To help shape thinking in this area, Beijing think tank the Cathay Institute for Public Affairs invited me to discuss with officials and experts how the system works in Britain at a symposium and workshop in Beijing, with additional comment from local policymakers and experts on general practice reform.
Britain presents a case study of how not to organise a health system. Since britain nationalised healthcare in 1947, subsequent governments have struggled to improve productivity, contain costs and improve the quality of care. Up until 1991, the system was mainly managed through central targets and control, with a chain of command going right up to the minister's office in Whitehall. By the late 80s, this system was beginning to look rather tired.
As part of the Thatcher government reforms, competition was introduced into the health service, in the form of an internal market. Providers and purchasers were split for the first time, and GPs were given the power and budget to buy care on behalf of their patients from any NHS provider. The aim was to use their market power to drive down costs and promote innovation. While this system achieved some success in reducing patient waiting times, Tony Blair’s government on election in 1997 decreed that this created a two tier system in which some received faster treatment than others.
This nascent market was therefore abolished and replaced with the old command and control system based on centrally-mandated targets. But by 2004, it was clear that this system was failing to manage an increasingly complex and massive health system, so the government reintroduced a diluted form of the internal market it had abolished, wherein GPs could form voluntary groups to commission care on behalf of patients. This time the budgets were notional instead of real, and any notional savings would be reimbursed by the ministry for spending on developing innovative services. Not surprisingly, few doctors found they had the time to engage with this new bureaucracy, so it has remained something of a sideshow to the main modus operandum of the NHS which is targets and central dictat.
Finally, the new government of David Cameron proposes reinvigorating the internal market by making it compulsory for GPs to commission care on behalf of their patients, and extending it to the majority of areas of care. This met with fierce opposition from opposing parliamentarians, as well as doctors unions and most of the medical profession, who fear that moves to a more market based system might undermine their not inconsiderable pay and generous employment conditions (as well as having ideological objections to the involvement of markets in healthcare). Pro reformers worry that the new bureaucratic apparatus required to manage this quasi market will work against physician autonomy, and could act as conduit for central government to reassert control - health civil servants are notorious jealous of their status as guardians of such a significant part of the body politic.
The key lesson for China, then, is that once they embark down a route in which central government is the primary provider and guarantor of care, it is very difficult to inject market force to tackle the problems that always arise from monopolies - interest groups, once entrenched, are very difficult to tackle. As a result of these failings, GP care in the UK is no way comparable to that in the US, as they have little incentive to develop the doctor patient relationship beyond responding to a narrow set of clinical and waiting time targets.
While things are bad in the UK, in China they are several orders worse. At our workshop Qin Jiangmei from the Ministry of Health outlined the major problems with the GP system, including the poor quality of doctors and service providers, and the fact that patients (especially in rural areas) normally have to pay out-of-pocket to poorly trained GPs. And as GPs derive most their income from sellling medicine or hosptial procedures, a visit to the doctor for even a mild ailment can end up with a huge bill as a result of over-prescribing. As a result, the majority of Chinese simply avoid the healthcare system altogether.
Professor Gu Yuan of the General Practictioner Association of Chinese Medical Association outllined her vision of the future system, which included training 300,000 extra doctors by 2020, and creating a new system of contract between patient and doctor that would inject some accountablity into the system. She also pointed out that General Practice is a very unpopular career choice for medical doctors, the majority of whom aim for a clinical specialism. This is hardly surprising when General Practitioners earn less than average civil servants. As a result, GPs are few and far between, particularly in rural areas, and they are often only in possession of a sketchy knowledge of medicine. In order to increase their wages to something reasonable, GPs routinely overprescribe, and make unnecessary use of expensive diagnostics (when for instance the patient may only have a cold). This is exacerbated by the fact that doctors receive a large proportion of their salary from profits they generate for the hospital, which leads to overprescribing, and not enough focus on preventative care and basic diagnostics (such as checking blood pressure).
Prof Wang Zhen on the Institute of Economics noted the problems inherent in expanding a system of coverage to a rapidly ageing population, in the face of rapidly changing technology and medical knowledge. The NHS experience shows that state-monopolies are not well-placed to foster innovation either in managerial techniques or the use of new medical technologies. China therefore needs to embrace choice and competition in its design of coverage systems if it is to avoid making the same mistakes as Britain. He noted that the government’s role should be restricted to supervision or the provision of additional services that cannot be provided by the market.