the uk’s national
health service - the nhs: usa comparison
for those who care about comparative data on health services
One of the central points is that is,
it is very difficult to compare systems. In the United
States, both ‘sides’ of the health care discussion
are trimming mightily, some are even making it up as they
go along! Most are dreadfully uninformed, and are making
little effort to correct that problem. Most are just cheering
for football teams without even knowing the point of the
The reasons for the French and the
British reporting better life expectancy and infant mortality
rates than those in the USA, while their health services
cost less as a percentage of GDP, are complex. One is
the USA being ahead on the fat curve - they have started
to reduce the numbers of morbidly obese people. Another
reason is that, in the States, there are guns for killing
in ghettos and for convenient suicide. These statistics
are very poor and dubious indicators of the state of a
country’s medical services. There are many extraneous factors making
such statistics unreliable.
In the USA, people can choose medical services. People are neurotic, especially about
their own health. There is much corruption in the US health
industry. For instance, the estimate is the drug companies
employ about one sales rep. for every 4.7 medics. The
profits pay for ‘conferences’ in exotic locations.
In the USA, law makers are handsomely bribed to produce
laws that suit large corporations such as big pharma and
the insurance industry.
US medics are extremely cautious, they
order every test they can manage, in order to protect
themselves against law suits. That also ups the bills!
Most advances in medicine originate (or are developed)
in the USA. They are sold cheaper in overseas government-run
systems than in the USA, thus American medicine tends
to subsidise the likes of the NHS.
For examples of corruption in US government
see, for example, Dick
“An embarrassed Conservative Party leadership
was forced to rebuke one of its MEPs yesterday after
he spent the last week on a tour of the United States
rubbishing the NHS in a series of interviews.
Hannan, an outspoken and popular Conservative politician,
gave a damning verdict on the British health service,
telling American television viewers: "I wouldn't
wish it on anybody." ” [Quoted from timesonline.co.uk]
Both the UK and the US health systems
who has motor neurone disease [Gehrig’s disease,
also known as ALS - aminotrophic lateral sclerosis]
and has recently claimed that he owed his life to the
NHS. He is both wealthy in his own right and is enmeshed in Cambridge academic society. Cambridge has one
of the most advanced health centres in the world for that sort of disease.
In both countries, the richer you
are, the better off you are. But I suspect you are better
off in the UK if you are poor.
Both the French and British health
systems are packed with medics who should be better
educated. US medics I have met are better trained. The
UK system is filthy compared with anything I have seen
in France. The service is much quicker in France, they
have about twice the medics per head of population.
All Western societies provide for
the poor, including the USA.
In my view, a major improvement
in France is that (those) who can afford to, pay about
30% of bills (and that is widely covered by private
insurance). Anything given away ‘free’ is
A major advantage in France is it
is simple and easy to obtain second opinions and to
dump incompetent medics.
If you want the NHS, you’re
welcome, but no serious politician dare say that! Of course the politicians will go private when
it matters, just as they do in education.
Stephen Hawking is wealthy in his
own right and is not solely dependent on the NHS.
He is embedded in Cambridge academia,
with access to one of the world centres of excellence
for his type of problem (motor neurone disease).
Research into diseases, such as
motor neurone disease, is an integrated whole with
the patients being the guinea pigs and with high-level
people (neurologists in this case) running the trials.
Statisticians, ethicists, biochemists/big pharmaceutical
companies all working together. Even GPs and generalist
neurologists form links in the teams. Commonly, medics
go on to be part of research teams and work for big
The results of the labs tie into
the work of researchers looking to patent a treatment
and to develop a start-up with venture capital. Cambridge,
where Hawking is based, is deeply involved in the
I have little doubt that Hawking’s
outcomes would have been different in the extreme if he
were Mister Smith of 7 Back Street Cul-de-sac. Hawking
has a disease which usually kills in less than a decade.
He has survived about 40 years. In these circumstances,
it is very difficult to believe that he receives standard
Of course, Hawking is not treated as
Sam Sawkins would be - I doubt Sam would have a chance
in a million of even obtaining an appointment with some
of Hawking’s medics.
