Rediscovering their core principles

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For at least ten years, the Conservatives in the Senedd have been telling us that a policy of issuing free prescriptions is wrong in principle, because it means that a millionaire can go to the doctor and get a prescription for paracetamol instead of just picking up a packet for a few pence at the local supermarket. As far as I know, they’ve never been able to identify a single millionaire who would prefer to telephone the surgery, make an appointment, travel to the surgery, spend an hour or so in the waiting room, collect the prescription, and then travel to a pharmacy to obtain said paracetamol rather than just pick up a packet at a supermarket, but it’s always been about the principle. The fact that millionaires don’t do it doesn’t mean that they shouldn’t be banned from doing it – poorer people with more serious requirements who would also be hit by prescription charges are just so much collateral damage.

This week, however, we find that free prescriptions is not such a bad thing after all; the same people are now in favour of retaining free prescriptions. The cynical amongst us might think that this is just some sort of electoral ploy – after ten years of plugging a highly unpopular policy, they’ve suddenly realised, with an election pending, that it might be losing them more votes amongst those who benefit from the policy than it gains them from those who don’t. There is, though, an alternative possibility: the performance of the UK government during the pandemic has reminded them that one of the core ‘principles’ of the Conservative Party is actually to stuff as much public money as they can into the pockets of the richest in society. Seen from this perspective, they might just be eliminating one small inconsistency in their thinking.

There they go again

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Perhaps it was the result of it being a bank holiday, and a general shortage of non-weather-related news, but Monday’s Western Mail granted the Tories yet another headline based on their opposition to giving free paracetamol to millionaires.  The sense in which this can be classed as news, let alone a hold-the-front-page revelation, escapes me; it’s not as if they haven’t been saying the same thing for many years.  Here’s the 2012 version of the same story, and here it is again from 2014.

‘Paracetamol for millionaires’ is, of course, short hand for ‘giving over the counter medicines on prescription’ to anyone who needs them; but since they keep using that shorthand, it’s far to ask whether there is any truth at all in the claim.  There are, apparently, around 12,500 millionaires in Wales, out of a total population of around 3 million.  I suppose that some of them must get headaches from time to time – it’s not easy looking after all that cash – and thus require an occasional paracetamol.  And millionaires don’t get rich by spending money if they don’t have to, so the attraction of not spending 30p at the local supermarket is clearly attractive.  But here’s the thing – millionaires also don’t get rich by wasting their time phoning the doctor’s surgery to make an appointment, travelling to the surgery and sitting around for up to an hour waiting their turn to be seen.  I suppose that, on the law of averages, there must be at least 1 of those 12,500 who has had free paracetamol at some point over the last year, but I somehow doubt that millionaires’ predilection for paracetamol is a significant cause of cash problems for the NHS.

The fact that, under a policy of making prescriptions free, it is theoretically possible that an occasional millionaire can get his or her paracetamol free of charge doesn’t mean that it’s actually happening on a wide scale, which is what the Tories’ hyperbole is effectively claiming.  But what we do know is that, under the previous system of paid-for prescriptions (which, let us remember, had such a wide range of exemptions that the majority of prescriptions in Wales were free anyway), some people on the margins, who struggled to find the money to pay, felt pressed into not taking all the medications which they were prescribed.  And if the ‘cost’ of helping that group is the purely theoretical possibility that the very rich could, if they were so minded, get free paracetamol, then I and many others would consider that a very cheap price for the benefit delivered.

There is, though, a much bigger threat to the viability of the NHS than an occasional free packet of paracetamol ending up in the hands of a millionaire.  That threat comes largely from those politicians who don’t really believe that the NHS should be free to all at point of use, who want to introduce more charges for services, who limit the amount of money available to pay for the service, and who try to create false choices and conflicts between different groups of users of the service.  For them, sweeping away free prescriptions is just the starting point for a wider rolling back of the service.  No wonder that they return to the same subject, year after year.

Identifying the right problem

Tweet It was interesting to read today that Wales apparently has a grand total of 12,000 millionaires.  As I understand it, these are the wicked people whose prediliection for taking time out of their busy schedules to visit their doctors to obtain prescriptions for free paracetamol, according to the Tories, is bankrupting the Welsh NHS. 

