French newspapers revel in describing what they refer to as the "Dickensian" state of Britain's public services, and especially the National Health Service (NHS), using this as a justification for their own country's relatively high levels of taxation.

The NHS is certainly a centrally-planned government-funded institution that tends to respond to excess demand in the classic style of a nationalized industry – by rationing. In most of mainland Europe, in contrast, governments take a more flexible and pragmatic approach both to the funding and the provision of health care. Both in Britain and elsewhere in Europe, it is generally assumed that problems with Britain's health services arise as a result of that country's relatively low tax levels.

Newspapers in Britain habitually refer to the underfunding of the NHS, and Prime Minister Tony Blair has promised to raise health care spending to the European average. While it is true that many European countries spend more taxpayers money on health services, the difference in private rather than public health spending accounts for most of the gap.

According to Organization for Economic Cooperation and Development data for 1998, the latest available, the Netherlands spent 8.7% of GDP in total on health, Italy spent 8.2%, Austria 8% and Britain just 6.8%. But expenditure by the state was generally similar – Italy spent 5.5%, Britain 5.7%, Austria 5.8% and the Netherlands 6.0%. Even in France with total expenditures of 9.5% and Germany at 10.3% of GDP, most of the gap was accounted for by private-sector spending. Governments in mainland Europe, by accepting a mixed system based on social insurance, rather than a taxation-based system with the government being virtually a monopoly buyer, have succeeded in bringing more money into paying for health care.

In Britain, the idea of paying a fee to see your primary care physician (family doctor) is seen as a dangerous first step toward privatization of the NHS, which Blair has sworn never to allow. In contrast, a visit to your physician in Germany, France, Belgium or Austria will end by payment at the end of the appointment, with most of the expenses reimbursed by your health insurance plan.

In France, typically only about 85% of out-of-pocket expenses are subsequently reimbursed by health insurers, although around 80% of the population have also taken out private voluntary top-up insurance to cover the balance – often provided by employers as part of the pay package.

In Germany, more than half of all hospitals are run on a private or independent nonprofit basis, providing their services under a contract system. The German mixed health care system provides seven acute-care hospital beds per 1,000 people, compared to two per 1,000 in Britain.

Employees in Germany must join a health-insurance plan, but there are more than 400 insurance funds (Krankenkassen) that compete both on price and on benefits offered, with close to half a million people switching between funds each year. This is a common pattern in many European countries, where people can choose their physician and hospital in the same way as their hairdresser.

The British government has confirmed its commitment to greater private-sector involvement in the NHS, with an announcement in June of plans for some private companies to manage some of the 20 planned fast-track centers, although Alan Milburn, UK health secretary, has stated in Parliament that "The principles of the NHS are not up for sale." He added, "We will use the private sector where it is appropriate to do so and where it can bring something to the table, whether that is expertise or finance."

The private sector already is involved in the building or modernizing of hospitals and of reequipping them under the government's private finance initiatives, but the Institute of Public Policy Research has proposed that the private sector should be permitted to bid for the modernizing and refurbishing of 3,000 primary care centers, estimated to cost around $1.5 billion. The NHS also is planning to increase the contracting-out of certain classes of surgical operations to private hospitals in an effort to reduce waiting lists.

In January, the total waiting list for inpatient hospital treatment had risen over the past year by 4,500 to 1.039 million, with 47,100 patients waiting for more than one year for surgery. One of the major disappointments in the NHS has been a very slow uptake of minimally invasive surgery (MIS) techniques, which could potentially help to cut waiting list substantially.

According to Professor Andy Adam, a consultant radiologist at Guy's and St. Thomas' hospitals (London), most British surgeons are traditionalists and slow to accept new techniques. Although the benefits of MIS are clear, "you cannot change things because of the traditional ways of thinking," he said. Speaking at a recent London meeting in hosted by the Health Service Journal and sponsored by Boston Scientific (Natick, Massachusetts), Adam said he felt that more local and national studies were needed to measure benefits for patients, as well as cost savings. The National Institute for Clinical Excellence has published guidance reports on colorectal cancer laparoscopy and hernia surgery laparoscopy, which are a beginning, but the attendees said much more is needed.

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