Mistaken priorities

LEVEL PLAYING FIELD
The Hindu, 22 January

Thanks to a minor but persistent ailment, I recently paid a series of visits to my local doctors’ surgery. As always, the waiting room was filled. The patients – mostly working-class, many from the Turkish and Kurdish communities that are prominent in the area – were calm. We all felt the anxieties that anyone waiting to consult a physician feels but we all knew that there was one thing we didn’t have to worry about: money.

Those of us with prior experience of this particular surgery also knew that our miseries would be dealt with promptly and efficiently. Over a period of weeks, I was seen by doctors, technicians and clerical staff; all sympathetic and responsive. Diagnosis and treatment were thoughtful and thorough. It was first-class health care, and there was no bill to pay. There was not even a form to fill in or a claim to file. For the umpteenth time since I migrated from the US to Britain thirty five years ago, I gave thanks to the gods of social democracy for their wonderful bequest, the National Health Service, a jewel in the crown of human civilisation.

The NHS was launched in 1948 in unpropitious circumstances. Post-war austerity still reigned. Food and fuel were rationed. There was a housing crisis. Sterling was fragile. But there was a strong and confident labour movement and a Labour party with a solid parliamentary majority and a popular mandate for radical change. What that government created was not a safety net for poor people, but a comprehensive service based on the democratic principle that everyone should have access to the best available health care, delivered free at the point of need and funded from general taxation.

From the beginning, there were problems. The sheer scale of the organisation – Europe’s largest employer – gave rise to bureaucracy and sometimes made it slow in responding to diverse and changing needs. Rapid developments in medical technology as well as new forms of ill-health steadily increased pressure on resources. But through it all, the NHS has remained Britain’s most cherished institution, and the exclusive provider of health services for 90% of the population.

To most people in the USA, where access to medical care is a major anxiety, my recent NHS experience will sound like a utopian fantasy. It’s not that the US lacks doctors and nurses; it has more than twice as many per head as the UK and ten times as many as India. And it’s not that it doesn’t spend lavishly, devoting 15% of GDP to health care, a higher proportion than any other country. The problem is a profligate and chaotic health care system governed by the priorities of private profit. This is a system that excludes 14% of the population – the 45 million Americans without health insurance – and leaves most of the rest with only partial and often expensive coverage. The Institute of Medicine estimates that at least 18,000 Americans die prematurely each year solely because they lack health insurance.

Although the US spends two and a half times as much per capita on health care than Britain, people in the US are likely to live less long and spend more years in ill health than people in Britain. The child mortality rate is 33% higher in the US than in the UK, and the same as in Malaysia, where per capita income is only one tenth the USA’s. And these average rates disguise extreme inequality within the USA. Child mortality among African-Americans is twice the national average and higher than in Sri Lanka or Kerala. A baby boy from a family in the wealthiest 5% will enjoy a life span 25% longer than a child born in the poorest 5%.

Meanwhile, thanks to the billing and accountancy required by a fragmented, privatised system, a quarter of US spending on health is swallowed up by administration: $400 billion a year, four times the combined health budgets of the 62 lowest-spending countries in the world, including India and China. Other costly chunks go on marketing, on profits for shareholders and on lobbying politicians to ensure those profits remain healthy – whatever the cost to the health of the nation as a whole.

Now Tony Blair wants to import this madness into Britain. Thatcher did her best to undermine the NHS – cutting services, raising charges, squeezing out dentistry and eye-care, imposing an “internal market” that prioritised balancing the books over clinical need. But she never dared propose the kind of far-reaching changes currently being sought by Blair’s cabinet. Just as only Nixon could go to China, only a Labour government could so compromise the NHS’s founding principles. For the first time, NHS primary care provision is being franchised out to private sector entities, including US-based health care giants. NHS hospitals are being asked to “compete” with private counterparts in providing operations on the cheap. Capital investment in new facilities is mortgaged to private finance – which takes no risk but is guaranteed a long-term income stream from the taxpayer. An ever increasing proportion of NHS spending is winding up in corporate coffers.

Despite substantial increases in the health budget in recent years, the NHS finds itself once again, this winter, in crisis. As a result of a ?700 million overspend, services around the country are being rationed, curtailed or eliminated. As ever, the biggest losers are the poor, the elderly and the disabled. The government says the overspend just shows the need to bring in the private sector faster. But in light of ?1.5 billion the Exchequer managed to find to prosecute the war in Iraq this year, it seems more likely that this is really a monstrous case of mistaken priorities.