Here’s a thing. I was preparing a long piece about the current NHS reforms, exploring whether the government’s changes are really the end of the NHS ‘as we know it’ or whether they are an administrative rearrangement that stands a decent chance of improving the service. I drafted a letter to the press after some madmen advocated marketising our health service, as follows:
Mr Brancher’s argument (Times March 7) that competitive markets are a good way to deliver health care has been rejected by almost all economists who have considered the matter, including Nobel laureates like Kenneth Arrow and Paul Krugman. A market approach needs an informed consumer: but we don’t have the knowledge to distinguish between medical treatments. There are, in economist argot, huge asymmetries of information between consumer and producer. A market would be unable to stop over-treatment from profit seeking hospitals and doctors. Unlike consumer good purchases, costs would be uncertain. A market would be unable to deal with the rich and healthy opting out, and insurers would discriminate, leaving the sick, poor and old with inferior care. Administrative costs would climb to American levels. The most recent authoritative study concluded that “in cost-effective terms, i.e. economic input versus clinical output, the USA healthcare system was one of the least cost-effective in reducing mortality rates whereas the UK was one of the most cost effective over the period”.
The US citizen spends twice as much as the UK on a health care system that depends on the competitive market, and dies younger. What madness is it that leads us down that path ?
A friend living in Israel was not so sure. He replied:
Well, we have a competitive health service here in Israel. The four big competitors are Clalit (General), Leumi (National), Meuhedet (United) and Macabbi (Macabbi). A citizen is more or less obliged to belong to one of them. If a member wants to change service, its a no-fuss, almost no charge, no embarrassment procedure. The general public are by and large well-informed and have strong views on all aspects of the service. There are service hospitals, government hospitals and private hospitals and clinics of all sorts, and dentists and what not.
Some notable exceptions. Skin doctors, for example, seem to be in very short supply.) I get my pills and equipment at a very subsidised cost. Elective surgery (yuch – twice) and first rate treatment.
All aspects of the services are obsessively covered in the press. I’d say that by and large the public have access to useful knowledge. My access to my doctor(s) is almost unlimited and quick. I’m not saying that its perfect. But the system is not bad at all and has done me and mine very well indeed for a moderate cost over 35 years. I’m covered for trips abroad at a very reasonable cost. Given a choice of seeking treatment in the UK, the USA or Israel, I’ll take Israel every time. Before you make a blanket condemnation, take a look at Israel’s competitive medical services.
Which all leads one to ask – what do we mean by a national health service ? To me, it covers four essential elements. Firstly, treatment should cover everyone in the population. Secondly, it should be free – or nearly so – at the point of use. Thirdly, the quality of treatment should be comparable wherever you live. Fourthly, it should be substantially taxpayer funded. I responded in these terms when the twitterocracy was bemoaning the end of the NHS because of competitive tendering for some services. I don’t think that a health service can only fulfill my criteria if I is a centrally run nationalised industry: I had my knee seen to by a private contractor a year or so ago, and it was a quick, quality service. On the other hand, I do not think that we must accept on trust any market driven neo-liberal rip-off that directs funds to the private sector.
The reason I am suspicious is that this is the first government I have ever lived under that I thought was a rip-off. I’ve lived in the UK since 1945, so have endured/enjoyed Tory Prime Ministers from Churchill to Cameron, with many stops in between. I have not agreed with them, but in the past I have felt that even right wing governments were genuinely, if mistakenly, taking measures that they felt were best for the economy and for UK citizens. It now seems that measures are taken simply to enrich friends of the government. George Osborn is happy to take an emergency flight to save the City of London from EU regulations, in a way he would never do about (e.g.) workers’ rights or manufacturing investment. Bank bonuses seem sacrosanct at a time when my daughters – nurses in tough jobs – have had no pay rise for three years. So NHS changes from the present lot should be worrying. There is a disturbingly large number of MPs and peers who will profit personally from the NHS commissioning changes. I think that should actually be illegal – to me, it’s more offensive that making a profit on a second home in London.
Which – here is the personal touch that all good bloggers and columnists have to include – leads me to my recent experience. I woke up two nights ago with agonizing back pain, and started vomiting. This went on all night, and I was too sick to keep down any analgesic. It was awful: my wife got some pills from the pharmacy that improved things a bit but finally I gave in and range the NHS direct line on 111. There have been some adverse reports on this service recently, but they were OK for me. They collected the essential info and got a doctor to call me back. He made a swift analysis, and arranged for me to be seen at the out-of-hours GP centre at Northern General Hospital inside an hour. The treatment there was prompt and (seems to me) accurate – renal colic, basically kidney stones. I got the drugs I needed and good advice, and it was all free.
Samuel Pepys had bladder stone, and opted for an operation without anaesthetic. Having had a dose of how stones make you feel for just hours, I can understand his choice. He recovered well – you can get the details in Claire Tomalin’s wonderful biography – probably because he was the first patient of the day, and so had clean sheets and instruments. Nevertheless, for the rest of his life he celebrated the anniversary of the operation with a banquet with friends.