The hugely controversial idea of a two-tier NHS came under the spotlight today after it was revealed that health chiefs in Scotland touted the idea of potentially charging the wealthy to access care.
This was just one of the ideas discussed in a leaked meeting of senior officials on how to fix the health service’s financial problems and boost its continued sustainability.
The idea runs counter to the founding principle of the NHS that treatment should be free for all, regardless of means.
Scotland’s First Minister Nicola Sturgeon has already closed down the possibility of a two-tier system and reacted to the leaked document by saying the idea was “not up for discussion”.
And, though not directly pressed on the issue, Rishi Sunak vowed to ‘always protect’ healthcare as free at the point of use during a speech.
But political commentators say the concept has been quietly emerging in recent years, especially in the wake of Covid.
It comes as an increasing number of Britons opt to pay for treatment privately, to skip record NHS waiting lists.
But what would a two-tier system actually look like?
Here MailOnline looks at four potential models based on what’s already happening in the health service and elsewhere in the British Isles, including one place where you could end up paying £200 to use an A&E at night, rising to more of £500 if you are seriously injured.
How could a two-tier NHS system work in principle? Here MailOnline presents four basic scenarios based on the healthcare systems already in place in the UK and those used by British citizens in places like the Channel Islands,
Could the wealthiest mothers-to-be, cancer patients, and the elderly afford their own medications and dental appointments?
One of the key differences between the NHS in some UK nations is whether it pays for prescriptions.
In Scotland, patients do not have to pay anything for prescription medicines, while in England many patients have to pay full price for most medicines.
However, there are exemptions.
Currently, regardless of wealth, people over the age of 60, pregnant women, children, cancer patients and a variety of other conditions in England are among those who do not have to pay anything.
Low-income people are also protected from prescription fees.
There are other advantages too, all expectant mothers for example have access to free dental checks on the NHS, which continues for a year after the due date.
One way a two-tier NHS system could work would be to remove these exemptions for people who earn above a certain income or asset threshold.
This would be controversial and would probably see some people whose income only tilts them towards the given threshold to be significantly worse off compared to those who earn just below the limit.
But it would generate billions for the NHS, which spent £16.7bn on medicines last year.
The idea of having people with means pay for some NHS services has been proposed before.
In his 1995 column, Mr. Johnson said it seemed reasonable that middle-class wage earners should be able to pay for non-essential services that they “might as well pay for.”
Should the rich pay an excise tax to access NHS services like we have for immigrants?
Another potential way to create a two-tier NHS would be to create an excise tax that the wealthy could pay to access healthcare if the need arose.
England already has such a system for immigrants arriving in the UK, which could be used as a model.
Called the immigration health surcharge, this sees anyone immigrating to the UK to live and work charge £624 per year plus £470 per year for any dependents under 18.
This charge is based on the potential need for these people to use the NHS and does not reflect how often or how frequently they use it.
Charges end when a person leaves or becomes eligible to stay in the UK permanently and chooses to do so.
Expanding such a scheme to the British would be highly controversial, to say the least.
Since Brits, or their parents, have already paid taxes for years to support NHS services, some people would be charging double.
But it provides an example of a segment of the population already being charged for their potential use of NHS services.
Could we charge some richer Brits to access emergency services?
The idea of charging people to access emergency services or general medical care seems outrageous to most Britons and would evoke fears that hospital bills run into the thousands.
However, there are parts of the British Isles where it is already happening.
Located in the English Channel, the Isle of Guernsey and the Isle of Jersey do not have an NHS, despite being under the protection of Great Britain and having British citizenship.
His system, where people pay in whole or in part for hospital and GP services that are free in the UK, gives an idea of what a two-tier system would look like for the NHS.
The island of Guernsey charges people for A&E care based on whether it is in or out of peak hours and the amount of medical intervention needed.
For adults this can start at £120, which covers minor treatment in a hospital between 8am and 6pm Monday to Friday.
But life-saving treatment between 11pm and 8am could cost up to £570.
The island of Guernsey charges people to visit A&E, could a system similar to a ‘two-tier’ NHS be incorporated one day?
The system also applies to GP appointments, with the average cost to see a doctor around £50.
Not without its exemptions, like the UK, the islands also recognize the importance of lowering barriers for pregnant women and young children to access healthcare.
For example, hospital treatment for children in Guernsey only costs £25, although this only applies to residents, not visitors.
A two-tier system for the NHS could work in a similar way, Britons below an income threshold or in vulnerable groups would be entitled to free emergency care, while wealthier people would have to pay extra on top of their taxes. .
Could the wealthiest elderly Britons be asked to sell their homes to access NHS care?
Whatever the model, any potential two-tier NHS system would require a method of determining who could continue to use the NHS for free and who would have to pay.
One model that already exists is the means test for social care in England.
Whether a person is entitled to free welfare is determined by how much money they have.
In England, the local council will usually help pay for care costs if the person has less than £23,250 in savings.
The more you have over this amount, the more you will have to pay.
A two-tier NHS system could use a similar model, if you have more than a certain amount in savings you pay, if not you don’t.
In recent days, flagship plans to limit the cost of social care have been pushed back two years.
The measure, which was due to come into force next October, would have capped the amount anyone would have to pay for future care to £86,000.
It would have drastically reduced the pressure on people to sell houses that might otherwise have been inherited by the family.
The delay, announced by Chancellor Jeremy Hunt last week, is expected to save £1bn next year and up to £3bn in subsequent years if the cap is lowered further.
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