In Search of the perfect Health system. Mark Britnell.
This is an important and timely book. It is more than good: it is pragmatic and excellent in its clarity. To describe the history and medical care system of 25 countries (after visiting 60!), and summarise the best and worst of each is an achievement in itself. To recommend different system virtues at different stages of a county’s development is even better, and to round the debate off with suggestions of the main drivers for future change is as good as readers could expect. It is very accessible for a work on health policy, and that in limiting the chapters to around 1800 words on average it clearly wasn’t possible to cover everything in global health.
Because National systems and ingrained and slow to change this book will stand for some time. If there is a country with low GDP spend and longevity that might also be included, it would be Ireland. The author avoids “rationing” as a possible solution, but he does seem to accept co-payments as a necessary evil (Australia, New Zealand). There is no magic silver bullet, but then we all knew that.. He does not point out clearly that governments have a duty to populations, whereas doctors have a duty to individuals. This natural dissonance, and systemic perverse incentives, occurs in all health care systems.
For some years now doctors, especially public health planners, have been interested in different nations’ health systems. What a pity that the main readers are likely to be such doctors, nurses, and academics. The book should be compulsory reading for politicians, and recommended for Health Trust Board members, but I suspect they are unlikely to read it, let alone feel safe to comment. The benefits of patient autonomy, involvement in strategy, along with social solidarity and a reasonable percentage GDP spend are evident in just a few countries. If Russia and Mexico are ignored, universal coverage is best portrayed in Singapore and Hong Kong, but even these low spenders are struggling with projected demographics, the multiple morbidity of old age, and reduced birth rates… Insurance based systems seem to increase inequalities, which might be acceptable in Germany at present, but may not be once over 50% of people are over 60 years old….
Comprehensive and universal cover without competition between providers has economies in saving on transaction costs, but the author does not point out the different staff sickness and absenteeism rates when comparing systems.. Choice is not important since all systems are stretched to capacity (except Switzerland, and the fully insured or private parts of the USA).
The author does not answer his implied titular question, except to say it is spurious… He does make it clear that politicians drive the system, and that where countries have tried reform and integration, they have sometimes failed if there are tensions between National and State providers. (Australia)
In considering the UK the author points out there are now 4 different systems and focuses on England. He is critical of the UK’s inability to integrate primary and secondary care especially after ignoring the Griffiths report, and of the general lack of consistent leadership, with ministerial change every 2 years. He does not refer to the covert rationing and obfuscation, and the obtuse language used – prioritisation and restriction being examples. He does not point out the lack of “exit interviews” which could help to bring back an honest culture, and the absence of the open discussion of perverse incentives before a change is initiated. Also, the lead that well designed GP information systems could make to cultural change is not recognised.. The absence of suggestion on how to deal with SIPGs, and a sensationalist media, is an omission in the chapter in “patients as partners”. This chapter ends with “As the greatest untapped resource in healthcare, patient power will increasingly be the factor that makes our health systems sustainable.”
Several countries have moved away from comprehensive universal free at the point of access, cradle to grave and without reference to means, provision; notably New Zealand and Scandinavia, but they were only able to do this with the agreement of the people, and when they were persuaded by left wing administrations. This seems to exclude right wing parties from designing the pragmatic changes needed to be sustainable. The progress of true patient representation is promoted, and as honesty becomes evident any changes will obviously need social persuasion and democratic approval. The author sees a general weakness in all current systems – they need to be flexible enough to be able to change speedily, when necessary,
Update 1st December 2015: Chris Ham: Learning from others—devolved governance in the Australian state of Victoria BMJ 30th Nov 2015