All the main parties in Britain regard the National Health Service (NHS) as a fundamental part of the modern British welfare state, but a number of recent scandals suggest that there are weaknesses and flaws in the system.

The Mid-Staffordshire NHS trust, which was the subject of a recent official inquiry into the standards of care at the hospital, has been dissolved. The inquiry revealed serious flaws in the culture of the NHS. There was a lack of openness to criticism and general defensiveness. There was a lack of consideration for patients, an acceptance of poor standards and a failure to put the interests of the patient first. The administrators concentrated on achieving targets rather than improving care.

The responsibility for ensuring that the NHS looks after patients lies with a quango called the Care Quality Commission. The commission did not do its job properly in this case. It later emerged that officials had suppressed a report, which showed that the commission had failed in another case, because it showed the commission in a bad light. The commission has shown that “it was not fit for purpose.”

Accident and emergency (A&E) services have suffered from staff shortages and have had difficulty in meeting their target, which might seem an unambitious one, of seeing all patients within four hours.

The demand for A&E has greatly increased since the previous government, which allowed general practitioners to opt out of providing services after hours or at weekends, reached an agreement.

A special “hot line” for patients, which was supposed to provide off-hours coverage, did not work properly.

The problems of the NHS are at least partly due to budgetary constraints. While the NHS budget has been exempt from austerity cuts, it has not been increased and the service is expected to make large “efficiency savings.” People are living longer and the old need more medical and nursing care than the younger generations. Costly new drugs and improved medical and surgical treatments are being developed.

The problems are compounded by the difficulty and cost of providing care at home for old people. Various proposals have been discussed which would mean a cap on the amount individuals would have to pay for nursing care, but the cap will not be adopted before the next election and will not solve all the problems.

The present government thinks that stimulating competition in the NHS should lead to improvements and blames the former Labour government for allowing a culture to develop in which achieving performance targets was paramount. But the Labour Party believes that “commercializing” the NHS and injecting the profit motive into the service is wrong and dangerous.

Morale is poor in certain sections of the NHS, and attempts to cover up mistakes and gag whistleblowers have harmed the image of the service.

Nevertheless, the NHS, despite its failings, despite the mistakes of the regulators and despite botched attempts by successive British governments to reorganize it, generally provides a pretty good service, but more must be done to ensure that patient care is always put first.

The issues facing the NHS are not unique. Most developed countries face similar problems of aging populations and cost pressures. International comparisons are difficult to make because standards vary and like for like comparisons are almost impossible. But British health care costs as a proportion of gross national income are comparable with those of other West European countries and lower than the United States despite the fact that NHS services are free and available to all citizens.

There are no easy solutions to the problems facing the NHS and other health services. A greater part of the national income could be devoted to health either by increasing taxes or cutting other services or by charging for services in ways, which would be acceptable to users and would not be too costly to administer. But at present there is no consensus in favor of any of these alternatives.

Another alternative would be rationing of services and rejecting costly new drugs or treatments. Rationing would be highly unpopular and is unlikely to be adopted overtly. Already the National Institute for Clinical Excellence vets new drugs and treatments to ensure that they are “cost- efficient.” This is difficult to define and decisions to reject a new drug are often controversial not only with drug companies but also with patients who may be denied a drug because it “only gives a patient a few extra weeks of life.”

The British government is probably right to put the main emphasis on improving quality by greater efficiency. A change must be made in the culture of the NHS by giving top priority to patient care and not attempting to gag or bribe whistleblowers.

The government must also be careful to ensure that lobbying is transparent and dealt with objectively. The British Medical Association, which represents doctors, is a professional body but it acts in the interests of doctors, not of patients. Commercially motivated representations by drug companies must be treated with even greater caution.

Health services are just as important for Japanese as for British people. Japan has a higher proportion of old people. Japanese health scandals have not been publicized to the world in recent years.

Is this because there have been few of them or is it because the health professionals have managed to ensure that they are not publicized in the media?

The Japan Medical Association (JMA) has formidable political clout and support within the Liberal Democratic Party. It is reported to be working hard against any liberalization of medical practice in Japan, which might impinge on the earnings of Japanese doctors.

In particular it is apparently against any modification of Japanese rules, which makes it difficult for foreign doctors to practice in Japan. This was an issue in which I was involved more than 50 years ago when I was a junior diplomat in Tokyo. The JMA has not apparently moved on in the decades since.

Hugh Cortazzi served as Britain’s ambassador to Japan from 1980-1984.

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