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How (not) to fix the NHS, part 2

There have been a handful of articles recently querying the model of healthcare that the NHS uses, and suggesting that we should pursue a continental model instead. Most commentators know enough at least not to suggest overtly that we go down the American route. But I am not sure that commentators always know enough about continental options to understand the differences between the NHS and, say, France or Germany – and more importantly, which differences are the ones that matter. France and Germany could have differences that lead to worse results than the NHS alongside differences (such as spending more) that are better as well as a context (a higher skilled jobs market, or a more equal country, or cleaner air) that is also better for health. So the overall result could be a population with better health and a healthcare system that obtains better outcomes, yet the differences that commentators point to could be ones that would make the UK’s system worse. We need to be very careful, therefore, when we call for change that we are calling for something that has widespread evidence of a strong effect, not something that happens to be present in a place where something else is causing the positive effect.

In this post I am going to comment on How to Fix the NHS in the Daily Sceptic by Ed Hoskin. In a previous post I commented on the first paragraph of an article from the Telegraph, which was as much as I could read as I don’t subscribe to the Telegraph.

Hoskin takes the view that “political dogma and the refusal to accept criticism of what has become a national icon manages to blank out any consideration that methods and experience from elsewhere could ever be applicable in the U.K.” I’ve already addressed this topic in previous posts, including the one immediately before this and one comparing our system to Germany. There is zero evidence that politicians and civil servants don’t consider what happens elsewhere, and plenty of evidence that politicians, academics and commentators all regularly look abroad to deliberately consider other models of healthcare. The NHS itself is regularly reorganised, whilst the reduced funding available to it under Conservative compared to Labour governments – and the associated reductions in NHS performance – further confirm that the NHS is not subject to one uniform political dogma.

Hoskin repeats the myth that government funding comes from taxation. It does not, just as the government issue of postage stamps in 2022 does not in any way depend upon the number of postage stamps used for post (as opposed to lost, saved or put into stamp books) in 2021. What matters is the level of resources in the country, and that does not vary rapidly in response to whether it is the government or the individual who pays for healthcare. The government can, however, increase the level of healthcare available in the country by doing such things as training more doctors, allowing doctors to be more easily recruited from abroad (I am not in favour of such poaching), buying in more equipment, or investing in research in medicine.

The government can also reduce the need for healthcare by investing in measures that improve public health, such as by reducing the level of inequality in a country and taking measures to get rid of the toxic jobs that pervade the bottom of our labour market. By having the government pay for healthcare, rather than individuals or private insurers, a greater incentive is placed upon the government to invest in measures that improve population health, because they then benefit a second time through the reduced cost of healthcare. The failure of our current government to do so is, again, a political problem that is not likely to be resolved by switching away from the only funding mechanism that incentivises such behaviour.

Hoskin thinks that the NHS “was set up as if patients were incapable of having any responsibility for their own health”. I don’t know how many people he knows with chronic illness, but I know many and am a researcher in this area as well as having chronic illness myself. I can assure Hoskin that we are acutely aware of just how little the NHS can do, and we take huge responsibility for our own health, including the administration and the combining of sometimes conflicting information from doctors in different specialities.

‘Free at the point of use’ may encourage some people to attend when they don’t need to. But it also enables people to attend when they absolutely need to.

Morally, I am vastly more in favour of making sure that people who need to attend are not put off by cost than I am worried about people attending who don’t need to. The latter will take up only a short GP appointment; they won’t be taking up repeat appointments, medication, investigations, surgery and other secondary healthcare. The cost of ‘unnecessary’ appointments is small. The cost of delayed healthcare is huge. Furthermore, Hoskins earlier complaint that people don’t take responsibility for their own health does not fit with a picture of people taking responsibility to go to a doctor. Not taking responsibility is what happens when you don’t make an appointment, not what happens when you do. And no-one expects a doctor to wave a magic wand. If the doctor offers diagnostic or therapeutic tools, the patient expects to have to actively do something in order to take them. That is taking responsibility.

