Yesterday President Obama assured us that healthcare reform was at the top of his agenda. Opponents raise the spectre of socialized medicine and Britain's NHS is held up as an example of what lies down that path.
The truth is that both Britain and America have a mixed economy of social and private healthcare.
The great worry is that socialized medicine leads to rationing. At one time the NHS had a waiting list of five years for a hip replacement and there is a built in delay in getting the new cancer drugs, some of which have not been and may not be approved by NICE.
However, this indictment of the NHS does not tell the whole story. Even when it took 5 years to get a hip replacement on the NHS you could get one next week if you had health insurance. At the time I was practising around 20% of the population had healthcare insurance. This is a far lower percentage than in America, of course, but there are reasons for this, which I will explain. Health insurance for the 20% is largely provided by employers who naturally enough regard it as a good investment since it gives them control over when their employees will be absent on health grounds. The whole private healthcare industry is geared towards elective surgery, since it is this area that is easiest for socialized medicine to ration. If you were paying through your taxes for someone else's treatment you would be happy to cover treatment for cancer and heart attacks but you might be unsure about paying for their varicose veins or their sticking out ears to be remedied.
Private health insurance usually extended to the employees family. Many self-employed individuals were able to write off healthcare insurance as a business expense and saw it as a good investment.
The other element to my thesis is that America also enjoys socialized medicine. The largest plank in this is the VA service. Some commentators have suggested that this is the most efficient part of American healthcare. In addition there is Medicare and Medicaid and a separate provision for children. It is also true that there are government subsidies to the private insurance industry in the form of tax breaks. Finally, there are the county hospital ERs that provide free healthcare to the indigenous poor.
The UK currently spends about 7.4% of GDP on the NHS. Surprisingly, the American government spends a staggering 11% of a much larger GDP on healthcare. The healthcare purchased by insurance is on top of this.
There is no doubt in my mind that the very best healthcare is provided by doctors working in private practise. Isn't that what you would expect? The more you pay for something the more you are likely to receive for you money. After all, Honda makes very good cars, but Rolls Royce make better ones. In any business transaction you largely get what you pay for. It is also true that among the best paid doctors there are some flim flam men who are taking money under false pretenses, but that's the market for you.
The problem with the market is that we can't all afford Rolls Royces and some of us have to settle for a Ford. But even a Ford is expected to get us from A to B on time.
There was a time that the Ford provided by the NHS was a beat-up Edsel, but at that time only about 4% of GDP was being spent on it. I remember when I started as a hospital consultant I was single handed in haematology; now there are 5 people doing the job I was doing and 5 junior doctors being trained in the department where there were none before. There were 3 general physicians in my hospital; now there are 33. I have seen improvements in the quality of medicine that are almost unbelievable. Nonetheless, there are still blackspots in the system that need remedy.
The reason that private medicine has never been purchased by more than 20% of the population in the UK is that the NHS is so good. It is so good because it is very efficient, avoiding buying things that are unnecessary, using the power of central purchasing in the way that the Supermarkets do to drive down prices, yet at the same time allowing a high degree of local autonomy to take advantage of local situations.
I suspect that the reason that so many buy medical insurance in America is because the alternative is so awful.
Let's take some of the specific criticisms of the NHS. How about those long waiting times? Our own hospital has been at the forefront of getting these down. No-one has to wait more than two weeks to see a consultant about a suspected cancer. Hip replacement waiting times are down to six weeks. No-one in the country waits for more than 18 weeks for any procedure.
The NHS won't pay for expensive cancer drugs. There is some truth in this. But until recently the only way you could get rituximab for CLL in America was by terminological inexactitude. If you called your CLL a type of lymphoma then you could get the insurance companies to pay for it. You could do the same in the UK until the authorities got wise to the fact that there was no evidence that rituximab showed benefit in CLL. It was not until the German CLL8 trial reported that we were sure that rituximab improved the length of remissions in CLL. It is the pharmaceutical companies who are to blame for this. They could have conducted the relevant trials a decade earlier if they had had the will.
Doctors all round the world are still performing procedures for which there is no evidence of benefit. NICE has addressed this problem and is reducing the pressures on doctors to continue in their bad old ways. A good example would be the use of protein-pump inhibitors like omeprazole for indigestion. The bill for this is greater than the bill for all cancer chemotherapy put together. Even switching to ranitidine would make lost cancer chemotherapy affordable, but most indigestion responds perfectly well to antacids from the drugstore. If it doesn't then suspect peptic ulcer which can be cured by two weeks omeprazole and some cheap antibiotics.
The other criticism of socialised medicine is that it reduces doctors' incomes. The frightening example of Cuba is often brought up. And it is true. For my few private patients I was paid at 10 times the rate that the NHS paid me. On the other hand the NHS was paying me roughly the same as the Prime Minister was getting, so I shouldn't complain. Lots of people on salaries earn plenty - as we are finding out in the banking crisis.
There is a real problem with bureaucracy in anything run by the government and it is very important that the government is kept at arms length from anything to do with medicine. In the NHS every family doctor is an independent contractor, not a slaried employee. Nor is it necessary for a national health service to come from taxes; most European schemes are insurance-based. But with such a large number of Americans getting such poor healthcare, change is inevitable.