Reader Phil B., the UK Expat now living in New Zealand who recently left a long comment that I turned into a post has done it again. This time in an email:
I’ve used that same Humpty-Dumpty quote myself a couple of times, for similar reasons.
“Fierce urgency” again, I suppose.
Anyway, here is Phil’s Überpost, from a man who’s seen it – up close (too close) and personal:
I would agree with the conclusion of Dr. Flier and can describe the situation in the British National Health System (NHS) which will indicate the direction, if not the exact end result of the reforms being proposed for the American healthcare system.
I will give a brief history of the development of the NHS and then describe how it operates now. The baleful influence of politicians will be outlined and the effects this has.
William Beveredge (a dyed in the wool “Socialist”, strongly influenced by the Fabian Society – a left wing “think Tank” which included Karl Marx as one of its founding members so draw your own conclusions – and firmly committed to centralist planning and control) set up the framework for the NHS during the Second World War. He was the head of the Ministry of Labour (where his central planning and control tendencies were used to direct the war effort) and was tasked at looking at the shape of Britain post war, including how a universal National Insurance system could be introduced and how it should operate.
He produced a report which envisaged a complex array of universal benefits paid for by a compulsory “National Insurance” levy on wages and employers. The benefits would include unemployment payments and the setting up of the NHS where ALL treatment was to be free at the point of use. The report was accepted (as far as I can discover) in its entirety and on 5 July 1948, the system came into being.
The basis of the universal insurance concept was that there would be zero unemployment (defined as under 3%) and to kick start it, the wholesale requisitioning of property (i.e. theft) including community owned and private hospitals, residential nursing homes and institutions was mandated without compensation.
Almost immediately the problems which would plague the system became evident. After the war, due to the reduction in wartime activities, the unemployment rate increased, leading to a reduction in contributions or revenue. Other services were included (dentistry, opticians and “free” spectacles etc.) were an immediate and ongoing cost which placed a strain on the system from the word go. It has never been self-financing and general taxation was used to make up the shortfall.
Prior to 1947, there was an inexpensive private insurance scheme for basic healthcare (almost always referred to as a “Penny Policy” but more correctly as the provident Associations Insurance scheme) which was operated as a non profit scheme by insurance companies long before the NHS was considered. Everyone except the destitute and the feckless subscribed to this privately run insurance scheme. Since Doctors were self-employed (on the whole) they either claimed the costs of the treatment from the insurance company or, they could decide the fees they charged depending on the patients’ ability to pay. Many operated a charitable form of healthcare and either allowed the people to pay a small amount every week or waived the fee as well as working in surgeries in the poorer parts of the town voluntarily and without pay. Following the introduction of the NHS, the Doctors and charities naturally stopped doing this – there was no need, the Government would provide everything.
So very, very few people were denied healthcare by the system and there were many local charities which would step in to finance healthcare as a last resort. The monies the insurance companies held from premiums could not be retained (it was a non-profit scheme) so the British United Provident Association (BUPA) was set up with the funds to build new hospitals and continue on with privately funded health care. BUPA still exists to this day and there are other private insurance health schemes but are paradoxically only for the wealthy.
It must be borne in mind that the standard of healthcare available to even the wealthy was not as good as today. It is difficult to appreciate the advances in Medical Science, pharmaceuticals, surgical procedures (many driven by the impetus of the war) since 1947 and the accompanying increase in costs to provide these new treatments. So to claim that people were poorly cared for in comparison with today must be qualified by this. EVERYONE did not have the potential level healthcare of today – whether you were Duke or labourer.
There were immediate problems with personnel – up till then, all Doctors were self employed or, if a hospital consultant, were working under negotiated contracts which allowed them about half their time to see private patients (the normal hospital patients paid via the insurances they held). However, at the strike of a pen, they became Civil Servants – every one of them from the cleaners to the most highly skilled surgeon were working under the umbrella of the NHS. Today, the NHS is the third largest employer in the World – behind the Chinese Peoples Liberation Army and the India State National Railway. A grand total of 1.37 Million people are employed by the NHS as of March 2009 (courtesy of the Tax Payers Alliance).
Private Patients were, and still are, are a lucrative source of income for the consultants and they took the attitude that if they were not going to be paid for the work they would do during the time they would normally be seeing private patients, they would play golf (or whatever they enjoyed doing) or still see their private patients but in the BUPA hospitals or the NHS hospitals if necessary.
Immediately, there was a reduction in the numbers of patients being treated – who could have predicted this? – and to ensure that everyone was seen in turn, a queuing system was devised. The infamous waiting lists for hospital treatment were instigated and are a major problem today. The urgency of your condition did not matter – strict “first come, first served” prevailed and the delays in seeing a specialist naturally resulted in people either dying before they could be treated or due to their condition worsening, what could have been a treatable and recoverable condition became far too advanced to do anything but stabilise the problem and no full recovery was possible.
