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May 03, 2006

As alternatives to the NHS are considered, which model of healthcare will Britain adopt? The French, the Swiss, the German or the American? Theodore Dalrymple thinks it might well be the Zairean

Posted by Theodore Dalrymple

The Zairean model of healthcare as pioneered by Marshal Mobutu Sese Seko is gradually being adopted in Britain - or so argues Theodore Dalrymple. This model is a simple one - the rulers receive the best healthcare money can buy, the mass of the populace get an aspirin if they are lucky. In Britain, the mass of the populace will do rather better than that - after all Britain is a much richer country. Nevertheless, Theodore Dalrymple argues that the underlying principle will be the same - excellent healthcare for our rulers, a second tier system for the rest of us.

What model of health care provision should Britain adopt - assuming, of course, what now seems very likely, namely that it cannot think of one for itself? The Swiss, German, Dutch, French or American?

I think the model that the government would prefer is the Zairean, under the late and much-lamented (at least lamented by comparison with what came afterwards) Marshal Mobutu Sese Seko. That model was roughly as follows: when the Marshal had a toothache, he got in a Boeing 747 and flew to Paris; when an ordinary Zairean fell ill with a life-threatening disease, he went (if he still could) to a nurse in a clinic and got an aspirin, if there was one.

The Zairean model is very economical. Its costliness at its summit is more than compensated for by its cheapness at its base. The cost per person of a few flights of a Boeing 747 spread over 30,000,000 people is very little. And it is very egalitarian (and therefore, by definition, just), since the vast majority of the population gets more or less the same attention, i.e. very little.

What makes me think that this is the preferred model of the government? First, I should point out that it is only the principle of the model that attracts the government, not its details as put into practice in Zaire. Britain is still at a higher level of development than Zaire; and therefore when the British population goes to see the nurse, it will get rather more than an aspirin, and the building in which she works will be considerably grander and cleaner than the mud hut of her Zairean colleague.

The government has contrived the introduction of the Zairean model with considerable cunning. One of first steps in this introduction is the dramatic increase in pay of British doctors (or should I say of doctors in Britain, which is a rather different thing) that the government has granted.

Surely, you might reply, a huge increase in pay for doctors is a recognition of their importance? It is a token of the deep respect in which the government holds the medical profession.

On the contrary: the quid pro quo for the increase in pay is ever more detailed control over what doctors do. Doctors now routinely bully their patients into attending their surgeries, to have their blood pressure checked or for some such reason, not because they think it vitally necessary for their patients, but merely so that doctors reach a target laid down by the government in return for extra payments.

Even when what the government wants doctors to do is perfectly sensible and potentially advantageous to patients, this still represents a perversion of medical practice. It makes doctors the agents of the state rather than of the patients. It is inherently corrupting, because it means that if, or rather when, the government demanded something that is not sensible or potentially harmful to patients, the doctors will be in a poor position to object to it, for they will long have sold their independence for their mess of pottage.

In fact, doctors are spending more and more of their time not on what they think they ought to be doing, but on what they are told by the government to do, in return of course for money. This is Aneurin Bevan all over again, stuffing the mouths of doctors with gold to make them acquiesce in whatever is demanded of them.

But the pay of doctors is clearly leading to budgetary problems. It is one of the causes of the deficits of NHS trusts, despite the vast additional sums that have been spent on the NHS as a whole. But pay increases are rarely reversible: and doctors no more than others will not accept to work for less than they have once been paid.

In other words, it is part of the government's strategy to price doctors out of the market that the government itself controls, to justify the employment of less qualified people. More and more work will have to be done, for economic reasons, by health workers who are cheaper to train and to pay than doctors. This is already happening: nurses, help-lines (such as NHS Direct) and pharmacists are doing an increasing proportion of the work. A government scheme supposedly trains nurses to prescribe in a mere thirty-seven days. Another scheme exists to train second-class doctors in a shorter time than it takes to train first-class ones.

Perhaps no harm will come of all of this. Much of the work that general practitioners have done in the past could equally have been done by nurses or pharmacists, precisely because so little of it needed to be done at all. A service that was free at the point of contact encouraged people to take no thought as to whether or not they needed that contact in the first place; doctors began to see fewer and fewer people who actually had much discernible wrong with them.

