by James Meek
Enthoven himself seems to have been taken aback by the speed with which Thatcher’s sunset coterie latched onto him. In an interview with the British Medical Journal in 1989 he said of the Conservative proposals: ‘I was very surprised by the lack of detail … I thought that I was throwing out a general idea that needed to be developed.’ It is eerie to read the interview now. Everything that Enthoven prescribed then was either brought in by New Labour or is being put in place by Labour’s supposed opponents a generation later. ‘I recommended that the district health authorities be recast as purchasers of services on behalf of the populations they serve, with choice of where and from whom they buy the services, rather than being cast as monopoly suppliers’ – check. ‘Another very strong idea is that money follows patients’ – check. ‘Pay hospitals prospectively by diagnosis-related groups as our Medicare programme does’ – check. ‘Self-governing NHS trusts’ – check.
What seems to have happened since 1985 is that Enthoven’s ideas have become embedded in individual careers, financial aspirations and personal relationships independently of the rise and fall of parties. For individuals, there is money to be made by promoting the market. In 2006, Accountancy Age reported that the NHS was spending more on consultants than all Britain’s manufacturers put together. The figure for 2007–08 was £308.5 million. The post-political careers of the Labour cabinet ministers responsible for marketising the NHS don’t make for comfortable reading. Alan Milburn became an adviser to Bridgepoint Capital, a venture capital firm backing private health companies in Britain, and to the crisps and fizzy drinks maker PepsiCo; for eighteen days a year advising Cinven, which owns thirty-seven private hospitals, Patricia Hewitt, one of Milburn’s successors as health secretary, was paid £60,000. The revolving door has become a blur. Simon Stevens, Blair’s special adviser on health, became a senior executive at UnitedHealth, one of America’s largest private health companies; he is now back on the government payroll as head of NHS England. Mark Britnell, a career NHS manager who rose to become one of the most powerful civil servants in the Department of Health, upped sticks in 2009 to become global head of health for the consultants KPMG.
This last move did have the advantage of giving an insight into what had actually been going on in Whitehall and Downing Street. In 2010 Britnell was interviewed for a brochure put out by Apax Partners, a private equity firm: it had organised a conference in New York on how private companies could take advantage of the vulnerability of healthcare systems in a harsh financial climate. ‘In future,’ Britnell said, ‘the NHS will be a state insurance provider, not a state deliverer … The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years.’ Responding later to the dismay his comments had caused, Britnell said in an article for the Health Service Journal that the NHS had saved his life in the year he left government service, that he would always support it, and that the quotes attributed to him ‘do not reflect the discussion that took place’ at the conference. But he didn’t deny making the comments. ‘Competition,’ he added, ‘can exist without privatization.’
Yet Britnell had topped his own ‘no mercy’ line in an article he’d written for the same magazine the previous week. There he made the unremarkable if contentious point that ‘all over the world, the size of the state has been increasing.’ What furrowed the brow was the base year he chose for the comparison with today’s level of public spending: the year was 1870, when infant mortality in Britain ran at 16 per cent, working-class men had just been given the vote, and four years had passed since a cholera epidemic killed 3,500 Londoners.
Critics of the NHS often cite Enthoven’s favourite health organisation, Kaiser Permanente, as a model for efficient, integrated care. And yet from the British point of view Kaiser stands out among American providers not because it’s better or worse than the NHS but because it looks a bit like it. It’s huge: it provides medical care to a mainly Californian membership roughly the size of the population of Austria. Its doctors are salaried and its hospitals are non-profit. It offers patients a complete service of hospitals, labs and family doctors, as the NHS does, although it also has its own pharmacies. And one explanation for its efficiency, as with the NHS until a few years ago, is that it actually limits choice. Most Kaiser members have a health plan that offers them or their employers relatively low premiums in exchange for using only Kaiser facilities.
