(Editor's Note: As the end of 2013 approaches, the Washington Examiner is shining a spotlight on its top stories of the year. Today, it's senior writer Philip Klein's in-depth look at the problems within Britain's government-run health care system, the National Health Service. This story first ran on Oct. 4 and can be found in its original form here.)
LONDON — In early September, Julie Bailey was settling into her new home. Weeks before, she had been chased out of her town after a succession of death threats, the desecration of her mother’s grave and the collapse of her small business.
No, Bailey isn't the star witness in a mob trial. She's just an average British citizen who became a lightning rod for exposing failures of the country's vaunted National Health Service after her mother died while in its care.
Founded in 1948 on the premise that health care should be made available to all without charge, the NHS remains a tremendous source of national pride. In Britain, the NHS is often described as the “envy of the world.” A vast bureaucracy boasting 1.7 million workers, it is the fifth-largest employer on the planet, according to the BBC. NHS workers are so esteemed that they’re treated to a wide range of discounts – in restaurants and hotels, for instance, and even for mobile phones – typically reserved in the United States for senior citizens and members of the military. When London hosted the 2012 Summer Olympics, the opening ceremony included a glitzy tribute to the health service, complete with a parade of dancing nurses.
Though the NHS has been subject to an endless stream of reorganizations and reforms over the decades whenever the government has transferred power, no prime minister - not even “Iron Lady” Margaret Thatcher - has had the political will to make fundamental changes. As Nigel Lawson, chancellor of the exchequer under Thatcher, famously put it, "The NHS is the closest thing the English have to a religion.”
The Conservative government of David Cameron has enacted some modest reforms to the NHS since taking over in 2010, but the Tories made the calculation that in order to get elected they had to neutralize the health care issue by portraying themselves as protectors of the institution. So they have steered clear of radical changes.
Yet as the United States embarks on an overhaul of its health care system, Britain’s government-run system is showing signs of age.
Julie Bailey, founder of Cure The NHS, with protesters outside an NHS board meeting in Manchester, England, earlier this year. (Photo: Martin Rickett/PA Wire)While it remains politically suicidal to campaign for major changes to the NHS, it is starting to become more acceptable to criticize it – if not publicly, at least socially and around the family dinner table. Younger, Internet-savvy generations with better access to information are more willing to question the authority of the medical establishment and push for choice than earlier generations who happily followed the orders of doctors and nurses.
In recent years, the institution has been besieged by a succession of major scandals, notably by the one at Stafford Hospital brought to light by Julie Bailey.
Bailey was an unlikely candidate to gain notoriety as a whistleblower against such a cherished institution. “Seven years ago, Mum and I were proud of the NHS,” she recounted. “So when we went into Mid Staffs [hospital], it was a huge shock to find what we did.”
A former social worker and lifelong liberal, Bailey lived in Stafford, a town 140 miles northwest of London, where she took care of her mother, Bella. In the fall of 2007, her mother was hospitalized at Stafford Hospital after a rough, sleepless night interrupted by coughing and retching.
|When I came out, I just knew I had to do something, because I had left these people behind.|
Once in the hospital, Bailey was bullied by staff members and dismissed when she suggested her mother needed medication for a chest infection. One night, her mother was left lying in her own vomit, despite screaming for help. One doctor told Bailey that her mother would die a “painful death,” snapping his fingers for emphasis.
Her confidence shaken, Bailey took to sleeping on a hard plastic chair in the hospital to attend to her mother’s care. But spending more time in the hospital meant being exposed to the depth of its horrors. “What I saw was the abuse of vulnerable adults,” she said.
Bailey said she witnessed nurses leaving food out of reach of immobile patients who couldn’t feed themselves. Sometimes, nurses would come by to say they forgot the keys to the drug cabinet, meaning they couldn’t distribute medication to those in need of it. Patients who required assistance going to the bathroom were often forced to relieve themselves in their own beds. Desperate patients deprived of fluids resorted to drinking water out of the dirty flower vases in the hallway. “One of the worst things was walking down the corridor,” she recalled, “and it would just be, ‘Nurse! Nurse! Help! Help!’ ” More mobile patients would often wander around the hallways, confused, in a futile search for care.
Bella Bailey, 86, who died while being treated at Stafford Hospital. (Photo: Rui Vieira/PA Wire)Without any nurses around, Bailey started feeding the other patients herself, helping them go to the bathroom and providing whatever assistance she could. But one day, an inadequately trained health assistant dropped her mother just as she was preparing to be discharged from the hospital. “From that moment on, it was murder,” Bailey said.
