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Health of the State

September 23, 2004

By Theodore Dalrymple

Doctors, patients, and Michael Moore

According to Sicko, Michael Moore’s current film about health care in America, the British and French live in a world of “we,” while Americans live in a world of “me.” This is reflected in their respective health-care systems: The British and French sunbathe in the cloudless uplands of universal state-funded health care, where everything is free, at least to the consumer if not to the taxpayer, while Americans struggle horribly in a muddy swamp to pay exorbitant costs for themselves, and even then have often simply to die for lack of funds.

One does not, of course, expect films made for specific propaganda purposes, such as The Battleship Potemkin or Triumph of the Will, to present human dilemmas in a subtle or complex fashion; furthermore, no one can pretend that a comparison of health-care systems is an easy, obvious, or exciting subject for filmmakers. A book on the subject would put most normal people to sleep quicker than a sleeping pill, however concerned about their health they might be. I therefore understand Mr. Moore’s need to simplify by means of a dialectic between heartrending and uplifting human stories.

Nevertheless, and even allowing for his need to avoid ambiguities that would bore the pants off an average audience, his portrayal of Britain’s National Health Service, in which I have worked for 20 years as a doctor at intervals over more than a third of a century, irritated me profoundly. In effect, only someone intent on telling a lie could have presented the situation as he presented it — for even the most fervent ideological supporters of the National Health Service would admit that, as it currently exists, it is not exactly problem-free (to put it mildly). To avoid public criticism of the NHS in Britain is like avoiding evidence of dictatorship in North Korea: It is possible only for the willfully blinkered.

Can anything be said in favor of a system like the National Health Service? Since Bernard Shaw, at least, it has been suspected that if doctors had a financial interest in providing treatment they would provide it regardless of whether or not it was medically necessary. A famous cartoon in Punch, some decades before the inauguration of the NHS, showed a tall and elegant surgeon standing before the mantelpiece of his London club.

“What did you operate on Jones for?” asks another member of the club.

“A hundred pounds,” replies the surgeon.

“No,” says the club-member, “I mean what had he got?”

“A hundred pounds,” replies the surgeon.

This, it should be remembered, was not mere satire, for it was not long after the days of the famous surgeon Arbuthnot Lane, who took out the colons of the rich on the pretext of preventing autointoxication by their bowel contents.

The NHS ended that kind of thing, very largely if not entirely. (Private practice was still allowed after the hospitals and profession were nationalized in 1948, and middle-class children of my generation nearly all had their tonsils removed, with the effect, if not the conscious intention, of boosting the incomes of ear, nose, and throat surgeons.) Whether the NHS extended the best treatment to the poorest section of the population is another matter entirely.

LIVING OFF CAPITAL
In its most successful period, the state-run NHS was possibly the least bureaucratic health-care system in the world: far, far less bureaucratic than the American free-enterprise, or increasingly corporatist, system. This was because the doctors were still the most powerful group within it. The few managers in the system were their handmaidens, not their masters. In return for their salary, the doctors had effective control of most things, including who got what. They neither knew nor were interested in what anything cost: Rationing was informal and implicit rather than formal and explicit as it is now, and quite without bureaucratic control or costs.

The NHS also had the cultural capital of the hospital system that existed before it. It took over hundreds of voluntary hospitals that had been funded by local benefactors and charitable collections, and that were the pride of their area. It takes a long time to vitiate institutional pride, especially when the government is intelligent enough (as were successive governments, both Labour and Conservative) not to attack it directly.

But there were problems from the first. Chief among them was that capital expenditure came to an immediate halt after the NHS was begun. Fewer hospitals were opened in the first half-century after the start of the NHS than in the 1930s alone — that is to say, during the Great Depression. Thus the NHS was initially a relative success because it was, in effect, living off capital. The result has been that the vast majority of NHS hospitals are now run-down institutions, depressingly hideous and jerry-built; the one in which I worked was a 19th-century workhouse. Only someone intent on telling a lie could have missed this characteristic of the NHS.

The NHS was founded on the supposition that, as the population grew healthier thanks to its socialized ministrations, health-care costs would decline. The exact opposite was the case, of course: Not only did health care become vastly more expensive, but the population aged fast and needed ever more such health care. Government funding from general taxation always limped behind what was necessary to keep up with demand and with technological developments. Waiting lists for expensive investigations and procedures lengthened as shortages became ever greater. Emergency care remained good, but at the expense of almost everything else.

