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As a Brit using the NHS I can only add that I trust, and expect, every government to make the NHS worse whilst they talk of how marvellous it is.
I would really like it given to an independent cross-party body, or the civil service, to try distance it from politics and The Treasury. I'd like to see legislation to heavily penalise drug companies seeking 20,000% price increases and the like.
Both sides fiddle with it, trivially and constantly. They will even fiddle when they have won a second term or reorganised ministers - because what they themselves thought 4 years ago must have been stupid and should be immediately changed, or something.
Much of the waste is from badly thought through political fiddling, remnants of previous fiddling, and public-private partnerships stupidly chosen during a time of lowest borrowing in British history.
Neither side is honest about it however.
I'd like to see a long-term outcomes-based comparison between NHS England and the Scottish NHS, frankly.
The Scottish NHS is a fully devolved issue and has been diverging from the English system for most of a decade now, with a greater emphasis on preventative healthcare and screening programs (not to mention free prescriptions for all).
In another couple of years we may even have some hard statistical data on what practices work best!
I believe they did a study and outcomes were better in England. I'll try google it.
Imagine how well an NHS organised as it was in 1948 would function in today's world. Although there is no doubt that it could be better managed setting it in aspic will kill it surer than a nail in the back of the head. The NHS will face massive challenges in the next 30 years from demographic pressure on demand and staff, technology change and citizen behaviour and expectation. Radical "fiddling" is going to be needed to keep it alive. This is 100's bn pounds - it's the core of UK politics and it should be - we are a democracy.
> I would really like it given to an independent cross-party body, or the civil service, to try distance it from politics and The Treasury.
They did that. The governmental bit (in England) is the Department for Health and Social Care.
NHS England is the qango that runs the NHS in England. They provide money to CCGs to commission most services. NHS England directly commissions some (so called "tier 4" services) - eg inpatient mental health services for children; medium and high secure mental health services; etc.
I genuinely have no idea what happens in Wales, Scotland, or NI. Health is devolved and they run their systems independently.
By comparative metrics to the rest of the world the NHS comes out either top or pretty damn good. By comparison to whatever the metrics of whatever government is in power at the time the NHS always looks terrible. Budgets can be set arbitrarily by the government so it’s easy to make the NHS look like it is over budget (in fact all you need to do is increase the budget by less than inflation and talk about absolute numbers to fool the public and hey presto “the NHS is terribly inefficient”).
The whole “4 hour” thing is mad - you should be seen in a reasonable time frame for the ailment you have. Severed hand? Go right ahead. Headache and photo sensitivity that’s been going for a couple of days already? We’ll be with you when we can and if things get substantially worse come back to the reception and you may be deemed more critical. Obviously I am over simplifying the matter but the NHS is staffed by competent trained professionals who should be allowed to use their own judgment as the whether someone can wait 30 seconds, or 6 hours.
>By comparative metrics to the rest of the world the NHS comes out either top or pretty damn good.
Ish. The NHS is remarkably cost-effective, but has relatively poor survival rates for cancer, stroke and myocardial infarction. International comparisons seem to damn the NHS with faint praise - it's cheap and the patients are happy, but it's not very good at keeping people alive.
http://www.qualitywatch.org.uk/sites/files/qualitywatch/fiel...
> The whole “4 hour” thing is mad - you should be seen in a reasonable time frame for the ailment you have. Severed hand? Go right ahead.
it's already like this, A&E is run on triage, "4 hours" is a target not an instruction
and if you go to A&E with something like a cold you'll be given a stern talking to and sent home
Here in the US I had to take my son (he was 5 years old at the time) to the emergency room when he had slipped in the bathtub and hit his head which caused a huge gash right above his eye. We sat in the emergency room for 5 hours before any of the staff bothered to look at his open wound and then another 4 hours after that before they actually treated him.
The most infuriating part of the experience was the not-so-subtle attempt by the staff to see whether or not I had told them the truth about how he had sustained his injury by constantly asking him to recount how he had sustained his injury instead of actually treating his injury. On top of that, the staff were rude and generally dismissive when I asked how long they thought it would be before my son would receive treatment.
