Britain’s National Health Service, Creaking but Revered, Looms Over Elections
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Version 0 of 1. LONDON — The room was bare and crowded, and as patients waited impassively to see a doctor, workmen labored noisily around them installing seating while one man vomited discreetly into a bucket. Sometimes, when visiting a hospital here, it is hard to see why Britain’s National Health Service is held in such high esteem that competing claims to be its protector could help decide the national elections next month. Yet as much as ever, the health system, now creaking under the strain of an aging population and tight budgets, remains a touchstone of British life, an institution that has, to a remarkable degree, escaped the ideological conflicts that have characterized the debate over health care in the United States. With the governing Conservatives and the opposition Labour Party locked in a tight race, the political jousting over health care essentially boils down to one question: Who would spend more on it? Largely untouched by the conservative revolution unleashed by Prime Minister Margaret Thatcher in the 1980s or by Britain’s continued drift toward a more market-based society, the National Health Service still mostly provides what it promised when it was established by a Labour government in the 1940s: free treatment for all. Ahead of elections on May 7, Labour has pledged to find an additional 2.5 billion pounds, or $3.76 billion, for health care, a sum it describes as a “down payment.” The Conservatives — whom, according to opinion polls, voters trust less on health care — have trumped that by promising an extra £8 billion a year, but without explaining where the money would come from. Despite the system’s many shortcomings and failures, regularly documented in newspapers and on television, there is no serious debate in Britain about moving away from universal health care. Indeed, the right-wing, populist U.K. Independence Party, the one British party to flirt with the idea of shifting to a private insurance system, has retreated on the issue. In an era when Britons disdain their politicians and detest their bankers, government officials see the National Health Service as “the most revered public institution in this country,” said Chris Ham, chief executive of the King’s Fund, an independent health care charity. “No government would want to seriously entertain changing the basic principles on which health care is funded and provided,” Mr. Ham said. “It would be electoral suicide to move away from that model, even though clearly it’s under huge strain.” The system not only directly touches nearly every person in the country but also claims to be one of the world’s five biggest employers, with a staff of more than 1.6 million people: up there with the Pentagon, McDonald’s and Walmart. Health care in Britain is funded by general taxation and payroll deductions, and with a few exceptions, such as dentistry and medication charges, treatment is delivered without any money changing hands. Britons can buy additional private insurance for more choice in treatment, but at the start of 2014, only 10.6 percent of the population was covered by such policies, according to LaingBuisson, a health care consulting firm. By contrast, many continental European health systems are financed by insurance programs that require varying degrees of individual payment. Britain spends around £115 billion, or $172.8 billion, on the system each year, and even the use of outside companies to provide services is contentious — portrayed by the Labour Party as “privatization.” The Conservative-led coalition government says that private providers receive around 6 percent of the system’s funding, up from around 4 percent in 2010. This is ideologically ticklish because the N.H.S. was created in 1948 to help improve conditions for the survivors of World War II. Ill health was one of the “five giants” — want, disease, ignorance, squalor and idleness — to be slain in postwar reconstruction. Partly because the Labour Party created the system, voters still trust it more on health than the Conservative Party, which, according to opinion surveys, scores better on economic competence. Though decades have elapsed since treatment was denied to those unable to pay, the founding principles of the British health system retain a strong grip. Last year, Bruce Keogh, medical director of N.H.S. England, described the service as “an international icon of the British social conscience,” designed “to replace fear with hope.” Mr. Keogh then summarized the challenges facing modern clinicians, who, confronted by almost infinite demand, already make difficult choices about where to deploy limited resources. “Medicine has become much more advanced, has become more complex and more effective, but importantly, it has also become more expensive,” Mr. Keogh said, adding that Britain was “gripped in the quadruple pincer of increasing demand, escalating costs, a set of rising expectations, all in a constrained financial environment.” At the same event, Simon Stevens, chief executive of N.H.S. England, predicted a funding gap by 2020 of £8 billion a year between what the English health care system will receive and what it will need. The Conservative-led government argues that it has protected health spending since 2010 despite deep cuts in other areas. Labour claims that standards are slipping. Partly because patients struggle to get appointments with family doctors, many go directly to emergency rooms instead. Figures for England showed that 91.8 percent of visits in the first three months of 2015 were dealt with in four hours, below a government target of 95 percent. The Conservatives counter that health care in England, where they are in overall charge, outperforms that in Wales, where responsibility lies with the Labour-led Welsh authorities. Yet debate is often conducted on an emotional level, with Labour highlighting shortages and casting its adversaries as uncaring and out of touch. Prime Minister David Cameron, wealthy and educated at one of Britain’s most exclusive schools, Eton College, points out that the N.H.S. cared for his son Ivan, who had cerebral palsy and severe epilepsy and died in 2009. Beneath the fog of competing statistics, the N.H.S.’s performance is hard to assess. In 2014, the Commonwealth Fund, a foundation based in the United States, ranked England’s as the most impressive of the 11 national health systems it compared. A less generous verdict came from another research institute, the Health Consumer Powerhouse, which is based in Sweden and ranked England’s health service 14th out of 36. But rarely do British politicians risk asking whether the structure created in 1948 can withstand the pressures of the 21st century. One of the few tempted by this heretical thought is Nigel Farage, leader of the U.K. Independence Party, who raised the possibility in 2012 of moving to an insurance-based system. In a recent book, Mr. Farage, who has survived testicular cancer and two serious accidents, described good and bad treatment from the N.H.S. One episode he recounted was of visiting a consultant when his left testicle was “as large as a lemon and rock hard.” “To say that this consultant was disinterested would be an understatement; perhaps he had a round of golf booked for the afternoon,” Mr. Farage wrote. “ ‘Keep taking the antibiotics,’ he preached, and that was that.” After deliberations, however, Mr. Farage’s party opted for a commitment to keep health care free for Britons, while requiring immigrants and visitors to have medical insurance. Others could have warned of the futility of challenging one of the few institutions still widely admired in Britain. In his memoirs, Nigel Lawson, the chancellor of the Exchequer under Mrs. Thatcher, wrote that health practitioners regard themselves as “a priesthood,” making the sector “extraordinarily difficult to reform.” “The National Health Service,” Mr. Lawson wrote, “is the closest thing the English have to a religion.” |