Still, not to worry. At least it was FAIR, and if someone was left permanently disabled due to the delay in treatment and unable to work, there was the National Insurance disability payment to ensure they could survive.
This lead to another “unforeseen” problem – if you could be declared permanently disabled and unable to work, then you would not have to work again for the rest of your life. The state would provide you with income which today, due to the distortions of the taxation system, means that although the actual benefit paid is apparently a modest amount, due the additional non cash benefits (rent and local taxes paid for, mobility allowance which can be used to purchase a car and its running expenses, free medicines, no contributions to the pension you will receive, additional benefits based on the number of children you have, free school meals for those children etc. and so forth ad infinitum – Google “Citizens Advice Bureau” and see what benefits are available if you are classified as disabled) it is financially more lucrative to claim benefits than work. People coming off disability allowance and working 40 hours a week are financially worse off.
So lots of people with “bad backs” and other difficult to prove conditions became effectively retired and lived on State provided benefits.
An additional problem was that the Civil Service was increased to deal with this new system. There is a Tax Office (Inland Revenue) which taxes pay at source (“Pay As You Earn” PAYE) as well as company profits etc. and a second, new department set up called the Department of Health and Social Security (or DHSS as it was termed then) which recorded the National Insurance Contributions you had paid during your working life. The concept was that, you had to have a “full” contribution record to receive the Full State Pension when you retired. It would not be “fair” for everyone to receive the same pension if they did not contribute – but if you did NOT receive a full pension, you can claim a top up benefit to make up the difference which, surprise surprise, is administered by a different Department and funded from general taxation. Unemployed people who registered with the Department of Employment received credits for the contributions they could not pay so that they receive a full pension too.
Now, for the people who are reading this who are not very intelligent, I must point out that there are effectively TWO armies of Civil Servants recording the fact that you are working and paying into the system – The Tax Office and the DHSS. These two departments record essentially the same information. Civil Servant pay levels are good and, having worked at the DHSS for a while, I can confirm that the work is not arduous and the real art is not simply being able to do the work but in making the Job last all day.
The resultant increase in bureaucracy did two things – it mopped up the unemployed people who were out of work due to the cancellation of wartime contracts for armaments, returning veterans etc. and increased the power of the state and its hold on the Country. This was all in line with the centralised planning beliefs of Beveredge and set up a client voter base who would not vote themselves out of a job. The Unions were quick to see the potential too in so many of the newly created civil servants.
But, everyone will argue, at least universal healthcare is available and the people working in the NHS were dedicated and caring people. Surely they would ensure that the very best of treatment was provided?
One major snag – the Politicians had promised a utopian, unlimited benefits available free to all at the point of use. So if someone decided that their “entitlement” was not being provided, they would see their local politician (Member of Parliament or MP) and demand their “rights.” This was slow to start (people were inured to wartime conditions and shortages and unlikely to complain) but gradually, over time, the concept that they were entitled to the healthcare became entrenched.
Hospital managers no longer answered to their patients but to their political masters. It was the politicians who decided how much funds would be allocated to health spending, how much their increase in salary was going to be this year, now many new treatments were to be funded, new hospitals built etc. The politicians effectively micromanage the system in knee jerk response to complaints from voters, newspaper reports and pressure groups according to the prevailing latest scandal or horror story.
So the NHS Managers concentrate on pleasing the politicians – nowadays the politicians demand and get reports and tick lists on the status of waiting lists, bed occupancy (the higher the better – an empty bed means that someone isn’t being treated), costs of drugs etc. A growing and specialist bureaucracy in the NHS caters to this demand so much so that there are SIX Bureaucrats for every five “beds” (i.e. hospital places) in the NHS (this number does NOT include doctors and nurses but ONLY pen pushers).
This is a consequence of political meddling and as the paymasters are the Politicians, then the success of the hospital is measured not by patients treated but by form filling and compiling statistics to prove the hospital is run according to the centralised instructions passed down from Government. Innovative methods are dreamed up to comply with the arbitrary rules and regulations.
Two examples will suffice to illustrate this:
First, a patient in an emergency department must be allocated a bed within 4 hours of admission. It is trivially easy to rig the definition of “admission” to be “when a bed is found.” Hence the target is achieved but this results in patients being left in hospital corridors on stretchers or gurneys for prolonged periods or refused admission to the hospital and kept in an ambulance until they can be dealt with or simply told “No room – take them to another hospital.” This can be miles away and there is no guarantee that a casualty would be admitted to the second hospital either. But the target is met. THAT is the important point.
