IN PRAISE OF THE HEALTH SERVICE
Andrew Gimson says that we are better off
than we know, not least because we have fewer doctors than the French and the Germans
THE immense virtues of the National Health Service were almost entirely ignored during the grubby argument about the 94-year-old woman who may or may not have been treated as well as she should have been. I do not mean that the NHS is perfect, or that if it did not exist, one would wish to recreate it in its present form. But there are wonderful things about it which are not found in France, Germany or the United States.
In pursuit of this thesis, I went to see Dr Henri Thuau, who trained in Paris and has also worked in Zurich but is now a consultant facial surgeon at the Central Middlesex Hospital. The only other time I had been to this hospital, set amid the warehouses of the Park Royal industrial estate in west London, was to see a friend who had suffered a heart attack. He was being treated in a very crowded, old-fashioned ward, though he himself said that the nurses' training and uniforms were not as old-fashioned as he would have liked, The doctoring seemed competent, but the general impression was of a friendly but overstretched hospital somewhere deep in the Soviet Union. Yet the adjoining ACAD building where Dr Thuau works is not like that at all. If you were watching a television documentary about, say, the French health system, you might expect to see such an elegant and spotlessly clean piece of modern architec
ture, but not here. Perhaps, without our quite noticing or crediting it, the NHS is already reinventing itself.
When I asked Dr Thuau why he likes working in this unglamorous part of London, he instanced the extraordinary variety and volume of cases he sees: 1 ast year I had five or six gunshot wounds in the face, which I'd never seen before. And machete wounds, and samurai swords. So it's a very lively area.' But beyond this, he likes the relatively flexible and informal way in which doctors work together within the NHS: 'I like the system here, because I feel the human relations within the hierarchy and the hospital are pleasant. If you want to develop something, you usually can. Things can be sorted out informally, without even sending a letter. This is what I like. You have lack of staff, lack of beds, the nightmare scenario. But when I needed a stateof-the-art microscope, I got it within six weeks, thanks to a very proactive manager at the Central Middlesex. And when I was doing 12-hour operations and I said that I couldn't do this on my own, they created a new consultant post, which is very rare.'
Dr Thuau did not seek to minimise the difficulties within the NHS, citing in particular the loss to private agencies of some of the extremely good nurses he found when he started work in London in 1994: 'You have a lot of good people, but they're getting disillusioned, they're getting tired. I've spent all these years; I never saw my daughter growing up. She's nine now.' But he still said that he would rather work in Britain than in France: 'Things there are much more rigid, definitely. Obviously there are more doctors in France, which, from the patient's point of view, is certainly better, but throughout Europe medicine doesn't have the prestige it used to have.'
This is exactly the complaint of the medical profession in France, where many doctors, nurses and other staff recently went on strike in protest at their low fees and pay. A study of 400 general practitioners in Burgundy showed that 47 per cent of them 'ont la sensation d'etre vides nerveusemene, with the greatest problem they face being the 'aggression' and 'lack of respect' shown by patients, variously triggered by refusal to provide a sick note, by seemingly ineffective treatment, by the death of a loved one, or by an unduly long time spent in the waitingroom. Rather to my surprise, Dr Thuau said that British patients are on the whole more polite than French ones: 'I am amazed by the kindness and patience they show. They won't complain. In France, if you took them to some of the wards we have here, there'd be a revolution, What I also like here is the informed consent. You tell the patient the truth. In France, the culture of explaining things to the patient is not the same, though they're gradually getting there.'
In France you can get an appointment with your doctor almost instantaneously, but, as Dr Thuau pointed out — only half in jest — this is not always to the patient's advantage. It places much greater pressure on doctors to prescribe drugs for conditions that would clear up anyhow, with the result that the drugs bill is out of control. In England, he said with a laugh, you either recover or are in hospital by the time you see your GP.
A German doctor who works in the NHS, and who asked not to be identified, said, The big difference between Britain and Germany is the perception of the health system. In Germany nobody knows what's happening in the health system. In Germany it would be unthinkable to publish the sort of data on mortality levels that the Times published. The data are not available. The hospitals compete against each other for patients, so each tries to look as good as possible, and each doctor too. The patients are not confronted with the truth. The doctor is meant to be infallible. There are lots of examinations, even if these are unnecessary. In England people will drive miles and miles to look for the best school for their child, but in Germany that is what people do when they are looking for a hospital or a doctor.'
