Healthcare reform is on the agenda in the US. It’s a contentious subject, with the UK NHS referred to, often pretty pejoratively. Can the US learn anything from the NHS?
First of all, the systems are radically different. Both have their strengths. It’s a nice feeling to know that every UK citizen has the right to treatment. There has been a lot written about the problem this brings in terms of long waiting lists, lack of choice and lack of access to facilities and treatments.
Waits in the UK, however, have fallen dramatically. We have a framework whereby increased government investment has resulted in falling waiting times (Labour have got something right over here), and although everyone still doesn’t get treated when they would ideally like, people, on the whole, get treated reasonably promptly. Certainly, treatment for life-threatening diseases like cancer have speeded up considerably, and aren’t a million miles from what you might expect in the UK.
In the UK primary care physicians (the main access route to specialist treatment) are now obliged to offer choice when referrals is made. However, the evidence tends to suggest that most patients don’t really want it – what they want is to be reassured their local hospital is a good place to go to, and that they’ll be seen promptly. On both fronts things have got a lot better. In terms of choice of primary care physician, governments have been trying to get the public to choose more carefully since the 1980s with little success. It seems we don’t really want choice there.
In terms of lack of access to facilities and treatments, the NHS has a comprehensive care system, which means that it guarantees to treat you, but not necessarily with the treatment that the patient demands. Treatments are approved for the NHS by the National Institute for Health and Clinical Excellence (NICE), and then has to be affordable locally through the budget available there. But if you’ve got something treatable, the NHS will offer to treat you.
So the NHS treats people pretty quickly, offers choice (even if the public don’t seem to want it) and will treat you, although not necessarily with unproven or very expensive treatments. And of course, if you don’t like it, you can always take out private health insurance – although most of those working for our not-for-profits and private healthcare providers also tend to work for the NHS as well.
What’s remarkable to a non-US citizen, is that your public health system costs you nearly as much as our NHS, but provides a much lower standard of service, and much less comprehensive care. That makes us wonder what on earth you’re doing with all that money.
And then there’s the private sector over there. You spend more than any nation on Earth for healthcare, and yet the health outcomes of your nation, according to bodies such as the WHO, aren’t that good. This is because of the 40 million plus uninsured, but also because the care you get is extremely expensive in the private sector, and there still seem to be a whole range of what seem to be perverse incentives leaving to over-prescribing and the use of expensive unproven health technologies.
If you’re going to spend as much money as you do on healthcare, it surely makes sense for you to do it efficiently, and the relationship between cost inputs and health outcomes suggests you’re not really achieving this at the moment. In contrast, the NHS doesn’t do at all badly – in simple input-outcome terms it does a great deal better than the US system. Somewhat extraordinarily given how productive the US economy is compared to the UK, we do healthcare a lot more efficiently than you.
I appreciate that talk of an extension of public healthcare in the UK gets allegations of socialism and even communism, and so doesn’t fit with your prevailing ethos too well. I guess the question is whether you want to continue to pay so much more for your healthcare system than the rest of the world, and whether there is a justification for treating healthcare as a right, as we do in the UK. John Rawls’ idea of the veil of ignorance is useful here. If you were in a position of not knowing which position you were to adopt in society – that you were about to be born to a family in the US say, but you didn’t know who you were to be born to, but you had a say in what kind of health system your country would have, what would argue for? You could take the chance of being amongst the lucky insured, but that carries risks if you’re unlucky. Surely it would make sense to argue for a healthcare system that allowed private practice for those that could pay for it, but guaranteed care for those that could not? Or perhaps I’ve been living too long in the UK.
Equally, it seems to me that lots of lots of choice is not necessarily something to aspire to in healthcare. Barry Schwartz’ work suggests that people, before they contract a serious illness, claim that they want a choice in treatment, but upon actually contracting that disease, change their mind pretty quickly. I don’t have the medical knowledge that a doctor has, and more disturbingly, am not sure I could tell a slick medical fraud if I came across one. I could ask for a second opinion, and try and assess who was telling the truth, but have to respect, even then, that I may get it wrong. When it comes to my healthcare, I want a doctor who gets it right on my behalf, not to have to choose myself. I think choice in healthcare is over-rated.
I’m aware that the NHS gets things wrong too. People aren’t encouraged to take full responsibility for their health as they know they’ll always be treated, but I’m not convinced that people behave any more irresponsibly in the UK than they do in the US. A great deal of our buildings need refurbishment, and our equipment certainly isn’t as up to date as yours. But you can get better buildings and get access to more expensive machines if you go private.
Perhaps it’s time for the US to get over it’s problem with public healthcare, and focus on getting a great deal more for the great deal you already spend on it. What the UK can teach the US is how to provide a public-funded healthcare system that everyone can access at a remarkably low cost. I’m not suggesting that you take away your private healthcare system (although you really do need to stop it costing you so much). But you could get a great deal more care for the amount you already spend on your public system.