Comparing like with like? How does our free service compare to other nations' free services for the non payers or non insured.
Most Northern European countries provide excellent universal healthcare to all their citizens regardless of income. However its very hard to compare like healthcare (HC) systems with like as every country has its own culture and doing it their way. One thing that strikes me as odd about debates on the NHS, is that its generally only compared to the US system and those comparisons are usually rather crude. Whats is surprising is universal HC that is essentially free in Europe that gives good outcomes are not talked about in the UK. This is especially odd as on some metrics they give better outcomes than the NHS. Not to say that the NHS isn't superb and something to be immensely proud off.
Newspapers and UK politicians very rarely look at Northern European HC and don't do analysis of where those countries are delivering better national outcomes to the NHS in some areas- metrics like cancer survival rates, waiting times and overall mortality rates. Its probably because the ones with the best outcomes operate in a very different cultural and historical context to ours, and maybe innovations would be hard to implement, and impossible politically as NHS is a highly politicised issue in the UK.
Most European HC systems have a mixture of private, charity and church based hospitals, these are either paid for by the patents insurance or by the state. In most countries its not free at the point of use, but reimbursed through insurance schemes, although countries such as France issue citizens with a national credit card to pay. The Bismarkian insurance type schemes (Germany's comprehensive insurance based national healthcare dates back to 1880) enable these countries to raise more funding for their H/C system than the UKs tax based system - from 1% to 2% of gdp more and in a less politicised environment than the UK. There is a market element that enables them to charge the rich more, which helps raise significantly more money.
Free for the poor.
Citizens in most Northern European states (states with similar standard of living to the UK) are compelled to take out health insurance from an approved provider, a bit like UK car insurance is compulsory. In several countries there is a choice of provider offering different levels of cover. For all patents, the basics are the same ie good safe H/C, but those that pay more get slightly quicker service and slightly posher hospitals. The unemployed and poor have theirs paid for by the state and get the basic service (of a standard as good as the UK). The trick is for those in paid employment, pay about 13% of their salary into the insurance on top of other taxes. The way I liken it is an analogy with taking a plane flight, the state pays for an economy flight whereas the private insurance pays for business class. They pay 13% plus and get a slightly faster and more comfortable service, but both passengers get the same safe flight that takes them from a to b. This extra 1% to 2% of extra finance enables continental countries to employ more doctors per 1000 people than the UK. I think its this two tier structure that makes the European systems less political than in the UK. The rich pay up because they see they get a better service (even if its only cosmetically different), the poor like it because they get excellent healthcare for free. Because of the duel funding structure there is less funding from general taxation so its not such a hole at the treasury.
To my mind, the other huge benefit of these HC systems is how un-politicized they are. They are not associated with one political party as the founding of the NHS is, but a consensus that goes back to Bismark with subsequent improvements as social modernisation and innovation in social democracy developed in Europe. Originally the schemes were only available to those who could afford insurance, but since WW2 the state has covered those whose incomes are low or the unemployed.
In terms of delivery, the different private hospitals groups compete for patients, which means they need to provide an excess of resources such as beds and doctors (an in-efficiency cf the NHS) but means they have extra capacity available for winter flu, patients have more choice, and lower waiting times. Its probably the main reason COVID death rates in Northern European countries are lower than the UK, they have a bit more critical care capacity than us.
These schemes are not much discussed in the UK. I think its largely that they are so different to the , tax payer financed NHS and universal monolithic offer. They are probably impossible for us to copy without politically impossible changes. Its could be seen as privatising the NHS and we don't trust our governments sufficiently to allow for such reforms and we are terrified that we would adopt a US model so its just not discussed. For the right of centre politically the continental systems is paid for disproportionately by the well off. So I can see that politically it does not appeal to either the left or the right.
Every EU country is different to a degree, there finance and paying structures reflect their history and culture, but they have broadly similar Bismarkien insurance based schemes with government top up for the unemployed, disabled, this makes comparisons across Europe really quite hard as not country is the same.