Her mother – a tough woman who had worked in a munitions factory during World War II – now required constant attention, so Bailey said she had to ignore the pleas of others who had become dependent on her help.
“I just bought earplugs and I pulled the curtains around so I couldn’t see anything, because these were people I’d grown attached to,” she said. “To see them scrumming down in bed after food and eating it with their fingers, and feces all over them, it was just terrible.”
Even as she recounted the story six years later, she broke down in tears.
“It’s still something I don’t think I’ll ever get over,” she said. “Seeing that despair, I don’t think I will. So when I came out, I just knew I had to do something, because I had left these people behind.”
Defenders of the British health care system typically tout several features of the NHS. Most significantly, health care in the U.K. – with few exceptions – is free at the point of service and made available to all. And though Britain covers everybody, in 2011 the U.K. spent only $3,405 per person on health care while the United States spent $8,508, according to data from the Organization for Economic Cooperation and Development. This disparity remains despite the fact that the NHS budget more than tripled between 1997 (the first year of Tony Blair’s Labor government) and 2013. It now stands at roughly $160 billion – roughly one-sixth of government spending and nearly triple Britain’s defense budget.
Typically, when people need health care in the U.K., they visit general practitioners, who serve as gatekeepers who will either treat patients directly or refer them elsewhere, depending on the diagnosis. Because doctors are on salary and typically aren’t very worried about the threat of lawsuits, they have little incentive to order tests that may prove unnecessary. In 2010, just 41 MRIs and 77 CT scans were performed per 1,000 people in the U.K., according to OECD data, compared with 98 MRIs and 265 CT scans per 1,000 in the U.S.
The drawback of such an approach is that because the system prides itself on creating equity by putting the needs of society as whole ahead of any given patient, it means that the needs of individuals often get lost in a sea of managers, administrative targets and rationing decisions.
“The individual is essentially a supplicant,” said Philip Booth, program director at the Institute of Economic Affairs, a free market think tank in London. “He's irrelevant to the whole system as far as the National Health Service is concerned.”
'Closest thing the English have to a religion': The NHS was one of the British institutions lauded during the opening ceremony of the 2012 London Olympics. (AP Photo/Jae C. Hong)Individuals cannot get tests within the NHS if its doctors don’t approve them. The National Institute for Health and Care Excellence (whose acronym NICE is a source of irony to critics), a board of experts that recommends treatments based on cost-benefit analyses, can deny cancer patients drugs if it concludes that a short extension of life isn’t worth the expense. In a further bit of irony, NICE was created in the 1990s to foster equality within the system because certain drugs were more available in some regions of the country than others.
The NHS is rife with examples of centralized policies producing real-world results that range from tragic to absurd.
For instance, the former Labor government responded to complaints about waiting times at hospital emergency rooms by instituting a target for NHS hospitals to treat patients within four hours. Under pressure to meet these targets, the Daily Mail reported in 2008, hospital administrators let seriously ill people wait in ambulances for hours outside the hospital so that they weren’t technically counted as patients. As a result, the ambulances weren’t available to answer emergency calls.
One of the more recent scandals has its roots in the 1990s, when the NHS established a set of best practices for providing care to patients at the end of their lives. Known as the Liverpool Care Pathway, it has since been applied to hundreds of thousands of people. Last November, the Mail reported, an independent review found that 60,000 people were put on the pathway without their consent and a third of the time families weren't even informed. Thus, they had no idea that their close relatives were removed from life support equipment and were being denied nourishment. In extreme cases, nurses shouted at relatives who attempted to give their dying loved ones sips of water. According to the Mail, hospitals were given incentive payments for putting more people on the pathway - effectively, the government was providing bonuses for ending people's lives earlier.
In July, the government said it would phase out the pathway after its own review concluded, “Caring for the dying must never again be practiced as a tick-box exercise and each patient must be cared for according to their individual needs.”
At the same time, the NHS' accident and emergency departments have been grappling with a massive doctor shortage. In July, the Health Committee of the House of Commons warned that just 17 percent of emergency departments had sufficient levels of staffing during the week. “The situation is even worse at weekends and consultant staffing levels are nowhere near meeting recommended best practice,” the committee's report found. As a stopgap measure, Cameron in August authorized an extra $800 million to avert a crisis.
After her mother passed away within weeks of being dropped by the NHS worker, Julie Bailey began a campaign demanding accountability and changes at Stafford Hospital. She was convinced that once she told higher-ups about what she saw, they would address the problem. But she came to learn that the NHS knows how to protect its own. “It’s like a brotherhood – a bit like the mafia,” she lamented.
