August 25, 2017

Guernsey: a vision for healthcare reform?

Guernsey: a vision for healthcare reform?

With the NHS facing the unedifying prospect of its worst A&E waiting times in living memory, and bed-blocking up by 52 per cent in three years, a quiet corner of the British Isles has employed a healthcare funding model that keeps its health service in fighting form, says William Walter.

Our healthcare system is in crisis. NHS performance is in decline. Last winter saw waiting times in A&E departments up and down the country soar to record highs. Meanwhile, sharp spikes have been recorded in the number of people waiting to begin treatment or to be transferred from hospital to social care. The demands imposed on the health service continue to exceed projected levels.

Two General Elections in as many years have helped amplify an ever-present national debate on the health service and its future, but, despite these, viable long-term solutions have been hard to come by. The only game in town is the status quo generously topped up with yet more public spending.

But, one possible solution to the country’s healthcare woes may come from a quiet corner of the British Isles. Situated within sight of the Normandy coast, but swearing allegiance to the Queen, lies the small Channel Island of Guernsey. Independent of Westminster, with its own system of government, and with no UK National Health Service to rely on, responsibility for the provision of healthcare to the island’s 63,000 strong population falls upon the island’s government, the States of Guernsey.

Under this system, primary healthcare for the island’s citizens is delivered by competing private primary care practices. Patients are charged around £60 to see their doctor. The island’s social security system sees this consultation fee reduced by £12 to £48 for all patients. Roughly half of all patients are covered by private health insurance (often provided through their employer). Insurance premium assessment criteria vary depending on provider and scheme.

For those with insurance, an automated system sees the primary care practices claim this fee back directly from insurers with no direct cost to the patient. Meanwhile, means-testing ensures those unable to afford the costs of their GP or nurse consultation (currently around 13 per cent of the island’s population) have their costs of treatment covered by the States of Guernsey at specially negotiated rates. Those who qualify for social security will see the costs of their consultation invoiced directly to the States of Guernsey.

Patients lacking primary care health insurance, and who do not qualify for social security support, pay as they go. Local competition law ensures each healthcare provider sets its own rates.

States social security funding ensures prescription charges are heavily subsidised at a cost to the patient of £3.90 per item (currently £8.60 in the UK). Those over the age of 65, or those receiving welfare support, are exempt from prescription charges.

Health & Social Care (HSC) is funded via the States of Guernsey and provides a community service, comprised of community nursing staff and a caring service, where short or long-term domestic support is required to give clients an acceptable quality of life at home and to avoid having to enter residential care. The costs associated with the provision of the Island’s long-term care system, including the costs of nursing and residential care, are funded in part via an additional social security levy, which is in turn used by the Social Security Authority to cover a portion of the patient’s costs.

Like in the UK, hospital care is provided free at the point of delivery by the state. All referrals to secondary care are made either by a GP or an emergency care clinician. But unlike the NHS, the Guernsey model is financed via what is in effect a compulsory insurance system: the Specialist Health Insurance Scheme. Funded via the Social Security Authority, the scheme is used to negotiate a contract with a group of specialist consultants, who then provide the core of the island’s secondary healthcare. Additional input to the costs of secondary care are made via general taxation in order to provide other services, such as nursing, psychiatry, pathology and radiology.

Patients have the option to be treated privately at the island’s main hospital, the Princess Elizabeth Hospital, offering a separate wing for private care. The revenue from the private wing subsidises patient care in other parts of the hospital, and includes a fee for service to the medical staff. The hospital offers islanders a comprehensive range of services from intensive and high dependency care to maternity care. Specialist consultant services are provided on Island by visiting specialists for haematology and rheumatology.  The only specialities not offered on the island are interventional cardiology and neurosurgery.

