A tale of two systems

US attacks on the NHS also raise issues about the academy, says Kevin Fong

September 10, 2009

I'm in Houston, and the 24-hour rolling news has degenerated into a brawl over healthcare. There is little in the way of balanced debate, just revolving, point-scoring rows. It is a war so far-reaching - waged on screen, via blogs and in print - that even a few British academics have been sucked in.

"Stephen Hawking wouldn't have a chance in the UK, where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless," read an editorial in one US newspaper. At this point, Hawking felt compelled to point out that a) he did in fact live in Britain and b) he was alive ostensibly because of the NHS.

Then came the Tweets displaying some of the most robust defences of a state-run health service ever mounted in fewer than 140 characters. Gordon Brown himself entered the fray with a genuinely touching Tweet that all but extracted an emoticon from me.

So isn't this a bizarre turn of events? We in the UK spend most of our time bashing The Nash, then someone on Fox News has a snipe and suddenly we go all Boston Tea Party about it. Explain that!

When we moan about the NHS, it is mostly about the Americanisation of our system: the obsession with metrics and the market as a driver of efficiency in a sector where free-market conditions do not appear to exist. Themes familiar to those in higher education. The lumbering, monolithic NHS of the 1980s was ripe for reform, but lately those reforms have begun to look overripe.

Most NHS employees respect the adherence to its founding principle: a service "free at the point of access, independent of the ability to pay". That doesn't make them card-carrying, banner-waving socialists, just a bunch of people who believe that good healthcare shouldn't be a privilege. One might argue the same of a good education.

As I click through the cable channels in my hotel room, they're still on about "death panels"; this is a jaded reference to the UK's National Institute for Clinical Excellence. It reviews the scientific and clinical evidence supporting therapeutic strategies and weighs their costs and benefits as best it can. It is a manifestation of the UK's system of rationed healthcare.

In the US, where the right of the individual and his wallet to self-determination is sacrosanct, this is anathema. Oddly, Americans seem much happier leaving the business of life and death decision-making to insurance company actuaries.

The NHS is far from perfect. Wandering around the enviably resourced specialist hospitals in Houston, you are reminded that the best that US healthcare has to offer is excellent - better than the best the UK can provide. But at its worst it is lamentable, letting down 40 to 50 million underinsured US citizens, for whom sickness is genuinely something to fear.

And those it fails are not the poorest in US society: the so-called "indigent" are covered by Medicaid. It is those in low-income employment forced to choose between everyday necessities and healthcare premiums who are the real losers.

Which works better? A comprehensive system that provides for a serving Prime Minister in the same way it would for a homeless, intravenous drug user were he to require the same? Or one that at its upper echelons offers the most excellent healthcare in the developed world, but which at the same time leaves more than 10 per cent of its population without adequate healthcare cover?

There are flaws aplenty in both. Whether one is superior to the other depends largely on where your swingometer sits on the spectrum of opinion between Sarah Palin and Barack Obama.

A comparison of the US and UK healthcare systems based on World Health Organisation data goes something like this: the UK spends less on healthcare as a fraction of gross domestic product by a long chalk, but Britons are more likely to live longer and our children are less likely to die in infancy. Against this we have more hospital beds per head of population but fewer doctors; our cancer survival rates are poor by comparison; and the best therapies are sometimes not available on the NHS as a result of the rationing of resources.

Some of this is also relevant to our system of higher education. US doctors earn a lot more than their UK counterparts, but they have to work off higher medical school loans. NHS salaries are unlikely to support the same level of debt without significantly altering the intake demographic. As we enter a brave new era of uncapped tuition fees and projected medical student debt of up to £67,000, comparable with the current median debt among US medical graduates, this is worth considering.

Second, in a system that transitions from being free at the point of access to one in which the ability to pay is a prominent, determining feature, someone will miss out. The US healthcare system shows that while you can find ways to provide for the poorest in society through charitable grants and government schemes, the people left wanting are those less dramatically challenged in financial terms but for whom proper access remains a formidable challenge.

If this is true of healthcare, then it is likely to be true of higher education. For education as for healthcare, there is no perfect system. But there should be more honesty and open debate about the effect that the imminent uncapping of tuition fees will have on the fabric of the academy.

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