Bailey wrote to hospital managers about what she had witnessed. After being ignored, she drafted a letter to the local newspaper. As responses flooded in from people who had similar experiences at the hospital, she founded Cure the NHS in December 2007 and set up a website to help gather accounts from others. But she continued to meet resistance from government officials.
A copy of Robert Francis' report on the Mid-Staffordshire NHS Foundation Trust. (Photo: Dominic Lipinski/PA Wire)When she wrote her local Labor Member of Parliament about the issue, he dismissively responded with a letter citing an inspection that found the only problem at Stafford Hospital was a jar of jam that didn’t have a lid. When she wrote to the secretary of state for health, she recalled, “He wrote back offering commiserations on the loss of my wife. It was pretty obvious he hadn’t even read the letter.”
Bailey’s first vindication came in March 2009, when a report by the Healthcare Commission found that “appalling” care along the lines of what she had witnessed had led to an estimated 400 to 1,200 deaths at the hospital.
During the 2010 election campaign, the Tories promised that if elected they would order an even more thorough inquiry into what happened at Stafford Hospital, which is run by the Mid Staffordshire NHS Foundation Trust. The conservative government followed through on that promise, and the inquiry – led by Robert Francis – was released in February. It further corroborated Bailey’s accounts, with hundreds of pages of patient interviews and documentation showing rampant neglect in the hospital from 2005 to 2009. Francis concluded that patients “were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety."
Robert Francis reads a statement to the media following the publication of his report on the Mid-Staffordshire NHS Foundation Trust earlier this year. (Photo: Dominic Lipinski/PA Wire)The level of detail in the Francis inquiry and the succession of news stories about the horrific state of care at Mid Staffs was a shocking blow to those who like to think of the NHS as supremely humane, especially compared to the U.S. health system. It was followed by another report detailing similar failings in ignoring patient needs at 14 other trusts, or hospital systems, within the NHS.
Ruth Carnall, who spent 36 years in the NHS and served as head of its London division, said the media have done a disservice by focusing on the number of unnecessary deaths at Mid Staffs. The oft-quoted figure of 1,200 is based on a misreading of statistics, she said, and the true number is much lower.
“I wouldn’t go around saying ‘it was only about a few deaths,’ because I actually believe what happened there was a complete failure of the quality of care delivered to patients and in the experience they had in their health care,” she said.
Carnall, who now works as an outside consultant and advises London Mayor Boris Johnson, said the NHS has an unfortunate tendency to respond to events like Mid Staffs by piling on new regulations and directives on top of existing ones. During her decades in the NHS, she said, she has been through nine separate reorganizations as different political parties came to power and attempted to blame their predecessors for failures within the system and put their own stamp on it.
The resilience of the NHS model rests on the willingness of the British public to more or less trust the judgment of doctors, nurses and administrators. As things stand, the system typically ranks reasonably well on measures of public satisfaction even as it lags behind by more objective standards.
“Satisfaction is a measure of performance versus expectations,” said Matthew Sinclair, chief executive of the TaxPayers’ Alliance, a grass-roots group that favors increasing choice within the NHS. “You can get there by having high performance ... or you can get there by having low expectations and low performance.”
Britain typically ranks poorly among developed nations when it comes to cancer outcomes. The U.S. ranks well ahead of the U.K. in five-year survival rates for 22 out of 23 types of cancers, according to data from the American Cancer Society. (The U.K. fares marginally better in treating larynx cancer.)
Sinclair said that if the U.S. health care system performed like the NHS, it would probably have extremely low satisfaction ratings and be subject to constant lawsuits. “Frankly, I don’t think it would survive the U.S. legal system, the NHS,” he said. “It would collapse in minutes under legal challenges to various rationings and queues and delays.”
Another source of NHS strength is the sense of social responsibility on which wealthier Britons pride themselves. “People, by what they believe, think they're being virtuous,” said James Bartholomew, author of the book “The Welfare State We're In,” which detailed the failings of the NHS. “I don't have to do anything virtuous, I just have to believe in the NHS.”
Slightly less than 11 percent of the British population bought private coverage in 2012, according to research firm Laing & Buisson. But even when wealthier people do use the NHS, they typically go to its best hospitals in London. Bartholomew said that people who are more educated are better at navigating the NHS bureaucracy by informing themselves about various treatment options and articulating to doctors what they want and expect.
As a result, there is often a wide disparity in health outcomes in the NHS based on income and geography. “The NHS doesn’t produce the equality of outcomes that one would hope for given the degree of redistribution in the system,” Sinclair said.
