Checking in on the NHS

Take a look across the pond and discover that the U.S. isn’t the only developed country with a dysfunctional health care system.

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Ambulances queue outside the accident and emergency department of the Bath Royal United Hospital, on October 17, 2022, in Bath, England. (Photo by Matt Cardy/Getty Images)

For months, the British press has been filled with alarming accounts of long waits for medical attention among National Health Service (NHS) patients facing life-threatening conditions and emergencies. While wintertime hospital crowding is not unusual, the steep deterioration in the system’s overall performance over recent months is unprecedented and points to something more serious and fundamental than a bad flu season. So too, do surveys that show the British public is more dissatisfied than it has been in decades with the quality and accessibility of the NHS.

Charting a way out of the current crisis is something only the elected leaders of the U.K. can do, but identifying what has gone wrong is a matter of interest outside of the country too, as the NHS has been held up for years as a model to study and possibly emulate. In the U.S., where there is still an active debate over the relative merits of the government and the market in health care, growing unease with the fully public system of a close Western ally is noteworthy.

Making sense of the NHS’s challenges requires some understanding of its origins and evolution. The current crisis, as well as the many less intense episodes of impaired access to services that have occurred in previous years, are not unrelated to how it all began.

Labour’s NHS.

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  1. Avatar photo
    Ben Connelly

    “ It is up to them to find a formula that retains the NHS’s founding principles and yet also embeds within it incentives for continuous productivity and quality improvement.”

    Some would say that might be an impossible task. It was only a matter of time before an unstable system began to collapse. Maybe throwing even more money at it would shore it up though - if it weren’t for those evil pesky free market fundamentalists standing in the way of good people getting things done, utopia could be achieved on Earth and we could have free health care for everyone and a free puppy in every household.

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  2. Jonathan Didier

    I am a US citizen living in London. I have private health insurance (I insisted my employer provide me with global insurance, since I travel internationally extensively and have health issues) but I have used the NHS and have friends who are NHS doctors. An important point was missed here - one of the biggest issues being faced right now, and one of the major reasons for those waitlists, is a shortage of doctors. Despite this, there are artificial caps on the number of medical students trained in the UK. The system could handle more, but the government, for some reason, has so far refused to increase those caps. (I’ve seen conflicting information as to whether those caps are set nationally or locally, but either way it’s ridiculous.) Many of those positions are taken by students who immediately leave the UK after training to practice in other countries, where they can make a better living. Australia is a popular destination right now. I gather that this is similarly true for nurses, but I don’t know any of them and stories like this about them don’t make the headlines.

    Also, many private doctors are also NHS doctors - they work one or two days a week for the NHS, and the rest of the time in a private practice. So it can be a bit disingenuous to distinguish between the two groups as individuals, rather than as part-time jobs. Many NHS GP’s are full time NHS, though, and I’m sure my sample is skewed by the fact that I’m in London - this is probably less true outside the cities.

    Last point - those doctors who act as the primary point of care, the A&E doctors and GP’s, are seriously burned out due to the pandemic. They were working far too hard with far too few people and resources. I disagree with the concept of striking in most cases, but I can’t bring myself to do so with the NHS strikes right now.

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  3. Hartzlk

    "...the returns from such spending often occur on timeframes that do not match with the electoral cycles of the officials who are held accountable by voters..."

    This truth echoes across oceans.

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  4. Avatar photo
    Donald E. L. Johnson, Florida

    Every country has people who think their health insurance markets and schemes are the worst in the world.

    None are perfect. But most of us are living and will live relatively long lives thanks to hygiene, medical technology, bright doctors, nurses and allied professionals and relatively affordable health insurance.

    The United States has health care insurance schemes like Medicare for the elderly, Medicaid and Obamacare for the poor and Military and VA Healthcare organizations and providers.

    Every state and territory has distinct health insurance laws and regulations for private insurers who mostly deal with employers and unions, not individuals.

    Because of the complexity of humans' bodies and minds and very complex and onerous Medicare, Medicaid, VA and private health insurance regulations, no one can shop health care markets for the best prices. The only way individuals can shop price is to look at the health plans offered by their employers and shop for employers who have the best and most cost effective health insurance benefits programs.

    Few people know how to shop for health insurance, and fewer bother.

    Because politicians and bureaucrats have created extremely over regulated Medicare, Medicaid and Obamacare programs and over regulate insurers and providers, administrative costs in the U.S. on a per patient basis are extremely high in government programs. Private insurers keep their administrative costs relatively low, but they make running hospitals and medical groups very expensive because dealing with insurers requires a lot of administrators and highly trained reimbursement and compliance clerks and administrators.

    What separates America from the rest of the world are our relative wealth, our demographic and educational diversity, our geography and our values.

    That is, we can afford good health care, we want it tomorrow, we want the freedom to go where we want for health care, and even with PPOs and HMOs, we generally can fire bad providers and find doctors and nurses we can work with.

    Equally important, hospitals and health care systems can try to hire the best doctors and nurses, and they can fire those who don't measure up. They can compete for talent by offering better wages and benefits. Health care professionals in America have financial incentives to keep their jobs by delivering good and friendly care to patients.

    Under Obamacare, however, medical groups have been forced to sell out to health care systems. Anyone who has experienced care by physicians and nurses in physician-owned practices and by professionals employed by hospitals and systems knows that the salaried talent is a lot lest motivated than the small business talent.

    Similarly, I'd much rather be cared for by a non-government physician than by one employed by the VA, a hospital, insurer or drug store chain.

