A TALE OF TWO HOSPITALS
The National Health Service has a great deal to learn from the French approach to medicine,
argues Mary Wakefield
'THE challenge is to make the NHS once again the healthcare system the world most envies,' said Tony Blair before the election. 'We will bring it up to European standards and deliver world-class public services to all the people all of the time.' When he talks about 'European', many commentators believe that he ought to mean 'French'. According to the World Health Organisation. the NHS ranks 18th in the world, whereas the French healthcare system is the best. To put those statistics in context, I went to talk to staff, patients and residents in two one-hospital towns on either side of the Channel.
I pulled into the carpark of Buckland Hospital in Dover accompanied by Paul Watkins, former chairman of the local community health council and a professional nurse. At the last election, Paul stood as Conservative candidate and campaigned vigorously to save the hospital. But why should it need saving when the government has promised a 1.102 million redevelopment of all East Kent hospitals, in an announcement that made a special mention of Buckland? 'You'll see,' said Paul — and so I did, even before we entered the hospital.
As we looked for a parking space, a small, agitated figure in a white coat walked quickly towards us, poked his face through the driver's window and said, 'Bloody hell!' loudly. 'Hi, Paul. Sorry, but what a bloody mess.'
Over the next two minutes I had my first lesson in New Labourspeak. Modernising means downgrading. Dr X had just come out of a meeting in which it was made clear to him that he and a colleague were being encouraged to leave the hospital, against their will. Two night nurses had left Buckland the previous week, the pathology unit is closing and the emergency services are being cut back, leaving only a minor injuries unit. The hospital shows all the signs of being shut down.
Paul took me up to a picnic table perched on the edge of the white cliffs. A warm soothing wind blew over from France. 'Look beneath you,' he said. 'That's the busiest port in the UK. Can it be sensible to close down the accident and emergency unit in a place like this, with locals, asylum-seekers and tourists all in the pub here on a Friday night? It's a bumpy 30 to 45 minute ambulance ride now just to get to the nearest A&E in Ashford, and then the poor sods have to wait for hours to be seen.'
The problem appears to be that while the government has pledged to increase spending on health by 6.1 per cent year on year from the current 6.7 per cent of GDP, and
has formed grand plans for 20,000 extra nurses, 7,500 more consultants, 2,000 more GPs and 100 new hospital developments by 2004, they are simultaneously making savings by removing facilities and staff from local hospitals such as Buckland. This means an additional workload for the hospitals that have been chosen for improvement, long before they have the additional staff and resources, which creates a domino effect: Buckland suffers cuts, leading to falling standards and a collapse of morale; Ashford and Margate have to deal with more patients than they can cope with, so they feel as if they, too, have been cut, and their morale also suffers.
Paul told me that only last week that 100 junior doctors and consultants wrote to NHS managers and to the Health Secretary, Alan Milburn, warning them that they could not provide a safe service in the
three main East Kent hospitals. They pointed out that porta-wards have had to be erected as a temporary solution in Ashford, while beds lie empty in Buckland.
Back at Buckland, the low lighting almost succeeds in concealing the nasty things embedded in the waiting-room carpet. Disconsolate pensioners rock backwards and forwards on rows of metal chairs, coughing violently with every forward rock. There is an awful smell of rotting meat. Nurse Sarah (not her real name) explains: 'A dead mouse. Under the floorboards. Revolting, isn't it? Hang on,' She sprays peach mist air-freshener in figures of eight around the room. 'The mouse will probably stay there for ever. I'll just cover up the bad smell. Like government solutions to NHS problems,' she laughs.
'Seriously, though, the mood in nursing is appalling, rock-bottom,' she says. What about all this increased spending; isn't that encouraging? Nurse Sarah is firm: 'There is no progress and there is no hope. I was working in Ashford last night — it's supposed to be one of the improved hospitals. There were 32 patients waiting on trolleys in corridors because of lack of ward space. These people don't show up as trolley-waits in government figures, because a junior doctor will have whisked by and asked them a couple of cursory questions. That counts as having been "seen".'
Apart from cost-cutting, Nurse Sarah explains, the major reason for centralisation is that doctors and nurses do not want to work in minor local hospitals. All hospitals are dependent on trainee doctors who need to be exposed to a wide variety of cases in order to learn. But as most local hospitals are stuffed full of pensioners with breathing difficulties, young Doogie Howsers working in them do not have the opportunity to see a proper menu of serious ailments. So they try to find alternative postings, yet the local hospitals cannot survive without them.
As I wandered back to the railway station, dazed, breathing sea air deeply into my lungs to extinguish traces of mouse, I picked
up a copy of the Dover Express. On the letters page a woman told a sad but salient story. Her husband had collapsed while working in the fields. Paramedics arrived quickly, but he died halfway through the long journey to Canterbury. Like everyone else in Dover — residents, doctors, nurses alike — this correspondent wanted to know where all the extra money that Mr Blair has promised is actually going.
It is obvious where the money has gone in the Centre ITopital de Calais. Whereas Bucldand is a low grey building in need of a paint job inside and out, the hospital in Calais is gleaming and impressive. It boasts an enviable list of departments: paediatrics, intensive care, endoscopy, gastro-enterology, cardiology. All are in full use_ From time to time, busy-looking women in white coats and heels clipped across the smart black-andwhite chequered floor, followed by men in green overalls pushing wheelable cleaningunits stuffed with brushes and disinfectant. To the left of the receptionist's Perspex capsule, patients sat talking to visitors at a sprawl of chic little café tables.