I am advising a person with a similar
nasty. Already I know more than the first-line neurologist,
let alone the general practitioner. And I am still studying
I have access Sam couldn’t, simply
because I know more and push harder; and I have paid extra
when necessary. There ain’t no equality in the real
world, and certainly not for Hawking. So, in that sense
he is certainly trimming, if not outright lying. Hawking
is not ‘equal’ in the NHS, and he would not
be ‘equal’ in the USA. Nor is Ted Kennedy,
and nor are congressmen, and nor are the star TV anchors
at Fox News.
Any suggestions otherwise are abuse
of rational argument.
Maybe it was a mere coincidence that,
coincidentally with Stephen Hawking’s endorsement
of the NHS, President Obama, somewhat besieged in his
attempt to create a public health system in the USA, rushed
him a US government medal?
In my view, it is clear that Brown
the Clown and Obama are doing the you-scratch-my-back
“Ten Commandments of Business Failure,
first drawn up by Donald R. Keough, the past president
and former CEO of the Coca-Cola Company.
Stop taking risks. A 2006 study of change capability
by the Office of Government Commerce gave the NHS
a score of just two out of five points for seven of
the nine categories assessed.
Be inflexible. Businesses are hamstrung by state
control over factors of production: staff pay is set
centrally; capital expenditure is constrained by the
DH; the National Programme for IT is a top-down programme;
and NICE increasingly decides what treatment can be
offered. Local initiative is crowded out
reports from the world health organisation and others
For those who care about comparative data on the health
services, in contrast to the highly uninformed twittering regarding the British NHS and Obama’s ambitions
to take over another swathe of the USA economy.
1997 figures - see Annex Table 1. I
do not know whether there have been any updates. Governments
tend to hate comparisons and do not cooperate well.
Note carefully the categories, which are almost designed
to generate results that please the WHO.
“Annex Table 1 is designed as a guide for
using Annex Tables 5-7, 9 and 10. Each measure of
goal attainment and performance - disability-adjusted
life expectancy, health equality in terms of child
survival, responsiveness level, responsiveness distribution,
fairness of financial contribution, performance
on level of health, and overall health system performance
-is reported as a league table ranked from the highest
level of achievement or performance to the lowest
Plenty of double talk. Many other
factors have much greater effects on a nation’s
health than do medical services, for instance ‘race’,
fatness, illegals, poverty. Thus the WHO report is
not a reasonable assessment of a society’s health
“Americans are also more likely to be obese,
leading to heart disease and other medical problems.
Among Americans, 31 percent of men and 33 percent of
women have a body mass index of at least 30, a definition
of obesity, versus 17 percent of men and 19 percent
of women in Canada. Japan, which has the longest life
expectancy among major nations, has obesity rates of
about 3 percent.”
“Infant mortality rates also reflect broader social
trends, including the prevalence of infants with low
birth weight. The health system in the United States
gives low birth-weight babies slightly better survival
chances than does Canada’s, but the more pronounced
difference is the frequency of these cases. In the United
States, 7.5 percent of babies are born weighing less
than 2,500 grams (about 5.5 pounds), compared with 5.7
percent in Canada. In both nations, these infants have
more than 10 times the mortality rate of larger babies....”
“The 47 million also includes many who could buy
insurance but haven’t. The Census Bureau reports
that 18 million of the uninsured have annual household
income of more than $50,000, which puts them in the
top half of the income distribution. About a quarter
of the uninsured have been offered employer-provided
insurance but declined coverage.”
There is more in the item. Mankiw is
one of the few economists who almost invariably talks
care and poverty
As you can see in the graph above, the USA is listed
as spending a considerably larger proportion of their
GDP on health services. However, it is very difficult
to trust such comparisons as the American health system
is so different from nationalised health systems. For
example, 10% of the American budget goes on litigation,
whereas in Europe it is virtually impossible to receive
compensation for medical errors.
It is political rhetoric to go on about 40 or 50 million
uninsured. In fact, more than 10 million of these are
illegal immigrants, another 10 to 15 million are young
people who think they will not become ill, known cynically
as “the invulnerables”. And there are 10 to
15 million who genuinely cannot get insurance because
of low incomes. However, the uninsured in need of medical
services can simply turn up at a free clinic or at A and
E (casualty). The over-65s are covered by Medicare, while
the seriously poor are covered by Medicaid, but the poor
do receive second-class and worry. (To be expanded.)