Having thus created and fostered an insatiable demand, it has become necessary for the government to control the escalating cost of meeting it. The educational level and rates of pay of the people employed to meet it will have to be lowered. Nurses and the British equivalent of Russian feldshers (staff whose training is intermediate between nurses and doctors) will step into the breach.

But not, one suspects, for our leaders. Epidemiology may prove that nurses and feldshers are just as good as doctors, but when one of our leaders falls ill, he will not phone NHS Direct, or consult a nurse: he will go straight to the most eminent doctor he can find, even when his illness is trivial.

This, in essence, is the Zairean model, adapted to British circumstances. Marshal Mobutu Sese Seko comes to the rescue of the NHS. There will soon be a propaganda effort to persuade us to accept the glories of the new model; but as is so often the case with our leaders, le patron ne mange pas ici.

Theodore Dalrymple is a writer and recently retired as an inner city and prison doctor.

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I have taking the liberty of referring to the article on NHS BLOG DOCTOR


Posted by: Dr John Crippen at May 3, 2006 03:46 PM

JAMA has published the fascinating news that "middle-aged to older U.S. residents have higher rates of diabetes, hypertension, heart disease, heart attack, stroke, lung disease and cancer than their English counterparts" (quotation from press release quoted in New York Times). Maybe there is something to be said for our much derided model of health care as, in addition, to various lifestyle factors, it has some contribution to this disparity where the incidence of disease in the highest US socioeconomic classes is similar to that in the lowest socioeconomics classes in England.

Posted by: Tony Plant at May 3, 2006 05:34 PM

What's a "feldsher"?

Posted by: james mcqueen at May 3, 2006 09:02 PM

You judge a healthcare system on the way it treats people AFTER they get sick, not before! So the press release referred to by Tony Plant is irrelevant. the fact is that if you have any of the dideases or conditions mentioned your cjhances of survival are far, far betterin the US than in the UK.

Posted by: Peter L at May 4, 2006 04:51 AM

Peter L: Am I to take it that you don't believe prevention to be the best form of cure?

Posted by: James Cue at May 5, 2006 11:45 AM

Once you have an accurate diagnosis and proper prescribed treatment, of course you would like your medical care to be a socialized as possible from that point forward. Up until that point, you want a more American system.

Posted by: Assistant Village Idiot at May 6, 2006 04:51 AM

Another fine piece. However one wonders if Zairean mud brick clinics are that much dirtier than the NHS counterparts. I was recently in filthy St Thomas's, in London, and while there was less dirt on the floor and walls than one would find on floors and walls built entirely of mud, there was not a great difference. And the Zairean mud might be cleaner mud.

Posted by: s masty at May 7, 2006 05:33 PM

Re:Tony Plant's comment
: In America the rate of those deseases is higher b/c of lifestyle and other difference but the qulity of treatment and survival rates once you get ill with those illnesses is much better in the US. There are many studies that attest to this.

I personally moved overseas b/c of the NHS. My brother still lives in the UK and it shocks me how he can't get to see a GP for weeks.
I disagree with only one thing in the article; I don't think that so many people who see GP's have nothing wrong with them and are just wasting time because it is free.

Posted by: Rachel at January 11, 2007 07:16 PM

"Am I to take it that you don't believe prevention to be the best form of cure?"

An unwarranted inference: "Peter L" didn't imply any such thing. However, your own comment could be interpreted as implying that the NHS has been surreptitiously "curing" people before they become ill. I'd love to know how. All those costly state-funded "education" drives, maybe? I'm sure that Americans --- with their roundly derided approach to health care --- have absolutely no idea that smoking isn't conducive to well-being, and that fresh produce is generally more nutritious than convenience food. My, how they could learn from us!

Posted by: Paul H. at August 1, 2007 03:13 PM

As a practicing psychiatrist with interests in evolution, demedicalisation and social context, I have found your article fascinating. I am quite distressed that over the years both doctors and patients have become pawns in a game of political chess which devalues personal resposibility/independence and promotes reliance on NHS directives. As result values and trust within the patient doctor contract have been undermined.
Of course I hope that your comparisons are somewhat exagerrated, as we all want to believe in the NHS dream, but I feel that your article gives us all food for thought and could spark healthy debate. Unfortunately there are many who have careers which now depend on "towing the party line" or are so enmeshed in the system that they cannot stand back to get perspective.

Posted by: Andreas Schenk at January 31, 2008 09:31 AM
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