Choices for the national patient

The wicked old Tories want to abolish National Health, I hear. One would be made to think that they intend to replace it with National Sickness. The choice their opponents would set before us is the NHS or the US model. Left-wingers are often fond of accusing the US of forgetting about the world beyond its doorstep; it is ironic that those same left-wingers should forget about the Continent beyond our own doorstep.

So let's leave the angry hordes of British lefties for more Continental climes, and ask ourselves how some other countries organise their healthcare systems. I'm going to draw most of this from Wikipedia, but I'm sure it's basically accurate.

Bear in mind that the opponents of reform invariably cast their concerns in terms which imply that what they really want is a centrally directed healthcare system: one giant super-hospital, with multiple branches throughout the nation, paid for entirely out of taxation.

First on our round-Continent trip, then, it's off to Sweden, that social-democratic paradise so beloved of the left (W). It has, like us, what is termed a 'Beveridge' system, as opposed to the other three we shall inspect, which have 'Bismarck' systems (src). The national Ministry of Health sets general policy and provides funding. County councils commission care from private providers, and raise most of the funding from local income taxation (how very Liberal Democrat!). Every doctor's visit and prescription has a small charge attached, but there is an annual cap on the amount that patients pay.

Next off, let's go to the place where everything is always in order, Germany (W). Here, they have an insurance system, where the government offers a sort of basic insurance policy which you can take, or you can opt to take private insurance instead. 85% of Germans take the government plan. Co-payments are a feature of the system, and a little over half the hospital beds in Germany are provided by public sector hospitals (ppt), with the rest being a mix of charitable and for-profit private provision. The private provision is growing, while the public provision is shrinking.

Well, let's follow the historically-usual route out of Germany and skip past the Maginot line by heading into the Netherlands (W). The Dutch have a system of "social insurance", in which policies cannot be priced according to age, medical history or other factors; instead, insurers pool the risks and charge roughly the same premium. About half the finance for the system comes from premiums, with the other half coming from taxation. Most of the healthcare system, including the insurers and hospitals, is privately run on a not-for-profit basis. Interestingly, the Dutch allow opt-outs (some Christian groups object to insurance), and so have a small, parallel healthcare savings system as well.

Finally, we'll enjoy some of the finer things in life by visiting la belle France (W). Widely regarded as having the best healthcare system in the world, the French are required to buy insurance from a public insurer according to their income. Doctors mostly form private practices, while provision of hospital beds is about two-thirds public, a fifth profit-seeking and a sixth charitable. French people pay up-front for their healthcare and then get typically about 70% back from the insurer: so much for free at the point of use!

Four major European countries. Four different healthcare systems. But all far more similar to each other than to the UK system, and all have the following key points:

• Private delivery ranges from being the norm (Sweden) to a minority but accepted element (Netherlands, France).
• Sometimes a flat levy (Netherlands), at others strictly proportional to income (France), all systems but the Swedish have a direct contributory principle at their heart, in addition to taxation funding.
• Co-payments are entirely common, with costs either co-paid on the spot (Sweden), or the patient's cost being defrayed later (France).
• The multiplicity of providers ensures in all four systems that patient choice is real and occurs, from insurer where.

If anything, the Government's healthcare reforms will make us more European. So are you forward-looking, progressive, European in your outlook? Then for pity's sake, support the healthcare reforms. Let's leave opposition to the Little Englanders who think the United Kingdom so far superior to the Continent we can learn nothing from them, and the reactionaries who think that the late Forties are just the years for us.

That referendum

Firstly, the usual call for voting. I don't go in for partisan calls to vote: just vote. On this point, I don't care how you intend to vote. And if you haven't thought about it, think about it and then vote.

To that end, I would like now to try and persuade you that the Alternative Vote system is an improvement on the existing system by putting forward two absolutely true facts which, for me at least, clinch it.

Fact the first: You can get the existing system back from AV.

This is the kicker. If you fill in your ballot with a '1' against your preferred candidate and no other, then it contributes to the poll in exactly the way that it would under the existing system. (Don't believe me? Think about it!) If everyone did that, then we would have first-past-the-post back: the bottom candidate drops out, no preferences exist to be redistributed so the next one drops out and so on, until the candidate with the most votes wins. So by opting for AV, we don't have to be opting against FPTP! In other words, supporters of FPTP can vote for AV and still have a first-past-the-post ballot, while permitting those of us with more than one preference to express ourselves more clearly.

Fact the second: AV means more choice without radical change.

Nick Clegg made this argument very briefly but very well yesterday morning when he said that it baffled him how the Conservatives, so long the champions (and I would add, rightly) of choice and competition in public services, are opposing a voting system which gives voters more choice. Instead of having to vote for a single candidate, I can list as many as I like in preference order. This reduces the need to think tactically, and it pretty much destroys vote-splitting effects. In sum, this is a point about free expression: FPTP needlessly restricts the amount of expression I have; AV is a refinement which increases that freedom.

As a sentiment additional to that second fact, I would point out that it is, curiously, the fissiparous and anti-consumerist 'left' which offers more choice than the supposedly pro-consumer 'right'. I am hopeful that AV will encourage a little more amicable break-up on the 'right', allowing especially those of us with more distinctive political tastes to vote for an Orange Booker, a liberal Conservative and maybe even a Blairite without needing to run the risk of getting John Reid, David 'Top Cat' Davies, or Simon Hughes.

So, the two killer facts which drive me to vote for AV tomorrow: AV contains FPTP as a simple, mathematical restriction; and AV allows us to express our preferences and choices more fully.

AV: tell them what you really think!