What is the beef for poor people or those without insurance?
Well, sometimes they do have assets and they have chosen
not to take out insurance; and then they are saddled with
a bad situation, such as an accident and run up very big
bills. At which time, they may have their assets taken
to pay the bills. For America is far more of a free and
self-reliant society. There are also insurance companies
that may play fast and loose when faced by a client with
of the population has hardly any bills, so the insurance
industry happily rakes in the premiums. By the 80th percentile,
the insurance companies become liable for about $3,000
of medical bills. By the 95th percentile, it may well
be $12,000, and for the very top 1%, the people with really
serious long-term illness, we may be up around $35,000
a year. So it is particularly these very expensive patients
where some insurance companies try to wriggle out of their
responsibilities. But of course, in Europe it is the same
cases where the State is most inclined to ration care
by delays and by refusing expensive drugs.
Therefore, you will see that, like some many things,
it is swings and roundabouts. Medical services are heavily
back-loaded, that means that most of medical costs come
at the last couple of years or months of life. Hence in
Europe, you will regularly come across cases where very
old people are treated with disgusting inhumanity, another
form of rationing.
Another item concerning the health of the nation
that should be considered is GINI (differentials in income) - the greater the GINI value,
the lower the health expectation. This is thought to
be related to social status. Those of lower status have
more ‘illness’ probably related to stress
“I deeply resent the Americans sneering at our
health service: but perhaps that’s because the
truth hurts.” [Quoted from dailymail.co.uk] Remarkably well written and
accurate article, other than a foolish comment concerning
“The UK was found to be one of Europe's worst
countries for cancer survival and one of the lowest
spending on cancer treatment.”
[Quoted from bbc.co.uk,
spending as % of GDP
cancer deaths per 100,000 people
Health Organisation, 1998; Berrino et al, 1995;
Murray 1998; World Bank,1993
Close examination will show that
this report is more useful for assessing health
services than the WHO
report of ten years ago, but it still suffers
from confusing tinsel with substance. Total scores
put the UK and Canada far down among wealthy countries
Separating out the tinsel from
the substance [p.15]. It is better to attend to
rows 2 and 3 of the table, and to put much less
stress on rows 1, 4 and 5. to the right, we reproduce
rows 3 and 2. (Row 3 has been re-ordered in score
order, countries with the same score are listed
Again, Britain shows very badly.
Canada is bad on waiting times, but considerably
better on the vital ‘outcomes’ measure.
This report skips over [omits]
the Japanese and USA systems. it does give some
idea of ‘money’s worth’. This
measure rates Canada and the UK well down among
wealthier countries [p. 25].
“The warning signs of what lay ahead came
on our first visit to Great Ormond Street, when
there was a young couple who had travelled down
from the north-east of England in front of us, their
tiny sick baby almost lost in its blankets. "Didn't
anyone tell you – your appointment's been
cancelled?" the receptionist told them breezily.
They looked at each other despairingly.”
“After 10 minutes, we left his consulting
room. The waiting area felt tense, with harassed
parents, bored children, raised voices and too few
seats. This unfortunate doctor had to see more than
50 patients during his two-and-a-half hour clinic
– or one patient every three minutes, with
no time for reading notes, let alone a break. And
we had already ruined his schedule. No wonder people
were getting exasperated.”
“For all the rhetoric, this is daily reality
in our health service. This is not to denigrate
the many fine workers, both on the frontline and
behind the scenes. We have come across doctors,
nurses, paramedics, therapists and many others who
have been supportive, caring and inspirational.
Some have gone way beyond the call of duty to help
in times of distress or difficulty, such as our
palliative care team and the community nurses. But
equally, we have come across too many ground down
by a sclerotic system that crushes out the idealism
or caring nature that presumably made them join
the health service.
“Clearly there is systemic failure. And it
is a question of management, not money...”
times for treatment
Amenable mortality chart from Putting
patients last by Davies and Gubb [publ. Civitas]
health care: private/public - usa/uk,
continuing a comparison
“And so it went. When it came time for my husband
to undergo physical rehabilitation, I went to look at
the facility offered by the N.H.S. The treatment was
first rate, I was told, but the building was dismal:
grim, dusty, hot, understaffed, housing 8 to 10 elderly
men per ward. The food was inedible. The place reeked
of desperation and despair.