And then of course the billing nightmare that ensued was just extra icing on the cake. The hospital was in network for my insurance (which I verified before I went and again while I was there) but the staff neglected to tell me that they were contracted through a completely different company that turns out was not in network so I ended up having to pay almost $2000 for what amounted to a few stitches for my son.
100% f'ing right. People who think the US health care system is fantastic either (a) haven't used it much, or (b) are rich enough not to care - and in this category I'll include those with good employer-provided health care (although this number is dwindling rapidly)
I am a lot like the author (dual national, lived in both US and UK). One of my children was born in the US, the other in the UK. I agree with the author 100%. I would emphasize more the peace of mind that in the UK my family's health care is in no way tied to my job (I earn plenty of money and have never had trouble finding employment).
There are also huge societal benefits to socialized healthcare. There are far fewer desperate homeless people in the UK, because many homeless people in the US are stuck in that situation in large part because of some health issue. There's just a fundamental feeling in the UK that we're all going through this life together.
"In the UK, I showed up at 9am and was seen instantly"
I don't think that's ever happened to me. Most likely this person was the first patient of the day, so appointment times haven't slipped yet. 30 minutes in the minimum I've had to wait in general. I've also had to wait weeks to see a GP (in the countryside).
I find anecdotal articles like this pretty unhelpful in general. We all have our own anecdotes, it's more interesting to look at the data. Comparisons between UK and US healthcare are also somewhat meaningless. They've very different systems, and their are many other countries with private and public healthcare systems that you could compare.
I'm not really familiar with NHS processes, so when it took you weeks to be seen, did someone just take your info when you walked in and say they'd get back to you when they could, or was your condition evaluated first (diagnostics run, etc) and an appointment scheduled for you for a particular date a few weeks in the future?
Overall this is a great compare and constrast article, but I do have one quibble with it.
> In the US, I've always been able to see a specialist within a few days. Score one for America.
This is really, really heavily dependent on where you live and the number of doctors and specialist doctors in the area.
I live in a mid-sized city. If I need to see a typical general practice doctor for a routine problem (coughs, etc.) I can usually be seen the same day, but I'll probably have to wait a 2-4 hours depending on when I go.
But if I need to see a specialist (allergist, dermatologist, sleep doctor, etc) and it's not a life-or-death emergency, it's usually a six-week to six month wait for an opening. It literally took six months before I was able to see a dermatologist last year.
My only other option is to drive 2 hours away to the next (bigger) city that has a medical school and a large concentration of doctors. Sometimes you can get an appointment in a few days if you're willing to drive. This is actually what I've started doing when I'm referred to a specialist.
And if you live in a rural area, even routine medical care can be difficult to come by. Many towns will have a small clinic staffed by a doctor who lives in the community, but often this doctor may have rounds where he covers several communities in a geographic area. So, for instance, he may only be in the office in your nearest town Mondays and Thursdays. So if you need to see a doctor and the local nurses can't handle it, you either have to wait or drive to wherever the doctor is that day.
Where I grew up in East Tennessee, we also had a volunteer service called Remote Area Medical [0], which provided free service to very remote areas of Appalachia. I remember going to the Knoxville airport with my Dad once and seeing their DC-3 fueling up for its next trip.
So how does the US improve its healthcare system?
More interestingly, can the US political system ever enable an evidence-based debate around it?
From the other side of the pond, it feels like debates end up being emotional rather than scientific.
(I’m a Brit and love the NHS with a passion but would not claim that it’s without flaw. Neither would I claim that we necessarily have more reasoned debates about issues here...)
> More interestingly, can the US political system ever enable an evidence-based debate around it?
I honestly think the reason the US is slipping so much is because their political system never seems to have evidence-based debates around anything.
Worse, they have absolutely no interest what-so-ever in comparing their country and how it's actually functioning to other Developed Countries for the purposes of improvement. In fact, I genuinely don't think they care to improve anything, at all.
