Universal Mediocrity

Universal Mediocrity
Profile photo of Theodore Dalrymple

Reprinted from City Journal

In April, the British Medical Journal published “How the NHS Measures Up to Other Health Systems,” a report about two studies conducted by the New York–based Commonwealth Fund that compared the health-care systems of 14 advanced countries. On the 20 measures of comparison, Britain’s famous (or infamous) centralized system, the National Health Service, performed well in 13, indifferently in two, and badly in five. Was this a cause for national rejoicing?

If popular satisfaction is the aim of a health-care system, the answer must be yes. According to the report, the British were the most satisfied with their health care of all the populations surveyed; they were the most confident that in the event of illness, they would receive the best and most up-to-date treatment; and they were the least anxious that their personal finances would prevent them from receiving proper treatment. One could doubtless raise objections to these measures of comparison, but let us for the sake of argument take the results at face value. Subjective satisfaction and relief of anxiety are not minor achievements. Indeed, though the free market’s ability to satisfy more needs and desires than any other system is usually cited as one of its principal advantages, here was an apparent instance of the contrary: a nonmarket health-care system that yielded the most satisfaction.

Still, the studies contained a paradox that the authors of the BMJ article failed to notice or, at any rate, to remark upon. On several measures of actual achievement, rather than subjective assessment, the NHS came out the worst of all the systems examined. For example, it ranked worst for five-year survival rates in cervical, breast, and colon cancer. It was also worst for 30-day mortality rates after admission to a hospital for either hemorrhagic or ischemic stroke. On only one clinical measure was it best: the avoidance of amputation of the foot in diabetic gangrene. More than one reason for this outcome is possible, but the most likely is that foot care for diabetics—a matter of no small importance—is well arranged in Britain; the amputation rate is four times higher in the United States.

Overall, however, Britain seems to face a self-esteem problem: too much of it. How is it that the population most confident that it will receive treatment of the highest possible standard, featuring the latest medical advances, actually has the worst survival rates in precisely those diseases that require the most up-to-date treatments?

One explanation is ignorance. I do not mean this in a disparaging way; the differences between countries’ survival rates are not immediately visible to casual inspection. The average Briton or Swede is unlikely to know that the five-year survival rate for colorectal cancer is 51.6 percent in Britain but 59.8 percent in Sweden, or that the 30-day fatality rates for myocardial infarction in those two countries are 6.3 percent and 2.9 percent, respectively. (The figures for the United States are 65.5 percent and 5.1 percent.) Personal experience or acquaintance is not enough to reveal these facts. By contrast, the average Briton knows that if he suffers a heart attack, he will be taken to the hospital and connected to a lot of machines, from which he concludes that he is having the best possible treatment.

Another explanation is ideology. The British population has largely been persuaded that the NHS embodies social justice. The system has become a golden calf before which even Margaret Thatcher found it necessary to bow down: “The NHS is safe in our hands,” she said. And the egalitarian nature of the NHS makes it almost the only institution in a fractured and antagonistic society that can claim allegiance across many divides. We are not proud of our armed forces any longer or, indeed, of anything else; only the NHS survives to unite us. We increasingly are a nation defined by our health-care system.

In my youth, I often heard the refrain that the NHS was “the envy of the world,” and people in Britain are still inclined to believe it, even though they probably have never met anyone who envied the NHS and, indeed, know only of Continental Europeans residing in Britain who hurry home as soon as they require medical treatment, horrified by the prospect of subjecting themselves to the rigors of a British hospital. A marked cognitive dissonance reveals itself here.

This attachment to the NHS, notwithstanding any particular experience of it, finds reinforcement in a generally accepted historiography that is propagated by the system’s praise singers. According to this narrative, medical treatment in Britain was all horror, cruelty, and darkness until the NHS’s creation in 1948 suddenly brought ease, kindness, and light. Such stories as the following are told ad nauseam:

As I was born in September 1939, I am one of those who can remember what a difference the NHS has made. I had hospital treatment both before the NHS came into existence in 1948 and pretty soon afterwards as well.

I had an operation to remove my adenoids in 1946 and, when asked to provide a specimen, was handed an empty milk bottle. At the time I loved drinking milk, and for an impressionable seven-year-old the thought of urinating in a bottle almost turned me off milk for life. It certainly turned me off private healthcare.

A couple of years later I had to have my tonsils removed, this time under the NHS. When asked to provide a sample, I was handed a proper receptacle. That story, offered by a Labour MP on the occasion of the NHS’s 60th anniversary, appeared in the Western Mail, a large daily newspaper in Wales, and is, in fact, a mild example of the genre. It does not occur to the MP that his anecdote does not by itself prove much. Horror stories from the NHS also abound, as in this paragraph from the April 10 Independent reporting British patients’ recent experiences with nurses:

Diana watched her father “fighting for breath” and “thrashing around in blood-stained sheets” while five or six nurses “laughed and joked about their recent holidays.” Caroline was told by the midwife who was meant to be helping her through labour that she was busy “eating her biscuits.” Lesley woke up from her operation for breast cancer and was given a drink “reluctantly,” by a nurse who wouldn’t stop reading her magazine. Bronwen, who had open heart surgery, said that there were plenty of nurses “hanging around chatting, sometimes on mobile phones,” but not many who seemed to want to do “their job.” Denis “woke up in something akin to corrective treatment camp” where he saw “elderly confused people being threatened in quiet corners” and patients “being verbally abused.”