The hospital also provides a fully serviced emergency department, open all year round. Like its counterparts in the UK, the department accepts walk-in patients and ambulance emergencies and is the acute assessment point for all GP referrals both in and out of hours.  The service treats, stabilises and investigates all patients, from those with acute injuries to those with minor ailments. But, significantly, unlike emergency departments in the UK, all those patients presenting to the emergency department as their first contact and who have not been referred for secondary treatment by a GP, are charged a fee for service.

While the majority has this fee met through either their health insurance or welfare support, a significant proportion will be required to finance it themselves. Facing the prospect of more significant service fees at the emergency department, many patients opt instead for primary care treatment. This incentive helps ease the pressure on the island’s A&E department and avoids the type of patient congestion that has ground emergency care provision on the mainland to a halt.

Finally, a tertiary healthcare service is provided through contractual arrangements with specific UK NHS Trusts for specialist care (e.g. interventional cardiology) unavailable on the island.

So far, the evidence suggests the system works. Life expectancy on the Island continues to exceed that of the UK. The Island’s infant mortality rate is less than half that for England & Wales, and continues on a downward trajectory. Like the UK, circulatory diseases, cancers and respiratory diseases are some of the leading causes of death, accounting for 31 per cent, 29 per cent, and 13 per cent of deaths respectively. Furthermore, child immunisation rates are above those of the UK and continue to exceed World Health Organisation (WHO) target levels.

The Island’s healthcare model may present some alluring solutions to the challenges facing the NHS. But at the very least, it can provide a fresh perspective as the debate over the NHS’s future rumbles on.

This article was first published by the Institute of Economic Affairs on 9 August, 2017 (click here). 

5.00 avg. rating (98% score) - 8 votes
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William Walter
William Walter is the Founder and Editor of Comment Central. He began his career in Parliament working for three Conservative MPs — the then Shadow Minister for Universities & Skills, Rt Hon David Willetts MP, Opposition Treasury whip, James Duddridge MP, and former Shadow Pensions Minister, Nigel Waterson MP. In addition to his Parliamentary work he has also written for a range of publications, including: The Daily Telegraph, City AM, Metro and Conservative Home.
  • Dacorum

    I don’t accept your main point that other major European countries spend more than the NHS has no bearing on whether the NHS is underfunded. Comparable spends are a benchmark and nothing you have said has undermined that important point.

    I have certainly heard other people compare the NHS unfavourably with comparable continental European health care systems but that unfavourable comparison is unfair because the spend on health care in comparable countries is greater than here so you would expect shorter waiting times etc.

    Anyone seeking 200 appointments with their GP in a year is more than likely to have psychological issues that need treatment but not with their GP.

    I had a groin hernia operation in March. I had a 4 month wait which wasn’t too bad. It was day surgery and I had to attend by 1.00pm but it soon dawned on me from the overflow of people waiting in the corridor that there was a problem because the day ward where we waiting was full of in-patients and there were no day beds available for recovery before being discharged. In the end I was lucky, as together with another patient, they found beds for us in an orthopaedic ward elsewhere in the hospital. That was 2.30 pm and we left a number of patients who were being told “We are still trying to find you beds”. During the pre op procedure, which took far longer as we weren’t in the normal day ward, I asked the doctor how common it was for ops to be cancelled from lack of beds and he said it was a common occurrence and that the entire list had been cancelled 3 days before. I finally had my op later in the afternoon knowing the operating team was being paid and the theatre had been lying idle for hours. As my op was much later than planned I was offered an overnight stay but I declined saying their need of a bed for someone taken really ill over night was far greater than mine.

    My experience is being repeated all over the country because there are not enough beds for planned ops, not even for day care surgery. And yet we have seen Ealing A&E being shut down which puts yet more pressure on my own hospital. I saw at first hand how the system is cracking under the pressure because there aren’t enough beds when we have the doctors and theatres available to treat patients effectively, efficiently and on-time. Only additional bed resources and more nurses can fix that and if it means taking money out of the overseas aid budget and HS2, well that would be money very well spent.