Trying to speak to the hospital staff as they sailed through reception was a daunting task, They had an angular, focused air with none of the homeliness of British nurses, but I managed to corner one long enough for her to explain the French system. Compulsory health insurance, which costs 20 per cent of one's salary, covers 99 per cent of the population, she said, but only half of total health expenditure, which is about 9.8 per cent of GDP (3 per cent more than ours). Patients fork out money up front for any medical attention, and then send off
record sheets feud/es de SOInS — to the Secu (social security) which will reimburse 75 per cent of the total bill. As the compulsory insurance does not cover all services — it excludes dentistry, spectacles and cosmetic surgery, for example — roughly 80 per cent of the French population choose to spend a further 2.5 per cent of their wages on voluntary mutual funds.
All this sounds expensive, messy and complicated. But whereas our system is simple in theory and appallingly complicated to execute, the reverse seems to be true in France. In almost all cases the cost of an operation is much lower than in Britain. According to the British Cardiac Patients' Association, bypass operations in France are a third cheaper than over here. They can also be had more quickly. At the end of last year there were 74 patients who had been waiting six months or more for bypass surgery in East Kent. In France, the average wait for the same operation is two days.
Feeling enthusiastic about the French system, I took a taxi to a downtown bar to see what the residents thought of their hospital. 'Eeuuuh, the hospital, bah!' said my taxi-driver. It looks like a very nice place to me,' I protested. 'Well, let me tell you,' continued the driver, 'I wouldn't want to get ill in Calais. My father had his leg crushed by an industrial roller. Horrible. The staff at Calais said that they'd have to amputate. They were sharpening their knives. But we went for a second opinion in Lille, and the doctors there managed to save the leg.'
Whether it proves that Lille is exceptional or Calais frighteningly incompetent, my taxi-driver's experience at least shows the benefit of one aspect of the French system. Unlike us. French patients can have as many second opinions as they like at no extra cost. They can also choose to see a specialist straight away without going through a GP. In the same situation in England, my taxi-driver's father's leg would have been history.
'The French health system is useless (nut),' said Jean, a barman. emphatically, as he sliced the foam from my glass of Stella with a metal spatula. 'I skewered my finger, pierced it right through with a piece of metal, and I had to wait an hour in the emergency waiting room before anyone saw to it.'
'Look, I nearly severed my thumb,' said Michel, later that day, in the accident and emergency waiting-room. He peeled back a yellowing bandage to let me have a look. 'I had to wait three hours to be seen. It was an outrage.'
It was obvious that Dover residents and nurses felt real, dead-end despair, but the grumbling in Calais had a routine quality; it did not seem deeply felt. From what I gathered, although there does seem to be a staff shortage in Calais, no one has real problems with the system as a whole. Most of my conversations concluded with: 'Eh! But our health is better than yours, isn't it? You're really screwed in England, aren't you?' If, only 50 miles from Ashford A&E, French patients think an hour's wait is worth complaining about, then yes, we are.
The relative price of operations in France is also something for Alan Milburn to ponder. A cataract surgery, costing up to £3,000 here, would cost only £1,000 in a French hospital. Hip replacements are £2,000 less expensive across the Channel, while varicose veins surgery and hysterectomies are about 50 per cent cheaper. Whereas you might have to wait two years for a hip or knee replacement in Britain, there is a two-week wait in France.
There are also indications that the con dition of the NHS prevents British doctors from performing as well as their European counterparts. As the Centre for Policy Studies points out: of Italy, France, Germany, the USA, Canada and the UK, Britain has the highest mortality rates for respiratory diseases, malignant tumours and heart disease. At the age of 60, French men can expect to live a further 19.9 years and French women an extra 25.1 years. This is 1.1 and 1.2 more years respectively than British men and women.
Perhaps one of the lessons we have to learn from the French is not to be so wary about private healthcare. Last week, the mere suggestion that the government might involve private firms in the NHS provoked an uproar, whereas the French are unconcerned about the fact that their national insurance makes no distinction between public and private hospitals (public hospitals provide some 65 per cent of the beds, and the remainder are private, divided between non-profit organisations and those that make a profit).
Nor is it just the extra money that makes the French system work so much better. The fact that French patients have to pay 25 per cent of their costs up front discourages them from wasting medical time. The British public increase the NHS workload enormously by trooping off to see their GPs with head colds and sore throats. In France, super-efficient pharmacists, presiding over hundreds of drawers full of pills, lotions and suppositories, are often considered authority enough for minor ailments.
Most importantly, French nurses, although paid about the same as those in Britain, have only about half the workload. When Nurse Sarah first started working in the NHS 30 years ago, the morning shift overlapped with the afternoon shift by an hour. This meant that nurses had a chance to chat about the best solutions to various patients' needs. Successive British governments have eroded that overlap so as to increase productivity as measured on paper. Sarah is convinced that if British nurses had time to talk, as they do in France, accidents would be prevented, patients would be better treated, and it would be easier to attract recruits to her profession.
This sort of improvement would not produce grand, election-winning statistics. That should not be the priority. As Paul Watkins says, 'Until our various political parties stop seeing the NHS as a political tool, and start countenancing practical, long-term measures, there is going to be a horrific divide between the publicised government figures and the reality.' Whatever problems there may be with their health, the French at least seem to understand that, as Macmillan once said about housing, 'It is not a question of conservatism or socialism. It is a question of humanity.'
Mary Wakefield is assistant editor of The Spectator.