The NHS and the French Health System compared
I am a lucky man. I was born in an NHS hospital not many years after its creation in 1948. The NHS was designed by William Beveridge and brought into being by Aneurin Bevan. It is rightly noted as one of the proudest and most defining moments of post-war Britain.
With care and diligence, could it have remained the ‘envy of the world’? Some would argue it never was. And yet it did provide first rate health care, free at the point of use. Half a century ago, before ‘gap years’ meant time abroad, I did a year working as a hospital porter. Whilst not everything was perfect, I have never met a more dedicated, hard-working or caring group of people.
Waiting Lists Climb
Now waiting lists are climbing – approaching eight million and rising, with over three million waiting longer than the 18 week maximum for urgent treatment! And this ignores the weeks, months or years to get a GP’s appointment, a valid referral and actually achieve the consultant’s appointment that gets you on the waiting list.
I had a hip replacement earlier this year. Under the NHS hip replacements are non-urgent unless you can barely move, so this would not have been covered by the 18 week referral pathway which is often exceeded. NHS data shows that over 90% of people are waiting over 46 weeks for appointments, let alone surgery. Over 400,000 people are waiting more than a year for hip and knee replacements and some more than two years.
Are There Alternatives?
The US model seems designed to make profits for insurance companies. My hip surgery would have been £30-35,000. With health insurance tied to employment, it is not surprising that one in ten US citizens have medical debt and over 500,000 file for bankruptcy over medical bills each year. This model is not worth discussion.
If my operation had been undertaken in the private UK medical system it would have cost £10-15,000. And with the problems of the NHS, more of those who can afford it, or who have private health insurance via their employer, are taking this option.
Most of Europe follows the Bismarck model. The key to this is the ‘health union’ where people pay into a common fund which then provides care when needed. Unlike with private health care, these common funds do not need to make a profit. Taxation is the primary means of paying in, where taxes are a subscription to living in a civilised society. In France, where I live, these are called social contributions (cotisations sociales). The secondary source of funds is the optional ‘top-up insurance’.
Private health insurance in the UK rises if you claim on it and rockets as you age. French top-up insurance is different. There is some increase with age, but making claims has no impact on what you pay. This is because it is a mutual insurance rather than a for-profit insurance.
I have lived in France for over 15 years and paid into the system, so I am entitled to French healthcare. The state covers about 85% of costs and my top-up insurance – my ‘mutuelle’ – covers almost all of the rest. From the initial GP’s appointment, made at three days’ notice, to surgery, by the consultant of my choice, was just 28 weeks. As well as not having to wait, neither did I have to bear the cost.
And as I am over UK pension age with sufficient years of NI registered, the state costs are charged back to the UK. The actual cost was under £7,000. At least £6,000 was billed back to the UK and the balance covered by my top-up insurance. And this included a district nurse attending my home for about eight days to change my dressings and remove the stitches. So I got French quality healthcare paid for largely by the UK taxpayer.
So What is Going Wrong in The UK?
The statistics are clear – waiting lists rose through the 1980s and 90s. They fell shortly after 1997 and continued to drop until 2010, and since then they have climbed inexorably. Rishi Sunak has stated that this is all the fault of doctors going on strike so please do not think it had anything to do with which political party was in power and when.
So the Beveridge model, as used in the UK, is hitting the problem of not enough money. Brexit drove a lot of NHS staff away and the Conservatives have demoralised the rest. The result is long waiting lists and dilapidated buildings.
The French Model
One complaint about the NHS is that it is huge, impenetrable, badly managed and that any extra money will disappear into ‘management’. France has enabled a different approach. Most healthcare is offered by small, private companies – and the key word is small. These may be a group of surgeons offering a type of surgery, such as orthopaedics. They may be a group of radiographers with a single office. They may be a team of GPs offering services in a small town. Very largely they charge the rates that the state set so there are no vast profits being made, they are just earning a living.
And I see a huge distinction between a company whose members are working to earn a living – GPs, surgeons or radiographers – and a company that is working to make a profit for its shareholders. The latter usually ends up with the solitary purpose of making money and whatever the founders’ original intentions, ethics and morality get pushed away.
Taxes in France are higher than in the UK, and there are still opportunities for the wealthy to avoid taxes, just not as extensively as in the UK. This allows France to spend about 20% more per person on healthcare than the UK.
Different Models, Similar Problems
Both the UK and, to a lesser extent, France are suffering from professionals who are becoming less and less happy with how they are being expected to work. How you drive nurses and doctors to go on any form of industrial action would have been unthinkable just a few years ago – but the Conservatives have achieved it. And France has areas, both urban and rural, where GPs are becoming difficult to find, mainly due to squeezes on medical student places in past years. The UK continues to cap student places and recruit from abroad – and fails to have enough doctors for current vacancies.
Both nations have disappointed many young people who had all the grades for degrees in medicine and potentially becoming doctors but there were no places for them. That has begun to be reversed in France and there are some ‘promises’ in the UK. Given recent promises about Northern transport, we shall see.
Additionally, as our populations age there will be growing costs. Brexit has and will continue to have a disastrous impact on the UK economy. Liz Truss’s 2022 budget did more damage, and nothing Sunak has done since seems likely to improve things. France does not want to spend more but at least they have only a hill to climb. The UK has a mountain.
For the UK, a general increase in taxation would be extraordinarily difficult for many people. The obvious choice of putting up taxes for the rich will never happen under the Conservatives and regrettably Labour are reluctant to commit to specifics a year before an election.
But the health and care professions must be properly funded or the poor will suffer, the rich will go private and the middle will be painfully squeezed. The biggest danger is that 13 years of crippling the NHS leaves it more and more vulnerable to people accepting private health insurance, often via their employer, with a move to the appalling US model.
The UK must spend more on its health system. Private health insurance through employment becomes valuable to those who receive it, but it risks driving the NHS toward a full for-profit insurance model – and just look at the USA. Optional top-up insurance may have a place, but I believe the vast majority should come from increased taxation and that increase should be levied on the richer members of society.
What I Like About the French System
I think the NHS could benefit from considering these aspects of the French system.
I need a Carte Vitale to prove I am in the system – so there are no arguments about health tourism. I pay my doctor, radiologist or consultant and am reimbursed in days from the state and my mutuelle – so I know what is being spent where and I feel less likely to waste services because they are ‘free’. For major costs such as my hip replacement, this is planned so I do not have to pay anything but a small balance after the event. There are almost no prescription charges in France. (I once had to pay for surgical stockings.)
Large public organisations always seem to create inefficiencies. Large private organisations become far too focused on profit. Dealing with small medical companies I have much more choice than in the UK. If I dislike one set of radiographers or their appointments are inconvenient, I can choose another, and it does not cost me anything extra. Small companies treat me as a customer, in part because treating me earns them a living, whereas large organisations sometimes treat individuals as a nuisance.
In France, whilst not free at the point of delivery, this is a comprehensive health service and I believe people have more respect for it because they know what each service costs.