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Highlighting news stories important to the Civic Republican
particularly those that are overlooked or little covered in the main media.
In the last newsletter I commented on the all-pervading touchy subject of immigration. This week I am going into even more dangerous territory.
In fact it is so dangerous that most people, but especially politicians, suffer mental rigor mortis when they go near it. The brain freezes up leaving usually articulate opinionated speakers dumbstruck – for it can be the subject of no rational analysis.
When changes to the system do occur as they have under the coalition, they are done without any consensus or thorough debate. Debate is after all impossible. By the time changes have been implemented no one in the subsequent chaos can remember what purpose they were supposed to serve.
I live in France and so it is inevitable that I compare the British health service with the French one. I have been a user of both and so that experience colours my view. I know a bit about the way they are both set up although I am not an expert.
[Incidentally, perhaps this is the occasion for answering a question that occasionally comes up. People ask me why it is as a leader of a British political party I don’t live in Britain. Well, from the practical point of view I can get to many parts of Britain from Toulouse airport as quickly, as easily and as cheaply as I could from Plymouth where I was living until 2006. Britain is a horrendously expensive country now. And it is so much more agreeable to breathe the charmed republican air of France than the putrid monarchist air of England. Also there is a great difference in health care – which is where we came in.]
There are two fundamental aspects to the structure of any national health service.
Let’s look at these in turn
Britain’s health system is a one tier system, that is to say, it delivers the same standard of healthcare to all - at least in theory. Except it is not single tier – at all. It is two-tier. There are those that receive the NHS care free (except it is not free - at all) and those who receive private healthcare paid by private insurance companies (except they often refuse to pay).
All these ‘except’s refer us to the fact that the system does not work as it is supposed to. It is a mess. Why is this?
To answer this, at what is perhaps a rather grand sounding philosophical level, it is because the idea that you can deliver the same service to everyone is utopian idealism. We should indeed always strive for justice but there is a point at which we have to accept that we might be trying to force society into a mould into which it just will not go – trying to make the world do something it naturally just does not want to do.
This constant grasping for utopianism makes the debate about the health service doomed from the start. And behind the camouflage of the debate about how to achieve utopia, horrible things are done with the way the service is run, nasty things are done to the people who work in it and ghastly things happen to patients.
When you try to create a single tier utopia, you are bound to fail. A whole bunch of people have the money will create a different, alternative system - a private health care system - and so your idealistic one tier system inevitably transmogrifies into a messy two tier system.
I am not talking here about the NHS contracting out care to private hospital but about patients choosing to go private. The private alternative to the NHS is expensive and, when it comes to the big ticket healthcare items, next to useless, letting the NHS take the strain. Insuring yourself privately is a battleground. When you take out insurance they try to avoid covering you for as much as possible and when you make a claim they fight you all the way to reduce what they pay out. We decidedly have two tiers. Both have major problems for the users.
So what happens in France? Well, it is not utopia. It is something even better, and more real – a Rolls Royce. There are faults of course. But (as long as you make sure you avoid the occasional crooked doctor) the system delivers probably the best healthcare in the world.
The French system is not single-tier. Nor is it two-tier. It is multi-tier. How does this work? It works basically through the private health insurance,, which is strictly regulated so that there is a level playing field for the private companies and a guarantee of insurance for the patient.
Now before explaining more about how this system works, it is worth reflecting for a moment on a principle that is really quite profound to the way we conceive of our society and even the way we conceive of human nature.
Is it natural to human society that some people will have more money than others? Is it natural to human society that those people will want to use that money for, amongst other things, giving themselves better healthcare?
Surely, we want to say yes. We want live in a free society as long as this does not lead to extremes.
In France, there is a basic service for everyone. You won’t die in France from treatable illness. You won’t languish and suffer unreasonably. But what you can do is take a top up insurance – and this is what a huge proportion of the population does. So your service can be better than the basic service dependent on how much you contribute to private insurance. It is not like in Britain where private health insurance effectively launches you into a completely difference system. In France, the private and public systems are fully integrated.
For this to happen the insurance companies have to be well regulated. In France all health insurance has to be carried out by mutually structured companies –that is they are owned by their customers not by shareholders.
Absolutely central is that they cannot take you on, or charge you, according to your health history. In Britain private health companies invariably exclude cover of ‘all previous conditions’. So if you suffer from heart problems for instance you cannot get private cover for any treatment of that condition in the future. Brilliant! The very thing that is most important to cover you cannot get covered.
The French ‘mutuals’ by law cannot ask you to divulge a single thing about your medical history. The only factor they can take to consideration in determining your payments into the scheme is your age.
Most people who have mutuals will pay between 30€ and 80€ a month. Not an insignificant sum but you get money back for dentistry and glasses and other things that reduces the cost. Young people are less inclined to have a mutual as they don’t get ill so often and so in many ways the system is self-adjusting whereby the heaviest users tend to pay more.
Under the British system you cannot purchase an enhanced service in the NHS, however much you may like to. The utopianism means that everyone in theory has to have the same standard of treatment, unless they choose to entirely circumvent the NHS and go private, in the process paying twice for their healthcare – one, through taxes and, two, through the scoundrels that run private health insurance. It is a rubbish choice
And let’s scotch once and for all the idea that the NHS is free. It is nowhere near being free! You pay a lot for your medications. In France, you pay nothing in most cases. Support for dentistry in the UK in close to zero, whereas in France normal non-cosmetic care is free and you receive back a lot of your payments into you mutual for dental bills.