On coming into power, Margaret Thatcher realized that things could not continue as they were and that reform was necessary. Inadvertently, however, she made everything much worse in the long run. Instead of root-and-branch reform, she adopted a compromise. Her government acted as if it had a mistrust of professions, believing with Bernard Shaw that they were nothing but conspiracies against the laity, and that the inefficiencies of the service were caused by the restrictive practices of nurses and doctors. Accordingly, the answer to the problems of the state-run service was to introduce the methods of commercial business into them, but without the profit motive to discipline them.

NIGHTMARES OF BUREAUCRACY
The result has been a bizarre amalgam of the business ethics of Enron with the organizational principles laid down by Gogol. Bureaucracy has run riot in the NHS, to the extent that senior doctors now spend less than half of their time actually practicing medicine — which, in turn, creates the need for more doctors.

And the more administrators there are, the more administration doctors have to do. A senior physician at my hospital, who retired a couple of years ago, summed it up by saying that when he arrived in the hospital it had 1,800 beds and 3 administrators, but now it had 3 beds and 1,800 administrators. A slight exaggeration, of course, or perhaps a prediction.

It is hardly surprising that the system is capable of absorbing huge sums of money without producing much in the way of discernible benefit for patients. Expenditure has increased by 300 percent in ten years, but most people believe that very little, if anything, has changed for the better, and some things for the worse. The cash has largely disappeared into the pockets of those who work in the system, as a bribe to buy off their disaffection, and into the hands of managers, for whom increased bureaucracy has been hugely profitable, and their management-consultant cronies. (Developing Mrs. Thatcher’s legacy in a creative fashion, Tony Blair’s government has spent scores of billions of dollars on management consultants and information-technology systems that do not work. Contrary to Moore’s insinuation in his film, a state-run system is at least as susceptible to corruption as one run for profit.)

He who pays the piper calls the tune, at least eventually. For many years the government refrained from interfering very obviously in the running of the health service in Britain, but it has increasingly set targets for hospitals and doctors to meet, and interfered with the minutiae of medical practice, laying down who must be treated first, and with what treatment — just as Ronald Reagan, who made a recording in 1961 on behalf of the AMA, said it would once a command system of health care had been set up. Moore, who plays the recording in the film, obviously thinks that Reagan’s predictions must strike the viewer as ridiculous, simply because they are his, Reagan’s; but in fact Reagan was quite right.

Indeed, Moore — without realizing it — presents evidence that Reagan was quite right. The one completely happy and satisfied doctor in Britain — whom Moore has remarkably been able to find — tells us in the film that he is paid more by the government if he reduces the percentage of smokers among his patients. Now of course smoking is very bad for you, and it is perfectly legitimate for doctors to advise their patients to quit — indeed it is part of their duty to do so — but for the government to provide doctors with an incentive to cajole and bully their patients into doing so is another matter altogether. It changes the whole basis of the relationship between doctor and patient; the doctor becomes in effect a conveyor of government orders. Orders can be benign or malign, but the habit of obeying them can become ingrained.

Managers in the NHS now often decide on the priority of patients’ operations, not on clinical grounds, but according to government targets; they scour the wards for patients they believe can be discharged; they set priorities in the emergency rooms, again not according to clinical criteria, but according to the need to meet government targets. Managers now screen all referrals to psychiatrists, and decide which patients the psychiatrists should see, which is a fundamental breach of medical ethics. A central organization, the National Institute for Clinical Excellence, lays down what drugs may be prescribed by doctors in the NHS. Reagan was not fantasizing; he was describing the logic of the situation, a logic that should be obvious to anyone of average intelligence.

Now of course problems such as the ones I have just mentioned exist in all systems where payment for medical services is made by third parties. But to make a single, all-powerful third party — and the government at that — responsible for all such payment is to magnify and compound the problems.

PORTRAIT OF FAILURE
Sicko artfully implies that in a system such as the British NHS your social class or income makes no difference to the treatment you receive under it. The old aristocratic leftist, Anthony Benn, is wheeled out to declare this. But in fact nothing could be farther from the truth. Variation in morbidity and mortality between the social classes in Britain is as great as it was before the NHS was instituted, and possibly greater. This is because the middle classes are better housed, better fed, better educated, and therefore better able to take advantage of the service than those who are at the bottom of the social scale, who may safely be disregarded because they can neither write nor speak coherently. The NHS has done nothing to further equality.

