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Can the NHS ever measure up? 19/2/02
When it was created, it was the
envy of the world - but few would
suggest that now. It's no disaster,
but it doesn't match the noble
aspirations of the founders. Indeed,
what it excels at, is being cheap.
Now, Britain is in the midst
of a collective re-think on
health services, and how to improve
PROFESSOR JULIAN LE GRAND:
When Bevan set up the NHS in 1948
he said the great thing about the NHS
the new NHS is going to be if a bed pan
falls off the bed in Northampton
its sound will reverberate
throughout the House of Commons.
The whole problem since then has
been the House of Commons has been
deafened by the sound of falling bed
pans, it is ridiculous when the Prime
Minister has to stand up and defend
the action of one particular hospital,
one particular occasion in respect of
There is still plenty of din in the House
of Commons, but there is also a more
serious debate, or two debates as it happens.
One, how to organise and structure
health services in Britain, and how
much power should be given to hospitals.
Call that the "supply" of health services.
And two, the "demand" and how do we
pay for health services? Taxes or some
other way. How are our health
debates going? Start with demand -
the funding. Look at enviable
health systems abroad, like that in
France. Here's a man who runs a
hospital in London and here's one
who runs a hospital in the southern
French city of Nice. Jonathan
Michael runs Guy's and St Thomas's
Trust, across the Thames from
Westminster. The Government may
have eased funding difficulties,
but they remain a constant problem.
DR JONATHAN MICHAEL:
In reality we know the moment we
are, we are not unique in this part
of London but we are struggling to
balance next year's budget, we are
having discussions about what we
think we need to deliver the
targets for next year against the
amount of money available and there
is a significant gap.
El Hadi Benmansour runs the
L'Archet Hospital in Nice, part of
a publicly owned chain around the
city. When talking about funding,
the main contrast with France is
the amount spent. Over there, they
spend over a third more on health -
and it shows.
EL HADI BENMANSOUR:
More individual rooms by that I
mean one person a room, clean well
maintained room and equipment
replaced at the right time. We don't
wait for equipment to be obsolete
before we replace it.
More generous funding, yes, but
France's system is complicated
social insurance, private top-up
fees and private insurance. It's not
clear the French model is actually that
Social insurance is basically a tax
on employers and employees and
the employers get angry about it as a
tax pushing up their costs so they
have been pushing strongly to
getaway from the social insurance
system and one based upon taxation
A look at Nice, France
and other health systems tells us
the UK debate on funding will
conclude we need more money.
Funding is only half the subject.
What about the other half - the
organisation of health services?
Jonathan Michael may run a hospital
- but he is never alone. He has the
friendly man from Whitehall to help.
Health in the UK has been
centralised - daily initiatives on
things like cleaning and food.
There are large numbers of
priorities and documents and
guidance and so on. There is no
doubt about that. They are not all
do-able at the same time.
Particularly within the financial
Monsieur Benmansour does not have
complete freedom either, but he doesn't
get a constant stream of directives.
On a day-to-day basis, absolutely not.
If tomorrow I want to paint the wall
I won't have to wait for instructions
from our government. It is our
responsibility and we are autonomous
But Britain isn't standing still.
England, for example, is getting
its traditional solution to health
problems - a reorganisation. From
April 1st, we'll have new strategic
health authorities. We'll have
primary care trusts to provide
GP services and buy hospital
services, and more local
management for the best hospitals.
The name of the game is
decentralisation - that's been
recognised as a need already.
everybody is in favour of those,
But it might be there is a whole lot
more to those issues than meets
the eye. Instead of devolving power
the existing institutions what
the NHS needs is different
institutions. This recent paper for
example, compares the NHS to an
American health service, it finds
that compared to the Americans, the
NHS puts too much weight on hospital
treatment as oppose to GP clinics.
At the moment we don't know whether
we ought to have large or small
hospitals, specialised centres,
really the evidence isn't in on all
of that so what we need is a system
which allows experimentation and
allows different flowers to bloom.
The Austrian-American economist
Joseph Schumpeter put it well.
The competition which counts,
he said, is not simple competition
between existing firms, but:
"competition from the new commodity,
the new technology, the new source
of supply, the new type of
organisation." He saw the process
of "creative destruction" as the
driving force of progress.
There is a debate to be had about
how far Britain wants to go down
that route. But it's a lesson from
France, there's more patient
choice more competition between
different types of provider public
and private. This is a private
specialist in Nice. He sees
patients without referrals and
works in a private hospital for
public patients it is a more
DR JEAN FRANCOIS REY:
There are huge differences
between France and UK. This is due
to the competition because if the
French public hospital work as the UK
system, there will be out of
Out of patients, talk
like that is enough to raise the
blood pressure of health insiders.
It remains a controversial view,
competition and adversity may
happen but it does make the NHS
less of a National Health Service.
The key to a good health system is
one that allows for experiment,
innovation and change. There was an
economist who talked about waves of
creative destruction and in some
ways that is what we would like.
We would like the creative bit but the
destruction is more of a problem
and that is always a bit that every
health system has got to get right.
What do you do with the experiments
At last though the NHS is getting
some treatment. A long-term view, a
look back at first principles but
there will be no return to the
unshakeable faith to the early days.
The view that a solution will be
found to the problems of the
service, that there is a perfect
somewhere. Today's debates will
improve things but don't ever
expect them to arrive at a solution.