As an Englishman living in France who worked in the NHS some long time ago, it is of great sadness to me that both political dogma and the refusal to accept criticism of what has become a national icon manages to blank out any consideration that methods and experience from elsewhere could ever be applicable in the U.K.
This is particularly so in the NHS, where the dogma that the Government has to be directly responsible from taxation for the administration and supply of health care has been inbuilt for so long. It seems that from its earliest days the NHS that was set up as if patients were incapable of having any responsibility for their own health and therefore the Government had to take on that administrative responsibility. This may be one of the reasons why the NHS has been continually overburdened with self-perpetuating and ever-growing bureaucracy.
This combined with ‘free at the point of use’ was particularly damaging. ‘Free at the point of use’ in the U.K. encourages people to regard the access to such services as being free and as of right, encouraging time wasters and thus unnecessary use of medical services.
‘Free at the point of use’ is also a fallacy as so little in the NHS is actually free at the point of use – there are prescription charges, dental costs and the endemic rationing, which itself translates into huge costs for the individual patient.
So why are things so different here in France, where national expenditure on health is on a par with the U.K., yet we get far more bang for our buck?
First, the system is run on an insurance basis based on income, supervised by the state but not directly administered by the state. The system has 100% state protection for the low paid, the chronically ill, pensioners, children etc.
Normally, the state pays the larger part but not all the medical costs. Individuals have the option to buy supplementary top-up insurance (mutuelle) to cover the balance. This ensures that people do have an understanding of the value of their healthcare.
In France, health provision is supported by a very effective IT system. It was originated as early as 1982 with the Minitel online system, although it has now been superseded by the Carte Vitale.
The Carte Vitale is a type of credit card with a chip issued to all insured patients. It provides the data required for the insurer to pay the sums necessary to whichever health provider has been used. It retains minimal health information, such as the chronic illnesses for which the patient is due full reimbursement. Most health professionals, such as the GP, have card readers and are reimbursed directly through the system. The Carte Vitale can be updated on a terminal at any pharmacy. There is a parallel manual system which can be used by any small-scale provider, for example the visiting chiropodist.
The insurance organisations provide regular reports to the patient noting all the payments that have been made on their behalf, thus ensuring that the patient knows the value of the health care he or she has received.
Importantly, GPs are not paid by a capitation fee based on registered patient numbers but on their actual patient appointments. This means that there can be a modicum of competition between them as health providers. Well-liked health providers are successful and as busy as they want to be. And the patient retains his or her ability to choose.
Only recently, a system of affiliating patients to particular GPs has been introduced; before that it was totally open to the choice of the patient on any particular occasion.
All the providers in the system – the GPs, consultants, diagnostic labs, district nurses, etc. – are either private company groups or self-employed private contractors within the system. But they normally work at the nationally prescribed fee scales.
The contractors in the system choose their mode of working from the point of view of their own businesses and personal circumstances within those fee scales. This results in health service outcomes most of which would be remarkable in the U.K., other than in the costly private sector:
- My GP has no secretary and no appointment system. Turn up when you need and wait perhaps 20 minutes on a busy day.
- The GP will also be happy to make home visits; the reimbursed charge is rather more.
- The patient also has the choice of which consultant to see and can contact the consultant’s office directly without GP referral, but the GP will always recommend the one he or she considers suitable.
- The district nurse will turn up on the doorstep to take a blood sample at 7am in the morning for a fee of €6.35 (reimbursed).
- The pharmacist will provide over-the-counter advice and drugs for almost any common aliment. He or she will also provide prescription drugs (un-reimbursed) if needed at his discretion. Thus the load on the GP is much reduced.
- The dentist has no dental nurse and runs the practice single handed. A large proportion of his fees are reimbursed to the patient.
- The busy cardiology practice with three consultants has just one administrative assistant.
- The consultant dermatologist answers his own phone and makes his own appointments without any need for administrative help.
- As well as doing major surgery, the consultant orthopaedic surgeon does not hesitate to do his own minor splint work on the spot.
- There is a rigorous system of reminders about medical appointments by text and email so the waste from missed appointments is unusual.