I personally get the sense that it's quite easy for the NHS to look good when you compare it to America. When you compare to other western countries the results don't always seem so great and there are definately situations where as an outsider I think things are clearly pretty bad (like NHS IT system procurement).
I don't hold out much hope for reasoned debate to help things though - who can form a reasonable opinion about ~6% of GDP directly managed by the Department for Health? I certainly can't.
The US's problem is that things are massively inequal with income and wealth. And political power tends to follow the income and wealth. So for a significant (and over-represented politically) fraction of the US, we have better health coverage than what I can see about the NHS (I read Terry Pratchett's descriptions with despair and disbelief). Similarly, the problems the writer describes in the US system - those haven't happened with my health plans, despite costing them very large chunks of money at times. General doctor scheduling seems good in the article, but that's a pretty minor aspect of the complete care picture.
A more fair system could be quite a bit worse for people currently in positions of influence, and that's what's going to make it hard. That's how we got Obamacare in the first place - incremental improvement for some, trying not to screw it up for the most consistent voters - and even it's coming close to voter revolt-driven rollback.
If you want meaningful change I'm convinced it's going to have to come from the Sanders-style wing. The mainstream Democratic and Republican parties are too aware of how good they've got it, and at whose expense that comes, currently.
>So how does the US improve its healthcare system?
On both sides of the pond, we need to break the false dichotomy of UK vs US. Our systems are almost diametrically opposed, but they get vastly disproportionate mindshare and airtime. In any debate about NHS reforms, people will inevitably hold up the US as a cautionary tale and vice-versa, but hardly anyone raises Germany or Australia as a workable middle ground. This false dichotomy also dominates the debate over gun control.
Healthcare Triage did an excellent series of videos summarising the strengths and weaknesses of various international healthcare systems. I can highly recommend it to anyone on either side of the pond who is thinking about how their healthcare system could be reformed.
https://www.youtube.com/watch?v=ylsO0VVy29U&list=PLkfBg8ML-g...
The NHS is based on solidarity. Good luck with that in the US.
What evidence do we want to compare?
That's kind of where it loses me. We already have a system very similar to single-payer for our veterans and it is notoriously inefficient, bloated, and unpopular. What many are clamoring for in the US is already being tried in the US and failing exactly the way opponents claim it will.
Evidence that it works well in other countries is worth considering, but it in no way proves such a system would work well here. It'd probably work well in states that are similarly culturally homogenous (like Vermont or New Hampshire), but the discussion always seems to be at the federal level.
I think what we need is more freedom for experimentation. Pick maybe a city or county and make it eligible to sidestep all of the federal and state regulations and build/create their own. Some will undoubtedly shoot for a libertarian approach while others might imitate the NHS. See how the costs and outcomes compare. Gather more evidence in a more relevant way.
As I'm also an American using Britain's NHS, I was pleasantly surprised to see the article mostly matches up with my experiences using local services (though as others have called out, NHS GPs and Specialists still have regular 15-30 minute delays for pre-scheduled appointments, IME)
The only downside I would call out is that I pay slightly higher taxes in the UK than I would in the US, and I imagine that part of it goes to fund NHS programs.
That said, the small increase is a relative bargain, given the the excellent level of care provided by NHS staff and the avoidance of insurance nightmares I was used to dealing with back in the states.
I'm not sure how it factors into taxes, but the US government spends more per capita on healthcare than the UK government does.
https://visual.ons.gov.uk/how-does-uk-healthcare-spending-co...
As a point of anecdata, my dad, an American, lived in Wales the last ten years of his life. His arthritis got too bad for him to work, and the NHS took excellent care of him for years. Then he had cardiac issues and although his NHS doctor recommended heart surgery, they didn't schedule the procedure for several months and he died of a heart attack in the meantime (age 62).
Public healthcare took great care of him and then it killed him. Hard not to be ambivalent about that (though n.b. this is not an endorsement of the US system by any means).
