Britain should look to Europe to fix the calamitous NHS monopoly
Germany and Switzerland provide universal healthcare but with less waste and better results
On most measures, the National Health Service is one of the worst healthcare systems in the advanced world — perhaps the very worst. It has had 70 years to get it right but patients continue to wait longer for treatment than in other countries and do not have the benefit of the latest drugs or up-to-date equipment.
Thousands of people – probably more than 10,000 – die unnecessarily every year as a result. They would not die if they lived in, say, Belgium, the Netherlands or Germany. In the UK the proportion of people who remain alive five years after being diagnosed with lung cancer, to take just one example, continues to be lower than in other advanced countries. The unnecessary deaths regularly estimated for various types of cancer are undoubtedly replicated among other fatal illnesses such as heart disease, where measurement is more difficult.
Most international institutions, including the OECD, agree with this assessment. There is one think tank, the Commonwealth Fund, based in New York, which thinks the NHS is excellent but its study does not primarily measure health outcomes. When one deals with this vital issue, the Commonwealth Fund, too, agrees. This gave rise to the grimly amusing Guardian assessment of one of its studies: “The only serious black mark against the NHS was its poor record on keeping people alive.”
Every now and again, someone comes along who reckons to have “the answer” or at least “an answer”. Only yesterday, Prof Keith Willett, the NHS’S medical director for acute care, argued that things would be better if only consultants – frustrated that their operations had been delayed – would spend their wasted energy ensuring that bed-blockers are enabled to get out of hospital. He is the latest in a long history of politicians, doctors and others who have come up with NHS “answers”. This goes back to the 1970s at least, when Sir Keith Joseph – then health minister – thought that management consultancy would make the NHS efficient. Much complexity and no improvement resulted.
The NHS cannot be made into a good healthcare system by any clever initiative. It is like tinkering with your bicycle to try to make it into a car. The NHS problem is structural. It is a monopoly. The government rightly has laws against monopolies in commercial life because they tend to be inefficient and serve the public badly. That is the NHS in a nutshell.
We do not have to go on like this. We can learn from countries in Europe and elsewhere that have a better record. As the Netherlands has shown, it is possible for a system with similarities to the NHS – with relatively long waiting times and rationing – to be transformed into something better.
The most common system in Europe is based on social insurance. Many variations exist but let us take Switzerland as a good example. Everybody there must have a health insurance policy regardless of means. The government helps the poor to buy one. There is universal coverage of the entire population. People can choose a policy from a variety of competing organisations, which include professional bodies and trade unions. The cheaper policies require you to go to a general practitioner before seeing a specialist, but the ultimate treatment is the same.
Those who are older or who have a record of illness do not have to pay more for the same policy than the young and healthy. That’s because there is a system of compensation. Any insurer that has a larger-than-average proportion of older people receives money from other insurers.
The key to the quality of Swiss healthcare is competition: two layers of it. First, insurers compete to offer customers the best deals. Second, doctors, diagnostic facilities and hospitals compete to provide high quality for a good price to the insurers. Efficiency, modernity and convenience are all things that these healthcare providers must strive for. That means less waste and more money left over for treatment and making a service that offers minimal delays and modern equipment.
The German and Dutch systems have a lot in common with the Swiss one. On a recent visit to Germany, I asked how long a German would expect to wait for tests and what sort of regular checks were routinely provided. I was told that the wait for an MRI scan was between a day and a few weeks. Everyone is entitled to have a pretty full health check at 35 years old and every two years thereafter. Among other things, the check includes a cardiac health test with sensors on the chest, a series of blood tests and urine tests. Men aged over 50 are offered a colonoscopy at 55 and then every 10 years thereafter. The routine continuing care that a German gets is far higher than we are accustomed to with the NHS.
Looking around the world, there is another system that is worth considering. In Singapore, everyone is obliged to pay part of their salary into their own health savings account. This is backed up by a compulsory insurance scheme. In their 20s and 30s, people usually do not need much healthcare and the savings accounts build up to a substantial sum. Then, when they need an operation, they are able to pay out of their own account. They can choose which hospital to go to, either a private one or a subsidised government hospital. They can decide whether they really want to spend the money in their account on, say, cosmetic surgery or a diagnostic test of doubtful value.
Three benefits of the system are: spending power in the hands of the individual; an incentive on each person not to waste money on unnecessary procedures, and competition between hospitals on price and quality. These incentives have radically reduced costs. Singapore spends only 4.9 per cent of GDP on healthcare compared to 9.7 per cent in Britain.
Do any of us really want to end up on a trolley for hours in A & E, waiting to be admitted, or having our treatment for heart or kidney disease delayed until it is too late? The NHS is testing the courage of Britain to face up honestly to a problem. The alternative is pretending that it does not exist.