Issue XXXIX: The Kaiser, the Economist, and the Communist (Part II)

13 Jul

Semashko

                In the Soviet Union’s health care system was designed by a Nikolai Semashko who exported his health system to other Eastern European countries under communism.  These health systems are completely controlled by the government and have no forms of private practice but also no charges at all for hospitals, prescriptions, or GP visits.  In practice, there were many inefficiencies and underfunding of the health system which led to patients having to bribe physicians to get services needed.  The systems also over-relied on hospitalizations for essentially healthy people.  These practice patterns continue in the post-Cold War era.  One man told me his girlfriend in the Ukraine was being hospitalized for a dermatology biopsy.  She had to spend the entire month in the hospital waiting for the biopsy.  To escape on the weekends, she used to bribe the hospital staff.   

                After the Velvet Revolution, these systems were abandoned in Eastern Europe as they moved to their pre-communist systems of social health insurance.  In Russia, Ukraine, and “the ‘stans”, these state systems are still largely in place but have become even more underfunded except for the top state hospitals in the capitals.  The opening of private practice has encouraged the best doctors to quit working for the state and serve only the rich elite of the nation in the private sector.  For more information on Russia’s current post-Semashko system, read report from The Lancet.  Anecdotally, I hear that physicians were just given raises to the average Russian salary ($600 a month) while I’ve read that historically physicians made less money than factory workers under communism.          

                It is worth noting that system wasn’t all bad.  Health services were undoubtedly worse or non-existent in tsarist Russia while the collapse of the Soviet Union led to large drops in life expectancy.  Tuberculosis rates (a proxy for public health system performance) in Eastern Europe went through the roof in the 1990s.  Unemployment, alcoholism and economic crisis were certainly part of the problem, but the collapse of the state health care system certainly contributed to that fall in life expectancy.  Russian men currently only live to 59.        

Beveridge

                The British equivalent of the New Deal started during World War II.  Winston Churchill, a Conservative, commissioned a report by the economist William Beveridge, a Liberal, to look into the needs of postwar British society.  Beveridge’s report concluded that Britain needed a “welfare state” that would provide support to people from cradle to grave.  A proper secondary school system would be needed (unlike America at the time, there was no universal secondary school system) as well as a health care system.      

Meanwhile the democratic socialist Labour Party had also come up with ideas for a health system.  Their Left Book Club in the 1930s featured a book on a new health system by a certain Clement Atlee.  In the shocking 1945 election landslide, Atlee and the Labour Party defeated war hero Winston Churchill on a program of nationalization and the welfare state.  For this reason, the Labour Party is seen as the party of the National Health Service. 

                Aneurin Bevan became health minister.  Bevan was a high school dropout who had to work in the Welsh mines at 16.  His lack of formal education was made up by his unquestionable brilliance.  As minister of health, he navigated the opposition of the British Medical Association by dividing the general practitioners from the specialists.  After three years in government, the National Health Service debuted in 1948 under the principle that health care should be free at the point of service in both hospitals and clinics.  All outpatient prescription drugs cost £7.20, no matter how much they cost, but there are exemptions for the elderly and others.  All inpatient care is free.     

                The British health care sytem is one of the most completely government-controlled systems in the post-Cold War era.  Depending on who you talk to (doctors, economists, the common man), at least 82% of all funding from the system comes from the government and probably more like 90% by what normal people consider health (clinic and hospital visits and prescriptions).  Incidentally, it is the biggest employer in Europe and only Wal-Mart and Indian Railways employ more people in the world. 

                The system is fairly straightforward when you understand that there is a strong division between primary care and specialists.  Primary care means general practitioners, nothing else.  GP’s are in private practices of 1 to 7 people contracting with the government.  Everyone in Britain registers with a GP and gets on their list of patients.  The government pays a capitation fee for the size of the GP’s list.  No one can see a specialist without first seeing the GP, who is only responsible for outpatient care.  When a patient is admitted to hospital, he is under the care of the specialists who can only work at hospitals as employees.  Specialists include pediatricians, cardiologists, surgeons, and anyone else not a general practitioner.  There is no such thing as general internists in either outpatient or inpatient care, everyone is admitted to a specialist ward.