- Etcetera etcetera.
Thus, the administrative load created by centralised control and rationing of access to consultants, treatments and hospital appointments does not seem to exist.
As separate private contractors, all health professionals work as if their time was their money. Most U.K. hospital consultants are already private contractors as well as being well-paid part-time Government employees. A piece-work remuneration system has been working for dentists in the NHS for many years. In France this also applies to GPs and their remuneration does not seem to be excessive as it often is in the U.K.
Prior to any hospital intervention, all the necessary preparatory checks take place as outpatients including blood tests, anaesthetic checks, cardiac checks etc. This means that inpatient hospital time is not used for these preparatory activities.
In France there is a real emphasis on preventative medicine and prompt treatment is considered to be economically worthwhile. Thus, certainly in my experience, long waiting lists just do not exist. In addition, speaking as a pensioner, the health service does not seem to think that age is an impediment to treatment.
There is certainly an abundance of medically qualified people in the system and indeed there is a degree of real competition between them. According to OECD figures, there are around 25% more medically qualified professionals per head of population than in the U.K. health service. They are not rewarded with the high salaries received in the U.K.
The medics seem to control the running of the hospitals and other facilities, not the Government. They see the benefit of having an absolute minimum of administrative overheads. Those that exist are mainly involved with ensuring that the various state mandated insurance organisations are charged correctly.
This also means that there are no artificial limits placed on maximising the use of expensive capital equipment and the 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 patients’ medical records.
Patients have bought the service via their insurance: they are therefore the owners of the results. The responsibility for the ownership of such records is reasonably unloaded on to the patient. As the patient owns the records, he or she is freely able to read them and understand them to the best of his or her ability.
This eliminates another whole swathe of administrative costs. As there is no Government duty of care with regard to patient records, there is no demand to create an expensive nationwide database of everyone’s medical records, as was tried and failed in the U.K.
The ambulance service is merged with the fire service as a single emergency service. Voluntary membership is prestigious in the community. If you have a regular treatment appointment, say for radiotherapy, a taxi will come and fetch you and bring you home – all part of the service.
In other words, the French health service is pretty well ‘privatised’, and that’s why it works rather well.
The nation’s health, not the National Health Service, should be the priority of Government.
The NHS is certainly not the only way to organise a Health Service and the clear alternative evidence is just across the channel. But dogma means that the Brits will never want to learn from foreigners.
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The NHS is dying and needs to be put out of its misery. Perhaps the nurses’ strike will show the public the truth of the situation – we live in hope.
Er, will anyone notice th3 nurses on strike. They haven’t been doing much at work.
In other words, the French health service is pretty well ‘privatised’, and that’s why it works rather well.
Great insights, thanks. I lived in a few EU countries and like France, their approach to health care is about health, with a heavy emphasis on privatisation, private medical insurance, prevention, and low admin costs. Access was guaranteed with minimal waiting time. Technology applied (scans etc) on demand. The exact opposite of the Saintly, never to be touched or even mildly reformed, National Death Service in the UK.
I wonder if the French health system responded differently to the Rona fascism? If they did, that would be another benefit for dismantling the Communist Death Service here.
No the French health system was just as awful.
The biggest problem that the NHS and most other Western health systems face is that they are dealing with vast amounts of illness caused by completely dysfunctional diet/nutrition. A huge percentage of modern illness is the result of what people are eating, actively promoted by the food and beverage industry …
… and also of course in the last few/couple of decades the iatrogenic disease caused by the pharmaceutical industry.
The state run/supervised and part-funded/subsidised systems act as a disguise/camouflage for this situation, by normalising the modern levels of chronic degenerative disease, as if this amount of chronic disease was/is an inevitable part of life which just has to be dealt with, so normal/unavoidable that governments just have to organise/provide a response.
Whereas real concern for health would involve restraining the food and drink and pharmaceutical industries, and educating and supporting the population to eat healthily.
That’s ridiculous.
Far too sensible and where’s the profit going to come from.
It’s quite a business model they’ve got. Bigtec/MSM tells you to take jabs and pills – and eat the rubbish provided by the food industry, while bigpharma manage the consequential chronic disease.
