of their elderly.
4. Public Health (requires Act of Parliament)
Public health (PH) currently, like social care, is currently based at the council. Hence there is currently little/no link between health of the public and the NHS – each blames each other for each’s failings.
So, in the NHSS, responsibility (and costs of) public health will pass to the SIOs, each of whom will have significant public health systems.
Why is this needed? Currently there is little/no incentive not to use the NHS. If you are overweight/obese, do not exercise, smoke, or drink heavily, that is your concern – and the NHS has to ‘pick up the pieces’ if things go wrong.
The responsibility for public health needs to pass to:
- Individual – so there is personal gain for staying healthy and avoiding medical contact
- SIOs’ public health divisions – leading to financial incentive to educate the public, and ‘nudge them’ into pro-health behaviours, with ongoing media campaigns (including and a significant focus on social media).
How? Firstly, in the NHSS there will be a £480 end of year reward scheme (see above) at the end of the financial year; which will provide some incentive for people to look after themselves and prevent disease (and not initiate care for minor issues).
Secondly, 2% of the income of each SIO will be ‘top-spliced’ for their PH divisions, and the Office for Health Improvement and Disparities (OHID; which will supervise public health in England). The 2% figure can be increased (by 1%) every 2 years (to a maximum of 10%) depending on performance markers, e.g. cancer survival, mental health data, longevity. Different levels of top-splicing can occur in different SIOs.
Each SIO will have large PD divisions with 1000 (or more) full-time employees (linked to named PCNs) with 2 PH executives on each SIO board (one for physical, and one for mental and social health). OHID will have 500 or more full-time employees, including 20 linked to each SIO.
OHID can continue as an over-arching organisations publishing a yearly ‘Health of the Nation’ report, with national health data (and SIOs will be compared, both activity and mortality); and writing yearly guidelines and priorities for the SIOs.
5. Modern working practices: Consultant, GP contracts and a 7 day NHSS – Requires Act of Parliament
7 day NHSS. The NHSS will run identically 7 days a week. This basic principle is applied to all jobs, clinical and non-clinical. In particular, elective care will be a 7 day service, reducing wastage of NHSS facilities; and making continuous use of the (now previous) private hospitals.
Registration. All consultants and GPs (including locums), and senior managers, will have to register with at least 1 SIO yearly (they pay £500 a year to join). That contract can be terminated yearly (with an appeal process).
Why is this needed? Currently senior doctors on longterm NHS contracts who consistently underperform are almost impossible to retrain (or remove). They continue to do damage (by inaction) throughout their careers. But if an underperforming doctor was dropped by the organisation that paid their salary, they would have an incentive to retrain and improve.
Bonuses. Salaries will be set nationally, with (an upto 40%) yearly bonus (related to performance in previous year) that can be applied by SIOs if they wish. London-waiting, Clinical Excellence Awards (CEA; consultants) and Long Service Awards (LSA; GPs) will be abolished.
Bonuses will be linked this to annualised contracts. E.g. per year, a hip surgeon must do W hip replacements per year, a physician must see X new patients, a GP must assess Y patients, a pathologist/radiologist must review Z slides/scans etc. This is decided upon at a yearly job plan meeting with their SIO.
Why is this need to do this? In the current NHS, there is no (zero) incentive for senior doctors to work hard and see more patients. In fact there are incentives not to see more patients, and do less activity; as by doing so, they are offered the same work as Waiting Lists Initiatives (WLIs) and/or private practice – usually both.
GPs and walkin centres. All GPs (including locums) must do 5x12h shifts at a weekend or bank holiday) per year at walkin centres
Private medicine can continue to exist but fully outside DHSS; and cannot employ any NHSS staff.
Private social care – can continue to exist but fully outside DHSS; and cannot employ any NHSS staff.
Arms-length and other bodies
NHS Justice and NHS Defence continue to exist and report to the DHSC. HEE and NHS Digital – should be reformed as independent entities (removed from a disbanded NHS England) and work with SIOs, as a group. NICE, CQC, GMC (and all regulators), MHRA – will continue and remain independent – with MHRA aligning closer to its European equivalent.
Conclusion – ‘Cradle to the Grave’
Bevan’s dream was an NHS that looked after us all from the ‘cradle to the grave’. It still does OK in the cradle but as we approach the end of our lives, it stops caring for us. This is no one person’s fault. Its everyones fault. We have all watched it happen, and blamed everyone else.
All the people of the UK now need to decide if we want to sort it out – or merely keep blaming the government, ‘them”, ‘the authorities’, lack of money/staff, or someone else, for the NHS’s woes. Because if we want to sort it, we are all going to need to be part of this ‘new NHS’
We need to go back to the Bevan dream. This means we must come together. We must unravel the 1948 model of the NHS, as it is outdated and no longer appropriate for a developed country. We must get rid of all the quangos competing for money; GPs acting as mini-business people; consultants doing private practice and working (but not being fully committed to) the NHS; management consultants dealing with (or not) issues in the ‘too difficult box’.
What if we don’t? What will happen? Nothing much. There will be another reorganisation brought in by the new government, having limited or no effect. The NHS will slowly decline into an even poorer service for less advantaged people; whilst more advantaged people will have private healthcare, a private GP, operations and procedures done at their local private hospital. In short, we will become a mini-USA type healthcare system. This has started to happen all over the UK, especially in London, where private practice is booming.
We have argued in this paper, the NHS now needs fundamental reform, not tinkering. We need to run health and social care as the NHSS; as a carefully regulated, kind and caring group of SIOs – that provides care that is free at the point of delivery. Let’s unite under one new health/social care service. Let’s fall in love with the NHS again, as the new NHSS.
Summary
We have described how to convert NHS (and social care) in England to a (Dutch-style) social insurance system called NHSS (National Health and Social Service). If we do not make such changes the NHS’s performance and costs will continue to worsen every year.