    Because politicians, physicians, hospitals, nurses, trade associations, insurers, medical supply companies and pharmaceutical companies all have major says when health care "deform" laws are proposed, nothing helpful ever gets done.

    This makes suggesting real reforms pretty much a waste of time. Over the last four or five decades I've wasted a lot of time writing about potential reforms of our health insurance laws, Medicare, Medicaid and VA Healthcare.

    For example:

    1. We need better educated patients because literate people who've been trained to manage their risks and take care of themselves require less acute care and are less expensive to insure.

    2. Laws and regulations are written to stop bad actors, which plague every community and profession in the world. After awhile, the regulations pile up and become very conflicting. Taking a job as a hospital administrator is signing up for a prison term. Cut administrative and compliance requirements in half to save money and make life easier for providers and patients.

    3. For decades, I wrote, edited and published articles about "integrated health care" and continuous care. Such fantasies never took account of human nature, which makes huge organizations like VA and the U.K. health scam unmanageable. Break up the health insurance industry, health care systems, medical group practices and so called group purchasing organizations. More small players would be much more cost effective than today's monsters.

    4. Larger and richer employers select and help pay for health insurance plans for their employes. They offer the plans that work best for the employers, not the best for the workers and their families. And they offer way too expensive plans with "wellness" programs that don't work for well people. Get employers out of the health insurance business and let them focus on their core competencies, not on health benefits.

    5. Physicians are quitting health care because they are being over managed, treated like fast foods cooks and denied the right to deliver the thoughtful health care that they're trained to offer. We need more physicians, and physicians need to spend their time treating patients, not spending hours filling out insurance forms on their laptops.Expand full commentShow lessExpand full comment

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    1. Hartzlk

      Thank you for taking the time to write out your thoughts here!

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  5. Jchundt

    As a resident of the UK, I can offer some first hand experience of where I live.

    First of all, I cannot chose any doctor as my general practitioner (GP). I must live in the catchment area of the doctor's office. I can't go to the GP with the better office, better services, and better parking across town.

    Prenatal care here is a wildly different experience than in the US. In the US, we saw the same nurses and doctor for every checkup, and the doctor was present for the delivery. In the UK, we didn't know who we would be seeing us each time we'd go for a checkup and it was usually a different person each time. Also, all expectant mothers were expected to carry their physical medical records with them at all times...as in take them home and bring them to every doctors visit. The records were not digital...this was in 2016.

    It may be a surprise to hear that private medical insurance is a popular incentive that some businesses offer their employees here. My policy acts as a supplement to the NHS. For example, if you need to see a specialist you can get your GP to sign a form that will authorize the insurance to pay for a private consultant, so you can wait days instead of months for an appointment. The insurance also runs private GP offices that can replace your own GP. This may be necessary because it can be difficult to get a same day appointment for your GP. For example, if your child develops a rash, you might not be able to get in to see your GP that day or the next. People without insurance have to then decide if it's worth it to go to the nearest hospital's emergency department and wait all day to be seen.

    I know a lot of people that work within the NHS and they are good people that try to do their best. It's just that the incentives are all distorted to the point that it doesn't work very well.

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  6. Jennifer Stanowski

    I've always thought my dogs have better healthcare than I do. The only barriers are my visa limit, and finding a veterinarian with availability.

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  7. MathewA

    People and organizations need competition to ensure that they keep quality high, and prices low. Absent competition it becomes extremely challenging to keep a large organization efficient.

    This becomes even more difficult if you allow public sector unions. Which then work to elect politicians to give them higher salaries and less accountability.

    Moreover, of course there's the problem with anything that's "free". If there is no cost then people over consume then the optimum amount. Thus government uses other things to control costs such as making things "elective" or making you wait a REALLY long time.

    My preferred method is to focus on increasing healthcare supply and healthcare competition then let market forces bring down total costs (see elective healthcare like plastic surgery where this does work)

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    1. GenZConservative

      What plagues America and what plagues the UK is largely the same thing - people aren't spending their own money on services. There's no market if you don't get a choice.

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    Xsearnold

    "In the U.S., where there is still an active debate over the relative merits of the government and the market in health care, growing unease with the fully public system of a close Western ally is noteworthy."

    Why anyone in the US wants to push a nationally-managed healthcare system for all its citizens is beyond me. We have two case studies already in existence, Medicare and VA Healthcare, and neither of these provides evidence that the Federal Government can competently run such a thing.

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  9. Stormer93

    This is a good rebuttal of the idea that all the US's healthcare problems would be solved by going to a model based on the UK or a Scandinavian system.

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    1. David R

      The thing is that those are, I'm pretty sure, very different things (pure single payer models like the UK's are in fact not very common). There's no "European" health care system; every country has their own model.

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    Connie

    In the fall of 2006, I tore my ACL and medial meniscus.

    At the time, I was also spending about a week every month in the UK. Because of this, I was a regular on an AOL UK News & Politics message board, where I met a retired UK police officer who also had a torn ACL.

    I was given the option of reconstructive surgery, with the ability to pick the hospital, surgeon, and date of procedure. I decided on early January, 2007, as it would be easier to rehabilitate through the dark winter days than be laid up in nice weather. To this day, my reconstructed ACL functions perfectly.

    Which brings me to the fate of my message board friend in the UK who had the same injury. This retired police officer was not even on a waiting list to be on a waiting list for surgery. It was a non-starter. The NHS said no, and unless he had private insurance (which does exist in the UK), he was living the rest of his life with an injury that would only grow worse with time.

    So, no… I am not keen on having nationalized health care in the United States.

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