This is the last part of a series on the inherent flaws of the National Health Service which mean it can never work satisfactorily no matter how much money is poured into it. You can read part 1 here, part 2 here, part 3 here and part 4 here.
IN THE third of my previous articles I mentioned the Stockholm syndrome from which many British people seem to suffer when considering ‘our’ NHS. The more blatant its failures, the more they strive to excuse those failures and even transform them into heroic deeds in the face of daunting odds.
The stoicism of the British in the face of such incompetence is amazing. The prevailing attitude seems to be ‘Well, it is what it is – mustn’t grumble.’ In such an atmosphere of medical fatalism, a wait of two months for an appointment seems like a lottery win when others are having to wait two years.
This final article is intended to provide an insight into what a health service can be like when it is properly funded and organised – the Swiss system.
I apologise for its length and complexity, but for too long the discussion about alternatives to the NHS has been characterised by ill-informed waffle. The analysis here is under two major headings: performance and payment.
After our early years in Britain, for the last 40-odd years my wife and I and our three sons have lived and worked in Switzerland, Germany and France. From the viewpoint of the health service consumer, the Swiss system is by far the best. I have never had to wait more than a day or two to see a GP. On a few occasions I have deliberately chosen a later appointment: the one offered was too soon!
My GP cut out a suspicious growth on my forehead in a same-day service; he did a beautiful job, leaving no detectable scar. The biopsy revealed it was a basal cell carcinoma – better out than in.
Of course for such flexibility a system has to have spare capacity. It cannot be running on 100 per cent all the time. Three cheers for a system the normal condition of which is not ‘at breaking point’, but one with some buffer resources. I am quite happy that the people who treat me are not knackered and having to work till exhaustion.
Let me give you a personal case study to illustrate the consumer’s experience of the Swiss health service. After an otherwise generally medically untroubled life, in 2015 I ran out of patience with my waterworks. The medical opinions of GP and specialist were that it was just the typical ageing gent’s ailment. Try a month of pill swallowing. If that doesn’t do it, some simple surgery will ream out the prostate.
Well, the pill swallowing didn’t work, so under the knife I went.
Afterwards the surgeon told me that, while reaming, he had found a small tumour hidden near the entrance to my prostate. This discovery shifted the medical gears from enlarged prostate in elderly geezer to prostate cancer. The treatment tempo changed
immediately. Let me list the treatments I received.
Thu 03 – Pre-op exam
Wed 09 – Hospital: Prostate operation 1
Sat 12 – Hospital: Discharged
Fri 18 – Colonoscopy 1
Mon 21 – CT scan
Mon 28 – MRI pelvis
Wed 30 – MRI prostate
Thu 07 – Bladder endoscopy
Fri 08 – Pre-op exam
Mon 11 – Hospital: Prostate operation 2
Wed 13 – Hospital: Discharged
Mon 01 – Debriefing from urologist
Wed 24 – Colonoscopy 2 detects adenoma (cancer precursor)
Mon 07 – Consultation with surgeon
Mon 21 – GP pre-op check-up
Thu 24 – Pre-op exam (anaesthetist)
Wed 30 – Hospital: Operation (20cm of colon was sliced out with keyhole surgery and a generous quantity of lymph nodes were removed and biopsied)
Sun 03 – Hospital: Discharged
Mon 11 – GP takes out the stitches
Some clearing up took place in May and June:
Thu 19.05 – Cardiac tests
Tue 07.06 – Prostate MRI
Mon 20.06 – Final consultation with urologist
Note that all the important events took place within the space of five
months. The benefit of having a system with capacity reserves became clear as my case developed from a straightforward prostate reaming into something quite complicated and potentially problematic. This five-month period stretched over the Christmas and New Year holiday and over Easter as well. The system responded with enormous flexibility and with measured haste.
‘What costs nothing is worth nothing.’ My medical crisis cost £15,193 altogether. I know this because I got the itemised bills. I paid £3,698 and my insurance paid the rest, the equivalent of roughly six years of premiums. Worth every penny. What costs something is worth something.
