Passport to health
The best healthcare system in the world is just a train ride away - but the train is Eurostar. As patients and staff cross the Channel and 'health tourism' grows, Jo Revill reports on what we can learn from the French
Sunday May 25, 2003
The Observer
Silence hangs over the accident and emergency department of the hospital in Lille, northern France. To Robert Thompson, a senior nurse manager who runs a casualty unit in a British hospital, such profound calm seems eerie. The emergency cases are all being seen in separate rooms. Each tiled room is immaculately clean and full of high-tech equipment. There is no noisy waiting room, no stressed-out staff, no long wait for an X-ray.
It is a world away from Thompson's busy A&E in Kent. He is proud of his department, having reduced waiting times to four hours, but sometimes he still has to put patients on trolleys. 'I deal with 150 patients a day - my French counterpart sees perhaps 30 cases,' he said. 'But they have lots of beds here, too - they seem to be running at maybe 50 per cent capacity, and there are days when we're over 100 per cent, which means more patients than available beds.'
The two hospitals are part of a unique experiment to see what England and France can learn from each other. Under a two-year project using £1million of EU funding, staff will be encouraged to cross the Channel and work in the other hospital. The British health professionals want to see how the French manage their surgery so well, to the point where waiting lists don't exist. Is it simply down to a much higher level of funding - or are they doing something different? The French are amazed by the efficiency of the NHS, and the way teams of carers can provide an important bridge between hospitals and the community.
Although the two regions share many similarities and are joined by the high-speed Eurostar, fascinating differences between the two unfold as staff take a tour of the St Philibert hospital. They are as impressed by the kindergarten set-up for the hospital staff as they are by the spotless corridors and beautifully designed palliative care unit, which has ensuite bathrooms for each patient.
Thompson is interested in the way French patients can avoid putting pressure on the hospital by making more use of their GPs and local pharmacy. 'Patients in Britain often come into casualty because they face a two-week wait to see their GP,' he said. 'Here you seem to see your doctor that day, and the GPs still do home visits at night. I don't know how the French system would work during a big emergency though. Our nurses are very skilled at dealing with all kinds of situations - they have to be - and they also have more responsibility than their French equivalents. I think we're more efficient because we have far fewer beds in which to place people.'
Thompson works at the Darent Valley Hospital in Dartford, which was only recently opened and feels more clean and well-designed than many NHS hospitals. Yet it does not have the feel of a hotel, which is the impression given by the wide, airy spaces in Lille.
For Tony Blair and his Health Secretary Alan Milburn, the question of why French hospitals offer a first-class, consumer-driven service when ours do not is causing unease. Last week the Prime Minister was caught out in the Commons when a Tory MP spoke of a constituent who recently had a successful hip operation in a clean and modern hospital. Nigel Waterson, MP for Eastbourne, congratulated the Government on Velma Paterson's happy outcome under the auspices of the NHS. The Tory benches erupted in laughter as Waterson then asked Blair: 'But can he explain why she had to have her operation in France?'
No one in the Government relishes such comparisons, but the reason for her trip to France was that Blair has pledged to cut waiting lists by sending certain types of patients for routine operations to France and Belgium to make up for the shortfalls of the NHS.
Health tourism of this kind is likely to become increasingly common as British authorities battle to meet the tight deadlines set for waiting times. Already this year 247 patients needing hip and knee operations have travelled to France, paid for by the NHS. They are accompanied by 'care advisers' who ensure they are properly looked after. Managers insist that even with the cost of travel these operations work out cheaper than in a private UK hospital because consultants' private fees here are so high.
Heart patients also benefit from the new entente cordiale. The first two British men to travel abroad for major heart surgery on the NHS are now recovering in Leeds. One of those is 73-year-old Denis Waistell, who had a double heart bypass operation in Ghent, Belgium, last month after being on the waiting list for six months in Britain. He said this weekend: 'I had a heart attack eight months ago and was told I needed a double heart bypass. When I was offered a choice I said I would go anywhere because I just wanted to get the operation over and done with.'
Patients like Mr Waistell, who are fit enough to make the journey, are the ones who currently benefit from foreign expertise, but soon the overseas teams will be coming to Britain to carry out thousands of operations. The Government will award contracts to international companies to run diagnostic and treatment centres across the country, and hopes this will make major inroads into the waiting lists. The firms, and their staff, will be French, South African, Italian or German but will be expected to meet the same clinical standards as their British counterparts. In short, it will be foreigners who come to rescue the NHS, because there is too little time to train all the staff needed to turn around the NHS under the 10-year timescale set by the Government.
Health Minister John Hutton told The Observer that the old ideological barriers to looking abroad for new ways of doing things were breaking down. Speaking during a break from a conference with his foreign counterparts to discuss health reforms, Hutton said: 'There are other countries like us that face constraints, such as Sweden and Slovenia, and we're all trying to find ways of build ing up our services to make them more responsive. The overall capacity of the NHS holds us back. We don't have enough beds or doctors or operating theatres. But it's also about the way we organise the services, and that's what we're working on. The NHS needs to be able to learn from other countries. It's important that we are prepared to listen to how others do things.'
But Hutton is not talking about the way other countries fund their health service. France enjoys a level of spending far beyond ours. Last year, 9.9 per cent of its gross domestic product went on healthcare, compared with 7.7 per cent in the UK. The money has given them nearly twice the number of beds and a larger number of doctors and other staff.
The French system was rated the best in the world by the World Health Organisation when it looked at access to healthcare, efficiency and effectiveness. But it is not the highest spender; that dubious honour goes to America, which puts an astonishing 14 per cent of its GDP into healthcare but still leaves a large section of its population without proper medical cover.
In France, every working person contributes towards healthcare, through the securité sociale which comes straight out of their pay packet, typically at around 14 per cent of their wages. Different professions also pay into insurance schemes, known as the mutuelle, which is a top-up system resulting in their healthcare being free at the point of delivery. The unemployed, elderly and children receive free care at the state's expense.
This system gives patients enormous bargaining power. They can see the doctor of their choice, whenever they want. They can go to their local GP or refer themselves straight to a specialist. Yet politicians are now looking at ways of curbing health spending, amid concern that the costs could rise and rise if there is no limit to what patients can demand. They want treatments to be based more on evidence of what works, and less on individual whim. Family doctors have far greater rates of prescribing antibiotics than in Britain, for example. Hospitals also have less incentive to encourage staff to work harder to get patients out of bed and back home because there is no pressure on bed availability.
Myriam Brunswic, a health expert at the University of Greenwich, set up the cross-Channel initiative between Kent and Lille and believes the NHS has become used to working to maximise its limited resources. 'The French health teams are just beginning to face serious reductions in funding. There is so much we can learn from each other. I think our team will be really interested in looking at how they manage their paperwork and their patients.'
Another great bane of NHS patients - the food - may also come in for inspection. British health staff marvelled at the quality of the hospital meal served to them in Lille, with a fresh salad followed by chicken escalope with macaroni, none of it overcooked. 'Do you have a cook-chill service?' asked one of the British dietitians to the French caterer. 'No, of course not,' the woman replied indignantly. 'How would patients get their fresh vegetables if we didn't prepare the food properly in our own kitchens?' It was a salutary moment for those accustomed to the cost-cutting ways of the dear old NHS.