National health might be less than you bargain for
The African National Congress (ANC) proposal for national health insurance (NHI) draws extensively from similar systems implemented in the developed world. One such system is the National Health System (NHS) implemented in the United Kingdom on 5 July 1948. The publicly funded healthcare system gobbles up the bulk of that country’s Department of Health budget, £98.7 billion in 2008. Could we clone the NHS in South Africa? The short answer to this question is “No!”
South Africa is a country of some 50 million people. It’s a country where one in every four job seekers is unable to find work and approximately seven million taxpayers (income tax) support upwards of 12 million social grant recipients. We’re in poor shape when compared to England. They have 56 million citizens, of which 90% contribute to state coffers. Instead of asking whether we can clone their system, we’ll focus on whether the UK NHS delivers on its promise... We found some anecdotal evidence from Dr Willie Lambrechts, who shared some of his NHS experiences during a recent Old Mutual Actuaries and Consultants’ healthcare breakfast.
The wealthy get better care!
Dr Lambrechts’ first observation was that the UK healthcare landscape consisted of two tiers, each controlled by the Department of Health. On the one hand British-only private practitioners – stocked by the Royal College of Surgeons – cater to the well to do medical scheme members. The NHS, on the other hand, accommodates all comers. NHS doctors and specialists are sourced from countries around the globe, with plenty of South African qualified medical practitioners finding a home there.
At the grassroots the NHS relies on a system of general practitioners who essentially act as a filter to keep the hospital system from clogging up. NHS hospitals are run as trusts which are allocated funds each year based on their “throughput”. “The trusts keep data on what happens in the course of each year – and are then allocated funds in terms of the services rendered,” said Dr Lambrechts. These hospitals have to meet all of their expenses from this allocation, including doctors, chemists, purchase of apparatus, nursing staff, laboratories etc.
Money gets in the way of logic
England has many funny laws. The NHS requires hospitals to discharge patients into the care of a relative or family member. This person must be willing and able to take the discharged patient home and administer whatever post-hospitalisation care might be required. In the event nobody can be found the patient ends up occupying a hospital bed indefinitely. How can this work in the managed healthcare environment?
“It works like a dream,” said Dr Lambrechts, “because a healthy patient in hospital is very cheap to accommodate.” Everybody is happy. The trust administrators are happy because there are no expensive procedures or medical investigations. The nurses are happy because they don’t have to bother with admission / discharge paperwork. And doctors are happy because their rounds are over in a heartbeat. “English doctors – with all due respect – don’t work!”
A surgeon’s work is never done
Dr Lambrechts talked us through a typical day as a surgeon operating in an NHS hospital – we’ve paraphrased his story in our own words: On this particular day I have 15 minor operations and five major operations on my list. I walk down to the admittance room at 7am to see my patients pre-op. At this point I’m told by an orderly that only four of my patients have been admitted, all for minor procedures. Ok – no argument from me – I speak to the four patients and make sure they’re ready to proceed before heading to the theatre for a 9am start. The anaesthetist only arrives at 9:30am and tells me he’s cancelled two of the four patients because they’re asthmatic. Strange – they looked fine two hours ago! I finish the two remaining operations in the hour between 09:30 and 10:30 am. Every one gets their full salaries for this “shocking” productivity.
This erosion of productivity is further offset by the cost of medical technology and the ever present threat of litigation. Dr Lambrechts observes: Nobody working in the NHS has any idea of the cost involved.” He mentioned the use of standard x-ray versus CT scan for urology patients. Every single patient in the hospital’s urology ward had received both x-ray (around R200 in 2002 money) and CT scan (at R17 500), despite the x-ray being sufficient in 97% of all cases. Why? “Well doctor – we do it for medical legal purposes!”
Can it get worse?
The next story should give the architects of South Africa’s eventual NHI food for thought, because a dual private-public system is open to a variety of abuses. The doctor mentioned 63-year old male patient who had been on the NHS operating waiting list for nine months. This gentleman had to use an in-dwelling catheter until such time as the surgery could take place. Concerned with his patient’s discomfort, Dr Lambrechts made sure the surgery went ahead. His reward – apart from the gratitude of the patient – was an unpleasant confrontation with the hospital executive.
The said: “What you did is not acceptable – you’ve jumped the waiting list – a lot of people are on the list before this guy…” But what came next was even worse. “Nobody can last an in-dwelling catheter indefinitely – if you’d left this gentleman he would have eventually become frustrated and gone private!”
Editor’s thoughts: Whether or not you view the UK’s NHS as an exemplary healthcare system depends on how closely you scrutinise it. We cannot ignore the inefficiencies exhibited in a health system with multiples of the locally available funding and human resource. We can do better than the NHS, but only if all healthcare stakeholders set aside their profit motive and focus on social outcomes instead. Can South Africa build a better health system than the UK? Add your comments below, or send them to [email protected]
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