                Another interesting feature is the difference in the ranks compared to American medicine.  Medical school usually begins at 18 and finished at 23.  All doctors must do two years of “foundation” which are rotating internships in different specialities as house surgeons (like the internships for anesthesia residents).  They then go into their specialty tracks and are called junior doctors.  Once they have fully finished training, they are called registrars because they are on the register of the board of specialists.  You can continue to work as a registrar or you can look for a job as a “consultant” which is similar to an American attending but actually higher.  A consultant is somewhere between an attending and a department chairman and has a special interest in a certain part of the body.  An oncology consultant, for example, would only focus on kidney or bone tumors in a hospital.  To get a job as a consultant, you must publish lots of papers and do lots of cases (for procedural specialties).  Overall the system is more inclined towards academics than the American system because papers are used for promotions and publications are encouraged in what would be considered a private practice job in the U.S.       

                  GPs now make more money than specialists, which is a recent trend from the latest NHS contract.  NHS GPs now generally make over £100,000.  Specialists (who are hospital employees) make salaries similar to academics with consultant salaries starting at £70,000 and seem to peak at about £100,000.  Again, this can vary depending on where you practice and if you take private patients (only consultants can see private insurance patients) and how long you want to work.  Overall, the lifestyle is more relaxed than in America, and it is closer to a 9-5 job (the government even sponsors 10 days of CME training a year.) 

Interestingly, this doesn’t mean that physicians lack power or autonomy.  The British Medical Association acts in effect as a union for the physicians when it comes to contract negotiations with the government.  An interesting discussion with an ophthalmologist revealed to me that the medical specialties have a large amount of control over the procedure volumes at hospitals.  For example, the Royal College of Ophthalmology has guidelines for what the appropriate amount of time a postoperative visit should be for optimal medical care.  The Royal Colleges will de-credential hospitals that do not follow their volume and time guidelines, guaranteeing a leisurely pace for physicians.  And yes, the NHS physicians do get to have time for tea breaks.  Unthinkable, really.         

Sure, but does it really work?

                Measurement of health systems performance is a multimillion dollar industry filled with hacks, know-it-alls, and people with business agendas.  But the evidence from neutral sources is pretty clear: the United States consistently underperforms in health care despite spending the most in the world.  Most reports score the United States very low on access, particularly for the poor, black, and uninsured.  The Commonwealth Fund, for example, scores the US last in patient safety, access, coordination, efficiency, and equity.  One pediatric nephrologist in Wales told me that 80% of his patients would die if it weren’t for the NHS. 

The United Kingdom spends much less than the United States and considerably less than most industrialized countries like Germany and France.  In fact, the United States government health spending (Medicare, Medicaid, VA, CHIP, county hospitals, military) is actually more as a percentage of GDP than the UK.  A majority of spending in the US is now public, even before health reform passed. 

A recent article described the outcomes differences between the two countries.  The United States is known to have superior outcomes in cancer than the UK which has one of the worst in Europe.  However, this article states that while this is true, it is slightly exaggerated because older data excluded many African-Americans who have much poorer outcomes.  Also screening for certain diseases (especially prostate cancer screening which has not been shown to decrease mortality according to USPTF) is more aggressive in the US and gives them a higher number of early stage cancers to treat.  However, the US performs very badly in chronic care and no longer has a longer life expectancy than the UK.  Interestingly, racial disparities disappear in the American VA health system, which is actually more socialist than the NHS because all physicians are employees of the government and more free-spending.     

                So what’s the best health care system?  Really, it is all about values and culture.  What a society measures is what it values.  Under communism, the Russian system was about striving for an equal society and promotion of science and rationality over religion and moneymaking.  In Continental Europe, the social health systems are about having a neutral health system separate from government that are co-managed by business and unions.  In the UK, the health and political system is about eliminating the shocking health inequalities across this very unequal nation.  Life expectancy in parts of Glasgow (54) is worse than much of Africa.     

                If American medical schools, state medical societies, and politicians gave monthly reports on how bad disparities are and how they are striving to close them instead of how many millions of dollars in research grants they scored then our system would be totally different.  In my borough of London, I can tell you exactly where life expectancy is highest and lowest by neighbourhood.  Can anyone do that in America?  And if no one asks the question, how can anyone answer it?       

Links

Commonwealth Fund – U.S. Health System Performance      

WHO – Year 2000 Health Rankings (controversial)

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