An English Perspective on Health Care

Here in Stockport, England, it was discovered that my now-82-year-old grandmother needed a heart procedure[i]. We were told that if she had it, she would easily live at least another ten years, as apart from that, she was healthy. Since we were warned that her lifespan would be short if she did not, we elected to apply to have the surgery. We then had to see whether or not the National Health Service (NHS) would allow it. Thankfully, they did. 

However, there are a number of ways to have the surgery, from putting the patient out with general anaesthetic and slicing open the chest to a local anaesthetic and a simple line put through an artery in the patient's leg.  To our dismay, they decided to go for the cheapest and highest-risk option. I don't wish to go into details, but post-op was touch-and-go for a while, as well as very stressful, and what should have been an "in-and-out" procedure has taken months to get her home. We are still unsure (but hopeful) that she will eventually make a full recovery.

Now, both sides of the health care debate have horror stories and stories of good care. (English nurses have a long-standing reputation of excellence, for example, despite their pitiful wages in comparison to their American counterparts.) We know that there is no such thing as the perfect health care setup, and that the plural of "anecdote" is not "evidence." I use our story not to tug heartstrings (there are much worse stories of the NHS than ours -- at least we were allowed to have the operation), but as a typical, everyday example of the philosophy behind a nationalized health care system, the type of system the USA took a big step towards on Sunday.

We are not a rich family, but neither are we poor. As an extended family, we have not had much need for large amounts of health care. Yet for years we have paid our taxes, a large part of which pays for the NHS. Accordingly, these taxes have probably paid for countless other people's health care needs -- everything from false teeth and cancer treatments to sex changes and abortions. However, when it came to our family needing a specific treatment, we were given the cheapest and the riskiest option despite having paid for countless others to have their services. Is it fair that the next person who has the same type of surgery may potentially be given the less risky operation despite having paid less into the NHS system, or that this person's treatment may even be paid for by our family's taxes? Since individual contributions are not used to judge the level of care received, people who pay less may often receive significantly better and more expensive treatment.

In addition to this, because the amount of money put into the system is fixed independent of demand (it is usually a manifesto promise to raise taxes and put more money into the NHS as opposed to being decided by actual costs), it means that the patient is seen as a burden and not as a paying customer. The money you pay in is decided (for the most part) on what taxes you pay, not on what health care you need, so you pay the same taxes whether you need 24-hour care or you don't enter a doctor's surgery once, as opposed to paying more or less depending on the amount of care you receive. 

In privatized systems where costs are decided on basis of treatment, there is an incentive to deliver better and more expensive treatment, as more and better health care leads to more money being paid by the customer. In a nationalized system, the NHS is allocated a set amount of money, so the incentive is to get people in and out as quickly as they can, spending the least amount of money on them as possible, as there are only a limited amount of services and money to go around. It is the same rationale that means you get better food at a restaurant than you do at a soup kitchen -- demanding more expensive procedures from the NHS is the equivalent of going into a soup kitchen and asking if you can browse their selection of aperitifs.

It is bemusing for an Englishman to hear President Obama tell stories of woe where Americans have been subjected to "unnecessary procedures" and "five tests instead of one," when people in England are finding it difficult to get approved access to necessary procedures and probably wouldn't mind a few extra tests. 

The other philosophical issue is that of choice. If the reader looks back on my story again, he will see that the only choice we were given was whether or not to ask to have the surgery. The actual decision was not ours, but that of the NHS, as was the decision as to whether my grandmother had the more expensive, less risky surgery, or the cheap hack-and-slash surgery that left her in such a poor condition. Certainly there were no ominous "death panels" in the strict sense of the word, but if they had made the decision not to approve her for surgery, it would have amounted to something similar, and the decision to what type of surgery she received was almost an issue of life and death as well. At no point were we consulted as to what surgery she would have, nor were we told, "The NHS will cover only  this type of surgery, but if you contribute some more money, we can upgrade to a higher level of care" -- which (although wrong, considering the amount of money we have pumped into the system) would have still given us an element of choice[ii].

Nationalized vs. privatized care is not about quality of care in itself; it is more the question of the underlying philosophy that decides the care. Do we really want people who have paid more potentially receiving worse health care than those who have paid less, simply because the latter have more politically correct health care needs (e.g., there is no rationing of contraception and abortion, while the breast cancer drug Herceptin® is frequently denied to patients)? Do we want our patients treated as valued customers who can encourage a drive for higher-quality care, or as drains of the system who are lucky to get what they are given? Finally, who do we want making the decisions? Doctors free of government interference and families, or government bureaucrats and doctors with their arms twisted by government targets and rationing? Here in England, we have already made our decision on health care, and we are living (and dying) with the consequences. It is now time for you in America to make your decision.

Adam Shaw is a writer based in Manchester, England and can be contacted at He specializes in religion and politics and is seeking work in both the U.S. and the U.K.

[i] This article deals specifically with the National Health Service in England. Scotland, Wales, and Northern Ireland have similar but independent forms of the NHS.

[ii] It is worth noting for accuracy that there is a skeleton of a single private option remaining in Britain, known as BUPA, that offers significantly better care. However, access to it is a complicated issue, and not one I have time to go into in such a short article. In brief, when one considers that the average taxpayer is forced to pay for their NHS care and the NHS care of many others, it is tough to then find the money to pay for BUPA health care costs on top of that, although a surprising number of Britons do so anyway.