Sense and nonsense in the UK-US health debate

Goodness, Obama’s health plans have spurned a hornet’s nest of nonsense on both sides of the Atlantic. In the US, the plans are apparently being portrayed as an attempt to bring UK-style healthcare to America, and a mass of misinformation about the NHS is appearing alongside including claims that old people’s care is limited by death-panels. In the UK there is the claim that somewhere between 40 and 50 million people have no access to healthcare at all in the US as they lack insurance, and that those mean Americans should stop being rude about our health system. Things get worse when Conservative MEPs start talking about the NHS as a 60-year-old mistake, and their leader feels the need to leap to the health service’s defence and try and reclaim his political party as being the best guardians of the NHS. I’ve even seen claims from Labour politicians that to insult the NHS is to be unpatriotic.

How much sense is there in all of this? Well, to start with, we all have to be a bit more honest about our healthcare. The NHS is good at providing (relatively) cheap healthcare, which is free (for the most part), universal (so long as your British), and comprehensive (so long as you don’t mind waiting and don’t want to choose the latest care). The US is good at providing the very latest healthcare in expense-looking healthcare facilities, provided that you have the right insurance package, and you don’t mind America, as a whole, paying getting on for a third more than most other nations (in terms of healthcare as a % of GDP). Both systems have their merits and their problems.

The problems with the NHS are traditionally expressed in terms of poor facilities and longer waiting times. More recently they have been expressed in terms of delays in getting access to the latest drugs and technology. The Labour government have attempted to address the first two problems, poor facilities and longer waiting times, through the PFI (private finance initiative) programme and the NHS Plan. PFI has led to a rash of new hospitals being built – this in itself is a pretty good thing as a great deal of the UK’s health infrastructure was getting rather old, and that last round of hospital building on any scale occurred in the 1960s and 1970s. However, PFI has been questioned because it may not offer terribly good value for money for the taxpayer long-term, and the private sector building and maintenance contractors who have been involved have often got extremely high returns for building for the government, with little attached risk. The NHS Plan was about improving UK healthcare in return for an increased healthcare investment, raising healthcare expenditure as a proportion of GDP to European averages, but demanding particularly that waiting times come down. And they have – dramatically so. Waits are not as short as available through private healthcare in the US, but are much, much better than they used to be across most treatments. And of course, there is still the option of purchasing private healthcare in the UK if you wish to be seen quicker – critics of the NHS from across the Atlantic often seem to forget that we have a private healthcare system too, should people wish to take out insurance or pay for it directly.

The US system also has problems. The uninsured aren’t left completely without access to care, but their options clearly are limited. I wouldn’t want to have a long-term condition of any kind (and around 1/3 of people are generally estimated to have a ‘chronic’ condition of some kind or another) without insurance in the US. Those lacking insurance have access to emergency rooms and to some basic primary care, but not a lot else. So why, given that such a lot of people have access to basic healthcare only, does the US system cost so much? Well, they seem to pay a lot more for drugs over there because those with insurance demand access to the very latest treatments, and the very latest treatments tend to be only incremental improvements (if improvements at all) on established, cheaper drugs. There are big breakthroughs from time to time, but they are few and far between. Equally, those with private cover often want access to the latest technologies, which again don’t come cheap. In the UK decisions about whether to pay for access to these drugs and technologies would be far more closely monitored and controlled, and this might mean that particular drugs and technologies would be denied. But this doesn’t mean that patients would be denied treatment – but that they don’t necessarily get the treatment that they might be demanding. There is a big difference between no treatment and cost-effective treatment. This isn’t to say that NHS’s approach is correct – but if you don’t like it you can still take out private health insurance and try and get the treatments you want that way instead.

Equally, there are other, well-documented problems in the US. Doctors have incentives to over-prescribe and treat that tend to be minimised in the UK (although not removed completely) and getting treated, even if you have insurance, can be complicated because of the sheer complexity of many insurance policies and programmes that may have opt outs for the insurer for a range of reasons. In comparison the UK provides comprehensive care – it will provide some kind of treatment – but again there may be a wait and it may not be the treatment you wanted. So, a bad knee might lead to you receiving physiotherapy after a wait rather than chiropractic immediately – the latter is not widely available in the UK because it is not regarded as having proven itself adequately in clinical trials.

So both systems have their advantaged and disadvantages. I think the US can learn a thing or too about providing more treatment at lower cost than the UK, and the UK can certainly learn something about providing better healthcare service from the US. Neither is intrinsically a better system, but the UK system does at least treat everyone, and so to dismiss it without thought is a significant error.

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