Playing the system

A new report from Civitas describes how the National Health Service is failing the poor at the expense of middle class patients. This is not just because of variable quality of NHS services in different parts of the country (although this is a factor). The Guardian reports:

In spite of unprecedented sums spent on healthcare, the gap between the sort of NHS treatment that can be expected by those at the top and those at the bottom of society has actually grown under the Labour government, [Nick Seddon, of Civitas] said.

In the report, Quite Like Heaven?, Seddon quotes a series of studies which he said indicate the extent to which healthcare has become a lottery.

He points to a York University study which showed people living in deprived areas are more likely to need hip replacements but they are less likely to get them.

And he said patients in Wales can expect to wait only 47 days for an MRI scan, while those in the north-east of England can expect to wait 100 days. Individual hospitals offer scans in anything from 10 to over 170 days.

Older people and ethnic minorities also suffer "substantial inequities" in NHS treatment, the report said. It quotes watchdog the Healthcare Commission, which found the problem was even worse for elderly people who had a mental illness.

And while people on lower incomes are more likely to see their GP, they are less likely to be referred on for further care such as hospital treatment, the report said.

Seddon said this is partly because the middle-classes are more likely to have the assertiveness, articulation and confidence to communicate their demands to healthcare professionals. But personal contacts in the NHS also count.

"Higher socio-economic groups are more likely to have family or friends who work in the health services, and even if these contacts are not directly used to gain access to services they act as an important source of advice on how to work the system," he said.

Seddon said there are no panaceas but lessons can be learned from other nations. He pointed to the mixed financing of the Swiss healthcare system and a health insurance scheme based on regulated competition in the private sector in Holland. Both, he said, show that equitable care can be delivered through more responsive and high performing systems.

In other words, bureaucratised public services work in the best interests of those who are best able to navigate their way through bureaucracy: in general, the middle classes. The same applies also in the benefits system - those who are best able to play the system are best placed to get the most out of the system. Seddon is of course correct that the best way to overcome this problem is to replace the bureaucratic ethos of public service with a competitive one. Service providers - if they are obliged to compete for customers - will naturally seek to attract the largest possible client base, and are therefore less likely to be manipulated by the smaller numbers who make up the cleverest or most motivated sectors of society. A freer, more responsive, higher performing health care system will also be a more equitable one.