Wednesday, August 5, 2009

A letter from the UK about their health care system

From Rick Ford, Floridians for Health Care:

A friend of mine recently wrote to a friend of his in England asking the following questions about the British National Health Care system and received the response below. It is educational reading for everyone interested in a nationalized single payer health system and has useful information in answering the Republican attacks on the so-called “socialized medicine” system in England. Most of the current problems in the British system are a result of Margaret Thacher’s efforts in the 1980s to involve private for profit insurance companies in the system and to cut spending on health care.

Dear Chris,
America is in the process of trying to improve health insurance. The Republicans keep saying that "you can't do that because it would lead to socialized medicine, which has failed in England and resulted in long lines for treatment and surgery." I understand that 20 years ago there were numerous delays. If you have the time would you please straighten me out on how good (competent doctors, adequate medicines and only reasonable delays in scheduling surgery) is British health insurance?

Dear Steve,
Of course socialized medicine has not "failed" in UK. The original nationalisation of the NHS back in 1948 by the post-war "very leftie" Attlee Gov't (along with all the energy + transport industries) was huge leap in both social progress and fairness, and gave us a health service which was the envy of the known world (+ the high taxation levels to pay for it and all the other nationalisations). The key ethos/creed is healthcare delivery by a non-profit system according to need, not out of individual ability to pay, and it is dearly cherished by the British people as the mark of a truly civilised society. The costs are paid by general taxation which is levied more or less in direct proportion to ability to pay - surely the fairest of systems (though nevertheless still never popular!). There is a consensus among nearly all advanced developed countries that a national health system paid for out of general taxation is by far the fairest and most cost-effective method of delivery, and there is general amazement in Europe at the US system which is seen as very "backward", socially divisive and hugely expensive (about a factor of 2, I think) while failing to "deliver" for the poorer sections of your society. Vicious Republican opposition to past political attempts to introduce a fairer system are seen over here as the worst examples of "neanderthal red-neckery".

The basis of the UK system is that the limited (though "generous", by standards of pre-1980) healthcare funding was limited by rationing of the total budget, with committees of senior doctors deciding how to split said budget, with the noble intent (not always achieved) of relatively equal funding per 1000 patients in all geographic areas. All decision-making was in hands of experienced medical specialists rather than managers (vs. see below). One detailed debate that has been going on "for ever", as technical specialisms have increased, is how best to provide care for people in sparse rural areas and how far it is "reasonable" for people to travel to hospital (in the UK, this debate gets quite "heated" re. distances of 20 miles!), while clearly it is both more cost-efficient and technically better to concentrate specialists/expensive equipment, e.g. cancer care , in large specialist units.
Two things have happened over the last 30-odd years that have led to questions being raised on this long-held philosophy:

1. On a global basis, the rate of improvement in high-cost medical technology of all types, and the resulting public demand for them, has now accelerated so fast that the potential demand for healthcare funding has now become effectively "infinite" and un-affordable, so it has become strongly budget-limited. This is a big headache for all health systems, not just socialised/national ones.

2. From 1980, Mrs Thatcher bravely dared to "think the unthinkable" about alternative, more 'US-style' funding mechanisms due to her perception of "waste" in the existing system and her blind/ simplistic (I'm tempted to say 'childish') faith/dogma (often with very little evidence) that private sector-style market mechanisms would improve efficiency of delivery. She had a belief that NHS consultants were arrogant, unmanageable and unfit to manage financial budgets. This idea was, and still is, hugely unpopular with the British people, to the point of massive public demonstrations (near-riots). The Labour opposition coined the phrase "the NHS is not safe in their hands" and it has stuck and become part of the UK's political language ever since. Nevertheless, (despite being eventually "de-throned" by her own party as "an out-of-touch liability"), her ideas have unfortunately become pervasive/near-universal in the modern British political class. New Labour , despite its 'brand-name' (which is all it is), is actually "new Conservative" in policy terms, and some of both Tony's and Gordon's policies have been to the 'right' of Thatcher!

Anyway, Thatcher and Major in their own time introduced (without public majority consent) a sort of "back-door creeping privatisation" into the NHS. We had always had a very small private health sector (Harley Street etc), but she legitimised a regime of separate US-style insurance-funded private hospitals which now handle maybe 10% market share at the "top end", including treating rich foreigners. These have syphoned-away some of the best doctors from the NHS, to the disgust of the rest of us. Arrangements were legitimised for many NHS consultants to spend a small part of their time in the private hospitals, or even treating private patients in spare NHS beds. The majority of the UK citizens who don't/can't use these regard them as an unfair system for "fat-cats", (in opposition to the central NHS ethos), that they would rather were abolished. We have just had a 'landmark' decision, in the TV news this week, that donor organs for transplants (these are given freely by donors in the UK) are not to be made available to these private hospitals, as there is a perception (which I share) that rich people are "jumping the queue".

