As an Englishman living in France who worked in the NHS some long time ago, it is of great sadness to me that both political dogma and the refusal to accept criticism of what has become a national icon manages to blank out any consideration that methods and experience from elsewhere could ever be applicable in the UK.
This is particularly so in the NHS, where the dogma that the government has to be directly responsible from taxation for the administration and supply of health care have been inbuilt for so long. It seems that from its earliest days the NHS that was set up as if patients were incapable of having any responsibility for their own health and therefore the government had to take on that administrative responsibility. This may be one of the reasons why the NHS has been continually overburdened with self-perpetuating and ever-growing bureaucracy.
This combined with “free at the point of use” was particularly damaging. “Free at the point of use” in the UK encourages people, to regard the access to such services as being free and as of right, encouraging time wasters and thus unnecessary use medical services.
“Free at the point of use” is also a fallacy as so little in the NHS is actually free at the point of use, prescription charges, dental costs and the endemic rationing, which itself translates into huge costs for the individual patient.
So why are things so different here in France, where national expenditure on health is slightly less than in the UK.
A The system is run on an insurance basis based on income, supervised by the state but not directly administered by the state. The system has 100% state protection for the low paid, the chronically ill, pensioners, children, etc.
Normally the state pays the larger part but not all the medical costs. Individuals have the option to buy supplementary top-up insurance, (mutuelle), to cover the balance. This ensures that people do have an understanding of the value of their health care.
In France health provision is supported by a very effective IT system. It was originated as early as 1982 with the Minitel online system, although it has now been superseded by the “Carte Vitale”.
The Carte Vitale is a type of credit card with a chip issued to all insured patients. It provides the data required for the insurer to pay the sums necessary to whichever health provider has been used. It retains minimal health information, such as the chronic illnesses for which the patient is due full reimbursement. Most health professionals, such as the GP, now have card readers and are reimbursed directly through the system. The Carte Vitale can be updated on a terminal at any pharmacy. There is a parallel manual system which can be used by any small-scale provider, for example the visiting chiropodist.
The insurance organisations provide regular reports to the patient noting all the payments that have been made on their behalf, thus ensuring that the patient knows the value of the health care he has received.
B Importantly GPs are not paid by a capitation fee based on registered patient numbers but on their actual patient appointments. This means that there can be a modicum of competition between them as health providers. A well liked-health provider is successful and as busy as he wants to be. And the patient retains his ability to choose.
Only recently a system of affiliating patients to particular GP’s has been introduced. Before that it was totally open to the choice of the patient on any particular occasion. That choice and thus competition between providers still exists.
C All the providers in the system, the GPs, consultants, diagnostic labs, district nurses, etc. are either private company groups or self-employed private contractors within the system. But they normally work at the Nationally proscribed fee scales.
D The contractors in the system choose their mode of working from the point of view of their own businesses and personal circumstances, within those fee scales. This results in health service outcomes most of which would be remarkable in the UK, other than in the costly private sector:
- This form of privatisation means that the elderly are not regarded as a cost burden on the system but rather as profit centres needing services.
- The GP has no secretary and no appointment system. Turn up when you need and wait perhaps 20 minutes on a busy day. The GP is paid on the the basis of the people he sees not on the number of patients on is list as in the UK.
- The GP will also be happy to make home visits: the reimbursed charge is rather more.
- The patient also has the choice of which consultant to see and can contact the consultant’s office directly without GP referral, but the GP will always recommend the one he considers suitable.
- The district nurse will turn up at on the doorstep to take a blood sample at 7.00 am in the morning for a fee of €6.35 (reimbursed).
- The pharmacist will provide over the counter advice and drugs for almost any common aliment. He will also provide prescription drugs, (un-reimbursed), if needed at his discretion. Thus, the load on the GP is much reduced.
- The dentist has no dental nurse and runs the practice single handed. A large proportion of his fees are reimbursed to the patient.
- The busy cardiology practice with three consultants has just one administrative assistant.
- The consultant dermatologist answers his own phone and makes his own appointments without any need for administrative help.
- As well as doing major surgery, the consultant orthopaedic surgeon does not hesitate to do his own minor splint work on the spot.
- There is a rigorous system of reminders about medical appointments by text and email so the waste from missed appointments is unusual.
Thus, the administrative load created by centralised control and rationing of access to consultants, treatments and hospital appointments does not seem to exist.
E As separate private contractors, all health professionals work as if “their time was their money”. Most UK hospital consultants are already private contractors as well as being well-paid part-time government employees. A piece-work remuneration system has been working for dentists in the NHS for many years. In France this also applies to GPs and their remuneration does not seem to be excessive as it often is in the UK.
F Prior to any hospital intervention, all the necessary preparatory checks take place as out-patients including blood tests, anaesthetic checks, cardiac checks, etc. This means that inpatient hospital time is not used for these preparatory activities.
G In France there is a real emphasis on preventative medicine and prompt treatment is considered to be economically worthwhile. Thus, certainly in my experience long waiting lists just do not exist.
H There is certainly an abundance of medically qualified people in the system and indeed there is a degree of real competition between them. According to OECD figures, there are ~25% more medically qualified professionals per head of population than in the UK health service. They are not rewarded with the high salaries received in the UK.
I The medics seem to control the running of the hospitals and other facilities not the government. They see the benefit of having an absolute minimum of administrative overheads. Those that exist are mainly involved with the ensuing that the various state mandated Insurance organisations are charged correctly.
J This also means that there are no artificial limits placed on maximising the use of expensive capital equipment and the hospital installations.
K Also, crucially, as the government is not supplying the service, the state does not own the product of the service nor most importantly the patients’ medical records.
Patients have bought the service via their insurance: they are therefore the owners of the results. The responsibility for the ownership of such records is reasonably unloaded on to the patient. As the patient owns the records, he is freely able to read them and understand them to the best of his ability.
This eliminates another whole swathe of administrative costs. As there is no government duty of care with regard to patient records, there is no demand to create an expensive nationwide database of everyone’s medical records, as was tried and failed in the UK.
L The ambulance service is merged with the Fire service as a single Emergency service: voluntary membership is prestigious in the community.
As a personal aside, I recently had an emergency, a fall and a potentially serious head injury. At 5pm the ambulance was called, the ambulance came within 10 minutes, admittedly from the fire station nearby, I was in the local A+E within 30 mins – seen immediately and sown up – had to wait 2 hours prior to a brain scan to check for a cerebral bleed – the scan was read immediately and the positive report prepared – the scan was given to me as a print out and on a CD – I was home by 11.30.
M If you have a regular treatment appointment, say for radio-therapy, a taxi will come and fetch you and bring you home, all part of the service.
N The path labs are not centrally run by the government but are private contractors. My wife takes blood thinners and has a regular test. She goes to the District nurse regular surgery at 10 am, the blood sample is transferred to the path lab and the results are available to her by email by noon that same day.
In other words, the French health service is pretty well “privatised”, and that is why it works rather well.
The Nation’s Health not the National Health Service should be the priority of government.
The NHS is certainly not the only way to organise a Health Service and the clear alternative evidence is just across the channel. But dogma means that the Brits would never want to learn from foreigners.