Kaiser is doing a lot right. Its model of ‘integrated care’ – where a single health organisation looks out for people not just during treatment but before, after and between, and hospital admission is seen as a failure – has long been a goal for progressives in the NHS. It seems to have done a better job than the NHS of getting medical information off paper and into computers. A 2003 study in the British Medical Journal, investigating the length of time the over-65s spent in hospital, found that for hip replacements, British pensioners went home, on average, twelve and a half days after admission; Kaiser patients were home after four and a half. Kaiser doesn’t tie its consultants to its thirty-five hospitals; those who deal with chronic conditions are as likely to be in its 455 medical centres, alongside family doctors.
Getting ideas from Kaiser is one thing (as alluded to by Martyn Porter, NHS lengths of stay in hospital have dropped sharply since 2003); using it as a template is another. The major problem that militates against importing the Kaiser model to the NHS is money. England isn’t the only country that has studied Kaiser. In 2011 a Danish think tank, the Rockwool Foundation, reported on its investigations. Its team, led by Anne Frølich, found that Kaiser was better than the Danish health service at getting its constituent parts to work together, at getting patients to take responsibility for their own health and at preventing unnecessary hospital admissions. Everything was great, except that for every krone Denmark spent on healthcare, Kaiser spent one and a half. According to the latest OECD figures, Denmark outspends Britain on healthcare, head for head, by 25 per cent. On the basis of the Rockwool study, the Kaiser system could be reproduced in Britain only if health spending were increased by 87 per cent. That is not going to happen on any Tory or Labour planet in this galaxy.
The curious thing about the Lansley plan is that it was supposed to save money, yet despite the increase in spending on the NHS under Labour, the organisation remains a bargain. The two foreign systems with which it is most often compared, the American and the French, are more expensive, are coming to be seen as unaffordable in their own countries and contain elements that it would be hard for Britons to accept. Kaiser works well and is cheaper than traditional American healthcare. But it reflects the US model. Although that model is being changed by the introduction of President Obama’s Affordable Care Act, it remains idiosyncratic. Most people over sixty-five are eligible for Medicare, a kind of gold-plated American NHS for the elderly, but otherwise, if you have no insurance, you have no guaranteed access to medical facilities, including Kaiser’s. If you fall seriously ill in the US, aren’t insured and aren’t rich, you have two main options: to go to a hospital’s accident and emergency unit, where they’re obliged to treat you, or to try to get Medicaid, a government programme to help the poor and disadvantaged run on a state by state basis. But the hospital will charge the full rate for treating you, which it will then try to recover against any assets you have, while Medicaid is means-tested. In other words, being uninsured and having a serious car accident in the United States is hard to make compatible with owning a house.
The Affordable Care Act (ACA) is a giant step towards equality of opportunity in America, though it falls short of a revolution. The new law proposes that all fifty states accept a more generous means test for households trying to enrol in Medicaid. The threshold depends on household size; in most states, a family of four could be earning up to $32,500 a year and still qualify. In many parts of the US, where the current threshold is less than $12,000, this is a massive increase, and should enable proper health care for the first time to millions of low-paid
working Americans whose employers are too mean to cover them. But a swathe of southern and mid-western states with Republican legislatures, including four of the five with the highest poverty levels, Mississippi, Louisiana, Alabama and Texas, are refusing, with the approval of the Supreme Court, to implement the system.
For middle-class Americans, the new system is just as radical. Individuals still aren’t forced to take out health insurance, but they now suffer a stiff tax penalty if they don’t. In return, for middle-income households earning up to $94,000, the government offers hefty subsidies on a choice of health plans, and has abolished the brutal ‘pre-existing condition’ rule, which allowed insurance companies to refuse coverage to people who were already ill. All businesses above a certain size will be obliged to start offering their employees health cover. Supporters of the law believe it will more than pay for itself; its increased costs will be offset by thinning out the armies of walking wounded who throng hospital emergency rooms, and by spreading risk more widely.
But as many as thirty million people will still be left without medical cover – low-paid people in the pro-inequality states, illegal immigrants and people who gamble that they won’t need a doctor and prefer to pay a tax penalty rather than a premium. And even if you are insured in America, and have access to some of the world’s finest medical facilities, just paying the premium each month doesn’t make healthcare free at the point of delivery. Two standard features of US health insurance, before the ACA and under it, are the ‘copay’, a fee for consultations or drugs, and the ‘deductible’, an amount the patient is expected to pay before the insurance kicks in, like the excess on car insurance. The lower the premiums, the higher the copays and deductible.
