Healthcare: another thing that the Germans just do better

Germany has rejected restrictions on doctors visits.

Recent Conservative ideas to restrict the number of GP visits in a year may be discounted as too controversial. But with the concept of universalism in health and welfare under threat we should not be so complacent. This is another area where we should follow the current trend of noting what has happened in Germany: consultation fees for visiting the doctor were abolished in Germany on 1 January 2013.

Co-payments, as they were called, of €10 if you visited the doctor in any given quarter or if you went to a specialist without a referral, were introduced by Schroder’s government in 2004. Addressing similar concerns to the NHS at present on health costs and the waste of doctors’ time on trivial conditions it was thought, at the time, to be a good idea by all the main parties in Germany. It was supposed to deter the practice in Germany’s compulsory health insurance system of patients hopping from specialist to specialist. They also thought it would bring in approximately €2bn per year.

Once in opposition the Social Democrats (SPD) and Greens turned against the idea of co-payments. As you would have predicted the charges deterred many people from going to the doctor. So it is obvious that the cost in dealing later with deteriorating conditions and in personal misery was great. Even on the projected revenue the German government did not meet its targets. When the abolition of co-payments was debated in the Bundestag last November the Financial Times Deutschland reported that medical practices spent approximately 120 hours a year collecting the fee, a total administrative cost of €360m. Once it came to a vote at the end of last year – coincidentally on the historic date of 9 November – the ruling conservative-liberal coalition (CDU/CSU and FDP) also changed their minds and the Bundestag voted unanimously to abolish the charge.

Could co-payments be introduced in Britain? The idea could be sold as a fairer method than restricting the number of GP visits per patient, it would be said "only those who can afford to pay will have to make this small contribution". But people of all income brackets have commitments to meet, whether it is a mortgage, rent or bills and any fee, no matter how small will deter people from seeking medical help. For those with long-term conditions the need to see your doctor regularly is clear. For the rest of us, also, we need to see the doctor when we have concerns. We may dismiss our niggling symptoms, but we will all get something serious eventually and it may happen sooner if, being human, we decide to spend our tenner on something other than going to the doctor for a trivial matter.

I would suggest that following recent top-down healthcare reforms it is only a matter of time before a formal proposal on GP visits is made – the Tory idea on restricting the number of visits is just to test the water. Universalism has not been defended but is a sound principle. It is more straightforward, we all contribute (even those on out-of-work benefits pay VAT) and we all benefit. The bureaucracy of means-testing is avoided. The case for the better-off benefiting is clear, we are all part of the community and the costs can be recouped by looking at the tax paid by the better-off. In terms of GP visits this is another case where we can learn from the way the Germans do things – a mistake was made but they reconsidered it and put it right.

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Air pollution: 5 steps to vanquishing an invisible killer

A new report looks at the economics of air pollution. 

110, 150, 520... These chilling statistics are the number of deaths attributable to particulate air pollution for the cities of Southampton, Nottingham and Birmingham in 2010 respectively. Or how about 40,000 - that is the total number of UK deaths per year that are attributable the combined effects of particulate matter (PM2.5) and Nitrogen Oxides (NOx).

This situation sucks, to say the very least. But while there are no dramatic images to stir up action, these deaths are preventable and we know their cause. Road traffic is the worst culprit. Traffic is responsible for 80 per cent of NOx on high pollution roads, with diesel engines contributing the bulk of the problem.

Now a new report by ResPublica has compiled a list of ways that city councils around the UK can help. The report argues that: “The onus is on cities to create plans that can meet the health and economic challenge within a short time-frame, and identify what they need from national government to do so.”

This is a diplomatic way of saying that current government action on the subject does not go far enough – and that cities must help prod them into gear. That includes poking holes in the government’s proposed plans for new “Clean Air Zones”.

Here are just five of the ways the report suggests letting the light in and the pollution out:

1. Clean up the draft Clean Air Zones framework

Last October, the government set out its draft plans for new Clean Air Zones in the UK’s five most polluted cities, Birmingham, Derby, Leeds, Nottingham and Southampton (excluding London - where other plans are afoot). These zones will charge “polluting” vehicles to enter and can be implemented with varying levels of intensity, with three options that include cars and one that does not.

But the report argues that there is still too much potential for polluters to play dirty with the rules. Car-charging zones must be mandatory for all cities that breach the current EU standards, the report argues (not just the suggested five). Otherwise national operators who own fleets of vehicles could simply relocate outdated buses or taxis to places where they don’t have to pay.  

Different vehicles should fall under the same rules, the report added. Otherwise, taking your car rather than the bus could suddenly seem like the cost-saving option.

2. Vouchers to vouch-safe the project’s success

The government is exploring a scrappage scheme for diesel cars, to help get the worst and oldest polluting vehicles off the road. But as the report points out, blanket scrappage could simply put a whole load of new fossil-fuel cars on the road.

Instead, ResPublica suggests using the revenue from the Clean Air Zone charges, plus hiked vehicle registration fees, to create “Pollution Reduction Vouchers”.

Low-income households with older cars, that would be liable to charging, could then use the vouchers to help secure alternative transport, buy a new and compliant car, or retrofit their existing vehicle with new technology.

3. Extend Vehicle Excise Duty

Vehicle Excise Duty is currently only tiered by how much CO2 pollution a car creates for the first year. After that it becomes a flat rate for all cars under £40,000. The report suggests changing this so that the most polluting vehicles for CO2, NOx and PM2.5 continue to pay higher rates throughout their life span.

For ClientEarth CEO James Thornton, changes to vehicle excise duty are key to moving people onto cleaner modes of transport: “We need a network of clean air zones to keep the most polluting diesel vehicles from the most polluted parts of our towns and cities and incentives such as a targeted scrappage scheme and changes to vehicle excise duty to move people onto cleaner modes of transport.”

4. Repurposed car parks

You would think city bosses would want less cars in the centre of town. But while less cars is good news for oxygen-breathers, it is bad news for city budgets reliant on parking charges. But using car parks to tap into new revenue from property development and joint ventures could help cities reverse this thinking.

5. Prioritise public awareness

Charge zones can be understandably unpopular. In 2008, a referendum in Manchester defeated the idea of congestion charging. So a big effort is needed to raise public awareness of the health crisis our roads have caused. Metro mayors should outline pollution plans in their manifestos, the report suggests. And cities can take advantage of their existing assets. For example in London there are plans to use electronics in the Underground to update travellers on the air pollution levels.

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Change is already in the air. Southampton has used money from the Local Sustainable Travel Fund to run a successful messaging campaign. And in 2011 Nottingham City Council became the first city to implement a Workplace Parking levy – a scheme which has raised £35.3m to help extend its tram system, upgrade the station and purchase electric buses.

But many more “air necessities” are needed before we can forget about pollution’s worry and its strife.  

 

India Bourke is an environment writer and editorial assistant at the New Statesman.