11 JANUARY 1992, Page 11


Robert Lefever challenges

our prejudices about the superiority of the National Health Service

FEW THINGS shock the liberal British about their American cousins more than the fact that in the United States there is hardly any state welfare provision. The health and welfare services in America have tended to receive a cynical and patro- nising press in Britain since the inception of our National Health Service, 'the envy of the world'. We in Britain are told that in America only the super-rich receive ade- quate medical care, the poor receive none that is worth having, and the middle- income groups have to sell their houses, if not their grandmothers, if they suffer any significant medical mishap. While America spends more per capita on health care than Britain, this is declared to be rashly spent on high technology, high fees for doctors and high costs of malpractice insurance. Conversely, the relatively lower expenditure in Britain is said to be evi- dence of deliberate government 'under- funding', in order to boost private practice.

These are over-simplifications, but there is, nonetheless, some truth behind them. Perhaps the greatest hidden truth, howev- er, is what actually happens in the health and welfare services of each country. As is customary in many areas of politics and journalism, truth is the first casualty. If we try for a moment to put aside our preju-

dices — a difficult process because we rarely see them as such — we can see that the problems and even some of the solu- tions are remarkably similar in the two countries.

In Britain, the NHS was born on a tide of hope. Doctors (largely out of greed and self-protection, although they would say otherwise) opposed it. The politicians, dreaming that health would improve along with health care, overlooked the fact that ill health and perceived ueed for expensive clinical services can only be postponed rather than cancelled.

In America, dramatic technological advances were immediately held to be the birthright of all: insurance cover deemed that they should be so, at least to those who had insurance. Doctors (largely out of greed and self-protection, although they would say otherwise) welcomed it. The politicians, dreaming that they could con- trol the costs of insurance and spread its franchise to a wider public, overlooked that ill health and perceived need for expensive clinical services are mostly concepts rather than absolutes.

In Britain, the stunted remnants of pri- vate hospital and general practice began to sprout again under a socialist government. In America, Republican administrations allowed burgeoning costs of health care to be carried by industry in welfare benefits to employees and often their dependants, and also increased the Medicare and Medicaid State .support systems of welfare to the poor and elderly.

In one respect there was a significant difference: America is fundamentally a litigious society, whereas the British are prepared to grunt, groan and grieve, pro- vided that what they receive is free. The difference lies not so much between the two countries' doctors as their lawyers. Or perhaps the system breeds the lawyers it does not deserve.

In Britain, lawsuits against doctors used to be rare and against State hospitals well nigh impossible because of Crown protec- tion: government largely holds itself to be above the law. In the United States, medi- cal malpractice became big business for lawyers, with legal fees sometimes taken only as a percentage of successful awards for damages. British doctors became casu- al in their record-keeping and sometimes in their clinical practice. American doctors became defensive, often appearing to spend more time and energy on their records than on their patients. Each side, acknowledging its own problems to a degree, said, 'Well, at least we haven't got a system like that one over there on the other side of the Atlantic.'

But times and systems of health care are changing. In Britain, groups of general practitioners can become budget holders, controlling where and how hospital funds will be spent on the care of their patients. iHospitals can opt to become self-govern- ing trusts, competing with others. Mal- practice charges are increasing. In America, health maintenance organisa- tions (groups of doctors to which an annu- al fee is paid by or on behalf of the patient) and principles of managed care serve to bring all medical services under progressively more centralised control. In Britain, the patient and the company pay taxes. In America, they pay the insurance companies.

Most recently, in a double twist, the British private sector has been importing the principles of managed care from America, while in America the insurance companies are now tending to determine 'I'm after something I won't fall off in mysterious circumstances.' the length of time and the type of care to be provided according to centralised proto- cols — not unlike our own NHS. The sup- posed fears of the British population, faced with what they are told by the Labour Party is the dismantling of the NHS, are paral- leled by those of the American population faced with the dismantling of their Employ- ee Assistance Programme benefits.

So where does this leave us? You guessed it: back at the start, with nobody even now prepared to look at the central truth expounded by the American objec- tivist philosopher and writer, Ayn Rand: 'The difference between a welfare state and a totalitarian state is merely a matter of time.'

We can struggle as much as we like to fund health and welfare services through the State or through the insurance compa- nies but, although centralised control waxes and wanes and takes on differing guises, it ultimately works against the patient. Two simple lessons in algebra demonstrate this point: Firstly, when A (the politician or insur- ance company) gives the work of B (the provider) to C (the recipient individual or organisation) three things happen: A wants the credit, B gets fed up and all the Cs fight each other.

Secondly, when A says he is robbing Peter to pay Paul, he is in fact taking money from Paul, administering it at great expense and inconvenience and then giving Paul back less than he had in the first place — and again expecting Paul to be grateful and fearful of any alternative.

But there is an alternative, as the Ameri- cans seemed to have found, before they started importing the worst aspects of our system: private practice, where doctors and other providers go hungry if they do not provide the services that are needed and wanted (these services are less expensive to provide in the less expensive areas), and private charity. The state and other massive central organisations need not and should not appear to be indispensable.

If we are to have insurance company provision, then let it cover only catastro- phes and not those aspects of normal expectation of ill-health and accident that can happen to anyone at any time. If we have to have state provision, then let it cover only those who cannot help them- selves or at least let it focus primarily upon them rather than upon being universally available. When all responsibility is taken away from the individual, in the long term he or she is hindered rather than helped.

If we forget simple human kindness and generosity to each other, and merely rely upon the State or insurance companies or

some other Big Brother, then we are lost. And are they really too big to take on or replace? The journey of a thousand miles begins with a single step.

Dr Lefever is a private general practitioner in London.