With the new subsidies Kaiser’s Platinum 90 plan, for instance, costs $345 a month for a forty-year-old woman with one child living in San Francisco and earning $40,000 a year. Although much more affordable than it would have been pre-ACA, that’s a high premium, and there’s no deductible. But each year she has to pay $20 to see a doctor after the first visit; $150 for a trip to the emergency room; between $5 and $15 per prescription; $250 a day for a hospital stay, and so on up to a maximum of $8,000 a year. At the other end of the scale, there’s a Bronze plan that costs $123 a month. That’s a bargain if she doesn’t get sick. But if mother or child falls ill, she has to pay the first $9,000 out of her own pocket. After that the copays kick in – two-fifths of the actual cost of everything from chemotherapy to x-rays – until she’s forked out $12,700.
A Harvard-led study found that 62 per cent of all bankruptcies in the United States in 2007 were due to medical bills, an increase of 50 per cent in six years. Most of those affected were well-educated, middle-class homeowners. Astonishingly, three-quarters had their finances destroyed by medical costs even though they had insurance. In a significant number of cases, it was paying to look after a sick child that bankrupted parents. Among the common ailments were neurological conditions like multiple sclerosis, which left households $34,000 out of pocket on average, diabetes ($26,000) and stroke ($23,000). In his paper ‘Sick and (Still) Broke’, the lawyer Ryan Sugden points out that while the ACA puts a helpful cap on copayments, it doesn’t eliminate them, and does little to help people who have to quit work through their or a child’s illness. ‘While the Affordable Care Act will reduce the overall number of bankruptcies, and arguably eliminate the most morally objectionable causes of medical bankruptcy, in a system based on market principles there will – and must – be consumers whose own bad choices spell financial trouble,’ he writes. ‘For society to “win” and receive the benefits of a consumer-driven system, there must be some who “lose”.’
Latest figures from the OECD and the World Health Organisation suggest that the US spends 2.4 times more on health per person than Britain, yet Britons live slightly longer, on average, than Americans. British men can expect to live to be seventy-eight, two years older than American men; for women it’s eighty-two versus eighty-one.
The US healthcare system is unique, as is the NHS. Most rich countries lie somewhere in-between the two, using mandatory insurance, with a mixture of state, for-profit and non-profit medical organisations providing the care. France, for instance, spends slightly more on health than Britain, and French women, though not French men, live slightly longer. French people of working age, together with their employers if they have them, pay into a social security fund that’s supposed to cover healthcare, pensions, disability and child support. The poorest French people get healthcare absolutely free under a system called Couverture Maladie Universelle, or CMU. There is also a list of thirty conditions, known as Affections Longue Durée, which are treated free of charge for everyone: cancer, HIV, diabetes, Parkinson’s, all the way to leprosy. Otherwise the relatively well-off, though shielded from ruin by the sickness insurance system, Assurance Maladie, are faced with a system of copays not much less onerous than America’s. Where in Britain copays are restricted to dentistry and prescription charges, in France patients pay a fee each time they visit the doctor. They pay a percentage, known as the ticket modérateur, of hospital costs, ambulance bills and medical procedures. Each visit to your GP, for instance, costs €23 up front, of which €15.10 will be reimbursed. A replacement hip is free, but to get one put in you have to pay 20 per cent of the cost of surgery, lab tests, consultants’ fees and the stay in hospital.
The huge sums France spends giving its citizens free, universal access to the latest cancer drugs and equipment are popular, but the country’s lavish spending on extreme illnesses doesn’t put it as far ahead of Britain as critics of the NHS claim. One recent study led by Philippe Autier of the International Agency for Research on Cancer in Lyon showed that the number of people dying of breast cancer in England and Wales fell by 35 per cent between 1989 and 2006, against an 11 per cent fall in France. France is still doing slightly better than England but the rates have almost converged.