“Then I toured the other option, a private rehabilitation
hospital with air-conditioned rooms, private bathrooms
and cable televisions, a state-of-the-art gym, passably
tasty food and cheery nurses who made a cup of cocoa
for my husband every night before bed.
“We chose the private hospital, where the bills
would be paid in their entirety by insurance. My husband
lived there for nearly two months. We saw the other
patients only when they were in the gym for treatment
when my husband was. Most of them seemed to be from
rich countries in the Middle East. Perhaps they were
the only ones who could afford to pay.” [Quoted
“The figures, published by the Lib Dems, show
that 236,316 people are currently waiting more than
18 weeks for a range of treatments including oral surgery,
rheumatology and geriatric medicine.
“This means that nearly 10 per cent of patients
are not being treated within the government's waiting
“It stands in contrast to comments made by Mr
Burnham on Tuesday that Labour had wiped out all waiting
lists on the NHS.”
“ The Department of Health said the NHS had met
targets for the first time last summer for 90 per cent
of admitted and 95 per cent of non-admitted patients
to receive treatment within 18 weeks.”
What is interesting to me is
this sort of statement is presented as ‘success’.
Even if it were not for the widespread fudging of government
stats, it would come nowhere near the results for any
high-street supplier - even the worst of them.
This video is fascinating and well
worth watching, as long as you have ample pinches of salt.
It is propaganda, classy propaganda, but still propaganda.
It is not analysis.
The UK’s NHS is one of the biggest
employers in the world. Not like the French system with
approximately similar population, not like the German
system with considerably higher population. Why does it
that such a huge monolithic organisation in the UK? How
much resources are wasted by these health systems? Maybe
the NHS is cheaper because of low wages, but that also
must mean there are less road sweepers or church fabric
Meanwhile, the users of the USA system
make far more of the choices, and they choose,
as a society, to pay more. And further, the USA is a much
richer society than Europe.
I keep asking what the situation would
be in Europe if the public chose their
level of expenditures on health, rather than being captive
to a government cartel.
The higher costs in America could easily
reflect the higher level of discretionary income available
to the average American and a widespread choice to spend
a good proportion of that on medical services, rather
than any argument about ‘waste’ or ‘too
high’ health care costs. There is a great deal of
disinformation about the American health system. Almost
everybody does, in fact, have health care. In fact, about
45% of American health care is paid for by the government
under the headings of Medicare and Medicaid. Medicare
is essentially for the over sixty-fives and Medicaid for
those on low incomes. There is also a system for veterans
It is difficult to compare American
costs with those of the UK and Europe. In particular,
legal liability for medical errors is widely enforceable
in the USA, whereas in Europe it is very hard to enforce
recompense. Legal liability is estimated at about 10%
of the American medical costs, but I think it may very
well be higher in view of all the insurance and legal
services implications. It is also claimed that drug bills
are about 10% of medical costs and that higher charges
are made for drugs in the USA.
In the USA, able citizens in good standing
are expected to shift for themselves and take out appropriate
health insurance. Three groups tend to under-insure themselves:
illegal immigrants (maybe 10 million+ people), young workers,
often referred to as the Invincibles because they believe
nothing will happen to them (maybe 15 million people),
and those poor but not poor enough to qualify for Medicaid
(perhaps another 15 million people). But even these groups
can turn up at A & E (accident and emergency, or casualty
in the UK) and it is illegal not to treat them.
Note the surprisingly low contribution
of health (medical) costs to a nation’s welfare,
despite the high levels of agonising about health services,
both private and political.
related material twitter
and iran - This makes an interesting contrast, because
in the main, the NHS twittering is uniformed, full of
emotion, while being generally bereft of information.
"Up to 3,000 foreign doctors are being urgently checked after a fake psychiatrist was allowed to practise for 22 years with no qualification. Zholia Alemi claimed she had a primary medical qualification from the University of Auckland in New Zealand when she first registered in the UK in 1995." >>
"Alemi, 55, was jailed for fraud in October this year after she changed an elderly patient's will to make herself a beneficiary."
The NHS mostly measures success by inputs. No useful science
can progress without measuring outputs.
On output measures, the NHS does far worse than it does
Thus, government monopolies and socialists always prefer