Andrew Lawson, a former NHS doctor and senior lecturer on medical ethics at London's Imperial College School of Medicine, was diagnosed with lung cancer in 2007. Had he relied solely on the NHS for treatment, he wrote in the Telegraph in August, he might be dead by now. Instead, he was able to supplement his NHS treatment with private care and participated in a clinical trial in the United States.
In September, we met at a coffee shop across from Chelsea and Westminster Hospital in London, where he was helping out. “I’m always wary of shibboleths,” Lawson said, contrasting the reflexive adoration Britons have for the NHS with their abhorrence of the U.S. system.
When he was diagnosed in the U.K., Lawson was told he had 12 to 14 months to live. But he found American doctors more open. “I like their attitude,” he said. The approach was, “ ‘Maybe this will help you. Why don’t you try this?’ Around here, at times, it was, ‘You’re finished. Make peace with your God and go sort out your mortgage.’ ”
By no means does Lawson support scrapping the idea of a system of universal health care, and he views American conservatives' description of President Obama's health care law as socialism to be exaggerated “nonsense.” But at the same time, he does believe in shattering the taboo against criticizing the NHS so that the system can become more flexible.
Carnall agreed that people’s religious attachment to the NHS is “undoubtedly” a barrier to helpful reforms. She has been pushing for centralizing treatment for emergencies such as heart attacks and strokes in larger, better-equipped hospitals. But, she said, a lot of people are sentimentally wedded to their local hospitals.
That said, she has observed a huge generational shift. Whereas her father remembers life before the NHS and has great faith in the system and its doctors, her children are much more likely to do their own research on the Internet and challenge doctors and authority figures. “In the space of two generations, people’s attitude to service has completely changed,” she said.
Julie Bailey’s public campaign for accountability for what happened at Mid Staffs made her a polarizing public figure, especially in Stafford. Her critics portrayed her as wanting to close the Stafford Hospital and destroy the NHS. She was subjected to harassing notes and phone calls that devolved into death threats. Her mother’s grave was vandalized. And business suffered at the small cafe she owned as activists staged a boycott and others were afraid to go inside and be viewed as enemies of the NHS. Last summer, fearing for her safety, she sold the cafe and moved to another location.
In the meantime, despite all the revelations, nobody at NHS has been held accountable for what happened at Mid Staffs. Bailey observed that “one of the things you’ll find with the NHS is that they don’t get rid of people.” Instead, if an administrator fails in one place, they’ll just be transferred to fail elsewhere. “They really are like wildebeests – they just move on,” she said.
Will the publicity surrounding scandals such as Mid Staffs – coupled with people’s own experiences – eventually make it possible to fundamentally reform the NHS?
“The way you do it isn’t to touch the third rail,” Booth said of reforming the NHS. “It’s to make an obvious improvement to the way in which people can access health care which undermines the system while appearing not to undermine the system.”
As an example, he suggested giving people the option of using the money the NHS would have spent on them toward the purchase of private insurance.
Bartholomew is more skeptical that there will ever be real changes to the NHS because people’s attachment to the idea is more powerful even than their own experiences.
“Often two parts of the brain are operating simultaneously,” he said. “One part will think the NHS is a good thing, and another part says, ‘Actually, I remember a number of things not being quite right and being bad.’ So it’s almost as if the brain is capable of thinking on two different levels two completely contrary thoughts.”
Under Obamacare, the United States will be shifting toward more government control. But British reformers who want to see more market mechanisms within the NHS would see it as a huge step forward — relative to what they have now — if the U.K. were to move toward a system of subsidized compulsory health insurance along the lines of Obamacare
If Britain does begin to introduce more choice in the coming decades just as America embraces more centralization, “one day we might cross,” Booth speculated.
As America embarks on a vast health care experiment, one of the deeper questions is how such change may affect the American character. Are the British less willing to question authority than Americans because of some essential national trait, or did a heavily centralized welfare state make them that way?
“Culture does exist, but I think that the culture is changed by systems,” Bartholomew said, noting that the British national Image has undergone dramatic changes throughout the centuries. “There is no fixed, immutable national character. The American national character can completely change over the next 100 years.”
If America's bitter health care debate over the past several years is any indication, more government control means increasing politicization of health care. And that is something that has been a constant in British politics, even though both major parties accept the basic principle of government provision of health care. As Enoch Powell, Britain's health minister in the early 1960s, put it, “Whatever is entrusted to politicians becomes political even if it isn't political.”