These ordeals are far worse than anything that the Labour MP suffered in 1946. Would he conclude from them that state-sponsored medicine was an abomination?

The horror stories in the Independent were relayed to the columnist after she publicized some bad treatment that she had received; in a health-care system employing 1.2 million people, it would be surprising to find no such stories. For every one of those, however, one could probably find another of devotion and good care. My mother was nursed extremely well in the NHS in the five weeks leading up to her death; my 92-year-old uncle was nursed in it abominably before he died. What is clear is that articles like the one in the Independent, though they appear regularly in the British press, leave no trace in Britons’ opinions about their health-care system. Apparently, the NHS was born with original virtue; all other systems partake of original sin.

The two most common measures of public health—used because they are relatively trustworthy, from a statistical point of view, and because they are thought to reflect the state of people’s health in general—are life expectancy at birth and the infant-mortality rate. If we look at these two measures, it is clear that the NHS has been neither a triumphant success nor a complete disaster.

In the 48 years of the twentieth century that preceded the establishment of the NHS, British life expectancy rose from 47 to 66 (that is, by 19 years, or 40.4 percent); in the 48 years after the institution of the NHS, life expectancy rose from 66 to 77.5 (by 11.5 years, or 17.4 percent). Thus life expectancy rose more, both absolutely and relatively, before the NHS than after it. It is clear that the NHS made absolutely no difference to the century-long improvement. Similarly, the infant-mortality rate fell from 140 per 1,000 live births in 1900 to 36 per 1,000 in 1948, a decline of 104 (or 74.3 percent); between 1948 and 1996, the rate fell from 36 to 6, a decline of 30 (or 83.3 percent). Again, it is obvious that the NHS made no difference to the trend.

What happened in France was broadly similar. But one finds an interesting, if slight, difference. In 1948, when Britain inaugurated its National Health Service, France’s life expectancy was six years less than Britain’s; by 1998, France’s life expectancy had overtaken Britain’s by a year. Of course, the connection between life expectancy and health-care systems is not necessarily straightforward. Nor does this statistic tell us much about universal health-care systems in general. But at a minimum, the figure shows that the NHS has not proved the salvation of Britain’s population, as popular mythology claims.

The NHS was founded on the principle that health care should be allocated according to need and not according to ability to pay, so that treatment, paid for by general taxation, should be free at the point of service. In this way, the health of the poor would come closer to equaling that of the rich.

Has this happened? The answer must be no—quite the contrary. According to a 2009 report of the House of Commons Health Committee, the difference in the death rates of men in the highest and lowest social classes has widened considerably in the epoch of the NHS. (The report uses the registrar-general’s classification of the population, with “social class I,” the highest, consisting of professionals and upper managerial staff and “social class V,” the lowest, of unskilled workers.) Between 1930 and 1948, a man in the lowest class in England and Wales was 1.2 times more likely to die at any given age than a man in the highest, a ratio that remained constant even as general life expectancy increased. By 1993, after 45 years of the NHS, a man in the lowest social class was 2.9 times more likely to die at any given age than a man in the highest. The class gap widened even further between 1997 and 2007—a decade in which the Labour government doubled health-care spending. So whatever else may be said, the effect of the NHS has not been egalitarian.

Two considerations arise here, however. The first, as a simple thought experiment shows, is that equality in health is not necessarily desirable in itself. Suppose that the infant-mortality rate in the highest social class is three per 1,000 live births, while that in the lowest is six per 1,000 (approximately the case in Britain today). Then suppose that we could reduce the rate by one death per 1,000 births in each social class, yielding two per 1,000 in the highest class and five per 1,000 in the lowest. A cause for rejoicing, certainly—but not from the point of view of equality, for the ratio of deaths in the lowest class to deaths in the highest class would widen from 6:3 to 5:2—that is, from 2.0 to 2.5. Surely, however, only a latter-day Lenin would reject such an improvement because it increased inequality. Similarly, an increase in the infant-mortality rate of the highest social class, to six per 1,000, would represent an advance to complete equality; but again, no one but a Lenin would wish it.

Second, the increased inequality of British health is necessarily attributable to the NHS only if the health-care system is the only, or overwhelmingly the most important, determinant of a population’s health—and it is not. For example, it has been estimated that half of the variance in life expectancy between the highest and lowest social classes in England and Wales is attributable to the difference in their rates of smoking. One’s level of education also has a profound effect on one’s chances in life. Both factors are beyond the scope of the NHS, or of any system of health care, to affect.