Pure Genius.
lol
Nobody is being forced to eat bad food.
Is the solution for the state to be our nanny and tell us chich are the right things to eat and which aren’t?
If people want to eat unhealthy food that they like, smoke, drink and whatever else, it’s their choice. Just don’t make me pay their medical bills.
While we have the NHS as it is currently, I think we have to treat everyone and yes you will be paying people’s medical bills. I choose to skate and risk falling over – maybe you shouldn’t pay my bills. I drink too much. But I am pretty fit and eat well. It’s tricky. How do you decide?
If we move to an insurance-based system then underwriters might be free to charge based on your risk profile. That might lead to some people being charged very high premiums indeed to the point they are close to or actually unaffordable, and those least able to pay will often be those who present the highest risk. And what happens – the state steps in, or private insurers choose for political or ethical reasons to share the burden. All health insurance is going to have some burden-sharing that is unequal, if only because young people rarely get ill.
I’m not defending the NHS at all here, just pointing out the possible difficulties in getting a perfect system where you are not paying for other people’s poor choices. And not just choices – poor health is often a choice, but often not.
All slightly academic as I simply cannot see any change coming in my lifetime. I think the country would need to be very seriously and obviously bankrupt before the NHS was not a sacred cow.
Governments couldn’t “nanny-state” their populations into eating healthily without almost completely overhauling how society is structured, because a truly healthy diet and way of life is beyond most people’s means.
The vast majority of modern populations are used to living on what is essentially cosmetically-enhanced “famine food”, stuff that an early homo-sapiens would not have eaten unless they were practically starving/literally dying of hunger.
It is very bad for our health, it is poverty food, but because it’s dressed up with flavourings, sugar and salt, gels and foamers and thickeners/gums, and other cheap ways to improve “mouthfeel” and promoted constantly, everywhere, most people think it’s good stuff, “tasty”, etc, and don’t realise that they are eating food of last resort, the food of the desperate.
Most people are worse fed now than they have ever been before, unless they were starving/suffering from famine.
And the other significant thing about this diet is that it is largely made up of foods that are literally painkillers, ( eg sugar ), or contain food opioids, ( eg glutenous grains and dairy foods ), and that the pap most of us eat is “baby-food”.
Mother’s milk is sweet and contains opioids to ease an infant animal’s passage into life outside the womb. But any young animal that does not move on from that food source, that is unable to step away from it, remains a dependant, and extremely vulnerable.
Animals that weren’t able to step away from mother’s milk died out because of that vulnerability.
But human animals seem to be increasingly addicted to and unable to kick baby-food. Most of us never really grow up, never really become adults, as a result. We need to eat every few hours, like babies, and can’t go far from “home”/the mother/the source of food as a result. We are hobbled, tethered, dependants.
And it shows.
Yes Fascism is always the solution. Make choices for people and make them behave differently as those of us in charge dictate.
The problem with ‘health care’ is Governments are involved.
‘… modern levels of chronic degenerative disease,’
Degenerative – because they are diseases of advancing age. They are ‘modern levels’ because previously people didn’t live long enough to degenerate enough to get them.
Lifestyle is indeed causing degenerative diseases – less arduous work, shorter work hours and more leisure, better nutrition, better medical care = live longer to get those degenerative diseases.
Diabetes, heart disease, cancers, autoimmune disorders, etc aren’t ( only ) diseases of the old.
Thought obesity was a Western problem so which health service is coping with that is surely irrelevant? Or are they slimmer in France, Italy or the USA?
The NHS system design features a lack of incentives for consumers to limit their demand and a lack of incentives for providers to be productive. The involvement of politicians ensures high levels of bureaucracy and that resource allocation is based on political rather than clinical priorities. The NHS is flawed by design and bound to fail.
There are incentives such as long waiting times, receptionists etc. Since my GP’s website says the Covid-19 vaccines are safe and effective that is a reason to avoid the GP if possible. Is he safe?
The design flaw is it is a State-run non-contestable monopoly. It simply cannot work by virtue if that.
Name one such that has ever worked anywhere at any time.