    Incidentally annual blood tests are NOT a waste of money if the condition of the patient warrants it as they help save the NHS a considerable sum of money. A patient who takes action to prevent the onset of diabetes following a blood test result could save the NHS a fortune. The cost of diabetes to the NHS is over £1.5m an hour or 10% of the NHS budget for England and Wales. In total, an estimated £14 billion pounds is spent a year on treating diabetes and its complications, with the cost of treating complications representing the much higher cost.

  • Jonathan Munday

    I am not advocating the French system, doh! I am pointing out that your comment that major European systems spend more than the NHS has no bearing on whether the NHS is objectively underfunded. There is no objection to anyone in the UK spending more than the State on their own health, as In other major European countries but you want the State to pay more out of compulsory taxes, which is quite different.

    Demand over and above illness might be for performance enhancing drugs or plastic surgery or annual blood tests or to placate health anxiety. In my surgery one patient had over 200 GP contacts in a single year – that is 11 whole surgeries devoted just to her. No wonder other people cant get an appointment. That is not underfunding.

  • Dacorum

    I’ve read your post and it really is utter rubbish, trust me!

    What does this sentence of yours mean – The problem with the NHS is that there is no mechanism for coping with health care demand from patients over and above illness. What is over and above illness?

    You really prove my point for me in your second paragraph by saying comparable countries pay more as a % of GDP because the spend more privately. What relevance is that except to show that those countries spend more than we do on health care than we do, which is precisely the point I was making when I said the problem with the NHS was underfunding?

    You say In France everyone pays an extra 20% on top of what the State spends so of course their GDP spend is more than ours but again that really is a huge reason to support the principles of the NHS. A huge number of people here cannot afford to spend anything extra on their health care, can they, so what happens in France? If the poor don’t have to pay, then you can imagine the huge cost of working out and administering who should pay and who shouldn’t pay extra. What a waste of money and effort that is! And any system that requires health top ups of 20% – a huge sum – with exemptions for the poorest means that those just about managing who are just above the limits for not having to pay a top up 20% cannot afford health care in France, can they? The French model is one to avoid like the plague.

    The whole point of the NHS is that it a compulsory health insurance for all covered by general taxation and free for all at the point of need is by far the best health model because it covers everyone and nobody is excluded because of a chronic condition or previous medical condition. No country beats that but it cannot work well when it is underfunded.

  • Jonathan Munday

    No the only way to get reform is to forbid any vested interest anywhere near the Commission.
    The Kings Fund, the RCN or RCMW or the RCS – all should give evidence: none should decide on the Commission’s report or I could write the report before it sits – “All is for the best in the best of all possible worlds”.

  • Jonathan Munday

    Rubbish Utter Rubbish!
    The problem with the NHS is that there is no mechanism for coping with health care demand from patients over and above illness.
    Comparable countries in Europe pay more as a % of GDP because they spend more privately, rather than as in England all through the State. In France everyone pays an extra 20% on top of what the State spends so of course their GDP spend is more than ours

  • gunnerbear

    Totally agree about the need for a RC but I’d let everyone chip in…..the more information that comes out the better….in this day and age, given how sensitive the NHS is to voters, it would be irrelevant who the Commissioners are because if they were seen as possibly being less than fair…..the public would soon get the Commissioners the chop….

  • gunnerbear

    I always find this amazing….I know you’ve mention millions – a lot of cash of course – but think about the Int. Aid Budget….. ….all £13bn of it….thirteen thousand million pounds…. …the NHS eats through that amount of cash roughly every 730 hours….. …that is the scale of NHS operations.

  • gunnerbear

    “France, Germany and the Netherlands have compulsory insurance but it is handled by private companies rather than out of general taxation.” There is a polite fiction maintained – especially in the Dutch system – that the firms are private (as in the US Private Medical Insurer / Provider model) but in reality the firms in the Dutch / German / French system are ruthlessly controlled by their respective governments (granted though at arms length). For the record, I think the Dutch / German model would work in the UK – but here’s the kicker – we’d have to pay more for health and social care.

