David Laws: The NHS is suffering a terminal illness

Could we not have a more meaningful and adult debate about how to build a health system fit for the 21st century?
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Any constituency MP in Britain will see, on a regular local basis, the individual successes of the National Health Service and the affection in which it is held by so many people. The NHS provides a first-class emergency treatment service, is staffed by hard working and often deeply dedicated staff, and has made a real impact for the better on many people's lives.

But any constituency MP in Britain is also acutely aware of the weaknesses and failings of the NHS - huge numbers of people waiting unacceptably long for operations and diagnostic tests; bed shortages; cancelled operations; over-stretched staff; the collapse of NHS dentistry; buildings that often date back to before the Second World War; micro-management from Whitehall; poor standards of customer care and frequent problems with standards of cleanliness in hospitals.

Two or three years ago, Gordon Brown promised a national debate on the NHS. He published the Wanless report which documented in stark terms the extent of the problems in Britain's health services, compared with other developed countries - shorter life expectancy, high infant mortality rates and poor cancer survival rates. Wanless argued that Britain's health system had delivered some of the worst health outcomes in the developing world. But, bizarrely, it claimed that the NHS was the best model of healthcare funding and delivery on offer! So, the great debate over UK health services was over before it had even begun.

In fairness to the Chancellor, many of the problems of the NHS have been caused by low levels of investment over a long period of years. But many others are not simply a consequence of poor levels of funding. The NHS is one of the biggest employers in the world, running a bureaucratically driven system which is driven by central diktat from Westminster and Whitehall.

The NHS is a system that fails to allow for the disciplines of choice, diversity and competition which can help to ratchet up standards. Most of my elderly constituents, given appointments for vital diagnostic tests and consultations which may be months or years in the future, have no alternative to the NHS if they need faster treatment. The only option for the wealthier minority is to buy treatment in the private sector - which usually means seeing privately in a week the same consultant who could not be seen for six months or a year on the NHS.

The NHS suffers from two other obvious problems - political instability and funding uncertainty. Because the NHS is run from Westminster and Whitehall, it is subject to sharp policy changes, and targets that meet political imperatives and not local needs.

New Labour's supposed conversion to a "localist" agenda is unconvincing and skin deep. As the Liberal Democrats have consistently argued, Labour's idea of "localism" is extending to a minority of local hospitals or schools limited powers to implement policies which have already been set in Whitehall.

In addition, this is a system that relies on the Government of the day funding the NHS generously out of general taxation. The Government can rightly boast a good record on funding the NHS for the few years from 1999/2000 - but these levels of funding have been the exception rather than the rule for the whole history of the NHS, which strongly suggests that we cannot rely on future governments funding the NHS in the manner of recent years.

But what other alternatives are on offer? The Tories used to favour subsidised private health insurance, and they are now peddling their "patient passport", which is a payment to help people to opt out into the private sector - if they can pay the balance of costs themselves. This attempt to provide an escape route from poor-quality state provision for an affluent minority, while leaving the NHS fundamentally unreformed, has convinced few commentators and even fewer voters.

So are there any other alternatives to the state monopoly which fails so many citizens and the private opt-out which will never be an option for so many people on lower incomes?

Liberal Democrat policy advocates a portion of income tax being earmarked only for the NHS as an "NHS contribution", to allow people to understand how much of their tax is used to fund the NHS, and to help to build the case for higher funding to cover higher future health costs and the implications of an ageing population.

We have also advocated a genuine decentralisation of the NHS, with a presumption that local NHS professionals know better than the man in the ministry - reversing the existing Government assumptions.

Finally, we have advocated introducing more choice and diversity into the NHS, with new providers and greater choice. In an essay published yesterday (in The Orange Book; Reclaiming Liberalism), I have explored whether our policy could be developed further in the future to offer even greater choice and diversity.

To some people, this may seem radical, even dangerous. The public's views about the NHS are, to a certain degree, contradictory - people simultaneously express strong support for the NHS and its values, but seem sceptical as to whether existing Government policies and extra money will deliver success.

Meanwhile, in many continental European countries (often regarded as dangerously left-wing by commentators in this country), a totally different model of health care provision does exist, which does offer citizens greater choice and variety. The model is usually described as representing a "social insurance" approach, where the state funds all health care out of progressive taxation but people can choose between different providers.

In many of these European countries, waiting lists are regarded as an absurd British eccentricity, and the fixation with having only one state provider is regarded as absurdly out of date. The social insurance systems are identified with greater choice and competition for patients, better funding and health outcomes.

This is surely a model which we in the UK could be learning from. Could we not have a more meaningful and adult debate about how to build a health system fit for the 21st century, on the basis of the very principles which underpinned the foundation of the NHS? For example, why not switch from a monopoly NHS system to a National Health Insurance Scheme - with the NHS remaining in place, but as only one of the options available to all citizens?

Why not raise an NHIS contribution from every citizen from their incomes, and on the basis of ability to pay? Why not allow the private and voluntary sector to offer their own schemes to citizens, provided that they are open to all citizens without payment of any top-up, and delivering care which is free at the point of need?

It is time for a liberal vision of the NHS's future, building on existing Liberal Democrat policies, but offering a genuine alternative to the Government's centralised monopoly purchaser vision. When so many other countries in the world have health systems which deliver so much better results, why are we so scared in this country of considering how we can marry our national commitment to health care for all of the population to a system with real choice and better quality?

The writer is the Liberal Democrat MP for Yeovil