Why the French model may have the answer to the NHS’s many challenges

Elliot Bidgood

IT IS often said that the NHS is “the envy of the world”, but this claim is now increasingly difficult to justify. Yesterday, professor Sir Bruce Keogh published his review into 14 NHS hospital trusts with high mortality rates. “Mediocrity is simply not good enough,” he said, with the probe uncovering poor standards of care, staffing problems, and weak leadership.

Keogh’s review was launched after the Francis inquiry into failings at Stafford Hospital found that up to 1,200 of its patients died needlessly between 2005 and 2008. Many are now calling for culture change in the NHS. Some point out that the UK at least has a better system than the US. But the solution to the NHS’s many challenges could be found in a health system closer to home – just across the Channel.

In its most recent major study of global healthcare systems, the World Health Organisation ranked France as best in the world. And France has the fewest healthcare-preventable deaths among 16 OECD nations. According to US think tank the Commonwealth Fund, France performed best on mortality amenable to healthcare. This is the best measure we have of how effective a health system is at saving lives, and judges the number of premature deaths that should not occur with effective and timely care. Britain had the second highest number of these deaths per 100,000 people, beating only the US.

Waiting times for elective surgery are shorter in France – in 2010, 7 per cent waited longer than four months, compared to 21 per cent in Britain – and the French have more doctors per 1,000 people. In 2008, 70 per cent of the French public described their system as “the envy of the world”, higher than in the UK.

The reasons are simple. The French universal healthcare system is better-funded and puts patient choice, provider competition and mutualism front and centre. This creates accountability and drives up standards. The French are used to a patient-centred system, where they are a member of one of several public insurance funds and have their pick of doctors and hospitals. A French Socialist health minister once described the lack of choice in the British NHS as “medieval” by comparison. And while many French hospitals are government-run, just under 40 per cent of hospital beds are provided by charities or for-profit companies, a settlement the French associate positively with choice and pluralism.

Like several other Western European countries, France also spends more on healthcare per head than we do. This is because they have a better funding mechanism – French people and their employers pay for health through national insurance-style ringfenced contributions, giving them a clearer sense of value for money compared to the more opaque way we fund the NHS. Some French employers fear this acts as a tax on jobs, but in the nearby Dutch health system they’ve successfully adapted the basic French model in a way that eliminates the need for employer funding, showing how this problem could be avoided.

France does have charges at the point of use that all but the poorest and chronically-ill must pay, such as a fee on GP visits. But they have long adapted to this – 92 per cent take out extra private coverage with mutual insurers to account for these costs, and President Francois Hollande is now also looking at ways to extend it to the remainder. The British Medical Association recently initiated a controversial debate about whether similar measures might be needed in the UK, so on this too France may offer guidance. Further, France has a state-of-the-art system of personal electronic health cards, which contain health records and prove eligibility for public healthcare. This prevents some of the issues with IT and fraud that the NHS grapples with.

This model of mixed public-private healthcare has served the French well for 70 years and there is a strong consensus around it. Even centre-leftists like Hollande prefer it to an NHS-style nationalised model. But there is a major barrier to bringing such a system to the UK. While France shows that the NHS values of universal social solidarity, which Britons rightfully hold dear, are perfectly compatible with pluralistic consumer-led healthcare, our political class remains unwilling to grasp the nettle of reform. And this is in spite of a natural Conservative belief in markets, and Labour having historic ties to mutualism and the requisite public trust to drive forward reform.

We must debate the 65-year old assumption that a Whitehall-controlled public monopoly is the only way forward. Major change would have to be done with proper consultation and consensus. But with the NHS facing so many challenges, we must now have a proper and frank discussion about whether our model is still best for delivering high quality healthcare to all in the twenty-first century. The mixed systems of Europe hold the key.

Elliot Bidgood is a healthcare reform researcher at Civitas: the Institute for the Study of Civil Society.

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