  • gunnerbear

    AM, Fair comment for putting an idea forward, but the NHS and social care is designed to operate on ‘shared risk pool’ basis….so what happens to those not in work, the retired, the people working for firms that simply ‘can’t’ pay the PMI bill? They’d still need cover, so with much reduced NI contributions arriving at HMT, how would you fund all those without PMI….especially those on the NMW…..

  • gunnerbear

    “if you can provide private health care for all your staff, a care package that includes everything from a cold to brain surgery, then you don’t have to match fund your employees NI payments, thus you save £2k per month, any halfway smart business owner would find a private health insurance for their company for less than the £2k per month…” The Private Medical Insurers won’t touch that sort of deal for comprehensive insurance for every single employee…..major companies are restricting who gets private care because the costs are going through the roof.

  • gunnerbear

    Which is why, personally, I think the Dutch system is a good match for the UK though I know that means we’ll have to pay more for healthcare.

  • gunnerbear

    “In the same way as pensions are provided by employers.” Which employers are these then? I don’t know many employers that provide a pension…don’t confuse the s**t government mandated WPP with a proper DB scheme.

  • gunnerbear

    It’s long past time we had a Royal Commission on the NHS – as to making loony statements, I’ve heard Righties shout that Singapore is the system to follow or that the US is the best model as it will really let the private companies in….

  • gunnerbear

    “Roughly half of all patients are covered by private health insurance (often provided through their employer).” So on a tiny, but generally wealthy island that has to pay for nothing like defence etc. because it can be bailed out by the UK taxpayer…. …private healthcare sort of works……but there is no statement of how to transfer what works for a tiny number of people onto a system that caters for millions every day…..

  • gunnerbear

    “other comparable countries spend a bigger percentage of GDP on health care than we do.” Stop being so awkward….that sort of comment ruins the debate! 🙂

  • Dacorum

    And there was me thinking the NHS is treating more patients than ever before…
    One major problem with the efficiency of the NHS has bee constant reorganisation instead of first looking to see how you make the existing structure work better without radical and expensive change every few years that usually resulted in yet more managers.
    The NHS is also hampered by bad decisions in the past like the PFI initiative that led to some extremely bad deals because the Dept of Health/Treasury was not up to the task of overseeing that we got value for money. They should have employed the same sort of contract experts that the PFI builders used to avoid the expensive pitfalls that occurred.

  • getahead

    And yet when The Blair/Brown government threw £millions at the NHS efficiency did not improve.

  • Dacorum

    Why no “grown up” country has followed our model has probably a lot to do with vested interests like the insurance companies losing their profits and the medical profession themselves. In GB, but I’ve nothing against that because it meant we retained all the top consultants we had to work in the NHS whilst preserving their right to work part time privately the medical profession had to paid off very generously

  • Mel Shaw

    In a recent survey of health systems in eleven wealthy countries, the NHS was judged the best, despite coming in the bottom two for keeping patients alive. Not a key measure, apparently. Go figure!

  • Myleene Klass

    If the NHS is so brilliant, how come no other ‘grown-up’ country in the world has copied our model. France, Germany and the Netherlands have compulsory insurance but it is handled by private companies rather than out of general taxation. The government steps in and regulates things like premiums but, for instance, in the Dutch model, the Dutch government does not own a single hospital.

  • Jonathan Munday

    All of this is irrelevant – the NHS is a sacred cow, self-evidently insusceptible of any improvement whatsoever.
    The only practical position is to set up a Royal Commission to examine alternatives or improvements and then to promise to put the resulting report to a referendum of confirmation before enactment to take the heat out of the bun fight that would ensue. This would have to be done and completed within the first 3 yrs of an electoral cycle so all the actual groundwork would have to be done within the previous parliament in great secrecy. The commissioners would have to be chosen with even greater care and exclude any of the NHS blob. This is not easy, which is why it has not been attempted either.

