Nearly a decade ago now, David Laws MP raised the idea of evolving the NHS into a continental-style universal ‘National Health Insurance Scheme’ (NHIS), where healthcare would be progressively funded from dedicated income contributions, individuals could choose insurers and everyone would be entitled to a comprehensive package of set treatments within a decentralised but heavily regulated system. It was a bold and interesting proposal, which for better or worse helped define the 2004 Orange Book in eyes of many, though it has perhaps also been misunderstood and straw-manned to a degree.
However, besides substantive criticisms and the understandable sensitivities that talk of large-scale NHS reform tends to trigger, proposals like Laws’ also face a hurdle in terms of imagining how such huge changes could conceivably be brought about. In 2009 when the Social Market Foundation examined social insurance, they commented that “It would be very risky to embark on a massive structural reform in the UK without any international evidence about how best to proceed”.
This is where Ireland, the subject of a new report for the think-tank Civitas, comes in. Irish healthcare centres on the Health Service Executive (HSE), a centrally-administered national service financed primarily from general taxation and the country’s single largest employer. Based on this, many experts categorise Ireland and the UK as roughly comparable health systems. Ireland is of course also familiar to us culturally, population health is comparable and their service faces many of the issues Laws and others have raised about the NHS – rationing, underfunding, accountability, politicisation, outcomes that somewhat lag those of the continent and the arguable need for more patient choice. Recently, the Euro Health Consumer Index (EHCI) 2013 declared the UK and Ireland to be the 13th and 14th best health systems in Europe.
In response to these sorts of long-standing concerns, however, a left-right coalition government in Ireland has now launched a new reform initiative called Universal Health Insurance (UHI). This is essentially a plan to overhaul and decentralise the current Irish service and instead emulate the Dutch healthcare system, which is based on competition, choice and universal insurance. The Netherlands has also been ranked first by the EHCI and the health think-tank Commonwealth Fund for its ability to combine quality and equity. Further, just as the Laws proposal made clear that a mutualised NHS should remain as one of a number of insurers for individuals to choose between in his ideal NHIS system, both Irish coalition parties have stressed retaining a government-run public insurance option to act as check on competing private insurers.
Intended to be completed by the end of the decade, Ireland’s bold reforms could be a very valuable example for the UK. They could help settle the question of whether something like David Laws’ vision of a National Health Insurance system would be worth pursuing here, and tell us what the plausible roadmap to get there could be. Their experiment will be worth watching closely.
* Elliot Bidgood is research fellow in health reform for the think tank Civitas.