Let the Americans Give Us First Aid

SUNDAY TIMES (LONDON)

February 13, 2000

In the first of a new series on Britain's healthcare crisis, Irwin Stelzer advises importing foreign expertise

I recently had occasion to learn two things about the British healthcare system. The care it provides is exceptionally good - and more immediately available than in America. And to get it, you'd best not be on the National Health Service.

The sudden onset of double vision led me to need a doctor early one morning. A 6am call got me an 8am appointment with the doctor covering for my regular physician, and an appointment with a specialist at 10am. First question: are you on the NHS? Answer: No. "Good. Please take your credit card to the desk."

Eight hours later I emerged from more medical machines and tests than I knew existed, to be told that all the "nasty possibilities" had been eliminated, and that the ailment was a minor one that would correct itself in due course. It did.

Relieved, I asked what would have happened had I been an NHS patient. Pause. Since there was a high probability that the ailment was minor, and only a low probability that it was lethal, the specialist said sadly, I would have been sent home to wait for developments, among which might have been a stroke or worse.

If the affliction had not disappeared in three months, I would then, and only then, have been scheduled for the tests I was given so promptly as a private patient. Meanwhile, said the specialist in a whisper (making me wonder if the NHS, like the BBC, has listening devices everywhere): "I would have held my breath." And I would have learnt the meaning of the NHS queue, up close and personal, as we say in America.

Why is there no shortage of trainers in Britain? Or of knickers? Because Britain quite sensibly relies on foreign workers, using foreign capital, to provide it with these necessities. And why is there a shortage of healthcare services in Britain? Because the government has decided, foolishly and lethally, to ring-fence the country so thoroughly as to deny it access to the world's healthcare resources.

Let me stop here to head off a sackful of letters to our editor. First, there is no denying that Britain successfully makes use of doctors from other countries - but too few to make a dent in the astounding death rate from heart disease and cancer, or to relieve the suffering of those lying on trolleys in hospital corridors or entombed on ever-lengthening waiting lists.

Second, it certainly is the case that the level of care offered by the NHS - once a patient gains access to that care - is generally first-class. Anecdotes about mistaken amputations, botched operations and the like are sufficiently horrible to warrant the press coverage they receive, but anecdotes are not data: by and large, British healthcare - or what there is of it - is better than acceptable in many areas of medicine. So any solution to Britain's healthcare crisis - and that is an appropriate term to apply to a system incapable of coping even though the nation avoided a flu epidemic this winter - must be found within the framework of preserving the NHS. That may not be as efficient as allowing tax credits for those seeking to exercise their right to use their own money to opt out of a system that is not working. But a solution that relies on, rather than rejects, the NHS is more in tune with the national psyche and with political reality, at least so long as Britain chooses to be governed by a Labour party, new or old.

New Labour thinks that the solution to the problem is to spend more money on healthcare. Few would doubt that is part of the answer, although just how much more of the taxpayers' money to throw at the problem, and how that money might be spent most efficiently, are legitimate subjects of debate. As is the question of just what treatments should be available free at the point of care, and what treatments should be paid for in whole or in part by the recipient.

No matter. However those problems are resolved, a key issue, given the development of optional procedures ranging from cosmetic surgery to sex-change operations, is that the NHS will remain in crisis for several years unless there is a massive switch to some form of financial contribution by patients for the care they receive, so that they have an incentive to think twice before calling on NHS resources. Doctors aren't trained in a year, nurses don't become skilled overnight, and hospitals can't be built immediately.

The prime minister counsels patience. Meanwhile, people suffer and some die. Last week, the "dismal" state of the NHS and its cancer care made front-page news in The New York Times.

It is difficult to be patient while being denied treatment of a cancer that refuses to stop growing while the healthcare system is being geared up to meet the legitimate demands being placed upon it. Or when discovering that the oncologist who might treat you has only minimal experience of the operation he is about to perform.

Instead of relying solely on a long-run cure accompanied by near-term suffering, why not open the system to the world's intellectual and capital resources? Assume that, in the long run, the government will solve the problem with more money and some policy tweaking. That still leaves it in need of an interim solution that is better than its current plea for patience.

Here is an idea outside of the box - perhaps so far outside as to be unacceptable to those charged with finding some way of improving the performance of the NHS. The government could contract with some first-class medical institution, say America's Mayo Clinic, established 100 years ago and now among the foremost multidisciplinary medical education groups in the world; or Johns Hopkins medical centre, another world-renowned centre recently signed on by Singapore to develop clinical treatment facilities for the care of patients with cancer and cardiovascular diseases.

Some such organisation could be retained to come to Britain and provide the staff and equipment to treat those most in need of immediate care, say those suffering from cancer and heart disease. The contract might be for five years, after which Mayo (or whomever) would leave, having trained doctors and nurses, and put in place the most modern equipment, leaving Britain with a much-needed addition to its infrastructure. And all care could be provided within the NHS.

There is no reason why a system such as this cannot work. The on-site doctors would have full access to the skills of their faraway colleagues. Experts I know have seen operations performed with the principal medical expert thousands of miles away, present in the operating room on a life-sized television screen. Medical data can easily be sent over the internet, allowing, to cite only one example, oncologists with long experience to participate in the diagnostic process. This is not pie-in-the sky technology; it is here-and-now stuff. That is why Hopkins is in a position to assist Singapore in meeting its increasing healthcare needs.

Add an on-the-ground presence under a suitable contract to modern technology and you might, just might, have a solution better than "patience".

Alternatively, if it proves too difficult to bring the facilities and the talent to the patient, why not send the patient to where the facilities and doctors are. Surely British Airways, which benefits from the government's efforts to maintain its semi-monopoly of slots at Heathrow, would be willing to offer the NHS an attractive "humanitarian fare" to get those in need of treatment to America, or wherever else they can be best cared for.

It would cost the NHS a bit of money, but any treatment of the seriously ill will be more expensive than the present alternative of leaving them on a waiting list until they die - at zero cost to the NHS.

These solutions might wound the pride of those who won't concede that the rest of the world has something to offer in this crisis, but what matters the wounded pride of a bureaucrat or ideologist compared with the healed wound of a patient?

Before readers deluge me with claims that no American is fit to comment on the healthcare system of another country because 40m Americans are denied healthcare, let me note that that charge is false. What is true is that 40m Americans do not have health insurance. But they do have care. Most of the hospitals in my country are run on a not-for-profit basis, and are obliged under the law to treat all who present themselves for care, whether insured or not. For the poorest, the emergency room of their local hospital is their primary care facility - the place to which they bring children suffering from a head cold or a bellyache, or something more serious, and to which they themselves repair when they need medical attention. Which they get. Without charge.

The cost is covered by inflating the bills of wealthier patients, a form of cross-subsidisation that may be as efficient as using taxes on the rich to cover the costs the NHS incurs in treating lower-income patients.

Finally, it is often said - quite correctly - that it is difficult for an American to understand the unifying effect that an egalitarian healthcare system has on British society. I like to think of myself as an exception. I can recall the late Lord Wyatt - now remembered, alas, more for his cranky diaries than for his good humour and generosity - emotionally describing to me the deplorable state of the health of the servicemen assigned to his unit during the second world war, and how that converted him into an advocate of a national health system.

And I have studied the statistics enough to know that being poor and sick in pre-NHS Britain was a bad thing to be. All the more reason to repair it before it collapses.