Friday, 11 January 2008

21st Century Health (2)

This is the second half of a post I began yesterday, in response to Johann Hari's Independent column, in which he posits that the British model of healthcare funding is the 'smartest choice' for the coming century.

Yesterday, I contrasted the UK and US healthcare models, and came to the conclusion that of the two the NHS is indeed superior overall. However, there are more than two ways of building a healthcare system.

Few would say the status quo is ideal. The Dr Rant team's description of the NHS as comprising "a centralised, bureaucratic monolith that measures its tractor production quotas each year for [the Health Minister] to produce at the annual party conference" (Link) is as good a nutshell description of the primary perceived problem with (and from a supporter of and worker in) the UK system as I'm likely to find.

When the long-serving NHS GP and medical blogger Dr Crippen exclaims in his post of a welcome return from a 3 month hiatus:

The Paediatric Professor...[at a dinner party] said,
“You know, if I were suddenly taken ill, I would be terrified to be admitted to a British NHS Hospital.”
We went round the table. Each and every one of the ten doctors present felt the same.
...There has to be some degree of acceptance that all is not well in the world of UK healthcare (keep reading the NHS Blog Doctor blog - almost 2 years worth of posts in total - to get a much fuller picture than I could get across). Can the UK learn from the ways in which other nations run their health systems?

The state/private hybrid, means-tested French healthcare system, ranked number one in the world by the World Health Organization in 2000 (Link), is one alternative. Although it is highly regulated, it represents a much more heterogeneous, diverse system than the NHS, and offers universal coverage unlike the US. It is not surprising that the French model is favoured by several critics of the NHS and US systems alike, such as Tim Worstall. And a recent survey (albeit judging on one aspect of healthcare) found the French system to be the best of those in 19 developed countries - the UK was second from last (Link).

The French system is however not universally admired. Like the UK system, it is expensive to administer (though not to the extent of the US's healthcare spending); the arrangement appears to lead to over-prescription of drugs such as painkillers relative to other countries; and it failed to cope well with a countrywide emergency in 2003 (Link).

Alternatives that retain fundamental state control, but avoid the 'monolithic' centralisation of the NHS model include the Swedish system. There, health spending is controlled by local rather than central government (Link). Denmark's model also contains similar elements - responsibility for healthcare management is split between central government, the counties, and local authorities (Link). Both of these models have obvious parallels with the UK's system, but both are much less centralised.

Even supporters of the NHS such as Dr Rant recognise that there is real room for improvement, and that many of its major problems are related to over-centralisation of administration (Link1,2). The Swedish and Danish models provide proven and, I expect, politically palatable alternatives to the current monolith that would help to ameliorate some of these.

So, to conclude the post I began yesterday to respond to Johann Hari's contention that "the [NHS] health funding mechanism...is the smartest choice for 2048", the answer is, er, sort of. As I outlined in part 1, in direct comparison with a non-'socialized' private insurance-based system such as that in the US the answer has to be yes. But when French, Swedish, Danish and other non-US arrangements (e.g. Switzerland) that I haven't mentioned are considered in opposition to the UK status quo, the answer to which is the 'smartest' model is much less discernible.

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