Aneurin Bevan, the father of the NHS, meets a patient at Papworth Village Hospital in 1948. (Photo: Edward G Malindine/Getty Images)

All this week, Splinter is talking to healthcare experts about what advocates for a single payer system can learn from the National Health Service in my home country, the United Kingdom. Yesterday, we spoke with professor Martin McKee. Today, we’re talking with Rebecca Givan, an associate professor at the Center for Work and Health at Rutgers University, where she studies privatization in the NHS, labor relations and unions.

Libby Watson: What’s the difference between the NHS and single payer?

Rebecca Givan: The NHS is single payer, single provider. Single payer would mean multiple providers which could be public or private, and single provider means the government is the provider as well as the payer. Single payer means the government is purchasing services from a number of providers, which might still be private.

LW: The NHS is often used as a scary boogeyman by conservatives in the US, saying there are long wait times or poor conditions in NHS hospitals. Is that fair? What are the main problems with the NHS?

RG: The main problems with the NHS have been underfunding problems, which lead to capacity problems. Any system has to be funded properly or it won’t have enough capacity, but the fact is that the NHS is able to make decisions on need rather than based on profit.

LW: In my hometown in the UK, the local authority has often tried to end certain services at the hospital, like maternity services—there’s this idea of creating one big hospital per area that can do everything and closing local hospitals. How can that be avoided in designing an American system?


RG: I think making decisions based on need, rather than the other incentives of insurance companies and providers, is basically a better way to make decisions. You can decide that it’s important for everybody to have, let’s say, a trauma center or a place to give birth within a reasonable distance of their home, even if that’s expensive, the same way we do with fire departments. We believe everybody should have a fire department within a reasonable distance even though there are places where the population is more spread out & it’s more expensive.

LW: So why have those decisions—the lack of willingness to allocate the funds—been made in the UK?

RG: I think it has to do with the public budget and unwillingness to spend money, particularly when there’s a sort of general sense in the air that the right thing to do is keep corporate taxes low and incentivize corporations. There’s been an unwillingness to spend money. The general cost of healthcare has gone up as people are living longer and as technology has advanced, so more treatments for more conditions are available, when people would have earlier just died of those treatments. The most cost effective thing to do is always to let everybody die; that’s very very inexpensive, so a society has to decide whether and how much it wants to stop short of that, and what money it’s willing to spend. It’s always cheaper to let as many people die as possible.


LW: What’s your take on the New Labour approach (between 1997 and 2010)—bringing elements of privatization, like public-private partnerships, as a way to supposedly save money? How did that work out?

RG: The private provision has generally been fairly mixed. It’s a way to increase capacity by spreading out the cost, so if you want a new hospital, instead of having to have the public sector foot the bill this year for a new hospital, you can spread out that cost over 30 years, which makes it appear more affordable, but unfortunately means the for-profit private provider has the first call on any funding that you have and so the ability to be flexible and increase capacity goes away.

The jobs tend to be worse, although that’s not uniform, but if you’re hiring people like technicians and support staff they often don’t have the protections of public sector workers; they may be temporary workers for very low pay, without good background screening, so the work has been potentially degraded. Having an unstable inconsistent workforce can lead to all kinds of problems that are ultimately healthcare problems, like cross-contamination and infection. Having a stable, long-term workforce is something the public sector does really well and private providers tend to less well. But it’s primarily an accounting move: let’s move this off of the public sector bill now and pay for it spread out over time.


LW: What about the changes brought in by the Conservative government (since 2010)?

RG: They focused on internal markets and internal purchasing, the idea being that even though it’s a public-run system, if you believe that market forces are the answer and provide more efficiency, then you’ll provide a lot of internal markets and internal choices, sometimes administered by local administrators and sometimes administered by doctors. That’s created a lot of bureaucracy and introduced market incentives, which are generally problematic in something like healthcare, which is not really appropriately administered based on profit and competition.

I think just trying to push the requirement to save money onto doctors and onto patients, instead of letting doctors use their professional expertise to make decisions, asking them to make decisions according to budgets. To some extent, not anywhere near as bad as in the US, but at the margins requiring them to consider budgetary factors rather than their medical expertise.


LW: How can that be avoided in the US, where the desire to consider market forces and balance budgets is even stronger?

RG: I think it’s going to be very difficult because the single payer system will include a good amount of profit, whether we’re talking about for-profit providers, non-profit providers which in some cases act very much like for-profit providers, but also if we’re not regulating drug and device companies the way they are in other countries, and probably supplemental insurance will still play a role. There’s a lot of opportunity for decisions to be based on market factors rather than on good health, but I think if we can do things like encourage co-operative providers rather than big non-profits, things like community based health centers, federally qualified health centers, that really do work as the best interest of the highest need patients. I think we will have to regulate drug and device makers a lot more, because right now as we see in the opioid epidemic, the profit incentives and lack of regulations on advertising and marketing mean that we’re getting terrible health outcomes. I think if we’re going to prioritize better health for everyone, we’re going to need to regulate a lot of aspects of the system, not just one aspect.

LW: That seems to be part of the hurdle—even single payer advocates acknowledge the problems with American healthcare go beyond how it’s paid for, and when you try and tackle how it’s paid for, it’s hard to do that without tackling all this other stuff too.


RG: I think I’d say that a Medicare-for-all type system, if that becomes the most viable proposal, is a big improvement from what we have now but it’s not a cure-all without other forms of regulation and reform.

The fact is that the Medicare population is the population most satisfied with their healthcare in the US, and they have the best outcomes. The only portion of the population that has decent health outcomes in the US compared to other countries is the population that is in Medicare, which is the single payer system. Even a flawed single payer system is better than what the rest of the population has now.

The important thing, I think, to keep in mind, is that you don’t want people to be avoiding healthcare because it’s too expensive. That almost always leads to higher cost later. Even if you’re talking about people not getting their teeth cleaned, that leads to more expensive dental needs and possibly medical needs beyond their teeth later, or whether you’re talking about people getting a physical so they can get screened for cancer and diabetes risk at a point where it’s inexpensive to treat, rather than waiting until it becomes an acute need and much more expensive to treat.


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