But the point is that one of the claimed vindications of the system is that it is egalitarian in effect. Clearly, it is not. What is striking in Britain is the persistence of the idea that the NHS is egalitarian, even while journalistic and governmental laments at the widening health gap between the rich and the poor grow ever louder.

Of course, there is more to life than the infant-mortality rate and life expectancy; the years between infancy and death must be occupied somehow. Does the NHS make the passage between birth and death easier, better, and more comfortable, or more difficult, worse, and more uncomfortable, for those who come within its jurisdiction?

This question is by no means easy to answer, and perhaps the same answer cannot be given for everyone. The statistics demonstrate that the system is neither the total disaster that some claim nor the answer to mankind’s prayers (as Michael Moore’s tendentious film Sicko suggested). At one time, the NHS could even claim certain strengths that other systems lacked—for example, in the coordination of medical care by means of a universal (and compulsory) system of family doctors. The lack of such coordination in the United States leads not only to a high rate of medical error but to duplication of effort. For example, the American rate of polypharmacy (the taking of four or more medicines daily) is twice the British rate. This difference is unlikely to reflect genuine medical need; the American polypharmacy rate is also two and a half times the Swiss rate, and whatever one might think of British medical care, few would impugn the quality of care in Switzerland.

Traditionally, the NHS has been inexpensive compared with most health-care systems, Britain spending less on its health care per head and as a proportion of GDP than any other developed country. But this reality is changing quickly. The NHS was inexpensive because it rationed care by means of long waiting lists; it also neglected to spend money on new hospitals and equipment. I once had a patient who had been waiting seven years for his hernia operation. The surgery was repeatedly postponed so that a more urgent one might be performed. When he wrote to complain, he was told to wait his turn.

Such rationing has become increasingly unacceptable to the population, aware that it does not occur elsewhere in the developed world. This was the ostensible reason for the Labour government’s doubling of health-care spending between 1997 and 2007. To achieve this end, the government used borrowed money and thereby helped bring about our current economic crisis. Waiting times for operations and other procedures fell, but they will probably rise again as economic necessity forces the government to retrench.

But the principal damage that the NHS inflicts is intangible. Like any centralized health-care system, it spreads the notion of entitlement, a powerful solvent of human solidarity. Moreover, the entitlement mentality has a tendency to spread over the whole of human life, creating a substantial number of disgruntled ingrates.

And while the British government long refrained from interfering too strongly in the affairs of the medical profession, no government can forever resist the temptation to exercise its latent powers. Eventually, it will dictate—because that is what governments and their associated bureaucracies, left to their own devices, and of whatever political complexion, do. The government’s hold over medical practice in Britain is becoming ever firmer; it now dictates conditions of work and employment, the number of hours worked, the drugs and other treatments that may be prescribed, the way in which doctors must be trained, and even what should be contained in applicants’ references for jobs. Doctors are less and less members of a profession; instead, they are production workers under strict bureaucratic control, paid not so much by result as by degree of conformity to directives.

This can happen under any system with third-party payment: it is an old observation that he who pays the piper calls the tune. But to have only one paymaster is to compound the problem, to make sure that there is only one tune. Therefore, even when the paymaster gets something right, an intangible harm is done.

And often, of course, unique paymasters do not get things right, since they have little incentive to do so, if not positive incentives not to do so. For example, the NHS recently abandoned its attempt to introduce a single database containing the entire population’s medical records—after $20 billion had been spent on the project. There is absolutely nothing to show for the money, except possibly a number of new information-technology millionaires. Historians will later sift through the records to decide whether incompetence or corruption was more to blame.

In obeying directives not because they are right but because they are directives, doctors lose their self-respect, their probity, and their intellectual honesty. Gogolian absurdity can result—with a hint of Kafkaesque menace and Orwellian linguistic dishonesty. When the British government decreed that every patient arriving in the emergency room should be admitted to a hospital ward within four hours if admission was necessary (and that hospitals would face fines if they failed to adhere to the rule), traffic jams of ambulances formed outside one famous hospital, with their patients prevented from entering the emergency rooms until the hospital could comply with the directive. Other hospitals redesignated their corridors as wards so that they could claim that patients on stretchers had been admitted in time. In a centralized system, the setting of targets will encourage organized deception, as well as distortion of effort.

In the United States, after President Obama’s health-care law proposed fining hospitals that readmitted too many patients within 30 days of discharge, editorials in the New England Journal of Medicine pointed out the dangers posed by that rule. They omitted to say that when giant bureaucracies set targets for others to reach, they intend not so much to procure improvement as to impose control.

Profile photo of Theodore Dalrymple

Theodore Dalrymple is the Dietrich Weismann Fellow at the Manhattan Institute and a contributing editor of City Journal. He is a retired doctor who most recently practiced in a British inner-city hospital and prison.

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