Richard Smith: Will health become more like education or education more like health in the UK?

richard_smith_2014Uwe Reinhardt, the world’s funniest health economist, says that eventually all health systems will be the same: whatever they want for the rich; an insurance based system for the majority; and a rump service for the poor. “Never in Britain,” say Reinhardt’s British friends, but I wondered if he might be right as I read David Kynaston’s compelling lecture on private schools in Britain. Will health become more like education or education more like health? Which way will Britain go?

Some 7% of people in Britain go to private schools, but 71% of senior judges, 62% of senior officers in the military, 55% of permanent secretaries, 53% of senior diplomats, 50% of members of the House of Lords, and 54% of the 100 top people in the media went to private schools. The Prime Minister, the Chancellor of the Exchequer, the Mayor of London, and several of Britain’s top actors all went to Eton, Britain’s most exclusive private school. A child at a private day school is 55 times more likely to win a place at Oxbridge than a child with a state school background from a poor background.

Fee paying, writes Kynaston, “leads directly to engines of privilege, blocks relative social mobility and perpetuates a Berlin Wall not just in our education system but in our society.”

He quotes the sermon of Alan Bennett, the playwright: “We all know that to educate not according to ability, but according to the social situation of the parents is both wrong and a waste. Private education is not fair. Those who provide it know it. Those who pay for it know it. Those who have to sacrifice in order to purchase it know it. And those who receive it know it, or should. And if their education ends without it dawning on them, then that education has been wasted.”

Social mobility has become worse in modern Britain, and political leaders are unanimous in bemoaning this: they all have proposals for increasing social mobility. Their problem is that in relative terms more upward mobility means more downward mobility: we might arrive at a world where 7% not 71% of senior judges went to private schools. If that was the case would it be worth paying up to £30 000 a year to send your child to a private school? All political leaders are for more upward mobility but none are for downward mobility.

It would be politically difficult, probably impossible, to merge private schools into state schools, but that’s what needs to happen to stop private schools being “engines of privilege” and barriers to social mobility. Kynaston quotes Isaiah Berlin’s two notions of liberty: “the negative liberty of not being interfered with or constrained, the positive liberty of being a full citizen enjoying the same potentialities as all one’s fellow citizens.” Should it be, asks Kynaston: “Negative liberty for the 7%? Or positive liberty for the 93%? Ultimately, it is a value judgment about what sort of society we want.”

About 11% of people in Britain have private health insurance, but people use the insurance mostly for routine hospital and dental care. Very few people use private primary healthcare, and few access the private sector for emergency care. Virtually everybody has an NHS general practitioner, and most people receive emergency care in the NHS. Even the very richest will be scooped up by the NHS if they crash their Daimlers. And there is no evidence that people in the private sector receive higher quality care; rather they are paying for single rooms, daffodils beside their bed, and a glass of champagne for their postoperative breakfast. Indeed, the absence of intensive care and junior staff may mean that the quality of care is poorer in the private sector; and my personal prejudice is that patients in the private sector may be more likely to have operations they’d be better off not having.

But, as everybody knows, the NHS is under strain and will be under increasing strain even with billions more pounds. Plus patients are increasingly elderly with a complex range of problems, and for many social care, which is mostly not funded by the state, is more important than healthcare. It may not make sense to continue with healthcare being largely funded by the state and social care means tested. But it’s impossible to imagine all of health and social care being funded by the state.

Might a combination of increasing difficulty accessing GPs, growing waiting times in A&E departments, lengthening waits for routine operations, the impossibility of getting some drugs and services on the NHS, and the increasing need for social care lead those who can afford it to begin to look to the private sector? Currently the private sector couldn’t meet increased demand, but could there come a tipping point where the private sector ramps up, the middle classes desert the NHS and refuse to pay taxes to support it, and the NHS withers to a rump service for the poor?

One vexed question is the role of the private sector within the NHS. Currently more than half of hip and knee replacements funded by the NHS are now undertaken by the private sector, and Clinical Commissioning Groups (CCGs) are giving many contracts to the private sector. Some see this as the cracking of the NHS, but it could be exactly the opposite, keeping the private sector working with the NHS rather than competing with it.

Kynaston argues not for the demolition of private schools but rather their incorporation into the state sector—presumably by contracting rather than through ownership. He points out that schools are being given more freedom within the state sector, and the same is happening within the NHS: foundation trusts and CCGs are less centrally controlled.

My choice for the future would be Berlin’s positive liberty with the whole population able to access private schools and everybody continuing to use a combined NHS and social care system.

Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.

Competing interest: RS attended a state school; his three children went to a state primary school but private secondary schools. He was employed by and has shares in UnitedHealth Group, and he’s the chair of the board of and has equity in Patients Know Best, a private company that gives NHS patients control of their records. He’s a member of the advisory board of and has equity in Eliaso, an Israeli company that offers health advocacy for people anywhere in the world for whom cost is no object, and he has a pension from the BMA. The views expressed in the blog are entirely his own.