Why the health service works in France
Ed Hoskins, 28 April 2022
The Nation’s Health not the National Health Service should be the priority of government.
As an Englishman living in France who worked in the NHS some long time ago, it is of great sadness to me that political dogma and the refusal to accept criticism of what has become a national icon manages to blank out any consideration that methods and experience from elsewhere could ever be applicable in the UK.
This is particularly so in the NHS, where the dogma that the government has to be directly responsible from taxation for the supply of health care have been inbuilt for so long. This combined with “free at the point of use” is particularly damaging.
(What is even more amazing is the fact that so little in the NHS is actually free at the point of use, prescription charges, dental costs and the endemic rationing, which itself translates into huge costs for the individual patient.)
So why are things so different here in France. These are my simple conclusions:
The system is run on an insurance basis based on income supervised by the state but with no direct participation by the state. The system has state protection for the low paid, the chronically ill, pensioners, children, etc.
“Free at the point of use” in the UK is a fallacy and only encourages people to use UK medical services unnecessarily and to regard the access to such services as being as of right.
Here the modest fee ~€20 payable to the GP, most of which reimbursed later, is a disincentive to time wasters and malingerers, even in France. It is amazing how effective the cash flow consequences of having to pay the doctor his €20 fee, even though it can be claimed back later, is in making sure that patients really need to be there. Of course, anyone with a noted chronic condition or socially disadvantaged will be reimbursed 100% and if he has a Carte Vitale the GP is credited automatically without money changing hands.
The Pharmacist will provide over the counter advice and drugs for almost any common aliment. He will also provide prescription drugs (un-reimbursed), if needed at his discretion. Thus the load on the GP is much reduced.
All the providers in the system, the GPs, consultants, diagnostic labs, district nurses, etc. are self-employed private contractors within the system. But they normally work at Nationally proscribed fee scales.
The contractors in the system choose their mode of working from the point of view of their own businesses, within those fee scales. This results in the outcomes most of which would be remarkable in the UK except in the costly private sector:
- The GP has no secretary and no appointment system. Turn up when you need and wait perhaps 20 minutes on a busy day.
- GPs are not paid by a capitation fee based on registered patient numbers but on their actual patient appointments. And only recently a system of affiliating patients to GP’s has been introduced, before that it was totally open to the choice of the patient on any particular occasion
- The patient also has the choice of which consultant to see and can contact his office directly without referral without consultation, but the GP will always recommend the one he considers suitable.
- The GP will also be happy to make home visits: the reimbursed charge is rather more.
- The dentist has no dental nurse and runs the practice single handed. A large proportion of his fees are reimbursed to the patient.
- The busy cardiology practice with three consultants has just one administrative assistant.
- The district nurse will turn up at on the doorstep to take a blood sample at 7.00 am in the morning for a fee of €6.35 (reimbursed).
- The consultant dermatologist answers his own phone and makes his own appointments without any need for administrative help.
- As well as doing major surgery, the consultant orthopaedic surgeon does his own minor splint work on the spot. Etc. etc.
Thus, the administrative load created by centralised control and rationing of access to consultants, treatments and hospital appointments does not exist.
As separate private contractors, all health professionals work as if “their time was their money”. Most UK hospital consultants are already private contractors as well as being well-paid part-time government employees. A piece-work remuneration system has been working for dentists in the NHS for many years.
There is a real emphasis on preventative medicine and prompt treatment is considered to be economically worthwhile. Thus, certainly in my experience waiting lists just do not exist. In addition, speaking as a pensioner, practitioners do not seem to think that age is an impediment to treatment.
There is certainly an abundance of medically qualified people in the system and indeed there is a real degree of competition between them. According to OECD figures, there are almost twice as many medically qualified professionals per head of population as in the UK health service. They are not rewarded with the high salaries received in the UK.
The medics seem to control the running of the hospitals and other facilities not the government. They see the benefit of having an absolute minimum of administrative overheads. Those that exist are mainly involved with the ensuing that the various state mandated Insurance organisations are charged correctly. This also means that there are no artificial limits placed on maximizing the use of expensive capital equipment and the hospital installations.
Also, crucially, as the government is not supplying the service, the state does not own the product of the service nor most importantly the patients’ medical records.
Patients have bought the service either directly or via their insurance: they are therefore the owners of the results. Responsibility for the ownership of such records is reasonably unloaded on to the patient. This eliminates another whole swathe of administrative costs. As there is no government duty of care with regard to patient records, there is no demand to create an expensive nationwide database of everyone’s medical records, as was tried and failed in the UK.
Any minimal useful information is retained on the chip of my Carte Vitale. The Carte Vitale is a type of credit card with a chip, that is used to organise the data required for my insurer to pay the sums necessary to the whichever part of the health system I have used. The Carte Vital can be updated on the terminal at any pharmacy. This seems to be a truly efficient use of Information Technology as applied to the health service.
And in France there is a much simpler health IT system. It has been working for decades and it is visibly successful just across the channel.
The NHS is certainly not the only way to organize a Health Service and the clear evidence is just across the channel. But dogma means that the Brits would never want to learn from foreigners.