The first time I ever appeared in the press it was not for something I wrote. It was a picture of my mum carrying me, about three years old, as she spoke at a rally to defend our local hospital, the Horton General in Banbury, Oxfordshire. For almost my entire life, the local authorities and the national governments, both Conservative and Labour, have repeatedly tried to close or limit maternity services at the Horton, the ward where I was born.
Just this year, the government has succeeded in making permanent its plan to keep the maternity services at Banbury “midwife-led,” meaning there are no obstetricians on staff, and only uncomplicated and “natural” births (with no epidurals) can be performed there. If a birth becomes complicated, a patient will have to be transferred 40 minutes down the road to the John Radcliffe in Oxford. The local Clinical Commissioning Group, a body put in charge of such decisions by the Conservative government’s signature health law, also voted to move immediate care for suspected stroke patients to the Oxford hospital. That adds at least 40 minutes in travel time alone before a stroke patient gets care. Any doctor would tell you those minutes—which could easily turn into hours—are critical in stroke patients.
When the U.K.’s National Health Service (NHS) is brought up in American health reform debates, it’s often to highlight the worst stories, a cautionary tale about the horrors of “government healthcare”: long wait times, poor conditions, hospital closures like those affecting my hometown. That puts advocates for single payer in a tricky position. (The NHS is not a single-payer system, which is the most likely form that universal healthcare would take in the US, but it’s often used as a scary boogeyman by American conservatives anyway.) I hear it all the time: During my year abroad at UCLA, a classmate asked me if “everyone has to go to the doctor in groups” in the U.K..
That’s rubbish, of course, but the existence of these misconceptions makes defending the NHS while acknowledging its problems quite tricky. If there are problems in the NHS—if hospitals are closing and stroke patients are waiting, freezing cold, in the corridors of teeming hospitals—how can I suggest that America should look to it as a model? If I’m livid at the local health authorities when I’m in Banbury, should I be singing the NHS’ praises when I’m in Washington?
The majority of the problems that plague the NHS aren’t problems intrinsic to government healthcare, but instead to the introduction of market-based approaches to healthcare: forcing doctors and hospitals to consider cost when assigning treatments, auctioning off services to the highest bidder, closing services that aren’t “cost-effective.” The main lesson from the NHS for the U.S. is not that government-run healthcare is inevitably bad—it’s that the fight for health justice won’t end when we get single payer. (And we will.)
This week, Splinter is speaking to experts on the NHS and on universal healthcare in general to ask what the U.S. can learn from the NHS, both the good and the bad. Our first interview is with Martin McKee, professor at the London School of Hygiene and Tropical Medicine and research director of the European Observatory on Health Systems and Policies.
Libby Watson: What are the biggest problems with the NHS that can be avoided in designing a single-payer system in the US? For example, in my hometown of Banbury, the local authority keeps trying to shut down maternity services in the local hospital and make people go to Oxford instead—is that something that should be expected under any government-run system?
Martin McKee: I’m not sure I really understand your question. Most of the problems in the NHS stem from the fact that the government is unwilling to spend enough money on it. It consumes vastly fewer resources than the American healthcare system yet gets results that are, in many respects, as good or better. To the extent that it does have other problems, many of these can be traced to the implementation of market-based reforms since the 1980s, adding to the costs of running the system.
The most obvious benefit of a single-payer system is the cost. The presence of multiple payers creates enormous transaction costs, with healthcare providers having to comply with different requirements and produce bills in different formats for each payer. To some extent, the introduction of primary care trusts, and subsequently, clinical commissioning groups, has taken the NHS in this direction. All of this money could be spent much more effectively on delivering patient care.
LW: What were the problems with the reforms/changes enacted by the Blair & Brown governments, and the Tory government?
MM: The concept of the purchaser provider split was fundamentally flawed. In a country like the U.K., or the US, with an aging population whose health needs are dominated by multi morbidity, often requiring input from a range of different services and specialist, it makes no sense to fragment providers. Moreover, given the compelling evidence for investing in public health measures at the population level to reduce the demand for healthcare, there is a clear case for integrating public health and healthcare for a defined geographical population.
A second problem, which Tony Blair inherited from the previous Conservative government, was the private finance initiative, by which the cost of capital developments was deferred long into the future, but at much greater overall cost. This has left many hospitals with unsustainable levels of debt.
As for the reforms introduced by the 2010 Conservative government, the problem here was that they were driven by ideological intention to privatise as much as possible of the health service but the politicians involved were unwilling to spell this out. As a consequence, the legislation was the worst of all worlds. It was confused, contradictory, and essentially unworkable. As a consequence, more recent approaches have sought to integrate care at the level of defined geographies, even though it is arguable that there is no real legal basis for doing so. However, given that the health service is now so toxic for the Conservative party, there is no inclination to revisit the legislation.
LW: One of the biggest things that American conservatives like to talk about from the British system is NICE (the National Institute for Health and Care Excellence)—it’s held up as this kind of horrifying death panel where people are denied the drugs they need to survive. Can you talk a little bit about what the reality of NICE is and what problems it has that could be avoided in the US?
MM: We have a problem with paying for new drugs. The days in which drug companies could launch on the market blockbusters for common conditions, taken by millions of people, for the rest of their lives, have long gone. We now have safe and effective medicines for virtually all of the major common conditions. As a consequence, most new drugs now are for very small numbers of people, such as those with quite specific types of cancer, or perhaps inherited conditions. The former are likely to be taken for only relatively short periods of time. As a consequence, the volume of sales will never be that high. This means that the price charged to treat an individual patient that can recover the costs of investment will be enormous. There is only so much money available for healthcare. Choices have to be made. NICE has developed a transparent, objective means of assessing the value of medicines. Quite simply, it is better to pay for something that leads to a large health gain at low-cost that something that cost a fortune and provides very little benefit for health. From a public health point of view, it would be difficult to justify any alternative view.
Unfortunately, in the USA, any measure that can be portrayed as rationing treatment is used as a political stick to attack what is described as socialised medicine. In other words, NICE became part of the political game being played by those opposed to the Affordable Care Act. Much of what was written was simply nonsense. Moreover, it ignored the fact that, despite the enormous sums that it spends, outcomes for many Americans, and particularly the poor, and African-Americans with chronic diseases are dreadful. So, in both countries, choices have to be made about what treatments should be available for whom. The advantage of the British system is that it is fair and transparent.
“What Can the U.S. Learn About Healthcare From the NHS?” is a series of interviews with healthcare experts that will run all this week on Splinter.
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