IN PRAISE OF MUDDLES

Die in Britain, survive in the US (James Bartholomew, The Spectator, February 12th, 2004)

Let’s try the simple way first. Suppose you come down with one of the big killer illnesses like cancer. Where do you want to be — London or New York? In Lincoln, Nebraska or Lincoln, Lincolnshire? Forget the money — we will come back to that — where do you have the best chance of staying alive?

The answer is clear. If you are a woman with breast cancer in Britain, you have (or at least a few years ago you had, since all medical statistics are a few years old) a 46 per cent chance of dying from it. In America, your chances of dying are far lower — only 25 per cent. Britain has one of the worst survival rates in the advanced world and America has the best.

If you are a man and you are diagnosed as having cancer of the prostate in Britain, you are more likely to die of it than not. You have a 57 per cent chance of departing this life. But in America you are likely to live. Your chances of dying from the disease are only 19 per cent. Once again, Britain is at the bottom of the class and America at the top.

How about colon cancer? In Britain, 40 per cent survive for five years after diagnosis. In America, 60 per cent do. With cancer of the oesophagus, survival rates are low all round the world. In Britain, a mere 7 per cent of patients live for five years after diagnosis. In America, the survival rate is still low, but much better at 12 per cent.

The more one looks at the figures for survival, the more obvious it is that if you have a medical problem your chances are dramatically better in America than in Britain. That is why those who are rich enough often go to America, leaving behind even private British healthcare. One reason is wonderfully simple. In America, you are more likely to be treated. And going back a stage further, you are more likely to get the diagnostic tests which lead to treatment. [...]

There is much that is wrong with American healthcare. The inflated cost is boosted by restricted entry into the medical profession. It has been pushed up by the courts which have given crippling damages for medical negligence. The doctors have to insure themselves against such damages and so the insurance premiums they pay are huge. Doctors can only pay these by charging high fees. The risk of being sued is also an important reason why American doctors would rather give you too many tests than too few.

Let’s face it, the American system is rotten. It is not even a system. It is a hotch-potch. Most hospital provision is by not-for-profit, private hospitals. But the biggest buyer of medical care is the US government. Through Medicaid (for the poor) and Medicare (for the old) and other schemes, the government pays for 45 per cent of all healthcare. (The British assumption that American healthcare consists of an unfettered free market could not be more wrong.)

Most British people do not realise that the non-private hospitals in America are not run by the federal government. They are local government hospitals. The San Francisco General is run by the City of San Francisco. And another unexpected thing for Brits is that even in such local government hospitals treatment is not free to those who can afford it. (Incidentally, all sorts of American hospitals — especially the not-for-profit ones — receive large sums of cash from charitable benefactors.) And if you think all the above is confusing, that is hardly even the beginning of the bewildering diversity and contradictions of American healthcare. It is a muddle.

The British system was a muddle, too, until Aneurin Bevan came along in 1945. As minister of health, he set about unmuddling it. We, too, used to have local government (‘municipal’) hospitals until he took them over. He took over the charitable hospitals too, like St Mary’s and Moorfields and many other famous ones. He made it not confusing at all. What could be simpler than the central government being in charge of everything? Over time, the government put itself in charge of all the doctors, too. So all was made simple and clear.

But the curious thing is that the new, improved, simple state system of Britain does not work as well as the American muddle. You have a better chance of living to see another day in the American mishmash non-system with its sweet pills of charity, its dose of municipal care and large injection of rampant capitalist supply (even despite the blanket of over-regulation) than in the British system where the state does everything. It is not that America is good at running healthcare. It is just that British state-run healthcare is so amazingly, achingly, miserably and mortally incompetent.

A good rule of thumb on this issue is to take a contract out on anyone who dares even mouth the words “comprehensive”, “universal” “integrated” or “rational”.