In both Germany and France the patient can go straight to whichever specialist he thinks may be able to help him, or often to several different specialists whose efforts are completely unco-ordinated: a very costly and not necessarily better system than having a
good GP who sends you to the right specialist. As the German doctor said, 'The British health system is sometimes perceived as chaotic, and it definitely is. A theatre list can be cancelled for lack of equipment, anaesthetist, doctor, nurses or beds. In Germany this is much better controlled: I never experience such cancellations. But the German system is chaotic too — in a different way. In Germany you might just go to a hospital where someone says "I can do thisbut he's not properly qualified — just because he's under economic pressure to perform. You don't want to transfer the patient to a specialist unit at another hospital, because then you lose money [paid from the patient's compulsory insurance]. It's an immoral incentive. In Britain, once you're in the system it's much better structured. You go to a hospital and very, very often you are sent to more specialised clinics where you get very highly specialised care, leading to very good results.'
What the German doctor is describing is, in part, the perverse consequence of having too many doctors rather than too few. The result is that there are not enough patients to go round, leading to a propensity for doctors to lack practical experience, to cling on to those patients they have, and to carry out excessive numbers of tests and operations on them. While living in Berlin, my wife and I were treated by some excellent doctors, but she was surprised by the high number of scans carried out during her two pregnancies there, until
she realised the economic incentive for these. Every employer and employee in Germany pays the cost of this superfluous treatment in the form of very heavy monthl),, health-insurance payments, which is one reason why about four million Germans are unemployed.
To learn something of the American healthcare system, I went to hear Professor Howard J. Bolnick, the genial former president of the United States Society of Actuaries, lecture on it to Politeia, one of the most enjoyable of London's right-leaning think-tanks. The learned professor said that 'marvellously, and I compliment you on this', Britain spent only 6.8 per cent of GDP on healthcare in 1997, compared with an EU average of 8.2 per cent and a gargantuan 13.7 per cent in the United
States: yet disability-adjusted lifeexpectancy (meaning the number of years you can expect to live in good health) is
71.7 years in Britain, compared with an EU average of 71.4 years and an American score of 70.0 years. Professor Bolnick concluded that while the American system is far more responsive, in the sense of giving patients 'personal and prompt attention' from the doctors of their choice (except, that is, for the 40 to 45 million people who are not covered by health insurance), this makes 'little difference in terms of health'.
Dr John Wiklen, a British neurosurgeon who has practised in the United States, asked why. then, the rate of death from carcinoma of the breast, from carcinoma of the cervix and from acute myocardial infarction is about 25 per cent higher in Britain than in America. The answer is presumably that these are conditions where speedy intervention is of the essence, so the ability to get treated quickly can save your life. But Professor Bolnick was content to stand by his general point, which is that the overall outcome of the two systems is about the same, despite vastly greater spending in America, a considerable proportion of which goes into lawyers' pockets.
These comparisons have left virtually no space to do justice to the many things that the NHS does extremely well. One that springs directly from the GP structure has to do with medical research. As Professor Tom Meade of the Medical Research Council explained, because almost all of us are registered with a GP, it is relatively easy in this country to study a representa tive sample of the population in order to establish whether, for example, it is worth treating mild hypertension (an early survey showed that it is) or what the benefits and hazards of hormone replacement therapy are (a subject of current research).
But I hope that these cursory comparisons have at least helped to suggest that the relative scarcity of doctors in the NHS has great advantages. Once you manage to see a doctor here, he or she is more likely to be experienced, and less likely to recommend superfluous tests and operations, many of which can easily do more harm than good. The doctor may also be in a better position than is the case in some other systems, should your condition not have mended in the months you have waited, to refer you to a centre of real expertise.
You might also be dead by the time your appointment comes, or living in unnecessary pain. But, as we wonder how to remedy the obvious shortcomings of the NHS, let us also remember that this strange socialist institution contains, despite the best endeavours of Alan Milburn, some pockets of intellectual liberty, and that although central planning is a very absurd idea, so is the notion that one can ever have a completely informed market in health. As taxpayers and also, for most of the time, as patients, we should remember that no health system is perfect, and should be less ungrateful for the relatively cheap, high-quality service we have. We are as neurotic about our health service as we are about our railways. A few deaths and we — or at least our media — fly into a frenzy of lamentations, recriminations and despair. What hypochondria, what ingratitude; for in health, as on the railways, any dispassionate observer can detect at least as many signs of hope as decay. It is very hard, when one hears British commentators grumbling about the state of the NHS, to avoid Frederick the Great's question, admittedly uttered in rather different circumstances: 'Rascals, would you live for ever?'