The New Statesman Interview - Bernard Kouchner
France's health minister says Britain is wrong about the NHS - too little money, too much talk of pr
The minister seems excited by what he has just seen. He is shaking his excellently groomed head. Five thousand nurses and medical workers down on the street. In the heart of Paris. That's a big demo, he is telling himself. Particularly when so much else is happening in the world and it's pouring with rain to boot. Maybe the reason why Bernard Kouchner, France's health minister, is so moved by this latest protest by health workers is that it shows how important his job is. He should worry. He presides over the best health system in the world, as ranked by the World Health Organisation, and Britain's sick are even now preparing to hobble across the Channel, with a sheepish nod from the Labour government, to seek the care that our own health system is unable to provide.
Healthcare is a major battle even in a country where it works admirably. As the man who was sent to govern Kosovo for the United Nations after foreign troops secured it from Slobodan Milosevic's ethnic cleansers, Kouchner is familiar with conflict. In health, he gets a generous bedpanful a day. He expects no less. "You never have peace in health. That's why our system progresses, and perhaps that's why it is good." The rebellious nurses, it seems, are down on the street demanding the creation of more hospital jobs - over and above the 45,000 new positions that France's left-wing government has just announced to compensate the health service for the 35-hour week.
What's so good, then, about the French system that ours can't match? A moment, here, to define basic differences. In Britain, the government allots an annual sum of money to healthcare, and the NHS is required to work within its limits, theoretically providing free care to all who seek it. The sum involved accounts for around 6.8 per cent of national income, which may have edged up with the new input promised by the Chancellor, Gordon Brown. In France, the system is more liberal. It is, in fact, a largely non- governmental operation, which the government, being French, regulates fairly heavily. It is based on insurance: everyone in work has to pay into an insurance fund managed not by the government, but by health unions, which reimburse people for what they spend on treatment and medicine. And spend they do. France disburses 9.4 per cent of national income on healthcare, comfortably above the EU average of roughly 8 per cent.
To Kouchner, Britain's main problem is clear: we are stingy on health. We get the care we pay for. "Progress in health will always cost more. You must know it will cost more. The question is this: are you willing to pay more? Not the government, but the citizens. Are British citizens ready to pay more?" Put like this, the cure for the NHS sounds straightforward. "You are a modern country," Kouchner says, "one of the leading countries of the world, and you cannot place your citizens in a situation where they don't receive the healthcare they need. In the 21st century, this is intolerable." All right then, no scrimping, no corner-cutting. "If you approach healthcare as a matter of economy," he warns, "it can't work."
In his view, France also has the advantage when it comes to management. Admittedly, he would like to tinker with the structure, in which the health unions largely manage the system, pulling in the money and paying it out. It all happens under the state's watchful eye, but he would prefer patients' associations to take a hand. He has no argument with the role of French doctors. GPs and specialists are private operators, charging patients each time they see them and putting the money straight into their own pockets. To an extent, their fees are controlled by the government. But if they charge above an officially set scale - which most do, especially in Paris - patients get fully reimbursed via the mutual insurance funds they are required to sign up with in order to supplement the basic cover. Given that fees are settled in cash up front, it is hardly surprising that there are almost twice as many doctors in France as there are in Britain. Patients can choose their doctors, see them as often as they want, go to other doctors for second opinions, consult specialists at will and pretty much choose their own date to have a hip replaced or a cataract removed.
A health minister who has it on unbiased international authority that he heads the best health system in the world may perhaps be excused for offering tips to others. "You have made big mistakes in your approach," he says of the NHS. "The structure is bad. To have to take your doctor from a prescribed list, register with him and then be unable to move: it's medieval." I catch a glimpse of a million Britons on hospital waiting lists touching their forelocks in submissive frustration. Nothing so feudal in France. "We once tried it here, lining the public up with a registered doctor, one they had to go to: 80 per cent of people refused. They wouldn't do it. They go where they want. Why? Because health is a service. As long as you don't change your system, it won't work."
