Critics say it's a queue jumper's charter. Supporters claim the NHS would crumble completely without the extra cash from private patients. Margaret St John asks ...; Do we need
The political arguments about health care go round in circles. Wherever you look in the world, people are unhappy, not so much with their health care but how they pay for it and the system that delivers it. What I want to do is ask a simple question: does it make sense for my very ordinary family of two adults and two children to pay the extra premium of private health care as an insurance against gaps in the NHS?

I have flirted with the idea before, but decided against taking out a policy - partly because of the expense but more because I felt that I and my family did not need it. We are registered with an excellent (non- fundholding) GP and for my three visits to our local teaching hospital, all requiring a general anaesthetic, I can only praise the service and attention that I received.

Last winter was long and hard and the NHS was stretched to breaking point. The shortage of paediatric intensive care beds made me think again. I realised that the NHS could no longer be counted on to provide what it was best known for - emergency care. Stephen Dorrell, the Secretary of State for Health, has ordered action over the shortage of intensive care beds, but changes must come from within the existing, already stretched budget. It does not inspire confidence.

But is private health insurance the answer to my worries? Having lived in the United States for four years, I am used to the idea of private medical cover. There, only the very poor and the elderly are covered by the state, so it is up to individuals or their employers to arrange protection. Frankly, it is nerve-wracking. You always have to make sure that your payments are up to date before going on holiday and you must remember to telephone the health insurance company if you need to go into hospital.

I learnt that private health insurance doesn't stop the worrying at all. Despite the high premiums, you are not always covered. For example, one American friend who needed fertility treatment had tried a number of procedures. But the health insurance company said she had reached her ceiling on cover for that ailment before she had tried all the options available.

A fully private system is extremely expensive for subscribers, for companies and for the nation. The US spends 18 per cent of its GNP on health care - more than twice the UK. Doctors' fees are incredibly high but they would argue that they have to pay crucifying insurance to protect themselves from malpractice lawsuits. It is argued that doctors order far too many unnecessary diagnostic tests to protect themselves which, of course, puts up the price of medical insurance. It is quite common for obstetricians in the US to give up delivering babies because of their fear of court proceedings. There is no such thing as a basic immunisation programme for babies in the US - you take the baby to your doctor for a check-up and then the nurse pops in to give the jabs; it's all very pricey.

Returning to the UK, I thought, would be an end to those concerns. But the system here has become so complex, with the NHS frequently working with the private sector, that it is very difficult to work out who is paying for what. At least the system in the US was straightforward - you had health insurance or you didn't.

Most private insurance policy holders do not have to concern themselves with these matters because private health insurance is mostly a company perk. However, if I take out a policy, it will be out of my pocket and I need to know where the money is going, what the NHS still covers, and what private health insurance does not. Poring over the brochures is exhausting and the early-evening follow-up calls from the insurance companies are annoying.

Private health insurance companies exclude some medical conditions from coverage. I was rather shocked to discover that regular renal dialysis was not covered by a plan offered by Prime Health - these patients, who have presumably paid their premiums to the health insurance company for some years, go back to the NHS for help. Other exclusions from most of the companies cover alcohol and drug abuse, Aids, normal pregnancy and any previously known condition. My neighbour had to have physiotherapy for a sports-related back injury and no insurance company will cover any back problems she may develop in the future. However, some companies will cover some of these conditions if you have been a subscriber for two years before developing any of the symptoms again.

A big surprise for me is that private health patients use NHS GPs. In the US, you pay to see your GP and claim from your health insurance company. Most babies are born on the NHS and only ever see their NHS GP, unless they develop a nasty ailment that requires a specialist's opinion. Only then would their private health cover kick in.

Another shock is that Accident and Emergency is covered by the NHS. While I accept that billing a private patient and the insurance company for what happens in an ambulance and trauma room would be very difficult, it does highlight the strange relationship that has built up between the private and public sector.

Critics of private health insurance describe it as a queue-jumpers' charter. Supporters say that the NHS could not survive without the extra cash that insurance companies now supply for NHS pay-beds, let alone cope with those who are treated in private hospitals. In 1994-95 the NHS purchased more than pounds 500m of health care from the non-NHS providers and the income from private patients for the NHS was pounds 193m. Some people argue that the NHS is steadily becoming privatised. But Trust hospitals insist that profits made from private patients are used to improve NHS services.

What would I get for my money if I took out private health insurance? The big advantage is that if I need to see a specialist, I can get an appointment quickly, at a time to suit me. If I need to go into hospital, this also can be arranged to suit me.

Subscribers also have more choice of doctors. Friends tell me that going privately allows patients more time with the doctor or surgeon to explain things. After an operation, private health insurance pays for private rooms with telephones and televisions and extended visiting hours. There are many different types of policies offering varying levels of cover. Some policies insist you choose from a limited number of hospitals throughout the country and some, for example, give a free medical each year.

But I find that I am uncomfortable with the idea of private health insurance in this country. I do not trust the health insurance companies to deliver. Friends report problems with claims. My sister, for example, thought she was fully covered when she had to have an emergency Caesarean section. Her health insurance company, however, would not fully cover her anaesthetist's bill, saying he had charged too much and that they would have been able to tell her that, had she phoned them on the 24-hour helpline.

The debate over whether to pay for health care differs from the other great debate in this country, whether to pay for education. With private schooling, you are virtually (except for those schools with charity status) leaving the state system. With private health care, you are occasionally buying an upgrade from the NHS economy class, safe in the knowledge that you have the NHS safety net to fall back on.

It appears to me that health insurance companies can pick, choose and dump policy-holders because they have the NHS to fall back on. It is not that I am opposed to the principle of private health cover, rather that I do not feel that consumers are always going to get a fair deal, particularly those who have been paying their premiums for many years.

So do we need private health insurance? No. But we do need more, yes more, investment in the NHS or else we need to accept an open approach to rationing. And, if we can't accept rationing, then we will have to accept tax increases to fund the extra pounds 6bn that the British Medical Association demanded at its annual meeting. As I was considering spending up to pounds 1,500 per year on an insurance scheme, I would have to say that I would be willing to pay more taxes for a consistently reliable health service. I don't need "hotel-type rooms and visiting hours to suit the family". I need to know that the health service is fit and healthy.

Meanwhile, I plan to save the money that would have gone into private health insurance into a PEP in case I ever need to buy some private service. As I am under 40, friends tell me this is a better way of spending my money. I hope a government is courageous enough to address the financing of the NHS and what to do when there is a financial shortfall.

What do you think?

Every Monday you can give the Do We Need...? subject of the week the come-on-down or the thumbs-down. Send your verdict, in no more than 100 words, to Do We Need...?, Section Two, the Independent, 1 Canada Square, Canary Wharf, London E14 5DL or fax 0171-293 2182 no later than Friday morning.