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Why the NHS should look to France

Civitas, 20 August 2009

It is of great sadness that political dogma manages to blank out any consideration that methods and experience from elsewhere could ever be applicable in the UK, writes Ed Hoskins.

This is particularly so in the NHS, where the dogma that the government has to be directly responsible from taxation for the supply of health care have been inbuilt for so long.  This combined with “free at the point of use” is particularly damaging.  (What is even more amazing is the fact that so little in the NHS is actually free at the point of use: prescription charges, dental costs (if available at all on the NHS) and the endemic rationing, which itself translates into huge costs for the individual patient.)

So I want to explain why, and how, things so different here in France – and why I think it works better.  These are my simple conclusions:

•    The system is run on an insurance basis based on income supported by the state, but without direct participation by the state.  The insurers are competitive amongst themselves.  The system has state protection for the low paid, the chronically ill, pensioners, children, etc. And top up insurance can be purchased out-with the system to cover the balance not paid for within the system.

Insurance organisations report on all transactions and produce an annual account for each of its clients showing the premiums paid and the amounts disbursed on each client’s behalf, so the actual costs of health services are abundantly clear.

•    “Free at the point of use” in the UK is a fallacy and only encourages people to use medical services unnecessarily and to regard the access to such services as being as of right.

Here the modest fee €20 payable to the GP, most of which reimbursed later, is a disincentive to time wasters and malingerers, even in country of hypochondriacs.  It is amazing how effective the cash flow consequences of having to pay the doctor his €20 fee, even though it can be claimed back later, is in making sure that patients really need to be there.

Of course, anyone with a noted chronic condition or on income support etc. will be reimbursed 100% and if he has a Carte Vitale the GP is credited automatically without money ever changing hands.

•    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.

•    All the providers in the system – the GPs, consultants, diagnostic labs, district nurses, etc. – are self-employed private contractors.  They normally work at proscribed fee scales.  But importantly the GP’s or consultant’s charged fees are his income and he/she, like other health professionals, are in competition with each other.  They are free to choose their mode of working from the point of view of their own businesses, within these fee scales.  This results in the outcomes most of which would be remarkable in the UK, except in the costly private sector:

o    The GP has no secretary and no appointment system.  Turn up when you need and wait perhaps 20 minutes on a busy day.

o    GP’s are not paid by a capitation fee based on patient numbers, but on their actual patient appointments.  Only recently a system of affiliating patients to GP’s has been introduced; before that it was totally open to the choice of the patient on any particular occasion.

o    The patient also has the choice of which consultant to see, but the GP will always recommend the one he considers suitable.

o    The GP will be happy to make home visits, although the reimbursed charge is rather more.

o    The dentist has no dental nurse and runs the practice single-handed.  A large proportion of his fees are reimbursed to the patient.

o    The busy cardiology practice with three consultants has just one administrative assistant.

o    The district nurse will turn up at on the doorstep to take a blood sample at 7.00am in the morning for a fee of €6.35 (reimbursed).

o    The consultant dermatologist answers his own phone and makes his own appointments without any need for administrative help.

o    As well as doing major surgery, the consultant orthopedic surgeon does his own splint work on the spot.  Etc. etc.

Thus the administrative load created by centralised control and rationing of consultants and hospital appointments does not exist.

As separate private contractors, all health professionals work as if “their time was their money”.  This difference vis-à-vis the NHS was emphasised on the recent Gerry Robinson documentary when an NHS consultant clearly stated that this was the difference was between his work in the NHS and his outside private practice.  Most UK hospital consultants are already private contractors as well as being well-paid part-time government employees.

•    There is a real emphasis on preventative medicine and prompt treatment is considered to be economically worthwhile.  Thus, certainly in my experience, waiting lists just do not exist.

•    There is an abundance of medically qualified people in the system and indeed there is a degree of competition between them.  According to OECD figures, there are almost twice as many medically qualified professionals per head of population as in the NHS.

•    The medics run the hospitals and other facilities not the government or the administrators.  They see the benefit of having an absolute minimum of administrative overheads.  Those that exist are mainly involved with ensuring that the insurance organisations are charged correctly.  This also means that there are no artificial limits placed on maximising the use of expensive capital equipment and hospital installations.

•    Also, crucially, as the government is not supplying the service, the state does not own the product of the service, nor most importantly the patient’s medical record.  Patients have bought the service either directly at the proscribed rate, or via their insurance, and they are therefore the owners of the results.  Responsibility for the ownership of such records is reasonably unloaded on to the patient.  This eliminates another whole swathe of administrative costs.  And as there is no government duty of care with regard to patient records, there is no need / apparent obligation / or demand to create an expensive nationwide database of everyone’s medical records.

Any minimal useful information (such as the fact that I am diabetic, have allergies, my blood type, etc.) is retained on the chip of my Carte Vitale.  The Carte Vitale is a type of credit card with a chip that is used to organise the data required for my insurer to pay the sums necessary to whichever part of the health system I have used.  The card can be updated automatically with any changed circumstances when visiting the pharmacy.
This seems to be a truly efficient use of IT in health care.  Along with a pragmatic hands-on approach to consultant referral and appointment making, the need for a failing £20 billion government-organised National Programme for IT collating everyone’s medical records is eliminated at a stroke. And here a much simpler IT system works and it has been working for decades.

It should be the nation’s health, not the National Health Service, that is the priority of government.  As a qualified medical person I certainly believe that health outcomes are much better here than in the UK.  The NHS is certainly not the only way of organising a health system and we would do well to look across the channel.

Ed Hoskins is a qualified dentist, and architect, who now resides in France.  You can read more about the French health system here.

5 comments on “Why the NHS should look to France”

  1. I am a dentist and whatever the rights and wrongs of the two systems, quite frankly it is poor clinical practice to work without a dental nurse, and I can absolutely assure you it will inevitably lead to lower quality treatment.
    That is not to say that some treatments can be carried out without a nurse, but they are limited.
    There is nothing magic or special taught in French dental schools that somehow makes makes them able to do everything alone, nor, the last time I looked did they have four arms, two of which would have to be about six feet long.
    Believe me, I KNOW what I am talking about.

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