    And so we stumble on, shovelling money we dont have at the problem of indisputably the best health service in the world.

  • Dacorum

    No, the original idea of the NHS was NOT just to give the very poor a health system hey could access at any time. It was to ensure that everyone regardless of their means to pay had access to health care free at the point of delivery.

    The NHS is in effect a compulsory insurance system paid for out of general taxation with the rich paying more than the poor but all getting the benefits of not worrying about rising private insurance premiums or whether private health insurance would cover the cost. The rich also had the advantage of still going private if they wished.

    The problem with the NHS is insufficient funding – other comparable countries spend a bigger percentage of GDP on health care than we do.

  • Dacorum

    Rubbish. Utter rubbish!

    How under your scheme will the families of those workers be covered or the retired parents and elderly grandparents? We need the full contributions from healthy workers to pay for the health care of their children and parents/grandparents.

    The NHS model of compulsory health insurance for all covered by general taxation and free for all at the point of need is by far the best health model because it covers everyone and nobody is excluded because of a chronic condition or previous medical condition. Insurance companies increase premiums or refuse to over for existing treatments which is not an issue with the NHS, thank goodness.

    The real problem with the NHS is underfunding. Comparable countries in Europe pay more as a percentage of GDP on health care than we do.

  • Nockian

    Closer to a free market health care system but I note the fixed price of consultations-suggesting the state is intervening, as it does with supply of GPs on the mainland.

    My concern is for all the people in the UK who dilligently paid tax for the majority of their working lives on the promise of end to end healthcare and have been deprived of the opportunity to save, or budget for the eventuality and will then be stuck with funding themselves in their later years.

    I’m reminded of the pensions planning that was unavailable to most manual workers of the 70s who were taxed so heavily directly, or through inflation, that they didn’t have any spare cash anyway. Suddenly the state announces it can’t afford to fund state pensions and all the workers are suddenly expected to magic up funds to put in a pot -one which the continuing economic collapse/low interest rates has decimated anyway.

    Forget ‘means testing’ I know how that works. Those who were early into the Ponzi scheme welfare system took the jackpot and the rest get four fifths of sweet FA. Certainly it could be looked at for those beginning employment, but they should not be penalised at the expense of those who are older and likely to require more care.

    The whole thing is a mighty mess and there won’t be an ideal outcome-some of us will end up in severe financial hardship as we are left on the rocks as the welfare states tide receded.

  • Dacorum

    “Under this system, primary healthcare for the island’s citizens is delivered by competing private primary care practices. Patients are charged around £60 to see their doctor. The island’s social
    security system sees this consultation fee reduced by £12 to £48 for all patients. Roughly half of all patients are covered by private health insurance (often provided through their employer). Insurance premium assessment criteria vary depending on provider and scheme.”

    Is the author really saying they don’t charge according to risk or age or that patients don’t face higher premiums if they make greater use of primary health care? In any case, it really is a load of boll*cks for the author to suggest that Guernsey offers a better system of healthcare than the NHS when he admits that “Patients lacking primary care health insurance, and who do not qualify for social security support, pay as they go” when such people are clearly those without the means to pay for primary health care
    insurance. £48 to see the GP is a huge sum of money for those who cannot afford private health cover and, with charges as high as £48 to see a GP, you can only imagine how expensive private health cover must be and why only half of patients are covered! On the basis of those figures alone, the Guernsey health care system doesn’t provide adequate care at a price affordable to all.

    The author says unlike the NHS, hospital treatment “is financed via what is in effect a compulsory insurance system: the Specialist Health Insurance Scheme”. So who pays, how much does it cost and why doesn’t it cover the cost of visits to the GP and other services provided
    by the NHS?