Moore does not tell us this, nor does he tell us about waiting times in the NHS. (I remember one patient, a man of 70, who had had a hernia diagnosed seven years previously. He was put on the waiting list for an operation, but hearing nothing from the hospital for seven years wrote a letter to enquire when he would have his operation. He received a letter telling him to wait his turn. In a system such as the NHS, an apparently rational and just reason not to operate on him — i.e., there was something more urgent to be done — can always be found.)

He also fails to tell us there has been a rising tide of public dissatisfaction with the NHS; that 75 percent of senior doctors in Britain want to retire as soon as possible; that at least 50 percent of general practitioners have been threatened or assaulted by frustrated or angry patients; that ways of measuring waiting lists have been so corrupted by government manipulation that no one can say for sure whether they are increasing, decreasing, or staying the same; that more and more patients are seeking treatment abroad — even in India — rather than wait; that results in the NHS for many cancers and heart conditions are among the worst in the Western world; that the hospitals are filthy and that rates of hospital infection are also among the highest.

This is not to say that no good work is done in the NHS, or that everyone is badly treated. I myself have received nothing but excellent treatment under it. When a friend of mine collapsed and nearly died with an allergy in my house, the ambulance arrived within four minutes; she was resuscitated and taken to a hospital, where she received treatment that no amount of money could have improved upon.

On the other hand, when my mother, at the age of 82, had a serious and distressing skin condition that disfigured her, she was told there was an 18-month waiting list to see the dermatologist, and the pent-up demand was so great that even to see a dermatologist privately, paying the entire fee directly out of her own pocket, would take nine months. Horror stories of neglect and even cruelty, especially to those over 75, are commonplace. I remember visiting my 92-year-old uncle in the Royal Free Hospital — an august institution — where there was one nurse on duty for 20 aged patients, and she was an Australian bird of passage working a few weeks to earn enough to travel to her next destination. She wore a dirty uniform, and to say that she couldn’t have cared less about my uncle when I told her that he had slipped dangerously down the bed would be to put it kindly. The humiliations visited upon many patients under the NHS are so well understood that they are now taken for granted.

Why do the British put up with it, you might ask? One reason is that they have been assiduously indoctrinated with an historical lie, namely that before the institution of the NHS only the rich received medical treatment in Britain, and that therefore all except the rich must now be grateful to receive any treatment whatsoever, no matter how backward or grubby the conditions in which it is given. Thus we have a paradox: that the people in one of the richest countries in the world put up with hospital conditions that no late-Victorian or Edwardian charitable institution for the sick poor would have tolerated.

The father of a friend of mine was a doctor before the NHS, and he was furious at the takeover of hospitals and the medical profession by the state, not only because it meant a loss of professional independence, if not immediately then in the long term, but because it was a misappropriation by the state of institutions that had been built up, sometimes for centuries, by charitable and municipal endeavor, and because it was a means by which a new class of bureaucrats would cheat the poor.

Before the NHS, he and his fellow doctors would charge their patients according to their ability to pay: practically nothing if they were poor, a lot if they were rich. Thus the rich subsidized the treatment of the poor directly, without a lot of the funds sticking to the hands of an intermediary bureaucratic apparatus. Perhaps such a system would not be practicable now; but it was certainly not the case, as is now widely believed, that the poor did not receive treatment. In any case, 75 percent of the population had private medical insurance, and they couldn’t all have been rich.

With his film, Michael Moore is trying to foist an untruth upon the American public similar to the historical untruth that has been foisted (with great success) upon the British public. He is trying to persuade the American public that the American system needs to be replaced by one such as the British, or perhaps even the Cuban.

It is clear that the American system leaves a lot to be desired — as do most systems. It is expensive and not particularly effective when viewed from the point of view of public health. It has strengths, never of course mentioned by Moore: for example, that it is by far the most innovative and performs by far the most important medical research in the world.

Nor is it even a complete public-health disaster: Life expectancy at birth in the United States increased from 75.4 years in 1990 to 77.5 in 2003 (not, incidentally, that people go down the street humming happily about it, suggesting that, within limits, public health is not a major determinant of happiness). And it certainly does not follow from the fact that the American system has weaknesses that the U.S. ought to follow Britain or Cuba, as Moore suggests. As for France: Despite Moore’s dithyrambs, its population consumes by far the highest doses of tranquilizers and antidepressants in the world. There must be some reason for it.

Sicko is a slickly made and compelling piece of propaganda masquerading as a serious documentary. You could write an entire book about its errors and omissions. America going to Canada for medical treatment indeed! Just as Italians go to Norway for the sunshine. Sicko’s real title is an old one: Suggestio falsi, suppressio veri.

 

 
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