Dame June Clark “The evidence that insurance and the access to care it facilitates improves health, particularly for vulnerable populations (due to age or chronic illness, or both) is as close to an incontrovertible truth as one can find in social science.” —Austin Frakt “Socialized medicine” is not a phrase that British people would use to describe their health care system, and many are puzzled by the rather contemptuous tone in which it is often spoken by those who do use it. British people are more likely to describe the UK National Health Service (NHS) as a core public service, alongside other public services such as schools or the fire service, and to see health care as a citizen’s right rather than as a commodity to be sold for profit to those who can afford to buy it. However, this does not mean that the British health care system does not include private practice or that the market plays no part in publicly funded services. In 2010, the UK NHS is no longer (if it ever was) a monolith in which all components are centralized, all facilities are government-owned or run, and all health care providers are government employees. Since its inception more than 60 years ago, the NHS has been subjected to a constant process of organizational reforms and restructurings, boom and bust expenditures, and constant criticisms and “scandalous exposures” in the media. The NHS is a top issue in every general election, and a top priority for every government of whatever party. What it does mean is that the fundamental principles upon which the NHS was based in 1948 remain, and are now deeply embedded in the British psyche. Even the British Medical Association, which strongly opposed its establishment, is now a strong supporter of its principles, however much it may carp at some of the details. Any attempt to undermine these principles provokes public outcry reflected in newspaper headlines such as “Hands off our NHS!” The founding principles were that the NHS should provide the following type of services: • Universal: available to all citizens based on clinical need and not ability to pay • Free at the point of delivery In July 2008, the Health Ministers of the four countries of the UK reaffirmed their commitment to these core principles, issuing a Statement of Common Principles that affirms the following: (All UK health ministers affirm commitment to core principles of NHS, 2008): • The NHS belongs to all the people of England, Scotland, Wales, and Northern Ireland. • The NHS provides a comprehensive service, available to all. • Access to NHS services is based on clinical need, not an individual’s ability to pay. • The NHS aspires to high standards of excellence and professionalism. • The NHS is accountable to the public, communities, and patients that it serves. The concept of the NHS as “socialized medicine” contains many myths that were made visible in the debate about health care reform in the United States. Perhaps the silliest example was the story published in the Investor’s Business Daily and on television that “People such as scientist Stephen Hawking wouldn’t have a chance in the UK, where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.” In fact, Stephen Hawking is British, does live in the UK, and is sustained by the services provided by the NHS. Hawking himself responded via the UK newspaper The Guardian: “I wouldn’t be here today if it were not for the NHS; I have received a large amount of high-quality treatment without which I would not have survived.” The UK countries’ governments do set national policy priorities; and, at the local level, health authorities (Primary Care Trusts in England, Local Health Boards in Scotland and Wales) do plan services for their populations based on assessment of need. But at the level of the individual patient, clinical freedom is demanded and given, both by nurses and by doctors—and is probably greater than in a system in which insurance companies specify what they will and will not pay for. The organization that appears to perpetuate the myth to U.S. audiences is the National Institute for Health and Clinical Excellence (www.NICE.org.uk), which, in fact, was originally modeled on the U.S. Agency for Healthcare Quality and Research. This organization, established in 1999, is the independent organization responsible for providing national guidance on the best (and most cost-effective) treatment (including drugs) for specific diseases and conditions. NICE guidance is developed using the expertise of health care professionals, patients and caregivers, industry, and the academic world. Health organizations are not compelled to follow its guidance, but they usually do; problems arise primarily when a new and expensive drug (often for the treatment of the terminal stages of cancer) is not recommended by NICE, and is therefore not provided by a particular health care agency. In the past, waiting times for non-urgent hospital treatment were unacceptably long, and waiting was used as a form of rationing. Over the past decade, waiting times have been dramatically reduced; in 2008 in England the median waiting time between referral by a primary care or general practitioner (GP) and admission to hospital was 8.3 weeks, and the accepted maximum was 18 weeks. For an urgent condition, the waiting time is much less. A consultation with a GP is usually achieved within 48 hours. Access to an emergency department is immediate; after initially being seen by a triage nurse, patients must receive treatment within 4 hours. Every UK citizen has the right to “register” with a GP of his or her choice. About 96% of the population do so, although there are sometimes difficulties for some mobile or homeless people. Patients often remain with the same GP from birth until death or until they move to another locality, although they may change their GP at any time, subject to the GP’s willingness (usually limited only by geographical practicalities) to accept them on his or her “list.” Except for access to the hospital emergency department, the GP is the point of first contact for people needing health care and acts as “gatekeeper” to other services to which he or she refers patients as necessary. Patients will usually accept the advice of their GP about treatment and about which hospital specialist is most appropriate, but every patient has the right to a second opinion and at least a limited choice of which hospital. (In England, patients may choose any hospital, but for most patients, especially outside the big cities, choice is limited by practicalities such as nearness to home, travel facilities, and so on.) Currently there is debate about the right of UK patients to receive treatment in any country of the European Union (EU). There is no such thing as free health care. The debate is about the source of funding and the way in which the money is collected and distributed. There are various funding models used in different countries, but there is no consensus among analysts about which one is best. The choice among the various options depends on a country’s history, culture, and political ideology. The UK system of financing health care is based on achieving equity and social justice through the concepts of social solidarity and risk pooling. Risk pooling in health care means spreading the risks and costs of ill health across society—from poor to rich and from ill to well. The basic principle is that the cost burden is shared by everyone, even though not everyone will need to receive its benefits. This idea is deeply embedded in European culture and in stark contrast to the American ideology of individualism and commitment to a free market. It explains the choice of funding health care from general taxation or compulsory universal social insurance in order to ensure that health care is available to all who need it and free at the point of need. The UK NHS is funded primarily (approximately 95%) from taxes, including a small proportion from the national insurance scheme, which is compulsory for all employers and employees; approximately 5% is derived from co-payments, mainly for drugs (only in England) and dental and ophthalmic services. In the NHS, the only third-party payer is the government. In 2001, at the height of the “New Labour” impetus to “modernize” the NHS, the UK government commissioned Sir Derek Wanless to undertake a review of the NHS, including possible funding models (NHS Confederation, 2009). He described one of the report’s conclusions to journalists (Hall & Martin, 2001): The current message by which health care is financed through general taxation is both a fair and efficient one … There is no evidence that any alternative financing method to the UK’s would deliver a given quality of health care at a lower cost to the economy … Indeed other systems seem likely to prove more costly. Nor do alternative balances of funding appear to offer scope to increase equity.
The United Kingdom’s Health System
Myths and Realities
Fundamentals: Philosophy and Values
Myths
Realities
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