Britain’s cherished, lousy National Health Service
In April, the British Medical Journal published an article about two studies conducted by the New York-based Commonwealth Fund. The studies compared the healthcare systems of 14 advanced countries, and on the 20 measures of comparison,Britain’scentralized National Health Service performed well in 13, indifferently in two and badly in five.
On several measures, the NHS came out the worst of all the systems examined. For example, it ranked worst for five-year survival rates in cervical, breast and colon cancers. It was also worst for 30-day mortality rates after admission to a hospital for either hemorrhagic or ischemic stroke. On only one clinical measure was it best: the avoidance of amputation of the foot in diabetic gangrene.
This hardly seems like a cause for national rejoicing, yet according to the report, the British were the most satisfied with their healthcare of all the populations surveyed. They were the most confident that in the event of illness, they would receive the best and most up-to-date treatment; and they were the least worried that their personal finances would prevent them from receiving proper treatment.
So, how is it that the population most confident that it will receive treatment of the highest possible standard, featuring the latest medical advances, actually has the worst survival rates in precisely those diseases that require the most up-to-date treatments?
One explanation is ignorance. The average Briton or Swede is unlikely to know that the five-year survival rate for colorectal cancer is 51.6% in Britain but 59.8% in Sweden, or that the 30-day fatality rates for myocardial infarction in those two countries are 6.3% and 2.9%, respectively. (The figures for the United States are 65.5% and 5.1%.) By contrast, the average Briton knows that if he suffers a heart attack, he will be taken to the hospital and connected to a lot of machines, from which he concludes that he is having the best possible treatment.
In my youth, I often heard the refrain that the NHS was “the envy of the world,” and people in Britain are still inclined to believe that, even though they probably have never met anyone who envied the NHS and, indeed, probably know Continental Europeans residing in Britain who hurry home as soon as they require medical treatment, horrified by the prospect of subjecting themselves to a British hospital.
That said, there are some strengths the system can claim. Medical care is coordinated, for example, by means of a universal (and compulsory) system of family doctors. The lack of such coordination in the United States leads not only to a high rate of medical error but to duplication of effort. The American rate of polypharmacy (the taking of four or more medicines daily) is twice the British rate. This difference is unlikely to reflect genuine need; the American polypharmacy rate is also 21/2 times the Swiss rate, and whatever one might think of British medical care, few would impugn the quality of care in Switzerland.
Traditionally, the NHS has been inexpensive compared with most healthcare systems. But this reality is changing quickly. The NHS was inexpensive in part because it rationed care by means of long waiting lists. I once had a patient who had waited seven years for a hernia operation. The surgery was repeatedly postponed so that a more urgent one might be performed.
Such rationing has become increasingly unacceptable to the population. This was the ostensible reason for the Labor government’s doubling of healthcare spending from 1997 to 2007. To achieve this end, the government used borrowed money and thereby helped bring about our current economic crisis. Waiting times for operations and other procedures fell, but they will probably rise again as economic necessity forces the government to retrench.
But the principal damage that the NHS inflicts is intangible. Like any centralized healthcare system, it spreads the notion of entitlement, a powerful solvent of human solidarity. Moreover, the entitlement mentality has a tendency to spread over the whole of human life, creating a substantial number of disgruntled ingrates.
And while the British government long refrained from interfering too strongly in the affairs of the medical profession, no government can forever resist the temptation to exercise power. Eventually, it will dictate, because that is what governments and their associated bureaucracies do. The government’s hold over medical practice in Britain is becoming ever firmer; it now dictates conditions of work and employment, the number of hours worked, the drugs and other treatments that may be prescribed and the way in which doctors must be trained. Doctors are less and less members of a profession; instead, they are production workers under strict bureaucratic control.
In a centralized system, the setting of targets can lead to organized deception as well as distortion of effort. For example, when the British government decreed that every patient arriving in the emergency room should be admitted to a hospital ward within four hours if admission was necessary (and that hospitals would face fines if they failed to achieve this goal), traffic jams of ambulances formed outside one hospital, with patients prevented from entering the emergency room until the hospital could comply with the directive. Other hospitals designated corridors as wards so they could claim that patients on stretchers had been admitted in time.
In the United States, after President Obama’s healthcare law proposed fining hospitals that readmitted too many patients within 30 days of discharge, editorials in the New England Journal of Medicine pointed out the dangers posed by that rule. They omitted to say that when giant bureaucracies set targets for others to reach, they intend not so much to procure improvement as to impose control.
Theodore Dalrymple, a retired British doctor, is a contributing editor of City Journal and a Manhattan Institute fellow. This piece is adapted from the summer issue of City Journal.
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