English Health Care: Not Your Cup of Tea: Part 2 in a series

Published March 1, 2002

An Englishman I met while in Sheffield was most colorful when I asked him to describe the National Health Service (NHS). In a printable response he said, simply, “Hobson’s Choice.”

He quickly offered me an explanation: Seems as though Hobson was the owner of a stable of horses for hire. He developed a practice of always requiring every customer to take the horse closest to the barn door. When asked by a patron for a different horse, Hobson always replied, “take this horse or take nothing at all.”

“Hobson’s Choice” has evolved, according to Webster’s New International Dictionary, to mean “the apparent freedom to take or reject something offered when in fact no such freedom exists: an illusion of freedom of choice where there is no alternative.”

The Illusion of Freedom

Today, the Labour Party line proclaims the NHS needs an enormous dose of tax money. It has not occurred to Blair and his social engineers that the United States and most of Europe spend so much more on health care—and spend it so much more effectively—because consumers have choices and a right to private spending on health care.

I had firsthand opportunity to witness Blair during his last campaign for reelection. He doesn’t appear to be as socialist on health care as he really is. He walks a different walk, while talking the same old talk. His reform plans have been sliced and diced so many times by the London media, you can see right through them.

The NHS reform measures are, from my perspective, all style and devoid of any consideration for consumer choice and privatization. The doctors, nurses, and businessmen I visited in England made clear that even the newest of the Labour Party thinkers still holds fast to a reverence for a state-run, state-funded system. That sort of tunnel vision creates an environment in which ideas supportive of consumer choice and free-market competition rarely get serious consideration.

The NHS is, as Hobson would have it, “an illusion of freedom of choice where there is no alternative.”

Stephen Pollard, a senior fellow at the Centre for the New Europe in Brussels, agrees. “It doesn’t matter how much you talk about management incentives and the importance of ‘consumer focus,’ or how many businessmen you ask to conduct ‘reviews’: the NHS was created to serve a society where rationing was the norm and the state was viewed as the ideal engine for growth. The rest of us have moved on.

“Labour’s language may have changed,” he notes, “but when it comes to the nation’s health, its mind is stuck in 1948.”

Dysfunctional Bureaucracy

Judith Smith and Kieran Walshe, senior lecturer and senior research fellow, respectively, for the Health Services Management Centre at the University of Birmingham, write, “Governments often regard a degree of medical disapprobation as a sign that their NHS policies are generally heading in the right direction. However, NHS managers have traditionally been stalwarts of public service, implementing government policy because that’s their job, regardless of any personal reservations they may have.”

But the problem goes deeper than NHS managers blindly following their marching orders. Smith and Walshe state, “The truth is that this government has never trusted or respected [NHS] managers. It blames them for the poor state of the NHS (for example, dirty hospital wards and long waiting times in emergency departments) and doubts their competence. While NHS managers are used to being unloved by the public and health professionals, to find that their political masters have little regard for them leaves them isolated and disempowered.”

Leaving Home

One way to manage the ever-present health care queuing would be to take patients out of line and send them out of the country for their medical care.

The European Court of Justice has ruled the British government must provide treatment for patients abroad if it cannot ensure their timely medical care in the National Health Service. In response, the United Kingdom Department of Health has established a program for sending patients to other European countries for treatment.

If implemented, that effort could reduce the waiting lists for care. But it ignores the root cause of queuing and causes legal complications for the patient. Implementation of the program has been stalled, according to a report in the British Medical Journal, over concerns about the availability of legal redress for patients whose out-of-the-country treatment goes wrong.

In the U.K., roughly 90 percent of all medical negligence claims are financed by a government-funded legal aid system. It is the only European country to have such a program in place. But the plan provides coverage only for claims brought in U.K. courts, and therefore usually excludes claims against defendants located abroad. In Germany, by contrast, most people are covered by legal expenses insurance, which they can call on when a claim arises. Most other European countries have a similar system.

Truth Rises to the Surface

The pressure on NHS managers to cut queuing is evident in a new government order to establish a “one strike and you’re out” approach to patients who fail to keep appointments.

Like the “get out of the country” approach, this one ignores the root cause of long queues. Nevertheless, the Department of Health defended the tough approach toward no-shows, adding that mitigating circumstances would be taken into consideration. A spokesman noted: “Patients will see that this makes sense and it has been agreed with patient [focus] groups. If people simply do not turn up without a genuine reason, they will be sent back to their GP [primary care doctor].”

“This is laughable,” said one GP, requesting anonymity, when I asked for an opinion. “This bloody well accomplishes nothing. It just moves the patient from one place in line to another place further down the line.”

Details of the new edict emerged as the National Audit Office (NAO) released the results of an ongoing investigation of hospital trusts, aimed at determining whether they’ve been fudging the numbers when reporting their waiting lists. The NAO is an independent government agency that examines public spending on behalf of Parliament to determine the effectiveness and efficiency with which government bodies use public money.

The NAO issued a highly critical report, accusing nine trusts of “a major breach of public trust” for altering waiting list data to make it appear they had met government-recommended targets. In those nine trusts, 6,000 patient records had been manipulated to make waiting lists look shorter.

The NAO report explains many NHS trusts warranted investigation because a high number of patients have mysteriously dropped from the waiting lists.

Patients may be suspended or removed from lists legitimately if, for example, they become too ill to face a serious operation, get better on their own, seek their own private care out of the country, or die while waiting.

But in the case of many trusts investigated by the NAO, some suspensions were improper and simply designed to make the lists look shorter. The NAO said trusts should be investigated if more than 10 percent of their patients have been suspended from the waiting lists or more than 2 percent of their patients have been waiting more than 12 months.

One of the nine trusts named in the NAO report is the Royal United Hospital in Bath. Until recently, it was run by Barbara Harris, who was promoted to become director of the NHS Leadership Centre, also in Bath. The Centre is intended to exemplify and embody all that is best in NHS management.

Harris recently resigned from th NHS Leadership Centre position after the Commission for Health Insurance issued a report criticizing the way she ran the hospital. While further inquiries into financial management and accuracy of waiting list data at the hospital are underway, Harris will continue to work for the NHS in another capacity.

Next month: Trying to fix the NHS.

For more information …

The National Audit Office’s investigative report, “Inpatient and Outpatient in the NHS,” is available on the Internet at http://www.nao.gov.uk.