I found myself wondering just how much paracetamol such a small number of people must each be popping in order to arrive at such a horrendous situation.  A packet of 16 pills costs around 20p, so if each of them gets a packet once a week all year round, the total cost of the tablets would be a massive £120,000.  To be close to bankrupting the whole NHS, I dread to think how many tablets they must each be swallowing.  

Perhaps the real problem which the Tories keep highlighting is a widespread addiction to painkillers amongst the very richest people in Wales.

Paracetamol and millionaires

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Given the high profile of the Welsh Government’s commitment to free prescriptions, I find it hard to believe that any Health Board in Wales would have decided to ban GPs from prescribing certain medicines without consulting the government.  And the calm response by “a spokesman” also suggests that the decision by the Hywel Dda Board did not exactly come as a surprise.

It amounts to the introduction of what Welsh politicians usually like to call a “post code lottery”; which items can be had for free will now vary from one part of Wales to another.  It touches on the long standing issue that there is a lack of consensus about which decisions should be taken nationally and which should be taken locally. 

As a general rule, I tend to favour local democracy rather than central imposition; but in this case, health boards are not subject to local democracy, and this looks like a case of local appointees trying to weaken or undermine a decision taken by electorally-accountable politicians.  Purely for that reason, I’m surprised at the calm response of the government – unless, of course, they are actually looking for a way of back-pedalling on their commitment.

From the figures included in the report, it appears that the introduction of free prescriptions has had no impact on ‘over-the-counter’ sales, which have remained static, but it has increased the number of prescriptions for those same medicines by a significant margin.  It therefore appears, at first sight, as though the extra prescriptions are not for people who would otherwise have purchased the same medicines.  And as far as I’m aware, there is not a single reported instance of a millionaire obtaining a prescription for paracetamol.

But I’d like to understand better where that increase has come from before coming to a conclusion.  Is it the case that people are now going to see the doctor when they wouldn’t have bothered before?  Is it that doctors are now issuing a prescription when they might previously have just said “take a couple of paracetamol”?  What’s the impact on health of removing that option?

From the reports so far, the decision appears to have been taken on purely financial grounds, without considering that health impact at all.

Politicians of principle

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The Lib Dems’ flip-flop on prescription charges is really too easy a target, as Vaughan pointed out yesterday.  Free prescriptions have gone from being an example of wasteful and unnecessary expenditure to being a key element of the party’s health policy.

There is, of course, nothing wrong with any party changing its policy, and I suppose we should all be pleased that the Lib Dems have seen the light.  Keynes famously said that “When the facts change, I change my mind.”; so the question going through my mind is simply this – “Which are the facts that have changed, as far as the Lib Dems are concerned?”.

In 2007, their then health spokesperson declared that “Free prescriptions for all sounds great on election leaflets”, before proceeding to set out why, even though it might be a popular policy, they thought that it was the wrong one.  Presumably, their own election leaflets will look a bit better this year as a result of their change of heart, but surely the policy change can’t just be down to an acceptance that free prescriptions are popular?  Responsible politicians wouldn’t just support something that they’d previously argued was wrong in principle for such an unprincipled reason would they?

Visiting the Doctor

Tweet There are those who argue periodically that the days of ideology in politics are dead and gone. In much of what passes for political debate, that often seems to be true. But I'm not convinced; there are plenty of issues where the underlying disagreement is really an ideological one; it just isn't presented in those terms.

Yesterday's news about a Labour-leaning think tank suggesting a £20 charge every time anyone visits the doctor is a case in point. It's presented as though it's merely a suggestion, an option, for addressing the budget deficit, but there really is an ideological disagreement underneath that.

There are, in practice, three ways in which we can pay for health care:
• We can pay for what we use at point of use;
• We can pay through an insurance scheme; or
• We can pay through taxation.

There is no necessary reason why the total cost of delivery or the total amount paid should be any different under those three potential models, but there is a huge difference in the impact on who pays, and how much they pay. Under the first, those who are ill most often pay the most, under the second, we all pay broadly the same, and under the third, payment is based on the ability to pay.

Whilst people can and do put forward practical arguments why one is better than another, or why we should mix and match elements of two or three of them, the argument at root is not a pragmatic one. Positions are taken on the basis of a belief about what is right and what is wrong – and if that isn't, ultimately, an ideological argument what is it?

I'm in no doubt that my own commitment to free health care – including prescriptions and visits to the doctor – stems from my view that health care should be universally available as needed without cost at point of use, with contributions being based on ability to pay. And I shall continue to make that argument.

Blue Wales

Tweet I nearly gave up on Nick Bourne's article yesterday after reading his assertion that Oscar's defection is a clear sign that the Tories are broadening their appeal across Wales. It's a complete non-sequitur, especially given that it has subsequently become clear that the underlying reason for the defection was much more to do with the Tories' laissez-faire attitude to the employment of relatives than with any issue of policy or principle.

If I had given up, I would have missed a couple of gems. His claim that the Conservative Party's position is 'clear' on further devolution is risible, and his suggestion that a Tory Wales would be a greener Wales is a nonsense given local Tory demands for new dual carriageways and unqualified support for the wasteful use of scarce energy resources.

At one point, he even seems to manage to blame Labour for making people ill ("Under Labour, considerable sections of our population have deep-seated health problems"). If only solving that problem was as easy as changing the party of government…

The piece was long on criticism of Labour (not always unjustified, mind), but remarkable short on specific proposals. Giving us all an annual entitlement to volunteer and re-imposing prescription charges do however give us a flavour for what to expect. It's the same old Tories deep down; these policies are two different faces of the same underlying idea – public services should as far as possible be either charged for or else provided by charities and volunteers, leaving enough money in hand for tax cuts for the most well-off.

Wales might indeed be a blue nation if England elects a Tory government; but perhaps not exactly in the meaning of the word 'blue' that they are suggesting.

Still digging

Tweet The more the Tories try and 'clarify' their position on the NHS in the wake of Dan Hannan's comments, the deeper they seem to be digging themselves.

Last week, Cameron himself pledged his support for the NHS - by promising to open the NHS to "new providers". This is clearly an indication of an intention to move elements of health care from the public sector to the private sector. Promising to privatise parts of the NHS seems to be a curious way of showing support for it.

On the same day, the spokesman for the Conservatives in Wales in the National Assembly wrote a letter to the Western Mail in which he said that they would not scrap the policy of free prescriptions. They would, however, only safeguard the policy for 'most people', and would 'allow' others to make a 'small contribution' to the cost. To me 'allowing' people to pay sounds like it would be voluntary; somehow I doubt that is what he means, since they are counting on generating a net saving of £30million.

In yesterday's Sunday Times, there was a report of a survey by ComRes, which indicated that some two thirds of Tory MPs want to privatise at least some elements of the NHS, and move away from a system funded by taxes to an insurance-based system.

So, it seems that they plan to support the NHS by privatising parts of it, maintain the policy of free prescriptions by making some people pay for them, and deep down, many of them are opposed to the whole principle on which the NHS is based. Hannan managed to open a very large can of worms with his interview on US television – and we haven't got to the bottom if it yet.

Universality

Tweet This week's 'news' about the fact that there are no plans to abolish pensioners' free bus passes has been something of a controversy about nothing. A ministerial advisory group recommended looking at the issue again; the government said a firm 'no'. End of story.

Amanwy is amongst those who pointed out that the BBC were about three weeks late in drawing attention to the report concerned. The delay in responding is surprising, certainly; but I was also surprised at the time about the lack of attention given to a number of significant decisions made by the government in relation to the recommendations of the Ministerial Adisory Group. There is a sense in which the rejection of certain recommendations was actually more newsworthy than the acceptance of those which found their way into the national transport plan.

The bus pass policy has been both popular and successful, but in a time of budget cuts, universal benefits were always going to come under greater scrutiny, and there were always going to be those who would start to argue for cuts. The leading cutters of public services in general, the Tories, have responded by supporting the idea of curtailing, if not scrapping, the scheme, having already proposed scrapping the system of free prescriptions in Wales.

