In an earlier post, I raised the ideological differences that may underpin much of the political rhetoric.
Of course, many informed commentators understand the problems and challenges facing US healthcare, which can be the best in the world. And much good learning about how to make a health system better come from the US. The NHS has learned much from the US, too.
But the NHS is like any system, built on assumptions and reflects a view of healthcare delivery that may not be shared by everyone. However, many do share the underlying principles of universal healthcare, just not the organising principles that the UK used in designing the NHS. There are other systems of healthcare organisation, and there is evidence that Bismarckian systems (non tax-funded systems) may actually produce better outcomes and care. On that basis, the NHS is vulnerable to structural criticism, but not for trying to deliver a universal healthcare system that decouples the need for healthcare from the ability to pay. The Americans in particular would not argue that people need healthcare, but they would debate how best to pay for it. Hence the debate.
But the NHS does have vulnerabilities. Let’s summarise a few:
1. NICE is seen by many as establishing a value for a human life based on quality adjusted life years, general affordability of a medicine based on a blend of clinical effectiveness and cost. While NICE lacks statutory authority to enforce its decisions, its role from a US perspective would support the conclusion that within the NHS is a decision process that indeed does value human lives.
2. Overseas observers may be forgiven for not following the daily reform of the NHS, and on that basis, cursory searches of the health literature will produce historical documentation that supports the view that the NHS has been known to cause considerable personal suffering through the persistence of waiting lists. For many US commentators, this equates to a form of rationing, which in their view is unacceptable. Granted that people wait in all health systems; but in the past, the NHS can be accused of having used administrative procedures, like waiting lists, to queue patient care on the basis of clinical need, but with fewer deployed resources per capita than other countries, patients did in fact suffer health consequences from waiting.
3. As a cash-limited system, the NHS is open to greater criticism from American commentators, who are more comfortable with co-payment systems, and systems which in effect enable people to buy their way to the front of the queue. Since it is deemed unacceptable to use co-payment as a mainstream payment mechanism in the NHS (unlike the health systems in other European countries such as France, where co-payments are the norm, coupled with supplementary insurance), other commentators would naturally wonder why resource constraints that penalise people seeking greater healthcare cannot be overcome through personal discretionary payments. The Canadian healthcare system comes under very similar US criticisms here. That the NHS as a purchaser fails to fully integrate the provider infrastructure would seem odd to Americans and many Europeans, more accustomed to receiving care from a system that is largely agnostic over who owns the provider (public, private, voluntary, profit, not-for-profit). More generally, the ability to pay more would be seen by some as not necessarily penalising others who might pay less or nothing — there is no moral contradiction for some here — as both types of patients will in the end get seen; the consumption of healthcare by the rich does not necessarily reduce the availability of healthcare for the poor, some would argue. But it is important to keep in mind Titmus’s point, that a welfare system that only services the poor will lack support of the middle class, and in the end fail in its social welfare objectives, and also be financially unviable. This is one argument for community risk rating and pooling.
4. The NHS can be criticised for confusing the politics of the NHS and the politics of healthcare, itself. To external commentators, this mixes the essential relationship between the doctor and patient, with a state-mandated intermediary. US commentary in part is predicated on avoiding any government intermediary between doctor and patient. The NHS is a system for delivering care, while healthcare itself is essentially a private matter between doctor and patient, as many would argue. You can always change the system, but the relationship remains. Tinkering with the former in ways that alters the latter for many is unacceptable.
It is worth keeping in mind that the UK is not the only health system that American critics could attack; it is probably one of the easier to learn about and which offers an extreme view from their perspective. Critics for years have attacked Canada’s health system as ‘socialised’, but have failed to target Italy’s. They have generally ignored insurance-based or Bismarckian systems perhaps because of the insurance approach, which is closer to their view of how risk should be managed — buy insurance, don’t buy the risk itself.
The NHS itself, is a particular way of organising and paying for a universal health system, and there are separate debates in the UK about whether the NHS should become an insurance-based model, and so and so forth. But in the end, few Americans are actually inconvenienced by their healthcare system, and perhaps think very little about it, in much the same way as UK citizens enjoy the benefits of the NHS, without necessarily being concerned exactly how it is financed.
Universal health systems do work well and apportion risk across the whole population in most cases without a lot of public hand-wringing. UK politics is perhaps overly sensitive given the past problems with NHS waiting lists and apparent rationing, and dysfunctional separation of public and private providers adding delay to access to treatment. These problems are largely absent from Bismarckian health systems of France, Germany etc, and so there is always the general public accountability to be had about whether the UK is making appropriate evidence-based decisions about the financing system it uses. But that is quite apart from the fact of universal coverage.
In the end, the US doesn’t want an NHS style healthcare system. In fact, very few countries actually copy the form the NHS form of financing (tax funded), preferring to use insurance, and of those that are tax funded they tend not to copy the organisational style of the NHS (state-run/owned hospitals for instance). This is keeping in mind that there are four NHS’s — one in each UK country, with the English NHS being the most progressively reformed (with some US ideas, too).
There is much to learn from looking at other health systems, and the US clearly isn’t having that sort of reform debate. Something perhaps for the US to think about again.