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Education And Debate For and against

Education and debateSocial insurancethe right way forward for health care in the United Kingdom?ForAgainst

BMJ 2002; 325 doi: (Published 31 August 2002) Cite this as: BMJ 2002;325:488

This article has a correction. Please see:

Social insurancethe right way forward for health care in the United Kingdom?

The NHS in the United Kingdom is struggling to meet the needs of patients as costs continue to rise. Does the current system of funding need to change? David G Green and Benedict Irvine argue for a system based on social insurance, while Martin McKee and colleagues suggest that a tax based system is more equitable


  1. Benedict Irvine, project manager, Civitas Health Unit,
  2. David G Green (, director
  1. Civitas (Institute for the Study of Civil Society), Elizabeth House, London SE1 7NQ
  2. aLondon School of Hygiene and Tropical Medicine, London WC1E 7HT
  3. bLondon School of Economics and Political Science, London WC2A 2AE
  4. cLSE Health and Social Care, London School of Economics and Political Science
  1. Correspondence to: D G Green

    Comparing systems of funding healthcare is controversial. We suggest, however, that the following six questions should help to put the controversy on an evidence based footing. We believe that the case for social insurance deserves a more serious hearing than the British government has so far given it.

    Value for money—Can individuals tell whether they are getting good value for money? It is impossible for taxpayers to make a well informed judgment about value for money because they have no knowledge of the amount being paid nor any ability to vary it. Social insurance schemes allow individuals to see clearly (usually on pay slips) how much they are paying towards care. In Germany employers and employees make equal payments (totalling on average about 13% of the salary) to the independent sickness fund chosen by each individual. In France sickness funds are usually run by a board comprising employers and trade unions, and individuals cannot choose which sickness fund to use. In the past, employers in France paid about two thirds of the premium, but recently the share paid by individuals has been increased. In Switzerland there are competing insurers, and premiums are paid solely by individuals.

    Standard of care—Do poor people enjoy a high standard of care? The standard of care is generally lower for people of all incomes in the United Kingdom than other European countries of similar wealth. In 1993 Wagstaff and van Doorslaer tentatively noted that higher healthcare spending …

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