NHS Crisis, do the French have the solution?!

[Taipan]

Interesting article in The Daily Sceptic. I think the NHS is too hallowed for people to want or allow a change to a system like the French one, which is a bit of a shame IMO.

As an Englishman living in France who worked in the NHS some long time ago, it is of great sadness to me that both 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 U.K.

This is particularly so in the NHS, where the dogma that the Government has to be directly responsible from taxation for the administration and supply of health care has been inbuilt for so long. It seems that from its earliest days the NHS that was set up as if patients were incapable of having any responsibility for their own health and therefore the Government had to take on that administrative responsibility. This may be one of the reasons why the NHS has been continually overburdened with self-perpetuating and ever-growing bureaucracy.

This combined with ‘free at the point of use’ was particularly damaging. ‘Free at the point of use’ in the U.K. encourages people to regard the access to such services as being free and as of right, encouraging time wasters and thus unnecessary use of medical services.

‘Free at the point of use’ is also a fallacy as so little in the NHS is actually free at the point of use – there are 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, where national expenditure on health is on a par with the U.K., yet we get far more bang for our buck?


Data for most recent year available. Sources: World Bank, Nuffield Trust, eurostat.
First, the system is run on an insurance basis based on income, supervised by the state but not directly administered by the state. The system has 100% state protection for the low paid, the chronically ill, pensioners, children etc.

Normally, the state pays the larger part but not all the medical costs. Individuals have the option to buy supplementary top-up insurance (mutuelle) to cover the balance. This ensures that people do have an understanding of the value of their healthcare.

In France, health provision is supported by a very effective IT system. It was originated as early as 1982 with the Minitel online system, although it has now been superseded by the Carte Vitale.

The Carte Vitale is a type of credit card with a chip issued to all insured patients. It provides the data required for the insurer to pay the sums necessary to whichever health provider has been used. It retains minimal health information, such as the chronic illnesses for which the patient is due full reimbursement. Most health professionals, such as the GP, have card readers and are reimbursed directly through the system. The Carte Vitale can be updated on a terminal at any pharmacy. There is a parallel manual system which can be used by any small-scale provider, for example the visiting chiropodist.

The insurance organisations provide regular reports to the patient noting all the payments that have been made on their behalf, thus ensuring that the patient knows the value of the health care he or she has received.

Importantly, GPs are not paid by a capitation fee based on registered patient numbers but on their actual patient appointments. This means that there can be a modicum of competition between them as health providers. Well-liked health providers are successful and as busy as they want to be. And the patient retains his or her ability to choose.

Only recently, a system of affiliating patients to particular GPs has been introduced; before that it was totally open to the choice of the patient on any particular occasion.

All the providers in the system – the GPs, consultants, diagnostic labs, district nurses, etc. – are either private company groups or self-employed private contractors within the system. But they normally work at the nationally prescribed fee scales.

The contractors in the system choose their mode of working from the point of view of their own businesses and personal circumstances within those fee scales. This results in health service outcomes most of which would be remarkable in the U.K., other than in the costly private sector:

My GP has no secretary and no appointment system. Turn up when you need and wait perhaps 20 minutes on a busy day.
The GP will also be happy to make home visits; the reimbursed charge is rather more.
The patient also has the choice of which consultant to see and can contact the consultant’s office directly without GP referral, but the GP will always recommend the one he or she considers suitable.
The district nurse will turn up on the doorstep to take a blood sample at 7am in the morning for a fee of €6.35 (reimbursed).
The pharmacist will provide over-the-counter advice and drugs for almost any common aliment. He or she will also provide prescription drugs (un-reimbursed) if needed at his discretion. Thus the load on the GP is much reduced.
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 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 not hesitate to do his own minor splint work on the spot.
There is a rigorous system of reminders about medical appointments by text and email so the waste from missed appointments is unusual.
Etcetera etcetera.
Thus, the administrative load created by centralised control and rationing of access to consultants, treatments and hospital appointments does not seem to exist.