Especially one that was designed in 1947 and hasn’t changed since then
One important aspect of healthcare is that ill people can be taken advantage of by people offering to help them. As diseases become more serious this desperation becomes more intense.
Part of the function of medical regulation is to ensure that this can’t get out of control. Thus we ensure that we pay healthcare staff ‘enough’ but don’t allow them to price gauge (‘enough’ might be ‘lots’ in some cases, but they’re professionals and require a professional salary — the important point is that they shouldn’t be in a situation to take away a patient’s entire wealth to cure them).
One of the bigger problems with the NHS is that administration/management don’t seem to have the same need to control costs, and will keep on scaling up non-medical provision and pay. As the ‘customer’ doesn’t see the cost of this directly (free at the point of need) there’s reduced push back to control costs.
Ie, the NHS appears to be the modern equivalent of unethical medical care in the wild-west, only with the administrators getting the bounty, not the medical staff; the NHS appears to be willing to take away the nation’s wealth in order to ‘cure the nation’.
Government should be controlling this aspect of the NHS monster, but they know that the NHS is a ‘simple voteloser’, ie, if you do anything considered by ‘lots of people’ to be bad you’ll lose votes (there’s no votes to be gained by doing things right, only votes to lose). Unfortunately, the NHS has lots of power, and thus any attempt to reign them in will result in stories about the nasty government and we’ll get a u-turn — it is easy to create these stories, because healthcare is full of failures (it is the nature of reality — there will always be people for whom the wrong decisions were made, even with the best intentions and professionalism) and these cases will be promoted but the successes ignored).
It is a bit of a mess, frankly.
‘ A patient cured is a customer lost’
That’s the doctrine modern medicine follows these days, I’m afraid.
Not in the UK. NHS shirkers get paid whether you live or die.
Two things are conflated: health care and medical care.
Health care is one’s own personal responsibility and dependent on personal choices.
Medical care is dependent on the intervention of others to treat trauma or disease.
Government involvement in medical care and implications for Govt spending has resulted in intrusion into private health to serve the interests of the latter.
My health is nobody’s business; my medical care is what I pay others to provide. If that puts a ‘burden’ on other citizens then that is the consequence of socialising medical care. The solution is privatise it, then it is up to the individual to balance lifestyle with how much they want to pay for medical care.
Most of the bureaucracy in France and certainly in Germany is in and due to the ‘insurance’/payment areas.
And that area does not even exist in the NHS!
I doubt though that this area and its bureaucracy has to be created to make patients more invested in it.
That could be achieved by a much more simple measure, as implemented in Germany and abolished because it was too successful: the introduction of a quarterly usage fee of just 10€/£per practice visited.
As someone who lived in France for 20 years, I can say that everything the auther says is true, but he strangely failed to mention the one, glaring, negative point of the French system.
But first, here’s a wee example of how good the system really is…. When we agreed that I needed an operation on my nose the ENT opened his diary and said, “So, when would be convenient for you?” Yeah!
So, what’s the glaring negative point, I hear you ask…Well, it costs a fortune! Now maybe it should, but that ‘mutuelle’/top-up insurance that he speaks of costs about 50€ a month per person. I met a lady whose family of four spent 267€ a month.
I would also disagree with the “large proportion fo dentist’s fees paid by the mutuelle”. He must have had better coverage than us (it varies widely on how much you pay, emplyer-paid mutuelles are normally better) because when my dentist quoted me 1,450€ the mutuelle was goning to cover 230€.
But he is essentially correct. The system is far, far better in every respect, even with the extra money it costs.
Costs a fortune compared to what? How much does the NHS cost per month? Well nobody knows because there is no way if knowing because funding comes from general taxation and NIC.
However a reasonable estimate is £10 000pa per household.
As for French dentist service: it works the same as everything else which is l’Assurance Maladie picks up 70% according to the convention. The rest or what is not refundable is paid for by private insurer according to what level of cover you have bought.