    The author forgets that the NHS is, in effect, a compulsory health insurance scheme covering everyone according to need and feed at the point of delivery that happens to be financed out of general taxation. How can Guernsey’s model be fairer than that when they charge and half are not covered by insurance? And how much is wasted in administration costs because patients in Guernsey have to pay?

    The problem with the NHS is not the model but the lack of adequate funding for the NHS. We spend less as a percentage of GDP than comparable European countries and the service we get reflects that underspending. The answer is most definitely NOT to go down the route of Guernsey but to increase NHS spending. I would cut the overseas aid budget to fund that increased spending.

  • Andrew Mitchell

    Why doesn’t our government make an offer to businesses that they wouldn’t turn down, today if a business employs 10 workers, and let’s say each of the workers pay £200 per month in national insurance, that’s a total from those workers of £2000 per month, but the company has to match that figure so they also pay £2000 per month for their workers, thus a total of £4k per month goes to the NHS, what if the government said to the business owner “if you can provide private health care for all your staff, a care package that includes everything from a cold to brain surgery, then you don’t have to match fund your employees NI payments, thus you save £2k per month, any halfway smart business owner would find a private health insurance for their company for less than the £2k per month, let’s say they manage to get cover for everyone for £1,800 per month, this would mean that the business can boast that they give their employees private health cover, while they’re saving £200 per month, the employees are happy because they have full private health cover, no long delays, if they get something wrong with them they get it sorted faster, the NHS are more than happy because their still getting the employees portion of £2k a month, from a bunch of people who aren’t going to use their services, so they’re getting money for nothing, and because there is now more cash going into private health insurance, that means more sales staff needed, more nursing staff needed in the private hospitals, more doctors, and more hospitals would be built, Christ the government could say to the employees “now your fully covered by private health, we’ll not take the £200 from each of you, we’ll take just £100 meaning the employees getting a instant pay rise of £100 per month. Everyone wins, even those not covered by private health because there would be less people using the NHS, but wait a minute, this is called ” common sense ” which means it would never be even talked about let alone tried, shame though because it would benefit everyone!

  • Marcus Shaw

    These statistics are misleading.
    The reason that half the patients have private health insurance is because the majority of the working Joe’s without insurance can’t afford to be sick!

    If you have any kind of long term condition but aren’t on ‘benefits’ you just have to suffer in silence.

  • obbo12

    Using the results from Guernsey is misleading. Guernsey does not have the same rate of lifestyle related diseases that the UK. The rates of smoking and obesity are lower leading to less heart attacks, strokes, diabeates and lung cancer. You find the same imbalance in the UK itself with deaths from cancer and heart attacks running at 5 times the national average in parts of the North of England and Scotland.

    I’m not against NHS reform but you have to use a model that has similar rates of diseases.

  • Mojo

    I do not know if Guernsey has unions prevalent in its health system. Unless we stop the influence of unions in our NHS and start to tackle the ridiculous belief that private means greedy, we will get nowhere.

    I have advocated for years that the law should expect everyone on starting work to take out a private health insurance. This would then cover the cost for the majority of their health needs and their old age care. The very big issues like accidents, natural disasters or disability could be looked after by the taxation of a working society. I believe we should stop national insurance contributions in order to encourage private insurance benefits supplied by employers. In the same way as pensions are provided by employers.

    The very rich will always choose private over state anyway and this could help towards the really needy getting their treatment. I also think that we should take the NHS back to its original idea of the very poor having a health system they can access at any time, funded by the middle classes and the wealthy through general taxation. This would also enable the very important research arm of the NHS. However, none of this can even start to be discussed while we have a body of people who wantonly blackmail the people with emotional propaganda of how wonderful the NHS is and doctors/nurses are next to Angels on the heavenly spectrum.

  • Mrs Crewe

    This is all very well, but we will never have a grown up conversation about the NHS the loony left won’t let us and the right are too cowardly. The NHS is the third rail of politics touch it and you die.

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