I’d also like to point out that who does and doesn’t need healthcare is not something that the untrained person can comment on. I don’t know if you’ve ever noticed adverts from the NHS encouraging you to attend the GP if you have mild, persistent tummy trouble because ‘it could be cancer’? Cancer has highly nebulous symptoms. If you want any hope of catching it before it is too late, you absolutely need to feel that you won’t be accused of time-wasting for going to the GP with mild tummy trouble. This pernicious attitude is deeply damaging to people’s morale and could be placing a substantial burden on the NHS by delaying people from going to the GP when they really need to. We are not experts. We cannot decide what is and is not important. We need to go to the GP when we are concerned, because the GP is the person who has the knowledge to tell us whether we have cancer or just a mild inflammation.

We aren’t even encouraged to take painkillers long-term without medical advice, because they come with side-effects – stomach ulcers, or worsened pain, or headaches – that need to be medically overseen and managed. Therese Coffey’s suggestion that people should be allowed to get antibiotics from the chemist flies in the face of the medical advice that says antibiotics should be safeguarded and certainly should not be used for viral or fungal infections. A child can take a minor fall, bumping their elbow, and it seems like nothing to go to the doctor about – but it’s actually a subluxed ligament that needs correct manipulation to be put back into the right place. Or you might have a bad case of tonsilitis, be turned away by A&E – and die a few days later.[1] We are not experts. We cannot decide what is and is not important.

To start off by complaining that ‘free at the point of use’ encourages time wasters, only to go on to point out that there is no real ‘free at the point of use’, seems doubly mendacious. Hoskin has complained about a vital aspect of universal healthcare, apparently out of a desire to see costs added to people’s access to healthcare, only to then admit that costs already do apply! This is perhaps particularly true for poor people, who are often in ‘toxic’ jobs that admit little flexibility and that punish people for the temerity of asking to avoid a particular time when the shifts are allocated. It can be very hard for these people to access healthcare, because of the costs of fitting it around their work. Indeed, the general result is that poor people don’t attend healthcare soon enough, not that they attend too much.

Hoskin’s argument is that the French system is better. As far as I can tell, the French system is the same as the UK system in that everyone above a certain income contributes compulsorily to the ‘insurance’ scheme. The difference is that in France, as in Germany, individuals can buy supplementary top-up insurance. And here I cannot agree that this is an advantage. It seems to me to be deeply morally dubious. Richer people should not, by virtue of being rich, get better, more or faster healthcare than poor people. I believe I have already said this. There is no appropriate healthcare that should be out of bounds to poor people because of their poverty. Nor should poor people suffer additional delays – suffer longer periods of ill-health or injury – because of their poverty. And if poor people can access all appropriate healthcare, what are rich people paying extra for?

Hoskin refers to “a very effective IT system” in France. Now this I can agree with. The evidence suggests two areas that are vital to a good healthcare system: a good primary healthcare system; and a good IT system. The UK, unfortunately, went down the neoliberal pro-competition route, and told healthcare providers that they could choose from a selection of computer systems for running their healthcare records. The consequence is that GP surgeries and hospitals cannot communicate with one another, because they are using different computer systems and different servers.

This is woeful, especially if you are attending A&E in an emergency and the hospital having immediate access to your healthcare records would save a lot of time and mistakes caused by them not having the knowledge they need of your health, past treatments, current medications, allergies and so on. Nor, in an emergency, can you be expected to carry a physical copy of your healthcare records with you; nor does any chronically ill person want to carry their pages upon pages of notes to every appointment; nor do their healthcare practitioners want to wade through reams of paper when they could have a searchable computer file. But having a good IT system does not require us to change our model of healthcare provision. If anything, it requires us to move closer to the reality of a nationalised system, by insisting upon there being just one computer system across the entire network.

