Why not charge people for being ill? A satirical letter in the Irish Times, recommended a monthly levy on illness. Declan Moriarty suggested a sliding scale so that MS sufferers could be levied €10 per month, Parkinson’s €9, Motor Neuron €8, Friedreich’s Ataxia €7, Arthritis €6, and a levy on every other illness of €5. In the context of prescription charges in Ireland, he thought it might make a more sensible system of tax. So, why does this sound unreasonable?

We expect the NHS to provide healthcare to all. If you choose private healthcare, its a personal decision and it leaves more money to provide for others.  Treatment may take a little longer and some of the more expensive drugs are limited but, in general, the NHS still provides a good service. But, will it always be so?

The squeeze on costs, rationing or, whatever euphemism you choose, has already begun to restrict the availability of some drugs and treatments. If you want the best available treatment as quickly as clinically appropriate, you might seek a private alternative.  We still retain a sense of justice and fair play, however, and are uncomfortable with the idea of charging people for being sick. After all, we wouldn’t unfairly tax the disabled, immigrants, or women. Would we?

There are many inconsistencies in our approach to funding the health service. The biggest problem is that the UK economy can, no longer, afford to provide universal quality health care. We cannot afford the NHS as it was initially conceived. But, what can we do about it?  No government dare announce the end of the NHS and hope to remain in power. No opposition could include that in their manifesto. Everyone will fudge, dress it in ambiguity, pass the responsibility of reducing health costs to others, call it choice, a free market, or democracy.  But, no one will ever say it straight. Someone has to pay for healthcare.  But, if we move from collective responsibility from provision of health care to personal responsibility we will, in effect, be charging people for being ill.

Domhnall Macauley is primary care editor, BMJ