Skip to main content
NCBI home page
The BMJ logoLink to The BMJ
. 2001 Jul 14;323(7304):107.

Stakeholder health insurance

Time for evidence based policy analysis

David G Green 1
PMCID: PMC1120717  PMID: 11480408

Editor—In their commentary to my article Dixon and Appleby seem to have been deeply taken aback by my claim that the NHS fails the poorest people in society and responded with a personal attack, asserting: “Green's aims are disingenuous at best.”1 The ordinary meaning of disingenuous is to be insincere or to have secret motives.

The essence of my argument is this: the rich can always take care of themselves and it is the government's responsibility to ensure that the poorest people have access to a reasonable standard of health care. But what should that standard be? Should it be perceived as a minimum or core standard, in which case it will always be possible to claim that it is too low? Or should it be seen as comprehensive, in which case it will be unachievable, as the BMA's recent inquiry acknowledged.

My proposed scheme tries to deal with this conundrum by removing the decision about the appropriate standard from the political domain. Instead, the standard guaranteed by the government should be linked to the choices made on their own behalf by people with middle incomes. I propose that the government should guarantee this standard for everyone. Yes, the rich will be able to afford more, but they can do so now under the NHS. That will not change, but the deeper reality is that all healthcare systems must be affordable, whether they are paid for by taxes on earnings or by private payments made from earnings.

My claim is that, compared with the standard currently provided by the NHS, such a guarantee would be a substantial improvement for the poorest people in the United Kingdom. In addition, the guaranteed standard will rise with growing incomes because it is linked to the personal market choices of middle income earners. It will not be a residual or second class standard.

The evidence for this claim is that the social insurance systems of France, Germany, and the Netherlands already work in a similar manner and it should be possible to put this case in a learned journal without being accused of bad faith. The King's Fund has been very keen to encourage the practice of evidence based medicine by doctors. How about some evidence based public policy analysis from Dixon and Appleby?

Footnotes

Created by potrace 1.16, written by Peter Selinger 2001-2019 We apologise to Dr Green for allowing through the phrase “Green's aims are disengenuous at best.” We certainly do not believe that Dr Green has secret motives.—richard smith, editor, BMJ

References

  • 1.Green D. Stakeholder health insurance: empowering the poorest patients [with commentary by J Dixon, J Appleby] BMJ. 2001;322:786–789. doi: 10.1136/bmj.322.7289.786. . (31 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Jul 14;323(7304):107.

Commentary is disappointing

Alain C Enthoven 1

Editor—Dixon and Appleby's commentary on Green's article is disappointing.1-1

Firstly, to turn disagreements over policy into personal accusations of dishonesty is wrong, making it hard to carry on a civil discussion.

Secondly, I am struck by their complacency—“What's the problem?”—as if all is for the best in this best of all possible worlds. That view is not tenable, especially in the wake of the secretary of state's plan for reform of the NHS.1-2 The secretary of state personally wrote to me: “The NHS is a 1940s system operating in a 21st century world. It has a lack of national standards, old fashioned demarcations between staff and barriers between services, a lack of clear incentives and levers to improve performance [and] over centralization and disempowered patients.” These frank statements suggest that he is sincere and serious about exposing the problems and proposing solutions.

Dixon and Appleby write: “Competition is instrumental, so a lack of it is not itself a problem.” Generally, competition has proved to be the only institution that has been able to motivate sustained improvement in economic performance. But, as illustrated by electricity in California, trains in Britain, and the internal market in the NHS, not any competition will do. There must be appropriate institutions, including regulatory frameworks.1-3 Green argues that Britain ought to find a way to bring competition into health services and proposes a rational design for doing so.

The secretary of state proposes to motivate improvement by harassment from the centre. Some hospitals are to be designated “green light” and left alone, some “yellow light” to be given warning, and others “red light,” which “will be subject to a bewildering gang of possible bodies who will be able to manage their performance . . . . [which is] messy and predatory performance management.”1-4 I share Dixon and Dewar's reservations. Other models should be examined in case this government's model fails.

