The recent overhaul of the American health care system, which has been inappropriately referred as “Obamacare” by the media, and the frantic efforts of the new American administration to dismantle it—so far unsuccessful but time will tell—has brought some forced comparison with other care systems; some policy pundits have insolently dubbed it as the “Anglicisation” of our highly fragmented health care delivery system.

Since the health care reforms of Premier John Major—who enacted the “internal market”—and Premier Tony Blair—who instituted the “patient choice”—the health policy experts in the United Kingdom have been talking non-stop about the ongoing “Americanisation” of their venerable National Health Service (NHS). In 1948, the UK authorities created a universal health care coverage for every Briton, who were mostly impoverished after the World War II and the loss of their colonies. Citizens and pundits alike have denounced those modernization drives as a “Trojan horse” to force the entry of the “private sector” in an extremely revered and popular British institution.

What the two health care systems have in common is the following: their citizens live longer and are consuming a higher percentage of public and private financial resources in a technologically-driven medicine. In the USA the Medicare and Medicaid systems have been slowly replacing the fee-for-service system for a more integrated and efficient system of “managed care” that must be accountable. In Britain, the timid introduction of some kind of accountable care has sparked a vivid rebuke of organized citizens groups and the media that have denounced it as illegal because voters had not approved it.

James Meeks wrote in the “London Review of Books” an excellent review of the present reform in the United Kingdom with the forthright description of two universe. “In universe one, the NHS will be upturned to give most of the healthcare people need at home or on their doorstep and admit to the big hospitals only patients with major trauma, or suffering diseases that demand intensive care, or complex surgical or biochemical expertise. Big hospitals are to become centers of research, high technology, rare skills and dramatic, life-saving interventions.” In contraposition to that ideal, clean environment the author describes the other universe. “In universe two a counter-reality prevails: the reality of winter, the reality of need, the reality of an ever increasing number of frail, elderly people converging on the help of last resort, the emergency hospital.”

In the United Kingdom the combination of a providential welfare state and a good universal health care system has led to the marked prolongation of life expectancy for men and women alike. However the entry into an ever older age has brought the emergence of “multiple co-morbidities” in their clinical condition. Nowadays a patient that has a peak of high blood pressure must be treated taking into consideration that he/she might be also diabetic, or suffering form renal diseases, or a neoplasia. As a result, efficient and comprehensive long-term care for the elderly and disabled is a high time and resources-consuming endeavor. Sadly, even though elderly people might elicit compassion and understanding at an individual or family level, they are mostly ignored by the younger generations that work and fill the purse with their salary deductions. That commiseration does not translate into the civic approval of more funding. Younger citizens are usually in a state of “self-denial” about their own future fragility in old age.

Meeks studied the reform in Leicestershire, a miniature expression of modern England: densely populated, a dynamic economy and a younger population, many of them immigrants and students. It’s on the south-eastern rim of the Industrial Revolution of the 19th century, it has three Labor elected representatives and it narrowly voted to stay (Remain) in the European Union. The counties surrounding Leicester are very different as they comprise extremely well-off areas where the country gentlemen live and run-down districts that could not recover from the modernization. It is a whiter, older world where the need for home health services and ancillary support is stronger. The Lansley reform—named after the Conservative health secretary Andrew Lansley—created seven local organizations as the point of delivery in Leicestershire.  The “Clinical Commissioning Groups” (CCG) are aggregation of general practitioners located at the city of Leicester and the east-west ends of the area. The Royal Infirmary Hospital, which has the largest Emergency department in England, is run by the “University Hospitals of Leicester Trust.” The “Leicestershire Partnership Trust” runs all the community care services, including Mental Health and the Prisons.

Meeks found that the authorities of Leicestershire have implemented a virtual system 256 bed “hospital” called “Intensive Community Support” (ICS) where the convalescent patients are being treated by nursing and ancillary personnel in their own residence. There is an integral, holistic approach to the patients that are discharged from the hospital as the home health personnel, social workers and ancillary personnel are being scheduled and supervised by the same administration. The author found that the altruistic objectives—like being able to access a local doctor until 8 PM seven days a week—are not completely attained, with some district areas worse than others. The push for cuts in services that are prodded by the central authorities of the NHS could not prosper.

Considering that the population of Britain is growing in overall number and longevity, there is dire financial need for more staff, more material resources, more distributive planning. Besides the demographic inflation, there is the salaries’ inflation to account for as the health care system is run by persons with increasing needs in a modern economy. In order to compete in a tight labor market for talent and expertise, the health care organizations must offer better benefits and good pay. The “Baumol cost disease”—named after the economist William Baumol—describes the asymmetry between industries like manufacturing that can be automated and require less workers with the ones like health care that cannot be readily automated and still require large number of employees.

Many citizens of modern societies like the UK and the USA (certainly not all and not in the same degree) are enjoying one of the biggest prolongations of their average life spans with an ensuing ability to continue enjoying their activities, including postponing their retirement and working into their late 70s. But they certainly are afflicted by chronic diseases like high blood pressure, diabetes, arthrosis, which require regular medical check-ups and proper long-term treatment. Young people will eventually reach that stage too and if they now refuse to fund the existing long term care services for elderly people, they will be dismantled by myopic bureaucrats that only know how to count beans. Watch out, Millennials. Those services take years to design and put up; they will not be available for you in your golden years if you don’t protect them now with your voices and votes. But there is a positive economic variable at play.  William Baumol considered that the efficiency savings in the manufacturing sector will eventually liberate more funds to invest in health care. Let’s hope that politicians don’t squander those funds.

