Best health system for patients?
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Or doctors?

The National Health Service (NHS) is unique.   Britain is the only developed country with a single integrated nationwide health system paid for directly from taxation and provided by the government.   It is very different from the social insurance model used in most similar West European countries, whose governments ensure that everyone has health insurance cover, but leave the provision of health care to a mix of the government, private and charitable sectors.  

The NHS is popular, especially among those who work in it.  Standards are uniform around the country.  Health planners like it because services can be phased in and out in an orderly way, and although staff grumble that it needs more money, they generally support the system.   

Patients may be less impressed.  Instead of being treated like valued customers they are often made to feel that they are inconveniencing the staff.   Waiting lists are entrenched in the system and when patients eventually get an NHS clinic appointment or an operation they often find themselves looked after by a doctor in training, particularly if their problem is routine or needs dealing with at inconvenient times. 

In obstetrics for example, women rarely see any consultant in labour, let alone the one nominally responsible for their care.  This may not matter if the delivery is straightforward, but consultants rarely appear even if complications occur.   Doctors in training now conduct the vast majority of complicated deliveries in the NHS.  

The National Caesarean Section audit, for example, did not report the rate of consultant presence at Caesarean but it must have been low.  They set an audit standard of consultant presence at only 10% of even complicated Caesareans such as those for very pre-term babies or where the mother was very overweight.    Much emergency care in other specialties is similarly delegated. 

I recently discussed all this with doctors in Belgium.   Health care there is typical of continental Europe.   Instead of a national health service there is the usual mixture of government, charitable and university hospitals, and both salaried and fee for service doctors.   Patients can pay for private care but most get free care using the government social insurance scheme to which everyone has to belong.   Everyone can attend whatever hospital or doctor they like, but the doctors and hospitals only get paid for the work they do.    

There is no such thing as a waiting list for surgery.   If a patient could not be operated on for six months she would go straight to the adjacent hospital for a second opinion and the fee for her surgery would walk out of the door with her.   Usually the hospital administrator would have called her back and opened a new theatre before she even reached the hospital gate!  

Obstetrics is different too.  Consultants see their patients personally and regularly, and attend them in labour.  It would be unthinkable for a consultant not to be present for a Caesarean delivery, let alone a complicated one.    A consultant who never attended his or her patients in labour, delegated emergency obstetrics, or made patients wait six months for an operation would soon be out of work.   

It is tough for the doctors.  Many who had worked in England told me they preferred the NHS system.  They complained that in Belgium they never had time to go to conferences, to recruit patients to trials, or teach their juniors.   

There are problems for patients too.  Some are over-treated, some antenatal visits may be unnecessary and many normal deliveries would probably go perfectly well conducted by a midwife only. 

None of this proves which system is better.  There is obviously a balance to be struck between letting patients choose what they want, and arranging for doctors to decide on their behalf.  

Nevertheless the Belgian doctors, despite saying they preferred the working conditions in the UK, were unanimous that they would prefer to be ill in Belgium.   

British doctors’ organisations such as the BMA have consistently opposed fundamental health reform.  Do they know what is best for patients, or does the NHS provide rather a comfortable style of medical practice?  

Jim Thornton 27 Dec 2005

Professor of Obstetrics and Gynaecology

Nottingham University

Jim.Thornton@nottingham.ac.uk

Conflict of interest

Jim Thornton is a member of the advisory board of “Doctors for Reform” a group campaigning for health care in Britain to be funded by social insurance.

 

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Last modified: November 12, 2006