The Stone City

Words Made to Last

Tuesday, August 30, 2005


Fiscal liberals in the United States tend to support government-mandated single-payer health care, largely on the grounds that it will provide more equal access than the existing system. With this in mind, it is worth considering some contemporary comments on Britain's National Health Service (NHS), formed in 1948 with that precise aim.

From the NHS's own internal audit:
2.16 ... For many surgical specialties the top 25% of hospitals get nearly double the output from their consultants as the bottom 25%. In the worst hospitals cancelled operations are running at 5%. The best ones have cancellation rates close to zero. Often the poorest services are in the poorest areas with the poorest results. The NHS has been unable to tackle these unacceptable variations because the 1948 settlement left it with inadequate means to drive up performance.
2.22 The current system penalises success and rewards failure. A hospital which manages to treat all its patients within 9 or 12 months rather than 18 may be told that ‘over performance’ means it has been getting too much money and can manage with less next year. By contrast, hospitals with long waiting lists and times may be rewarded with extra money to bail them out – even though the root of the problem may be poor ways of working rather than lack of funding. The NHS has to move from a culture where it bails out failure to one where it rewards success.
2.23 Rigid institutional boundaries can mean the needs of individual patients come apoor second to the needs of the individual service. On one day in September last year, 5,500 patients aged 75 and over were ready to be discharged but were still in an acute hospital bed: 23% awaiting assessment; 17% waiting for social services funding to go to a care home; 25% trying to find the right care home; and 6% waiting for the right home care package to be organised. Almost three quarters were not getting the care they needed because of poor co-ordination between the NHS and other agencies. This experience is repeated daily throughout the NHS.

While the later paragraphs provide more detailed diagnosis, the punch line is in the first excerpted paragraph [emphasis mine]. The NHS provides the same sort of "equality" as do public schools in the United States -- that is, a specious equality which little profits the poor, who continue to suffer subpar treatment at the hands of an objectively pro-discrimination institution.

The Socialist Workers, admittedly not committed centrists, describe the situation at Whittington Hospital, in downtrodden Islington [which achieved notoriety with the Rose Addis case]:
People often wait between four and ten hours in accident and emergency. There are not enough staff, and patients have to wait too long. Staff are working long shifts, often without a break. Politicians wouldn't last a morning in that environment. We get a lot of abuse and violence. We often don't have the time, so when patients are seen perhaps they don't get all the care they need because we are seeing so many patients.
In Bristol, which is a sort of outpost of Englishness into the scenic but underdeveloped Far Southwest and Wales, fatally subpar care was allowed to persist for a decade:
The report explains that due to national pressure to reduce heart disease in adults, especially after the introduction of the market into the NHS in 1990 to increase the income generated by the numbers of adult patients, the care of child patients suffered. The cardiac surgical service in Bristol was mainly an adult service, with the PCS unit tacked on to it, rather than being a dedicated service in its own right. The inquiry team found that the unit had no dedicated paediatric intensive care beds, no full-time paediatric cardiac surgeon and too few paediatrically trained nurses.
... Despite these reports, Sir Terence English, then President of the Royal College of Surgeons, recommended that the unit at Bristol should not only “retain designation but recommended they should be pressed to increase the workload”. Both the Department of Health (DOH) and the Welsh Office were made aware of the situation at Bristol and also took no action. But there existed a national shortage of paediatric cardiologists, which was described by the British Medical Association as “unacceptable” in 1988 and “perilous” in 1992. This shortage was particularly acute in the South West area, due to there being few large hospitals in the area and none in Wales. This may go some way to explaining why it is that no action was taken regarding Bristol’s poor record.

In the rich and well-insulated neighborhoods of Belgravia and Chelsea, the NHS may indeed provide a world-class service. [I still would not choose it for my own care, if I needed major medical treatment.] But it has given the ghettos of England, both rural and urban, healthcare in keeping with their station in life.