>In the US, having sat in many an ER waiting room for hours at a stretch, the idea of a hospital seeing nearly 9 out of 10 patients in four hours would be regarded as a miracle.
That is so bizarre. I'd be concerned if it takes and hour. Seriously it's called emergency room because it's an emergency, not a "it can totally wait" room.
My friend had a seizure while we were on a business trip in a suburb of London. We were taken to the hospital in ambulance, I remember we had to go through a series of 6 rooms each getting progressively smaller( first one had like 200-300 ppl) and less people. Took us about 5 hrs to get to the doctor. Doctor was patient and polite.
Rather depends who is there and why. Last time I went was for a small animal bite (had gone to the docs but they had no tetanus shots so sent me on), hardly life and death. Was triaged quickly, but then waited to be dealt with properly.
They have vigorous triage. If you're about to die they have fully stocked ambos with paramedics providing treatment to you on the scene and then transporting you, with blue lights, to an A&E and direct into majors.
If you turn up with a broken finger you're going to have to wait for most of those 4 hours.
(I'm not defending the 4 hour limit. I think it's weird and needs to go)
Although it is an emergency room, a lot of people still turn up when it's not an emergency. It's heavily triaged. If you seriously need attention RIGHT NOW, you will get it. It's not like people are sitting in waiting rooms and dying in the meantime.
A lot of patients are anything but emergencies though. Since it can be near impossible to get a same-day doctors appointment in some areas. In the South of England it can be weeks.
So people just go to the hospital A&E dept instead, sometimes for quite minor ailments - although not always.
Might be of interest to discuss other systems as well. I'm somewhat familiar with the system in South Korea:
- There's a National Insurance System that all citizens are signed up to at birth.
- Premiums are based on income with employers splitting the cost 50:50. Low income/unemployed people go on a slightly different but substantially similar plan with no premiums.
- Prices for procedures are nationally set and fixed.
- Hospitals and Doctors are generally private, but must accept the National Insurance.
- Patients pay a co-pay and doctors bill the National Insurance system for the full price.
- The National Insurance plan only covers a set of elective procedures. Unelective procedures are payed for out of pocket, or by private supplementary insurance (which are also quite popular). e.g. if you have cancer you can go with the prescribed National Insurance treatment and it's covered, or you can go with other treatments which the private hospitals are more than happy to provide.
- Upside: people go to the doctor early and often and as a result South Korea has some of the best medical outcomes in the world (with a few exceptions). The robust private hospital system brings in medical tourists for a wide variety of medical procedures at low prices. If you're in the Hospital and want better care than the National Insurance covers, and you have the money, your class of care options is virtually unlimited. Fewer bankruptcies than the U.S. and <7% of GDP is spent on healthcare. System is considered among the best in the world.
- Downside: The system tends to favor simpler problems that can be handled in an assembly-line fashion. Doctors need to see huge numbers of patients to make a living, so bedside chat time is very limited (but in practice it's about as much time as I see my doctor in the U.S.). Doctors over recommend procedures and tests to get the insurance money.
- Paradox: Because doctors are payed per procedure, but the procedures are limited, they tend to oversubscribe labs and imaging. This means that there are about 3x as many hospital beds and imaging machines than the U.S.
- Source: Visit South Korea semi-frequently, been sick there. Even not being insured (thus paying out of pocket) the cost was far lower than my insured care in the U.S.
Note that the UK also has a small private system; if you're really not happy with waiting for appointments or operations you can pay to be seen. Some higher-paid jobs come with health insurance, which is really cheap because anything difficult or expensive can be shunted off to the NHS.
The NHS will try many things to avoid expensive options like MRIs and more expensive medications.
For Multiple Sclerosis I was given one MRI and NO medications over the course of 12 years as I went from relapsing remitting to secondary progressive. Total postcode lottery so fuck the NHS.
I have never seen such a bureaucratic/inefficiently operated institution - and there are plenty to choose from in the UK. My electricity company replaced all Vs with Ks in letters to us for 7 months. The NHS is much worse (try even getting a letter to arrive within a month - to the right address - let alone receive any medical treatment).
