A Two-Tier NHS?

Could charging high earners save the NHS or create two-tier system?

The founding promise of the NHS for three-quarters of a century has been the offering of healthcare that is free at the point of use. This promise is now under threat with critics saying it is economically impossible to sustain. In response, many believe the concerns are overblown such as the British author Nick Timmins, who remarks that: “Virtually every day since 1948, the NHS has been said to be in crisis.”

Ben Ramanauskas works for the Conservative think tank, Policy Exchange, widely regarded as the most influential think tank on the right of British politics. He recently argued that the monumental health-related changes in the UK since 1948 has meant that Bevan’s vision of an NHS is no longer financially sustainable. His position is that middle and high income earners should start paying to use the service.

He advocates against a US system which is far more expensive and often leads to worse outcomes, but references the mixed funding model of many European countries. A policy put forward by Policy exchange was a £20 fee for GP appointments levied on middle and high income earners. Free prescriptions and sight and hearing tests for the over-60s should also be abolished.

The debate surrounding the economic privileges for the elderly or ‘boomers’ in our society is incredibly tenuous. The recent U-turn on the ‘Triple-lock pension’ is a recent example of this. There are many people in the public and in government who were rightly concerned about the cost of this scheme.

The IFS highlighted how in its current form, the state pension is on track to cost three times more than initially forecasted by 2029-30, but because the elderly turn out to vote in such significant numbers come election time, no political party dares touch this issue.

The so-called “grey vote” is too sacred to politicians, who dare not face their wrath. Once again, we run into the old predicament: The problems in our country require a longer term vision than short political careers allow for.

The Road To Favouritism

The British Social Attitudes survey suggests that only 21% of people are satisfied with how the NHS is run, but 90% believe it should be free at the point of need, regardless of whether you’re wealthy or poor.

For many this is more than just a policy preference, it’s a deeply embedded national value. If any government wants to change this, it would require more than just a policy shift, but a cultural one.

And then there are those like healthcare consultant Tim Read, who make the case that charging high earners would lead to a two-tier healthcare system. The slippery slope argument put forward asks you to consider whether a chief executive would not prioritise the patient who could provide an income to the trust?

Some high earners may argue they already pay more through higher marginal rates of tax. This policy may be enough to push some over the edge, such as the group paying a 60% marginal tax rate on earnings between £100,000 and £125,000 due to loss of their personal allowance. And moving a bit closer to home we must acknowledge that this earnings bracket includes all NHS consultants.

If you add in new charges for services that used to be free, you risk not only resentment of the state but a broader questioning of the what value the NHS offers to these high earners, who already feel like they are paying more than their share.

And so we circle back to a familiar problem: the claim that the taxman is once again targeting the wrong people. By focusing on income and treating ‘high’ earners like NHS consultants as though they were the true hoarders of wealth, we overlook the far larger fortunes held by some in the form of assets.

Many in society sit on vast property and investment wealth yet escape the same level of scrutiny or contribution. It is far easier for HMRC to go after income than wealth; so that’s exactly what they do.

“Work to Rule”: A Viable Industrial Action Alternative?

Is the On-Call community familiar with the law on industrial action? If not, don’t worry, put the law textbooks away, we have you covered.

Some doctors are concerned about prolonged striking, prompted by the financial costs at the individual level or the long-term consequences for patients of cancelled operations and outpatient appointments. These concerns are logically and ethically coherent and must be taken seriously.

Striking is not the only form of available industrial action however. Other options exist short of strike action, such as ‘Working to rule’. Working to rule means refusing to do work that is optional in one’s contract or refusing to work overtime. Literally, you work ‘to the rule’ and nothing more. Every day, significant amounts of good-will and unpaid work keep the NHS afloat. Work to rule would target these areas.

In 2024, the BMA advised GPs to adopt this approach, only undertaking tasks found in their NHS contracts. This reduced available appointments by one-third to 25 a day. Other proposed actions included not performing routine tests and check-ups requested by hospitals.

The logistics of work to rule are much harder to implement. They require individual resolve in refusing to stay late to finish notes or discharge summaries, and in leaving unfinished jobs at the end of the shift. Other actions include declining cover for rota gaps outside of one’s scheduled shifts.

Some would argue this would successfully slow the functioning of the health service whilst causing less ‘harm’ to patients. However, there is no doubt that ‘working to rule’ is susceptible to emotional coercion from seniors and colleagues and exerts far less pressure on the employer than strike action.

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Maybe They’re Not Rude, Maybe You’re Rushing to Conclusions

Challenging the assumptions we make about others—and the blind spots we overlook in ourselves

It’s a pleasant Sunday morning. The rota gods have excused you for the weekend and the sun is shining. You hop on a train to the countryside, and as the doors part, you are forced to one side as the passenger behind you squeezes past without so much as an “excuse me.” “What an awfully rude man, not even an apology,” you mutter to your partner.