As separate private contractors, all health professionals work as if their time was their money. Most U.K. 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. In France this also applies to GPs and their remuneration does not seem to be excessive as it often is in the U.K.

Prior to any hospital intervention, all the necessary preparatory checks take place as outpatients including blood tests, anaesthetic checks, cardiac checks etc. This means that inpatient hospital time is not used for these preparatory activities.

In France there is a real emphasis on preventative medicine and prompt treatment is considered to be economically worthwhile. Thus, certainly in my experience, long waiting lists just do not exist. In addition, speaking as a pensioner, the health service does 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 degree of real competition between them. According to OECD figures, there are around 25% more medically qualified professionals per head of population than in the U.K. health service. They are not rewarded with the high salaries received in the U.K.

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 ensuring that the various state mandated insurance organisations are charged correctly.

This also means that there are no artificial limits placed on maximising 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 via their insurance: they are therefore the owners of the results. The responsibility for the ownership of such records is reasonably unloaded on to the patient. As the patient owns the records, he or she is freely able to read them and understand them to the best of his or her ability.

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 U.K.

The ambulance service is merged with the fire service as a single emergency service. Voluntary membership is prestigious in the community. If you have a regular treatment appointment, say for radiotherapy, a taxi will come and fetch you and bring you home – all part of the service.

In other words, the French health service is pretty well ‘privatised’, and that’s why it works rather well.

The nation’s health, not the National Health Service, should be the priority of Government.

The NHS is certainly not the only way to organise a Health Service and the clear alternative evidence is just across the channel. But dogma means that the Brits will never want to learn from foreigners.

https://dailysceptic.org/2022/11/29/how-to-fix-the-nhs/

[irie]

... But dogma means that the Brits will never want to learn from foreigners.[/i]

https://dailysceptic.org/2022/11/29/how-to-fix-the-nhs/

Everyone knows that the NHS is an institutional football that both Conservative and Labour must continue to support in its current form for political reasons.

The more money that gets pumped in the larger and increasingly self serving its bureaucracy becomes. It's long beyond the point of reform, only complete failure will prompt reform. And then only if both Conservative and Labour recognise and agree that it has failed.

The cries of "Save the NHS" are truly shocking.

How about "Save the Patients"?

No wonder that up to 10% of the population are reported to be accessing private paid medicine.

[Mr Moofo]

The NHS currently costs each household 10k - it may well be free at the point of service.
My healthcare in Germany used cost me around 300 euro a month.

And was absolutely brilliant.
Swiss healthcare cost us (in todays money) 8000 pa as a couple. You could chose hospitals, surgeons - and get a GP appointment when you wanted them.

The NHS has become untouchable because of the myths about it being "world leading". I have no doubt that was the case in the past - but we are doing its customers no favours by continuing with a false view of its service.

[DefTrap]

Based upon my experience of the Fronch system ....

My GP has no secretary and no appointment system. Turn up when you need and wait perhaps 20 minutes on a busy day.
*** My GP has a secretary. It's certainly not turn up and wait, although they are flexible, I could probably get an appt late today with my preferred GP if i rang up and laid it on thick, otherwise it would be prolly early next week. Bear in mind this is a village practice of about 2k people. The GPs are extremely busy though (only 2 of them) , work hard, long hours.

The GP will also be happy to make home visits; the reimbursed charge is rather more.
*** yes, it's certainly possible, in some cases. Certainly the nurse will do home visits, to take bloods etc.

The patient also has the choice of which consultant to see and can contact the consultant’s office directly without GP referral, but the GP will always recommend the one he or she considers suitable.
*** I'm pretty sure you can't just contact consultant's directly, you need at least a GP's introduction, sort of a prescription. It's certainly easier with a referal. On the few occasions I've tried direct contact (you can do it online), they've essentially rejected me.

The district nurse will turn up on the doorstep to take a blood sample at 7am in the morning for a fee of €6.35 (reimbursed).
*** yes, that's possible.

The pharmacist will provide over-the-counter advice and drugs for almost any common aliment. He or she will also provide prescription drugs (un-reimbursed) if needed at his discretion. Thus the load on the GP is much reduced.
*** yes the pharmacist service is really good. And there are loads of them. And they're selling you just medicine (unless it's a parapharmacy) so not equally focused on selling you a meal-deal and some perfume. It is ALL about the pharmacy when it comes to medicines though - if you rock up at the supermarche then there literally is no medications aisle, you can't even get an aspirin. I get most of my vaccines done at the pharmacy.

The dentist has no dental nurse and runs the practice single handed. A large proportion of his fees are reimbursed to the patient.
*** certainly our practice has a receptionist. I have found fees are cheaper, accessibility, not so much.

The busy cardiology practice with three consultants has just one administrative assistant.
*** consultancy administration is really efficient. Hospitals have a huge ticketed check-in service in the entrance halls and they sort you out in no time at all without masses of fannying about and waiting. Yes, once you get up to the right department there are few admin people because the admin is already done. You pay in the entrance lobby on the way out. I do agree with the author that it's good to get all the preparatory tests done first, outside of the hospital, before your consultation appt, it works really well.

The consultant dermatologist answers his own phone and makes his own appointments without any need for administrative help.
*** This is ridiculous, not in my experience, typically there's an admin harridan fending people off on the phone, you can't have a consultant wasting his time doing it. And dermatology appt waiting times are notoriously lengthy - if you booked one now you'd be lucky to see one before next summer, so this is an awful example to use.

As well as doing major surgery, the consultant orthopaedic surgeon does not hesitate to do his own minor splint work on the spot.
*** if you say so.

There is a rigorous system of reminders about medical appointments by text and email so the waste from missed appointments is unusual.
Etcetera etcetera.
*** sort of. There are a fair few systems you can use to book appointments. If you book an appointment over the phone with your GP then you won't necessarily get an email or text reminder. It depends what IT system the GP is using and whether they can be arsed to update it. However if you book using one of the online services then yes you can opt in for electronic notifications.



When it comes to receiving lab results, scan results etc I would say the system is very efficient - typically you get results as you leave or very likely electronically the same day. Obviously the main problem then is that you have the results but not necessarily an analysis of what the impact is (you could do it yourself but we all know the horrors of googling medical results) - so often you have to wait for a further appt with the GP to go through that.

An awful lot of the services are contracted outside of the hospital, so you'll find satellite areas of dermatologists, labs, ophthalmologists, x-ray etc. Again all run fairly efficiently. You don't have to creep around the inner bowels of the general hospital searching out all the sodding clinics - you can get it all done in advance, away from all the drama, where there is easy parking.

Just my experiences. The author praising up the French system is obviously a fan but hasn't taken much trouble to go outside of his own anecdotal evidence. I'm reasonably happy with the services I get but yeah this is just me in a relatively well-off rural village, I doubt it's the same experience in a grotty Marseille suburb.

I've been out of the UK a while now (and TBH when I did live there I was young-er and lucky enough to never have to visit the GP or hospital) so I dunno how these compare to the current state of the NHS

[Yorick]

The Spanish NHS works well.
You walk into a clinic and take a ticket.
Wait 5 minutes.
See a doctor.

[Noggin]

The article is a bit 'rose tinted specs'. And I mostly agree with DefTrap (although, there are a lot of surgeons and consultants you can see without a referral/prescription - some you need one to get 100% of the costs back)

However, everyone I've been in contact with medically has said that there is a shortage of medical people. It's very difficult to find a GP in the countryside (up here, my GP opens once or twice a fortnight in the interseason - no appointments in or out of season as in season its mostly about trauma). My shoulder surgeon has commented that the system is about to fall apart (she's relatively young, but has concerns that the system just can't cope)

Almost impossible to find a dentist anywhere (well, might be simpler in big cities I guess)


However, for me it's the ethos that makes treatment here so much better as much as the system. They don't patch you up and send you home to manage. The do their best to fix you as best as they can to get you back to fitness or as close to fitness as possible. The follow up care, physio, residential rehab etc etc. Not available in the uk unless you are a famous footballer or extremely rich.


The idea behind the NHS was great. It still is a great idea. But it's being killed from the inside by shit management and stuff like that.

Oh - out here I pay 40€ a month for my mutuelle - this covers me for 100% of medical charges (including the taxis I've needed to get to appointments or to and from rehab)


I honestly do not think I'd have use of my right arm if I had stayed in the UK rather than move here. Essentially the surgeon in Bristol told me that the operation I had here would leave me with pain relief but no movement. But with the rehab etc, I have about 50% use of my arm. Equally, had I had any sort of support/rehab in the uk after the first op (and here - I didn't know I entitled to help in that first year) I probably wouldn't have needed the second op


It's less about the money for me but how they strive to fix people rather than patch and move on

[Taipan]

... But dogma means that the Brits will never want to learn from foreigners.[/i]

https://dailysceptic.org/2022/11/29/how-to-fix-the-nhs/

Everyone knows that the NHS is an institutional football that both Conservative and Labour must continue to support in its current form for political reasons.

The more money that gets pumped in the larger and increasingly self serving its bureaucracy becomes. It's long beyond the point of reform, only complete failure will prompt reform. And then only if both Conservative and Labour recognise and agree that it has failed.

The cries of "Save the NHS" are truly shocking.

How about "Save the Patients"?

No wonder that up to 10% of the population are reported to be accessing private paid medicine.

Its a better mantra for sure!

I had my knees replaced in private hospitals (Spire Hartswood and Nuffield) . It really brings it home to you how bad the NHS is and what we've come to accept.

The first consultancy with the Ortho Surgeon and he was says lets get an x-ray and see what going on. I asked him if i'd get that done at my local hospital and would he refer me, or would I need to see my GP to get an appointment? He said no, you go through those doors and x-ray is down on the right. I said oh great, when do I come back? He said straight away, which I did and there he was reviewing the images on the screen. That alone is probably a minimum of 6 weeks using my GP and local hospital.

Nearly all the Nurses and auxiliaries in the private hospitals are ex-NHS and their stories aren't good. None of them can ever see it changing either and most left reluctantly, but said it is just a soul destroying environment to work in. Our local NHS hospital is big local employer and I know quite a few people who work there who say similar. It's fair to say it's mainly staffed with well intentioned, but pretty disillusioned people.

[Pirahna]

I've just taken out private healthcare in Spain, I had to for my residency. 1700 euro for the year, it's expensive because for residency the policy must have no copay (you can't top it up). Included in that I also get dental treatment, not sure to what level though.

[Le_Fromage_Grande]

The NHS currently costs each household 10k - it may well be free at the point of service.

I wonder how much of that £10K is used for retired NHS employee pensions.

[Yorick]

I've just taken out private healthcare in Spain, I had to for my residency. 1700 euro for the year, it's expensive because for residency the policy must have no copay (you can't top it up). Included in that I also get dental treatment, not sure to what level though.

YUP, I pay just a bit less for ASSSA's top level.

[mangocrazy]

The NHS currently costs each household 10k -

I wonder how much of that goes into the pockets of non-medical 'consultants'?

In the early 2000s a friend/acquaintance of mine was married to a lady who worked in the NHS as a consultant. I never found out exactly what she did, other than general administration. It was certainly nothing to do with medical front line services. I also never knew precisely what her salary/remuneration was other than it was channelled through a limited company, but I do know that in a piece of arm-twisting to get him to give up bikes she bought him a Lamborghini.

[Ant]

The NHS is brilliant, the NHS has ran out of money to treat a cancer patient (it's the wife of a man at work), but you can still get gender reassignment on the NHS

[gremlin]

Mrs. Gremlin was told yesterday, with no hint of an apology, that after her x-ray was taken for an embedded foreign object in her foot, that the wait was between 8 and 11 hours to be seen.

I would have happily paid to get it done privately, but that option is not available as it falls under A+E.

I#ve argued for years that the great British public need to get the idea out of their head that the NHS is a sacred cow that cannot be touched. It needs a root and branch reform and the French system (it pains me to say it) seems a bloody good starting point.

[Yambo]

A few months ago I had a swollen elbow. I went to a local private hospital where the orthopedic guy told me it was bursitis. I told him I'd fallen and smacked it not too long before so he asked if I wanted an XRay. I thought it was a good idea so paid £4 at a counter and had two photos taken. I watched as they downloaded in the XRay dept then went back to the doc who had them on his computer screen. We had a look together and agreed there was nothing broken. He then drew some fluid off the elbow and gave me a prescription for antibiotics that were OK with all the other meds I take. All in all about 50 minutes and the cost to see the doctor was about £8.

I pay into the government health insurance scheme so only pay 10% of the costs when I go to a private hospital but it's worth it. The government hospital would be no charge but is awkward to get to and usually bursting at the seams with poor people. Works well for A & E though.

[Cousin Jack]

Once upon a time I had a local village GP. His surgery was 2 rooms in his house, he did his own prescribing too. Waiting time for an appointment varied, from about 5 minutes up to a couple of hours at busy times. You had the medicine in your hot sweaty hand as you left. When he was out on a house call (remember them?) his wife answered the phone, kept his diary, did anything else a PA could.

Now I live in a larger (but still smallish) town. My GP Practice has 6 GP Partners, 7 salaried GPs, 3 Clinical Pharmacists, 5 Nurse Practioners and a whole array of Nurses, Health Asistants, Phlebotomists, Receptionists and general dogsbodies. I cannot get an appointment face to face unless I have a phone appointment first, and that could be any time in a 3 day window. Prescriptions take 5 days to send to the pharmacy, and another 2 days to actually dispense.

Aren't I lucky to have the new modern improved NHS GP service.

[Noggin]

I've just taken out private healthcare in Spain, I had to for my residency. 1700 euro for the year, it's expensive because for residency the policy must have no copay (you can't top it up). Included in that I also get dental treatment, not sure to what level though.

Does that reduce once you have residency? I know that here you have to have private insurance until the point you are classed as a residence, then you have access to the health system and just need a mutuelle to top up the 30-35% balance

the French system (it pains me to say it) seems a bloody good starting point.

I'm under no illusions about the french system (especially for women of a certain age!! ) but it is definitely a good starting point!! LOL God knows how it could be implemented tho!!

Once upon a time I had a local village GP. His surgery was 2 rooms in his house, he did his own prescribing too. Waiting time for an appointment varied, from about 5 minutes up to a couple of hours at busy times. You had the medicine in your hot sweaty hand as you left. When he was out on a house call (remember them?) his wife answered the phone, kept his diary, did anything else a PA could.

Now I live in a larger (but still smallish) town. My GP Practice has 6 GP Partners, 7 salaried GPs, 3 Clinical Pharmacists, 5 Nurse Practioners and a whole array of Nurses, Health Asistants, Phlebotomists, Receptionists and general dogsbodies. I cannot get an appointment face to face unless I have a phone appointment first, and that could be any time in a 3 day window. Prescriptions take 5 days to send to the pharmacy, and another 2 days to actually dispense.

Aren't I lucky to have the new modern improved NHS GP service.

How much of the problem is people who are now unable to manage a cold or cough without a GP visit (or A&E), or need to see a doctor or minor injuries to get a graze cleaned up? If the general public were vaguely responsible humans, do you think the NHS could get out of its hole?

[Yorick]

Mrs. Gremlin was told yesterday, with no hint of an apology, that after her x-ray was taken for an embedded foreign object in her foot, that the wait was between 8 and 11 hours to be seen.

I would have happily paid to get it done privately, but that option is not available as it falls under A+E.

I#ve argued for years that the great British public need to get the idea out of their head that the NHS is a sacred cow that cannot be touched. It needs a root and branch reform and the French system (it pains me to say it) seems a bloody good starting point.

Ya could have flown over here. Spent 60€ for doctor and 20€ for X-ray.
Had a night on the piss for 20€

Then go home happy.

[Supermofo]

NHS in a short story.

I have a odd shaped heart valve that needs scanning and checking every 2-3 years. As they can't book appointments 2-3 years in advance I have to call my GP and get them to refer me.

Back in Aug I call GP secretary and explain what's what. Two weeks later I get an appointment at the hospital for 9th Dec. But it's a telephone consultation? So I call GP and say that must be wrong as I have to have the scan first as else the consultation is a waste of time. They go off and come back to me to say it's correct and maybe I'll get a scan before! They agree that it does seem odd though but nothing they can do.

First week of Nov I get a letter cancelling 9th Dec and they'll be in touch with a new appointment.

The following week I get 2 letters in the same post. One an appointment for the 9th Dec????? and another for 29 Nov. I then call hospital as now I'm not sure if I have 2 appointments or the 9th is a mistake. 50 mins on hold to be told the 9th Dec letter is a mistake...probably. I also explain again that I think this is a waste of time as without a scan we'll have nothing to discuss. Get told they know nothing so go with it.

Today I get a call for my consultation. Consultant says he's read my referral and the consultation is a waste of time without a scan so he's booked my scan and then I'll get another appointment to have the consultation. He says sorry this has been a waste of time, I explain that I've tried to explain that several times and got told it's how it is. He sighs and says 'Yes, it's all a post Covid process fiasco but it's how they are doing it now'.

So that's 4 calls, 2 secretaries, mine and a heart consultant's time wasted when all that needed doing was to book a scan and a appointment. It's not rocket science. Between Aug and Dec the only progress has been to book what should have been booked in Aug.

[Pirahna]

I've just taken out private healthcare in Spain, I had to for my residency. 1700 euro for the year, it's expensive because for residency the policy must have no copay (you can't top it up). Included in that I also get dental treatment, not sure to what level though.

Does that reduce once you have residency?

No. I keep paying until I'm 65 then I opt out of the NHS and go to the Spanish version.

[Cousin Jack]

Once upon a time I had a local village GP. His surgery was 2 rooms in his house, he did his own prescribing too. Waiting time for an appointment varied, from about 5 minutes up to a couple of hours at busy times. You had the medicine in your hot sweaty hand as you left. When he was out on a house call (remember them?) his wife answered the phone, kept his diary, did anything else a PA could.

Now I live in a larger (but still smallish) town. My GP Practice has 6 GP Partners, 7 salaried GPs, 3 Clinical Pharmacists, 5 Nurse Practioners and a whole array of Nurses, Health Asistants, Phlebotomists, Receptionists and general dogsbodies. I cannot get an appointment face to face unless I have a phone appointment first, and that could be any time in a 3 day window. Prescriptions take 5 days to send to the pharmacy, and another 2 days to actually dispense.

Aren't I lucky to have the new modern improved NHS GP service.

How much of the problem is people who are now unable to manage a cold or cough without a GP visit (or A&E), or need to see a doctor or minor injuries to get a graze cleaned up? If the general public were vaguely responsible humans, do you think the NHS could get out of its hole?

Yes, quite a lot of the problem is the modern snowflake mentality, but that is not the only problem.

I have some meds I take every day, when I order a repeat prescription I can ONLY order it if it is within a small time window AND if it has been reauthorised less than 12 months ago. The system itself greys out the tick box if it fails, so I can't order something I have not had before, something from years ago, nor can I stockpile the pills and flog it on the black market. All good stuff - so far.

So why does it take a minimum of 5 working days to get a doctor (any doctor) to put a squiggle on a piece of paper to say OK? The f***ing computer has done the work already.