I have not dealt with US healthcare but having experienced other countries' I'd strongly suggest not following the UK system - other European countries certainly come to mind as working substantially better. Of course, there's a huge "Save Our NHS" push due to the number of people it employs, unions, misplaced national pride etc.
Funny how your anecdotal point is just that, anecdotal. Here's another anecdotal point for you -- Pancreatic cancer (stage 2). Diagnosed on the first visit even though a private doctor had missed it previously. Surgery in less than 5 days, excellent follow-up and post-surgery care including the surgeon having a set of non-mandatory procedures approved in record time (10mins) as a preventative step towards recurrence. Two years later, cancer free with excellent reminders and follow-ups on periodic checkups.
Your experience does not dictate the system, as doesn't mine.
It's a myth to suggest the NHS is heavy on bureacracy. The NHS has less management than most UK business, and often those managers are dual role clinicians / managers.
https://www.kingsfund.org.uk/projects/health-and-social-care...
> The NHS Information Centre shows that there were about 43,000 NHS managers in 2009 (about 3.7 per cent of the total workforce), although this figure does not include many clinical managers. How does this compare to other sectors?
> According to the Office for National Statistics, the proportion of managers in the UK workforce as a whole in June 2010 was 15.4 per cent. These statistics also show that there were 77,000 hospital and health service managers across the United Kingdom, or 4.8 per cent of the NHS workforce. In other words, the NHS has a managerial workforce that is one-third the size of that across the economy as a whole.
Your letter taking a month to arrive is something that you can complain about. Did you make a complaint about it to the relevant trust?
> I have not dealt with US healthcare
Since we're detailing anecdata, I went on a working holiday to the US and had an accident in work. I was fully covered under my travel insurance, and doubly covered under my employer's insurance. I broke several bones in my hand and needed a costly operation to insert pins. The payment approval time from insurers took longer than the minimum wait for the operation before bones fused. I did not have the operation and have had problems in my right hand since.
I take your point about other European countries doing it better, I'm sure that's true. But the article is using the US system as a metric. I'm living in Ireland and would love to have a system as good as the NHS over here. Everything's relative but when you're comparing the NHS to clearly inferior systems there's not much point playing devil's advocate. There are enough individuals with a vested interest in the disassembly of the NHS as it is.
It's actually one of the best value health care systems.. Sadly it is being made inefficient by the current government.
If we are going by anecdotal evidence, the NHS has been absolutely brilliant for me.
https://www.theguardian.com/society/2017/jul/14/nhs-holds-on...
Many Brits are in the same situation and hold the same opinion, because they've never experienced anything else. Having personally experienced the US and UK systems, I assure you that's because you simply can't conceive how bad it is in the US!
> My electricity company replaced all Vs with Ks in letters to us for 7 months
What does that mean?
> Fifteen minutes to see a free doctor!
It's not free, the money to pay the hospital bills comes from
taxation
one of the meta challenges with socialized medicine is that there is virtually no innovation due to price controls (please no anecdotes). The US essentially funds medical innovation for the entire rest of the world. If the US goes socialized you will see almost a complete halt to medical innovation over time.
Here are 3 (not evidence based) reasons why medical care costs more in the US:
1) more administration (too many rules/regulations) 2) higher costs for the base goods (people get paid more, pharma, medical devices, etc) due to lack of price controls 3) people get more care, potentially even when it isnt going to help
https://www.pbs.org/newshour/nation/why-does-health-care-cos...
I strongly disagree with your first statement. The US definitely has a high rate of innovation in medical procedures, but by no means is it Atlas, carrying the world on its shoulders. Canada which is just a single socialized healthcare system has systematically produced fantastic innovations in drugs and therapy over the last 100 years. We have dozens of research hospitals who innovate regularly. I don't have the time to spend researching every single innovation, but a small sample is included below.
There is a lot of donor money and government grant money in medical research around the world.
