What could a two-tier NHS even look like?

The hugely-controversial idea of a two-tier NHS was thrust into the limelight today after it was revealed that health bosses in Scotland touted the idea of potentially charging the wealthy to access care.

This was just one idea discussed at a leaked meeting of senior officials on how to fix the health service’s financial woes and boost its ongoing sustainability. 

The idea goes against the very founding principal of the NHS that treatment should be free for all, whatever their means.

Scotland’s First Minister Nicola Sturgeon has already shut down the prospect of a two-tier system, reacting to the leaked document by saying the idea was ‘not up for discussion’.

And, while not pressed directly on the issue, Rishi Sunak vowed to ‘always protect’ the health service as being free at the point of use during a speech.

But political commentators say the concept has quietly been emerging over the past few years, especially in the wake of Covid.  

It comes as increasing numbers of Britons opt to pay for treatment privately, to skip record-long NHS waiting lists.

But what could a two-tier system really look like?

Here, MailOnline looks at four potential models based on what is happening already 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 over £500 if you’re badly injured.

Could wealthier mothers-to-be, cancer patients and the elderly pay for their own medications and dentist appointments?

One of the key differences between the NHS in some nations of the UK is if you pay for prescriptions. 

In Scotland, patients don’t have to pay a thing for prescription medication, while in England many patients must pay full price for most drugs.

However, there are exemptions.

Currently, regardless of wealth, people over the age of 60, pregnant women, children, patients with cancer and a range of other conditions in England are among the people who don’t have to pay a thing. 

People on low incomes are also protected from prescription charges.  

There are also other perks, all expectant mothers for example get access to free dental check-ups on the NHS which continues for a year after their due date.  

One way a two-tier system NHS 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 likely see some people whose income just tips them into the determined threshold being significantly worse off compared to those who earn just under the limit.

But it would bring in billions for the NHS, which spends £16.7billion on drugs last year.  

The idea of people of means paying for some NHS services has been proposed before.

In his 1995 column, Mr Johnson said it seemed reasonable that the middle classes earners should be able to pay for non-essential services that they could ‘well afford’. 

Should the wealthy pay a special tax to access NHS services like the one we have for immigrants?

Another potential way to create a two-tier NHS would be to create a special tax that the wealthy could pay to access the health service if the need arose.

England already has a such a system in place for immigrants coming to the UK which could be used as a model.

Called the immigration health surcharge, this sees anyone who immigrates to the UK to live and work charged £624 per year plus £470 per year for any dependents under the age of 18. 

This charge is based on the potential need of these people to use the NHS and is not reflective of how often or little they use it. 

The charges end when a person leaves or becomes eligible to remain in the UK permanently and they choose to do so. 

Expanding such a scheme to Britons would be highly controversial to say the least.

Since Britons, or their parents, have effectively already paid taxes for years to support NHS services it would effectively be charging some people twice. 

But it provides an example of already charging one segment of the population for its potential use of NHS services.  

Could we charge some wealthier Britons to access emergency services?

The idea of charging people for accessing emergency services or health care in general seems outrageous to most Britons and would evoke fears of hospital bills running into the thousands. 

However, there are parts of the British Isles where it is happening already.

Located in the English Channel, the Isle of Guernsey and Isle of Jersey do not have an NHS — despite being under the protection of Britain and having British citizenship. 

Their system, where people pay either entirely or in part for hospital and GP services that are free in the UK, gives a peak into what a two-tier system for the NHS might look like.

The Isle of Guernsey charges people for A&E care based whether it is on or off peak, and the amount of medical intervention needed. 

For adults this can start at £120, which covers minor treatment at a hospital between 8am and 6pm Monday to Friday.

But life-saving treatment between the hours of 11pm and 8am could cost as much as £570.

The Isle of Guernsey charges people to visit A&E, could a similar system be one day brought into a ‘two-tier’ NHS

The system also applies to GP appointments, with the average cost to see a doctor about £50.

It is not without its exemptions, like the UK the isles also recognise the importance of reducing barriers to pregnant women and young children accessing healthcare.

For example, hospital treatment for children on Guernsey only costs £25, though this only applies to residents, not visitors. 

A two-tier system for the NHS could work similarly, Britons below an income threshold or in vulnerable groups would be entitled to free care emergency care whereas wealthier people would have to pay extra on top of their tax. 

Could the wealthier elderly Britons be asked to sell their homes to access NHS care?

Whatever the model, any prospective two-tier NHS system would require a method to determine who could keep using the NHS for free, and who would have to pay.

One model that already exists is the means test for social care in England.

If a person is eligible for free social care is determined by how much money you have.

In England, the local council will generally 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 be expected to pay.  

A two-tier NHS system could use a similar model, if you have over a certain amount in savings you pay, if not, you don’t. 

In the last few days flagship plans to cap the cost of social care were delayed for two years.

The measure, which was due to come into effect next October, would have limited the amount anyone would have to pay for care in later life to £86,000.

It would have drastically reduce the pressure on people to sell homes that could have otherwise been inherited by family. 

The delay, announced by Chancellor Jeremy Hunt last week, is expected to save £1billion next year and up to £3billion in subsequent years if the cap is further pushed back.