Waiting lists – this is a BIG problem in that people have to wait months for the privilege of seeing a consultant or specialist. They need to see their family doctor first who will write to the Local hospital describing what they believe to be the problem. The consultant will acknowledge the letter and the patient’s details are put on a waiting list. When their name comes to the top, they will be seen and a decision made on their condition. They will then be placed on a second waiting list to await treatment. Waiting a further two or three years for a “non urgent” operation such as a hip replacement after the initial consultation is not unusual. More urgent treatments (such as for cancer) can take 3 to 6 months. This is one of the targets that has been dictated must be reduced (and rightly so).
Inevitably this results in rationing and delays in treatment with the attendant suffering and misery, loss of useful productive work and potentially a treatable condition becoming a crippling illness or death.
Solution – you create a waiting list to go onto the waiting list. The second waiting list can be as short as necessary to comply with the “must see a specialist within 3 months” BUT the waiting list to go onto the waiting list is not submitted to the government – only the one which meets the target. As there are two waiting lists (one to see the consultant, one to receive the treatment), then it is infinitely adjustable to meet whatever target is set but does not attack the basic problem.
The reality is that the numbers of front line staff is decreasing (Doctors and nurses) and the number of beds (i.e. places in hospital) is reducing too. The overall numbers of people employed is rising and the increase in bureaucracy is the cause.
You will recall (if you have read this far) that a wholesale requisition of property took place back in 1947. These buildings were locally funded and privately financed institutions relying on paying patients and charitable donations. This source of cash ceased in 1947. However there is a legacy of local sentimental attachment to “local” hospitals which are “ours” (as indeed they were).
Now, it can be argued that spending on buildings is not curing people of diseases and injuries. Hence the politicians will not spend cash on hospital infrastructure and over the years the buildings naturally deteriorate.
The Victorian buildings and concepts of healthcare have been superseded by developments in architecture, how people are to be processed through the system and developments in technology, advances in medical care and what people are used to. Large regimented communal wards in high ceilinged Victorian Hospitals were a wonder and cutting edge 100 years ago but nowadays people want privacy.
The NHS spends a large proportion of its cash on maintaining and heating decrepit buildings in prime inner city sites which the politicians will not allow to be demolished. It would make more sense to sell off the land (making a EVIL PROFIT – the first step in privatisation and the destruction of the jewel in the social security crown) and build a new hospital elsewhere. The chance to eliminate the problems of access due to traffic congestion and the risk of people dying stuck in traffic jams and designing a building which addresses the needs of staff and patients alike and cheaper to heat and maintain would be the logical thing to do. However the cost to build and equip a new hospital is high and the old one can be patched up yet again.
A repair or upgrade can always be delayed another year if the cash is needed for something else (and it is inevitably needed for something else) so politicians will arbitrarily refuse budgets for repairs etc. Consequently the buildings deteriorate until they are almost beyond repair – and then a massive amount is spent on them to restore them to a basic state. The cash would be better spent on a new hospital but this is not politically acceptable.
Of the two hospitals I have seen built in the UK, one was single-glazed – the budget was limited at the design and build stage but the heating bills were running costs. This hospital was obsolete before it was complete. The second is too small for the population – the design was accepted without consulting the planners who increased the number of new housing around the hospital. Again due to a limited, politically controlled budget, a larger than necessary hospital, which would have anticipated future needs, would not be authorised to cope with increased demand. The Victorian Hospitals they were intended to replace still exist and are still as inefficient as ever. So no cost savings to be had there.
The politicians will interfere in the planning process and to maintain votes, will vigorously join in the demands that not a single hospital is closed. After all, if it saves a single life …
The end result is that the NHS managers are like the Harem eunuch – all the responsibility, none of the authority to run the system and subject to day-to-day micromanagement by the politicians.
However, the system must be considered an outstanding success – if you want a “fair” system of universal healthcare where everyone (including illegal immigrants and health care tourists who come to the UK specifically to be treated – such as pregnant third world country women arriving at Heathrow and getting a taxi to the nearest maternity Hospital) can demand unlimited access to whatever treatment they want, it is highly successful at delivering this. Also it is NOT making a profit – which would be immoral.
The fact that everyone receives a highly substandard service is irrelevant. It is “free,” everyone is treated alike (except politicians of course who are scrupulous in avoiding the system and rely on private healthcare) and paid for by taxation.
Note that treatments include abortions, sex changes, cosmetic surgery due to stress and psychological problems (such as 16 year old girls receiving breast enlargements) and other such procedures never dreamed of in 1947 whereas treatments for cancer, heart conditions etc. are treated with exactly the same urgency.
The elderly are treated particularly badly. Healthcare is naturally rationed – everyone will be treated the same – but clinical judgements are made by NICE (National Institute for health and Clinical Excellence website http://www.nice.org.uk/ ) as to what is “cost effective”. Hence cancer drugs that extend the life of sufferers are deemed “not cost effective,” an elderly but otherwise fit person will be denied drugs and operational procedures (hip replacements, cataract surgery, hearing aids etc.) as it isn’t worth spending cash on them. Surely you must agree that cash should be spent on a young drug addict (a “victim”) who may at some point in the future, if they don’t kill themselves first, “contribute to society” is far more cost effective.