However, Hoskin’s “very effective IT system” seems to refer to something different. Indeed, it seems to be primarily a payment mechanism – the need for which is created by the approach that France takes. The system deliberately “retains minimal health information”. I am not sure that the system adds anything to the actual cost and performance of the healthcare system. Hoskin commends France for not having patient records kept centrally. He praises them for not having “an expensive nationwide database of everyone’s medical records”, even though this is one of the key features of a good healthcare system. This seems to be an example of taking whatever France does that is different to us and assuming that it is better, without good evidence or reason.

According to Hoskin, telling patients how much their healthcare costs makes them value their healthcare better. I don’t see any reason why a French model is needed to enable the NHS to do this, if it were really deemed cost-effective. The real worry, however, would be if it put people off seeking healthcare because they felt guilty about the expense. Alternatively, the sheer expense of certain procedures – such as scans, surgery and cancer treatment – might mean that anyone who has received a notification of the cost of these no longer sees a primary healthcare appointment as worth worrying about. It might drive higher GP attendance, precisely because this cost is nowhere near as high as certain aspects of secondary care. The mere provision of information cannot be assumed to have a univocal, let alone desirable, effect.

Hoskin says that, in France, “GPs are not paid by a capitation fee based on registered patient numbers but on their actual patient appointments. This means that there can be a modicum of competition between them as health providers.” Frankly, I don’t see how capitation payments prevent competition between GPs. When a person is looking to register at a GP practice, they will usually look at things like location and reviews. Where possible, they will register with a GP that has good reviews and they can easily get to. GPs that are paid per patient – a capitation fee – are therefore competing to attract patients to register with them.

For someone who complains about the over-use of healthcare, it is bizarre to favour per-visit payments over per-patient. The result of per-visit payments is that GPs are encouraged to have patients visit them as much as the patient likes, or even more, because the GP gets paid every time. There is no pressure to reduce the number of attendances or to provide an ‘efficient’ service that provides the best healthcare in the minimum amount of time. Capitation payments, as seen in the UK, tend to under-provide healthcare – but then I thought the complaint of Hoskin was the over-use of healthcare in the UK, so he should like any models that counter this.

GPs in the UK are private company groups or self-employed private contractors within the system – just as Hoskin says occurs in France. So there is no difference there. Hoskin then goes on to praise a system in which highly paid doctors do work that could be done by lower-paid administrators, and in which individuals have to have money up-front to pay for some healthcare, thus restricting the access of the poorest to timely and appropriate healthcare. He talks about not needing to ‘ration access to consultants’ without discussing whether this a unique feature of the French model, or the consequence – regardless of model – of having a higher ratio of consultants to patients, a better primary care system, a higher level of health in the population generally, or some other factor. Or, as Hoskin later admits, is simply the consequence of investing properly in preventative medicine and prompt treatment – neither of which are a necessary or unique feature of any model of healthcare provision, and neither of which is encouraged by complaints about people seeking healthcare unnecessarily!

Hoskin says that ‘the medics seem to control the running of the hospitals and other facilities, not the government’ but I am not sure that he has proven the converse – that the UK government runs hospitals. UK hospitals are paid per procedure and have their own managers, not government ministers, managing each hospital. There may be some political requirements, but France will have those too; it is part of being a modern country that there are certain standards which governments hold businesses to, including medical businesses. And because hospitals and GP practices in the UK do not get however much money they ask for, they – like French hospitals – will “see the benefit of having an absolute minimum of administrative overheads”.

In essence, Hoskin has taken every aspect of French healthcare and assumed that it is a source of good and the reason why France has better outcomes. In reality, some of the differences he has observed may be problematic rather than beneficial, whilst others – such as France having 25% more medically qualified professionals per head of population – are not particular, let alone central, to any particular model of funding. Others may simply be irrelevant.

The NHS is not the only way to organise a health service, but single-payer systems are cheaper than multi-payer versions. Brits want to learn from foreigners, but we aren’t going to restrict ourselves to only looking across the channel. We will look globally and take all the evidence, which saves us from post-hoc just-so-stories about which individual difference between us and one other country is the difference that matters.

For other posts on this topic, see

[1] Yusuf Mahmud Nazir, aged 5, died on 23 November.

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