The word 'free' itself is actually a misnomer, of course - nothing is 'free' in the widest sense. The underlying question is whether certain goods or services are paid for individually as and when required, or collectively, so as to be available when required. And that difference in approach is more fundamental than some seem to realise.

Those who would use the current economic crisis as a reason for cutting back on things like bus passes and prescriptions fall into two categories. The enthusiastic cutters are those who have never believed that such things should be free in the first place; the reluctant cutters are those who would prefer to keep current arranmgements, but believe them to be a lower priority when less cash is available for government spending.

Those in the second category need to be careful that they don't end up becoming the instruments by which the first category deliver their agenda. There is more than mere pragmatism involved in this debate; there is also, as Adam Price has pointed out, a difference in ideological standpoint.

Adam puts forward a particularly robust defence of the principle of universality on his blog, with his usual clarity of expression. It's a welcome contribution; there is a real dividing line in politics here which is far too often treated as merely a debate about priorities. One thing of which we can be certain is that if we find ourselves with the Tories in power in Westminster after the next election, universality is going to need a lot of defending. Conceding the argument in advance, as some seem to be doing, is hardly the best way of defending public services.

Those who can afford it

Tweet I was slightly surprised that the Tories have decided to make the re-imposition of prescription charges in Wales one of their key planks of their Assembly policy. Even some of their own people seem to have been a bit taken aback by the proposal.

It's not entirely clear how much money this will really save. The cost of abolishing prescription charges was put at around £30 million, but the Tories' proposal wouldn't raise that much in reality. In the first place, they are planning to increase the range of exemptions, and in the second, to impose a lower charge – both aspects which would significantly impact on the total of any saving. And that's without deducting the costs of reintroducing the systems to collect and account for the monies involved.

I doubt, however, that they're really interested in the saving; this is more to do with their political message than with financial prudence. After all, much of what they actually say in the Assembly seems to be about demanding increasing expenditure rather than cuts.

The line about "those who can afford to pay should do so" has a certain resonance, there's no doubt about that. And given that around 93% of prescriptions were free anyway, and that that proportion would increase under the Tory proposals, it seems that less than 7% of the population would be affected adversely by their proposal. (Although since that's likely to be the wealthiest 7%, one does rather wonder whether this is likely to affect the section of the population most likely, historically, to vote Tory.)

But, as I've argued before, if the principle to be followed is that "those who can afford to pay should", why pick on (or stop at) prescription charges? Why not fees to see the GP? Charges for hospital treatment?

I can understand them wanting to draw a clear line between themselves and the Assembly government. And at a policy level, there's a refreshing honesty about them returning to their traditional position of attacking both universality and the health service. But what's their game plan for 2011? Do they really believe that they and the Lib Dems will ever have the numbers to form an alternative government in Cardiff?

Keep taking the tablets

Tweet The Lib Dems' Health spokesperson took a lot of space and words in the Western Mail on Monday to fulminate against the policy of Free Prescriptions, but she actually said very little. (The Tories' Assembly leader was making similar noises just a week or so ago as well.) Specifically, she once again totally failed to explain why Lib Dems and Tories believe prescriptions should be singled out for charging, whilst other aspects of the Health Service remain free.

Their main lines of argument seem to be:

• We should not have to refuse some treatments on cost grounds when there are other people who could pay for their prescriptions and don't;
• Providing free prescriptions diverts funds from other areas of the health service;
• People don't appreciate something (such as prescriptions) which they get for free.

But suppose we substitute 'appointments with the doctor', or 'minor surgery', or 'hospital accommodation' for prescriptions in those three points? The statements all remain just as 'true'. There is no particular rationale for picking on prescriptions other than the fact that people have been accustomed to paying for them; but the fact that something has been so for a period of years is never in itself an adequate justification for it to continue.

I suspect that the Tories and Lib Dems actually believe that a wide range of health services should be means-tested; with those who can afford to pay being charged for the services they receive. Prescriptions is just the tip of the iceberg for them. Just think of all the money that that would free up for other parts of the health service (or would it just go on tax cuts, I wonder?).

Actually, I welcome the way in which the Tories and Lib Dems won't let go on this one, because it helps to draw a clear distinction between those of us who believe in a free health service, and those who have simply never understood the underlying principle of 'free health care for all'.