Alzheimers and Parkinsons disease sufferers are particularly shabbily treated – why waste cash and resources on them? They can be dumped onto local authority care and the “Care in the Community” scheme can look after them. This means that the cash does not come out of the NHS budget and instead the local councils can look after them. It is obvious that dedicated care by specialist nursing staff can more effectively care for such people than a nurse visiting once a week or every two weeks for a half hour or so and abandoning their elderly partner or their families to nurse them. There are far too many cases that are reported in the newspapers to list – only the really bad ones make it to the national newspapers – but search any British newspaper for the phrase “Elderly patient” (or elderly woman, elderly lady and whatever variation you can think of) will list a sickening catalogue and tales of neglect that shames any nation that calls itself civilised.
Conclusions
The conclusions are:
1. The State bureaucracy will vastly increase immediately after such a system is set up. It will continue to grow as the system matures and will not slow in its growth. The cash spent on the bureaucracy will be drained from healthcare.
2. The system will need property (land, existing hospitals etc.) and although the intention may not immediately be to take these over, why should the Government increase the profit of the evil people who own the existing hospitals. Surely healthcare should not be for profit and the Government will take steps to make sure wicked private companies and evil individuals do not benefit from peoples suffering. So confiscation will occur sooner or later.
3. People will be entitled to healthcare and if they don’t get what they want, then they will see their elected representative who will appear on all the news channels and the front page of all the local newspapers to fight for the rights of his voters. This will be a guaranteed vote winner – but only if the people needing treatment are photogenic children, minorities or cute grandmothers or someone with a rare disease which can be milked for political capital. Political interference will be an increasingly heavy and debilitating dead hand on the system. It will be increasingly paralysed by this micromanagement.
4. If everyone receives the same treatment (except politicians, of course. And old people), then no one can complain that it is unfair. It is irrelevant that the treatment is third world in its standards, it is FAIR that everyone is treated equally and that is the principle which is important.
5. As the Politicians are funding the system, the people operating the system will answer to the paymasters, not the patients. The system will become increasingly centralised with decisions made at a higher and higher level leading to less and less local accountability. The local bureaucracy will increase to keep politicians informed of the status of the system and drain cash and resources from the front line.
The Soviet system lasted less time than the NHS has been in existence – it is odd that the last bastion and embodiment of centralist soviet style state planning should be “the envy of the world,” the British NHS.
Britain is 62 years ahead of America on this one – I sincerely hope that you can stop the monster being born or at least prevent it from feeding on tax payers money before it grows in size to rival the NHS.
Sources and references.
Wikipedia can be searched for “NHS” and biographies of the people mentioned.
The Tax Payers Alliance has plenty of information on the facts and figures relating to the costs, staffing levels, types of jobs and their functions. Website here:
http://www.taxpayersalliance.com/
Click on the “Taxpayers Alliance Research” button for lots of interesting links and on the NHS link.
Burning Our Money is a private blog which has a searchable database of articles listed by category on the right hand side column and near the bottom of the current page. Look for NHS, click on the link and read until your eyes start to spin in your skull like a Tic Tac Toe machine … Link here:
http://www.burningourmoney.blogspot.com/
The NHS link is here:
http://www.burningourmoney.blogspot.com/search/label/nhs
Civitas again has some excellent well-researched free articles on the NHS (http://www.civitas.org.uk/) – look in the free books section (link here http://www.civitas.org.uk/books/openAccess.php) and look for the following:
· Before Beveredge – Welfare before the Welfare State
· Delay, Denial and Dilution
· England Vs Scotland – does more money mean better health
· Health Care in France And Germany
· Pharmaceutical Parallel Trade in the UK
· Regulating Doctors
· Stakeholder Health Insurance
· Why Ration healthcare.
That lot should keep you quiet for a while but if you must read only one or two, please concentrate on Delay, Denial and Dilution, Why Ration Healthcare and Health Care in France And Germany.
Civitas is worth browsing for information on the trends and developments in the NHS if you are interested in researching further.
The article was written following my experiences with the NHS and watching and nursing my wife as she slowly died of cancer over a period of 9 months. It prompted me to study the problem and form my own conclusions about how the NHS should be changed and the way that health care could be infinitely better. I hope that I have managed to be dispassionate about the system and that the article is does not come across as being unduly influenced by my own experiences.
If anyone wants to e-mail me to clarify any points I would be happy to explain things further.
My condolences, Phil. And thank you for taking the time to write this, and trying to help us avoid what your country has done.
Barring a miracle, I fear our Imperial Senate is going to pass this monstrosity, and we will, sixty-two years later, follow Great Britain down this path, but it is my hope that we the people can abort it.