Such much for the first fundamental aspect (one tier or not) of any healthcare system. What about the second one I cited – procurement?
Procurement refers to the matter of who orders the care from suppliers.
I used to have some difficulty getting my head around this idea in relation to healthcare. After all the doctor is there, the hospital is there. Both serve patients. Why do you need anyone else getting in the way? The point is that someone has to decide what services can be provided within the budgets available.
Originally this was the government or Department of Health but this function was passed to newly created quangos, called Primary Care Trusts. These decided how the hospitals were funded to satisfy the needs of patients now and also planning for the future, in theory taking health spending out of government hands.
The Conservative leaders of the coalition changed that system abolishing the PCTs and putting procurement in the hand of GPs. Recently it has come to light that no one ever understood the new system and they still don’t, so I am certainly not going to attempt that feat here. But we know the basic principle is that all the power for procurement, and so spending, has gone down to general practitioners.
Now at this point I want to tell you a story about how different your contact with a doctor is in France from in England, for this relates directly to this question of procurement.
In England when you go to see your doctor, reception will point you to a waiting room and when it is your turn to see the doctor a buzzer will sound. In my last experience of this system the surgery judged that certain of their patients might be visually impaired or hard of hearing and so the loud insistent buzzer was accompanied by a bright flashing light.
Having endured this insult to your dignity, just at time when you might be ill and stressed, you have to find the doctor’s room the door to which may well be closed. You have to timidly knock and when summoned to enter you find the doctor seated behind his desk. He finishes off what he may be doing, does not get up to greet you and then waits for you to explain exactly what you are doing there. It is like going into the headmaster's study.
French people liken British GPs to ‘fonctionaires’ or civil servants. They treat you as a civil servant would. They act like civil servants - not people who are supposed to be sympathetically looking after you.
If you want to understand why in France the system is better, you only need look at the attitude it generates in doctors. And here I am talking about doctors at every level from the GP right up to the most exalted specialists. The way you are received is always the same.
After being seated in the waiting room (whether in a local surgery or large hospital), when the doctor or specialist is ready for you, you don’t go to him or her. He or she comes to you. They come to the waiting room personally and greet you and then show you into their room. No buzzers, just common courtesy. You are treated like a person not a lump of meat.
But this is not just an exercise in good manners, important though good manners are. What you are seeing here a powerful demonstration of the way the French system is structured with regard to procurement.
So who does the job of procurement in France? The government? A quango like the PCTs? Your GP? No. The body doing the procuring is you, the patient.
And this fact is underlined by another difference in your standard visit to your doctor’s surgery. When the consultation is over, you pay the doctor by cheque or cash or sometimes credit card. Yes the doctor actually handles the money. There is nothing undignified about this. And the reason why you don’t pay the doctor with money in Britain is not because that would be unseemly for a doctor but because it would be unseemly for a civil servant – which is what British GPs effectively are. Their income comes from the state like a civil servant and they dispense services in the same spirit.
In France, whilst the doctor relies on patients for their income, the money comes back to the patient, assuming it is covered by the national social security system, which most normal care is. So why send the money from state to patient to doctor and not directly from state to doctor. Because the patient, by being in the loop, directs where the payment goes by their choice of doctor. Also it allows for money to feed in from the private insurance system as well.
Your doctor should not be a civil servant. I don’t expect to choose my tax inspector or the person who issues my driving licence. But I do want to choose my doctor. It is after all rather more a personal matter. The fact that you hand over the dosh in France means you choose which you see. Doctors thus have to compete for patients. No patients, no dosh.
But does this not make it a market place for doctors? Damn right it does. A doctor to get income has to be good like any other professional like an accountant or lawyer. This fact reverses the patient/doctor relationship as it is in England. The patient is the employer not the government or some faceless quango.
And now with new system of the GP doing the procuring, patients become just so many items for processing.
OK I know this is exagerrating. Most British doctors are excellent. What I am highlighting is that the position in the system of the patient is all wrong
In France, because you are in charge of selecting your healthcare you are expected to keep your own records, X-rays, scans, reports, etc. Imagine that in Britain where is it automatically assumed that everyone is far too dysfunctional to accomplish such a simple administrative task.
The French system might sound a bit complicated but with its superb computerised system it works like a dream. You could never have such a system in Britain because the neoliberal dominant mindset would always insist on contracting out the IT to a private company with the sure result that it would waste billions and be rubbish. The French state (horror of horrors!) built their IT system in house. Annoyingly for the neoliberal privatising agenda, that means that it actually works
In France, the patient has the power of procurement. Because of the way the mutuals work you can chose to use a private hospital. Even if you don’t subscribe to a mutual you still can chose which public hospital you use and you can chose your consultant. Everything is geared to the patient being the procurer, the patient being the payer (with a little help from the government social security), the patient being in the driving seat.
The British system of national health is in a mess. It is lumbered with the absurd ideology of a one tier system and it treats patients with contempt. I hear stories of patients waiting two weeks for an appointment. That would not happen in France for your GP, for you just go somewhere else and soon a new GP woul set up to satisfy demand
Someone still has to decide on how to allocate resources overall – which branches of medicine to give priority to and where to build new hospitals and close down existing ones. But this should not be the big deal it is made out to be.
In a properly run economy we could afford all the healthcare we want. The country is rich, but its wealth is constantly and increasingly being siphoned off and dispersed where no normal British person will ever benefit from it
Our prime concern in every decision we make, in every area of policy, should come down to achieving quality of life in the fullest, broadest and deepest meaning of that phrase.
And what could be more essential to good quality of life than good health.