part free of charge at point of use, the British system is far more accessible for the poor (and more efficient) than the complex French system, for example, which insists that patients pay up front for any treatment they receive, claiming back part or all of it much later.
The French system is the most expensive in the EC (costing 9% of gross domestic product in 1991), but also levies the highest personal costs on patients. Individual charges on patients have increased from 15.6% of the health budget in 1980 to 19.2% in 1991.
Despite its relatively high costs, the standards of French health care are not noticeably high: a consumer magazine survey of French casualty units late in 1992 described 200 of them as 'dangerous'. Low pay and poor career structures for nurses - which triggered a wave of unofficial strikes in 1988 - have led to a chronic shortage.
French health workers look on incredulously when told of British waiting lists: so, too, to German health workers, whose insurance-based system tendsto prolong and maximise medical treatment rather than ration it.
Compulsory
The German system, one of the oldest in Europe, first established in 1883, is based on compulsory insurance with contributions levied at the workplace, with state cover for the unemployed and pensioners.
1,100 separate insurance funds, many of them covering specific local districts, individual factories or particular categories of worker, act as 'purchasers' of care. While the care is generally free at point of use,! it is not cheap for the Boosting bureaucracy: Bottomley worker.
Insurance premium rates have increased from 5% of pay in 1950 to over 12% last year; this autumn has seen angry union protests at moves to increase it to 13.4% to pay for residential care for the frail elderly.
Another problem is that each fund has to balance its own books, bringing higher costs and higher premiums for members in poor localities, with greater ill-health. The huge porerty and unemployment in the former East Germany mean that the insurance funds now set up there are running at a permanent "In Italy, if a patient has to wait more than four days for out-patient care, they are entitled to use a contracted private hospital, and the health service will foot the bill" deficit, currently being bailed out by the Federal government.
The runaway costs of this, and a system where a powerful doctors' lobby has been able to drive up fees, are causing problems for the government, and there are moves to introduce 'co-payment' charges on patients for some treatment.
Meanwhile the system faces a serious shortage of nurses combined with a huge glut of doctors - with up to 15,000 of them unemployed.
The fragmented system of purchasing care in Germany finds a contrast in the Netherlands, where there is no NHS, and no profit-making hospitals. Dutch workers are obliged to buy medical insurance, and a large state bureaucracy oversees the complex system.
The government has powers to control hospital services, restrict investment in high-technology specialisms, and even order hospitals to make cuts and bed closures.
State funding
State funding of services for the elderly and public health programmes, together with cover for long-term illness, mental health, child health and disabilities, account for 41% of health spending, with the remainder covered by private, non-profit insurance.
Although most health care is delivered by privately-run organisations, they are dependent on public sector funding, which has more effect in holding down prices than in Germany.
With Maastricht Treaty inSOCIALIST OUTLOOK No. 54, December 11 1993, Page 6