What do you think? Please tell us.

Don’t leave me alone.




14 thoughts on “Reform at the NHS England

  1. It is informative and documentary .
    You crisise the American health system and you praise the British health system more.

    Just I ‘d like adding real information too, the system is so amazing because each patient has the best care and all the care is first class to all the patients.
    But, the patients are still suffering from long time in the waiting list.
    Really, the government tries to fund more the NHS hospitals to be better.

    Best wishes

    1. Good afternoon and thanks for this great commentary, mate. Yes, I do have, as many other practicing physicians in the USA, many complaints about the absurd fragmentation and the relatively low index of good outcomes/money invested of our American Health Care system. I believe the NHS has done a much better job at assuring both an equity of access and a standardized quality of care for all the segments of the British population, unlike our overtly mercantilistic system. However, the under-financing of Health Care is a chronic problem for all modern societies where the Treasury Departments of the central administrations dictate what gets financed and what not (or less) Well, I am glad that it seems that I was not that far off the mark.
      A big hug. Ta-ta!

      1. Well, well, we are treading into dangerous waters now, mate. Granted that the American military budget has ballooned in recent years but you have to consider that the USA is oftentimes the arbiter of last-resort to boldly separate and police the truce between old enemies like it has been sadly demonstrated in the latest catastrophic hurried retreat from the Syrian-Turkey border. There are major and minor examples of the positive intervention of American forces, foremost in the European continent. My relatives go to bed calmly in San Dona de Piave because the nearby USAF base at Aviano guarantees that there will not be a nasty surprise in the morning, like an uncouth guy pointing a Kalashnikov rifle at them. Please do not drag me into politics (at least not in this web page) as , even though I do not care to hide my opinion about issues, I have always tried to avoid the overt discussion of Religion and Politics here as it will inevitably alienate some of our readers. But with a good draft beer in our hands, we will certainly discuss many topics when we visit you in London (including Boris Johnson’s hairdo)

  2. Dr. Sahib Good Morning.
    The topical commentary of HEALTH CARE JUSTICE is really an eye opener. In this you have very clearly described the health care being followed in USA and UK. It good points and flaws. Health care of the populace is of paramount important. Every Government should make concerted efforts in ensuring that their people are looked after and their wellness cared for.
    In our country too, Government Hospitals are taking care of the populace with the resources they are provided. From this Financial Year onward, Govt. has proposed to give ensure cover a max of @ Rs. Five Lacs or as per the expenditure incurred on the patient. Lets see when this fructifies.

    As always, your people oriented write-ups are always worth appreciation.

    With regards,

    1. Good morning my dear friend and thanks for your nice commentary. Yes, politicians all over the world are trying to economize financial resources by cutting or curtailing health care services. But the poor are suffering. They have to start by cutting their expense accounts in fancy restaurant meals, costly five star-hotel stays, 24 hours chauffered limousines and even occasional “affectionate girls” to console them when they “have to work so hard” far away form their home cities. Please don’t make me talk about politicians… How is the Modi government? Is it really more clean than the Congress administrations, as they claim in the media?


        Yes, political classes, in all the countries, are responsible for cutting the funds for health securities due to which our people do suffer and rightly so the poor and hapless lots who have little or no resources to take care of health. Health, for them comes last of all, first is the question of subsistence.

        Your commentary on health care is really an eye-opener.

        Thanks and regards


  3. Hello dottore,

    Long time no see. Everything alright? I hope so.

    I think this is your longest post so far. But then, there was a lot to tell.

    Healthcare, although a basic need of every human being, is not considered a basic human right in many countries. The rich don’t have to worry since though all animals are equal, some animals are more equal than others.
    Everyone deserves at least basic healthcare, irrespective of their financial status. Period.

    I wanted to address one more thing here. Universal healthcare is referred to as free healthcare in some countries (as in Canada). In reality, there is nothing like free healthcare as somebody always pays for it. I was the perfect example. Basic healthcare was mostly good but when I ended up in hospital, real problems started since I didn’t have a private healthcare plan. I had severe internal bleeding and was checked by a doctor after 9.5 hours spent in the waiting room only to be released the following day with an explanation that everything was more or less ok. The thing is, I didn’t have the coverage. You’ll read the epilogue one day in my posts.

    To sum up, since Canada and the States are often compared in terms of healthcare, I can only say that Canadians are in a much better position that the Americans provided they don’t end up as inpatients. Then they’re screwed, so there isn’t much of a difference if you’re really really ill.

    Have a nice day, dear. A presto.

    1. Good morning and thanks for this nice commentary, my dear Bo. Your points are well taken; please tell us what your experience in Canada was asap. Yes, it is a long post but I have published other ones like this, just not in the “Emotional series”, which is supposed to be clear and tight in only one page. You have stoically read all the EF series and I don’t expect you to do the same with the “Wellness” and “Health Care Justice” series. I have been extremely busy with the writing of my second book and I will focus even more during the upcoming Summer. How is the reading of my novel going? Did you get tired already? I can’t blame you…You did try at least. Thanks.
      Un baccione. Arriverderci!

      1. You don’t want to blame me but you do. You do, my dear. I have a guest so I had to make a break, that is slow things down. I think I finished about a third.
        As for Canada, it’ll have to wait. I’m not done with post-war years in Yugoslavia yet. Be patient, dottore. And read me. How come you always forget?!
        Un baccione back.

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