Thatcher massively reduced the level of UK taxation, under the banner of "saving waste", but in reality by cutting public services everywhere, including massive real-terms cuts to the NHS funding. It is these cuts, not the basic system, that led to long waiting times for treatment in the 1990s. She made even larger % cuts in nurse and doctor training, leading to major shortages of them ever since (10-20 year cycle), the consequences of which we are still struggling with, including the 'unedifying spectacle' of one of the World's richest economies 'poaching' 10,000's of these staff from poorer countries. One gets a superficial feeling that non-English staff are now a majority in the NHS, with English speaking difficulties leading to a widespread erosion of patient trust in their competence.

One of her biggest changes was a total revolution in the NHS structure. This was broken up into a "pseudo -market" structure of individual "Hospital Trusts" with their own separate non-profit budgets. This required the employment of new class of Business managers (many outsiders from private industry) placed over the doctors to run said budgets - hugely unpopular both inside and outside the service. Their numbers and pay are actually small (less than 11% of total budget, much less than in private industry) (but blown up out of all proportion by the British press), but the irony is that this policy which was designed by her to reduce 'waste' is widely seen by the public as introducing an extra layer of wasteful, unproductive bureaucracy! It has also 'thrown into sharp relief' for the public the fact that provision is budget-limited ('rationed'), which has caused great opposition/controversy. As a result, despite the huge (nearly X2) NHS funding increase achieved by Tony Blair, there is now a large voluntary charity funding sector that 'tops-up' official funding to provide extra facilities such as MRI (Cat-scan) machines, cancer units, medical R&D funding, hospices and helicopter ambulances. Put another way, a sizeable proportion of the UK public think the Gov't doesn't spend enough on health and 'vote with their feet'.

These non-profit corporate Trusts operate under a loony "pseudo-market", imposed by the Gov't to try to drive up care standards by a "carrot-and stick" combination (mainly stick!). They (the business managers) get marked against "star ratings", with financial penalties to the Trust and them if they fall 'below-par'. This seems totally illogical to me - if a Trust is failing to deliver, what it needs is more funding, not less! Worse sill, the Gov'ts (especially New Labour) have dabbled increasingly in "micro-management" by setting very targets for very specific sub-activities like cancer-treating waiting times etc. These have been widely criticised for "headline-chasingf spin" and for unreasonably distorting internal budgets and management 'attention'/concentration, "over the heads" of the judgement of doctors, and of displacing a culture of caring for patients with a 'paper-trail' of chasing management/cost-control targets. One Trust was recently criticised for above-average patient fatalities over several years due to this kind of thing 'taking its eye off the ball' - no laughing matter, and probably just the tip of the iceberg. This system is now so unpopular withthje press that David Cameron (Conservative leader) now regards it as 'a vote-winner' to offer to withdraw it if elected. These Trusts now routinely poach staff (especially scarce Consultants) from one another.

Another major private-sector involvement started by Mrs Thacher is that nearly all investment in new hospitals since (which has been massive) has been by the profit-making private sector (via special "new-vehicle" project companies, many Consortia) - it's called the Private Finance Initiative (PFI). This is hailed as a "success" by all gov'ts both Conservative and Labour. It has certainly unlocked massive private capital inflow. However it's a 'big con', because the contracts all involve guaranteed return on investment (ROI) at 'crippling' rates over the next 20-30 years, locking-in future gov'ts to their repayment at high effective ROI rates irrespective of how the economy's doing (like now). These have been widely criticised by those economists "in the know" as a very bad deal for the taxpayers and of very high profit/ridiculously low risk for the companies.They are paying for fancy CEO bonuses on a "no-lose" deal, among other things.

Gordon Brown is still besotted with the private-sector and is now making noises about expanding private-sector service contracts in the NHS, which could even extend to 'commissioning'/managing healthcare delivery.This talk is extremely unpopular with the public.

We had/have a huge on-going public scandal about lethal hospital "super-bug" outbreaks of MRSA, C. Difficile, etc., due to the blatant shortcomings of low-calibre private-sector ward cleaning staff working on totally inadequate "cost-cut" budgets (compared with former NHS direct-labour under close direct supervision by medical staff), coupled with a very high "bed turn-over/occupancy" and a lack of isolation facilities, both due to other cost-cutting. I have direct experience, when my brother in law was lying dying in a coma for several months, there were visible long-term un-cleaned stains on both floor and bedding, and we were invited to bring in extra pillow for him due to "a pillow shortage" caused by cost-cutting to meet targets! (-sounds more like Baghdad than Birmingham). These stains would simply never have occurred back when I was serving briefly in a hospital lab way back in 1968 - cleaning was in the hands of trained professionals and rigidly supervised.

So in answer to your question, give me the good "old-fashioned" pre-1980 UK NHS system any day. All it requires is a voting public honest enough to vote-in the taxes big enough to fund it - at a significantly lower per-person cost to the current US system. (By the way, for comparison, the current cost for a NHS medication prescription sufficient for up to a month is a flat-rate 7 pounds (say 10 dollars), with further discounting for those on continuous medication, and lots of 100% exemptions for poorer/older citizens). You're all paying for it one way or another.


No comments: