Egalitarian or Libertarian

Egalitarian or Libertarian

Healthcare in Austria and the United Kingdom

by Wolfgang Geissler

Things could not have been more complicated.

The subject I was about to write has not been delayed by the Lockdown Number Two but by a horrendous crime. Two hours before that Lockdown a crazed IS follower went on a rampage armed with a Kalashnikov, a handgun and a machete, leaving four dead and 22 wounded before he was despatched by police nine minutes into his frenzied killing spree to meet up with the customary 72 virgins in paradise specially reserved for dead jihadists as a reward.

Healthcare in Austria and the UK

“In GB the NHS is overstretched at the best of times, and the situation with regard to care of the elderly is little short of disastrous, at least in England.  Moreover, the centralised track, trace and isolate (non) system is so bad that even Johnson has stopped praising it as ‘world-beating’,  admitting that it ‘needs improvement’.  The centralised Westminster system would not until recently use local public health departments which are already equipped to track and trace outbreaks of infectious diseases, such as measles, relying on experts with local knowledge.  Now it is probably too late.

“That is the backdrop to the worrying statistics about other diseases and the mental health of children.  I should also report that dental care has virtually stopped.”Colin Munro CMG, retired UK Ambassador, ABS Board member, commented on the latest developments in the UK.

To this recent email exchange Dr Ahmadolla Abdelrahimsai, a Board member of the Austro-British Society, wrote:

“Problems exist above all in those political systems that have neoliberally cut down on social medicine and hospital care!”

This comment correctly highlights the problem indeed, as we shall see.

Nevertheless, what is Neoliberalism? It is the 20th-century resurgence of 19th-century ideas associated with economic liberalism and free-market capitalism.

It is generally associated with policies of economic liberalisation, including privatisation, deregulation, globalisation, free trade, austerity, and reductions in government spending to increase the role of the private sector in the economy and society.

During her tenure as Prime Minister, Margaret Thatcher oversaw several neoliberal reforms, including tax reduction, exchange rate reform, deregulation, and privatisation. These reforms were continued and supported by her successor John Major. Although opposed by the Labour Party, the reforms were, according to some scholars, mostly left unaltered when Labour returned to power in 1997.

The Adam Smith Institute, a United Kingdom-based free-market think tank and lobbying group formed in 1977 which was a significant driver of the aforementioned neoliberal reforms, officially changed its libertarian label to neoliberal in October 2016.

What is libertarian? Libertarians seek to maximise autonomy and political freedom, emphasising free association, freedom of choice, individualism and voluntary association.  Libertarians share the scepticism of authority and state power but diverge on the scope of their opposition to existing economic and political systems.

Catholic Egalitarianism or Protestant Libertarianism?

The French aristocrat, diplomat, political scientist and historian Alexis Charles Henri Clérel, Comte Tocqueville (1805-1859), himself a Catholic, declared that Catholics are more egalitarian than Protestants, for whom individual freedom is more important than social equality.

1. History of the Austrian Healthcare System

The beginnings of statutory social insurance can be dated to 1749 when Maria Theresa introduced a general system for invalids, organised by the state, to provide for everyone who had made a living in the war. In the same year, she established a pension fund for officers and their surviving dependents. Her son Emperor Joseph II expanded the state disability pension introduced by his mother through the pension norms. Also, he introduced the right to care for civil servants in the event of illness or age-related incapacity for work in 1749/1750.

However, only the General Mining Act of 1854 is seen as the actual start of statutory social insurance, meaning that the law stipulates the obligation for mine owners to set up a  “Brothers' Box or miners' fund” (Bruderlade oder Knappschaftskasse ) and for miners to join it. In 1859 the trade regulations replaced the old guild regulations - with the aim of  “replacing the inadequate poor support and the rather primitive care provided by the guilds with legal claims and facilities on an insurance basis”, says Stefan Wedrak in his book “Die Allgemeine Arbeiter-Kranken- and Invalidenkasse in Vienna 1868-1880”. The two amendments that took place in 1883 and 1885 apply to the expansion of the cooperative health insurance schemes and the extension of the law to journeymen.

The Association Act of 1867 gave the support funds of the (factory) workers initially created through self-help a legal basis for the first time. The Workers' Accident Insurance Act followed in 1887/88 and the Aid Fund Act in 1892.

Since then, social security has been dominated by two endeavours: to continuously increase the number of insured persons and to expand the range of benefits. In 1949 the Principal Association of Austrian Social Insurance Agencies was established as an umbrella organisation over the insurance agencies. In 1955 the General Social Insurance Act (ASVG) comes into force, which has been amended a hundred times but is still in force. Little by little, the self-employed are also being integrated into pension and health insurance: in 1965 the farmers, 1966 the tradesmen. In 1967 the civil servants followed.

