Wednesday, 18 July 2012

NHS: the lessons of US healthcare

What a sterile argument I got into the other day over the relative merits of UK and US healthcare.

The very premiss of the debate is different in the two countries. Partisans of US healthcare start from the principle that healthcare should be world beating: the best, using the latest technology and the most powerful drugs. 

That’s certainly not a claim the National Health Service can make. On the contrary, we still have old people dying of dehydration in British hospitals. And I find it particularly shocking that we seem appallingly slow at making diagnoses: I only have anecdotal evidence on the subject, but I’ve known people who’ve waited up to two years, one of whom moved to Australia where he was correctly diagnosed and began treatment within weeks of his arrival.

Those, like me, whose sympathies are with the NHS despite its faults, start from a completely different principle: it is the hallmark of a decent society that it provide adequate healthcare to all those who need it, when they need it. On that criterion US healthcare falls a long way short. 

In passing, it surprises me that so many on the right of US politics, quick to proclaim their attachment to Christian values, seem content with the situation. Clearly, they see no particular obligation on the Samaritan to cross over to this side of the road. 

Supporters of the US system counter-argue that in reality outstanding healthcare is always provided to those who really need it, insured or not, and free of charge if necessary. 

What this fails to say is that an uninsured patient with heart disease will receive no treatment until there is a crisis, say a heart attack. Then he will be superbly, and very expensively, treated in an emergency department. However, his care will focus entirely on recovery from the heart attack, and, because he is uninsured, nothing again will be done about the underlying condition. 

Eventually, this will happen once too often and he will die of a condition that could have been treated, at far lower expense, by a drug regime administered by a General Practitioner. Incidentally, it is ironic that US opponents frequently accuse the NHS of drawing up ‘death lists’ of people denied treatment: they should give some thought to this kind of avoidable death in their own system. 

Let’s just focus on the extra expense that this approach in the US entails. It’s a key question because many British supporters of the US model tend go straight from a eulogy of its wonders to an attack on the alleged inefficiency of the NHS and its consequent excessive costs. Many such people are in positions of authority and are helping to sustain the political pressure to reduce ‘bureaucracy’ in the NHS, i.e. to fire managers, even though with management costs at around 3% of expenditure, it is one of the least managed organisations anywhere. 

Recently, groups of hospitals have also been joining together to put pressure on nurses and physicians to take lower salaries. 

The Cost cutters seem to be in the driving seat. But, as the graph below tellingly makes clear, it’s odd that so many of them express such admiration of US healthcare. 

Telling comparison: percentage of GDP spent on healthcare

What does the graph show? In blue, the percentage of GDP the UK spent on healthcare in each of the eight years up to 2010. In red, the equivalent figures for the US.

The NHS closed the gap on the US slightly over the lifetime of the last British government, which substantially increased healthcare expenditure. So from just under half the US level we moved to just over half.

The conclusion? We can argue until the cows come home about which of the US or the UK has the better approach to healthcare, and we’ll never convince each other. But on expenditure, I’m afraid the case is open and shut. There’s no evidence that the US has significantly better outcomes than the NHS, but it costs nearly twice as much.

On the financial front at least, the NHS has nothing to learn from the US.


Awoogamuffin said...

If they are so concerned about making sure that they get the best care possible, let them put their money where their mouth is. Like in other countries, have a national insurance policy that provides basic care, as well as being able to negotiate favourable prices for drugs due to their size, and then those who want truly exceptional care, let them pay for extra private insurance on top of that.

And it's funny how few people believe the American health system costs the state more than the British one.

David Beeson said...

Curiously, the actual state funded bit of the US system - Medicare and Medicaid - costs pretty much exactly the same per case as the NHS (i've heard it argued that it's marginally less but I've seen figures that put it at marginally more).

It's when you take all the rest into account that you end up with the colossal premium for the US version.