Dixon and Appleby argue that the NHS does not fail the poorest of society because “regardless of income and ability to pay, the comprehensive benefits of the NHS are available to all.” Their defence is that the misery is spread equally. In fact, there are wide inequalities, and the poor are unlikely to get even average NHS care.

Green argues that his plan will make everybody better off because those who opt out of NHS care will leave behind a part of their share of NHS funds, which will increase the per capita spending on those who remain in the NHS. More money would be brought into health care without raising taxes. Moreover, improved performance in the competitive sector would set higher standards and expectations for the NHS.

Dixon and Appleby doubt that there would be many takers for the stakeholder option because currently only 11% of the British population is covered by private health insurance. One important reason for this is that there is no tax subsidy.

Efficiency is much more than a matter of low administrative costs. The NHS is grievously undermanaged. It lacks basic data on cost, quality, and performance.1-3 A well run large scale competitive model could be run with very low administrative costs.

References

  • 1-1.Green D. Stakeholder health insurance: empowering the poorest patients [with commentary by J Dixon, J Appleby] BMJ. 2001;322:786–789. doi: 10.1136/bmj.322.7289.786. . (31 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Department of Health. The NHS plan. A plan for investment. A plan for reform. London: Stationery Office; 2000. www.nhs.uk/nhsplan . ( www.nhs.uk/nhsplan) ) [Google Scholar]
  • 1-3.Enthoven AC. In pursuit of an improving National Health Service. The 1999. Rock Carling Fellowship. London: Nuffield Trust; 1999. [Google Scholar]
  • 1-4.Dixon J, Dewar S. The NHS Plan: as good as it gets—make the most of it. BMJ. 2000;321:315–316. doi: 10.1136/bmj.321.7257.315. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Jul 14;323(7304):107.

Authors' reply

Jennifer Dixon 1, John Appleby 1

Editor—Green claims that stakeholder health insurance would improve health care for the poorest patients by allowing them the option to pay extra—to buy stakeholder health insurance. But is it realistic to believe that the poorest could or would pay extra? Evidence suggests not. Green is clearly not interested in social equity—he does not show that the distribution of contributions to his new system would be more or less equitable than is the case now.

If those who are comparatively well off took a tax subsidy out of the NHS, then less would remain for those who are sicker and those who remained in the NHS. The NHS would become a poorer quality service, dealing with a higher proportion of patients with significant health needs. Contrary to Green's claims, stakeholder health insurance would disempower the poorest.

Green says there should be a guaranteed core standard of service for everyone—in the NHS or no. He suggests it should be a political decision linked to the preferences of those who opt for stakeholder health insurance. Why is this appropriate? He also does not make clear quite how this would work. Would government be shamed into ensuring that standards of quality in the NHS were as high as in the private sector hospitals used by those with stakeholder insurance? Green suggests yes, citing countries with a plurality of purchasers and providers, such as France and Germany. But he is not more forthcoming with evidence. Would the government be more likely to set a minimum standard to keep costs under control? History suggests this is more likely.

Enthoven accuses us of complacency because we ask what is the problem? This was not rhetorical, rather, a way to identify to readers exactly what problem potential reformers of the NHS are trying to solve. Sadly it is often not obvious.

We generally agree with Enthoven that competition can be a highly effective stimulant to improve economic performance. But in public services competition can fail to strike the right balance between multiple objectives such as social equity, humanity of care, responsiveness, and so on. We do not agree that it is doubtful that the poor get even average NHS care—a recent review examines the evidence.2-1 The pertinent point to argue is whether Green's proposals offer an improvement to now. We argue the reverse for reasons already outlined.

Finally, we believe that there is an absence of a proper diagnosis as to why performance in service delivery is inadequate in parts of the NHS. Without this understanding the NHS is prey to perhaps intellectually interesting, but inevitably half baked solutions, whether they come from think tanks or, just as frequently, from the government itself.

References

  • 2-1.Dixon J. What is the hard evidence on the performance of “mainstream” health services serving deprived compared to non-deprived areas in England? Report for the Social Exclusion Unit. London: King's Fund; 2000. [Google Scholar]

Articles from The BMJ are provided here courtesy of BMJ Publishing Group

RESOURCES