Recent changes include, for example, the introduction of the social security number in 1972. A little later, the health check-up and the mother-child pass were added. However, the demographic composition of the population has changed since then. Numerous pension reforms and the introduction of private health insurance are the consequences.

Our journey through time ends with the e-card, which replaced the health insurance certificate in 2004, the emergence of the electronic health record (ELGA) in 2013 and the current debate this year about the amalgamation of the social insurance funds to form the Austrian health insurance fund. The direction in which social security will develop in the future, however, is still in the stars.

The Österreichische Gesundheitskasse (ÖGK) Austrian Health Insurance Company is the largest social health insurance company in Austria: It offers all 7.2 million insured persons in Austria protection - regardless of age or income. There is no risk selection like with private insurance. Whenever something changes in everybody's life - for example, the birth of a child, illness or incapacity for work - the ÖGK is there to help!

The Austrian health care system guarantees a high degree of fair access and has a robust ethically sound health insurance system based on solidarity. In 2011, over 99.9% of the Austrian population had health insurance. 

Compared to other European countries, Austria has the highest number of inpatient stays per 100 inhabitants. International comparisons show that in Austria there is an oversupply, especially in the intramural area.

For hospital issues, primary legislation is the responsibility of the federal government. Implementing legislation and enforcement are matters of the Länder (Federal States)

In addition to securing funding requirements, agreements between the federal government and the federal states also aim to ensure an equivalent level of high-quality healthcare throughout Austria. An agreement transcending federal state borders (Ländergrenzen) has also been reached. For this purpose, a structural fund has been set up at the federal level. A commission heads this made up of representatives of the bodies dealing with the hospital system (federal, state, social insurance, city and community federation, bishops' conference, Evangelical High Consistory, medical association, patient advocacy). The structural committee has to define and develop the basis for the hospital financing system.

The federal states are obliged to issue a hospital plan, which contains guidelines for the fund hospitals within the framework of the Austrian health structure plan.

The ÖGK in numbers

• 7.2 million insured
• around 12,000 employees at approximately 150 locations
• 20,000 contractual partners (doctors, therapists)
• 271 hospitals as contractual partners
• more than 100 own health facilities and outpatient clinics.

In conclusion, one may state that in an international comparison - and also across Europe - the Austrian health system is one of the most expensive, but is also rated as one of the best.

 

2. History of the National Health Service a story of a seemingly permanent social conflict.

A leaflet was sent to every household in June 1948, which explained that.

“It will provide you with all medical, dental and nursing care. Everyone — rich or poor, man, woman or child — can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a 'charity'. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness.”

— Central Office of Information, for the Ministry of Health

• Services were provided free at the point of use;
• Services were financed from central taxation;
• Everyone was eligible for care (even people temporarily resident or visiting the country).

Opposition

Many doctors were initially opposed to Bevan's plan, primarily because it reduced their level of independence. Being a shrewd political operator, Bevan managed to push through the radical health care reform measure by dividing and cajoling the opposition, as well as by offering lucrative payment structures for consultants. On this subject, he stated, “I stuffed their mouths with gold”.

Between 1948 and 1972 the NHS largely remained free of strikes but did experience some other industrial disputes. Doctors expressed this opposition through their largest professional organisation, the British Medical Association, which held several ballots canvassing its members' (mostly negative) opinions on arrangements for the new service.

The first dispute involving nurses took place when student nurses opened their first NHS pay packets in July 1948. Despite having received a modest pay rise, an increase in National Insurance contributions meant their take-home pay had gone down.  Up to the 1970s, student nurses were responsible for as much as 75% of the physical Labour on hospital wards. They were often subject to intense disciplinary regimes both on the wards and in their private lives, with many student nurses living in strictly-supervised hospital nurses' accommodation.

At that time the Royal College of Nursing (RCN) was reluctant to refer to itself as a trade union and nurses looking for more conventional workplace representation looked to the Confederation of Health Service Employees (COHSE) and the National Union of Public Employees (NUPE). Recognising the sensitive nature of hospital work both remained cautious regarding industrial action in the NHS until the 1970s, fearing that advocating action that might affect patients would drive away potential members. A combination of cautious organisations, staff who often saw their work as a vocation, and the overbearing influence of doctors over the rest of the workforce, led to an “old colonial” system of industrial relations, structured mostly by personal patronage and paternalism.

It all broke down in the 1970s with unions like NUPE, COHSE and ASTMS recruiting large numbers of all categories of staff, and professional organisations like the RCN and BMA becoming more aggressive in collective bargaining. Doctors also took strike action in 1975, with junior doctors walking out over long hours and inadequate pay for extra time and consultants taking action in defence of their right to place their private patients in NHS beds.

