There seems to be no argument when I report England’s National Health Service (NHS) is in need of major surgery. The evidence is difficult to ignore: The NHS is plagued by a political bureaucracy, endless delay, low-quality care, and poor medical outcomes.
NHS vs. HMO
A study produced by the Institute for Global Health at the University of California concluded the Kaiser-Permanente HMO in the United States and Britain’s NHS have similar resources, but the HMO performs substantially better. (See “U.S. HMO Beats Britain’s NHS,” Health Care News, March 2002.)
In particular, Kaiser patients have quicker access to both primary and secondary care doctors. In other words, the widely held notion that the NHS offers “universally available” care and is “remarkably efficient” may be wrong.
Comparisons between systems are always difficult, but the reviewers at the British Medical Journal conclude the results could not be explained away by differences in the two populations. They conclude the Kaiser HMO health care arrangement is superior to the NHS.
Kaiser may excel because primary and secondary care are better integrated and the whole system is better managed; because it has hospital stays shorter than those in the NHS; because the U.S. health care system has developed much better information technology; and because of free-market competition.
Wake Up or We Quit
As I documented early in this series, members of the medical profession, on average, were the most disenchanted with the NHS arrangement. This does not suggest British consumers are any less upset with their socialized medicine. It just happens the medicine men and women are closer to the problems, are clearly more vociferous, and make for good copy in the English press.
At the heart of the current reform debate is the Labour Party’s insistence the basic cause of the NHS’s failings is inadequate funding. Those who are on the frontlines of health care think otherwise.
When the Labour Party swept into power, medical professionals had high hopes for major reform. Most of them voted in favor of the ruling party believing the NHS would be better off with liberals than with conservatives. And while practitioners applauded the promises, doubt and cynicism have followed the broken word.
Late last year, the British Medical Association sent voting papers to all 36,000 General Practitioners (GPs) in Britain asking them if they would be prepared to resign from the NHS. There was a 66 percent response rate with 86 percent voting in favor of resignation.
Dr. Kevin Ilsley, a GP who works in a group practice in Bromyard, Worchester, stated, “I now say I only enjoy the first 40 hours of my working week and I don’t get much pleasure out of the last 30 hours.” Dr. Ilsley’s workload is so heavy he has given up his duties as an assessor of GP training practices.
Dr. Anita Goraya, a GP in Friern Barnet, talks of patients’ rising expectations and her frustration with the NHS. “I had a patient who came to see me about depression. Unfortunately, I am unable to refer anyone suffering from depression for counseling because there is a 17-month waiting list to see a therapist. There are few services locally and the waiting list for the few that exist is preposterous.”
Dr. George Moses, from Hammersmith, says violence in the surgery room is a growing problem. “My partner,” Moses explained, “was assaulted by a patient who received a jail sentence for the offence—that’s how bad it was.” The violence, Dr. Moses believes, is caused by “unrealistic” patient expectations.
According to Dr. John Chandy, consulting radiologist from Coventry and chairman of the Hospital Consultants’ and Specialist Association, “The real danger now is that doctors will leave the NHS and do something entirely different.”
Time for Reform
Liz Kendall of the Institute for Public Policy Research says she believes empowering patients with more information and genuine choice is critical to transforming the system. “It is a disgrace,” she says, “that information is currently the preserve of a few well-connected members of the articulate middle-class when it should be available to all.”
Drs. P. Buttar, J. Halfhide, S. Hunter, J. Reggler of the Independent General Practitioners Association all agree with Chancellor Brown when he says, “the NHS has had its day.” They urge reforms that would move the NHS towards a funding system similar to those in many Western European countries. The crucial difference, they point out, is that most European systems encourage patients to contribute private funds for their medical care. “When people spend their own money,” they say, “they expect and get better quality [health care] service.”
Stephen Pollard at the Centre for the New Europe, writes, “One would think, to judge from the dogmatic belief in the NHS, that no country on Earth was able to provide its citizens with a halfway decent health service. Far from being the only worthwhile model, the NHS is the oddity.”
Pollard points to the major difference between the British model and most of the European Union. “Contrary to mythology,” he says, “spending is on a par with that on the continent. The difference is made up by additional private spending, which continental systems use to promote the choice and the competition between providers which is so missing from our antiquated system.”
“The NHS will never deliver the level of health care our increasingly diverse society demands and expects,” writes Nick Corble, Catalyst Change Consultants. As an advisor to a variety of NHS bureaucracies for more than 15 years, Corble admits, “I have witnessed and, to some extent, aided and abetted a succession of policy changes designed to fix that which is beyond repair.”
Focus on Something Other than Funding
The greatest contribution to the debate over how to fix the NHS may be in the shifting of emphasis from funding to the root causes of NHS dysfunction. However, the dialogue must include freedom of choice, consumers’ rights, and the establishment of reasonable expectations.
Can any system committed to universal coverage of a comprehensive range of free medical care be financially sustained, without bankrupting levels of taxation? The British Medical Journal, along with England’s conservative policy analysts, argue it simply isn’t possible.
In the predictable manner of rationing care to save money, prescription charges appeared soon after the start of the NHS, and coverage of long-term care has been abandoned. Writing in the Sunday Times, editorial writer Martin Ivens says, “[The] NHS services could never meet our expectations. From its inception it has been ‘in crises.’ At the end of the Korean War, demand had to be rationed by charging for teeth and spectacles. Today its shoddy premises, rationed drug treatment, and over-worked staff confound all our consumer expectations.”
One structural change that hasn’t been seriously tried and might well raise a cheer within the NHS itself would be to separate the NHS from politicians. There is a theory, which even we Americans witness almost every day in practice with Medicare and Medicaid, that the most politicized health care plans around the world perform the worst.
The desire to hold onto constituents’ votes, elections every two years, constant changes to the tax code, and demand for instant gratification are features of politics that do not sit well with running a huge and complex service like the NHS or even our own Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration).
It’s the Competition, Stupid
One of the first acts of the Labour government when elected in 1997 was to set the Bank of England free to determine interest rates. It was an unqualified success. Why not do something similar for the NHS? Would not free-market competition enhance quality, accountability, and consumer rights?
Alain Enthoven, the inventor of managed competition and the evolved managed care market, argues competition is needed for improvement. Even though many judge Britain’s flirtation with competition a failure, supporters of competitive markets argue greater privatization has never happened. Politicians can’t risk the political consequences of hospital closures—inevitable when hospitals in a setting of market competition fail to serve their customers.
Increased competition is probably not in the NHS’s immediate future. But the collapse of any portion of the vast NHS empire might stimulate a return to competition, even if in a disorderly manner to start.
No Closure Here
Any good examination and analysis should bring closure to the discussion at its finish. What I thought and intended to be a series, with both a beginning and an end, now appears to me to be an unsatisfactory approach. What we have so far is a beginning with no end in sight.
The NHS is in a state of flux. On the positive side is a growing demand on the part of our British friends and their medical professionals to introduce, albeit slowly, a market-based health care system that responds to consumer demand instead of regulatory demand and introduces greater individual responsibility.
Less encouraging is the difficulty in weaning the entrenched, politically driven health care arrangement from 10 Downing Street. Giving up the political power that comes from keeping citizens trapped in a government bureaucracy will be neither easy nor painless.
The temporary solution—throwing massive amounts of tax money at problems inherent to socialized medicine—will not address the shortcomings of NHS. As such, it seems appropriate to continue this “series” on a recurring basis as the British struggle to regain their health care independence.