You ask: How can the 50 or 60 per cent of low earners in the UK, most of whom don’t even pay tax, afford that? They can’t, but that is why modern developed societies have welfare provisions that provide the safety net for the less fortunate. In Switzerland the health service provides medical services and always gets its money. It is not a charity. For people who cannot afford these costs it is the welfare system that pays.
Bevan got it the wrong way round. If you design a health system with the poor at the forefront of your mind, everyone ends up with a soup kitchen. Design a solidly financed system that works well for most people, then work out how to make it accessible to the poor. Then everyone ends up with a good health system. Healthcare is too valuable to be free.
I could give a lot of detail on how the Swiss system is paid for, but I will try to give the essentials. All costs have been converted from CHF to GBP at rates from mid-January 2023 (0.87619), rounded to the nearest sensible number.
Every Swiss resident is obliged by law to take out an annual health insurance policy. A large number of insurers offer a large variety of policies, but the government has defined a basic cover which all insurers must offer on standard conditions. I have never chosen anything other than the basic model and it has always served me well.
I pay £203 every month for my premium, that is £2,436 a year. If this amount shocks you I would ask you to consider that, if you are a taxpayer, the proportion of your tax and National Insurance (and all the other sources) that in the UK would go to the NHS (22 per cent) is no longer being deducted.
Under the basic insurance policy you are free to go to any doctor at any time, even specialists. You are also free to choose your hospital or any other health service providers such physiotherapists. Almost every element of the system is operating in a competitive market in which the patient is monarch. All these providers are really pleased to see you, the paying customer.
Next, let’s look at the ‘franchise’, the deductible (or ‘excess’). Insurers are required to offer a standard range of deductibles. I chose the maximum deductible of £2,190. This means I pay my healthcare bills myself up to an amount of £2,190 per annum. After that the insurance kicks in. I could choose the smallest deductible of £263, in which case my monthly premium would be £315 instead of £203. This is an important decision that only the patient can make. It means that patients have some scope to optimise their healthcare costs.
There is one more cost factor: the ‘cost contribution’. This is to discourage frivolous use of the health service or to discourage patients choosing the deluxe option just for the hell of it because someone else, the insurance company, is paying (Milton Friedman’s fourth type of money once more).
In my case, once I have crossed the deductible limit, I still pay 10 per cent of all bills up to a total contribution of £613 (i.e. total bills up to £6,130). After this point the health insurance picks up the remaining amount.
One final, important point: my premium includes accident cover, which is obligatory if you do not already have accident insurance. The point is important because in the NHS, accidents are treated as though they were illnesses. If you fall off your bike or break a leg skateboarding you will be doctored with no questions asked. In Switzerland (in Germany and France, too), accidents are accidents, not ill health. If you have been foolish enough to fall off a skateboard, without insurance you will get the bill for mending your wrecked body.
Unlike the NHS, in which children are just one more non-paying consumer of healthcare, in the Swiss system, children and young people also have to have health insurance. This respects the fact that children get ill, just like adults. The social welfare system puts about 50 per cent towards the premium as a support for families. This is a good example of Swiss clear thinking: medical services for small people cost the same as those for big people. The healthcare provider has to be paid, but the social welfare requirement to support and encourage families is worth the state subsidising these costs. Not only the rich should be able to rear children.
There are certain tax reliefs available which work to the benefit of the low earner.
Let’s sum it up: no one expires in front of the hospital door. Everyone gets treated with the same high level of care and efficiency. Someone pays.
One of the main takeaways from our analysis of NHS costs was that around 50 per cent of adults pay nothing or next to nothing for their health costs. In effect, the healthcare of the less well-off is enforced charity.
If the UK adopted the Swiss system, the large number of low-income and no-income adults (more than half of the population) would have to be supported by the well off, just as before. Under a Swiss-style healthcare system this support is a social welfare task that would fall on taxpayers as it does at the moment. The NHS is based on a redistributive welfare model while the Swiss system, apart from a few subsidies, is a pure healthcare model.
For those who cannot afford the premiums the government pays a proportion of their premium, depending on their circumstances. This is a cost clearly borne by social welfare, not the health service. The health service always gets its money for the services it provides. The fundamental point is that the Swiss system works, delivers top-quality care and no one is left behind. No soup kitchens here.