How to afford a just health service

David Jewell suggests means-tested direct charges to patients (co-payments) as ways to afford a just health service in times of austerity.¹ He had no need to search so far.

A best answer was provided 250 years ago by Adam Smith:

‘The subjects of every state ought to contribute towards the support of the government, as nearly as possible in proportion to their respective abilities; that is, in proportion to the revenue that they respectively enjoy under the protection of the state.’²

This is what we now call income tax. It was first instituted in 1799 to pay for our wars, but only became in any way socially redistributive in Lloyd George's budget of 1909. It is, of course, means-tested. Means tests are costly to administer, and it seems pointless to do this more than once, except as an effective deterrent to a high proportion of people entitled to benefits. Of 30 countries for which The Organisation for Economic Co-operation and Development data were available in 2005, the UK ranked 11th lowest for personal income tax as a percentage of income, below every other European country except Ireland, Iceland, and Switzerland.³

Unlike any leading politician or most economists today, Adam Smith understood the function of the state as guardian of property. ‘Till there be property there can be no government, the very end of which is to secure wealth, and to defend the rich from the poor’, he said.⁴ The rich should pay more for every aspect of the state, because without it, our obscenely unequal society would fall apart.

That's the closest one can get to the truth, looking from above. It's much easier to see from below, as most still do in Wales, Scotland, and Northern Ireland. Here NHS care is seen as a progressive and civilising extension of care within families at home. Both are social functions separated so far as possible from the commodity market. They are both motivated by perceived needs rather than opportunities for profit, and are cooperative rather than competitive in nature. Neither can gain in effectiveness or efficiency by remodelling to an industrial or commercial pattern.

In dismissing co-payments as a principle conceded long ago, David Jewell reveals ignorance of history. Charges for prescriptions, spectacles, dentistry, and so on (to Chancellor Hugh Gaitskell, and a cabinet majority who agreed with him) led two ministers and one junior minister to resign from Attlee's government in 1951 (Nye Bevan, Harold Wilson, and John Freeman). They understood that the NHS was founded on solidarity. Without this it can exist only in name. People may be slow to understand this, but when they do, there will be short shrift for such casuistry.