Crisis

By the end of the 1970s, industrial relations in the NHS were widely considered to be in crisis, with poor management and inadequate personnel procedures causing endemic conflict in a substantial minority of hospitals. The participation of large numbers of health workers in the events of “1978-79 Winter of Discontent” was one reflection of this. Ambulance drivers and ancillary staff were both involved in strikes over pay in January 1979, reducing 1,100 hospitals to emergency services only and causing widespread disruption to ambulance services.

Open Conflict under Thatcher

As in other sectors, industrial relations under the Thatcher Government continued to be a conflict. Successive health ministers looked to hold down pay in the public sector and to outsource ancillary staff where possible. Following the 1983 Griffiths Report, the NHS also tried to import a business model more similar to the private sector with professional managers taking over cost control, reducing the power of the medical profession.

Ancillary staff, in contrast, was increasingly marginalised during the 1980s. The Conservative Government put pressure on health authorities to outsource their catering, cleaning, laundry and maintenance services to private companies. Trade unions fought these policies, in some cases successfully, but many hospital services finally ended up in private hands, sometimes with companies who refused to recognise trade unions.

Doctors' relationship with the government deteriorated during the 1980s. The advance of “managerialism” under Griffiths irritated many doctors, previously accustomed to a dominant role in NHS governance. By 1989 doctors were extremely hostile to government reforms and were active in lobbying against the implementation of the 1989 government white paper, “Working for Patients”, which introduced an internal market to the NHS. Their defence of public ownership and opposition to market-based reforms marked a substantial shift from doctors' original opposition to the NHS, reflecting how far doctors' mindsets had changed concerning state medicine.

Relations between the NHS and the government were generally much improved under the Blair Government.

 

The condition of the NHS

Politicians attempt to shirk their responsibilities

As the seventh decade proceeded, the National Health Service remained, as it had ever been, in turbulent waters. It would probably never return to the comparative calm in which people accepted that the service was hard to be questioned. Whatever was on offer was to be received with gratitude. Hardly a day passed without a newspaper campaign, from the Mail or The Times, about the care of the dying, of the elderly, maternity services or delays in the diagnosis of cancer. Ministers had attempted to devolve their responsibilities to the service, commissioners or NHS England. Neither the population nor the political opposition was having it.

Improved efficiency alone, reconfiguring hospital services and Service Transformation Plans, moving care from hospitals into the community and general practice, or bolstering local authority social services, was not going to satisfy the need for care, let alone the demand. Raising taxes might be politically disastrous and economically foolhardy.

Performance

A 2018 study by the King's Fund, Health Foundation, Nuffield Trust and the Institute for Fiscal Studies to mark the NHS 70th anniversary concluded that the main weakness of the NHS was healthcare outcomes. Mortality for cancer, heart attacks and stroke, was higher than average among comparable countries.

The effect of Tory Austerity

Over 130,000 deaths since 2012 in the UK could have been prevented if progress in public health policy had not stopped due to austerity, analysis by the Institute for Public Policy Research found. Dean Hochlaf of the IPPR said, “We have seen progress in reducing preventable disease flatline since 2012.”

The British exit from the European Union

There is concern that a disorderly Brexit may compromise patients' access to vital medicines.

Rising social care costs

Social care will cost more in future according to research by Liverpool University, University College London, and others and higher investments are needed.

Mental health

Some patients have to wait excessively long for mental health care. One in four patients throughout the UK wait over three months to see an NHS mental health professional, with 6% waiting at least a year.

Surgery

Waiting times for routine surgery have fallen substantially since 2000. As of July 2019, the median wait for planned care in England is under eight weeks. The number of people waiting over 12 months has fallen from over 200,000 in the 1980s to under 2000 in 2019. However, the number of patients on the waiting list has risen recently as constrained funding, hospital beds and staffing growth has not kept up with the increasing patient need.

Chronic underfunding of the NHS

Funding for the NHS has failed to keep pace with the rising need for health care. The NHS does not have enough staff, or enough equipment, to meet the needs of the population it serves. (14.11.2019)

Add to this the impact of deep cuts in social care budgets and the lack of a workforce strategy and the evidence points to the NHS crisis being very much of our own making. The NHS is halfway through a decade of record underfunding - lowest average rises (2010/11 -2020/21).

In 2015, the UK had 2.6 hospital beds per 1,000 people. In September 2017, the King's Fund documented the number of NHS hospital beds in England as 142,000, describing this as less than 50% of the number 30 years previously.

Looking at it there are severe doubts about whether the NHS is sufficiently equipped to fight the war against the Covid-19 pandemic.

 

Wolfgang Geissleris a Board Member of the Austro-British Society and a Committee Member of the United Kingdom Citizens in Europe. He has lived and worked for 40 years in the United Kingdom. 

The opinions expressed in this article are entirely his and reflect in no way the opinions of the ABS or the UKCA.