I heard a Professor of H/C policy from Imperial college give a talk to us at work on improvement schemes in the NHS and I asked him to rank other countries, he said that although France appears fantastic, especially to British tourists, there are discrepancies in provision between wealthy areas (that tourists visit) and the depressed mining communities, so overall he didn't think the French got so much better treatment than we do through the NHS, even though they spend more gdp on HC than us. He said its difficult to compare data sets, however he held up examples of clearly more effective systems, the Netherlands, Finland, Nordics, Germany, Belgium as leading lights. He commented that the Netherlands and Finland spend about the same as us on HC but get better outcomes. Another fact of European H/C is they train more doctors and nurses per head than we do and they pay there doctors, consultants a lot less than their equivalent in the UK. This has the upside that it helps the NHS recruit from the EU, when desperate, but it means on the downside, on the whole we have less doctors and consultants than our pears overseas, and we expect them to be more productive.
I hope that answered your question, I've tried to keep it factual. But one observation on these various systems is one of how easy is it to convince a population to fund its HC.
I think that as long as we solely rely on taxation to fund the NHS, we will have to accept there are limits to what taxpayers will reasonably put up with. Healthcare is predominantly consumed by the old, (although we all use it, something like 85% of operations are on the over 65s) but paid for my the young fit and healthy, so there is only so much that politicians of all colours can persuade people to transfer through taxation. That is the one obvious benefit from the continental way of doing things.
The other comparison is value for money.
Its hard to compare things like efficiency and productivity as the boundaries of what is NHS and the rest of the state are so different. So with that caveat, there have been studies, one fact that differentiates the NHS is that is by an large a nationalised monopoly, it does not need to compete and so runs to keep its assets full through central/regional planning and has very high utilisation of its assets ie bed use, ration of staff to general population, whereas European hospitals are private or charitable entities that compete in a market for patients so need to have extra capacity. the NHS scores well on efficiency measure based on asset and people utilisation. However the NHS sufferer from structural inefficiency through its regionals and hierarchical structures, consultant fiefdoms and silos that are prevalent in a large employment structure. The more atomised continental systems are efficient at delivery and efficient with patents time. In many (but not all) European countries, the primary care center - cf our GP practice, often has a healthcare centers equipped with laboratories and scanners so that the doctor can get scans etc done while you visit. Cutting down on a lot of waste which we don't measure in the UK. One sad trend, is the UK system seems to have got less efficient over the past 10 years - not sure if this is just the way we measure it, its got more sophisticated, or the effect of the Landsley reforms
One benefit of having a national systems is in a global emergency, such as responding to a pandemic can be centrally planned and rolled out, we saw that this year where patients were transferred up and down the country during the hight of the pandemic, whereas Italy struggled with its excellent, but regionally organised H/C. In terms of value for money the NHS is up in the top tier (US is way down) but the Netherlands, Finland, Belgium Nordics seem to offer better value for money.
Most comparisons of H/C tend to focus on money - costs of this and than. But the other dimension is trust, brand image and care and feel. Here the NHS is outstanding in this regard. We trust the staff, we trust the motivation and care. Scandals in the NHS are usually due to incompetence, the odd murderous of competent professional hiding in the system, but the people, there motivation and the organisation is trusted and loved. However when I speak to work colleagues from Northern European visiting or resident in the UK, they prefer to go home to get treatment as they don't trust the NHS to the extent we do. And avoid British dentists at all costs has been something I've read about all my life, which I think is unfair as dental practice has improved during my lifetime.
Although these systems work well in Northern Europe, they are just so complety different to the UK that its hard to see how we can learn from them. If over time their healthcare massively outperform ours, then maybe there would be a case for a re-think.
So Jacob, to try and answer your questions - and I hope I've not introduced politics into this as its a genuinely interesting topic, out biggest national institution and the second biggest area of government expenditure - also my company is being paid by the tax payer to develop vaccines so I have a personal interest. There are HC systems every bit as good and free as the NHS, but we just don't discuss them in the UK. unfortunately they are so different that its hard for us to lean from them and vice versa. We can only look on enviously at the HC available to a Finn, a Dane, a German a Dutchperson, that does not have the same political interference as this country, they tend to leave it to the professionals, civil service, contracted, regulated insurance companies, private hospitals etc, to just get on with it. I do wish for that.