Until the lie is put to rest that the only alternative to the British system is the American one, nothing can be achieved. The scaremongering by the left – who have made NHS worship the modern equivalent of Clause Four – and the cowardice of the Tories to make cogent arguments for replacement have led us to this situation. My Dad is nearly 86 and not well. Part of the reason he’s so slow on his feet is that he’s being terribly careful, because he’s desperate to avoid having any sort of accident and being taken anywhere near a hospital.
We’ve spent a lot on private GPs and specialists of late, because it’s hopeless trying to see those same people on the NHS. In one case, my Mum had a skin cancer growing on her face and was told she’d have to wait FIFTY weeks to see a specialist. She paid £140 to see that same specialist immediately. He told her to tell her GP she needed to be put on the two-week emergency list for NHS surgery – he couldn’t refer her for NHS treatment, because it was a private appointment. She got her surgery seven weeks later, because she had to wait four weeks for a telephone appointment with our GP surgery to be put on the list!
When my Dad had a problem in France a few years ago, he got into see a GP that morning, and had a bit of minor surgery at the GP’s clinic that afternoon. He paid €40. Ironically, France is the openly left wing, statist country, while the UK claims not to be – in fact the bureaucracy of the UK public sector would do a Soviet state proud.
The UK’s state sector has infantilised its population for too long. Personal responsibility has gone out of the window. Getting rid of the NHS and BBC would be a major step in making the British public grow up.
I defy anybody commenting on the US ‘system’ to explain it.
The Americans don’t have a ‘system’ they have a dog’s breakfast: Medicare, Medicaid, ‘Obama Care’, private, HMOs, Practitioner Schemes, and various systems run by different States.
Interesting article. Worth pointing out perhaps that, in addition to more medical staff per 1000 population, French life expectancy is marginally greater than that in the UK.
The NHS needs to be completely re-written with all stakeholders having an input and yes, that includes Pharma. However, for as long as the unions and their lackeys scream “They’re privatising our NHS” they make such a process political suicide so all that’s going to happen is that successive governments will simply throw money at the problems and hope they go away.
But medical staff levels are not evenly spread across France and across the professions. Some areas, particularly rural areas have chronic shortage of GPs, some professions like ophthalmology have a chronic shortage of practitioners.
Waiting times of two to three moths for an appointment with an ophthalmologist are common. And in France you can’t just go to an optician for an eye test and prescription, you have to get an ophthalmologist to do the test and write the prescription in order to qualify for reimbursement from the State and private insurer.
How to fix the NHS. A flame-thrower comes to mind.
I lived in France for 20 years until recently and concur with what the author writes.
One important feature not mentioned is treatment of the elderly. Rather than old people being regarded as a costly nuisance, they are seen as premium customers. Old people mean lots of consultations, tests, treatments, drugs. To medical providers the elderly are a ‘nice little earner’ to be kept alive.
How terrible is the profit motive! That’s the problem with a private system, old people get better treatment. Disgusting! They should take their place at the end of the queue like in the NHS and have the good grace to die before their turn comes.
But when he talks about national expenditure is he including the private insurance element or just what is spent by Government out taxation?
And the State health fund is chronically in deficit – 11€ billion last time I looked. So the picture is not entirely rosey.
Well, that will never do. Something the French have come up with simply cannot be used to replace our sainted, envy of the world NHS!
Having lived in France for nearly 5 years I can confirm all of the above with knobs on – the service is spectacularly good. What struck me particularly in your article was the fact that in France spending is lower as a % of GDP than in the UK, but the number of health professionals much higher. It was also very helpful to understand better the nuts and bolts of the system – why my GP was quite cross with me for not coming to a face to face appointment but seeing her online – I suspect she may have been out of pocket!
one side remark I would like to make.
As far as I know employing someone in France is actually quite a liability and that may be one of the reasons the system does without lay staff as set out in your article.
Having medical staff doing lay staff work may not be entirely cost effective.
Looks like Common Sense prevails in France at least in this area.
Are we moving slowly but inexorably towards the point when the cry goes up from the BBC, unions, Labour Party and the Guardianistas “They’re privatising the NHS!” the people of Britain, having finally had enough of this outdated behemoth, will collectively respond this time by whooping and hollering “About time too”
Start by giving an option to opt out of the NHS and pay less tax.