Could rudeness be a core personality trait of the fellow passenger? Sure. Is this the only possible explanation for his actions? Unlikely. With a moment’s thought, we can conceive of numerous scenarios that would explain the passenger’s actions. Perhaps a loved one has just been admitted to hospital or he is late for a crucial job interview after six months of unemployment.

The Fundamental Attribution Error

There is a cognitive bias that refers to our tendency to attribute the actions of others to their character or personality, whilst downplaying the influence of other external factors. All the while, we cut ourselves slack by attributing our less-than-ideal behaviours to things outside of our control.

We call this the Fundamental Attribution Error and it might sound a bit like this: "I didn’t finish my clinic letters because the IT system is basically a medieval torture device. When my colleague didn’t finish theirs, it was obviously because they’re lazy."

Be honest… How many times do you see this cognitive bias at work in the NHS? What about when a colleague walks in five minutes late to handover, and eyes are rolled all over the doctors’ office, only for the same eye-roller to be late later that week, with their own excuse (a car breakdown), of course, being entirely legitimate.

Ultimately, we rarely know all the contextual factors that inform and govern someone’s actions, but the judgements never stop: The SHO who sounded ‘abrupt’ on the phone, the ‘arrogant’ consultant who never makes eye contact, or the pedantic nurse who won’t leave you alone with observation results.

Filling in The Blanks

Now do we necessarily always need to have all the information at hand before we arrive at conclusions? No. But let’s do our due diligence and make sure our evidence is strong enough before deciding we have the final answer.

If you find that a colleague’s patience is shorter than usual, that doesn’t mean they are an egregious character. It could mean they are having a difficult time in their relationships or studying for that dreaded FRCA exam. If it is a regular occurrence however, then the strength of the evidence changes.

So next time you catch yourself committing the fundamental attribution error, ask yourself: What contextual or situational factors might I be missing?

“When Nye Bevan created the NHS, he didn’t even include adult social care because demand was so minimal. Life expectancy for men was 66. People didn’t live long enough to require significant social care needs. Today, life expectancy is 81 and only rising, driving social care costs through the roof. Anyone who can’t see this huge distinction between 1948 and 2025 is either misinformed or in denial”

“What does it say about UK surgical training if 12 to 24 months of fellowship are required after 6-8 years of speciality training? In the USA, most residents do fellowships but their training is only 5 years long”

“If someone is telling you he understands AI, he doesn't understand AI.”

“Read an absolutely beautiful quote in The Times last week: ‘Sir, your leading article said that NHS consultants had earnings and pensions most of us could only dream of. Yes, but they do work and make decisions I would only have nightmares about.’ Absolutely brilliant.”

“Seeing the new F1s already settled in to the department after just a matter of weeks is so nice to see”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

The Times suggested last week that fewer than one-third of resident doctors decided to partake in the last round of strike action. This was 7.5% less than the industrial action in June and July 2024, with the NHS maintaining 93% of planned care during the five day walkout. The BMA was quick to respond noting that annual leave and rota differences mean these numbers are difficult to calculate accurately.

Allergies remain a modern day mystery… Why is it that only some of the proteins we encounter go on trigger these allergic responses? A recent paper in Nature suggests that allergens often share a unique property - the ability to form large pores in epithelial airway cells, through which calcium enter and trigger molecules that awaken the immune response.

Weekly Poll

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Would you be prepared to prolong your own training if needed, to balance the burden of household tasks and childcare with a partner?

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Could Looser Lending Rules Get Doctors On The Housing Ladder?

Any doctor who has followed the news closely or aimed to purchase a property knows we are in a housing crisis. Housing prices continue to rise due to high demand and sluggish homebuilding, the cost of living makes saving for deposits harder, recent stamp duty changes have affected more buyers, and unexpected moving expenses, such as legal fees, homebuyer surveys and relocation costs, averaging £5,837, continue to catch people off guard.

Mortgage repayment costs have roughly remained at the same level since the 2008 financial crisis, but deposit requirements have spiralled out of control in the same period. For many without family support and two fairly high income earners it has become increasingly difficult to save the amount of money needed for a deposit.

The most recent Financial Stability Report from the Bank of England concluded that lenders could be given more flexibility. The usual rule of thumb is that banks will issue mortgages that total 4 to 4.5 times annual income. Currently, only 10% of new mortgages exceed this 4.5 times limit.

The Bank of England is happy for that percentage to rise from 10%, allowing banks and building societies to issue more than 15% of their new mortgages at higher than 4.5 times loan-to-income. The Bank predicts that this could lead to 36,000 new higher loan-to-income mortgages a year, potentially helping many people in our On-Call community to get on the property ladder.

In the backdrop of this lives the memory of 2008 and the financial instability that ensues from the irresponsibility of banks and financial institutions. We sure hope there is no slippery slope to the fiscal irresponsibility of those times.