Britons who idealise the French system imagine that in France anyone can see any doctor they like and that the state will pick up the bill, but if this were ever true, it isn’t true now. The country’s social security fund is chronically in the red. To see a consultant inside the Assurance Maladie system, patients have to get a referral from a GP, as in Britain. And there are two kinds of doctor. Only secteur 1 doctors charge the Assurance Maladie fee. Secteur 2 doctors can set their own fees, but the share reimbursed by Assurance Maladie doesn’t change. An increasing number are taking out private health insurance to cover the gap.
All the rich world’s diverse health care systems are struggling with ageing populations, with the diseases of plenty – obesity, diabetes – and new, ever more expensive ways to treat their illnesses. But to speak in terms of ‘health care systems’ doesn’t accurately represent what’s happening to the NHS. The NHS used to be no more or less than a health care system; now it’s a health care system into which a whole other system, the system of competitive consumerism, is pushing. A system that was concerned first with making people well and, as a secondary preoccupation, looking after itself, is now trying to accommodate competition. But competition between agencies for business, even medical business, is easy to understand. The more insidious novelty is competition between patients. Once it used to be enough to get help for what ailed you. Now patients are being encouraged to think about how the NHS treats them in terms of the discontent-fostering narratives of advertising: to imagine other patients who are getting better or worse treatment than they are, in prettier or uglier hospitals, with therapies that are not necessarily more effective but are faster, more fashionable, that come in a wider range of colours. The blurring of the distinction between health care and the maintenance of lifestyle choices gives the enemies of the NHS another means by which to accuse it of failure.
One dark Sunday afternoon in February 1982 Jill Charnley waited at the wheel of a car outside a hospital in Mansfield. Through the storm she saw her husband bustling towards her with a plastic pail containing the haun
ch of a woman who’d just died. ‘Down the road he came with a triumphant smile on his face and this bucket with a hip in it,’ she told me not long ago. ‘He put it in the boot of the car. I remember saying: “My God, I hope we don’t have an accident, if they look in the boot of the car to see what’s there …” ’
John Charnley, Sir John as he was by then, managed to restrain himself from dissecting the specimen, preserved under formalin, until the next day. The dead patient’s hip was, in a way, as much his as hers. It was implanted in 1963, one of the world’s first successful total hip replacements, performed by Charnley using a hip of his own design. ‘This is truly a marvellous climax to my series of more than seventy cases,’ he wrote in his journal, referring to post-mortem examinations he’d already done on his early patients. To have his prototype hip work smoothly inside someone for almost twenty years and still be, as he described it, in perfect condition, gave him joy.
The first generation of NHS surgeons were front-line surgeons in a literal sense. In 1940, aged twenty-nine, Charnley went to France as a military medic with the makeshift flotilla evacuating British troops from Dunkirk. ‘He didn’t expect to survive,’ his widow said. ‘The boat he was in was bombed or shelled. I remember him saying to me that this was the point when he believed he’d been saved for a purpose.’
The foundation of the NHS in 1948 coincided with a golden era in the struggle against infectious disease. In postwar Britain, orthopaedic surgeons earned their spurs in hospitals built in the countryside as sanitoria, designed to deal with the bone and joint problems caused by tuberculosis and polio. But the incidence of these infectious diseases was dropping. Casting around for new reasons to be, the bone doctors fastened on arthritis.
Up to this point, the options for people with a dodgy hip were limited. Basic human actions – walking, getting up, sitting down – require smooth movement of the femoral head, the ball-like top of the thigh bone, against the cup-like socket in the pelvis known as the acetabulum. When it works as evolution made it, it is because socket and head are sheathed in a smooth layer of cartilage that secretes a natural lubricant called synovial fluid. Inflammation, fractures and swelling make the hip jam and chafe like a rusted-up hinge. The result is immobility and pain. By the 1950s, it was becoming fairly common to cut off the degraded top of a patient’s thigh bone and replace the femoral head with one made of metal or ceramic. Other surgeons focused on the acetabulum: they lined damaged hip sockets with cups made of steel, chrome alloy or glass. What was missing was a reliable way of replacing both head and socket. It had been tried in the 1930s, with the two parts made of metal, but it had never really worked.