Such candid counsel might conceivably annoy Tony Blair, or even Alan Milburn, who is clearly alive to how the NHS, as it stands, doesn't work, otherwise he wouldn't have hit on the humiliating wheeze of contracting out British patients to the Continent. However, the outspoken Kouchner insists that it is not his intention to meddle. Diplomacy may not be his speciality, but without some inkling of it he would not have survived as governor of Kosovo (where he thought the British soldiers were tops, "the best there are"). First and foremost, he is a humanitarian activist, with a doctor's diploma. In the 1970s, his passion led him to co-found the extraordinarily successful Medecins sans Frontieres squad of volunteer doctors for international emergencies. That he is not one of Prime Minister Lionel Jospin's Socialist Party insiders affords him a certain loose-tongued latitude. This is part of a can-do personality combined with acute media awareness, a trait he shares with his celebrity wife, Christine Ockrent, a TV presenter and news-programme hostess.
There is an upside to Britain's health sector. In medical research, Kouchner notes, Britain is well ahead of France. The snag is that we fail to take advantage of it. "You have wonderful pharmaceutical labs such as GlaxoSmithKline, absolutely world-class performers. How can you have these, and yet not make sure their products get straight to the British public? It's ridiculous." So it's back to the basic issue: our readiness - or unreadiness - to pay more. "The latest breakthrough treatments, say, for breast cancer, are extremely expensive. But how can you refuse your citizens fast access to them? It is not possible."
Dare I mention what may be wrong with the French system? The waste is conspicuous. Doctors widely overprescribe to please their patients, whom they naturally want to see as often as possible. The French are world-champion pill-poppers, spending 50 per cent more each year on medicaments than they spend on alcohol consumption, at which they are also world-beaters. Could waste be the reason why the French health system costs so much?
Kouchner doesn't see things that way, although he concedes that he could possibly eliminate a quarter of France's 4,000 public hospitals (the majority of hospitals are privately run) without prejudice to healthcare, if only the people in targeted provinces wouldn't refuse to shut their hospitals.
"It is true that the French consume more medication than the British. It's also true that our trains work well, and yours work badly. And that our health system works well, and yours doesn't." Ah, now we are stepping on to broader ground: the quality of public services. Kouchner is adamant. "There is an emphasis in France on public services that has been lost in Britain. Margaret Thatcher broke it. Should we keep this emphasis? Just ask the sick. Ask the people who ride trains." He has little time for the response that habitually rises up from Blair: privatisation of some kind. Especially not where health is concerned. Privatisation must lead, in his view, to one standard of health for the rich and another for the poor. While the French approach, with its mix of free- market and state-guided bureaucracy, is not free of ambiguity, it is most definitely seen by its users as a public service.
Whether British patients, sick of hospital waiting lists, can expect rapid satisfaction across the Channel, with the NHS footing the bill, is not yet clear. Kouchner cannot resist a little poke in the bruised British rib. It is, he says, a great honour for France that Her Majesty's citizens should want to come for treatment. He is proud to take them, in principle. "But your minister must pay, which is a problem, because in our public hospitals we don't pay." While France's private hospitals might be able to strike their own contracts with local health authorities in Britain, Kouchner would still want to have in place a "convention" agreed by the British government before our surgery-seekers begin invading Normandy. That points to negotiations with Milburn, which Kouchner says he is ready to open.
But doesn't the whole notion of Britons seeking efficient healthcare on the Continent also point in the direction of a completely new set-up in Europe? Kouchner sees where things are going. EU member states, most of them poised to use the single currency as sole legal tender in a matter of weeks, have common policies on most things of everyday importance. "I am a fervent supporter of a common health policy," the Frenchman says. "It doesn't exist, apart from some co-ordination on medical research. So this is a great chance to create a European health system with free circulation of patients and access to care." Better health, Kouchner contends, means a more integrated Europe. What irony if Britain's healthcare plight led out of a mess, not deeper into it.