Research Hospitals (off the top of my head)
- The Ottawa Hospital
- SickKids
- Sunnybrook Health Sciences Centre
- Sinai Health System
- Kingston General Hospital
Innovation
[1] http://innovativemedicines.ca/medicines/timeline/
[2] https://legionmagazine.com/en/2009/08/eight-great-canadian-m...
Do you not consider the billions of dollars which the U.S. government puts into basic medical research socialized innovation? It was only last year that the U.S. government spending dropped below 50% of the total following years of federal cuts:
http://www.sciencemag.org/news/2017/03/data-check-us-governm...
Your starting assumption that price controls are incompatible with innovation is a political belief, not a fact. There's no reason why that precludes funding bounties for improvements / cost reductions (e.g. why Japan's MRIs are so much cheaper than the U.S.), using different funding models for R&D than manufacturing, etc. Individual systems could choose not to fund research but that's a choice rather than a universal truth.
>one of the meta challenges with socialized medicine is that there is virtually no innovation due to price controls (please no anecdotes).
Thanks for parenthetically instructing us not to share anecdotes at the end of a statement which isn't even that.
https://www.statista.com/statistics/266141/pharmaceutical-sp...
That's per capital spending on pharmaceuticals. Two things to note from that: 1) The highest by far is in the US, that's absolutely true. 2) Substantial amounts are still spent in other wealthy countries.
American healthcare payers - insurance companies and their agents - also impose controls on what they will pay for drugs and for which conditions. They don't seem to be as effective in enforcing them since they haven't got the kind of monopsoninistic power as either single payer systems like Canada or constrained multi-payer insurance markets like the Netherlands.
That Americans overpaying for drugs helps to subsidise R&D that everyone benefits from seems like it make intuitive sense. I'd question whether the evidence supports a complete halt to innovation if the US adopted pharmaceutical price controls unless the price control they adopted was to restrict prices to cost of production - something that no government single payer health service does.
In the NHS, these decisions are made by the NICE which determines how many quality adjusted life years are gained from the use of a drug and then checks to see if they clear a threshold CBA value. It's worth noting that £100k+ cancer drugs that actually work are still frequently approved under this system. Recently, NICE approved Soliris at £330k/yr for treating aHUS. That's $450k/yr, treatment required for life. I suspect that many American insurance companies wouldn't fund that.
Moreover there are goods and services such as fighter jets where there is a single US government buyer and innovation still happens. Conceptually it doesn't appear that this needs to be a barrier to innovation spending.
> one of the meta challenges with socialized medicine is that there is virtually no innovation due to price controls
This is a strong claim presented with no evidence. It is clear that the US is, by far, the global leader in this area. But to say there is no other innovation at all is going a bit far.
Indeed, it is easy to see that communist China is the world's second in this area, whether you go by papers published, clinical trials, or whatnot.
Even the libertarian Cato Institute doesn't go so far as to say that no one but the US innovates.
https://www.cato.org/publications/policy-analysis/bending-pr...
The argument that "if the US goes socialized, you will see almost a complete halt to medical innovation over time," and therefore that private funding of research is preferred, is a bad one. It rests on the premise that the profit motive for pharma companies and the imperative to improve health care outcomes for the greatest number of people are aligned, which they are not.
Public funding of drug research is a better driver for the discovery of improved treatments than private pharma investment - under the current model, drug companies aren't incentivized to develop novel treatments (see Nexium), or to develop treatments that would improve outcomes for the greatest number of people (see Pfizer abandoning research into Alzheimer's and Parkinson's treatments).
Since the Bayh-Dole Act passed in 1980, pharma companies have profited hugely by purchasing patents held by publicly-funded researchers, and commercializing them with virtually no controls on the resulting drug prices. Even private development of drugs still relies on publicly-funded and publicly-available research. The assertion that the institution of stricter price controls would eliminate innovation seems to be untrue - I don't think that scientists are incentivized to do research solely by the promise of lucrative patents. Stricter price controls would likely mean that the government would have to participate more directly in the clinical trial phase, which would be a good thing, as there are minimal checks against manipulation of clinical trials.