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French healthcare: Plan B for the NHS reforms

This article follows another Opinion article by the authors, 'Myths about the US healthcare model risk the survival of the NHS'

Although the coalition government has forged ahead with its passing of the Health and Social Care Bill, the NHS reforms enjoy neither the support of the majority of doctors, nor of the main health professional bodies. There is even dissent amongst CCGs who were previously seen as supportive and trail-blazers of the changes.

Given that the reforms have little support and may indeed be unworkable, there is now an urgent need for a credible ‘Plan B.' In our search for an alternative, we may not have to look very far, and could consider the French healthcare system to inform our ideas. Not only is France in our geographical back garden, but the World Health Organisationhas ranked the French healthcare system as the best in the world. Moreover, the ultimate arbiters - the French themselves - are extremely positive about the healthcare they receive, rating it very highly.

More importantly – given the government's insistence upon opening up the NHS to the private sector - the French healthcare system provides an exemplar because it contains both ‘public' and ‘private' elements. For example, the majority of French hospitals are public, with the remainder being either wholly private, or private but not-for-profit. Thus, while the French healthcare system remains largely in state hands, it has significant private components.

The crucial point to note is that, while the French government recognisesand supports the need for private sector involvement in healthcare provision, it nevertheless maintains a tight reign on the activities of the sector, which is closely regulated and monitored. For example, although all general practitioners (Médecins Traitant) are self-employed, the fees they are able to charge patients are set by the government. Thus, the state has reached a balance whereby private sector practitioners have an important role in healthcare provision, but not to the detriment of patients.

A similar arrangement has been struck with the pharmaceutical companies. In this compact, pharmaceutical companies are given a free hand in developing innovative new drugs and other products, while the government mandates that the National Authority for Health (Haute Autorité de Santé) evaluate all new drugs within 90 days. At the same time however, the price of drugs is set by the government's health products pricing committee (Comité Economique des Produits de Santé), to ensure that drug companies do not make supernormal profits at the expense of patients.

Such mechanisms are designed to ensure that the pharmaceutical companies are free to innovate, but not to exploit their position, and that new medicines reach the market quickly, giving patients ease of access to the latest and best drugs. This sophisticated institutional arrangement is designed to strike a careful balance between the state and private sector, so that each operates not to their own narrow agenda, but in a concerted manner, and to the ultimate benefit of patients.

The key to the success of the French arrangement is that independent bodies such as the National Authority for Health use their authority to alter the behaviour of private sector stakeholders. In doing so, a balance is achieved between the needs of patients and the interests of the private sector. These institutional arrangements result in a harmonious relationship whereby the private sector is fostered, whilst its worst excesses are contained by the state. In this way, private healthcare providers are not able to run amuck, as they have done in the US.

In conclusion, there are substantial dangers in the government's reforms of the NHS, and therefore the need for a well thought-out Plan B. Given the highly favourable performance and satisfaction ratings of the French healthcare system, there is considerable merit in looking to France to inform our thinking. Although French healthcare is not of course without its problems, it is surely better to adapt elements of a successful model to suit UK needs, rather than slavishly sign up to US-style healthcare, and run the risk of destroying the NHS by throwing it to the commercial wolves.

Dr Salinder Supri and Professor Karen Malone have previously published 'Developing Leadership in Medicine: The Importance of "Institutional Awareness"' in Healthcare Reform Magazine, and 'On the Critical List: The US Institution of Medicine' in the American Journal of Medicine. Professor Malone has recently returned from the US, where she was Professor and Director of Education at the University of Medicine and Dentistry of New Jersey, the largest medical university in the US, and Dr Supri was Director of Änderung Consulting, New York.