I'm long overdue to post... and hope that this entry will serve.....
Several of my previous posts have dealt with the failings and trade-offs associated with government administered health care. Unbeknownst to most Americans, Britain's NHS 'devolved' into 4 'national' services some time ago, serving, England, Scotland, Wales, and Northern Ireland.
This recent series of articles by the BBC:
describes how England, Scotland, Wales, and Northern Ireland have diverged in their provision of health care since the 'national' system was broken into 4 parts some time ago. While each participates in the 'NHS', the reality is that each independently administers its own Health Service.
As readers of this blog might have predicted, there has been propaganda about the benefits associated with 'devolution':
but when serious analysts wanted reliable data, most of what they got was rubbish:
Commendably, interested parties have persisted in their efforts to understand the NHS, and the first two stories from the BBC above summarize their findings. Below is a cut and paste from one of them about the characteristics of the different national systems:
Northern Ireland - Somewhat hamstrung by
political situation, but re-organisation of trusts pushed through and
good integration between social care and NHS
More information is available from these sites (the BMA site is rich with info, the others are rich with flavor):
Northern Ireland - Somewhat hamstrung by political situation, but re-organisation of trusts pushed through and good integration between social care and NHS
Each of these systems has developed a very distinct priority list and identity in a very brief period of time.
These almost certainly reflect the desires of their subscribers as
communicated by their elected officials. As such, it represents both
good and bad: good that subscriber preferences influence the care that
is delivered; bad that up until now, these desires may have been
voiced, but not responded to. Already, news outlets in England
describe service availability as a 'postcode lottery'. For individual
patients, these differences can matter very much: it may be that the
service you most require is significantly more available somewhere else
than where you happen to live. I do wonder if we will observe internal
migration driven by service availability.....
Suffice it to say, it is not reasonable to expect the performance of these systems to come closer together over time - they are almost certain to continue diverging. Times change, and these systems are certain to change trajectories as well. As the above stories make clear, it is difficult to characterize the performance of these systems, which in turn frustrates assessing the effects of any changes that are made. Worse, as some of these 'nations' become more wealthy, it is very likely that they will elect to invest more resources in their health care system, which will produce substantial disparities across these entities. The poorer systems will find it much easier to obscure information than to keep up, and hence the quality of the information going forward is likely to go down, not up. Finally, it is clear that England has embraced the idea that the private sector does many things as well as or better than the NHS - and is allowing a private system to grow in parallel to its NHS.... which raises the distinct possibility that the private sector might completely supplant the NHS for England's wealthier people (not just the rich).
All of this should influence how we think about 'health care reform' during the upcoming election season. We should understand that, absent strict and forceful central control, that there will certainly be variation in any nationally administered health care system. We should also understand that variation may represent good, in that it might represent the adaptation of the local system to the preferences of the local populace. We should also understand that governmentally administered health care - in this case the NHS - does not necessarily have one best structure. Finally, when candidates or their 'experts' talk about Britain's NHS, it should be fair game to ask them 'which NHS?', as it is clear that each of these entities is now distinctly different in important ways. Do they mean Scotland's system, which is run by doctors? Do they mean Wales, with its free prescriptions? Do they mean Northern Ireland's system, which has integrated social services as a way to increase prevention and control costs? Or do they mean England, where there are now clearly two health care systems, one for those who can afford to get out, and one for everyone else (complete with means testing) ?
Finally, it is worth noting that health care remains a hot topic among the readers of the BBC. These recent news stories have generated nearly a thousand published comments as I write this...
And once again, the news from Japan makes me curious about its system:
For those of you for whom this link does not work, it is the story of an 89 year old woman who spent two hours in an ambulance while its crew attempted to get her admitted to a 'hospital' - my guess is to an ER. The story claims that the first 30 hospitals were 'full' or had no docs available to see her. Once again, we cannot verify any of the information in this story. It is cause for concern, especially for elderly Japanese, who seem increasingly likely to become casualties of a government administered health care system which has completely failed to generate the resources necessary for care for Japan's rapidly aging population.