Observations
South Africa: poor ‘third world’ country, 45 million people, about 30 000 doctors (1 per 1500).
The UK: prosperous ‘first world’ economy, 60 million people, more than 140 000 doctors (1 per 400).
South Africa's surplus doctors are desperately needed to relieve the critical shortage of doctors in the UK.
As one of these, I have experienced first-hand the delivery of health care in both systems. I'd fly back to South Africa should I be taken ill in the UK.
The ‘market’ approach
Starting my first practice in South Africa, I had to convince a bank manager that, besides the debt incurred over 7 years at medical school (all paid by myself and my hard-working wife), I was creditworthy for a bond to purchase a house, part of which I converted to a medical practice. Quickly learned plastering and painting: no money for contractors. All our income depended on patients deciding to come to me. So, I had to deliver the goods. On reputation, the practice grew until, within 6 months, I could hire a part-time receptionist and within a year could employ two working shifts. When we had about 3000 ‘regulars’ my wife could stop working for ‘charity’. Of course I was on call 24/7, working up to 14 hours a day, but this eventually paid the debts. I knew if I made one mistake or let down my guard one moment, my patients would simply go to another doctor next time. So, I had to keep abreast of developments.
The socialist approach
I've tried working in NHS hospitals, finding the corridors congested with doctors during the week but deserted over weekends. Several ‘grades’ were apparently at work, but no-one could tell me which does what. Massive bundles of paper files contained scribbled notes, often repeated on the same day by different people. To find three appropriate medical facts one could have to decipher 30 pages.
Thoroughly frustrated I returned to general practice. It really felt good to have a professional relationship again where doctor and patient could cooperate as a team.
Fool's paradise. Quite soon reality struck: Video machines nudge their presence into our consultations. Big Brother is watching.
Somewhere, hidden from view, are the ‘Elevator People’. Needing elevators to reach their offices, they can evaluate our performance from a vantage point way beyond ground level. Oblivious to the fact that our patients are complex bio-psycho-social organisms with major intangible components, ‘Elevator statistics’ require every patient being ‘labelled’ from a list of ‘ailments’. Then ‘best evidence’ dictates what to do. Research being dominated by the pharmaceutical industry obviously influences where the bulk of ‘evidence’ is likely to be found.
The difference
One model is a patient empowered by paying for his or her own services. The other is a bureaucracy that takes money from productive people and decides who ‘needs’ the goods or the services, then claims to give it for ‘free’. It is not free, someone else paid for it. Not only for the service or the product, however: in the absence of empowered ‘consumers’, you need intricate mechanisms to police the distribution of resources.
Eventually, the overall cost is just many times more than the profit the entrepreneur would have made. Small wonder that the new ‘injection’ into the NHS now sees a system with more ‘administrators’ than hospital beds! The UK can only ‘afford’ this because its relatively free economy is taxed to sustain a system that has proven too expensive for an unfree or third world economy.
Instead of having to satisfy the best possible ‘watchdog’ (the patient) everybody in health care now has to produce statistics to satisfy the Elevator People. In the name of socialism, paradoxically, the patient has been sidelined.
Of course the easy part is being critical; more challenging would be providing positive alternatives. I do not advocate spending less on health; we can, however, achieve so much more with the same resources, effectively invested. Perhaps one solution would be to bring the patient back to centre stage: give them the luxury of choice. Allow people to ‘opt out’ of the NHS. Let those who prefer to look after themselves, be relieved of paying that portion of tax/national insurance that goes to NHS, then make their own arrangements. And/or bring back compassion by choice, stop robbing churches and charities of the opportunity to serve the community. Wild thoughts? Perhaps so. But the future is pregnant with possibilities.
- © British Journal of General Practice, 2004.
