COPYING THE UK’S HEALTH CARE SYSTEM IS THE LAST THING THE US SHOULD DO: JANET DALEY
Copying the NHS is the last thing the US should do
http://www.telegraph.co.uk/comment/columnists/janetdaley/7883381/Copying-the-NHS-is-the-last-thing-the-US-should-do.html
The future health care in both countries must involve a mix of state and private provision, says Janet Daley.
Bad idea: Barack Obama has appointed a man as head of the American public healthcare programmes who professes a passion for some of the most discredited features of our NHS
This week, the Coalition will offer an example of how coping with an economic crisis may serve a reforming purpose. Having to cut back the power and the expenditure of the state will provide a rationale for dismantling the monolithic, bureaucratic monster that the NHS has become. In his health White Paper, Andrew Lansley will apparently propose sweeping away the command-and-control structure in which clinical decisions are taken and hospital procedures commissioned by Primary Care Trust administrators, rather than by general practitioners who actually come face-to-face with people in need of medical help.
Fine. But if GPs are to inherit all the authority in this system, then it should be possible for patients to choose – and change – their family doctors easily and without recrimination. For, alas, Mr Lansley has decided to pass on the powers that he is confiscating from the abolished PCT mandarins exclusively to doctors rather than to patients. This is a real missed opportunity, but never mind: he is at least facing the right way, devolving decision-making down to levels where it can be done with more responsiveness and sensitivity to individual needs, rather than with the impersonal, blanket uniformity of a target-driven central authority.
The US government, meanwhile, is galloping doggedly in the opposite direction, bizarrely determined to occupy precisely the ideological ground which Britain is abandoning. Barack Obama has, indeed, appointed a man as head of the American public health care programmes who professes a passion (no other word will do) for some of the most discredited features of our NHS. Dr Donald Berwick is to head the Centers for Medicare and Medicaid Services, which effectively means that he will be in charge of Obamacare – the new universal health care system on which the President has staked his political credibility.
The appointment has created an extraordinary kerfuffle, partly because it was made under highly contentious circumstances – as a “recess†appointment which allowed it to bypass Congressional approval – but primarily on account of Dr Berwick’s widely disseminated statements extolling the virtues of the most disliked aspects of state-funded medical care as we know it.
Dr Berwick professes a love (which he describes in ecstatic terms that will have a tragicomic ring to most British ears) of just those evils of a national health system with which we are exasperated: the calculated rationing of treatment, and the ruthless enforcement of uniform cost limits, which often puts the most advanced medication and procedures out of reach of patients whose lives might have been extended or transformed by them. Dr Berwick thinks that our own dear National Institute for Clinical Excellence (Nice) – which is scarcely ever out of the headlines for denying some poor suffering victim a remedy that is available in other countries – is simply wonderful.
Unfortunately, Dr Berwick is quite right to draw these particular conclusions about the inevitable consequences of state-sponsored health care. Which brings us back to Mr Lansley and his not-really-all-that-radical reform of the NHS. At a time when both the demand for care and the scope of medical innovation are virtually infinite, a tax-funded health system must involve rationing and often the outright denial of advanced, cutting-edge treatments. There may be no theoretical limit to what miracles medical science can deliver, but there is certainly a limit to what taxpayers can subsidise, or to what governments can spend if they are not to starve every other public service to the point of death. The Government’s refusal to cut NHS funding – at whatever cost to other departments – is rightly condemned as wrong-headed and politically cowardly.
So why the inevitability of those aspects of our system which we most dislike? Why is Dr Berwick correct when he says that the NHS way of doing things is basically sensible, given the principles on which it rests? Because we have – and America is apparently about to embrace – an approach to health funding which is inherently self-limiting. Rationing is what happens when you do not have enough of something to go around. And health care that is paid for entirely by taxation creates shortages where they need not exist.
In Britain, we have maintained a perverse ideological insistence on the principle that it is better to have rationed, centrally controlled, uniformly dispensed health care even if it is poorer in every sense – in terms of resources, productivity, and medical outcomes – than that in which individuals routinely contribute to the cost of their own care. The ban on what is called co-payment, or top-ups, is intended to ensure that no NHS patient will have access to better – or more – treatment than anyone else simply because he is wealthier. We prefer a uniformly mediocre standard of care to an “unfair†one in which the better-off may get different service.
This dogmatic self-denying ordinance against the supplementing of NHS provision by patients able and willing to pay has meant that no thought has been given to the role such a mechanism could play in raising revenue for the NHS as a whole. In Britain, we would be inclined to agree with Dr Berwick’s view (hugely inflammatory in America) that a civilised, humane health care plan must “redistribute wealth†from the richer to the poorer and less fortunate.
But we have failed to notice that such redistribution is not just a feature of taxpayer funding. All insurance is based on the principle of redistribution: the more fortunate, who have paid their premiums but not made a claim, are helping to pay for the less fortunate, who needed help. Medical care top-ups paid for by individuals, or by insurance policies designed for “top-up only†provision, could provide an extra stream of revenue for the NHS, and thereby help to fund better care for those not affluent enough to pay anything extra themselves.
If the barriers between private and public funding are not broken down, a health system fit for the 21st century will be for ever out of our reach. At a time when the limits of state power have become so clear, it is delusional to try to maintain a state monopoly in health, with all its self-imposed limitations and disadvantages. The future lies with a combination of state provision and private contribution: that is a lesson that both Britain and the US – coming from polar opposite ends of the debate – need to accept. Abandoning hidebound dogma is now a matter of life and death.
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